UIWWSJTY OF CALIFORNIA
COLLEGE OF MEDICINE
LIBRARY
AUG 2 2 1972
IRVINE, CALIFORNIA 92664
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'
THE
SCIENCE AND ART
OF
OBSTETRICS.
BY
THEOPHILUS PARYIN, A.M., M.D., LL.D.,
PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN, JEFFERSON MEDICAL COLLEGE ;
EX-PRESIDENT OF THE STATE MEDICAL SOCIETY OF INDIANA, OF THE AMERICAN MEDICAL JOURNALISTS'
ASSOCIATION, OF THE AMERICAN MEDICAL ASSOCIATION, OF THE PHILADELPHIA
OBSTETRICAL SOCIETY, OF THE AMERICAN ACADEMY OF MEDICINE,
AND OF THE AMERICAN GYNECOLOGICAL SOCIETY |
ONE OF THE HONORARY PRESIDENTS OF THE OBSTETRIC SECTION, BERLIN INTERNATIONAL CONGRESS, 1890,
AND OF THE PERIODIC INTERNATIONAL CONGRESS OF GYNECOLOGY AND OBSTETRICS, BRUSSELS, 1892 ;
HONORARY MEMBER OF THE WASHINGTON OBSTETRICAL AND GYNECOLOGICAL
SOCIETY, OF THE DISTRICT OF COLUMBIA MEDICAL SOCIETY, OF
THE STATE MEDICAL SOCIETY OF VIRGINIA,
AND OF THAT OF DELAWARE ;
HONORARY FELLOW OF THE EDINBURGH OBSTETRICAL SOCIETY, AND OF THE BERLIN SOCIETY OF
OBSTETRICIANS AND GYNECOLOGISTS, ETC.
THIRD EDITION, CAREFULLY REVISED.
ILLUSTRATED WITH 269 WOOD-CUTS AND TWO COLORED PLATES.
PHILADELPHIA:
LEA BROTHERS & CO.
1895.
\/U6> (oo
Entered according to the Act of Congress, in the year 1895, by
LEA BROTHERS & CO.,
In the Office of the Librarian of Congress. All rights reserved.
PHILADELPHIA :
DORNAN, PRINTER.
TO
THE CLASS 1894-95 JEFFERSON MEDICAL COLLEGE.
YOUNG GENTLEMEN:
IN dedicating to you the third edition of my work upon Obstetrics I testify
the strength and happiness your industry, fidelity, and loyalty have given me.
Let me add to this note a quotation from one of the ablest and most eminent
of my predecessors, one of the greatest of American medical teachers, the late
Dr. Charles D. Meigs, asking you to make his prayer the rule of your lives :
" I pray you ever to look upon the medical profession not as a business, but as
a great Morality not as a trade, but as a Mission appointed by God for the
benefit of the children of men."
(iii)
PREFACE.
IN preparing the third edition of this work I have made some
changes in the order in which the subjects are discussed, taking that
adopted by me in oral instruction. Nearly one-third of the book has
been rewritten, additional illustrations have been introduced, and my
endeavor has been to make it a faithful reflex of obstetric science and
art at the present hour.
"The judicious Hooker" said of his age that it " was full of tongue,
and weak of brain." The present age might be described as full ot
tongue, so far as the publication of many volumes in the various
departments of Medicine is concerned, but by no means weak of brain,
as is evidenced by the many excellent works on obstetrics of compara-
tively recent issue. The favorable reception of the previous editions
of this treatise, both by the profession in this country and in Great
Britain, has been a source of sincere gratification, and I trust this third
issue may be found to merit continued favor. The author is also
grateful for the many honors he has received from the profession
honors that were often unexpected, never solicited, and, therefore,
more highly appreciated.
The Contents and Index have been prepared by my assistant, Dr.
Charles H. Reckefus.
THEOPHILUS PARVIN.
PHILADELPHIA, JULY 20, 1895.
CONTENTS.
PAGE
INTRODUCTION 17
PART I.
SECTION I.
PHYSIOLOGY OF PREGNANCY.
CHAPTER I.
ANATOMY OP THE PELVIS . 21
CHAPTER II.
THE FEMALE SEXUAL ORGANS 46
CHAPTER III.
PUBERTY OVOLATION MENSTRUATION 92
CHAPTER IV.
CONCEPTION EARLY DEVELOPMENT OP THE IMPREGNATED OVULE
FORMATION OF DECIDUOUS MEMBRANES FCETAL APPENDAGES . 108
CHAPTER V.
THE EMBRYO AND F, month, and vaig t ces-
sation, is the end of the menstrual life. It is influenced by various
causes, such as social condition, climate, and race; aud hence presents
as great differences in time as does the beginning of menstruation. The
menopause occurs somewhat sooner in the poor than in the rich, prob-
1 Cincinnati Journal of Medicine, 1866.
- According to Villaret, Joan of Arc was " exempt from the tribute which women pay the
moon ;" and he suggests that this exemption was due to her high destiny. She was only twenty
years old when executed, so that, admitting the fact of her amenorrhoea, it is possible there was
simply delay in the establishment of menstruation.
P UBERTY VULA TIONMENSTR UA TION. 1Q3
ably earlier in cold than in warm climates, and also in the black races
than in the white. Some cease to menstruate in the third decade, while
in others the function is continued into the sixth ; thus Courty men-
tions the case of a woman who still menstruated regularly at sixty-five
years. Charpentier states that in a woman under his observation men-
struation ceased at forty-eight, but, after being absent for twelve years,
returned, and continued for two years, the recurrence and quantity
being normal.
The following remarkable case was recorded by the most eminent of
American physicians, Dr. Rush r 1 "I met with one woman, a native of
Herefordshire, in England, who is now in the one-hundredth year of
her age, who had a child at sixty, menstruated till eighty, and frequently
suckled two of her children, though born in succession to each other, at
the same time. She had passed the greatest part of her life over a wash-
tub."
Gibbon 2 states that Asima, the mother of Abdallah, when she was
ninety years of age, upon hearing that her son was dead, had her menses
return. Elsewhere we are told that the flow was fatal in five days.
Such hemorrhage and at so advanced an age would not be regarded by
a physician as menstruation.
If the puberty be early, the menopuse will be late, while on the
other hand delayed puberty indicates early cessation of the monthly
flow. According to P6trequin's 3 statistics, one-eighth of women cease to
menstruate when between thirty-five and forty years of age, one-fourth
from forty to forty- five, one- half from forty-five to fifty, and one-eighth
from fifty to fifty-five.
The obstetrician should remember that as girls have conceived before
menstruating, so conception has occurred mouths and even years after
the menopause.
THEORIES OP MENSTRUATION. CONNECTION BETWEEN MENSTRU-
ATION AND OVULATION. Probably the earliest theory of menstruation
is the chemical, or that which holds that certain materials which would
otherwise be injurious to the organism are eliminated by the discharge.
This view was to some degree expressed by pronouncing a woman un-
clean during the flow ; even to-day, as remarked by Fritsch, the expres-
sion monatliche Reinigung, monthly cleansing, is retained.
In recent years the doctrine has to a slight degree found a scientific
basis in this, that the quantity of carbon burned by man increases up
to thirty years, while in the female who menstruates it remains the same,
and hence, according to Aran, menstruation serves to eliminate a cer-
tain amount of carbon from her organism.
Dr. H. Newell Martin 4 suggests that there may be some truth in a
modification of the purification theory, saying : "One important function
of the mucous secretion of the alimentary canal appears to be that
the mucus entangles and carries on with it to the rectum indigestible
and other possibly harmful solid particles, as microbes. The uterus
not merely cleanses itself by secretion and expulsion of mucus, which
1 Medical Inquiries and Observations, 1793, Philadelphia.
2 Decline and Fall of the Roman Empire.
3 American System of Obstetrics, vol. i. 4 Quoted by Tarnier.
104 PHYSIOLOGY OF PREGNANCY.
might sweep and cleanse its lining membrane, but discharges during
menstruation all the superficial parts of that membrane. We know
that lying-in women are especially liable to be infected by pathogenic
bacterial organisms; and in the earlier stages of its evolution, when the
egg is still segmenting and the decidua reflexa forming, it may well be
that the young embryo might be easily infected by extraneous organ-
isms. This view gives us one logical meaning for menstruation. It
gives us a reason for that entire casting off of the surface layers of the
mucous lining of the womb which occurs each month. Menstruation
breaks down and discharges all the old mucous membrane, and gets rid
of bacteria which may have entered through the os and found a suitable
nidus for development. Hence, in a modified form, the purification
doctrine is still tenable as giving a physiological reason for menstrua-
tion."
This ingenious hypothesis is open to two objections. All observers
do not teach the breaking down and discharge of "the old mucous
membrane " as a phenomenon of menstruation, and according to some
of the best it does not occur ; the presence of pathogenic microbes, or
microbes of any sort, in the healthy uterine cavity has not been proved,
but disproved.
The theory that the flow results from plethora is one of the oldest
and most generally adopted. As the woman had to nourish the unborn
babe she was supposed to be endowed with superior blood-making
power. But if she did not conceive, a superfluous quantity of blood
was made, and nature brought the entire amount in her body to the
normal level by periodical hemorrhages from the womb.
Some made the function peculiar to civilized women. Thus Roussel
asserted that in the primitive or savage state women were exempt from
menstruation ; hard work and simple fare prevented them from being
plethoric, and hence no hemorrhage occurred, as it was not needed ; but
it was necessary in the case of civilized women, because they had less
exercise and more abundant and better food.
Auber also denied that menstruation occurred in savage women, and
asserted that it happened in the civilized because of failure to gratify
the reproductive instinct, and thus became a habit. 1 Some recent writers,
too, have sought to establish the pathological character of menstruation ;
in other words, menstruation is a disease which impregnation would
prevent. For the moment, admitting that Auber's theory is correct, that
is, menstruation occurs from failure to satisfy the reproductive instinct,
it has been suggested that a girl might be impregnated prior to men-
struation, and then as soon as possible after her delivery let her be again
impregnated, and thus through her entire reproductive life. At the end
of that life she would have given birth to thirty or forty children, and
if her example were to be generally followed, society would demand a
new proclamation of Malthusianism. It is hardly necessary to state
that menstruation occurs in savage women, and there is not the slightest
1 Dr. Gill Wylie, of New York, has recently given (American System of Gynecology) a quasi-
indorsement to the civilization theory of menstruation : " Although the generative organs are
essential to reproduction, they are not essential to the individual, and are not necessarily used.
Therefore, menstruation may be intended to take the place of the free exercise of the function of
these organs, and thus compensate for the restraint and disuse so much and so necessarily prac-
tised by civilized races."
P UBERTYO VULA TIONMENSTR UA TION. 1 05
probability that at any period in the history of the race in any land
women ever lived who, as a rule, became mothers without being subject
to menstruation. It has been suggested that the menstrual hemorrhage
is for the purpose of relieving a local plethora, that of the sexual organs,
especially of the uterus, hypertrophy of its mucous membrane with con-
sequent formation of a deciduous membrane being thus prevented.
Pfliiger regards the uterine hemorrhage as a preparation for the
attachment of the fructified ovum to the uterus. Menstruation, accord-
ing to him, is the inoculation wound of nature for the fastening of the
impregnated ovule to the maternal organism.
I)r. John Goodman has advanced the theory that menstruation is
dependent upon a law of monthly periodicity. This law is the resultant
and exponent of recurring cycles of physiological acts ; these monthly
cycles are supposed to depend upon the ganglionic nervous system. But,
as remarked by de Sin6ty, to attribute the flow to the nervous system
explains nothing.
Passing from these theories, which have little more than mere histor-
ical interest, we turn to that which is founded upon ovulation, and which,
though different explanations of the relations between the two phenomena
may be held, meets with general professional acceptance. The view that
has hitherto been commonly received, and is still held by many, is that
ovulation is periodical, the growth and rupture of an ovisac correspond-
ing with each menstruation. As the ovisac grows it presses upon ovarian
nerves, and by reflex irritation causes congestion of the internal genera-
tive organs, especially of the uterus : the uterine hypersemia results in
hemorrhage from its mucous surface. Here the question arises as to
whether this hemorrhage is facilitated by desquamation of the superficial
epithelium, resulting from fatty degeneration, complete casting-oif of the
mucous membrane being rejected. According to some, this superficial
desquamation does not occur until the close of menstruation, and there-
fore has nothing to do with the hemorrhage. Again, excellent author-
ities state that they have failed to find the proof of elimination of the
superficial portion of the mucous membrane in menstruation. De Sin6ty,
in examining the discharge during the monthly flow, could not discover
the least fragment of mucous membrane or of epithelium ; so, too, in
women dying while menstruating, he found the uterine mucous mem-
brane entire in all its extent. WinckeP says : " Since Huge and Moericke
have found that during menstruation the ciliated epithelium of the uterine
mucous membrane remains intact, an observation which we have re-
peatedly confirmed, the earlier view that during menstruation a fatty
degeneration of the superficial layers was a cause of menstruation is
incorrect."
Admitting these statements, the necessary conclusion is, that the
hemorrhage in menstruation occurs without destruction of any part of
the uterine mucous membrane, and that the blood escapes from the
superficial vessels, not by their rupture, but by diapedesis and through
an intact mucous membrane.
The periodicity of menstruation can be most readily explained by
attributing it to the ripening of an ovisac, for this, like other processes
1 Lehrbuch der Frauenkrankheiten, 1886.
106 PHYSIOLOGY OF PREGNANCY.
of growth, would naturally be supposed to require a certain time.
Again, this interpretation of the connection between ovulation and
menstruation corresponds with what we know of ovulation and "rut"
or "heat" in animals, which is the analogue of menstruation. Nature's
legislation is general rather than special, and it is not probable she would
make one law relating to reproduction for animals in general, and then
a special law for human beings.
But without pressing this point, let us see the proofs that are adduced
to show that ovulation is not periodical. The results of Leopold's iu->
vestigations are thus given by Foektistow: 1 Fully developed follicles,
those already ruptured, and fresh corpora lutea may be found at any
time during the inter-menstrual period. These may not be present dur-
ing menstruation. Hence ovulation occurs without menstruation, and
menstruation may occur without simultaneous rupture of the follicles.
Ovulation, therefore, is independent of menstruation, and is not period-
ical. Nevertheless, while Leopold denies the dependence of menstruation
upon periodic ovulation, he does make it depend upon the ovaries, and
he regards its periodicity as placing it in the category of rhythmical
manifestations, e. g., the pulse, respiration, or ejaculation of semen.
The uterine hypersemia results as a reflex from the ovaries caused, not
by the ripening of an ovisac, but by the continued growth of several.
Foektistow, in answer to the question Avhy does not menstruation occur
more frequently, gives these reasons : Comparatively slight ovarian
irritation is not sufficient to cause a reflex so soon. The essential, too,
of the menstrual process, is that anemia follows hypersemia, and irri-
tability ceases. Equilibrium is restored, and to cause another reflex
another sum of irritations is necessary, and these cannot occur at once.
The changes in the uterine epithelium which began with the hypersemia
pass away with the following ansemia, and the epithelium returns to its
normal condition, a process which continues through more than one-half
of the inter-menstrual period.
Another theory of menstruation which is founded upon ovulation is
that of Lowenthal. 2 According to him, the ovule reaches the uterus
before impregnation ; if it be impregnated, menstruation does not occur ;
but if it is not impregnated, it excites a uterine congestion which ends
in hemorrhage. Winckel 3 observes the Achilles heel of this bold hy-
pothesis is that the death of the ovule can cause active congestion of
the uterus. Further, this hypothesis is a revival of an old one ; that is,
menstruation results from the failure of impregnation, and is entitled to
no more credence in its new that it was in its old form.
Auvard* holds that the menstrual function is composed essentially of
two phenomena, ovulation and genital hemorrhage ; these two phe-
nomena are independent of each other, but dependent upon the same
cause, this cause being unknown, and resulting from the constitution of
the organism : in a physiological state they are associated, and on the
contrary frequently dissociated in a pathological condition. He asserts
1 Archiv fur Gynakologie, Band xxvii.
2 Archiv fur Gynakologie, 1885. 8 Op. cit.
* Travaux d'Obst6trique, tome premier, Paris, 1889. This hypothesis fails in adding to knowledge.
It is no more satisfactory than Avicenna's explanation of the cause of labor coming on : " At the
end of nine months labor occurs by the grace of God," or that of one of Moltere's characters in
regard to the action of opium : opium causes sleep by its sleep-producing properties.
PUBERTY VULATION MENSTRUATION. 107
further, that a genital flow simulating the discharge is not menstruation
if ovulatiou is absent, any more than is ovulation without hemorrhage.
It may be, as stated by de Siuety, that any positive theory of menstru-
ation is, with our present knowledge, premature ; nevertheless it must
be admitted that this function is connected with the ovaries, for if these
organs are congenital ly absent, or if they are undeveloped, menstruation
does not occur. So, too, after double ovariotomy menstruation ceases.
The exceptions to this rule cannot be admitted until a careful post-
mortem examination has proved that no fragment of ovarian tissue has
been left behind in the lower portion of the pedicle, as has happened in
some cases. Women have borne children after both ovaries were
believed to have been removed. Olshauseu performed, as he thought,
ovariotomy, but the result being fatal he found at the autopsy that
neither ovary had been removed. Further, even if both ovaries have
been completely removed, possibly there may remain a supernumerary
ovary, a condition that Beigel's and Winckel's examinations 1 prove to
be far less rare than has been thought. Until in those cases of alleged
perfectly normal menstruation 2 post-mortem examinations prove the
entire absence of all ovarian tissue, either a fragment of an organ that
has been removed or a supernumerary ovary, the doctrine that menstru-
ation depends upon ovarian action will remain. So, too, it is in the
highest degree probable that there is an intimate connection between
ovulation and menstruation. At the same time it must be admitted
that the two may.be distinct, the one occurring without the other,
though they are usually associated. Thus there may be occasional
monthly hemorrhages without ovulation, or the latter may occur without
the former. Ovulation may begin before the first monthly flow, and
impregnation take place ; during lactation it may occur without men-
struation, and it may happen, too, after the menopause ; thus there is an
explanation of the comparatively frequent instances of impregnation of
women while nursing ; and of rarer cases in which this event has oc-
curred after menstrual life has ceased. Further, there is reason, from
what has been observed in the rabbit, for believing that coition may
cause rupture of an ovisac, and hence ovulation occur independently of
menstruation.
Ribemout-Dessaignes and Lepage 3 conclude that there is no good
reason for not admitting, according to the classic theory, (1) that ovula-
tion has its external sign in menstruation ; (2) the escape of the ovule
from the ovisac usually occurs at the end of a monthly flow, and gener-
ally this is the one that is fecundated.
1 Beigel found in 500 sections supernumerary ovaries 23 times. Winckel from his own examina-
tions concluded they were present in 3.6 per cent. Nevertheless, Sutton asserts, Surgical Diseases
of the Ovaries and Fallopian Tubes : " So far as the evidence at present stands, an accessory ovary,
quite separate from the main gland, so as to form a distinct organ, has yet to be described by a com-
petent observer." But those who know Professor Winckel's ability and his thoroughness of inves-
tigation will doubt the error attributed to him in this quotation.
* Foektistow. 3 Precis Obstetrique, 1893.
CHAPTEK IY.
CONCEPTION EARLY DEVELOPMENT OF THE IMPREGNATED OVULE
FORMATION OF DECIDUOUS MEMBRANES FCETAL APPENDAGES.
CONCEPTION, from concipio, means in metaphysics a grasping into
one, and in physiology the uniting of two living elements, one male, the
other female, from which a new being is evolved. Fecundation, im-
pregnation, and by some incarnation are also used as synonyms.
A woman who has conceived is pregnant ; pregnancy begins with
conception and ends with labor. The pregnancy is single or simple if
only one ovule has been fecundated, but plural if two or more have
been. It is normal when the uterine cavity contains the fecundated
ovule or ovules, and abnormal, ectopic, extra-uterine should it or they
be external to that cavity. But whether the pregnancy be single or
plural, whether normal or abnormal, its beginning is the same.
Human conception was a subject of great interest to students of
nature, whether physicians or philosophers, 1 in ancient times ; 2 numerous,
and many of them very curious, hypotheses were proposed in explaining
it, and indeed it is only in comparatively a recent period that, guided
by the discoveries of the microscope, the initial step in reproduction has
been placed upon a scientific basis.
Aristotle compared the menstrual blood to a block of marble, while
the seminal fluid was the sculptor, and the foetus the statue. Galen,
who from his dissections had some knowledge of the ovaries, and gave
them, as has been previously stated, the name testes muliebres, held that
they furnished a secretion which in the womb combined with the sem-
inal secretion of the male to form the new being. For many centuries
these two opinions alternately prevailed, now one, and again the other,
receiving the more general acceptance. But they were alike rejected by
the recognition of Harvey's aphorism, omne vivum ex ovo. This illus-
trious physician maintained that reproduction in all animals was by a
female element analogous to the egg of the hen. But in explaining the
way in which development of the egg was effected he accepted the
hypothesis of a seminal aura ; fecundation occurred in like manner to
the action of a magnet upon iron contact with the former caused the
latter to have magnetic virtue ; again, he illustrated physical by mental
conception the uterus conceives the foetus, as the brain ideas that are
formed in it.
Confirmation of Harvey's views as to the essential element in human
1 " A man deposits seed in a womb, and goes away, and then another cause takes it and labors
on it, and makes a child. What a thing from such a material !" Meditations of Marcus Aurelius
Antoninus.
2 " Drelincourt, an author of the last century, brought together as many as two hundred and
sixty-two groundless hypotheses concerning generation from the writings of his predecessors ; and
nothing is more certain, quaintly remarks Blumenbach, than that Drelincourt's own theory formed
the two hundred and sixty-third." (Allen Thomson.)
CONCEPTION. 109
generation was for a time given by de Graaf s discovery of the ovisacs,
which were believed to be human eggs, and at first were known as ova
Grraafiana. But about 1677, Ludwig Hamm, of Dantzic, examining
with a microscope the discharge occurring in the nocturnal emission of
a patient suffering with gonorrhoea, discovered living spermatozoids.
He made known the fact to the great microscopist, Leeuweuhoek, who
also saw them ; the latter soon after found them in the seminal dis-
charges of healthy men, of the dog, of the cat, and of the rabbit.
Leeuwenhoek concluded from his observations that man was not pro-
duced ex ovis imaginariis, se,d ex animalculis vivis seu vermiculis in
semine virili contentis. He asserted : Sperma humanum parvulis puerulis
esse plenum. The supposed animalcula? received the name of sperma-
tozoa, the plural of spermatozoon ; but as these terms indicate that the
objects are independent existences, a view now held by only few, it is
better that they should be replaced by spermatozoid and spermatozoids.
Leeuwenhoek believed that the spermatozoids had sexual character,
and some observers went so far as to describe their sexual organs. Of
course, the Harveian theory of reproduction was for the time rejected ;
and this process was simply the development of one of these homunculi
in the uterus, the female merely furnishing a nidus for that develop-
ment. 1 But the progress of science has vindicated the truth of Harvey's
theory as to the origin of the human being and of all animal life ; it,
however, gives no support to the hypothesis of a seminal aura, which
acting upon the ovum causes its development. We now know that there
must be an actual combination of the male and the female element in
order that fecundation can occur.
THE SEMINAL, FLUID. The semen, when ejaculated, presents an ap-
pearance somewhat like that of thin, recently boiled starch ; it is alka-
line and mucilaginous, and has an odor which is called spermatic, and
has been compared to that of hemp flowers or of horn filings. The
odor, according to Robin, does not belong either to the spermatic or to
any other of the secretions that combine with it during the ejaculation,
but is developed by the mixture. Its specific gravity is somewhat
greater than that of water ; it is not coagulated by acetic acid or by
heat, and does not contain albumin ; but the substance found in it which
has been by some given this name is spermatine ; after it has become
dry it presents upon the stiffened linen where -it has been deposited
yellowish-gray stains ; the quantity discharged at a single ejaculation
varies from fifteen grains to two drachms, one to eight grammes.
Chemical analysis shows the presence of ninety per cent, of water, six
of extractive matters, three of lime phosphates and muriates, and one of
soda. In the sperm of the bull, Kolliker found 820 parts of water,
151 parts represented by spermatozoids, 26 by salts, and 21 by fat con-
taining lecithine. In the sperm of some men there may be an excess
of spermatozoids with a deficiency of water all fish and no water, as
Pajot has said and sterility be the consequence. With the microscope
there -are seen cylindrical cells, pavement epithelium, leucocytes, fine
1 The argument used in " The Furies " for the acquittal of Orestes for the murder of his mother
would have been still stronger had the Greek poet Known this view for then indeed, as asserted
in the successful defence of the matricide, the mother was only the nurse, and the father the
true parent , and mythology tells us that Minerva had no mother, only a father.
110
PHYSIOLOGY OF PREGNANCY.
FIG. 64.
granular matter, crystals of lime phosphate, and the essential element,
the fertilizing agents, spermatozoids.
SPERM ATOZOIDS. The form and size of spermatozoids vary in dif-
ferent animals, but there is no relation between the size of the sperrua-
tozoid and that of the animal from which it comes ; thus the spermato-
zoid of the elephant is no larger than that of man, while that of the rat
is five times as large. Waldeyer 1 states that the diversity of size and
form of spermatozoids is astonishing, and that he does not know a single
instance in which the spermatozoids of different animals are entirely
similar, and he believes that their form may be advantageously used to
determine their species.
The spermatozoid is composed of a head, of a tail, and of an inter-
mediate segment, the last being thus designated by some, but by others
called the body. The entire length of the human spermatozoid is not
more than -5-^5- to -g-^- of an inch, or one-
twentieth to one-twenty-fifth of a milli-
metre. The head is pyriform, or ovoidal,
the larger end being attached to the body
or intermediate segment, while the smaller
end is free. The head is about one-
tw r entieth the length of the tail, and is
quite or nearly twice as long as it is
broad. The body, intermediate segment,
or beginning of the tail, is only -nnj-f o"ff
to looHo-g- of an inch, or one-three-hun-
dredth to one-four-hundredth of a milli-
metre ; it is oval and flattened, giving it
somewhat the shape of an almond. The
tail, or caudal filament, is thick at its origin, then gradually diminishes
until its extremity is so fine as not to be visible even with the best
magnifying glasses. One of the most striking characteristics of sperma-
tozoids is the power of executing quick and rapid movements ; these
movements are especially rapid immediately after ejaculation ; a sperma-
tozoid moves a distance equal to its length in one second, and it was
stated by the late Dr. Marion Sims that spermatozoids pass from the
hymen to the neck of the womb in three hours. Lott states that
spermatozoids in a minute move 3.6 mm., and Wiuckel adds that at
this rate they might easily pass into the oviducts in a few minutes.
The head is the part which always advances first ; the movements have
been compared to that of an eel swimming in water ; the tail may be
curved in a circle, but very quickly becomes straight again, and its
simple undulatory movements, which cause progression of the sperma-
tozoid, are resumed; in its progress over the field of the microscope, it
may sometimes be seen quickly pushing out of its way epithelial cells or
crystals ten times its size. 2 The movements gradually lessen, then there
is no progression, but mere oscillations are seen, and finally all motion
ceases ; but by warming the slide, if it has become cold, or by adding
a little warm water, slightly alkaline, if the liquid has become thick,
SPERMATOZOIDS.
Arch. f. mikrosk. Anat, August, 1888.
2 Robin.
CONCEPTION. HI
movements are resumed. In avoiding these two causes of death to the
spermatozoids when the seminal fluid is placed between two glass slides,
the movements may last for twelve, twenty-four, or even thirty hours.
Spermatozoids have been found alive in men who were executed
seventy and even eighty-two hours after death ; in the bull six days
after it was killed ; in the oviducts of bitches and rabbits seven to eight
days ; in the cow six days after copulation ; in the human female they
were found endowed with active movements in the cervical canal, by
Hausmann, seven days and a half, and by Percy eight days after
coition. In the female bat they retain their fecundating power for
many months, and in the queen bee for more than three years. The
spermatozoids of a frog may be frozen four times in succession without
killing them. They will live for seventy days when placed in the
abdominal cavity of another frog. (Mantegazza.) Acid solutions kill
spermatozoids very quickly, and, on the other hand, weak alkaline
solutions quicken or awaken their movements ; cold water arrests their
movements, and corrosive sublimate, one part to ten thousand of water,
is destructive to spermatozoids, while they seem insusceptible to the
action of poisons of organic origin. 1 The normal secretion of the
uterus, as well as the menstrual discharge, is favorable to their move-
ments. In the examination for spermatozoids a magnifying power of
three hundred diameters is sufficient, but in medico-legal investigations
one of five hundred is necessary.
In temperate climates boys of twelve years may have a discharge
simulating the seminal fluid, but it is unusual for spermatozoids to be
found in these discharges before the age of fifteen or sixteen years. 2
The reproductive power begins somewhat earlier in woman than in
man, but it lasts much longer io the latter; Lieg6ois, from his investi-
gations, concluded that about one-half of men between sixty and eighty
years of age were capable of fecundation. 3
Men who are addicted to sexual excess may have seminal discharges
without any spermatozoids being present; so, too, spermatozoids may be
absent in the case of some men who are in good health ; thus Pajot
found this condition in six of eighteen husbands whose marriages were
sterile, and the late S. W. Gross stated, as an approximate estimate, that
in one case in six of sterility the husband is at fault.
Recent authors greatly increase the number of cases in which the
sterility depends upon the male; 35 per cent., Kehrer; 40 per cent.,
Lier and Ascher ; and even 57 according to Noeggerath. (See TraitS
pratique de Gynecologic, by Bonnet and Petit, 1894.)
As has been previously said, the animalcular character once given to
spermatozoids is now generally denied. The arguments against this
view are : they have neither organs of digestion nor of reproduction ;
they are anatomical unities which have their genesis from embryonic
male cells or spermatoblasts, but they do not produce such cells ; they
1 Duval.
2 In the light of the statement above made as to the time spermatozoids are first found, the
story of Cato being a father at eight years, as well as that said to have been told by St. Jerome, of
a boy ten years old, who, sleeping with his nurse, impregnated her, is to be rejected.
3 The illustrious Corvisart was skeptical as to the prolonged power of propagation, for when the
First Napoleon asked him if a man at sixty could be a father, he replied, " Sometimes." " And at
seventy ? " then asked the emperor. " Always, sire."
112 PHYSIOLOG Y OF PREGNANCY.
indicate a finality, not a progress ; they are regarded as similar to
ciliated epithelium.
In order that fecundation can occur there must be an actual union
between the male element and the female between the spermatozoid
and the ovule. In some animals external fecundation occurs, the eggs
being fertilized after they have been expelled from the female ; or, as
in the frog and crab, while they are being discharged. But in human
beings, as in most animals, fecundation is internal. The place of union,
between the spermatozoid and the ovule, was supposed to be the uterine
cavity, and this opinion is maintained by some eminent authorities,
among whom may be mentioned Mayrhofer, Wyder, and Lawson Tait.
But this opinion is generally rejected, because it does not explain the
occurrence of ectopic pregnancy, and because the spermatozoids are
found in the inferior animals to have entered the oviducts and advanced
to the pavilions. Moreover, it is known that in some animals the ovule
in its progress through the oviduct receives a covering of albumin 1
which is impenetrable by spermatozoids, and also that, unimpregnated,
it is affected during this progress by degenerative changes which render
impregnation impossible. It is therefore now generally held that fecun-
dation takes place in the external third of the oviduct, possibly near or
in the pavilion.
ASCENSION OF THE SPERMATOZOIDS. Four causes have been in-
voked to explain the passing of spermatozoids, deposited in vast 2 num-
bers in the posterior vaginal cul-de-sac at the end of coition, from this
point into the external portion of the oviduct, supposing this to be the
usual seat of fecundation. Three of these, that of capillary force,
of aspiration, or intraction by the uterus, and of the movements of the
cilia, make these bodies merely passive they do not ascend, but are
transferred or translated. But it seems probable that the spermatozoids
would not have been endowed with such force and rapidity of move-
ment unless for the accomplishment of an important purpose, and there-
fore we recognize the inherent power of motion on their part as the
chief, usually the only, cause of their being in the oviducts. Intraction
on the part of the uterus is impossible in certain structural diseases of
the cervix, and is powerless when the seminal discharge has been from
necessity or from precaution made upon the external sexual organs, and
yet in each condition impregnation has been known to occur. Ciliated
action would assist the spermatozoids once in the uterus to ascend to
the oviducts, but the action of the cilia of the latter would oppose their
further progress. It may be that Nature, rich in resources, does not
limit herself to a single cause in securing this important step in the
continuance of the race, but, while having a chief one, at times has this
assisted by others.
In all cases more or less time intervenes between coition and conception,
between insemination and impregnation ; this interval possibly is some
1 This argument is strengthened by Bland Button's discovery of glands in the oviduct, these
glands secreting albumin, according to his view.
2 Mantegazza admits the minimum period of fecundating power of man as from eighteen to fifty-
eight years that is, forty years, and stating that at each ejaculation the quantity of semen is 120
drops, and that a single drop is sufficient for impregnation, comes to the conclusion that a man
can reproduce 480,000 times.
Startling as this statement is, that of Lode, quoted by Ahlfeld, is still more remarkable the
number of spermatozoids in coition discharged in the vagina is 226,257,900.
CONCEPTION. H3
hours, and it may be, as illustrated by the fecundation of the hen's egg
twelve days before it is laid, several days. Hence the assertion made
by some women, and accepted by a few obstetricians, that a peculiarly
pleasurable sensation attends fruitful intercourse, is to be rejected. The
intercourse may be with cruel violence, or the woman may be paralyzed
by fear, or submit with indifference, or even with loathing and disgust ;
she may be in profound sleep, drugged, or anaesthetized ; or, finally,
artificial introduction of the seminal fluid into the uterine cavity may
be done, yet in all these instances fecundation can result. In such
cases pleasure was impossible, and in some both mental and physical
suffering were present. The role of woman in copulation is passive ;
the probability is her pleasure cannot promote nor her pain prevent
conception.
THE COMBINATION OF MALE AND FEMALE ELEMENTS. It has
been held that the spermatozoids after reaching the ovule were dissolved,
then by osmosis penetrated its walls molecule by molecule, and the de-
velopment of the ovule resulted ; it was vivified by a sort of spermatic
bath, and the richer the bath was in dissolved spermatozoids, the more
certain would be impregnation. Another equally improbable explana-
tion was that several spermatozoids entered the ovule, the greater the
number entering the more certain the fecundation, and then were dis-
integrated and were mingled with the yelk. But the more recent
studies of fecundation in some of the inferior animals render it in the
highest degree 1 probable, and it is quite rational too, that in all cases
only one spermatozoid is concerned in normal impregnation. It would
seem that nature teaches the law of monogamy at the very beginning of
life.
Certain changes occur in the ovule independently of impregnation.
The germinal vesicle moves toward the periphery of the ovule, and from
the vesicle there is formed a globule, which first presents as a bud-like
process projecting from the surface of the ovule, then the part nearest the
free surface of the ovule becomes constricted and separation follows ;
this process is repeated once, or oftener, and the bodies thus originating
from the germinal vesicle, and ejected from the ovule, are called polar
cells or globules. The formation of the polar cells 2 may occnr while
the ovule is still in the ovary, but more frequently afterward ; they may
precede or follow impregnation. These statements have been drawn
from observation of the ova of some of the inferior animals ; as re-
marked by Balfour, it is very possible, not to say probable, that such
1 Van Beneden, in only six cases of many thousands of impregnation of the egg of the ascaris
studied by him, found that two spermatozoids entered the ovule.
2 The apparently useless formation of polar globules has been given different explanations. One
is that these globules are ejected from the ovule in order to secure space for the segmentation of the
vitellus. Another is that they testify to a descent from ancestral forms having a lower organiza-
tion, in which the discharge of the globules plays an important part, as in the parthenogenesis of
bees, etc. Balfour suggests as one of the reasons for the ovule having this function the prevention
of parthenogenesis. It is the final act of the ovule ; unaided it can do nothing more. " There is but
little doubt that the ovum is potentially capable of developing by itself into a fresh individual, and
therefore, unless the absence of sexual differentiation were very injurious to the vigor of the
progeny, parthenogenesis would certainly be a very constant occurrence ; and on the analogy of
the arrangement in plants to prevent self-fertilization, we might expect to find some contrivance
both in animals and in plants to prevent the ovum developing by itself without fertilization. If
my view about the polar cells is correct, the formation of these bodies functions as such a con-
trivance." (Balfour : Comparative Embryology.) Thus parthenogenesis is prevented, and cross-
fertilization made possible.
114 PHYSIOLOG Y OF PREGNANCY.
changes are universal in the animal kingdom, but the present state of
our knowledge does not justify us in saying so.
It is generally held that the germinal vesicle is not entirely cast out
in the form of polar globules, but a portion remaining in the ovule
forms the female pronucleus, which is to unite with the male pronucleus.
The latter is believed to be formed by the head alone of the spermato-
zoid. The entrance of the male element into the female is provided
for in some fish by a minute opening, called a micropyle, in the cover-
ing of the ovule ; this opening is so small that only one spermatozoid
can enter at a time. But the ova of the mammiferse show no such
investment. Duval remarks that it is now proved that a great number
of ovules at the time fecundation occurs are simply encircled by a pel-
lucid zone that is to say, a layer more dense, and having a special
appearance, but which in a normal state is always fluid and permeable.
Fol, of Geneva, states that putting in contact with an ovule liquids con-
taining vibrions, the latter passed through this pellucid layer, and were
found in the yelk ; still more, then, this zone is permeable by the
sperraatozoid.
The vitelline membrane is a secondary formation, and is not found
upon the unfecundated egg ; but after the first spermatozoid has pene-
trated the vitellus the ovule is rapidly encysted by condensation of its
peripheral layer, a kind of catalytic phenomenon the nature of which
is not clear. It is thus seen that Nature provides for the entrance ot
one spermatozoid, but closes the door to a second, and if by mischance
the latter enter, the result will be a double monster.
The part of the spermatozoid which enters the vitellus increases in
size and is the male pronucleus. The male moves toward the female
pronucleus, which occupies the centre of the ovule ; the latter in some
cases has been observed to lose its spherical form and become crescent-
shaped, so as to receive in its concavity the male pronucleus. After
the fusion of the two prouuclei there is but a single nucleus, in which
are initiated all the changes that result in the formation of a new
being. Balfour describes the act of impregnation as the fusion of the
ovum and the spermatozoid, and the most important feature in the act
appears to be the fusion of a male and of a female nucleus. This is
brought into still greater prominence by the fact that the male pronucleus
is the metamorphosed head of the spermatozoid, which contains part of
the nucleus of the primitive spermatic cell, and the female pronucleus
is the product of a primordial ovum. The spermatic cells originate in
primordial cells, which cannot be distinguished from primordial ova,
and thus the impregnated ovule results from the fusion of morphologi-
cally similar parts in the two sexes.
TIME OF CONCEPTION. This cannot be certainly known, but the
time when coition is most likely to be followed by impregnation is well
known by the public as well as by physicians. The " conception curve "
given by Foektistow 1 shows that conception is most liable to occur from
coition in the first seven days following menstruation ; the first day
after the flow ceases has the highest percentage, and from this time the
1 Op. cit.
CONCEPTION. H5
latter gradually declines. Hensen's conclusions are in accordance. But
while conception is very improbable during a certain portion of the
menstrual interval, it cannot be affirmed that it is impossible at any
time.
FATE OF THE SPERMATOZOIDS NOT CONCERNED IN IMPREGNATION.
As has been previously stated, it is almost certain that in human beings,
as has been proved to be the fact in some of the inferior animals, only
one spermatozoid is concerned in impregnation, and the question natur-
ally arises, What becomes of the multitude who have no part in this
process, a number much greater than Penelope's suitors during the long
absence of Ulysses. Is it not possible that they may permanently
modify the organism or the undeveloped ovules so that the product of a
future pregnancy, though by another father, may be affected? 1 The
heredity of influence is that observed in the children born by a widow
who remarries, these children resembling morally and physically the
first husband. Occasional instances of such heredity occur, and it is
claimed that in reproduction in the inferior animals the first sire may
materially modify the offspring of subsequent sires. Admitting the
fact, possibly the factors in such modification may be the original sper-
matozoids that did not contribute to the first conception. Heredity of
influence has also been termed indirect atavism, and more recently
telegony. Lingard 2 has given a remarkable instance : The widow of a
hypospadian eighteen months after the death of her husband contracted
a second marriage, the new husband not being a hypospadian, and
having no history of any such deformity in his family. Consequent
upon this marriage she had four sons, all hypospadians.
PRODUCTION OF SEX. The essential causes of the differences of sex
are not known. By Sadler and Hofacker the following conclusions
were drawn as to the influence of age : If the husband be younger than
the wife, there are as many boys as girls ; if both are of the same age,
there are 1029 boys to 1000 girls ; if the husband is older, 1057 boys
to 1000 girls. These laws are not to be accepted as conclusive. The
normal proportion between female and male births is 100 to 105 or 106.
But in the case of illegitimate births the proportion is reversed, at
least for the children first born ; that is to say, in such births females
are more numerous than males. The proportion of male children to
females is slightly greater in the country than in the city. The chances
of the young wife having at her first pregnancy a boy are at their maxi-
mum, while those of the matron near the close of her reproductive life
are at their minimum. Swedish statistics prove that in the nobility,
the age of the husband being greater than that of the wife, there are
only 98.3 male to 100 female births ; this reverses one of the rules
given by Sadler, according to which there ought to be a preponder-
ance of male births. Bertillou states that the influence of the ages
1 This is by some called infection of the mother. Dolfiris regards it as without positive proofs.
He also quotes Colin as saying : If the male can indeed, in fecundating the female, exercise an
action upon the eggs contained in the ovary, and which contribute to subsequent gestations, this
influence is very difficult to conceive. Nouveau Dictionnaire de M6decine et de Chirurgie
Pratiques, tome xxxiv.
Modification of the ova was the view of the illustrious Haller, while foetal inoculation of the
mother was upheld by the late Professor Alexander Harvey, of the University of Aberdeen, in his
little volume, Foetus in Utero, London, 1886.
2 Lancet, April 19, 1884.
116 PHYSIOLOGY OF PREGNANCY.
of the parents upon the proportion of the sexes, if it exists, may be
neutralized by the inherent qualities appertaining to the parents.
Kaltenbach calls attention to the fact established by Hecker-Ahlfeld,
that there is a great excess of male births in old primipane, this being
124-140 : 100. He also states that in young colonies too, in which the
number of females is, relatively to males, very small, so that not merely
very young females, but also quite old marry, the excess of male births
is very great.
Some have held that the sex was preformed in the ovule, and thus
there are male and female eggs. Still another opinion held by some
physiologists was that the greater vigor of one or the other, husband or
wife, at the time of fruitful coition determined the sex, each sex tending
to repeat itself. More recently the view that each sex tends to produce
the opposite has been received with some favor. Thus, according to
Janke, 1 if a boy be desired, the sexual sphere of the wife and her sexual
appetite must be strengthened to the utmost by generous, even luxurious
diet, while the husband lives more as a vegetarian ; a week after men-
struation is the most favorable time for coition. Those who will consult
Debay's work, 2 will find that Janke has been anticipated in his advice
as to means for securing the creation of a male.
Mantegazza, 3 quoting from a report to the Anthropological Society of
Berlin by Miklucho-Maclay, refers to hypospadias made for Malthusian
purpose among some of the Australian tribes ; thus, in one tribe there
were 300 mutilated, and only three or four left with the penis intact ;
to this small number the continuance of the tribe was left, and the
female births greatly exceeded the male.
RELATIVE INFLUENCE OF THE FATHER AND THE MOTHER UPON THE
OFFSPRING. This subject is one of great interest. Runge, Lehrbuch der Geburts-
hilfe, 1894, refers to the old and widespread belief, illustrated by many ex-
amples, that the degree and condition of the intelligence are inherited from the
mother, character and inclination from the father this position being maintained
by Schopenhauer. Goethe said : " From my father I inherit my frame and the
steady guidance of my life ; from my dear little mother, my happy disposition
and love of story-telling." Debay, in his work previously quoted, upholds this
thesis : Physical and moral qualities are transmitted from the father to the
daughter, from mother to son, and he adduces many illustrious examples as
proofs. Gal ton, Hereditary Genius, finds one distinguished man among 4000
ordinary men, and one illustrious man in a million. In studying the relation
between transmission by the male and by the female, that for statesmen, judges,
literary and scientific men is as 70 to 30. Among poets and artists, too, ma-
ternal influence was much less than paternal. On the other hand, among theo-
logians the female influence was represented by 73, that of the male being 27.
It is shown, in regard to this class, " that the influence of the female line has an un-
usually large effect in qualifying a man to become eminent in the world." Galton.
" It is seen," Mantegazza remarks in his Hygiene de I' Amour, " that Galton
overturns a very popular belief, according to which great men almost always
1 Centralbl. flir Gynakol., 1891.
2 Hygiene et Physiologic du Marriage : Debay suggests that in order a boy shall be produced the
wife must for twenty or twenty-five days before the impregnating coition live chiefly on nitro-
genous food. There does not seem a greater probability of the truth of this theory of determining
the creation of a male, than that of a recent writer as to the relation between nitrogen and evil :
we might almost say boys and badness come from nitrogen. The writer referred to makes the fol-
lowing statement : "Every good thought increases the proportion of oxygen, as a deep breath does,
and lessens that of nitrogen, making the body finer and more beautiful. Every evil thought or
impulse that is indulged increases the nitrogen, and has the reverse eflect on body and soul." The
Arena, June, 1894.
3 L' Amour dans 1'humanite.
CONCEPTION.
117
have mothers of superior intelligence, while the father rarely transmits his
genius to his son. Nevertheless I believe Galton is wrong, and that the common
belief is reasonable ; without collecting statistics, we know how great the amount
of talent transmitted by the uterine way."
The excess of male over female births is somewhat greater in Phila-
delphia than the average, which is, 100 females to 106 males. In five
years from 1868 to 1872, inclusive, the relation was 100 to a fraction
over 110. In one year, 1870, the relation was 100 to a fraction over
113. In the five years from 1888 to 1892, inclusive, this relation was
100 to a fraction over 109.
TIME OF YEAK MOST FAVORABLE TO CONCEPTION. The subjoined
table comprising the births in Philadelphia each mouth during two
periods, each of five years the first from 1868 to 1872 inclusive, and
the second 1888 to 1892, also inclusive shows the births in each
month, the months being readily divided into three periods, maximum,
mean, and minimum of births. There are also shown the months, simi-
larly divided, in which conception occurs in relative frequency ; the dif-
ference between March and July as conception months is very striking.
Month of birtl
December
August
July
i.
Mor
ith of conception. Number of births.
March 21,001
November 20,410
October 20,396
January 20.178
December 19,934
April 19,812
October
September
January
November
March .
February
June
May .
April .
February 19,288
June 18,745
May 18,407
September 18,402
August . . 17,555
July 16,886
The following is an abstract of statements made by Ploss 1 in regard to the in-
fluence of the seasons upon conception. The fact that there is an increase in the
number of conceptions at certain times of the year does not indicate that there
is a greater ability on the part of the female to conceive at these times, or any
change in the physiological condition of the female sexual organs. The influ-
ence of the seasons upon the male is also to be taken into consideration.
Villerme found that the maximum of conceptions in Europe occurs in May and
June, and he attributed it to the influence of spring. In order to justify this
opinion he extended his observations to those parts of the world where, while
the seasons follow in the same order, they occur at different times, e. g., Buenos
Ayres, and found the results the same. The times when marriages are most, and
those when they are least frequent, have no apparent influence upon the number
of conceptions according to the season of the year. On the other hand, the
periods of comparative rest, of hard labor, and scarcity of food have a marked
influence. The number of conceptions is lowered by the harvesting season,
scarcity of food, and by strict observance of religious fasts, as Lent. " Those
conditions which strengthen us increase our fertility, and those which weaken
or depress us, or especially such as undermine the health, lessen it, though fer-
tility is by no means governed by health alone."
Wappenhaus's conclusions from his studies of the birth-rate in Sardinia, Bel-
gium, the Netherlands, Saxony, Sweden, and Chili are as follows : The maximum
of conceptions occurs in May and June. The cause is the vivifying influence of
spring, aided by the habits and customs of the church in all Catholic countries.
There is a gradual decrease to the minimum, which is in September and October.
The cause is in the increased heat of summer, and in the epidemic diseases re-
sulting therefrom, aided by the hard work of harvest. In Sweden this maximum
is in January. The cause is found in social customs and in the religion. The
1 Op, cit.
118
PHYSIOLOGY OF PREGNANCY.
dissipations incident to the period of Carnival, and the strict observance of Lent,
lessen the maximum in Catholic countries.
In Italy the maximum differs in the north and in the south. In the latter it is
in April, but in the former in July.
Illegitimate conceptions are more under the influence of physical conditions,
e. g., the seasons, than are legitimate conceptions. In western Europe the greatest
number of illegitimate offspring are conceived in spring and summer, the fewest
in fall and winter; the difference is much less marked in the conceptions occurring
in the married.
In Russia the greatest number of conceptions occur in April and in January.
CHANGES IN THE FECUNDATED OVULE. The first of these changes
is segmentation, or cleavage, the sphere dividing into two spheres. The
process of division occurs in the nucleus first, and is followed by that
of the vitelline mass surrounding the two newly formed nuclei, so that
each new sphere has a part of the original nucleus. These spheres
again similarly divide, thus the two become four, which also divide and
eight are formed ; subdivision after subdivision occurs until the entire
vitelline mass has been converted iuto a number of minute spheres
which from their supposed resemblance to a mulberry have been called
the muriform body.
These spheres are unequal in size and fulfil different purposes in the
process of organization. The larger and more transparent are called
epiblastiv from ITTI, upon, and /Syaoror, germ ; the smaller hypoblastic,
from vn-b, under, and p-yaaTo?, germ. The segmentation, too, is not
simultaneous in the spheres after eight are formed, but begins in
the epiblastic spheres ; a cup-shaped cavity is formed by them in which
the hypoblastic spheres are placed, making a solid central mass.
OPTICAL SECTION OF A RABBIT'S OVUM AT Two STAGES CLOSELY FOLLOWING SEGMENTATION.
(After E. VAN BENEDEN.)
ep. Epiblast. hy. Primary hypoblast. bp. Van Beneden's blastopore.
It will be seen at the end of segmentation 1 that the epiblast cells are
somewhat the smaller, that they are clear, and irregularly cubical in
form ; the hypoblast cells, on the other hand, are polygonal in form and
granular and opaque in appearance. A, Fig. 65, shows an opening in
the epiblast covering of the hypoblast cells ; this opening is called the
i Balfour.
FORMATION OF DECIDUOUS MEMBRANES.
119
blastopore ; it, however, is soon closed, as represented in _B, Fig. 65, by
the growth of epiblast cells.
After the segmentation and arrangement of the cells the ovum
passes into the uterus ; this is supposed to occur within five or six days
after fecundation.
FORMATION OF THE DECIDUOUS MEMBRANES. Before tracing the
further development of the ovum it is advisable to refer to the changes
in the uterine mucous membrane incident to the beginning of pregnancy,
the fitting up of the interior of the house in which the new being is to
dwell during the many months of intra-uterine development.
It was formerly taught by John Hunter and others that the stimulus
of pregnancy produced an inflammatory exudate upon the uterine
mucous membrane, and thus a closed sac occupied the uterine cavity.
The fecundated ovule could only enter the uterus by pushing before it
that part of this new membrane which was in relation with the uterus
in the immediate vicinity of the oviduct through which it came, and the
mouth of which was covered ; the portion thus pushed away, therefore,
became a reflected membrane, and hence was called the membrana reftexa,
while that which remained adherent to the remaining portion of the
uterine mucous membrane was a true membrane, unchanged in its rela-
tions, and received the designation of membrana vera. Finally, the
surface to which the reftexa had been attached was left bare, but a new
exudate covered it, making a membrane which, because of its late forma-
tion, was called the membrana serotina. As these membranes were dis-
charged with the ovum at the end of pregnancy, they were called
deciduous or caducous.
FIG. 67.
DIAGRAM SHOWING HUNTER'S THEORY OF
THE DECIDUOUS MEMBRANES.
a. Decidua vera. 6. Decidua reflexa.
FIRST STAGE OF FORMATION OF DECIDUA.
Hunter's theory was accepted as explaining the fact that in abortion
the unbroken ovum showed a complete investment from the uterine
mucous membrane. While the theory has been rejected, the names of
the deciduous membranes are retained, and, therefore, an explanation of
the origin of these names was necessary.
The deciduous membranes originate as follows : The uterine mucous
membrane is swelled and thrown into folds ; the ovum is thus stopped
from descent after it enters the uterine cavity, and lodges in one of the
120
PHYSIOLOGY OF PREGNANCY.
intervals between these folds ; there is formed at its place of lodgment
a cup-shaped cavity, a condition which is represented in Fig. 67.
FIG. 68.
FORMATION OF DECIDUA COMPLETED.
b. Decidua vera. o. Decidua reflexa. c. Decidua serotina.
The mucous membrane upon which the ovum rests, the membrane
which in the Hunterian theory was the serotina, is now called from its
FIG. 69.
SECTION THROUGH THE MATERNAL, MEMBRANES IN THE SECOND MONTH OF PREGNANCY. X 20.
D.v. Decidua vera. D.s. Decidua serotina. R. Decidua reflexa. The ovum has been
removed from its point of fixation between R and D.s.
final purpose the placental decidua. The borders of the cup-like cavity
grow higher, extend toward a common centre, and finally meet and
unite over the ovum, forming a complete covering ; thus that which
FORMATION OF DECIDUOUS MEMBRANES.
121
was called the decidua reflexa, but now appropriately termed the decidua
of the ovule or ovular decidua, is formed.
The third deciduous membrane, decidua vera, covers all the internal
uterine surface, including that upon which the ovum rests ; it is neces-
sarily continuous with the other membranes ; it was formerly called, as
has been stated, the decidua vera, but from its relation to the uterine
wall it may be appropriately termed the uterine decidua.
Subsequent changes in the deciduse will be considered in connection
with the formation of the placenta and with the uterine changes caused
by pregnancy, and the history of the development of the ovum will be
now resumed. .. ...
THE BLASTODERMIC VESICLE. We have found' the segmentation
of the vitellus and the vitelline nucleus the first step in developmental
changes ; subsequent segmentations occurred, but these were unequal
and not simultaneous, and the products were two kinds of cells differ-
ing in number, in form, in size, in arrangement, and as to transparency.
The next step after the inclosure of the hypoblast by the epiblast cells
is the formation of the blastodermic vesicle.
PIG. 70.
bv. Cavity of the blastodermic vesicle, or yelk sac. ep. Epiblast. hy. Primitive hypoblast.
zp. Mucous envelope, zona pellucida. (After E. VAN BENEDEN.)
A fissure now appears between the epiblast and hypoblast cells, and
this increasing cavity separates the two at all points, except at that cor-
responding with the position which was occupied by the blastopore.
There results a vesicle whose wall, inclosed by the vitelline membrane,
is formed by epiblast cells with the hypoblast cells accumulated upon
a part of its interior surface, and this is called the blastodermic vesicle,
or the blastoderm. In the subjoined diagram of the rabbit's ovum,
between seventy and ninety hours after impregnation, it will be seen
that the vitelline membrane, membrana pellucida, is external, then
the flattened epiblast cells completely line it, while the hypoblast cells
are arranged in a lens-shaped mass within the epiblastic investment.
122 PHYSIOLOGY OF PREGNANCY.
The growth of the vesicle is very rapid, and the hypoblast losing its
lens-shape is flattened and extended upon the inner side of the epiblast.
" The central part, however, remains thicker, and is constituted of two
rows of cells, while the peripheral part, the outer boundary of which is
irregular, is formed of an imperfect layer of amoeboid cells, that con-
tinually spread further and further within the epiblast. The central
thickening of the hypoblast forms an opaque circular spot on the blasto-
derm, which constitutes the commencement of the embryonic area."
Next a third layer intervenes, the mesoblast, from /^ffof, middle, and
f&aorbCj germ ; the formation of the mesoblastic layer is not perfectly
understood, but probably it originates in part from each of the primi-
tive layers. From these layers, epiblast, hypoblast, and mesoblast, all
the parts of the foetus are formed. " In the higher vertebrates the fol-
lowing structures are always derived from the epiblast namely, epider-
mis, epithelium of mouth, nose, and of cloaca when present; the nerve
FIG. 71.
DIAGRAMMATIC VIEWS OF BLASTODERMIC VESICLE OF A RABBIT ON THE SEVENTH DAY.
In the left-hand figure the vesicle is seen from above ; in the right-hand figure from the side.
The white patch (ag) is the germinal area ; and the slight constriction (ge) marks the limit to
which the hypoblast has extended.
cells of the brain, spinal cord, and ganglia ; the neuroglia or support-
ing tissue of the nerve elements in the brain and spinal cord ; the retina
the lens of the eye; epithelium of the conjunctiva; the special sensory
' end organs ' of nerve fibres in ear, nose, mouth, and skin. From
the hypoblast are derived the epithelium of the digestive canal except
of the buccal cavity and cloaca ; " of the trachea, bronchial tubes, and
air-cells ; the cylindrical epithelium of the ducts of the liver, pancreas,
thyroid body, and other glands of the alimentary canal. The muscles,
bones, connective tissue, heart and bloodvessels, lymphatics, and the
urinary and generative organs are formed from the mesoblast.
The embryonic area, area germinativa, becomes oval ; it is composed
of epiblast, hypoblast, and mesoblast. Following the pyriform ap-
pearance of the embryonic area there is found at its posterior and nar-
rower end the primitive line or streak ; a little afterward the primitive
FORMATION OF DECIDUOUS MEMBRANES.
123
line is seen to mark the middle of a straight, shallow groove, called the
primitive groove. The next step is the formation of the axial or
medullary groove upon the upper part of the embryonic area ; upon
each side of the groove are folds, the medullary folds, " which meet in
front, but diverge behind, and enclose between them the foremost end
of the primitive streak ; the groove is converted into a closed tube, the
neural canal, which is the beginning of the central nervous system."
FIG. 72.
SHOWING THE EMBRYONIC AREA WITH PRIMITIVE STREAK AND PRIMITIVE GROOVE OF THE OVUM
(RABBIT) AT THE SEVENTH DAY.
ae. Embryonic area. gp. Primitive streak, or groove, av. Vascular area. gm. Medullary
groove. Ip. Primitive line.
THE EMBRYO. The embryo, from ipjjpvoq, that which grows in
another's body, at first presenting form, results from a folding inward
of a portion of the blastodermic vesicle, and presents somewhat the
shape of a boat ; the extremities, however, are unequal in size, the
larger is called the cephalic or head end, while the smaller is the caudal
or tail end. This infolding of the blastodermic vesicle destroys its
spherical form, and a constriction divides it into two parts, the smaller
of which is embryonic while the larger is called the yelk sac or the
umbilical vesicle ; an opening corresponding with the umbilicus offers
free communication between the two.
FORMATION OF THE AMNioN. 1 The development of the uterine
deciduous membranes which furnish the external investment of the
1 The term amnios was first employed by Empedocles to designate the innermost membrane
covering the young, and was also subsequently applied to the fluid contained in it. Preyer
believes that it was derived from a/uevo<;, thin, delicate ; but this became corrupted, changed into
amnios, and then a false criticism made it mean "the membrane of the sheep," " the water of
the sheep," as if derived from the word afivbf, a lamb.
124
PHYSIOLOGY OF PREGNANCY.
ovum has been given, and there will be now considered the origin of
the internal membrane of the embryonic sac.
At both the cephalic and the caudal end of the embryo the mesoblast
is divided into a splanchnic and a somatic layer ; then a fold composed
of the somatic mesoblast and epiblast begins to rise up from and grow
over these extremities, and also a fold from each side ; the cephalic fold
appears first. These double folds are the beginning of a membrane
called the amnion. The caudal, cephalic, and lateral folds finally meet
and unite, and thus form a complete sac. As is seen in Fig. 73, each
fold is double; the inner layers form what is called the true amnion,
and the outer the false. The false amnion with the epiblast from the
umbilical vesicle forms the subzonal membrane.
FIG. 73.
DIAGRAM OF THE FCETAL MEMBRANES OF A MAMMAL. (STRUCTURES WHICH EITHER ARE OR HAVE
BEEN AT AN EARLIER PERIOD OF DEVELOPMENT CONTINUOUS WITH EACH OTHER ARE REPRESENTED
BY THE SAME CHARACTER OF SHADING.)
pc. Zona with villi. sz. Subzonal membrane. E. Epiblast of embryo, am. Amnion. AC.
Amniotic cavity, it. Mesoblast of embryo. H. Hypoblast of embryo. UV. Umbilical vesicle.
al. Allantois. ALC. Allantoic cavity.
THE ALLANTOIS. As the embryo grows and the amnion is developed,
the umbilical vesicle lessens, but another vesicle is formed, the allantois
or allantoid, from d/Ud?, sausage, and e i6oe, likeness, because of its fancied
resemblance to a sausage.
Observers differ as to the origin of the allantoid. Some claim it is derived
from the terminal portion of the intestine, others from the Wolffian bodies, and
still others directly from the walls of the pelvic cavity by an expansion from
the mesoblast and hypoblast. Kolliker describes the allantoid in the embryo of
the rabbit as appearing under the form of a hollow body in relation with the
posterior intestine, lined by intestinal epithelium, and covered externally by a
prolongation of the nbro-intestinal layer, and thus formed makes a projection in
the free space between the amnion, the serous envelope, and the vitelline sac or
umbilical vesicle.
FCETAL APPENDAGES. 125
A part of the allantoid protrudes from the embryo, and a constric-
tion separates it from the intra-embryonic portion ; the latter becomes
in a later stage of development the urinary bladder, while the isthmus
connecting the two is the urachus, and at birth is a fibrous cord uniting
the summit of the bladder to the umbilicus. The extra-embryonic
portion is at first spherical, but projecting to the subzoual membrane,
it becomes flattened and spread out like an umbrella, lining the mem-
brane throughout nearly or quite all its extent. The external layer of
the allantoid is mesoblastic in its origin ; this layer fuses with the sub-
zonal membrane, and from the fusion the second of the investing mem-
branes of the foetus is formed. The allantoid, especially that part
contributing to the formation of the chorion, becomes very vascular;
the blood is brought to it by two arteries, called the allantoic, which
arise from the terminal bifurcation of the aorta, and returned by one,
or in some cases two veins, joining the vitelliue veins from the yelk
sac. The vessels of the allantoid penetrate into the chorial villi with
which they are in relation. The sac of the allantoid incloses a fluid
which is at first colorless, but afterward is yellow or amber-like ; it is
alkaline, and contains chloride of sodium, albumin, sugar, urea, aud its
derivatives, and a substance called allantoidine, which has in a high
degree the property of converting fats into an emulsion. The chief
use of the allantoid in development seems to be in conducting the
allantoic, afterward the umbilical, arteries to that part of the chorion
where the placenta is formed.
FCETAL APPENDAGES. These are the membranes forming the sac
inclosing the foetus, consisting of the decidua?, that of the ovum and of
the uterus the reftexa and the vera, according to John Hunter's
theory which become united so as to form a single structure, the cho-
rion and the amnion the placenta and the umbilical cord.
THE AMNION. This is the most internal of the membranes, and
forms a sac completely surrounding the foetus. Its origin has been
stated and its further development can be traced in connection with
Figs. 73, 74, and 75.
In Fig. 74 the cephalic and caudal folds are seen projecting over
the back of the embryo; the former fold, first in formation, is somewhat
larger than the other. These folds approach very near each other, and
the intervening space is so small that it is called the amniotic umbilicus.
Fig. 75 shows them united. It is also seen, as previously stated, that
each fold is composed of two layers, and thus the completed amnion has
two walls, one internal and the other external. The former is separated
throughout almost its entire extent from the foetus by a fluid called
the liquor amnii, but is continuous with it at the umbilicus ; this is the
permanent, or true, amnion. The external layer, or false amniou, is ap-
plied to the internal face of the vitelline membrane. The internal or
true amnion covers the foetal face of the placenta and also the umbilical
cord, furnishing a complete sheath to the latter. It is thin and trans-
parent, and is composed of two layers, the internal, which is epithelial,
and the external, which is fibrous. It is without nerves, but compara-
tively recent investigations seem to prove the presence of bloodvessels ;
these are called vasa propria. From the middle of pregnancy the
126
PHYSIOLOGY OF PREGNANCY.
amnion is applied directly to the chorion, and united to it by a gelatinous
layer of tissue, the tunica media of Bischoff ; it is also called the vitri-
form body of Velpeau ; it adheres more intimately to the amnion than
it does to the chorion.
FIG. 74.
Fro. 75.
-PP
e. Embryo, ec. Cephalic extremity, eq.
Caudal extremity, ca. Amniotic hood. pp.
Pleuro-peritoneal cavity, y. Umbilical vesicle.
COMPLETION OF THE AMNION.
u. Umbilical vesicle, p. Pedicle of the allan-
toid. a. Amniotic cavity.
LIQUOR AMNII. The amnial liquor, Fruchtwasser, is a faintly alka-
line, serous fluid, having a specific gravity of 1002-1028 (Schroder),
1002-1015 (Winckel). It is at first transparent, but later in pregnancy
becomes somewhat opaque from the presence of lanugo, epidermic scales,
and particles of the vernix caseosa. In the case of pregnant women
who work in tobacco factories it has sometimes been found greatly dis-
colored and having a very oifensive odor ; in other instances this fluid
may be dark green or brown from the presence of meconium, or it may
be reddish if the foetus has been dead some time and macerated.
According to Robin, it sometimes contains epithelial cells from the
kidney and bladder, and leucocytes. The solid ingredients are from
to 2 per cent. (Landois), 1 to 1.3 per cent. (Winckel). Among these
are the chlorides of sodium, potassium, and calcium, lime and magnesium
phosphates and sulphates, sodium and potassium sulphates, and sodium
lactate, creatin and creatinin, albumin and mucosin, and urea. Winckel
states that at first the quantity seems to be greater than the weight of
the embryo : Weight of ovum, first month, 0.8 gramme ; liquor amnii,
0.42 gramme. Weight of ovum, second month, 22.06 grammes ; liquor
amnii, 15.3 grammes.
About the middle of pregnancy the weight of the amnial liquor is
equal to that of the foatus, but from that time the weight of the latter
exceeds, though the quantity of the former still increases, according to
Gassner, until the end of pregnancy, then amounting to 1.87 kilo-
grammes, although Tarnier asserts that if the quantity exceeds a kilo-
gramme the condition is pathological. Preyer states that there is no
relation between the volume and size of the placenta and the quantity
of amnial liquor, nor is there between the latter and spirals of the cord ;
FCETAL APPENDAGES. 127
sheep, for example, have an abundance of the liquor, though in them
the cord is scarcely if at all twisted.
Questions as to the source of the urea and the significance of the
albumin in the amnial fluid will be considered in treating of the func-
tions and nutrition of the foetu?.
ORIGIN OF THE AMNIAL LIQUOR. It has beeu, and still is, claimed
by some that this fluid is exclusively a foetal product ; but the experi-
ments of Krukenberg first proved that an easily diffusible body readily
passed from the bloodvessels of the mother into the amnial liquid
without entering the foetal blood. It is generally held, as was stated
by Virchow in 1850, that in the normal state the mother as well as the
foetus takes part directly in the formation of this fluid. It has also been
shown that iodide of potassium introduced into the amnial fluid may be
eliminated through the mother; that in the case of the hatching egg ot
the bird there is an amnial fluid which must necessarily have its origin
solely from the embryo, no more proves that this is the exclusive source
in viviparous animals than the presence of this fluid in ectopic gestation
establishes a similar truth. The skin and kidneys of the foetus and
transudation of liquid from the foetal blood through the amnion con-
tribute to the fluid, but its chief source 1 is the maternal bloodvessels.
USES OF THE AMNIAL LIQUOR. During pregnancy the amnial
liquor preserves the foetus and the vessels of the cord and the placenta
from mechanical injuries, facilitates the movements of the foetus, and
permits them to occur with less inconvenience or suffering to the mother ;
gives space for the development of the foetus, prevents adhesions of
amnion and foetus, and promotes the equable enlargement of the uterus.
During labor it protects the foetus and cord from injurious pressure, and
furnishes before rupture of the membranes a hydrostatic dilator for the
os uteri, while after rupture the escaping fluid lubricates the genital
canal. Further, this liquid contributes to the nutrition of the foetus.
Preyer 2 states that in the foetus the tissues contain more water than the
blood, and it must, therefore, get water from some other source than
the blood, i. e., from the amnial fluid. The foetus swallows large quan-
tities of amnial fluid, which is absorbed by blood and chyle vessels from
the intestinal tract ; in the early stages of development much amnial
fluid enters through the skin of the embryo.
THE CHORION. From x6pt> * ne membrane that incloses the foetus
in the womb. This membrane is external to the amnion, internal to
the decidua. At the beginning of intra-uterine life the external cover-
ing of the ovum, the membrana pellucida, or vitelline membrane, is
transparent and smooth ; but in the second week its surface presents
numerous projections, called villi, which are at first solid, and this is
known as the primitive chorion. The permanent chorion is formed by
the junction of the allantoid and subzonal membranes, followed about
the fourth week by bloodvessels which begin to penetrate into the chorial
1 This is the statement of Winckel, of Veit, and many others. Bar, however, whose thesis,
Etude clinique du liquide amniotique de la femme, is quoted by Ribemont-Dessaignes and Lepage
(Precis d'Obstetrique, 1893), gives only the foatal origin. A. Martin (Lehrbuch der Geburtshiilfe)
says " the origin of the amnial liquor is yet in dispute ; we do not know whether it is a product
of "the foetus, its skin, or its kidneys, or a transudate from the mother's blood."
2 Specielle Physiologic des Embryo.
128
PHYSIOLOGY OF PREGNANCY.
villi, and these now hollowed out become sheaths for the vessels ; an
artery enters each villus and supplies vessels to all its branches or bud-
like offshoots ; capillaries connect with veins, and the latter unite in a
single trunk which returns the blood to the umbilical veins.
FIG. 76.
FIG. 77.
COMPOUND VILLUS OF CHORION FROM A
THREE MONTHS' FCETUS. (Magnified
30 diameters.)
HUMAN EMBRYO AT THE THIRD WEEK,
SHOWING VILLI COVERING THE ENTIRE
CHORION. (HAECKEL.) .
At first all the chorial villi, thus made vascular, hypertrophy, but
this lasts only until the third month, when those villi in relation with
the decidua of the ovum, the decidua reflexa, atrophy, while those con-
nected with the serotine decidua, or the placental decidua, become larger
and more branched ; the portion of the chorion to which the former
belong is sometimes spoken of as the chorion leve or the smooth chorion,
while the latter is called the chorion frondosum or leafy chorion. The
chorion is thicker than the amnion, but is weaker ; it is composed of
two layers, one chiefly of connective tissue becoming fibrous in char-
acter at the end of pregnancy, and the other of pavement-epithelium.
(See Plate I.)
Doubtless the chorial villi even before they become vascular are con-
cerned in the nutrition of the embryo, but the chief use of the chorion
is in the formation of the placenta.
In the accompanying plate, exhibiting the evolution of the placenta
and of the umbilical cord, the atrophy of the larger number of the
chorial villi, and the hypertrophy of others, those which contribute to
the formation of the placenta, are well shown.
THE PLACENTA. This is also called the afterbirth. The name pla-
centa, from irZaxovs, a flat cake, was first used to designate this organ as
found in the human female, by Realdus Colombos. In many of the
inferior animals its form is very different from that signified by this name.
The placenta in woman is a fleshy, flattened mass, usually oval, but some-
times round or reniform. Its diameter is six to eight inches, fifteen to
PLATE I.
EVOLUTION OF THE PLACENTA AND OF THE UMBILICAL CORD. (From SAPPEY.)
1,1. Embryo.
2, 2, 2. Amnion.
3, 3, 3. Cavity of Amnion
i
4, 4. Digestive Canal.
5, 5 Pedicle of the Umbilical Vesicle.
6, Umbilical Vesicle.
7, 7. Allantoid Vesicle.
8, Pedicle of the Allantois.
9, 9, 9. Chorial Villi beginning to atrophy.
10, 10. Villi in relation with the utero-placental decidua, which hypertrophy.
[To face page 128.
F(E TA L A P PEN DA GES.
129
twenty centimetres; it is thickest at the insertion of the cord, varying
from a little more than one-third to more than an inch, one to three
centimetres, and thinnest at the margin, where its thickness is about
one-fifth of an inch, five or six millimetres; it weighs at the end of
pregnancy about eighteen ounces, or five hundred grammes. Never-
theless there is great variation in the weight of the placenta; it may be
only one-half that given, or may be twice as much ; usually the weight
is in direct proportion to that of the child.
FIG. 78.
FCETAL SURFACE OF THE PLACENTA.
The statement last made, as it has appeared in previous editions, having been
disputed, in one of my visits to Munich I suggested to Dr. J. H. Smith, then
acting as resident obstetrician in the Frauenklinik, that he should, with such
ample material there available, make a new study of the question. He did so,
and from the history of 500 cases of labor prepared an elaborate paper which
appeared in the Journal of Gfynecology, 1891, Toledo. The following are the
most important conclusions in which we are now interested : The proportion in
weight between the placenta and the child is in the thirty-third, and thirty-fourth
week 1:3; in the thirty-fifth, thirty-sixth, and thirty-seventh, 1:4; thirty-eighth
and thirty-ninth, 1 : 5. From the end of the thirty-ninth week until birth,
whether it takes place in the fortieth week, or delays until the forty- fourth week,
the ratio is 1 : 5. Dr. Smith also stated, as a result of his investigations, the pla-
centa seems to grow in delayed labor in multiparae or with large children, and
then the average rises from 1 : 5 to 1 : 4.
Winckel states 1 that there is a close relation between the weight of the pla-
centa and that of the child, the proportion being 1 : 5.5. Yet in the case of a
small and diseased foetus the placenta may be very large and heavy.
It presents two faces or surfaces, one internal or fetal, and the other
external or maternal. The external, or uterine, surface of the placenta
is dark red, somewhat convex, rough and uneven. It presents irregular
1 Lehrbuch der Geburtshulfe, second edition, 1893.
9
130
PHYSIOLOGY OF PREGNANCY
fissures, incompletely dividing the organ into lobes ; these fissures are
partially bridged over and lined by a whitish membrane, the remains
of the placental or serotine decidua. The internal, or foetal, surface of
the placenta is smooth, slightly concave, and covered by the combined
chorion and amnion, which thus form its superficial layer ; the attach-
ment of the cord and the larger divisions of its placeutal vessels are
plainly seen. A large vein, called the circular or marginal sinus, is
found at the border of the placenta. In some cases the placenta, instead
of being a single mass, is composed of two parts, and is designated as
placenta duplex ; if composed of three parts, placenta tripartita, and if
of many separated lobes, placenta multiloba ; if in addition to the usual
placental mass there should be one or more distinct and separate lobes,
such additional placentae are called subsidary placentae, or placentce sue-
eenturiatce.
FIG. 79.
MATERNAL SURFACE OF THE PLACENTA.
SITUATION OF THE PLACENTA. The placenta is generally in the
upper part of the uterus, upon the posterior or upon the anterior wall,
in the vicinity of the opening of one of the oviducts.
J. Veit, Muller's Hamlbuch der Geburtshulfe, first volume, makes the following
statement : Gusserow in 188 cases found in 77 the placenta at the anterior Avail,
in 93 at the posterior wall ; 12 at the right, and 6 at the left; Bidder, 139 women,
73 on the posterior wall, 53 anterior, and in 8 at the fundus ; while Schrader gives
the situation of the placenta 37 times in front, 18 times behind, 1 directly right,
8 right and in front, 7 right and behind, and 2 left and in front.
FCETAL APPENDAGES.
131
Attachment directly to the fundus once regarded as frequent, if not
the rule is as rare as is that to the lower part of the uterus. 1 But, as
remarked by Levret, " there is not a single part of the interior of the
womb where the placenta may not take root." When the attachment
is in the lower uterine segment the placenta is called prtevia. After
the delivery of the placenta the obstetrican can, by noticing the place of
rupture of the membranes, judge, approximately at least, the place
which the organ occupied in the womb.
FIG. 80.
SECTION OF A PORTION OF A FULLY FORMED PLACENTA, WITH THE PART OF THE UTERUS
TO WHICH IT IS ATTACHED.
a. Umbilical cord. 6, b. Section of uterus, showing the venous sinuses, o, o. Branches of
the umbilical vessels, d, d. Curling arteries of the uterus.
It is not until in the third month of pregnancy that the placenta
begins to be distinct, and it is not until the end of the month that its
formation is completed. Part of this organ is of maternal and part of
foetal origin, but these parts become so intimately united that they can
only be separated in an early stage of its development. The placenta
increases in weight until about the seventh month, when a regressive
metamorphosis begins. The large villi of the chorion frondosum pene-
trate into the tissue of the decidua of the serotina ; they do not enter
the uterine glands, but into crypts formed by the hypertrophied uterine
mucous membrane ; the villi, at first comparatively simple in form, not
only greatly increase in size, but in number ; they become complex,
presenting many branches and offshoots. Goodsir has compared a
placental tuft to a tree, consisting of a trunk with its primary and
secondary branches. Meantime the villi of the chorion not in relation
i Carmichael (Dublin Journal of Medical Science, 1839) having concluded, from his own ex-
aminations, that the usual site of the placenta was the lower part of the posterior uterine wall,
caused so much controversy by the statement that he pleasantly remarked if he had anticipated
such a result he would have left the placenta at the fundus.
132
PHYSIOLOGY OF PREGNANCY.
with the membrana serotina atrophy, and thus the chorion leve results.
The villi of the chorion froudosuin are formed of connective tissue, and
also, as stated by Goodsir and confirmed by subsequent observers, re-
ceive an epithelial covering from the hypertrophied serotiue membrane.
Each villus then is composed of connective tissue, of an epithelial cover-
ing, and of an artery and vein and connecting capillaries ; this arrange-
ment of the bloodvessels secures a closed vascular system. The placenta
is composed of the hypertrophied villi of the-chorion and of the serotine
decidua, which grow into each other, mutually inter-penetrating, so that
a single mass is formed.
After the interlocking of the chorial villi with the serotine membrane
blood-spaces or sinuses are found in the maternal portion of the placenta.
This results, according to some, from great dilatation of the maternal
capillaries, but according to others from disappearance of the walls of
the capillaries, caused by the pressure of the growing chorial villi. Into
these spaces, 1 these blood-lakes, maternal arteries 2 enter, and from them
veins issue. The terminal villi of the chorion float freely in the blood-
sinuses, and thus the maternal is brought into such close relation with
the fetal blood that interchange of gases and nutritive materials can
readily occur.
FIG. 81.
VERTICAL SECTION OF PLACENTA, SHOWING RELATIONS OF MATERNAL AND FCETAL BLOODVESSELS.
a, a. Chorion 6, 6. Decidua. c, c, c, c. Orifices of uterine sinuses.
USES OF THE PLACENTA. The placenta is the organ of nutrition
and of respiration for the foetus. It was once held that there was a
direct communication between the bloodvessels of the mother and the
foetus through the placenta, and thus the nutrition of the foetus was
1 Braxton Hicks (London Obstetrical Society's Transactions, vol. xiv.) denies the existence of
placental sinuses, stating that from dissections early and late in pregnancy there is no evidence
of a sinus system.
2 Delore (Annales de Gynecologic, 1874) contends that the entrance of maternal blood into the
placenta is chiefly by the placental coronary, or circular sinus, which was first described by
Meckel, and which sometimes has a diameter as large as the little finger.
FCETAL APPENDAGES. 133
explained. This view is disproved by the following facts : The maternal
and the foetal circulation are not isochronous ; prior to the extension of
the allantoid vessels to the periphery of the ovum the embryo had a
circulation ; if the foetus die in labor when the mother perishes from
hemorrhage, it dies from asphyxia, not from anemia. If the placenta
be delivered with the foetus, the circulation may continue several min-
utes, and there is no discharge of blood from the uterine surface of the
placenta ; if hemorrhage from the umbilical cord occur during labor, it
does not affect the mother ; the foetal blood differs from the maternal
blood in the form of the globules and in its composition. It is gen-
erally held that the interchange of gases and of nutritive elements
between the maternal and the foetal blood depends upon osmosis. 1 Ac-
cording to Marchal, the endosmotic processes by which nutritive juices
pass from the mother to the foetus are facilitated by the greater blood-
pressure in the vessels of the former than iu those of the latter. Ex-
periments show that substances in solution may pass from the maternal
to the foetal blood. Among such substances are potassic iodide, salicylic
acid, chloroform, chlorides, and turpentine. Many years ago Magendie
detected the odor of camphor in the blood of the foetus fifteen minutes
after a solution of this substance had been injected into the maternal
blood. Recent experiments, among others those of Dr. Pyle, 2 prove
that some undissolved substances and bacteria may thus pass from the
mother to the foetus. Several other observers, both before and since Dr.
Pyle's experiments, have arrived at the same results. The passage of
microbes through the placenta to the foetus is not a constant fact, and
when it occurs the explanation given is that these microbes have first
produced placental lesions permitting their migration.
That the placenta is the organ of respiration for the foetus is shown by
the fact that the blood going to the placenta is dark, and that returning
from it light; and that the only substitute for placental is pulmonary
respiration. If the umbilical circulation be arrested, the foetus dies, and
an autopsy proves the death was from asphyxia. In the placenta the
foetus exchanges carbonic acid for oxygen, just as a fish through its gills
receives oxygen from the water in which it swims. Bernard has shown
that the placenta has a glycogenic function in the earlier months of
1 Ercolani taught that the foetal portion of the placenta is vascular, or absorbent, and the
maternal is glandular, or secretory. According to his theory, the uterine juices, OP milk, secreted
by the epithelium of the latter, are absorbed in the chorial vllli, as chyle is absorbed by the intes-
tinal villi. Balfour has given a qualified and partial support to this view, saying : " The walls of
the crypts into which the villi are fitted also become highly vascular, and a nutritive fluid passes
from the maternal vessels of the placenta to the foetal vessels by a process of diffusion ; while
there is probably also a secretion by the epithelial lining of the walls of the crypts, which becomes
absorbed by the vessels of the foetal villi." Goodsir stated that the function of the placenta is not
only that of a lung, but also of an intestinal tube, and that the internal cells of the villi absorb the
matter secreted by the external cells. Kormann (Lehrbuch der Geburtshiilfe, 1884) states that the
nutritive material which the foetus finds prepared in the placenta is the so-called uterine milk.
According to Hoffman (Berlin. Zeitschr. f. Geb. und Gyn., 1882), the purpose of the decidua in man
as well as in animals is to furnish the necessary nourishment of the young. The decidua is a milk-
secreting organ ; this milk, which is secreted into the spaces which are gradually formed, and in
which the placental villi are placed, here is mixed with the simultaneously extravasated blood of
the mother, and thus the foetal nourishment is formed which is absorbed by the placental villi.
Landois (Manual of Human Physiology) states : "Between the villi of the placenta there is a clear
fluid which contains numerous small albuminous globules, and this fluid, which is abundant in
the cow, is spoken of as the uterine milk. It seems to be formed by the breaking up of the decidual
cells. It has been supposed to be nutritive in function." Stirling adds, that the maternal placenta,
therefore, seems to be a secretorv structure, while the foetal part has an absorbing function. The
uterine milk has been analyzed by Gamgee, who found that it contained fatty, albuminous, and
saline constituents, while sugar and casein were absent.
2 Philadelphia Medical Times, June and July, 1884.
134
PHYSIOLOGY OF PREGNANCY.
foetal life, prior to the formation of the liver. Foster suggests that the
placental glycogeu is of use, not for the fcetus, but for the nutrition and
growth of the placental structures.
THE UMBILICAL CORD. The funis umbilicatus, or umbilical cord,
receives its name from its twisted character. It is a cord, essentially
composed of bloodvessels, connecting the fcetus and the placenta. The
pedicle of the allantoid, originally a constricted portion connecting the
two portions of the allautoid, one within the embryo, the other external
to it, is the beginning of the umbilical cord. At first, this pedicle or
stalk had two veins as well as two arteries ; one of the veins, however,
atrophies, so that the cord has one vein and two arteries. Hyrtl found
in 6 per cent, of cases only one umbilical artery.
FIG. 82.
A. Umbilical arteries forming spirals (1, 1') around the vein ; constrictions indicating the
presence of folds (5, 5') ; lateral openings showing the arterial walls. B. Vein opened upon the
side, showing a constriction (2) corresponding to an interior valve (3") ; semilunar valves (3, 3', 3").
C. Section of vein and arteries, showing valve of vein (1), a semilunar arterial valve (2), and a
circular arterial valve (3). (TAENIER ET CHANTREUIL.)
The formation of the cord begins at the end of the fourth week. At
the middle of pregnancy its length is 5 to 8 inches, 13 to 21 centimetres,
and its thickness about one-third of an inch ; at the end of pregnancy
its average length is about 20 inches, 50 centimetres, and its usual
thickness that of a man's little finger. But the thickness may be much
greater, equalling that of the thumb, or even exceeding it ; if thus in-
creased in size, it is commonly called a u fat cord," while if its diameter
is notably lessened, it is called a " lean cord." The length of the cord
may be reduced to two inches, or increased to five or six times the
average previously given. Its surface is smooth and shining from its
amniotic investment; it presents a twisted or spiral aspect ; the number
of spirals varies ; in one case Meckel saw ninety-five : the largest number
of torsions, however, occurred in a case observed by Schauta, 380. The
spirals in the majority of cases turn to the left, and thus Auvard, 1 com-
1 Op. cit.
FCETAL APPENDAGES.
135
bluing the results obtained by Neugabauer, Hecker, aud Tarnier with his
own, found that there was sinistrotorsion in 533, dextrotorsion in 190, tor-
sion in opposite directions in 4, aud entire absence of torsion in 17, the total
number being 744. The movements of the foetus which produce torsion
of the cord begin very early, for when the embryo was only one inch
long the cord was somewhat twisted ; according to Preyer, torsion of
the cord uniformly commences in the eighth week. In most instances
the vein is central, aud the arteries turn round it ; but in others, all
three of the vessels are parallel, aud turn round a fictitious axis. Why
the torsions begin and are more numerous in the vicinity of the umbilicus
must be obvious to anyone who watches twisting two threads by the
finger and thumb at one end, the other being fixed. The torsions of
the cord are caused by foetal movements, and of course must first appear
nearest the moving body.
FIG. 83.
TWISTED CORD. (From SCHAUTA.)
The amuial sheath not only incloses the vein and arteries, but also a
greater or less quantity of a gelatinous substance called Wharton's jelly.
An unusual quantity of this material causes the cord to be very thick,
and when it is tied after birth there is great liability to subsequent
hemorrhage unless the tying be done very carefully so that complete
constriction of the bloodvessels is secured. Wharton's jelly is a gelat-
inous-like connective tissue, consisting of branched corpuscles, lymphoid
cells, some connective-tissue fibres, and elastic fibres. Accumulations
of the jelly at particular parts of the cord, making decided prominences,
cause what have been called false knots. But the absence of the jelly
at a part of the cord does not prove that any of the vessels are imper-
vious, or even that their capacity is lessened. 1 The vein has a thinner
1 The illustration, Fig. 84, represents the appearance of the ftetal end of the umbilical cord in a
large, seven months' stillborn foetus. The foetus was brought to me as showing intra-uterine death
136 PHYSIOLOGY OF PREGNANCY.
> wall than the arteries ; the diameter of its canal is greater than that of
either artery, and increases as the vessel approaches the foetus ; from the
inner surface of the vein crescent-shaped folds project, occluding two-
thirds of the canal. The arteries widen in the course of the cord from
the foetus to the placenta, and have projecting broad folds. The vessels
have well-developed muscular walls, and hence are very contractile.
FIG. 84.
APPARENT CONSTRICTION OP BLOODVESSELS OP CORD, FROM ABSENCE OP WHARTON'S JELLY.
According to Kleinwachter, the cord has lymphatics, and Ruyl claims
that he discovered nutritive capillaries in it. Winckel remarks that
Valentine, Schott, and Kolliker described nerves and lymphatics in the
cord, but these were not found by Virchow.
The strength of the umbilical cord varies, and in some cases very
slight traction causes its rupture. Duncan and Turnbull have from
experiments 1 concluded that the average weight required to break the
cord is eight and one-quarter pounds ; the weakest is torn by five and
one-half pounds, and the strongest fifteen pounds. Pfannkuch has
shown that a varicose cord has little more than half the strength of one
with its vessels normal.
True knots are sometimes found in the cord. They have been
attributed to the violent movements of the foetus, favored by excess of
liquor amnii, and to similar movements of the mother ; it is altogether
exceptional for knots, however numerous, to interrupt the circulation.
*
from obstruction of the umbilical vessels ; injections, however, proved that they were not only
pervious, but of normal calibre. Dr. James Young (Transactions of the Edinburgh Obstetrical
Society, Edinburgh, 1870) has reported a similar case, a dead fcetus at seven months being expelled ;
the umbilical cord was " greatly constricted near the abdomen ;" but the just test of constriction
involving the bloodvessels was not made.
1 London Obstetrical Society's Transactions, vol. xxiii.
FCETAL APPENDAGES. 137
The attachment of the cord to the placenta is usually at some point
between the centre and the margin ; the central insertion, though by
some authorities claimed to be the rule, Naegele correctly stated is rela-
tively rare ; Levret made a similar statement. In some cases the cord
is attached to the margin of the placenta, insertio marginalia, and the
placenta is called battledore placenta; in one variety of marginal inser-
tion the cord is attached first to the membranes and the vessels subdi-
FIG. 85.
VELAMENTOUS INSERTION OF THE CORD.
vide before entering the substance of the placenta/ insertio velamentosa
(see Fig. 85). Velamentous insertion occurs in nearly one per cent, of
cases. Auvard states that the insertion may be twenty centimetres
from the placental margin'. In some cases the vessels divide into
branches before reaching the placenta, but in others they continue
undivided to it. The dangers from this anomaly in labor are pressure
upon the vessels, causing asphyxia of the child, or rupture when the
membranes rupture, causing hemorrhage.
The insertion of the cord, 2 observed by Cre'de in 443 cases, was in
109 central, in 164 excentric, in 152 near the margin of the placenta, in
8 at the margin, and in 10 velamentous.
1 Lugol, Journ. de Med. du Bordeaux, June, 1889, has reported a case of single pregnancy, the
insertion of the cord relamentous, the placenta being double the two parts, which were nearly
equal, were three to four centimetres apart.
* Lehrbuch der Geburtshitlfe.
CHAPTER Y.
THE EMBRYO AND FCETUS DEVELOPMENT ANATOMY AND PHYSI-
OLOGY OF THE FCETUS PLURAL PREGNANCY.
THE term foetus, a Latin word for the young of mammiferae while in
the womb, is very commonly used as a synonym for embryo, the etymo-
logical signification of which has been stated. By many, however, the
product of conception in the human female is called an embryo up to
three months, and after that it is known as a fetus. This distinction
between the two words is plainly arbitrary, and as far as the term
embryo is concerned, is disregarded in such words as embryotomy and
embryulcia. Nevertheless, as the history of the first three months
differs very materially from that of the subsequent six of intra-uterine
life, since by the end of three months the placenta is formed, and the
new being has assumed the human form, and subsequent changes are of
growth and development rather than of the beginning of organs
belonging to the organism and essential for its existence or for its
perpetuation, it is well to retain the arbitrary distinction between the
words embryo aud foetus.
Naegele said that the obstetrician was more concerned with expe-
dition than with fabrication that is, with labor rather than with
embryology ; nevertheless, some study should be given to the latter.
While, of course, embryology belongs to physiology, and is there fully
presented, yet a general knowledge of the evolution of the new being
from the fecundated ovule, "the dim speck of entity," belongs to
obstetrics. Such knowledge is practically useful in that it enables the
obstetrician to recognize how far development has progressed in a case
of miscarriage ; in some cases to ascertain the cause of miscarriage,
whether the miscarriage be embryonic or foetal, and also to explain the
occurrence of certain deformities or so-called malformations, which are
in most cases arrests of formation, failures of development. This knowl-
edge, too, is of value in studying the physiology of the foetus. In the
following summary sketch of embryonic and foetal development no
attempt will be made to include all details and make a complete picture,
but chiefly to present practical matters of interest and importance to
the obstetrician.
FIRST MONTH. Recalling the statement made on page 121, as to
the formation of the blastodermic vesicle, its separation into two por-
tions, one embryonic, the other non-embryonic, and the appearance in
the former of the medullary groove, with a fold or plate on each side,
lamince dorsales, the two subsequently uniting, so that the groove is
converted into a cylindrical canal the medullary canal it is S-en that
in the very beginning of organization the nervous system is placed first.
The heart, at first a tubular cavity, is seen by the end of the second
THE EMBRYO AND FCETUS. 139
week, 1 when the embryo is only one-eighteenth of an inch, two milli-
metres, long ; by the middle of the third week it has taken an S form ;
and at the end of the fourth the different cavities are present and the
pericardium is formed. According to Preyer, 2 it cannot be doubted
that the heart commences to beat by the beginning of the third week.
The visceral clefts, four in number, and arches are apparent by the
twentieth day ; the former are fissures found on each side of the cervical
region, while the arches are thickenings of the lateral walls between the
clefts.
FIG. 86.
an
SCHEME OF A HUMAN EMBRYO WITH THE VISCERAL ARCHES STILL PERSISTENT.
A. Amnion. V. Fore-brain. M. Mid-brain. H. Hind-brain. N. After-brain. U. Primitive
vertebrae, a. Eye. p. Nasal pits. S. Frontal process, y. Internal nasal process, n. External
nasal process, r. Superior maxillary process of the first visceral arch. 1, 2, 3, and 4. The four
visceral arches, with the visceral clefts between them. o. Auditory vesicle, h. Heart, with e,
primitive aorta, which divides into five aortic branches. /. Descending aorta, om. Omphalo-
mesenteric artery, b. The omphalo-mesenteric arteries on the umbilical vesicle, c. Omphalo-
mesenteric vein. L. Liver with arriving and departing veins. D. Intestine, i. Inferior cava
T. Coccyx, all. Allantois, with Z, one umbilical artery ; and x, an umbilical vein. B. Umbilical
vesicle.
The extremities appear at the sides of the body as short uujointed
stumps or projections in the third or fourth week. At the end of the
fourth week the vertebral bodies and the nerve centres are quite distinct,
the thorax and abdomen make a single cavity, the diaphragm not yet
having been formed, and the heart is in the upper part of this cavity.
The ovum is about the size of a pigeon's egg. The embryo is a grayish
curved mass, the cephalic end is much larger than the caudal, and so
great is the curvature that the two approach ; the length of the embryo
1 Aristotle stated that the heart could sometimes be seen in the bird's egg as early as the third
day, no bigger than a point ; it is compared to a bloody spot, and its beating is mentioned ; from
bis description the punctum saliens of later writers is derived. The heart is the first of organs not
in formation, but in function, and in this sense is indeed primum vivens, though not in all cases
ultimum moriens. Modern observers know that the heart in the chick is at the end of the first day
" a small, bright-red, contracting point." Its development in mammals is much later.
2 Op. cit.
140 PHYSIOLOGY OF PREGNANCY.
is about half an inch, or thirteen millimetres. The primitive intestine
is a straight tube, proceeding from the head to the tail, and closed at
each end. It was at first a gutter, and had free communication with
the vitelline sac ; but the gutter is covered over, and is converted into a
cylindrical canal, and the vitelline duct, inserted at that point which at
a later period corresponds to the lower part of the ileum, is obliterated.
In some cases the duct remains pervious a short distance from the
intestine, 1 making a blind tube, the so-called "true intestinal diverticu-
lum ;" in very rare cases the duct may remain open to the umbilicus,
forming a congenital fistula of the ileum, or it may give rise to cystic
formations.
FORMATION OF ALIMENTARY CANAL.
a b. Commencement of amnion. c c. Intestine. /. Allantols. g. Umbilical vesicle, e. Dotted
line showing the place of the formation of the oesophagus.
Kolliker divides the primitive intestine into three segments the
buccal, middle, and terminal. From the buccal, or initial, segment all
the buccal cavity as far as the glosso-palatine arches is derived ; the
terminal portion furnishes the lower portion of the cloaca ; while all the
rest of the intestinal canal and a notable part of the uro-genital system
are derived from the middle segment. About the fourth week a depres-
sion upon the external tegument occurs at a point corresponding with
the lower end of the terminal segment, with absorption of intervening
tissue, and the anus is formed. A similar depression of the tegument
occurs at a point corresponding with the position to be occupied by the
mouth, and an opening is made which communicates with the buccal
portion of the intestine ; the mouth at first represents the space com-
prised between the first visceral arch and the most anterior part of the
base of the cranium.
SECOND MONTH. During this month the visceral clefts completely
close except the first, which becomes the external auditory meatus, the
cavity of the tympanum, and the Eustachian tube. " Should any of
the other clefts remain open, a condition that is sometimes hereditary
in some families, a cervical fistula results, and it may be formed either
1 Landois.
THE EMBRYO AND FCETUS. 141
from without or within. Branchiogenic tumors and cysts depend upon
the branchial arches, according to Volkmaun.
The first visceral or branchial arch divides into two branches called
the superior and the inferior maxillary processes ; the two inferior maxil-
lary processes, one from each side, grow toward each other, meet, and
unite, making the lower margin of the mouth. So, too, the superior
maxillary processes grow toward each other, but there intervenes the
frontal process (S, Fig. 86), which unites with each of the others, and
thus the upper boundary of the mouth is made, and the oral separated
from the nasal opening. The separation between the nose and mouth
within is made by the superior maxillary processes; from these the
upper jaw, the nasal, and the intermaxillary process are produced; at
the ninth week the hard palate is closed; upon it rests the septum of
the nose, descending vertically from the frontal process. Different
varieties of harelip result from arrest of descent of the frontal process,
or from its failure to unite upon one or upon both sides with the supe-
rior maxillary processes.
It not unseldom happens, that if an infant be born with harelip, the
mother attributes the deformity to her having seen while she was preg-
nant some one, adult or child, similarly affected. But if she saw such
an object subsequent to the second month of pregnancy, it is impossible
that the foetus could have been affected through her mind, for the de-
formity already existed.
Cleft palate arises from the failure of those portions of the superior
maxillary processes concerned in the formation of the roof of the mouth
to meet and unite. As is seen, the formation of the face chiefly results
from the development of the first or maxillary arches. The second
arch, hyoid, gives rise to the stapes, the pyramidal eminences, with the
stapedius muscle, the styloid process of the temporal bone, the stylo-
hyoid ligament, the smaller cornu of the hyoid bone, and the glosso-
palatine arch. The third arch, thyro-hyoid, forms the greater cornu and
body of the hyoid bone and the pharyngo-palatine arch. The fourth
arch gives rise to the thyroid cartilage.
In the second month the eyes appear first as two black points, one
on each side of the head ; the eyelids are not seen until the latter part
of the month or the beginning of the next. The external ear appears
as a slight projection at the seventh week. From development of
the viscera the body becomes less curved. The Wolffian bodies are
notably lessened in size, but meantime the kidneys and supra-renal
capsules are formed. The fingers and toes appear, but they are webbed.
The formation of the external sexual organs begins, as previously stated,
in the sixth week, but they present the same appearance in each sex ;
the testicles or the ovaries appear about the seventh week. At the end
of the second month the ovum is about the size of a hen's egg ; the
embryo measures from one inch to one inch and a half, twenty-five and
a half to thirty-seven millimetres, in length, and weighs about one
drachm, four grammes ; the umbilical cord measures a little more than
one inch, twenty-five and a half millimetres.
THIRD MONTH. The fingers and toes have lost their webbed char-
acter, and the nails begin to be developed, appearing as fine membranes.
1 42 PHYSIOLOG Y OF PREGNANCY.
The eyes are nearer, the ear well formed, the walls of the body are
thicker and lose their transparency. The sex can be distinguished by
the absence or presence of the uterus and vagina ; the umbilical cord,
inserted a little above the pubes, reaches a length of 2.7 inches, seven
centimetres, and begins to take a spiral form. In the twelfth week
the ovum is the size of a goose's egg, the embryo is from 2.7 to 3.5
inches, seven to nine centimetres long, and weighs five drachms, twenty
grammes.
At about three months points of ossification are found in all parts of
the vertebral column. Ossific formation begins in the cervical" vertebrae,
then in the dorsal, finally in the lumbar, and in all the vertebrae it
begins in the bodies before it does in the arches. Hence, spina bifida,
which is a hernia of the spinal membranes through a cleft in their bony
canal, is rarely anterior, and it is much more frequently lumbar than
dorsal or cervical.
FOURTH MONTH. The fetus is between six and seven inches, seven-
teen centimetres, long, and weighs nearly four ounces, three ounces and
three-quarters, one hundred and twenty grammes; the umbilicus is
above the lowest fourth of the linea alba, and the cord is seven and
one-half inches, nineteen centimetres, long. The development of the
female external sexual organs has been given on page 80 ; that of the
male is the same up to a certain stage, but in the first half of the fourth
month, in the male, the genital fissure closes, and the genital folds are
united together to form the scrotum ; the genital tubercle, which in the
female forms the clitoris, becomes in the male the penis, and in the third
month shows the formation of the glans. A very distinct raphe upon
the penis and scrotum indicates the place of union of the two sides of
the genital fissure. The prepuce is formed in the sixth month. The
prostate, beginning in the third month as a thickening at the point
where the urethra and genital cord meet, can be plainly seen in the
fourth month. If the sides of the genital fissure fail to unite, the con-
dition is known as hypospadias.
A slight down-like growth of hair, lanugo, appears on the body, and
a few hairs upon the head ; meconium is found in the intestine, and
feeble movements of the limbs occur. A foetus born at four months
may live some hours ; no respiratory movement is made, but the pulsa-
tion of the heart and that of the umbilical cord are present ; Cazeaux
observed an instance in which life continued four hours.
FIFTH MONTH. At five months the foetus is about ten inches, 25
to 27 centimetres, long, and weighs eight to nine ounces ; the average
is 273 grammes ; the umbilical cord is about twelve inches, or 31 cen-
timetres long. Hair on the head and lanugo distinct ; vernix caseosa
present. During the month, usually about its middle, the mother, in
most cases, first becomes conscious of foetal movements, and the sounds
of the fcetal heart can be heard by auscultation ; movements of the
foetus are felt somewhat earlier by the multigravida than by the primi-
gravida. If the foetus be born at five mouths, it breathes, cries faintly,
and lives longer than when born at four months, but dies in a few hours.
SIXTH MONTH. The foetus is 12J inches, 31 centimetres, in length,
and weighs a little more than one pound, 634 grammes. Its form has
THE EMBRYO AND FOETUS. 143
become rounded by the increase of fat, lauugo covers the body aud the
members also, except the palms of the hands and the soles of the feet ;
the growth of hair upon the head is plain, and the eyebrows can be
faintly seen, while the secretion from the sebaceous glands furnishes a
more abundant vernix caseosa. A foetus born at the end of six months
may live from one to fifteen days. Its death occurs not only because
the digestive apparatus is incompletely developed, and because the re-
duction of temperature is great and rapid, but because the rudimentary
condition of the lungs renders respiration almost impossible, 1 for, accord-
ing to Cornil, at this period of intra-uterine life air cannot distend the
final pulmonary ramifications because of their anatomical structure.
SEVENTH MONTH. At the end of the month the foetus is 13-15
inches, 3336 centimetres, long, and weighs between 3 and 4 pounds,
1200 grammes. The eyelids are open, the testicles begin to descend in
the seventh month, and are near the scrotum. The nails are almost
completely formed, the insertion of the cord is about one inch and a
half, four centimetres, below the middle of the length of the body. The
child is said to be viable at the end of the month, but its viability is
only relative to that of earlier birth ; the majority of children born at
this period die.
On the other hand, there are instances in which children born before
the end of seven months have lived. Tarnier states that by means of
the couveuse and gavage several accoucheurs have succeeded in recent
years in saving infants whose intra-uterine life was only six months,
or six months and some days.
A popular, 2 founded upon a professional, belief prevailed for many centuries,
to the effect that a child born at seven months was more likely to live than one
born at eight months. Possibly this belief is not yet quite extinct. It is, however,
somewhat astonishing to find the late Dr. John W. Francis, Professor of Obstet-
rics in the University of New York, in his preface to the American edition of
"Denman" (1821), using the following language: "The singular circumstance
that a child of seven months' gestation has greater chance of living than one of
eight was noticed by him," i. e., Hippocrates. Now, this notion, which was held
for more than two thousand years, had its origin in the infancy of obstetric
science, and arose from ignorance of the essential cause of labor. It was believed
that the foetus up to seven months had its head in the upper part of the womb,
but at that time the increased weight of the head caused it to fall into the lower
part of the uterine cavity ; the head of a boy, from its having greater size, turn-
ing downward somewhat earlier than that of a girl. But as soon as the foetus
had its head at the mouth of the womb it made an effort to get out, and, if a
very strong child, succeeded. If it failed, the effort was repeated at eight months,
and in case it then succeeded the foetus, haying been weakened by its previous
unsuccessful attempt, had less chance of living than if birth had taken place at
seven months.
EIGHTH MONTH. At the end of the eighth month the length of the
foetus is about 16 inches, a little more than 40 centimetres, and its
weight is about 5 pounds, or nearly 2 kilogrammes. The insertion of
the cord is about the middle of the length of the body ; only one of the
1 Pinard.
2 As illustrative of this belief the following passage from the Memoirs of Madame Guyon is
quoted. She was born in 1642, and was the founder of that peculiar form of religious belief and
conduct known as Quietism: "I was born before due time, for my mother, having received a
terrible fright, was delivered of me at the eighth month, at which time they say it is almost impos-
sible for a baby to live."
144 PHYSIOLOGY OF PREGNANCY.
testicles, usually the left, is in the scrotum ; during the month the body
increases less in length than in breadth.
NINTH MONTH. The length of the foetus at term varies from about
19 inches to a little more than 22 inches, 50-56 centimetres ; its weight
by many is placed as between six and seven pounds : Landois, however,
makes it seven pounds, 8^ kilos. The last statement corresponds more
nearly with that resulting from statistics, including 500 male and 500
female children, taken from the obstetric records of the Philadelphia
Hospital. 1 These statistics showed the average weight of female chil-
dren to be seven pounds one ounce and a half, and that of male children
to be seven pounds eight ounces. In only one of a thousand was the
weight eleven pounds.
Burns regarded the weight-proportion between the sexes in the new-
born to be such that twelve males would weigh as much as thirteen
females. The late Sir James Simpson has drawn attention to the fact
that from the great size of the head of the male the foetal mortality in
childbirth was larger with male than with female children ; Bertillon's
statistics prove that the foetal mortality in birth is in the proportion of
130 males to 100 females. If a child's weight at birth be decidedly
under the average, 2 the probability is that the labor is premature, or else
the normal development of the child has been interfered with. So, too,
if the weight be much above the average, it is possible that in some
cases the pregnancy has been protracted beyond the normal time.
In one instance in my practice a child was born weighing only one pound and
a half, the pregnancy ending a few days before the completion of the seventh
month ; the child lived, and is now a healthy boy of ten years. 3
Dr. R. P. Harris, in a note to " Playfair," states : " We have had children born
in this city, Philadelphia, at maturity that weighed but one pound. The well-
remembered ' Pincus ' baby weighed a pound and an ounce."
In some instances children weighing twelve pounds and even more have been
born. But it is remarkable that most of the cases of birth of unusually large
children occur in private, not in hospital practice. Pinard, from an examination
of the records of the Paris University, found but one in 20,000 that weighed
5300 grammes, a little more than twelve pounds.
Nevertheless children have been born whose weight was very much greater
than even this. For example, Dr. Adye, of Bentonville, Ind., in a recent letter
to me states that in his practice a woman was delivered spontaneously and
rapidly of a child weighing 16 pounds ; both mother and child did well. The
most extraordinary case that has been communicated to me, however, was one
occurring in the practice of Dr. Josiah Peltz, of this city. On the 29th of
1 I am indebted to Dr. R. J. Phillips, one of the internes at the time, for preparing these statistics.
A curious fact which I have observed in my hospital service is, that there is less difference in
weight between the sexes of the newborn in the black than in the white. While a sufficient
number of observations have not been made to establish a law, there are a priori reasons for
believing in its possibility.
2 Kormann, op. cit., believes that pregnancy may last at least two or three weeks beyond two
hundred and eighty days, and that then the foetus may be developed beyond the average, so
that its weight is 6000 grammes, and its length 30 centimetres. This subject will be referred to
again in connection with the topic of prolonfred pregnancy.
a Gilbert (Zeitschrift fur Geburtshiilfe und Gynakologie, Band 16, Heft 1) reports the case of a
female child, born in the twenty-ninth week of gestation, weighing three and a half pounds ; the
child was twenty-two inches long when five and a half months old. Various incubators were
tried, but daily warm baths were most successful. The child was taken into the open air from the
moment of birth. For the first week a wet-nurse fed the infant ; afterward the mother. From the
seventeenth day it was fed breast-milk with a spoon. When eighteen weeks old cow's milk was
given.
In growth the greatest gain occurred at the time when birth would have normally occurred.
The child suffered from frequent attacks of syncope until its fourth year ; it had also spinal curva-
ture (scoliosis 35) from rhachitis; this was afterward reduced by orthopedic treatment (to 5).
The milk teeth were complete at three and a half years.
PLATE II
THE MATURE OVUM. (After Runge. )
A. Uterine wall.
B. Placenta.
C. Umbilical cord.
D. Decidua.
E. Chorion.
F. Amnion.
G. Fcetus.
H. Amnial liquor.
[To face page 145.
THE EMBRYO AND FCETUS.
145
October, 1887, he delivered Mrs. S., at the end of her fourth pregnancy, of a
female child weighing 22 pounds. The child was stillborn, but the doctor
believes that it could have been resuscitated had proper means been used ; the
means were not used because for some time his sole care was of the mother,
who had dangerous uterine hemorrhage. Dr. Peltz states that his patient is a
woman of unusual size, ordinarily weighing 225 pounds, and that her pelvis is
remarkably large.
My friend Dr. T. G. Davis, of Bridgeton, N. J., informs me that Dr. J. R.
Thompson, of that city, delivered, with forceps, a woman of a dead child which
weighed 21 pounds.
Harris, op. cit., says : " Probably the largest foetus on record was that of Mrs.
Captain Bates, the Novia Scotia giantess, a woman of 7 feet 9 inches in height,
whose husband is also of gigantic build, reaching? feet 7 inches in height. This
child, born in Ohio, was their second, and was lost in its birth, as no forceps of
sufficient size to grasp the head could be procured. The fo3tus weighed twenty-
eight and three-fourths pounds, and was thirty-nine inches in length. Their first
infant weighed nineteen pounds."
Considering the pregnancy as lasting ten lunar months, the following
is the length of the embryo or foetus at the end of each month, as stated
by Haase :
At the end of the first month
second month
third
fourth
fifth
sixth
seventh
eighth
ninth
tenth
1X1=1 cm. or 0.395 inch.
2X2=4 cm. or 1.58 inches.
3X3=9 cm. or 3.55
4 X 4 = 16 cm. or 6.23
5 x 5 = 25 cm. or 9.87
6 x 5 = 30 cm. or 11.85
7 X 5 = 35 cm. or 13.82
8 x 5 = 40 cm. or 15.80
9 x 5 = 45 cm. or 17.77
10 X 5 = 50 cm. or 19.75
THE FCETUS AT TERM. There is no single criterion by which the
maturity of the foetus can be known, but a strong probability, amounting
to almost absolute certainty, is attained by combining certain charac-
teristics. Thus the foetus should have the average weight and length
that have been given ; the body should be plump, and more or less
covered with the secretion from the sebaceous glands, this secretion
being mixed with the detached lanugo and epithelial scales making the
vernix caseosa, or cheesy varnish ; this covering is chiefly in the groins
and axillae, at the flexures of the joints, and upon the back and chest.
The nails of the fingers and toes are hard, those of the former projecting
slightly beyond the tips of the fingers ; the cartilages of the ear and
nose are resisting ; the cord is usually a little below the middle of the
anterior portion of the body, in girls the insertion is said to be a little
higher than in boys ; the hair on the head is one to two inches, 2.6 to
5.2 centimetres, long ; the child cries vigorously, and makes active
efforts at sucking an object placed between its lips. (See Plate II.)
THE FCETAL HEAD. This is the part of the foetus which is usually
expelled first, and if it can pass through the birth-canal there is rarely
difficulty or delay in the delivery of the body, and hence the knowledge
of its form, size, and structure, and the changes in its measurements
and shape occurring in labor, is important for the obstetrician. The
general shape of the foetal head is ovoidal, the larger end of the ovoid
being posterior. It is composed of cranium and face ; the latter is of
minor obstetric importance. The bones of the cranium of the foetus
differ from those of the adult's cranium in two important respects :
they are to some degree flexible in consequence of incomplete ossifica-
10
146
PHYSIOLOGY OF PREGNANCY.
tion, and they are mobile, because instead of being united together by
bone, their union is by fibrous tissue. Further, in the foetal head
mobility of the squamous portion of the occipital results, as pointed out
by Budin, 1 from its being united to the basilar portion by cartilage,
which serves as a hinge, and the former is moved forward or backward
according to the action of external force.
SUTURES AND FOJNTANELLES. The membranous spaces between the
bones of the head are called sutures and fontanelles. The sutures are
straight or curved lines, and the fontanelles are at the junction or at
the intersection of sutures ; if at the former, the fontanelle is triangular,
but if at the latter, quadrangular. The three most important sutures
are the sagittal, the fronto-parietal, and the occipito-parietal. The
sagittal from sagitta an arrow, meeting the bowstring at a right
angle, passing directly over the bend of the bow, and thus intersecting
the middle of the arc described by the fronto-parietal suture is the
longest, and extends from the root of the nose to the upper point or
FIG. 89.
ANTERIOR AND POSTERIOR FONTANELLES, SAGITTAL AND OCCIPITO-PARIETAL AND
OCCIPITO-FRONTAL SUTURES.
angle of the occipital bone ; it is the dividing-line between the two
halves of the frontal bone and between the two parietal bones. The
fronto-parietal, as its name indicates, is between the frontal and the
parietal bones ; it ends on either side at the squamous portion of the
temporal bone. The occipito-parietal, usually called lambdoidal from
its suggested resemblance to the Greek* letter lambda, a, is between the
occipital and parietal bones ; it may be described as a bifurcation of the
sagittal suture.
The chief fontanelles are two, one anterior, the other posterior. The
former, also called bregma, from 8p% u to moisten, because of its being
so yielding to the touch, is at the intersection of the two sutures, the
sagittal and the fronto-parietal, and therefore quadrangular. It is a
large, membranous depressed surface, with unequal sides, the two ante-
1 De la Tete du Foetus au point de vue de 1'Obstetrique.
2 Its resemblance is greater, as Bailly has said, to a capital V, whose angle corresponds to the
end of the sagittal suture.
THE EMBRYO AND FCETUS. 147
rior being longer than the two posterior ; these features are so charac-
teristic that its recognition in labor by the touch ing- finger is usually
quite easy. The posterior foutauelle is at the junction of the sagittal
with the occipito-parietal suture, it is consequently triangular ; it is
quite small, and in labor cannot, as a rule, be recognized as a mem-
branous space, for in consequence of the movement of the squamous
portion of the occipital bone forward, the overriding parietal bones hide
it from touch ; but its position may be recognized by its corresponding
with the point of apparent bifurcation
of the sagittal suture, and by its being FIG. 90.
at the apex of a depressed triangle,
two of the converging sides of the
triangle being the posterior margin of
each parietal bone, and the inter-
vening space occupied by the occipital
bone.
Lateral and supplementary fonta-
nelles are also to be noticed. The
chief of the former are at the junction
of the occipito-parietal and temporal
sutures, but they are concealed by soft
parts. Supplementary fontanelles are
membranous spaces arising; from fail-
. V & . ANTERO-POSTERIOE DIAMETERS OF FCETAL
ure ot ossification ; they are sometimes HEAD.
found in the middle of a bone, some-
times in the course of a suture; remembering these facts as to their
position, one is not liable to confound them with either of the fonta-
nelles that have been described, and which are such important guides
in practical obstetrics.
DIAMETERS OF THE FCETAL HEAD. These are lines drawn between
certain points of the foatal head. Following the example of Budin,
these diameters may be classified according to their general direction,
as antero-posterior, transverse, and vertical. The antero-posterior are
four, viz., the maximum, the occipito-mental, the occipito-frontal, and
the suboccipito-bregmatic.
The maximum diameter extends from the chin to a variable point,
which is in almost every case situated in the sagittal suture between the
two fontanelles. The occipito-mental diameter reaches from the point
or angle of the occiput to the chin. The occipito-frontal is between the
angle of the occiput and the r.oot of the nose, and the suboccipito-breg-
matic is from the point of meeting of the occipital bone with the nucha
to the middle of the anterior fontanelle, that is, where the sagittal and
fronto-parietal sutures cross each other.
The transverse diameters are three, viz., the biparietal, between the
parietal protuberances, the bitemporal, between the origin of the fronto-
parietal suture on each side, and the bimastoid, which extends between
the mastoid apophyses.
The vertical diameters are two, the fronto-mental, extending between
the highest point of the forehead and the chin, and the trachelo-breg-
matic, from the middle of the anterior fontanelle to the -upper and
148
PHYSIOLOGY OF PREGNANCY.
anterior part of the neck in the immediate vicinity of the larynx. This
diameter is also called the cervico-bregmatic and the laryngo-bregmatic.
FIG. 91.
FIG. 92.
BlPARIETAL AND BlTEMPORAL DIAMETERS
OF FCETAL HEAD.
VERTICAL DIAMETERS.
The illustration which follows, taken from Tarnier, shows the three
diameters, suboccipito-bregmatic, suboccipito-frontal, and suboccipito-
nasal, as measured in an infant immediately after delivery. The fact
of the second diameter being greater than either of the others, and
hence the circumference of the child's head corresponding with it will
be that|which will be with the greatest difficulty forced through the
THE THREE SUBOCCTPITAL DIAMETERS.
vulval ring, are apparent. The importance of this diameter in regard
to expulsion of the head, that is, the greater danger to the perineum at
the time its circumference passes, has been in recent years especially
THE EMBRYO AND F(ETUS.
149
urged by Matthews Duncan and by Ribemont. But long before them
Smellie and Burton had referred to the essential fact.
The greatest circumference of the foetal head is that corresponding
with the maximum diameter, and the least that which is similarly re-
lated to the suboccipito-bregmatic.
In the following table of diameters and circumferences the measure-
ments given by Tarnier and Chantreuil are presented. Each metric
measurement is followed by its equivalent in inches and hundredths,
and this in turn by an approximative measurement, where it seemed
most convenient for remembering, substituting vulgar for decimal
fractious.
Maximum diameter
Occipitomental
Occipito-frontal
Suboccipito-bregmatic
Biparietal
Bimastoid
Fronto-mental
Bitemporal
Trachelo-bregmatic
Great circumference
Small circumference
. 13.5 cn
. 13. "
. 12.
. 9.5
. 9.5
. 7.5
. 8.
. 8.
. 9.5
. 37.
. 32.5
5.31 inches or 5X
5.11
4.72
3.75
3.75
2.75
3.15
3.15
3.75
14.57
12.80
if
i
8
14^
12%
Upon comparing these diameters of the foetal head with those of the
maternal pelvis, it will be seen that only two of the former exceed the
greatest of the latter ; but in normal labor neither of the two is brought
in relation with a pelvic diameter.
MODIFICATION OF DIAMETERS OF FCETAL HEAD IN LABOR. Budin
has shown that certain modifications in the diameters of the fostal head
are produced by the overriding of bones at the sutures, from the pres-
sure upon the head in passing through the pelvis, and that by these
changes the head is changed in shape, the change varying with the
position. In general the alterations in the diameters are as follows :
the occipito- mental and occipito-frontal diameters are lessened ; the
maximum diameter is increased ; the suboccipito-bregmatic and the
bitemporal are lessened ; the biparietal is very slightly lessened ; but
the mastoid not changed.
MOVEMENTS OF THE FCETAL HEAD. The head may be bent for-
ward or backward so as to come in contact with the body ; the first is
called complete flexion, and the second complete extension ; this move-
ment takes place chiefly in the articulations of the cervical vertebrae,
the occipito-atlantoid articulation participating only very slightly. The
last articulation, however, permits rotation of the head to the right or
to the left through a quarter of a circle. Tarnier, in reply to the ques-
tion whether the head can be made to rotate much more extensively
without injury to the cord or to the ligaments, asserts that the fears ex-
pressed are purely theoretical, and that a movement of rotation so
extensive that the face is turned directly backward may be made without
producing any lesion. This topic will be again referred to.
DIAMETERS OF THE TRUNK. The bis-acromial diameter from one
acromion to the other is the longest trunk diameter. It is 4.7 inches, or
12 centimetres ; it can be reduced one inch, or to 9.5 centimetres. The
dorso-sternal is 3.7 inches, 9.5 centimetres. The bis-trochanteric diam-
eter is 3.5 inches, 9 centimetres. The sacro-pubic diameter is a little
more than 2 inches, 5.5 centimetres ; by the flexion of the thighs upon
150
PHYSIOLOGY OF PREGNANCY.
FIG. 94.
the abdomen and the legs upon the thighs this diameter is nearly
doubled, but compression readily lessens it. All the trunk diameters
lessen by compression more than do those of the head.
INCREASE IN WEIGHT AND LENGTH OF FCETUS IN SUCCESSIVE PREGNANCIES.
As a matter that is of great practical importance in some cases in reference to
obstetric treatment, it may be stated that from the weight and length of the child
of the immediately previous birth those of the next can be determined. The
increase in weight is, on the average, 150 grammes, and in length 0.75 centimetre.
Suppose that in the first labor the child has the average weight and length, the
following table shows approximately those of children born subsequently ; it has
been taken from Ahlfeld :
The second child's weight will be 3400 gr., its length 51.75 cm.
The third " " " 3550 gr., " 52.50 "
The fourth " " 3600 gr., " 53.25 "
The fifth " " 3750 gr., " 54.50 "
ATTITUDE OF THE FCETUS IN THE WOMB. By this are meant the
general form and direction of the truuk, and the position of the limbs
with reference to it. We have seen that
in the very dawn of development the first
distinct form which the embryo had was
that of a curve, the ends of that curve
tending to approach ; and the curved
form is kept through all intra-uterine
life. As shown in the above diagram of
the foetus contained in the uterine cavity,
the back is bent forward, the chin in-
clined to the chest, the arms folded over
the breast, the feet flexed, the legs flexed
upon the thighs, and the thighs upon the
abdomen ; the foetus is thus folded upon
itself, making an ovoid, its position being
not unlike that of a chrysalis in the
cocoon, or a chick in the shell. Harvey's
explanation of the attitude of the foetus
was this: "The truth is, that all animals,
whilst they are at rest or asleep, fold up
their limbs in such a way as to form an
oval or globular figure ; so in like man-
ner embryos, passing as they do the
greater part of their time in sleep, dispose their limbs in the position in
which they are found, as being most natural and best adapted for their
state of rest." ^ Cazeaux regarded the attitude of the foetus as represent-
ing "a constrained position, which could not have been produced by the
mere pressure of the uterine walls upon the child, since the latter is in
a cavity much larger than its whole volume ; hence it must be referred
to the individual itself."
^ As has already been stated, the attitude of the foetus is the perpetua-
tion of that of the embryo, and the primitive form of the latter must
be regarded as one of the factors in causing it. But others are also
concerned indeed, by some made the exclusive factors ; Pinard, for
POSTURE OP THE FCETOS.
THE EMBRYO AND FCETUS. 151
example, saying 1 that the causes are material, extrinsic, and belong to
the pressure-forces much more than to the individual and these will
be considered under the next topic.
PRESENTATION OF THE FCETUS. By presentation is meant that part
of the foetus which is in relation with the pelvic inlet, and in labor first
descends into the pelvic cavity ; that part, in a word, which presents at
the inlet and in the cavity. In about ninety-six per cent, of cases of
labor at term the head presents; many obstetric authorities indeed
regard this as the only normal presentation, as it is certainly the most
favorable. Various explanations have been given of the fact.
The Hippocratic theory held that the foetus was attached by liga-
ments passing from the umbilicus to the fundus of the womb, its head
being above ; rupture of the ligaments occurred at seven months, and
then the child immediately turned its head down and attempted to
force its way out of the womb. Aristotle held with Hippocrates as to
the original position of the child, but added gravity in explaining the
turning downward of the head. Trentius, 1564, found in the form of
the uterus the reason for the head usually being in its lower portion at
labor. The illustrious Pare" attributed the presentation to instinct.
Dubois sustained this hypothesis, illustrating it by instinctive acts of
the newborn seeking the nipple and sucking. Sir James Simpson held
that reflex action was not the exclusive but the ancillary cause, using
the following language : 2 " At and toward the full term of utero-gesta-
tion the position of the foetus with its head lowest is thus greatly main-
tained by the relative physical adaptation of the ovoid shape of the
rolled-up mass of the foetus to the ovoid shape of the cavity of the
uterus. But this particular adaptation and position of the foetus
would be often lost if no other additional and vital means were in
operation, as we see, indeed, often happens when the child dies. The
other additional means, by whose influence this special position is still
further rigorously and carefully sustained, consists of the restoring
influence of reflex motions on the part of the foetus itself."
The gravitation theory proposed originally, as we have seen, by
Aristotle, is advocated by some to-day as an assisting, by others as the
chief cause, notwithstanding the experiments of Dubois and the criti-
cisms of Simpson, which appear conclusively to disprove it.
One of the most curious of modern hypotheses, mentioned by Cohnstein 3 in
his paper upon "Normal Presentation of the Foatus," is that of Probsting. The
head presents because of the efforts of nature to place the orifice of the respira-
tory organs of the foetus as near as possible to atmospheric air.
Cohustein denies that the cause of presentation of the head is in the
movements of the foetus, or in forces external to it, but asserts that it
is in the foetal circulation, for until seven months a larger amount is
sent to the upper part of the body, but then the amount of blood is
equalized.
For Pinard one law governs the relations between the foetal and the
maternal organism, and this law is absolutely the same as the law of
1 Dictionnaire Encyclopedique des Sciences Medicales.
2 Obstetric Works.
3 Archives Generales de Medecine, 1869 and 1870.
152 PHYSIOLOGY OF PREGNANCY.
accommodation of labor so well formulated by Professor Pajot : Wfien
a solid body is contained in another, if the container is the seat of alter-
nate movement and rest, if ihe surfaces are slippery and little angular, the
content constantly tends to accommodate its form and dimensions to the
form and capacity of the container.
While this law explains the presentation of the head of the foetus
better than the gravitation theory, or that of instinctive or reflex fcetal
movements, it seems probable that it is not the sole cause of the attitude
of the foetus, but merely assists the action of the primitive cause.
Studying Pajot's law, as it relates to presentation alone, we find in
the painless contractions of the uterus in pregnancy, in the varying
abdominal pressure, and the changes of position of the mother, which
have more or less action upon the foetus, the conditions of movement
and rest ; the foetus presents more of a rounded than of an angular
surface, and after the secretion of the sebaceous glands begins this
surface is smooth, slippery, and thus, the amnial liquor assisting, the
accommodation of the content to the container is effected. This accom-
modation fails in those months of pregnancy when the uterus is very
much larger than the foetus. Thus Veit's statistics show that in 247
deliveries between the first of the fifth and the sixth mouth the head
presented in 140, the pelvis in 95, and the trunk in 12. If the foetus
be dead and macerated, one of the conditions of the law fails, the con-
tent is no longer a solid body, and statistics show that in very nearly
one-half of the cases in which delivery takes place before six months
the pelvis presents.
As pointed out by Sir James Simpson, presentation of the pelvis is
common if the child be hydrocephalic ; here it is evident that accommo-
dation causes the presentation. In twin pregnancies accommodation is
difficult, and Kleinwachter's statistics show presentation of the head in
69 per cent., of the pelvis in 25 per cent., and of the shoulder in 5 per
cent. In polyhydramnios the foetus is usually small, and thus ample
space doubly secured interferes with accommodation, so that malpre-
sentations are common.
Pinard 1 attaches great importance to the action of the abdominal wall
in assisting in accommodation ; its elasticity and the contraction of its
muscles prevent the uterus from departing from the median line press
it at all points, especially upon the sides. He attributes the greater
frequency of malpresentations in multipart, seven to one in primiparse,
to the relaxation of the abdominal muscles caused by preceding preg-
nancies. So, also, he assigns to the same cause the frequent changes of
position of the foetus in pregnancy and the delay in the engagement of
the presenting part in the latter weeks. Nevertheless, while admitting
the force of these arguments, much must also be ascribed, as held by
Charpentier, to the greater relaxation of the multiparous than of the
primiparous womb, and its larger cavity as accounting, in part at least,
for these results.
Pinard divides the causes into active and passive. The latter are
the forms of the uterus and of the foetus in the different periods of
i Op. cit.
THE EMBRYO AND FCETUS. 153
pregnancy, the folding together of the foetal body and limbs, the gliding
surface of the foetus, and the amnial liquor. The active causes are the
contractions of the uterus, the painless contractions of pregnancy, and
the contractions and tonicity of the muscles of the abdominal wall.
Winckel concludes that the position and attitude of the child are determined
principally by the shape and activity of the uterus, aided by the shape and move-
ments of the parts of the foetus, and that the predominance of cephalic presenta-
tions results from the direction of uterine force, the greater size of the upper
than of the lower segment of the uterus, the greater mobility of the child's head,
and the shape of the uterus and child, the latter being better adapted to the
former when the head presents.
It must be obvious that the most important part of this explanation is that
which rests upon Pajot's law, previously stated.
Dr. D. T. Smith, of Louisville, Ky., some time since J gave an original explana-
tion of the cause of presentation of the head, and has recently repeated it : 2
" Whoever has practised diving in deep water has discovered that if he holds his
arms in such a way as not to hinder his progress folded at his back or breast,
for instance, or pressed to his sides and then kicks out with his feet he will go
directly to the bottom. Now the position of the child in the uterus, and the
course of its development, are such that it makes essentially similar movements.
The flaccid state of the walls of the uterus allows them to yield when pressed
against by the lower limbs, and in this way the foatus gains the advantage that
would accrue to it from swimming in a larger mass of water than that contained
in the uterus. Adding to the influence of these movements the increasing
conicity of the lower segment of the uterus that develops during the latter months
of pregnancy, we can easily account for the greater preponderance of head
presentations. In every position the mother takes, except that of lying on the
side, the outlet of the uterus is lower than the fundus, and in all except the
latter the movements the child spontaneously makes will tend to place its head
downward."
Dr. Smith has more recently presented his views in a valuable monograph
entitled Obstetric Problems, 1892.
Foulis 3 concludes from the study of sections through the pelvis and abdomen
that the continual movements of the child's lower limbs in extension cause the
head-downward position. The prevalence of the situation of the occiput and
back on the mother's left side results from the proportionally large size of the
liver in the pregnant woman, which fits over the uterus like a cap, affording firm
resistance to the impact of the child's feet.
PHYSIOLOGY OF THE FCETUS. The chief foetal functions are nutri-
tion, circulation, respiration, secretion, innervation, and motility.
NUTRITION. It is supposed that the nutrition of the impregnated
ovule is at first by the granular matter, the discus proligerus, which
surrounds it when it escapes from the ovisac. In some of the inferior
animals the ovule, during its passage through the oviduct, receives a
covering of albumin, and probably the same fact exists in the human
ovule; if so, this albuminous coat may nourish it. After entering the
womb the primitive chorial villi absorb nutritive material from the
uterus ; the granular contents of the umbilical vesicle probably nourish
the embryo, but as the vesicle is atrophied at the end of the fifth week,
this supply lasts but a short time.
The question as to the amnial liquor contributing to the nourishment
of the foetus that it is the sole or chief supply no one now holds is
1 American Practitioner and News, 1887.
2 American Journal of Obstetrics, 1890.
3 Edinburgh Medical Journal, September and October, 1888.
154 PHYSIOLOGY OF PREGNANCY.
still in dispute. According to Fehling, the human embryo has at the
sixth week 97.54 per cent, of water ; in the fourth month the quantity
of water of the fetus is between 88 and 93 ; in the fifth, between 88
and 93 ; in the sixth, between 83 and 90 ; in the seventh, between 82
and 85 ; and in the mature foetus born dead, 74.1. Bischoff, however,
found in the newborn only 66.4 per cent, of water. Preyer's statements
as to the foetus obtaining water from the amnial liquor by swallowing,
and by absorption through the skin, have been given on page 127.
Further, while the percentage of albumin in the amnial liquor is very
small, the absolute quantity the foetus obtains may be very great by
accumulation ; this liquor contains salts, sodium and calcium phosphates,
which are important for the development of the fetus.
Ahlfeld 1 concludes from the examination of the meconium that the foetus
swallows considerable quantities of the amnial fluid. This is a physiological
process ; he has found the amnial fluid albuminous in several cases, ranging
from twenty to fifty per cent, albumin. His tests were nitric acid and heat.
He believes that the albumin of the amnial fluid is nutriment for the foetus,
and by an elastic bag applied over the mother's abdomen at the location of the
child's back, he demonstrated movements of the child's thorax in the uterus,
which he considered those of deglutition.
Mekus 2 has met with an instance supporting the belief that the foetus swallows
the liquor amnii, in the case of a child who could not retain fluid swallowed ;
it died of inanition, and was poorly developed at birth. On examination, the
cesophagus was impervious at its middle. It was noticeable that the liquor
amnii was very abundant at birth. The case is virtually a ligation of the
cesophagus in the living foetus ; result, a poorly developed and nourished foetus,
no evidence of liquor amnii in the digestive tract, and an abnormal abundance
in utero.
Undoubtedly, materials present in the amnial liquor have been found
in the stomach and intestines of the foetus, and thus it is proved this
liquor may be swallowed, but it is not proved that this is the rule, and
up to the present most have regarded it as the exception. Moreover,
monsters in which the mouth is absent are born well developed, and
therefore the entrance of amnial liquor into the alimentary canal is not
essential to nutrition. Further, as pleasantly remarked by Pinard, the
same physiologists who assert the nutrition of the foetus by the amuial
liquor, also hold that the foetus passes urine into this liquor, and it is
singular if such a fluid contributes to its nourishment. 3
The permanent and certainly the chief, if not the only, nutritive
supply of the fetus is secured through the placenta other means are
only temporary or secondary; during the formation of this organ chorial
villi, especially those which contribute to its structure, the chorion fron-
dosum, supply nutritiye material to the embryo. The growth of the
new being is much slower before than after the development of the
1 Zeitschrift fur Geburtshiilfe, Band 14, Heft 2.
2 Centralblatt ftlr Gynakologie, No. 42, 1888.
3 Preyer, op, cit., admits the fact, remarking: However paradoxical it may appear, the foetus
discharges urine into the amnion, and drinks it, with the other constituents of the amnial fluid,
In quantity so much greater as the term of gestation approaches, like the embryo of the bird
before hatching.
DUhrsenn, Centralb. f. Gynakol., 1888, concludes from his investigations that in the latter part
of the intra-uterine life the organs of the foetus function as in extra-uterine life ; and that the
urine of the foetus from time to time is emptied into the amnial fluid. He believes the nutrition
of the foetus is dependent solely upon the placenta, and that amnial liquor is produced by fcetal
excretion.
THE EMBRYO AXD FCETUS. 155
placenta, the foetus increasing in weight during the last six weeks of
pregnancy to an amount equal to that which it attained in the first five
months. Foetal nutrition has been compared to that of a vegetable
parasite, which takes from the circulatory vessels of the plant on which
it is developed the materials necessary for its growth.
Reference has previously been made to the fact that the solutions of
various substances may pass from the maternal to the foetal blood. The
following are the conclusions of Preyer 1 in regard to the reciprocal
relation of the maternal and foetal blood :
1. Very many substances in solution, easily diffusible, can pass from the blood
in the sinuses of the maternal portion of the placenta into the capillaries of the
villi of the foetal portion of the same placenta.
2. That oxygen certainly passes from the haemoglobin of the blood globules of
the mother in the placenta, to the haemoglobin of the blood globules of the foetus
in the capillaries of the villi, as long as there is a sufficient quantity.
3. That some substances in solution, as the sodi-indigosulphite and the potassic
iodide, can be directly eliminated from the mother into the amnial liquor without
entering the blood of the foetus.
4. That soluble substances easily diffusible can pass abundantly from the blood
of the capillaries of the villi into the blood of the sinuses of the maternal por-
tion of the placenta.
5. That oxygen certainly passes from the haemoglobin of the blood globules of
the foetus in the placenta to the haemoglobin of the blood globules of the mother,
if the maternal blood contains but a minimum or no trace of the oxygen.
6. That some substances which are soluble may pass from the amnial liquor,
probably in small quantity, into the blood of the mother.
7. That formed elements cannot, unless extremely small, probably pass in
absolutely intact placentas, and that even then the transmission does not take
place uniformly, but only in certain conditions, sometimes dependent upon the
organization, as in sheep, sometimes in anomalous states, possibly increase of
blood pressure, or by means of diapedesis of leucocytes.
8. That it has not been conclusively proved that formed elements migrate from
the blood of the foetus into the maternal blood in the placenta, but such passage
is possible.
From what has been proved as to the action of atropine, the natural
conclusion is that soluble salts of opium will readily pass from the
maternal to the foetal blood. Two milligrammes of atropine were given
hypodermatically to a woman three hours before delivery; the child was
born with dilated pupils which did not react to light. So, too, the belief
is probable that a woman who is an opium-eater is liable to give birth
to a child affected by morphine; it is possible, too, more remote injury
may result.
In one case in which morphine was administered to a pregnant woman
by hypodermatic injection, the foetal pulse became less frequent and
arrhythmic.
It has been shown by Porak that when fifteen grains, one gramme, of
quinine were given to a woman in labor, the urine in the child, born an
hour and a half afterward, showed the presence of quinine. Runge gave
to women during several of the last days of pregnancy half a gramme
daily of muriate of quinine, and in almost all cases quinine was found
in the foetal urine. Now if, as is alleged by some observers, the child
i On. cit.
156 PHYSIOLOGY OF PREGNANCY.
may suffer from intermittent fever while in the uterus, obviously there
is every reason to believe that the disease may be cured by giving
quinine to the mother.
Occasional cases in which intra-uterine vaccination has succeeded,
and the transmission of certain diseases believed to depend upon germs,
such as syphilis, variola, rubeola, scarlatina, etc., from the mother to
the foetus, testify to the passage of micrococci from the maternal to the
foetal blood.
CIRCULATION. The circulation in intra-uterine life passes through
two important phases, while a third is entered upon at the close of that
life. The first is very brief, and depends upon the formation of the
umbilical vesicle ; it is called the vitelline circulation. The heart, still
a straight, tubular cavity, gives oif from each end two vessels ; the two
superior are the first aortic arches, and the inferior are the omphalo-
mesenteric veins. By the heart's systole the blood entering the aortic
arches passes first into the body of the embryo, then into the omphalo-
mesenteric or vitelline arteries, which carry it to the vascular area of the
vesicle ; from there it enters the venous sinus, situated at the periphery
of that area. The omphalo-mesenteric veins are formed by branches
originating at the sinus, and empty the blood thus collected into the
heart during its diastole.
Second, or Placental Circulation. The vitelline is superseded at the
beginning of the third month by the placental circulation. The heart
is developed into an organ of four cavities, and externally presents the
form of the adult heart ; internally there are important differences.
The most important of these differences is that the septum between the
auricles is imperfect ; it hag a large opening, described by Galen, but to
which the name of Botal has been given ; it is also called the foramen
ovale. Furthermore, the Eustachian valve situated at the entrance of
the inferior vena cava is remarkably developed, so that it turns the cur-
rent of blood coming through the latter vessel into the auricle to the
foramen ovale, and thus into the left auricle. Two important structures
must also be mentioned before describing the circulation, the venous
duct and the arterial duct, ductus venosus and ductus arteriosus ; the
former connects the umbilical vein with the inferior vena cava ; the
latter, the ductus arteriosus, which appears as if a continuation of the
pulmonary artery, connects the artery with the aorta at a point of the
arch just below the origin of the arteries of the head and upper limbs.
The blood, purified and rendered fit for nutrition in the placenta, is
brought to the foetus by the umbilical vein, which enters at the umbil-
icus ; the greater part of the blood passes at once by the ductus venosus
into the ascending vena cava, where it mixes with the blood brought
from the lower limbs, the pelvis and the kidneys ; a small part passes
to the liver, and on the other hand blood from the hepatic veins
empties into the cava. These various collections, chiefly of course that
coming from the placenta, make the common stream which is carried by
the vena cava into the right auricle, but the stream is turned by the
Eustachian valve through the right into the left auricle, from which it
passes, as in post-uterine life, into the left ventricle. The heart now
contracting, the contained blood is sent from the left ventricle into the
THE EMBRYO AND FOETUS.
157
aorta, from the right into the pulmonary artery. The blood which
enters the aorta from the left ventricle passes chiefly to the head and
upper limbs ; that which goes into the pulmonary artery being needed
in only small amount by the inactive lungs, and these organs incapable
of exercising their function, the blood does not need them, therefore
is in greater part carried by the ductus arteriosus into the aorta ; as
FIG. 95.
DIAGRAM OF THE CIRCULATORY ORGANS OF
THE HUMAN FCETUS AT Six MONTHS.
RA. Right auricle. RV. Right ventricle.
LA. Left auricle. Ev. Eustachian valve. L.
Liver. K. Left kidney. I. Part of small intes-
tine, a. Aortic arch. a'. Its dorsal part. a".
Posterior end of abdominal aorta, vcs. Supe-
rior vena cava. vci. Inferior vena cava near
its junction with the right auricle, vci. Pos-
terior part of vena cava. s. Subclavian ves-
sels, j. Right jugular vein. c. common car-
otid arteries ; the four dotted arrow-lines indi-
cate the course of the circulation, da. Ductus
arteriosus ; an arrow-line starting at vci indi-
cates the course of blood-flow from the inferior
cava through the foramen ovale. hv. Hepatic
veins, vp. Vena portse. x to vci. The ductus
venosus. uv. Umbilical vein. ua. Umbilical
arteries, uc. Umbilical cord, i i'. Iliac ves-
sels. (ALLEN THOMPSON.)
the ductus venosus transmitted a purified blood, so the ductus arteriosus
conveys an impure blood. The aorta, after the ductus arteriosus has
emptied its supply into it, contains blood from both the left and the
right heart, and transmits this mixed blood to the organs situated
below, to the lower limbs, and by the umbilical arteries to the placenta.
The blood which was expelled from the right ventricle had been re-
ceived from the descending vena cava through the right auricle, and it
158 PHYSIOLOGY OF PREGNANCY.
was therefore an impurer blood than that which was expelled simultane-
ously from the left ventricle ; thus it is plain that the lower half of the
body has a blood less rich in nutritive materials than the upper half,
and hence the greater development of the latter than of the former, a
development which is necessary for the exercise of certain functions in
the period of life immediately following delivery. The organ which
receives the purest blood is the liver.
At birth that which is often called the third circulation is established.
With the first inspiration of the newborn the blood flows in increased
quantity to the lungs, and the stream which passed from the pulmonary
artery to the aorta through the ductus arteriosus now goes into the
branches of the pulmonary artery, and the arterial duct is narrowed,
and obliterated in two or three days. The blood coming from the
lungs fills the left auricle, prevents that which enters the right auricle
passing through the foramen ovale ; this opening in the wall between
the auricles, not being used, is closed, the closure becoming complete
some weeks after birth.
RESPIRATION. The placenta is the respiratory organ of the foetus.
As remarked by Spiegetberg, the mother's blood is for the foetus the
external world from which alike its respiration and nutrition needs are
satisfied. The importance of a supply of oxygen for the foetus is ren-
dered probable by the abundance of haemoglobin in its blood. Accord-
ing to the investigations of several, the blood of the mature foetus is
richer in haemoglobin than is that of the mother. Hoesslin found, too,
in foetal blood which contained 13.72 per cent, of hemoglobin, there
were 5.88 millions of blood corpuscles in a cubic millimetre of the
blood, a very much larger number than woman's blood has. Preyer,
from his own investigations, has concluded that the haemoglobin in the
pregnant woman's blood is never greater, often very much less, than in
that of the foetus.
He also states that important changes of matter occur in the foetus,
as shown by the formation of certain products which are not obtained
from the mother's blood, secretions from its glands, or building up
permanent structures ; exercise of voluntary and of involuntary muscles ;
the foetus, too, has a higher temperature than that of the mother's
uterus ; and all these things indicate the fact that oxygen is necessary
for the foetus. The only source of supply is the maternal blood. The
proofs of foetal blood-changes in the placenta, analogous to those which
occur in pulmonary respiration, are the difference of color in the blood
coming from and going to the placenta ; the fact that, if the placental
circulation be temporarily interrupted, the blood in the umbilical vein
becomes dark like that in the arteries, and, if the interruption be per-
manent, the foetus dies asphyxiated, and the only substitute for placental
is pulmonary respiration ; finally, spectroscopic examination has proved
the presence of oxygen in the foetal blood.
It has been held that the foetus requires but a small quantity of oxygen because
the nutritive changes are so simple and its activity so slight. But it should be
remembered 1 as to the latter point that the heart begins its action early, and
that its pulsations are twice as frequent as in the adult ; that foetal movements
1 Preyer, op. cit.
THE EMBRYO AXD FCETUS. 159
occur some time before the mother is conscious of them, and that very many
take place after she has this consciousness without her recognition, for only
those affecting that part of the uterus which is in relation with the anterior
abdominal wall cun be known by her. In answer to the statement that the
nutritive changes are slight, Weiner, 1 from his study of these changes in the
foetus, has concluded that there exists in the foetus, especially in the last period
of fetal life, a certain number of organs which function as in the newborn. The
kidneys act, and this quite early, in relation to certain known substances arti-
ficially introduced into the foetus, exactly as the kidneys of the newborn, and
very rapidly excrete these products. Absorption by the lymphatics and rapidity
of the lymph currents are very energetic ; the intestinal mucous membrane not
only absorbs substances in solution, but also fat. These facts connected with
that of the active secretion of the liver, of the skin, and of the glands of the in-
testinal mucous membrane, as well as the relatively pronounced development of
digestion of the stomach, and the fermentation properties already present in the
extracts of the parotid and of the pancreas, permit us to admit with great prob-
ability that the secretory and absorbent organs of the foetus are capable of per-
forming their functions, and very probably do perform them, as soon as their
anatomical structure and degree of development permit.
SECRETION. The formation of the sebaceous glands begins toward
the end of the fourth month, and in the fifth month their secretion is
manifested, and in the sixth month becomes' quite abundant. The
vernix caseosa, smegma embryonum, which so generally covers the sur-
face of the embryo, is a whitish or yellowish, inodorous, adhesive matter
composed of epidermic cells, sebaceous cells, and fat globules. The
epidermic scales make the greater part of the mass, the amount of fatty
matter being relatively very small. Depaul, who did not disdain a
belief in nature's intelligence, regarded the vernix caseosa as a wise pro-
vision to prevent osmosis from the fetal vessels.
The sudoriparous are developed somewhat later than the sebaceous
glands, and probably do not secrete during intra-uterine life, though one
of the many theories of the origin of the liquor amnii was that it was
formed by their secretion.
That the serous membranes of the foetus have their normal secretion
is shown by those cases in which children are born having this secre-
tion in excess, as in cases of hydrocephalus, of hydrothorax, and of ascites.
The remarkable vascular ization of the liver in the fetus is, according
to Kolliker, proof of its great physiological importance ; but he regards
its role as an organ of secreting bile as subordinate to that of producing
in the blood special chemical and morphological modifications. The
secretion of bile begins in the third month ; a bile-like material is found
in the fifth month in the small intestine, later in the large intestine, the
precursor of meconium. The first excrement of the newborn has been
called since Aristole nnx^viov, meconium, from its resemblance to the
juice of the poppy. Its presence indicates not only secretion from the
liver, but also the activity of the intestinal glands, and its descent into
the lower portion of the large intestine peristaltic action of the intes-
tinal canal. From the seventh to the ninth month of fetal life it pre-
sents, almost the same characters as after birth ; it is homogeneous,
viscid, feebly acid, without odor, having a greenish, sometimes almost
black color; it is composed of bile and intestinal secretions with, in
exceptional cases according to some, in all cases according to others,
1 Archiv far Gynakologie, 1884.
1 60 PHYSIOLOG Y OF PREGNANCY.
materials derived from the amnial liquor, such as sebaceous secretion?
epidermic scales, and fine hairs.
Preyer states that Huber has described two kinds of meconium which are fre-
quently found in the foetal intestine, namely, the amniotic meconium, which has
as its component the swallowed amniotic liquor, and which is yellow-brown, and
the hepatic meconium, which contains bile and is dark green. The latter is also
characterized by the presence of yellow-green chiefly ovoidal bodies from 0.005
to 0.03 millimetre in diameter, which Huber has called meconium corpuscles.
The forensic proof of meconium may be given by these corpuscles ; they are gen-
erally surrounded by mucus, insoluble in ether and in acetic acid, but soluble in
potash solution.
Discharge of the meconium prior to birth rarely occurs except as a
pathological manifestation ; it is often observed in children born as-
phyxiated. The kidneys are exercised during the last half of pregnancy ;
upon an autopsy made of a foetus dying during pregnancy, it is usual
to find urine in the bladder, and it is not uncommon to see urine escape
from the newborn just after delivery, while in some cases it is expelled
during labor; hydronephrosis may occur in pregnancy from obstruction
of the ureters. Although still in dispute, the probability seems to be
that the foetus from time to time discharges urine into the amnial liquor,
for, in addition to the presence of urea in this liquid, in cases of imper-
forate urethra the bladder is found enormously distended.
FCETAL MOVEMENTS. INNERVATION. PASSIVE IDEATION.* Fcetal
movements are usually perceived by the mother some time in the fifth
month. According to Preyer, the foetus moves its upper and lower
limbs long before the beginning of the sixteenth week, probably before
the twelfth week. Many of the movements of the foetus are passive,
caused by change in the mother's position, by varying abdominal pres-
sure, by uterine contractions, and by external pressure upon the uterus.
Others result from changed conditions of the maternal blood, and they
are termed irritative movements ; many are reflex, and others impul-
sive. The life of the foetus is compared to that of a dreamless sleep
after birth. But, as Bailly has said, it is probable that a vague and
obscure will intervenes in the production of movements which the foetus
exercises after a change of position of the mother, and which appears
to have as their object the recovery of a comfortable position of which
the movement of the mother has deprived the foetus. Nevertheless, this
view is not supported by Preyer.
The question as to the capability of the foetus receiving impressions
upon the senses cannot be completely answered. As far as sight, hear-
ing, and smell are concerned, no such impressions are possible. Preyer
regards it as probable that the development of the sense of taste is the
earliest. Kussmaul has shown in one child born at eight, in another
at seven months, that impressions upon the gustatory nerves were very
distinct, as proved by the different expressions of face and movements
of its muscles, as well as those of the mouth, according as sugar or
quinine was placed upon the tongue. Jacquemier, Tyler Smith, and
[ Dr. Mortimer Granville very ingeniously maintains " that passive ideation, or the reception of
mental impressions, which are fixed as images in the mind, proceeds in utero." The argument is
interesting even if the conclusion be rejected. Lancet, 1876, vol. ii. p. 851.
PLURAL PREGNANCY. 1(31
Tarnier have each tried the following experiment : The uterus of a
pregnant rabbit being exposed, the foot of one of the young was seized
with forceps through the thin, transparent uterine wall, and immediately
the animal withdrew the member. But this movement on the part of
the foetal rabbit has been by many regarded as simply reflex, and not
indicative of pain, though probably such interpretation is erroneous.
The imperfect development of nerve ends is regarded as preventing the
sensation of pain from external impressions upon the foetus. Never-
theless, as stated by Tarnier, during intra-uterine life, especially at the
end of pregnancy, innervation ought probably to be almost as complete
as in the newborn. It is probable, too, as suggested by Harvey, there
are periods of alternate rest and action in the life of the foetus. Doubt-
less the intra-uteriue exercise of the voluntary muscles contributes to
their development, if not to the general development of the foetus.
Infantile Atavism, by Dr. Louis Robinson, British Medical Journal, December,
1891 : " The theory of Darwin that we are descended from a tree-climbing
quadrumanous ancestor led me to test the power of grip in infants, for this
seemed to be a habit indicating a means of self-preservation in remote ages,
which would most likely be still evident, owing to its supreme importance in the
past. The result was that I found that every infant, even those prematurely born,
had a very notable grasping power, and that the strongest were able to hang by
their hands and support their whole weight for over two minutes and a half."
Dr. Robinson's investigations are referred to in Revue des Revues, 1892, and it
is stated that if a finger is put upon the foot of a suspended child, it tries to grasp
it with the foot. " This instinctive movement is evidently a character derived
from the habitude of primitive races, which constitutes moreover a predominant
' quality of all quadrumana."
PLURAL PREGNANCY. When the uterus contains two or more
foetuses the pregnancy is plural. If there are two foetuses, they are
twins; if three, triplets; 1 if four, quadruplets ; and if five, quintuplets ;
and the pregnancies receive corresponding names, double, triple, quad-
ruple, and quintuple. There is no 2 established case in which a woman
gave birth to more than five children at one time. In order that plural
pregnancy can occur, a single ovary must furnish the necessary ovules,
or some may come from each ovary; or, in case of twins, one ovisac
may contain two ovules, or one ovule two germs, or the germ may split
into two germs.
Frequency. According to the investigation of G. Veit of 13,000,000
births in Prussia, twins occur once in 88, triplets once in 7910, and
quadruplets once in 371,126. In recent years there are about twelve
authentic cases of quintuplets, from various countries (Kaltenbach).
The frequency varies in different countries. Pliny stated that it was
greatest in warm climates, but modern statistics do not sustain this
theoretical opinion. Thus in France and in Belgium there are scarcely
1 Readers of Livy's History of Rome will recall the combat, iu the war of the Romans and the
Albans, between the brace of triplets, three representing each army, the Horatii and the Curiatii.
2 Nevertheless this statement as to five being the largest number of fo3tuses in the human female
must be set aside, for last year the case of an Italian woman, who in the fifth month of pregnancy
miscarried, expelling six foetuses, was reported, and the truthfulness of the report is generally con-
ceded. See London Lancet, October 20, 1888.
Soon after the publication of this case of sextuplets in Italy, some patriotic American Ananias
published in a Western newspaper an account of a similar event having occurred in the interior
of Texas, with a description of the six living children, stating also the names that had been given
them.
11
162 PHYSIOLOGY OF PREGNANCY.
ten twin births in a thousand cases of labor, while in Denmark and in
Sweden the proportion is between fourteen and fifteen, in Ireland be-
tween sixteen and seventeen to the thousand. 1 It is thus evident that
climate is not a factor in determining the frequency of plural preg-
nancies. A remarkable difference in the proportion 2 of twin to single
pregnancies is found in different Italian cities. While in Genoa there
is 1 to 54, Milan 1 to 56, in Palermo the proportion is only 1 to 114.
Between Genoa and Milan at one extreme and Palermo at the other, in
regard to the relative frequency of twin pregnancies, are placed Padua,
Trente, Turin, Bologna, and Naples.
Causes. In addition to climate, race, stature, and the great develop-
ment of the ovaries have been regarded as causes of pluriparous preg-
nancies. But, whatever influence may be attributed to any of these, the
chief causes are multiparity and heredity. The statistics of Duncan
show that the number of pluriparous multipart is about eight per cent,
greater than that of pluriparous primi parse ; those of Puech show that
multipart have triplets eight times as often as do prirniparse. Heredity
seems to be a more potent cause. Female twins often give birth to
twins. A woman had twin pregnancies three times, her daughter had
two twin pregnancies, and her daughter in turn a twin pregnancy. In-
stances in which this manifestation of heredity was transmitted to the
male are also recorded. Leroy states that four brothers, in whose
family twin pregnancies in the parents of a collateral branch had been
observed, procreated twins three of them twice each, and the fourth
four times.
The cases just cited indicate that excessive fecundity, though usually
belonging to the female, as a cause of plural pregnancy, may depend
upon the male.
Sue mentions the case of a man whose wife gave birth to triplets seven times
in seven years, and then seducing his servant girl she gave birth to triplets. Nor
is the case of the Russian peasant, Feodor Wassilief, to be omitted. It was
quoted by Velpeau from Merriman ; 3 this peasant was married twice, and his
first wife had quadruplets four times, triplets three times, twins sixteen times, in
all sixty -nine children ; his second wife had triplets twice, and twins six times,
making her contribution only eighteen to the entire number of seventy-seven.
Moreover, eighty-four of these children and the father, who was then eighty-five
years old, were living at the time the English merchant, whose story Merriman
publishes, visited Russia.
In sixty-one cases of twin pregnancy, analyzed by Kleinwachter, the
youngest mother was nineteen, the oldest forty-one years ; in 67^^- the
pregnancies occurred in women between twenty-three and twenty-nine
years of age, a fact which does not sustain Matthews Duncan's view
that " plariparity is an unnatural or abnormal condition connected with
sterility by being observed in the sterile ages, or ages of weakness or
imperfection of the reproductive power. 4
J Berlin, Nice-M6dical, December, 1888, in the study of the births at Nice for twenty-seven years,
in all 56,505, finds that the proportion of twin births was 1 in 75. of triplets 1 in 5575.
2 De robstetrique en Italic. Millet.
3 Merriman apparently believed the story, for in quoting it from the Gentleman's Magazine, 1783,
he also quotes the following " The above relation, however astonishing, may be depended upon,
as it came directly from an English merchant in St. Petersburgh to his relation in England, who
added that the peasant was to be introduced to the Empress."
Sterility in Women.
PLURAL PREGNANCY. 163
SUPER IMPREGNATION. The question naturally suggests itself as
to whether the ovules which are developed in plural pregnancy are
fecundated simultaneously or at different times. In the case of many
of the pluriparous inferior auimals fecundation is simultaneous ; for
example, the boar impreguates the sow at a single coition. So it may
be in the human female, and possibly is in the majority of cases. But
super- impregnation is, arbitrarily at least, divided into super-fecunda-
tion and super- foetatiou. By the former is meant the fecundation of
one or more ovules after one has been fecundated, that is, successive
instead of simultaneous fecundation ; by super-foetation 1 is meant fe-
cundation effected after the uterus is occupied by the product of concep-
tion. The latter requires the occurrence of ovulation several days,
weeks, or even months after the ovule was liberated which was first
impregnated.
That super-fecundation may occur in the human female, as well as in
some of the inferior animals, is certain. Thus a white woman has
twins, one a mulatto, the other white; or of a black woman's twins one
is black, the other a mulatto. The only rational explanation is that in
each case each child shows a different paternity. A mare may be
covered by a stallion, and at an interval varying from a few hours to
fifteen days is covered by an ass ; she has twins, one a horse, and the
other a mule. A bitch in heat is covered by different dogs, and in her
litter the puppies may indicate different fathers.
But when super-fecundation occurs in the human female, the fact is
presupposed that the ovules impregnated are liberated from their ovisacs
at the same menstrual period. Nature intended her to be uniparous,
and once fecundation has occurred ovulation 2 usually is suspended, so
that the probability of super-foetation is at once opposed by a physi-
ological reason ; in other words, there is no ovule to be impregnated.
This is admitted as a law ; nevertheless, as claimed by some, there may
be exceptions.
There is, however, an anatomical argument derived from the condition
of the uterine cavity occupied by the developing ovum ; room for the
spermatozoids to pass to the ovule, and then space for the entrance of
the latter into the uterus, present theoretical objections. It must, how-
ever, be admitted that prior to the union of the ovular and uterine
decidua, which, as has been before stated, occurs some time in the fourth
month, there is no invincible anatomical obstacle to a new impregna-
tion occurring. Nevertheless, with the difficulty just mentioned, and
with the physiological one arising from the suspension of ovulation
during pregnancy, the improbability of the occurrence of super-foetation
is very great ; the strongest argument against super-foetation is given
by Auvard in the fact that in five-sevenths of plural pregnancies there
is but a single placenta. Auvard also states that super-fcetation is only
possible in cases of a double uterus or of an ectopic gestation.
1 In regard to super-foetation in animals, some curious and absurd statements are made by He-
rodotus ; see Gary's translation, p. 216.
2 Playfair gives the occurrence of menstruation as a proof of ovulation. Before admitting such
an argument, it must first be proved that menstruation does then occur ; next it must be proved
that ovulation and menstruation are always necessarily connected. A woman may menstruate
after her ovaries have been removed ; and, according to Play fair's argument; she necessarily
ovulates.
164 PHYSIOLOGY OF PREGNANCY.
The hypothesis of super-foetation is proposed, first, to explain those
cases in which there is simultaneous expulsion of the products of con-
ception, one large, well-developed foatus, and the other a small and
feeble foetus, 1 or the second product may be still in the embryonic con-
dition. But twins usually differ in size and vital power, and this differ-
ence may be so great that the feeble ones dies soon after birth : it may
depend upon the fact that one was better supplied with nourishment
than the other and prospered to the detriment of its companion, or there
may have been an inherent difference in the vitality of the ovules im-
pregnated. Where one product was still embryonic and the other well
developed, the answer is, the former died early in pregnancy and re-
mained without material change until the pregnancy ended.
But, second, the hypothesis is thought to explain the cases in which
several days, weeks, or, as is alleged in some cases, months intervened
between the birth of twins. In some of these instances the mother was
found to have a double uterus ; one foatus was contained in one-half, the
other in the other half of the organ ; and under such circumstances
possibly a considerable interval occurred between the impregnations.
But most of the cases correspond to a premature labor or miscarriage
with one foetus, while the other was retained until full term or somewhat
beyond.
Many of the facts adduced to prove super-foetation belong to a past
age, when such marvels were more readily accepted than to-day; and as
a rule they fail in the details and thoroughness of investigation neces-
sary to establish their truth. " Few authors to-day believe in the reality
of super-foetation." 1 DoleVis suggests that super-fecundation that is,
the fecundation of several mature ovules expelled from the ovisacs at
the same period may occur within fifteen days, or at most three weeks;
after about this time fecundation seems impossible.
FCETAL APPENDAGES IN TWIN PEEGNANCIES. Where two ovules
from different ovisacs are impregnated, each foetus has its own chorion
and amnion, and originally the ovular decidua of each was distinct, but
the portion intervening between the two sacs is absorbed, so that they
have a common decidua. The placentae may be closely united, but there
is no vascular connection ; there is entire independence as to the circu-
lation in each.
If there be a single placenta with one chorion and two amnions,
either there were two germs in one ovisac, or the germinal vesicle has
furnished two germinal areas. The bloodvessels of the twins commu-
nicate in the placenta. (Fig. 96.) Either the twins are well developed,
or the greater heart activity of one takes away the nourishment needed
by the other, and the latter dies. The twins are of the same sex. Most
rarely there are one placenta, one chorion, and one amnion. - The amnion
folds between the two may have been absorbed because of pressure ; or
the origin of the twins may have been from the division of a germ ; the
twins are of the same sex.
1 In a litter of pigs it is not unusual to find one, generally the last born, smaller, feebler, and
more poorly developed than any one of its brothers or sisters ; it is commonly known as the runt ;
but farmers never adduce this fact as a proof of super-foetation.
* DoUris.
PLURAL PREGNANCY.
GRAAFIAN FOLLICLE WITH TWIN OVULES. (After v. HERFF.)
SEX, SIZE OF TWINS, COURSE OF THE PREGNANCY. In the great
majority of cases twins are of the same sex, and males predominate over
females. The united weights of twins at birth is usually greater than
that of a single foetus at the same period of development, but the weight
of each is considerably below the mean ; generally one of the twins is
larger and stronger than the other. One of the children may die early
in the pregnancy, and either be expelled with its appendages and preg-
nancy go on, or be retained and the liquor amnii absorbed, while it under-
goes the change called mummification ; or it may be pressed against the
uterine wall by the other foetus and its membranes, so that it is flattened,
making a thin mass called foetus papyraeeus. In other cases the con-
dition previously mentioned as to the heart of one of the twins having
greater power than that of the other may be present, and the latter fail
in development, except as to the lower part of the body and lower limbs,
and a monster known as acardia results, while the former is perfectly
developed.
Abortions, polyhydramnios, and monstrosities are more frequent in
plural than in single pregnancies ; acephalous monsters are only found
in the former.
Premature labor frequently occurs in twin pregnancies, its usual
cause being excessive distention of the uterus. Triple pregnancies
rarely, and quadruple probably never, reach the normal term.
CHAPTER VI.
CHANGES IN THE MATEENAL ORGANISM.
THE changes in the impregnated ovule having been traced from their
beginning in conception to their end in the completely developed foetus,
there are now to be considered the modifications which pregnancy causes
in the maternal organism ; in a word, to present the natural history of
pregnancy in regard to the mother. The changes in the maternal
organism caused by pregnancy may be divided into general and local.
GENERAL CHANGES. These chiefly involve the digestive apparatus
and nutrition, the heart and the blood, respiration, the nervous system,
the skin, and the urinary apparatus and secretion.
MORNING SICKNESS. Gastric disturbance is an almost constant
phenomenon manifested in the first mouth of pregnancy. From the fact
that nausea and vomiting are more frequent in the early part of the day,
or if occurring at other times are usually more severe then, the disorder
is commonly known as morning sickness. In some cases it may be so
slight as scarcely to constitute an indisposition, only a transient dis-
comfort, but in others so severe as to be a grave disease. It may begin
soon after the supposed time of conception, but more frequently at the
first following menstrual suppression ; in either case it usually abates or
disappears some time in the fourth month. In most cases the desire for
food is lessened, and in women whose nausea is great or constant dis-
gust may supersede desire.
In a very few cases pregnancy seems from the first to increase the
appetite, digestion is good, and the subject is in better health than usual.
In still others the appetite may be capricious, fickle as to kinds of food,
or wishing for those articles which at other times are not cared for, or,
finally, it may be perverted. The whimsical or perverted appetences of
pregnant women, commonly known as " longings," are in some cases
assumed, or imaginary, not real ; a primigravida, for example, has read
or heard stories of such u longings," and believing them natural to her
condition, the step is but a short one to imagining she has them. In
the word mother-marks there is perpetuated the once popular belief that
if the desire or longing of the pregnant woman for some particular
article of food is not gratified, the fetus will be marked.
Pliny used the word malaria to express the " longings " of pregnant women.
A distinction has been made by some between malaria and pica, the former being
used to signify that the appetite sought unaccustomed, but still nutritious, sub-
stances for food, while in the other there was a complete perversion of the
appetite, which sought materials, such as chalk or charcoal, that were entirely
indigestible, or which were repulsive and disgusting, like feces. But this dis-
tinction has not been generally held.
The word pica is the Latin for magpie, and was used, Gardien says ( ft-aiti
Complet d'Accouchements), to signify the whimsicalities of pregnant women and of
CHANGES IN THE MATERNAL ORGANISM. 167
chlorotic girls, because there was thought to be an analogy between their appe-
tites and the parti-colored plumage of the magpie, or its inconstancy as shown
in hopping from one to another branch of the tree on which it is perched.
Strange stories have been told of these "longings," as, for example, of a preg-
nant woman who longed for salted herring, and ate fourteen hundred during her
pregnancy; or of another who longed for a bite of the baker's shoulder, and the
kind husband, fearing he would lose his wife if the longing were not gratified,
got the baker's consent, and she took two bites ; and of another who longed so
earnestly to eat her husband that she killed him, ate heartily of his body, and
then pickled the rest for future consumption. 1
In the latter part of pregnancy, before descent of the uterus has
occurred, and while the fundus is pressing upon the stomach, some
women have a recurrence of gastric disorder, but this is slight and tran-
sient. Neither this manifestation nor that of the earlier months should
be confounded with the graver form of the disorder, which may occur
as a symptom of albuminuria and a forerunner of eclampsia.
It is easy to understand, as observed by Stoltz, that the irregularity
or depravation of the digestive functions in the early months of preg-
nancy must cause imperfect nutrition. " Hence the pregnant woman
emaciates in the first month; her appearance is bad that is to say, her
features are drawn, her eyes surrounded by dark circles, and her
expression becomes more or less dull. She is sluggish, melancholy,
drowsy. In a word, there is developed a condition more or less resem-
bling chloro-ansemia." But the nausea generally ceasing with the
beginning of the fourth month, at least before or by the middle of this
month, foetal movements being recognized by the mother, all uncer-
tainty as to her condition is removed, the appetite is restored, digestion
becomes better, her general condition is greatly improved, nutritive
processes are quickened, and she gains in weight. This increase of
weight is greatest in the last three months of pregnancy, being, accord-
ing to the investigations of Hecker and Gassner, from one kilogramme
and a half to two kilogrammes and a half each month. A woman's
weight is about one-thirteenth greater at the end than it was at the
beginning of pregnancy. " In the cases when the weight lessened in
the eighth or ninth mouth Gassner ascertained conditions unfavorable
to nutrition ; for example, the death of the foetus and its retention in
the uterus. This phenomenon^ observed in three instances, always had
as its consequence a diminution of the weight of two to three kilo-
grammes in a period of eight to fifteen days." 2
CHANGES IN THE BLOOD AND CIRCULATORY APPARATUS. The
blood-changes resulting from the pregnant state relate to quantity and
quality. There is a decided increase in the amount of blood, this increase
1 In the following passage, from Bartholomew Pair, these "longings " are well satirized : "Oh,
yes ! Win ; you may long to see, as well as taste, Win : how did the 'pothecary's wife, Win, that
longed to see the Anatomy, Win? or the lady, Win, that desired to spit i' the great lawyer's
mouth, after an eloquent pleading?"
The universal and deep-rooted popular belief in the "longings" of the pregnant woman, and
the necessity for their gratification, have no more striking; illustration than isigiven in one of the
Coventry Miracle Plays (Ancient Mysteries Described ; Especially the English Miracle Plays, by
William Hone, London, 1823). Mary and Joseph are passing along the road, when they come to a
cherry-tree laden with ripe fruit; she ' longs" for the cherries, which he refuses to get for her,
when the tree miraculously bends its branches to her, and her wish is at once gratified. Hone
states that a Christmas carol founded upon the play, and in which this incident is fully given,
was in his day sung in London and many parts of England. There was not a thought of irrever-
ence in play or in song. The event was regarded as natural and necessary.
2 Tarnier.
168 PHYSIOLOG Y OF PREGNANCY.
beginning about the middle of pregnancy. When we consider the
greater nutritive demands, especially for the foatus and its appendages
and for the uterus, and the larger area of the circulation, an increase in
the quantity of the blood is obviously necessary. It has until quite
recent years been held that in the course of pregnancy the watery por-
tion of the blood became more abundant, the fibrin and the white cor-
puscles increased, and the red corpuscles lessened. But the researches
of Fehling, 1 Reinl, and Richard Schroder prove that the haemoglobin
and the red corpuscles are notably increased. Vinay, 2 while admitting
that in the majority of cases the blood becomes richer, the globules
more numerous, their globular value augments, and these modifications
confirm the theory of plethora, so long admitted by physicians, that this
globular richness undergoes exceptions, and in some women pregnancy
is the occasion of auaamia.
Hypertrophy of the heart, as a constant phenomenon of pregnancy, was
first made known by Larcher in 1857. This hypertrophy, like that ot
the uterus, disappears after the pregnancy has ended. By Blot the
increase in the weight of the heart was stated to be about one-fifth.
Lohlein 3 and Gerhardt have denied cardiac hypertrophy in pregnancy.
The recent investigations of Dreysel, in the Munich Pathological In-
stitute, prove that there is a slight eccentric hypertrophy of the heart,
chiefly of the left side.
The greater activity of the circulation is manifested by increased
arterial tension. The veins, too, are fuller, and varicose enlargements
frequent.
RESPIRATION. The base of the thorax is increased during preg-
nancy, while its vertical and antero-posterior measurements are lessened;
but it seems doubtful if the former increase in the pulmonary capacity
compensates for the loss resulting from the two other changes men-
tioned. The pregnant woman, when the uterus has risen so high as
to interfere with the normal descent of the diaphragm in inspiration,
suffers from hurried breathing, or from dyspnoaa, when making great
bodily exertion, as in rapid walking or ascending steps. 4
The quantity of carbonic acid eliminated by the lungs constantly
increases as pregnancy advances.
URINE AND URINARY APPARATUS. The blood now being increased,
as well as the arterial tension, 'the quantity of urine secreted is greater.
But this increase of urine is almost exclusively of its watery portion ;
with the exception of the chlorides, the solid constituents progressively
lessen with the duration of the pregnancy. The lessened elements are
phosphates, sulphates, urates, uric acid, creatin and creatiuin ; and the
suggestion, which in part seems quite probable, has been made that the
lessened elimination of these in the urine may result from their being
used in fetal development.
1 Runge, Geburtshulfe, second edition, 1894, and Kaltenbach, Lehrbuch der Geburtshulfe, 1893.
2 Traite des Maladies de la Grossesse, 1894.
8 Lehrbuch der Geburtshulfe, second edition, 1893.
4 This fact would seem conclusive as to lessened pulmonary capacity. Nevertheless the measure-
ments made by Kuchenmeister, Fabius, Wintrich, and more recently by Vegas in Winckel's clinic,
show that there is no change even in the latter months of pregnancy.
CHANGES IN THE MATERNAL ORGANISM. 169
Kyestein, from the Greek wr/aig, pregnancy, is, as described by Nauche in 1831,
a white, grumous, soft pellicle found upon the urine of a pregnant woman about
thirty-six hours after it has been passed ; about the fifth day this pellicle breaks
up and falls to the bottom of the vessel. The late Dr. Elisha Kent Kane, who
became so famous as an Arctic explorer, in 1841 verified by observations at the
Philadelphia Hospital the statements of Nauche and other foreign investigators
as to the presence of kyestein in the urine of pregnant women, and as to its
character. Subsequent investigations, however, have proved that kyestein is not
an organic substance, but is chiefly composed of ammonio-magnesium phosphates,
vibrions and monads ; it may be found in the urine of the non-pregnant as well
as in the urine of pregnant women, and also in that of the male.
Renal congestion may result from compression, and albuminuria fol-
low. According to Spiegelberg, it is not rare to find albumin in the
urine, especially during the latter- weeks of pregnancy, and he regarded
it as usually depending upon a vesical catarrh. The results of observa-
tions made in the Philadelphia Hospital lead me to believe that albumin
is not found in the last month of pregnancy oftener than in one out of
ten women. In a very small proportion, probably not more than 6
per cent., sugar is present in the urine in the last weeks of pregnancy.
The close attachment of the bladder to the uterus produces changes
of position of the former corresponding with those of the latter organ ;
thus, in the earlier weeks of pregnancy, the bladder descends somewhat
with the uterus, and its full expansion is prevented ; hence vesical irri-
tability is one of the first symptoms of pregnancy. Observation shows
that the majority of pregnant women suffer from some disturbance or
disorder of the bladder, the liability being greater in primigravidse than
in multigravidse.
CHANGES IN THE SKIN. Pigment deposits may occur upon the face,
the forehead, the mamma?, the labia, and upon the abdominal walls.
Pigmentation of the mammae and nymphee will be described in another
place. Irregular yellowish-brown patches upon the forehead and the
face form what has been called the mask of pregnancy. The intensity
of the color 1 varies in different subjects ; the patches become less dis-
tinct after pregnancy, but do not disappear, and are renewed at each
succeeding pregnancy. In most cases a pigment deposit is found in
the median line of the abdominal wall ; it is more marked in brunettes
than in blondes, but is very indistinct in those having red hair. The
pigment band is two or three fingers' breadth, and reaches from the mons
veneris to the umbilicus, in some cases to the xiphoid cartilage, and
then there is a ring of discoloration about the umbilicus, the umbilical
areola ; the band is more distinct below than above. No satisfactory
explanation of these discolorations has been given, though they probably
are the consequence of a more rapid destruction of red corpuscles. Dr.
Barnes 2 has suggested that the pigmentation of pregnancy is dependent
upon a functional modification of the supra-renal capsules, while Jeannin 3
1 " Bomare, in article cited by Blumenbach, mentions a French peasant whose abdomen became
entirely black during each pregnancy ; and Camper gives an account of a female of rank who
began to be brown as soon as she was pregnant, and before the end was as black as a negress.
After delivery the color gradually disappeared. Le Cat relates the case of a female who was
similarly affected in the face only during three successive pregnancies ; and Gardien has recorded
another." (Laycock on the Nervous Diseases of Women.)
2 Transactions of the American Gynecological Society, vol. i.
s Gazette Hebdom., 1868
170 PHYSIOLOGY OF PREGNANCY.
attributed it to the amenorrhoea of pregnancy. Localized 1 eczema and
seborrhcea, especially upon the face and head, are often seen.
The anterior wall of the abdomen becomes thinner. The enlarged
uterus causes it to project, the projection being much more marked
when the woman is standing than when she is lying ; thus, according to
Schroder, the measurement at the end of the pregnancy, from the
xiphoid cartilage to the pubic joint, is, if she be standing, eighteen
inches and a half, 47 centimetres, but if she be lying, it is a little less
than sixteen inches, 40 centimetres.
During the first three months of pregnancy the umbilical depression
is slightly increased, or unchanged ; in the fifth month it has become
less, and at seven months has disappeared ; in the last two mouths
there is more or less umbilical protrusion.
Striae, strice gravidarum, linece albicantes, or cicatrices of pregnancy,
usually occur in the first pregnancy, and it is not uncommon for new
ones to be observed in subsequent pregnancies. These stria? are in
most cases abdominal, but in some are found upon the hips and thighs,
and then are not connected with the pregnant state, or they are upon
the breasts ; the last in most instances originate after labor. When
recent they have a pinkish or bluish-red tint, but after labor they
become white, or pearl-colored ; generally their surface is depressed,
but in some cases, as the result of serous effusion from compression of
the epigastric vein, it is prominent. They are caused 2 by partial or
complete atrophy of the lymph spaces, partial atrophy of the skin, and
longitudiual arrangement of the fibres of connective tissue. They are
generally in four concentric zones, the centre being an inch or more
below the umbilicus. They do not usually become well-marked until
the seventh month, and in the primiparous are a sign of some value in
the diagnosis of pregnancy ; nevertheless they are absent in from six to
ten per cent, of pregnant women. Montgomery 3 mentions the case of
a woman who had borne five children, nursing three of them, and yet
there were no cicatrices. According to Crede they are absent in 10 per
cent., and according to Hecker in 6 per cent. Schultze has found them
in 36 per cent, of women who have not borne children.
CHANGES IN THE NERVOUS SYSTEM. Pregnancy increases the
nervous sensibility, and hence numerous reflex disturbances may occur.
There may be occasional rigors, dizziness, flashes of heat, hysterical dis-
orders, fainting, disturbances of special senses, especially of sight and
hearing, and neuralgic affections, those of the teeth being very frequent.
In regard to the mental state, the general rule is women become more
sensitive, and in the majority, probably, despondent feelings prevail.
Dr. Hodge has remarked that " gestation has a very happy influence
upon the minds of a few women ; they feel well, their mental powers
are active, their imagination excited, so that they become more inter-
ested in reading, writing, or other intellectual pursuits than at any former
period; they become more cheerful, and more interested in the ordinary
affairs of life." Unfortunately this picture is of the few. A larger
1 Spiegelberg.
2 See contribution by Dr. Busey, Transactions American Gynecological Society, vol. iv.
2 Signs of Pregnancy.
CHANGES V THE MATERNAL ORGANISM. 171
number have needless anxiety as to their safely passing through labor
and as to the life and health of their offspring. The majority, however,
as the pregnancy goes on, become reconciled to their condition, and pati-
ently wait its end, while some indeed look forward to becoming mothers
with joyful expectation. Even in those women whose pregnancy is
marked by despondency and anxiety, it is not unusual as it approaches
its end to find the cloud lifting, and they are ready to meet their final
trial patiently, bravely, and hopefully.
OSTEOPHYTES HYPERTROPHIES OF VARIOUS ORGANS. Before
describing the modifications of the sexual organs caused by pregnancy,
brief reference will be made to some other changes. Osteophyte was
the name given by Lobstein to a formation originating from the
bone or from the periosteum. Rokitansky, in 1838, found in post-
mortem examinations that in more than one-half of pregnant women
there were growths upon the internal table of the cranial bones, and ex-
ternal to the dura mater, bone-like formations which he called osseous
neoplasms or osteophytes. Similar deposits have been found upon the
inner surfaces of the pelvic bones of women dying in childbed. Osteo-
phytes have no effect upon the cerebral functions, nor do they belong
exclusively to pregnancy, for they have been found in the tuberculous.
In addition to hypertrophy of the heart, which has been referred to,
and that of the uterus, which will be hereafter described, some other
organs, among which are the spleen, the kidneys, the liver, and thyroid
gland, increase in size in the pregnant woman. The increase in the
spleen is about one ounce and a quarter, forty grammes. Since Demo-
critus, swelling of the neck has been popularly regarded as one of the
signs of conception, and Cazeaux has remarked that hypertrophy of the
thyroid gland, independent of any local disease or of endemic influence,
is not rare during pregnacy. If the thyroid be hypertrophied in a
pregnancy, the hypertrophy lessens subsequently, but does not entirely
disappear, and it increases with each succeeding gestation.
LOCAL CHANGES. Under this head it is proposed to describe modi-
fications which occur in the external and internal genital organs, and
in the parts adjacent to them, in the pelvic joints, and in the mammary
glands.
CHANGES IN THE EXTERNAL, ORGANS OF GENERATION AND OF
THE VAGINA. It is not until about the fourth month of pregnancy
that changes in the external genitals are noticeable. The secretion of
the vulval glands is increased ; the great and the small lips are larger,
more elastic, resisting, and darker, pigmentation often being quite de-
cided upon the external surfaces of the labia majora ; the veins and
venous plexuses are fuller; in some cases varicosities are present; the
vulval orifice is more open. A greater supply of blood in the vagina
causes distinct throbbing of the vaginal arteries the vaginal pulse
which Osiauder spoke of as one of the signs of pregnancy. From
venous stasis the color of the vagina changes, becoming much darker,
so that it is purple or of a violet hue, which is regarded by Jacquemiu
and Kluge as an almost certain sign of pregnancy ; its value, however,
is lessened by the fact that a similar change of color has been observed
in menstruation. The temperature of the vagina is slightly increased ;
172 PHYSIOLOGY OF PREGNANCY.
its raucous membrane is swelled ; a more abundant secretion is present,
and the papillae are larger and more distinct, so that the surface may be
somewhat rough. The muscular coat, especially in the upper half of
the vagina, is hypertrophied. The vagina is lengthened by the ascent
of the uterus, but shortened again when the uterus descends, and also
then greatly expanded, admitting the entrance of the presenting part of
the fetus covered by the uterine walls.
CHANGES IN THE PERINEUM. The perineum is more freely sup-
plied with blood, it is somewhat hypertrophied, and it is gradually pre-
pared for the great distention to which it is subjected in labor. Tarnier
states that in many experimental applications of the forceps in women
who died in pregnancy, or soon after labor, and in others who died not
having been pregnant, he found in the last the perineal floor quite resist-
ing and very liable to rupture.
CHANGES IN THE PELVIC JOINTS. These joints are swelled and
softened, and some movement in the pubic joint can usually be detected ;
but the opinion that in either this or in the sacro-iliac joints there is
great increase of pelvic diameters, facilitating the passage of the child,
is not generally held by obstetricians.
CHANGES IN THE UTERUS. These are the most important of all the
modifications in the maternal organism caused by pregnancy. They
affect the structure, size, capacity, form, weight, position, relations, and
functions of the uterus. Some of the modifications of the uterus may
occur independently of the presence of the ovum in its cavity, for they
are present in extra-uterine pregnancy, but they are then limited in
degree and in duration. It will be convenient to consider first the
changes which occur in the body, and then those in the neck of the
uterus.
MODIFICATIONS OF THE UTERINE WALLS. A larger supply of
blood to the uterus causes increased growth of its tissues. The mus-
cular fibres become relatively colossal, increasing from seven to eleven
times in length, and from two to five times in breadth ; "embryonic
muscle cells, that have been stored up for the time of need," now grow
into larger and contractile forms; both hypertrophy and hyperplasia
occur. The serous coat is also developed in correspondence with the
general growth of the organ, but its connection with the underlying
muscular tissue is probably as intimate as in the non-pregnant condition.
The very great hypertrophy of the mucous membrane has been stated,
and the early history of the deciduous membranes traced. By the end
of the third month of pregnancy the decidua of the ovum, ovular decidua,
decidua reflexa, and the uterine decidua, decidua vera, are in contact.
In the course of the fourth month the two layers coalesce, making a
single membrane, which in turn is closely united with the chorion, the
external covering developed by the ovum, and thus the ovum has not
only the closely united chorion and amnion, but also external to these
the decidua. The mucous membrane of the uterus in pregnancy has no
longer ciliated, but pavement-epithelium.
The decidua, formed by the conjoined ovular and uterine decidua,
atrophies, grows thinner, and in preparation for being thrown off with
the ovum gradually becomes detached from the uterus. But the mus-
CHANGES IN THE MATERNAL ORGANISM.
173
cular tissue is not left bare by this detachment. Some physiologists,
among them Robin, asserted that a new mucous membrane begins
forming behind the decidua at four months ; Dr. Matthews Duncan's
criticism upon this view is that it implies at some time the muscular
tissue was left bare, aud that it produces upon its surface a mucous
tissue heterologous to it. According to Friedlander, the decidua is at
the end of pregnancy reduced to two layers, superficial and deep ; the
latter is composed of glandular culs-de-sac and connective tissue, aud the
former of cells in fatty degeneration, and this only is thrown off.
Engelmann also states that only the superficial part of the decidua vera
is discharged. Ercolaui 1 taught that the uterine decidua was a product
of materials elaborated by the utricular glands, and that the ovum,
arriving in the uterus already covered by this decidua, soon itself
receives a similar investment, this covering fixing it at a particular part
of the uterus. The deciduous membranes were regarded by him as
exudations, new formations. His views have not met professional
acceptance.
FIG. 97.
d
SECTION THROUGH THE DECIDUA. (FRIEDLANDER.)
a. Amnion. b. Chorion. c. Decidua. d. Uterine muscle, e. Line of separation in the
cellular layer. /. Cellular layer, g. Glandular layer.
MODIFICATIONS OF ARTERIES AND VEINS OF THE UTERUS. The
arteries of the uterus increase in length, in volume, and in number.
Jacquemier has stated that their increase in length cannot be attributed
to their becoming less flexuous, for they are more flexuous at the
end of gestation than they are in the non-pregnant uterus. The ovarian
arteries acquire a diameter of nearly one-sixth of aa inch, four and a
half millimetres, and the uterine arteries are still larger ; the branch on
each side connecting the uterine and the ovarian arteries is larger than
the radial ; its course is nearly parallel with the epigastric, and it has
received from Glenard, 2 who thought it the seat of the uterine souffle,
the name of puerperal artery. Arteries upon entering the uterus sud-
1 Utricular Glands of the Uterus. Translated from the Italian by Dr. H. D. Marcy.
2 This theory of the uterine souffle has been proved erroneous.
174 PHYSIOLOGY OF PREGNANCY.
denly enlarge ; branches of the one side anastomose freely with each
other and with those from the other side ; they are situated nearer to
the peritoneal than to the mucous coat, except in the vicinity of the
placenta ; those which pass to the mucous coat make numerous sub-
divisions, and end in an extensive capillary network. The venous
system in the muscular coat is composed of a large number of sinuses or
large canals which communicate with each other ; some of the vessels
are as large as the little finger. They are without valves, and in the
middle muscular layer are reduced to a single coat, which, however, is
closely adherent to the surrounding muscular fibres. They are more
numerous in the vicinity of the placenta. The ovarian veins become
almost equal in size to the external or internal iliac.
CHANGES IN THE SIZE, CAPACITY, AND FORM OF THE UTERUS.
Increase of the constituents of the uterus is associated with remarkable
development of the organ in size and capacity. The uterus undergoes
very great eccentric hypertrophy, so that at the end of pregnancy it
measures, according to Spiegel berg, about twelve inches and three-
quarters, 35 centimetres, in length, about nine inches and a half, 24
centimetres, in breadth, and autero-posteriorly nine inches, or 23 centi-
metres. The late Sir James Simpson gave the following measurements
of the uterus : length twelve to fifteen inches, breadth nine to ten inches,
the antero-posterior measurement six to eight inches. He further stated
the surface of the unimpregnated uterus is five or six square inches, and
its capacity one cubic inch ; but at the end of pregnancy the surface of
the organ is three hundred and fifty square inches, and its capacity four
hundred cubic inches. Tarnier regards the last measurement as somewhat
exaggerated; Krause states the capacity is increased 519. The weight
of the uterus is twenty to twenty-four times greater than in the virgin
state. Spiegelberg attributed the greater size of the uterus partly to
the organ being stretched by the ovum, claiming that the thickness of
the walls, which increases during the first months, diminishes in the
latter months so that it is less than before impregnation. Velpeau and
Depaul both held that pregnancy caused no great change in the thickness
of the walls, a view sustained by Charpentier ; the uterine walls are
thinner at the inferior segment, thicker in the fund us and body, espe-
cially at that part to which the placenta is attached, according to Naegele
and Grenser. Tarnier holds that the thickness generally lessens toward
the end of pregnancy, but is quite variable in different subjects, and is
very unequal in different parts. It is impossible, therefore, to fix a
uniform measure for the thickness of the walls of the pregnant uterus.
The uterus has different forms in the successive periods of pregnancy.
During the first three months it becomes pyriform instead of triangular.
After three months it gradually takes the form of a flattened spheroid,
and it is only in the latter part of pregnancy that it becomes ovoidal,
the smaller end of the ovoid being below. Nevertheless, as remarked
by Spiegelberg, the uterus is not to be regarded, especially in the latter
months, as a rigid body with a constant form, for many deviations
occur, the shape depending upon the woman's position, the volume of
the ovum, the situation of the foetus, the tension of the organ, and also
upon its primitive formation.
CHANGES IN THE MATERNAL ORGANISM. 175
CHANGES IN THE POSITION OF THE UTERUS AND IN THE CONSIST-
ENCE OF THE UTERINE WALLS. Modifications in the weight and in
the size of the uterus necessarily cause changes in its position. It is
generally taught that in the first weeks of gestation the uterus is lower
in the pelvis ; and indeed a flattening of the hypogastrium caused by
this descent 'is regarded as one of the earliest signs of pregnancy.
Tarnier thinks this change far from constant ; in a great number of
women the fund us of the uterus from the first weeks of pregnancy
passes the superior pubic margin, and the neck does not descend.
However this may be, at three months the fundus is a finger's breadth
or more above the pubes ; at the end of the fourth month it is two
inches or more, five to six centimetres, above ; at five months 3.5 to 3.9
inches, nine to ten centimetres, above ; the distance of the fundus above
the pubes increases, becoming greatest in the first half of the ninth
month, when it amounts to 8.6 to 9.4 inches, 22 to 24 centimetres. In
the last two weeks there is usually a marked descent, arising from the
entrance of the fetal head, still, however, inclosed in the uterus, into
the pelvic cavity. It should be remembered that in the multigravida
previous relaxation of the abdominal wall permits the uterus to project
further in front, and does not compel the fundus to ascend as high as
does the tense abdominal wall of the primigravida. Further, in the
latter the descent of the presenting part into the pelvic cavity occurs
earlier. While the chief factor in producing this descent is the resist-
ance of the abdominal wall to further encroachment of the growing
uterus, yet another factor is the uterus itself, which in the primigravida
is more rigid, and, according to Martel, 1 this rigidity maintains the axis
of the foetal ovoid in correspondence with the axis of the uterus, hence
there is a tendency to force the lower part of the uterine ovoid into the
pelvic cavity.
The uterus after ascending into the abdominal cavity in very few
cases occupies a median position, for its posterior convex wall is not
adapted to the convexity of the spine, and the organ therefore turns to
one or the other side to the right side in the great majority of women.
This obliquity of the uterus, probably having its cause in a condition
of embryonic development, should be borne in mind in case gastro-
hysterotomy is to be done. So; too, the normal latero-version may in
labor retard the descent of the foetal head, and require to be corrected
by changing the position of the woman. But iu addition to the usual
right obliquity, there is also a partial rotation of the uterus by which
the left side of the organ is thrown forward, and the right backward, a
change very plainly dependent upon its embryonic development, as has
been previously mentioned. This change of position causes the left
side of the uterus to be more accessible in auscultation made for the
purpose of hearing the uterine souffle.
The consistence of the uterine wall is greatly changed. Instead of
being rigid and resisting as in the unimpregnanted uterus, it becomes
yielding to localized pressure from within or from without ; but it is also
elastic, so that as soon as the pressure is removed there is complete res-
1 De 1'Accommodation en Obstetrique.
176 PHYSIOLOGY OF PREGNANCY.
toration of form. As Pajot observes, this suppleness and special elas-
ticity of the uterus are neither softness nor a flaccid condition ; it is always
possible to distinguish the uterus from the abdominal walls, and, on the
other hand, the suppleness and elasticity contribute to maintain the
normal accommodation of the fetus, and thus avoid unfavorable pre-
sentations and positions without interfering with its active movements.
RELATIONS OF THE UTERUS AT THE END OF PREGNANCY. The
lower fourth of the anterior uterine wall is in relation with the posterior
wall of the bladder ; the remaining three-fourths is directly applied to
the abdominal wall, but sometimes omentum or intestine may intervene.
The fundus is in relation with the transverse colon, part of the stomach,
with the anterior margin of the liver, the xiphoid cartilage, and the
lower floating ribs. The ovaries and oviducts are close to the sides of
the uterus at a point corresponding with the junction of the upper and
middle third ; this change in their position shows the remarkable
development of the fundus of the uterus. Further, the right side of the
uterus is in relation with the internal and external iliac vessels, with the
obturator nerves, the psoas and iliac muscles, the caecum and the
ascending colon ; the left side has similar relations to bloodvessels,
nerves, and muscles, and with the descending colon, instead of with the
ca3cum and ascending colon. The posterior wall is in relation with the
rectum, the sacrum, the primitive iliacs, the sacro-vertebral angle, the
omeutum, the small intestine, the aorta, the vena cava, the dorsal and
lumbar vertebrae, and the pillars and the posterior part of the dia-
phragm.
PROPERTIES OF THE PREGNANT UTERUS : SENSIBILITY, IRRITA-
BILITY, CONTRACTILITY, RETRACTILITY. Pajot has said, pregnancy
does not create any new property. But the properties which the
uterus already possesses are increased ; for example, the organ is more
sensitive and its nerves respond more readily to stimuli, or, in other
words, its sensibility and irritability are greater. From its vast in-
crease in size it is more exposed to the action of causes that affect these
properties. The sensibility of the uterus varies in different subjects,
and hence in some all active foetal movements cause severe suffering,
while others experience only a momentary inconvenience from such
movements. The suffering caused by foetal movements is often dif-
ferent in different parts of the uterus, in one severe, in another slight ;
the frequent repetition of movements referred to one portion of the
uterus will there cause, in some cases, increasing distress. So, too, the
irritability of the uterus is not the same in all ; trivial causes in one
woman will, from the great irritability of the uterus, excite contrac-
tions and lead to abortion, while another is subjected to the severest
violence without interruption of pregnancy. Idiosyncrasy is supposed
to explain cases of excessive sensibility, or of excessive irritability of
the uterus ; but in some instances at least the explanation is to be
sought, not in a peculiar physiological, but in a positive pathological
condition.
Consequent upon irritability is contractility, contraction is the re-
sponse to irritation ; contractility is manifested by shortening of mus-
cular fibre followed by lengthening. The physiological irritability of
CHANGES IN THE MATERNAL ORGANISM.
FIG. 98.
177
POSITION OF THE GRAVID UTERUS NEAR TERM, AND SOME OF THE RELATIONS OF THE INTESTINES.
a. Gravid uterus, d. Ascending colon, e. Kidney. /,/. Small intestine, h. Transverse
colon, i. Liver. I. Diaphragm.
12
178 PHYSIOLOG Y OF PREGNANCY.
the uterus is manifested by the occurrence of contractions, which become
more frequent as the pregnancy approaches its end ; these contractions
are painless, but as they gradually merge into the contractions of labor
they become more frequent and are accompanied with suffering. Con-
tractility is a property of all the muscular tissue of the uterus, but of
course is greatest in those parts of the organ where this tissue is most
developed. The painless contractions of pregnancy promote the circu-
lation of the blood in the uterine sinuses, and also assist in fixing the
foetal presentation. The manifestation of contractility in labor will be
elsewhere considered.
Retractility of the uterus has been defined as a property of the mus-
cular tissue, by virtue of which the uterine walls tend to approach. It
opposes distention, and is the antagonist of the elasticity which permits
for the moment stretching of a part of the uterine walls. While con-
tractility is a force manifested intermittently, retractility is constant in
its action and permanent. It restores the form of the uterus, tem-
porarily lost by foetal movements or by changes of the mother's posi-
tion ; it keeps the uterine walls closely applied to the ovum, and after the
detachment of the placenta it closes bleeding vessels, while during the
puerperal state it prevents distention of the uterine cavity by blood-
clots, and is one of the most important agents in promoting uterine
involution. Contraction and retraction are two distinct nodalities of
muscular action ; neither is a condition, but each is a manifestation of
muscular force.
CHANGES IN THE NECK OF THE WOMB. Slight hypertrophy of
the neck of the womb occurs in pregnancy ; this part of the uterus is
not so well supplied with blood as the body is, and is not subjected
to the irritation from the growing ovum, at least until the latter weeks
of pregnancy, and then the pressure of the ovum is chiefly at its upper
portion, and hence its little increase in size.
The position of the neck depends upon the position of the womb, and
therefore, as the latter ascends into the abdominal cavity, the neck is
drawn up and apparently shortened. Anterior inclination of the uterus
causes the cervix, unless there be marked anteflexion, to point backward
to the hollow of the sacrum ; lateral inclination directs the neck toward
that side of the pelvis opposite to the side of the abdominal cav:ty in
which the fundus is ; in primigravidaj the os uteri is usually found at
the end of pregnancy quite far posteriorly and to the left of the pelvic
cavity. In primigravidse the virgin form of the neck is more distinct
that is, more plainly conical ; but after a time, in consequence of the
accumulation of the secretion of its glands in its canal, it is spindle-
shaped. In the multigravidae it is cylindrical or expanded at its lower
portion so as to be club-shaped.
SOFTENING OF THE NECK. Early in pregnancy a change in the
consistence of that part of the neck adjoining the external os begins, and
is manifested by the superficial tissues yielding to pressure. This soft-
ening is at first simply a continuation of that caused by the last menstrua-
tion ; the softening advances regularly and slowly in the primigravida
to the remaining portion of the vaginal cervix, so that, approximately,
one-fourth is affected by it at four months, one-half at six, three-fourths
CHANGES IN THE MATERNAL ORGANISM.
179
at seven, and the remaining fourth at eight mouths. In the multigra-
vida the process is more rapid, because the neck is shorter and has been
previously, softened. The softening always begins below, thence passing
above. It is attributed to a greater abundance of plasma, to hypertrophy
and proliferation of fibre-cells, and, in the latter part of pregnancy, to
blood-stasis caused by the pressure of the foetal head in the lower por-
tion of the uterus. The sensation that the finger receives by pressing
upon the softened cervix has been compared to that which is given by
similar pressure upon a piece of velvet placed upon a hard substance, at
first a ready yielding to the pressure, and then a firm resistance. Soft-
ening of the neck is in the early months of pregnancy a valuable sign,
which may assist in a probable diagnosis of the pregnant state.
STATE or THE INTERNAL AND THE EXTERNAL Os. In primigra-
vidse the external orifice of the womb remains closed until the end of
pregnancy. In rare instances the finger can enter it, but usually for
only a short distance, and in some of these possibly the penetration has
been, not by an open canal, but from making it permeable by pressure.
In still rarer instances the cervical canal in primigravidae is permeable
by the finger in the latter weeks of pregnancy, so that the fetal mem-
branes and presenting part may be touched ; such cases are quite excep-
tional. In multigravidae the external os is not surrounded by a regular
smooth surface, but by a structure marked with irregular fissures ; the
cervical canal is open to a degree in direct relation with the period of
pregnancy, the finger readily passing, for example, to the middle of the
canal at seven months; the cavity thus entered by the finger is funnel-
shaped, or the neck of the womb may be represented as a hollow cone,
with its base below.
FIG. 99.
PIG. 100.
SCHEMATIC SECTION OF A PRIMIPARA IN
THE LAST MONTH. (SCHROEDER.)
SCHEMATIC SECTION OF A MULTIPARA IN
THE LAST MONTH. (SCHROEDER.)
1 80 PHYSIOLOG Y OF PREGNANCY.
SHORTENING OF THE NECK OF THE WOMB. The question as to
shortening of the cervix became the subject of controversy nearly two
centuries ago, and in quite recent years the contention has been greater
than at any previous time. De Graaf, 1671, held that the cervix re-
mained unchanged until the end of pregnancy, and the same view was
maintained by Verhegen, 1710, and Weitprecht, 1750. Roederer,
1753, asserted that expansion of the cervical canal, contributing thus
to the uterine cavity, advanced regularly from above downward during
pregnancy, stating that this change could be noticed as early as toward
the sixth month. 1 Stoltz, 1826, stated that the cervix was unchanged
until the last fifteen days of pregnancy, and then the internal os
opens, the cervical canal dilates from above downward, and the cervix
is gradually effaced. Taylor, 1862, brought forward important obser-
vations to prove that the cervix did not shorten until the beginning of
labor. In 1876 Bap.dl revived the teaching of Roederer, asserting that
during the last ten weeks of pregnancy shortening of the cervix is in
progress ; the upper part of the cervical canal is dilated so as to form
with the lower segment of the uterus the canal of Braun, or, as Tarnier
calls it, the cervico-uterine canal. Bandl contended that the superior
limit of the cervical canal, or the internal os uteri, could be demonstrated
at the close of pregnancy or during labor to be at the level of the pelvic
inlet.
While some have thus held that the lower uterine segment was cervical in
origin, 2 others partly from the cervix and partly from the body of the uterus, the
view now most generally accepted is, as expressed by Barbour, 3 " that no suffi-
cient evidence has been produced that the lower segment, which resembles in its
essential structure the rest of the uterus, is cervical in its origin ; and until new
evidence is brought forward we see no reason to ascribe to it an origin different
from the rest of the wall of the uterus."
It would seem, however, that after efFacement of the cervix at the end of preg-
nancy and the beginning of labor the cervical tissue must contribute to the lower
portion of the completed uterine ovoid, which then presents a simple nearly cir-
cular opening and no canal.
Bibemont-Dessaignes and Le Page, op. cit., assert that the neck keeps its entire
length during pregnancy, to the beginning of labor, and that the lower segment
of the uterus to the end of pregnancy is formed not by the neck but by the in-
ferior part of the body of this organ.
In regard to the changes of the cervix in pregnancy, Spiegelberg
observed, it is no longer doubtful that the opening of the internal os
uteri and the entering of the apex of the ovum into the cervical canal,
thus causing this canal to contribute to the uterine cavity, are possible
phenomena, and in fact do occur. Their occurrence is thus explained :
In primigravidae the lower portion of the uterus does not readily yield
to the pressure of the growing ovum and to the uterine contractions,
which become more frequent in the latter part of pregnancy, and hence
the development of the cervical canal is more frequent in them, but the
1 Although Kleinwachter refers impliedly to Roederer's views as indicating that the changes
occurred in the last teu weeks of pregnancy, yet upon referring to Wrisberg's edition of Roederer's
Elementa Artis Obstetricise, 1766, the time is stated to be versus sexlem mensem.
2 According to this view, Bandl's ring is the dilated internal os uteri, the upper limit of the
inferior segment, and Miiller's ring is that which appears to be the internal os, the upper limit of
the shortened cervical canal.
3 The Anatomy of Labor. Edinburgh. 1889.
CHANGES IN THE MATERNAL ORGANISM.
181
external os remains closed, or nearly so, until the end of pregnancy.
On the other hand, in multigravidse the lower portion of the uterus is
less resisting, yields readily to the growing ovum, and therefore the
internal os remains closed, not being subjected to so much pressure
either from the ovum or from uterine contractions, and the finger can
in these cases be passed further and further up the cervical canal with
the progress of the pregnancy, the development of the canal being from
below above.
Fig. 101 shows no shortening of the neck, but in the last two weeks
of pregnancy, according to Stolz, Tarnier, and others, such shortening
FIG. 101.
CERVIX OF A WOMAN DYING IN THE EIGHTH MONTH OF PREGNANCY. (After DUNCAN.)
occurs in most cases ; it is admitted, however, that this change may not
occur until a few days, or even a few hours before labor begins. Tay-
lor has more recently repeated his statement 1 as to the non-shortening
of the cervix in pregnancy, and sustained it by additional facts and
arguments.
Barbour's* conclusion from a study of " frozen sections" of women
dying in pregnancy is that the cervical canal, lined by characteristic
mucous membrane, remains of " pretty constant length." This view
is that which is generally accepted.
When the neck has disappeared, been effaced 3 by being taken up into
the body of the womb, the uterine changes of pregnancy are completed,
and labor is at hand.
1 Transactions Medical Society of New York, 1888. * Op. cit.
3 Charpentier, by a strange confusion of language, as it seems to me, refers to the effacement of
the neck as a phenomenon of pregnancy, but dilatation of the neck as a phenomenon of labor.
But how, after it is effaced, can it be dilated ? Dilatation of the os, but not of the neck, is a phe-
nomenon of labor.
182 PHYSIOLOGY OF PREGNANCY.
CHANGES IN THE UTERINE APPENDAGES. The broad ligaments
have their peritoneal layers separated by the growing uterus, and as the
organ ascends they are carried up by it; they share in the hypertrophy
of the peritoneum covering the uterus. The ascension of the uterus
compels a change in their direction, so that at the end of pregnancy
they are vertical instead of horizontal.
The round ligaments have their thickness increased fourfold ; they
become much longer, and at the termination of gestation extend from
the vicinity of the umbilicus to the inguinal canal on each side; in
consequence of the greater development of the posterior than of the
anterior wall of the uterus, they are not directly upon the sides, but at
the junction of the posterior four-fifths with the anterior fifth of the
lateral borders of the uterus. The utero-sacral ligaments, the uterine
retractors of Luschka, undergo remarkable development. The ovaries
increase in size ; according to Jacquemier, their size is doubled ; they
follow the movements of the broad ligament, and take nearly a vertical
position. Ovulation in most cases, at least, is suspended, but the corpus
luteum undergoes the changes which have been described as occurring
in pregnancy. The oviducts also hypertrophy ; their epithelial lining
loses its vibratile cilia. Robin has stated that the canal of the oviduct
contains a yellowish-white viscous matter, holding in suspension epi-
thelial nuclei and fine fat granulations.
CHANGES IN THE BREASTS. In some cases the mammary glands
become larger at the beginning of pregnancy, but oftener this increase
in size commences at the time corresponding with the first menstrual
suppression following conception. Their enlargement is accompanied
with increased sensibility, and occasional shooting pains are felt in them ;
the axillary ganglia may also be similarly affected. The superficial
veins are larger and more distinct ; if the increase in size of the breasts
be very great, it is not unusual for strise similar to those occurring upon
the abdominal wall to be found about the fifth or sixth month. In
some cases the enlargement lessens after four or five months, but re-
appears toward the end of pregnancy. The latter part of the second
or third month the nipple is firmer, harder, more prominent, and sensi-
tive; a milk-like fluid may possibly escape or be pressed from it, but
this is not usually observed until in the last three months, and it may
happen even in the absence of pregnancy.
Changes in the areola are more important and characteristic. These
changes are swelling, development of the mamillary tubercles, and
darkening of the entire surface. The first of these phenomena can
usually be seen the second month ; the swelling is not hard and tense,
but puffy, giving to the finger the sensation of an emphysematous
enlarged tissue. About the same time the areola becomes darker, and
the hue deepens until the end of pregnancy, when in brunettes it is a
dark brown, in some almost black, while in blondes this change is
much less pronounced, and in the red-haired scarcely noticeable. The
papular elevations, often called the tubercles of Montgomery, situated
upon the areola, and regarded by some as miniature mammary glands,
become much more prominent, projecting from the sixteenth to the
eighth of an inch. The primary areola, which has a radius of about
CHANGES IN THE MATERNAL ORGANISM.
183
an inch, three centimetres, is surrounded at the fifth or sixth month by
a secondary areola ; this is lighter in color, and necked with whitish
spots, presenting an appearance somewhat resembling that of dust-
FIG. 102.
THE PRIMARY AND SECONDARY AREOLA IN PREGNANCY.
covered, white blotting-paper upon which drops of water have been
sprinkled. The illustration (Fig. 102), from Depaul, very well repre-
sents the appearance of the breast in the latter months of pregnancy.
CHAPTER VII.
THE SIGNS ANJ> DIAGNOSIS OF PREGNANCY.
PREGNANCY is revealed by certain signs, and its diagnosis is made
by their recognition and application. It is essential that the obstetric
student faithfully study and clearly understand these signs, and then,
by giving to each its true value and combining all, he will reach a
correct conclusion. Van Swieten said that the physician's reputation
was never more imperilled than in deciding as to pregnancy : " frauds
everywhere, often everywhere snares prepared for the unwary." But
not only may a mistake in diagnosis be very injurious to his reputa-
tion, it may ruin the reputation of one unjustly accused of being preg-
nant, or risk the health, or even the life of another affected by a disease
simulating pregnancy ; and this disease, thus neglected, may become
incurable. That great mistakes have been made in the diagnosis of
pregnancy this condition asserted when it was absent, or denied when
it was present and that these mistakes have in some instances led to
most deplorable consequences, is matter both of printed and oral history.
Few practitioners of a dozen years' experience can truthfully say that
no error in the diagnosis of pregnancy has ever been made by them.
Pajot states that he could make quite a volume giving in detail the
history of all the erroneous diagnoses in regard to pregnancy which have
come under his own observation in an experience of thirty years ; and
these mistakes made, not by sages femmes, but by practitioners of more
or less, some of them with very long, experience.
Now, there must be reasons for such great and comparatively fre-
quent mistakes, and a brief exposition of some of these causes of error
may help to avert the latter. Socrates said : " To attain to a knowledge
of ourselves we must banish prejudice, passion, and sloth." These,
too, must be banished when we study the practical diagnosis of preg-
nancy. Especially must we investigate a case without prejudice that
is, without prejudgment whether the prejudice be from the opinion
of others, or from the subject's previous history and her surroundings.
That the judgment of another is in favor of or adverse to pregnancy
must not rule our own ; nor should our opinion be biased by the social
position, reputation, and circumstances of the party ; for some women,
around whom apparently every safeguard has been thrown, may sacrifice
their virtue, while others, less protected, preserve it in the midst of the
strongest temptations. In this judicial inquiry the woman must be
divested of all the accidents of life, of all her artificial surroundings,
and simply considered as capable of reproduction. Her statements are
to be received with great caution, for, on the one hand, a strong imagi-
nation will beget in her, if she ardently desires to be a mother, some of
the signs of pregnancy ; or, if, she wishes to deceive, she may assert
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 185
them, and, if she wishes to conceal, she may deny them yea, many a
woman in the agony of childbirth, or in the very article of death, has
denied her pregnancy with the vain hope of protecting her good name
from reproach, or, more frequently, for the purpose of saving her seducer
from exposure.
Ambition to give a prompt decision, or pride in opposing that of
another, may lead to error. Rapidity is very far from proving correct-
ness of diagnosis ; here, as Lord Bacon has said of another matter,
our intellects need not wings but weights of lead to moderate their
course. The man of greatest knowledge least exalts his attainments,
and is the most cautious and deliberate in judgment, and has respect
for the opinions of others. Sloth may hinder or prevent our thorough
investigation. We may be satisfied with a few facts instead of seeking
all that are available. We may give undue weight to one or more of
these facts, undervaluing or neglecting others. In illustration some cases
that have been under my own observation will be given : A young lady
of high social position, and against whose purity there was no whisper
or thought of scandal, is attacked with obstinate vomiting. There is a
denial of menstrual derangement; the vomiting resists all remedies,
and she dies, but while dying a fetus of three months and a half is
expelled. A woman having passed twenty years of married life child-
less, some months after the menopause becomes pregnant ; the pregnancy
is suspected by one attendant, and denied by another. Nieden (Cent.
fur Geburt., 1889) gives an instance of pregnancy after twenty-six years
of marriage (married at eighteen). The writer has had a patient who
was ten years married before giving birth to a child ; during these
years her health was perfect, and there was apparently no reason for
her delayed maternity. A girl who has never menstruated, and who
does not fully present the other signs of puberty, becomes pregnant
by violence, and gives birth to a child when she is twelve years
old. A woman has menstrual suppression, coincident abdominal en-
largement, the mammary and many other signs of pregnancy, but a
post-mortem examination proves cystic disease of the ovary. A girl
of twenty has never menstruated ; her abdomen enlarges, her breasts
are swelled and secrete ; after a^time severe uterine contractions occur,
and a physician of large experience called to her during this attack
declares she is in labor; the cause of the abdominal enlargement is
accumulation of many months' menstrual secretion, and the uterine
contractions simulating labor-pains are the efforts to overcome the resist-
ance of an imperforate hymen.
Time would fail to give all the published cases in which a pregnant
uterus has been tapped, or even abdominal section made for its removal,
because it was thought an ovarian tumor, and many a patient has been
saved from such perils because of the postponement of the operation
until happily labor prevented its performance ; the unpublished instances
of such errors are much more numerous.
Pajot 1 states that he has seen a pregnancy of four months taken for
an abscess, and the uterus opened by a bistoury, introduced into the
vagina, by one of his old masters, the most learned and venerated. But
1 Travaux d'Obstetrique et de Gynecologic.
186 PHYSIOLOGY OF PREGNANCY.
it is not necessary to multiply instances of wrong diagnosis leading to
an assertion of pregnancy when it does not exist, or a denial of it where
it is present. Tardieu 1 has said that all signs of true pregnancy, except
the bruit of the foetal heart, may be observed when there is no preg-
nancy, from the development of the abdomen and breasts up to move-
ments and the efforts of labor. It is not wonderful, then, that mistakes
have been made, and yet in most cases they are avoidable.
Liability to error is caused by the pregnancy being abnormal, or by
its complication with some pathological enlargement, for example, ascites,
ovarian tumor, or uterine fibroid ; but these topics will be considered
elsewhere. Concluding the subject of diagnostic errors as to pregnancy,
the practitioner who would avoid them must faithfully interrogate all
the changes, both organic and functional, in the maternal organism, and
those which are caused by foetal development; he must be patient,
thorough, painstaking in his investigation, not hasty, partial, and super-
ficial ; he must be willing to delay his decision in all doubtful cases,
rather than run the risk of a happy guess, or trust an average of prob-
abilities. Many other errors in diagnosis may never come to the light,
but time is the certain and remorseless revealer of these; alike the
asserted pregnancy which, like the weaving of Penelope's web, never
ends, and the denied pregnancy which in a few weeks or months a
babe's first cry contradicts, are too often made known, to the disap-
pointment if not disgrace of the hasty diagnostician.
CLASSIFICATION OF THE SIGNS OF PREGNANCY. These may be
conveniently divided into the subjective and the objective. The former
include the information we can get from the person herself all the
answers she makes to our inquiries as to the functional changes caused
by pregnancy, and as to the various new sensations she experiences ; she
tells us what she knows, or believes she knows. By objective signs, we
mean those discovered by our own senses, the special avenues of certain
knowledge ; we may, or we may not, believe what another tells us, but
that which we see with our own eyes, hear with our own ears, and handle
with our own hands, commands our credence. The subjective signs will
be considered first.
MENSTRUATION is ABSENT. The absence of menstruation is a sign
of great value in the case of a woman hitherto regular, there being no
pathological cause for the suppression and no pathological result from
it; the sign increases in value each month that it continues. But con-
ception may occur during lactation, in the first nine or ten months of
which menstruation is normally absent, or it may take place before any
flow has been observed ; as La Motte said, a woman may have fruit
before flowers, and in such cases of course the sign is without value.
Again, a monthly flow may occur once or oftener after conception, even
continue during the entire pregnancy ; and stranger still are those rare
cases of this hemorrhage occurring in women only when pregnant.
Naegele and Greuser, 2 referring to menstruation in pregnancy, state
that sometimes the flow does not differ in type, quality, and quantity
from ordinary menstruation. But the general law is that the pregnant
1 Sur les Grossesses Fausses et Simulees.
2 Traite Pratique de 1'Art des Accoucheinents. Translated by Aubenas. Paris, 1880.
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 187
woman does not menstruate, and the apparent exceptions to this law
are very few. Nature, when building up the foetus, has no excess of
material to be periodically discharged, and the intimate union which is
established early in pregnancy between the ovum and the uterine mucous
membrane prevents the latter being normally a source of hemorrhage,
whether irregular or periodical. Further, ovulation is, as a rule, absent
in pregnancy, and in like manner the associated or resulting hemorrhage
ought to be absent. Hemorrhages from the uterus of a pregnant woman
are pathological, not physiological, and generally threaten abortion or
premature labor, and should be so considered and so treated. Rarely
will one be deceived, says Stoltz, 1 who regards a woman menstruating
regularly, with all the characters of menstruation, as not pregnant,
while trusting the contrary opinion he is exposed to frequent errors.
NAUSEA AND VOMITING SALIVATION. Gastric disturbance is one
of the most frequent symptoms of pregnancy, and in rare cases it begins
about the time of conception. As illustrating the last statement, the
following report of a case by the late Dr. Montgomery is of interest :
" I attended a patient who was married on Monday, and began to be
squeamish on Saturday ; her delivery took place within nine months."
If the nausea and vomiting be associated with menstrual suppression,
if the disturbance occur at a regular time each day without any other
pathological symptom, and if food is vomited soon after it is taken, and
the appetite is unimpaired, this sign has great value. Copious secretion
of saliva occurs in some cases, but it is not very frequent ; it generally
accompanies excessive nausea and vomiting, though it may also occur
when these symptoms are absent or insignificant. The late Dr. Dewees
attached great importance to spitting a white, frothy mucus " cotton-
spitting " as a sign of pregnancy.
NERVOUS DISORDERS. Changes in the disposition, increased sensi-
bility, despondency, etc., are of no value as signs of pregnancy, " for
they are often just as great when a woman believes herself pregnant,"
the event proving her mistake, as when she is pregnant. The different
forms of neuralgia from which pregnant women sometimes suffer may
occur to the non-pregnant.
MAMMARY PAINS AND SWELLINGS. Pains in the breasts and some
enlargement of these organs, with possibly a slight secretion, will prob-
ably be observed by most women early in pregnancy, but all these
symptoms may occur in girls and women who are not pregnant. Many
females have more or less mammary pain and swelling in connection
with menstruation.
IRRITABILITY OF THE BLADDER LEUCORRHCEA. It is not un-
common for women in the first part of gestation to have some irritability
of the bladder and increased mucous discharge from the sexual organs.
While inquiry may be made concerning tnese symptoms, but little
importance is to be attached to them alone, for there are so many other
conditions in which they may be found.
QUICKENING. Certain sensations perceived by the mother were
believed to mark the time when the foetus was endued with life and
soul, and the woman was then " quick with child ;" this distinction was
1 Op. cit.
188 PHYSIOLOGY OF PREGNANCY.
recognized alike by physicians and by courts. We now know that the
child's life begins with the union of spermatozoid and ovule; then and
there was the quickening power, then the true creation, and the young
life in its dim dawn is as real and sacred as in its maturity.
The phenomenon commonly called quickening usually occurs between
the first and the middle of the fifth mouth, but in rare cases it is noticed
earlier, in others later, and in still others it is absent during the entire
pregnancy.
Different opinions have been held as to its cause. By some it is
attributed to the direct contact of the uterus with the abdominal wall.
Tyler Smith believed the sensations due to the first peristaltic actions of
the uterus, and regarded the date of quickening as marking the time
when the contractile tissue of this organ is so far developed as to admit
of these contractions. The opinion generally received is that it is caused
by the movements of the foetus that are first recognized by the mother ;
they are not felt until the uterus rests upon the abdominal wall, and
they are felt through it, and not immediately in the wall of the uterus.
Of course, foetal movements are made much earlier, and they can be
recognized by the stethoscope before the mother is conscious of them.
The value of this sign of pregnancy is lessened not only by the fact
previously mentioned, that pregnancy may be completed without the
mother ever having been conscious of them, but by this, that, as
Hamilton said, no woman ever yet fancied herself pregnant without
persuading herself she felt the movements of the child. Nay, more, a
woman after repeated experience as to the sensation in question may,
with the best faith in the world, assert she feels these movements, and
yet not be pregnant. Dr. Blundell 1 mentions a case under his own care
of a woman who had given birth to twelve children, and who believed
herself again pregnant, declaring she felt the movements of the child as
plainly as she had in any of her previous pregnancies, and yet she was
not pregnant.
The story of the supposed pregnancy of Queen Mary, of England,
and that of Joanna Southcote, furnish illustrious instances of self-
deception in regard to the sensation of fcetal movements.
OBJECTIVE SIGNS. These are sought, not by inquiries, but by direct
examination of the patient ; they are not her statements, but facts and
conditions directly recognized by our own senses.
INSPECTION. We observe the patient's countenance as to whether
anxious, haggard, expressive of suspicion, or indifference ; her face as
to whether full and florid, or pale, thin, and emaciated, and as to the
presence or absence of discolorations. When the patient is standing or
walking it is well to notice the position of the shoulders, the increased
lumbar curve, and the abdominal prominence. Examination of the
naked abdomen may show stria? and pigmentation, and changes in the
umbilicus, a deeper or effaced cavity, or umbilical pouting. The labia
majora may be found swelled and firmer, and presenting greater or less
discoloration, and the vaginal mucous membrane purplish. Never-
theless, visual examination of these parts is not necessary in most cases
i Principles and Practice of Obstetricy.
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 189
of supposed pregnancy. Exposure of one of the mammary glands is
less trying to the subject, and furnishes more important information.
Is the breast larger and firmer than usual ? Is the nipple more promi-
nent and harder, and can a fluid be pressed from it ? The areola is to
be closely observed as to whether swelled and darkened, and as to
hypertrophy of its tubercles ; supposing the primary areola to have
undergone the characteristic changes of pregnancy, if the gestation has
lasted five months, the secondary areola is beginning to appear. The
urine may be examined as to the presence of kyestein, or as to the
lessened quantity of its solid constituents ; but such examination is of
scientific interest rather than of practical value. Jorissenne's " sign "
may be tried, the pulse counted when the woman is standing, then
sitting, and, finally, when lying. 1
TOUCH. The obstetric definition of touch is a digital or manual
examination of the female internal and external generative organs and
adjacent parts for diagnostic or therapeutic purposes. Touch may be
vaginal, rectal, vesical, or abdominal. In the first three it is almost
always digital, but in the last it is usually manual, and commonly called
palpation; sometimes vaginal touch and abdominal palpation are com-
bined, and this is bi-manual or abdomino-vaginal examination.
VAGINAL TOUCH. This is usually made with the index-finger of
the right or of the left hand, whichever may be the more convenient
with reference to the position of the patient; while the right hand is
generally used, there are, as Cazeaux has said, some diseases of women
and some positions of the foetus which compel the accoucheur to use the
left hand, and therefore he should accustom himself to touching with
either hand. Some practitioners prefer to join the medius to the index,
thereby gaining, according to Stein, a little more than half an inch, 15
millimetres ; a gain of an inch is impossible. But if two fingers are used,
the examination may be quite painful in a primigravida, and the sensa-
tion given the examiner by two fingers is less clear than that from one ;
beside, the index can be more easily separated from the adjoining finger,
and thus can explore a greater part of the pelvic capacity.
Hubert, who happily characterizes the accoucheur's finger as clairvoyant? states
that in some localities in Holland accoucheurs and sages-femmes have for their
sign a representation of a long finger surmounted by an eye. A similar device
was placed by the late Dr. Valentine Mott upon the tickets of admission to his
lectures in the University of New York.
The practitioner must carefully notice if there is the slightest abra-
sion upon the finger used in touching, or upon the other fingers of the
hand, and if there be he should cover the abraded part with collodion
or other protective material ; if he neglects this precaution, he may, even
1 Jorissenne (Nouveau Signe de la Grossesse) states that in the first months of gestation, in the
ahsence or uncertainty of other signs of the pregnant condition, an important one is furnished by
the fact that the pulse does not correspond with the changes of position, but remains the same
whether the person is erect, sitting, or lying down. Fry (American Journal of Obstetrics, 1884) has
not found this sign of any value More recently and from quite extensive observations, Louge
(Le Pouls Puerperal Physiologique) found the sign only occasionally present, and then after the
fifth month, when other signs of pregnancy generally make the diagnosis quite easy.
Fry regards Cop cit.) a vaginal temperature of 0.7 above that of the axilla as presumptive of
pregnancy, if there is no fever or local disease.
2 Cours d'Accouchements, professe i\ 1'Universite Catholique de Louvain, 1878
190 PHYSIOLOGY OF PREGNANCY.
from a patient In regard to whom he has not the slightest suspicion of
such disease, be inoculated with the poison of syphilis ; many a physician
in the discharge of his obstetric duties has become the subject of syphi-
litic infection from not taking proper precautions in a vaginal exami-
nation.
SUBJECTIVE AND OBJECTIVE DISINFECTION. The thorough cleans-
ing of the hands, especially of the fingers of which are brought in
contact with the genital organs, is very important preliminary to an
internal examination. The nails should be short and thoroughly
cleansed. The hands are washed for five minutes in warm water and
soap, a nail-brush being industriously used. Sanger's method, using
green soap and sand, is excellent. After the washing the hands may be
immersed in a solution of corrosive sublimate, one part to 1000, for two
minutes. Then they may be dipped in a mixture of creolin and water,
3 to 5 per cent., or a solution of lysol, \ to one per cent. The employ-
ment of creolin or of lysol renders unnecessary the application of any
ointment to the examining finger. 1
So far as objective disinfection is concerned, it would be better in all
cases if the vagina be irrigated with a solution of lysol having the
strength previously mentioned, or a creolin mixture, half a teaspoonful
to one pint and a half of water. In some cases, those in which there
is a purulent discharge, this previous irrigation is absolutely essential,
and, indeed, in addition to one of the antiseptics mentioned, the vagina
should be well washed with a solution of corrosive sublimate, one part
to 2000.
PEEPARATION AND POSITION OF THE PATIENT EXAMINATION.
The patient must have been further prepared by having the bowels
and bladder recently emptied, and her clothing quite loose. The exami-
nation may be made when she is standing or when she is lying. If
made in the former position, her back should be against the wall or
some high, firm body, and the physici^u faces her, either sitting upon a
low stool or resting one knee upon the floor the right knee if the left
index finger is used the other knee furnishing a support for the elbow
of the hand which touches. In the erect position the pressure of the
intestines and the contraction of the abdominal muscles force the uterus
somewhat lower ; hence, in some women who are very fat, it is difficult
to reach the os uteri if they are lying, and the examination may have to
be made in the former position ; so, too, this position is more favorable
for vaginal ballottemeut. But in most cases the examination is made
when the patient is lying. She should be on her back, lightly covered,
the thighs and legs flexed ; the bed should be of such firm material that
her hips will not sink in it, or they should be raised by placing under
them three or four thicknesses of blanket or a hair cushion. The phy-
sician now takes his seat or kneels by that side of the bed nearest which
the patient is if it be the right side, his right hand is used in the exami-
nation extends the thumb and index finger, flexes the others, and
introduces the hand under the clothes of the bed and of the patient,
1 The question of disinfection will be further considered in connection with attendance upon labor.
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 191
touching the middle of the inner surface of the knee next him with the
extended thumb, then by following a line parallel with, and equidistant
from the thighs, his finger readily finds the vulval orifice, or this may be
entered by first carrying the hand directly to the perineum, and then
slightly raising the finger in the median line. Whichever plan of reach-
ing the vulval opening is followed, it is very much better, the examina-
tion is easier, and the movements of the finger more free, if the forearm,
instead of crossing beneath the thigh, is introduced under the clothing
so far as to lie in a longitudinal direction. Some obstetricians advise
passing the hand over the thigh of the patient, but this practice does
not so well secure her immobility and relaxation of the abdominal wall;
the latter is an important point if one failing to reach the os uteri, for
example, or other part of which exploration is desirable, wishes to press,
with the free hand upon the abdomen, the uterus toward the pelvic cavity.
Before the finger is passed into the vagina the condition of the vulva
may be learned, especially as to swelling from oedema, varices, or inflam-
mation ; it may be necessary subsequently to examine with the eye in
case he finds such conditions. When the finger is passed into the vagina
the state of this organ should be carefully noted as to size, temperature,
secretion, sensibility, and form. Next the examination of the pelvis
and uterus is made. Of course, any considerable encroachment upon
the pelvic diameters by a new growth or by change in the bones could
be readily ascertained. Such pathological growths and deformities are
rare exceptions, and the physician's constant and generally only concern
is the condition of the uterus. His first effort is to find the os uteri,
and this is not in all cases easy to do. Remembering the usual right
antero-lateral position of the body of the uterus in pregnancy, the os
would be directed backward to the sacral cavity and to the left side ; it
may be impossible to reach it while the patient is lying upon her back ;
nevertheless an effort should be made, first having her hips still more
elevated, and by pressing, with one hand upon the abdomen, the
uterus backward and toward the median line; if this fail, the woman
is directed to turn upon the side opposite to that of the latero- version,
the finger during this change of position being retained in the vagina,
and generally the os uteri may then be felt. The changes in the cervix
and os caused by pregnancy have previously been stated, and therefore
no further reference to them is necessary.
SANGER'S SIGN. Sanger has called attention to the condition of the
ureters in pregnancy as felt by vaginal examination. They are more
prominent, larger, and more resistant. Certainly those who have had
the opportunity of making this examination under his direction must
be impressed with the value of this sign of pregnancy.
EXAMINING THE BODY OF THE UTERUS. Examination of the
body of the uterus, as far as it can be reached by the finger in the vagina,
assisted by pressure upon the abdomen, is made ; if the organ has changed
its form so that the finger passes somewhat abruptly from the nearly
cylindrical cervix to a round, expanded body, and if its walls are elastic,
depressible, and yielding, the probability is, the uterine enlargement is
caused by pregnancy. This sign is one of the earliest that is available,
192 PHYSIOLOGY OF PREGNANCY.
and one which, if not deserving to be ranked among the certain signs,
yet gives a high degree of probability. 1
BALLOTTEMENT. In obstetrics this word means the sensation which
the examiner experiences when he communicates a sudden movement
to the whole or to a part of the foetus ; repercussion is sometimes used
as a synonym. It is the result of a momentary displacement of a solid
body in a liquid ; just as one by striking a lump of ice 2 in a tumbler
of water with the finger causes it to recede and the experiment would
be the same if a finger-tap were made through a membrane fastened
over the tumbler so an impulsion is made upon the foatus or a part of
it. If the entire foatus be displaced, and the finger be retained at the
point where this movement was produced, the return of the foetus may
also be recognized, and the sensation thus caused is known as the choc
de retour. It is thus seen that there may be a single sensation experi-
enced in ballottement, and this is the more frequent, or a double sensa-
tion.
Ballottement is either abdominal or vaginal ; the former will be con-
sidered hereafter. In vaginal ballottemeut the woman is either standing
or lying. The physician should, in the former case, pass one or two
fingers into the vagina, and in front of the cervix, until they rest upon
the body of the womb at its junction with the former ; the free hand is
applied to the fundus of the uterus, and then a quick movement is made
by the finger or fingers in the vagina, a sudden impulse thus communi-
cated to the foetus, dislodging it from its position and causing it to
float upward in the uterine cavity ; the return of the foetus may be felt
in many cases, that is, unless this return be very gradual, or in those
cases in which only a part of the foetus has been displaced. If the
woman be lying, it is well for her to have the head and shoulders some-
what raised, so as to throw the uterus forward, and then the ballotte-
ment may besought jusl as if she were erect ; if she be quite horizontal,
the finger must be passed into the posterior, instead of into the anterior,
cul-de-sac.
Ballottement is an almost positive proof of pregnancy ; nevertheless,
Pajot found it present in a woman who was not pregnant, but had a
multilocular ovarian cyst. The absence of ballottement does not prove
that woman is not pregnant ; for great size or small size of the foetus,
plural pregnancy, polyhydramnios, placental or shoulder presentation
may prevent it. A ballottement caused by entire displacement of the
foetus, though recognizable at about five months, is best perceived in
the sixth and seventh months, and that from a partial displacement later.
But before the date when ballottemeut is readily done signs of preg-
nancy are available which are certain.
KECTAL AND VESICAL TOUCH, HEGAR'S SIGN. Eectal touch may
be necessary in case of vulval or of vaginal obstruction, in posterior
displacements of the uterus, and in the diagnosis of tumors of the recto-
vaginal wall, of effusions in Douglas's cul-de-sac, and of extra-uterine
1 Before attempting the certain diagnosis of pregnancy in the first months it may be well to
recall the caution which Dr. Wm. Hunter manifested : " I cannot determine at four months ; I
am afraid of myself at five months ; but when six or seven months are over, I urge an examina-
tion." Of course, this is extreme, for it is only in exceptional cases that a positive diagnosis cannot
be made in the fifth month.
2 Tarnier.
THE SIGNS AND DIAGNOSIS OF PREGNANCY.
193
pregnancy. It is a method of examination very repulsive to the subject,
and is rarely necessary. Vesical touch or examination through the
bladder, the urethra having been previously dilated to admit the finger,
permits examination of the anterior wall of the uterus ; it is rarely re-
quired.
The sign of pregnancy known as Hegar's, is softening and thinning
of that part of the uterus immediately above the cervix. This condi-
tion may be recognized by introducing the index finger of one hand
into the rectum above the utero-sacral ligaments, pressing directly up-
ward, the patient lying upon her back ; three fingers of the other hand
press firmly upon the abdominal wall just above the pubes, so that they
are brought in approximation with the rectal finger : the thinning of the
lower portion of the uterus is thus discovered.
Sonntag 1 has published fifty cases in which diagnosis of pregnancy was made
by Hegar's sign. But for this examination anaesthesia is usually required, and,
moreover, in some instances it has been followed by abortion. Diagnosis in the
second or third month of pregnancy can only exceptionally be necessary.
ABDOMINAL TOUCH, OR PALPATION. This consists in the applica-
tion of the hands to the abdomen for the diagnosis of pregnancy and
FIG. 103.
THE HAND CIRCUMSCRIBING THE FUNDUS OF THE UTERUS IN PALPATION.
its duration, to ascertain whether it be single or plural, the presentation
and position of the foetus, and for the correction of an unfavorable
presentation.
The woman, her bowels and bladder having previously been evacu-
ated, lies upon her back, with her limbs extended ; the abdomen is
1 Das Hegar'sche Schwangerschaftszeichen. Leipzig, 1892.
13
194
PHYSIOLOGY OF PREGNANCY.
exposed from the epigastrium to the mons veneris. The physician,
having previously warmed his hands if they are cold, takes his position
at that side of the bed nearest which she is lying the left is the better
and places one of his hands upon the hypogastrium, keeping it pressed
there flat and with moderate firmness for two or three minutes in order
to accustom the abdominal muscles to this contact, and thus obviate
their contraction. So, too, if the pregnancy be well advanced, uterine
contraction may be excited by the hand; during it all pressure should
cease. The first object in palpation is to learn the presence and the size
of the uterus, and to do this let the left hand, if the physician is upon
the patient's right side, be pressed with the fingers and thumb slightly
flexed so as to correspond to the convex surface of the uterus upon the
hypogastrium, and gradually carry the hand further up the abdominal
wall, each movement of ascent marked, first, by relaxed, then increased
pressure, and the pressure being stronger at the ulnar margin of the
hand, so that when the fundus of the uterus is reached that part at once
FIG. 104.
recognizes the failure of resistance and dips deeper in the abdominal
cavity. Another method is by using both hands held almost vertically
so that the fingers begin pressing upon the hypogastrium in the median
line, then the hands are gradually separated, the space widened between
them until the fingers meeting with no resistance may be passed down
on each side of the uterus ; the sides of the uterus can now be followed
up until the fundus is reached. We recognize the uterus by its form,
by its position, and possibly by its being the seat of intermittent con-
tractions ; further in cases of doubt, while one hand circumscribes the
supposed fundus, a finger of the other may be passed into the vagina,
so as to touch the cervix, and the continuity of this with the mass felt
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 195
through the abdominal wall can be easily ascertained. The distance of
the fundus above the pubic symphysis, supposing the woman to be preg-
nant, enables an approximate determination of the time of the pregnancy.
Intermittent contractions of the uterus ascertained by palpation have
been especially studied by Dr. Braxton Hicks, and he states that this
sign is available by the last of the third month. 1 " If then the uterus
be examined without friction or any pressure beyond that necessary for
full contact of the hand continuously over a period of from five to
twenty minutes, it will be noticed to become firm if relaxed at first, and
more or less flaccid if it be firm at first. It is seldom that so long an
interval occurs as that of twenty minutes ; most frequently it occurs
every five or ten minutes, sometimes even twice in five minutes. How-
ever, in some cases, I have found only one contraction in thirty minutes.
The duration of each contraction is generally not long ; ordinarily it
lasts from two to five minutes."
Dr. Hicks has also stated, 2 referring to this method of examination :
" If we find a tumor changing in density and hardness, we have an
assurance that it is the uterus." But Tarnier has called attention to
the fact that a distended bladder gives the same sensation of intermittent
contractions, and the experience of others can give confirming proofs ;
so, too, according to Matthews Duncan, contractions quite as distinct
may be observed in case of a soft fibroid of the uterus, and with as
much change of shape as a pregnant uterus : the first source of error
would, of course, be readily avoided by the use of the catheter.
At five mouths the walls of the uterus have become so elastic and
depressible, and the foetus is sufficiently developed to be recognized by
palpation if the abdominal wall be not too thick ; in this examination
some parts of the uterine globe are harder, more resisting than others
which are elastic, and permit depression. As pregnancy advances an
indistinct fluctuation may be found, and if the uterus is embraced by
the hands at its sides, by pressing these alternately the foetus, or parts
of it, may be moved toward one and then toward the other. This is
known as abdominal ballottement.
Passive movement of the foetus may also be made by pressing with
a single hand upon some portion of the uterine globe where there is felt
a special resistance, that resistance coming from part of the foetus, and
the pressure forcing it momentarily away.
Spontaneous movements of the foetus are almost certain to occur
during abdominal palpation ; when they are being made the hand
should be kept immobile, but closely applied to the abdominal wall.
These movements may be recognized as early as the last of the fifth or
the first of the sixth month. They may be general or partial ; in the
former case the entire body changes its position, and a general change
in the form of the uterus temporarily occurs ; the movement is gradual,
gliding or rolling, and is slow. The partial movements are those of the
head or of the members ; they are quick, local, as if of sudden taps or
blows given at a particular part of the internal uterine wall, and causing
the uterus at that part for an instant to change its form.
1 Transactions of the London Obstetrical Society, vol. xiii.
2 Transactions of the International Medical Congress, 1881.
196 PHYSIOLOGY OF PREGNANCY.
Active movements of the foetus are most frequently observed in the
morning after the woman's rest, at least they are then most pronounced.
Of course, if the obstetrician recognizes such movements, he has not
only positive proof of pregnancy, but also of the fcetus being alive.
But the inability to perceive these movements, or their absence, is not
a proof that the woman is not pregnant ; for the feebleness of the child,
or excess of liquor amnii, may cause this sign to be absent. Or, again,
contractions of the abdominal muscles, or movements of the intestines,
may be mistaken, and have been so mistaken by even celebrated
observers, for movements of the fcetus. He, therefore, will act most
wisely who avoids possibility of error by repeating once or ofteuer this
examination, and also confirms the results obtained by touch by those
given by sight that is, both feels and sees the movements of the foetus.
It is, moreover, fortunate that he is not restricted in deciding as to
pregnancy by a single sign, but can combine others with it.
In many cases at the end of the sixth or the beginning of the seventh
month different parts of the foetus, as the head, breech, or limbs, may
be recognized by abdominal palpation. Nevertheless a tense, resisting
abdominal wall, or one that is very thick, may render this recognition
impossible.
The late Dr. Albert H. Smith, 1 of Philadelphia, advised in certain
cases the following method of "external bimanual ballottement : "
The woman is placed upon the edge of the bed with her clothing re-
moved from the abdomen, and then rolled upon her side ; so that the
anterior abdominal wall projects over the edge of the bed ; then the
rotation of her body is carried still further until the enlarged uterus
becomes so dependent that it may be supported by the hand placed
beneath it, while the other hand makes counter-pressure upon the
opposite side of the uterine mass. Thus let the woman be upon her
left side, the right side, therefore, being above, the examiner takes his
seat with his face toward her head, his left side being toward the
pendent abdominal mass, but about opposite the hips. The right hand
is then passed far under the uterus as it projects over the bed, the
palmar surface being in contact with the abdominal integument and the
ulnar edge toward the iliac bone. The left hand is thus placed similarly
upon the right side of the abdomen, making counter- pressure upon the
opposite side of the uterine body so as to grasp it between the two
palms. This gives a full command of the tumor, and enables the
examiner to appreciate the shape and density of the mass, its fluctuating
character, and the movement of a separate body within it, which can be
operated upon by manipulation and re-percussion." Dr. Smith further
stated that by this method he has been " able to diagnose a pregnancy
of six months when the foetal heart was entirely inaudible."
In another part of this paper its author said that even at three
months and a half it is sometimes possible, if the uterine wall be thin
and soft, to feel the movements of the child by a finger pressing firmly
upon the uterus posteriorly to the neck, while the other hand makes
counter-pressure through the abdominal wall upon the anterior and the
i " Manual Examination in the Diagnosis of Pregnancy." A paper read before the Philadelphia
County Medical Society.
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 197
superior surface of the uterus ; and further, " by a gentle thrust of the
vaginal finger upward, to feel the receding and return of a body loosely
floating in a liquid ;" during this abdoraino-vaginal manipulation the
woman is lying upon her back.
OBSTETRIC AUSCULTATION. Laennec's treatise upon Mediate Aus-
cultation was published in 1816, and two years later Mayor, of Geneva,
stated that upon applying the ear to the abdomen of a pregnant woman
the pulsations of the foetal heart could be heard, and he thus made
known one of the most important discoveries in obstetric science. Ker-
garadec, of Lausanne, ignorant of Mayor's priority in the discovery,
announced the same fact in 1821. The discovery was an accident to
each ; neither was listening for what he heard ; Mayor listened, hoping
to hear sounds caused by movements of the foetus, and Kergaradec those
occurring in the atunial liquor from these movements.
Kergaradec, beside hearing the pulsations of the foetal heart, heard
a sound attributed by him to the circulation in the placenta, which he
therefore called the placental souffle. As will be shown hereafter, his
theory of the origin of this souffle was erroneous ; the souffle is not
connected with the placental circulation, and therefore the name given
it was incorrect.
In addition to the two sounds mentioned, other sounds are discovered
by obstetric auscultation : those caused by foetal movements, a cardiac
souffle, attributed to the passage of blood through the foramen of Botal,
and a funic souffle j 1 but they are of minor interest, and the two sounds
first discovered are of chief importance.
Obstetric auscultation is usually abdominal, but it may be vaginal ;
Nauche, at the suggestion of Maygrier, devised an instrument called the
metroscope for auscultating through the vagina. The objections to
vaginal auscultation are its difficulty, the unwillingness of patients to
submit to it, and when the instrument is applied to the fundus of the
vagina, or in the cavity of the uterine cervix, great irritation, causing
abortion, may be produced. Nevertheless it has recently been revived
by Verardini, of Bologna, who by this means has been quite successful
in diagnosing early pregnancies. Abdominal auscultation should be
mediate for these reasons : The direct application of the ear to the
abdomen is indelicate; pressure 'upon a great extent of surface, causing
bruits from muscular contraction, is necessary ; it demands a constrained
position on the part of the observer, and it is not possible thus to aus-
cultate some parts of the abdomen, and the want of cleanliness on the
part of some patients may make it very objectionable to the examiner. 3
A stethoscope is less trying to the patient and to the doctor ; it permits
examination of parts that cannot be reached by the unarmed ear, and
the sounds heard through it are better defined and their limit better
determined. The stethoscope should not be less than six inches, about
15 centimetres, long. The woman should lie upon her back, with her
1 The funic souffle, discovered by Kennedy in 1833, is a blowing sound synchronous with the
foetal heart, and, according to Winckel, is heard in three-fourths of all cases. This observer also
states that in 33 per cent, of all the cases in which it is heard the cord is abnormally short, or long,
and that in 8 per cent, the children perish. The souud is, as a rule, heard over the child's back,
and near the heart.
2 Nevertheless, if failure occur using the stethoscope, immediate auscultation may be employed.
198 PHYSIOLOGY OF PREGNANCY.
limbs extended or only slightly flexed. In the course of the examina-
tion it may sometimes be necessary for her to turn upon one or the other
side, but the examination will be made chiefly without change of posi-
tion. In some cases, from motives of delicacy, the abdomen may be
kept covered, and a single thickness of thin unstarched material will
not, as a rule, materially interfere with hearing the sounds sought ; but,
as Depaul advises, in all cases of doubt or difficulty the abdomen must
be naked.
UTERINE SOUFFLE. Upon applying the stethoscope to the abdomen
of a woman some five or six months pregnant, or more according to
Spiegelberg, it may be audible at four months probably the first sound
heard is that which was originally called the placental souffle, and which
some physicians of to-day still thus miscall ; it is properly termed the
uterine souffle. That the placenta has nothing to do with the production
of the sound in question is proved by the fact that it may be heard two
or three in some cases five or six days after labor. Since this souffle
may be heard several days after labor, it is plain that when heard dur-
ing pregnancy the place at which it is most distinct does not indicate
the site of placental attachment. Beside the placental theory of this
sound, it has been attributed to an impoverished condition of the blood,
to pressure of the gravid uterus upon the iliac arteries and upon the
aorta, more recently by Glenard at first to the circulation in the epi-
gastric and then to that in the "puerperal" artery.
The theory of its origin which is now most generally accepted is that
of Dubois, somewhat modified by Depaul. 1 The sound is heard most
distinctly at the sides of the uterus where the blood-supply of the organ
is received ; the arteries upon entering the uterus immediately dilate,
offering permanently a capacity which seems too great for the blood
they have to receive. This disproportion, which does not naturally
exist in other parts of the organ, may nevertheless be produced under
the influence of different causes whose action is transient and varying
from one minute to another. Among these causes the most common
are those which result from compressions caused by projections of dif-
ferent parts of the foetal ovoid. Thus it happens, in correspondence
with these changes, there are changes in the uterine souffle which may
be heard distinctly one minute at a particular part of the uterus, and
then instantly cease. The sound is single, 2 without shock, is synchro-
nous with the mother's pulse, and resembles the souffle of a varicose
aneurism ; it varies in character and in distinctness ; it may be sibilant,
or humming, or sonorous ; it has been compared to the sound made by
saying in a low tone voo. It is best heard when the stethoscope is ap-
plied to the lower lateral parts of the uterus ; it is usually first recognized
in the fifth month, but Depaul heard it in the tenth week, Spiegelberg
from the eighth to the ninth, as did also Verardiui.
From the explanation that has been given of the cause of this sound
it can readily be understood that whenever the uterus has a notably in-
creased supply of blood the uterine souffle may be heard ; thus it has
1 Dictionnaire Encyclopedique des Sciences MMicales.
2 Winckel believes that the murmur is not only intermittent, but may be continuous ; in the
former case being arterial and in the latter venous.
THE SIGNS AND DIAGNOSIS OF PREGNANCY.
199
FIG. 105.
been found in some cases of large uterine fibroids. As a sign of preg-
nancy, therefore, it has little value ; taken in connection with others it
adds strength, but must not be relied upon alone. Even if the pregnant
state be known, this sound gives no information as to the condition of
the foetus, for its death makes no change in the souffle.
SOUNDS OP THE FCETAL, HEART. These sounds have been very
generally compared to the tic-tac of a watch put under a pillow upon
which the ear is placed. The first sound is the more distinct, and corre-
sponds with the pulsation in the umbilical arteries; the interval between
the two sounds is less than that between the double pulsations, or, as
one may say, it is twice as long between a tac and a tie as it is between
a tic and a lac, and this difference may be thus expressed, tic-tac tic-tac.
Depaul in several cases heard these sounds at three months and a half,
and in one at the latter part of the third month. 1 " At the end of the
fourth month the cases in which auscultation is uselessly practised are
much more rare, and they become so much more exceptional as women
are nearer the term." In 906 pregnant women examined by Depaul,
the sound of the foetal heart failed to be
heard but eight times, and some of these
failures, he states, are to be attributed to
another cause than the powerlessness of
auscultation.
In listening for these sounds the stetho-
scope should be applied up to four months
to the fuudus of the uterus, and in a line
corresponding with the axis of the inlet.
With the ascension of the uterus in the
abdominal cavity the instrument must
usually be placed upon one or the other
side, though sometimes the sounds are
more distinct in the median line. Dur-
ing the last three months of pregnancy
the sounds are, in the great majority of
cases, most distinctly heard at the middle
of a line drawn from the umbilicus to the
left anterior superior spinous- process ;
failing to hear them here, the physician
should next listen at a corresponding
point upon the right side ; if the sounds
cannot be heard at either of these points,
the stethoscope should be applied above
the umbilicus, upon one, then, if necessary,
upon the other side of the median line.
The following illustration, from Depaul's
.-,,. . _. . , , ,., DIFFERENT PARTS OF ABDOMEN FOR
(Jlmique Obstetncale, shows these different AUSCULTATION.
points. The examiner first applies his
stethoscope at D ; if he fails to hear the sounds at this point, or hears
them only indistinctly, he next listens at C ; finally, he tries the points
Depaul, op. cit.
200 PHYSIOLOGY OF PREGNANCY.
A and B, if no satisfactory result has been obtained by auscultating at
DorC.
. The pulsations of the foetal are much more frequent than those of the
maternal heart, and vary from 120 to 160 a minute, the mean being 140 ;
these pulsations vary in the same foetus as to frequency, becoming slower
or faster from one time to another. The distinctness with which they
are heard will of course depend upon the size and development of the
foetus, and upon its position, upon the quantity of liquor amnii, and the
thickness of the uterine and of the abdominal walls. The frequency of
the pulsations is uninfluenced by the mother's circulation, but it is by
her temperature, increasing as that increases.
Important movements of the foetus, whether spontaneous or resulting
from external causes, are followed by an acceleration of the pulsations,
while these become slower at the height of a uterine contraction.' Ex-
ceptionally, Kaltenbach states, the impulse of the heart is palpable.
OTHER SOUNDS HEARD IN ABDOMINAL AUSCULTATION IN PREG-
NANCY. Olshausen attaches much importance to the recognition by the
ear of foetal movements, stating that they may be heard in the latter
part of the fourth month, and therefore usually before the sounds of the
heart are audible.
FCETAL SHOCK, CHOC FCETAL OF PAJOT. Toward the end of the
first half of pregnancy v if the stethoscope is applied to the abdomen,
pressing but gently, the examiner perceives a double sensation of slight
shock and a bruit from a movement of the foetus. Pajot claims that
this sign, thus addressing general and special sensibility, is more readily
recognized in the existing period of development than are the sounds
of the foetal heart, and in many cases are heard earlier.
FUNIC SOUFFLE. The funic souffle, discovered by Kennedy in
1833, is a blowing sound synchronous with the foetal heart. Winckel
states that it can be heard in three-fourths of all cases. In 33 per cent,
of cases the cord was unusually short, or abnormally long ; it is heard
ten times as frequently in velamentous insertion ; tension, pressure, and
displacement are its chief causes. Ettinger's conclusion 1 is that the
funic souffle is caused by compression of the vessels, chiefly from coils,
true knots, or shortness of the cord.
Runge remarks that in very rare cases congenital valvular defects of
the heart may manifest their existence in pregnancy, continuing during
it, and also audible after birth, producing a sound similar to the funic
souffle.
PREDICTION OF SEX. It has been held that there is a relation
between the frequency of the pulsations and the sex of the foetus
Frankenhauser, and others while Gumming maintained that this fre-
quency depended upon the weight of the child. Danzats states that if
the pulsations are more than 145 a minute the probability is in favor
of the child being a female, under 135 a male, and between these num-
bers a prediction cannot be made. Hennig and Ziegenspeck found the
average frequency of the pulsation of the heart of the male foetus 136,
and that of the female 139 ; this difference is so small that, as Winckel
1 Inaugural Dissertation, Zurich, 1888.
THE SIGNS AND DIAGNOSIS OF PREGNANCY. 201
remarks, it is seldom possible to predict the sex, and this expresses the
general opinion of the profession. Some, however, differ. In this coun-
try Professor Frank C. Wilson, of Louisville, Ky., has for some years
given much attention to the subject, and his conclusions are here pre-
sented.
LOUISVILLE, Ky., July 14, 1884.
PROF. TH. PARVIN,
^DEAR DOCTOR : In reply to yours of 10th inst. I would say that with a rea-
sonable degree of accuracy the sex may be predicted from the rapidity of the
foetal heart sounds. These vary from 110 to 170 per minute, and 134 may be
taken as the dividing-line, above which the sex will be female, and below which
the sex will be male, the certainty increasing the further you recede from the
dividing-point. The following rules I have found useful in determining the sex :
From 110 to 125 the sex will be, almost certainly male
125 to 130 " " probably male.
130 to 134 " " doubtful with chances in favor of male.
134 to 138 " " " " " " female.
138 to 143 " " probably female.
143 to 170 " " almost certainly female.
Although failures occasionally occur, they are not numerous.
Very sincerely yours,
FRANK C. WILSON.
Certainly, in view of the statements of Dr. Wilson, who is one of the
most careful, competent, and conscientious observers, the subject is de-
serving of further investigation.
My young friend, Dr. Charles H. Reckefus, has recently been giving
considerable attention to the study of the possibility of predicting the
sex from the rate of the pulsations of the foatal heart, and in February of
this year, 1895, he has furnished me the following statement : " Using
134 as the dividing-line, I found out of 66 cases the prediction as to sex
correct in 49 instances, incorrect in 17. m
1 Dr. Ross, of Belfast, makes the following statement in the British Medical Journal, July, 1891 :
" If I find the mother describes the foetal movements are felt chiefly and most distinctly on the left
side, I emphatically predict a male birth : if on the right, I as surely determine the sex to be
female."
CHAPTER VIII.
THE DIAGNOSIS OF PLURAL PREGNANCY DIFFERENTIAL DIAG-
NOSIS OF PREGNANCY DIAGNOSIS OF PREVIOUS PREGNANCY, OF
PERIOD OF PREGNANCY DURATION OF PREGNANCY DATE OF
LABOR PRECOCIOUS BIRTHS PROLONGED PREGNANCY MISSED
LABOR.
DIAGNOSIS OF TWIN PREGNANCY. In the great majority of cases
this is not made until after the birth of the first child ; indeed, Capuron 1
thought that certain proof could only then be had ; in this, however, he
was mistaken, as will be hereafter shown. Yet the diagnosis is by no
means always readily made, and in most cases the obstetrician must be
content with a probability instead of attaining a certainty.
The signs of a plural pregnancy 2 are conveniently divided into prob-
able and certain. Among the former are extraordinary enlargement of
the abdomen, the size being greater than in correspondence with the
period of pregnancy ; unusual form of the abdominal prominence, the
uterus being developed more in its transverse than in its vertical diam-
eter ; lateral is more marked than median projection, so that in some
cases, as Mauriceau stated, there is a depression directly in the median
line, and " an eminence on each side of the abdomen ; " foetal move-
ments observed at different parts of the abdomen, these movements
being more frequent and stronger than usual ; and finally, the disorders
of pregnancy are more decided than when only one foatus is present ;
there is also greater liability to premature labor.
The venous circulation is seriously interfered with by the great de-
velopment of the abdomen, and hence oedema of the lower limbs and of
the abdominal walls. Depaul attached some importance to an cedema-
tous swelling, triangular in form, having its base at the pubes, and its
apex pointing toward the umbilicus, as indicative of a plural pregnancy.
DIAGNOSIS BY PALPATION. The certain signs of plural pregnancy
are given by vaginal touch, abdominal palpation, and by auscultation.
Vaginal touch may, after labor has begun, furnish the evidence of a
twin pregnancy ; thus, it is possible there may be recognized, as was
done by Depaul in two cases, a furrow dividing the protruding bag of
waters into two parts, indicating the presence of two foetal sacs ; Char-
pentier states this sign was first made known by Duges and Madame
Lachapelle. The cases are rare in which it is present. In consequence
of the relatively less quantity of liquor amnii, and of the fact that the
uterine cavity is so largely occupied by the foetuses, passive movements
1 When almost eighty years of ace, and after having been a teacher of obstetrics for nearly fifty
years, he one day said to Pajot: " My friend, there is but one way by which you may certainly
know a twin pregnancy. If you have seen one fcetus born, and find there is another in the uterus,
you may be sure there are twins."
2 Mr. Rigby, at the age of eighty, was the father of four children at one birth. Gooch's Com-
pendium.
DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 203
of these, or abdominal ballottement, cannot be so readily made ; and,
on the other hand, if the very great uterine enlargement be caused by
polyhydramnios, the mobility of the foetuses is greater than is normally
present. Again, there is, as expressed by Pinard, a permanent tension
of the uterine wall in case of plural pregnancy. "This wall, instead
of being easily depressed, is tense and resisting; it gives a sensation
similar to that caused by pressing upon a rubber bag distended by air
or by a liquid." Next the presence of fcetal members in different parts
of the uterus may be sought, and then the two foetal poles in the upper
and two also in the lower portion of the uterus conclude the diagnosis
of twin pregnancy by palpation. By this means Pinard discovered in
thirty-two cases the presence of twins in the uterus. He also diagnosed
triplets between the fifth and sixth month of pregnancy ; he found
three heads, one in the pelvic cavity, a second in the right iliac fossa,
and a third above and near the median line.
It is well not to entertain too great confidence in this method of diagnosis, and
therefore not to be disappointed by at least occasional failures ; indeed, Depaul
regarded it as only exceptionally possible, as the following passage indicates :
" Some practitioners in fact teach that one can distinguish through the abdom-
inal walls two foetuses. The necessary conditions for such a diagnosis are only
very exceptionally presented, for in multiple pregnancy the uterine and abdom-
inal walls are usually tense, and can only with pain and difficulty be depressed
by the hand of the examiner. Besides, it is much less easy than is generally
thought to distinguish the different regions of the foetus through the abdominal
and uterine walls, and when you wish to apply palpation to the diagnosis of pre-
sentations of the shoulder and of the pelvic extremity you will recognize how
much the hips, by their roundness and resistance, offer, through the walls which
separate them from the hand, resemblance to the cephalic extremity."
DIAGNOSIS BY AUSCULTATION. Kergaradec was the first to point
out the possibility of recognizing a twin pregnancy by hearing the
sounds of two fcetal hearts. Subsequently, however, others regarded
the supposed placental bruit as giving this proof, for indeed, according
to the original theory as to the origin of this sound, it would be heard
at two different points corresponding with the situations of the two
placentae. But this view, according to which the sound .referred to
resulted from the circulation in the utero-placental vessels, being, as
has been previously shown, an error, of course a correct diagnosis could
not be founded upon it. We return, therefore, to the original sugges-
tion of Kergaradec, and find that the " double pulsations of the fcetal
heart, heard at two different points of the uterus, with a maximum
of intensity and without isochronism, show the presence of two foetuses
in the uterine cavity." In making this examination care should be
taken to exclude any error which would arise from confounding the
sounds of the mother's heart with those of a fcetal heart. In order
that the diagnosis of twins can be correctly made by auscultation, the
obstetrician must hear fcetal heart-sounds most clearly at different
parts of the uterus, in neither case isochronous with the mother's pulse,
nor isochronous with each other. The variation in frequency be-
tween the heart-sounds of two foetuses may be only six or eight, or
1 Lejons de Clinique Obstetricale.
204 PHYSIOLOGY OF PREGNANCY.
it may be fifteen or sixteen, but there is always a notable difference-
It must be borne in mind that the comparative results must be, in
each case, those obtained at the same examination, for the frequency
of the sounds of the foetal heart varies from one time to another.
Usually the maximum of intensity of the heart-sounds of one foetus is
found higher than that of the other, nor are the two maxima upon
the same side of the median line. For example, referring to Fig. 105,
one maximum might be heard at D, and the other at A or at C. The
conclusion as to multiple pregnancy should not be drawn from a single
examination, lest an error may arise from change of position of the
foetus, in case of single pregnancy, or from change in the frequency of
its heart-sounds. Of course, an error might occur in case there were
more than two foetuses in the uterus, but the contingency of triplets
even is so small that mistakes thence resulting will be very rare. In a
case of triplets, H. F. Naegele, by auscultation during pregnancy, di-
agnosed twins ; when labor occurred, and after one of the children had
been born, he, by the same means, discovered that there were still two
foetuses in the uterus, and then made the diagnosis of triplets.
Even if the practitioner, after careful examination, is positive of a
plural pregnancy, it is not wise in most cases to let the woman know
his discovery, for to some the fact would be a source of fear and anxiety
as to the labor, and to others, of care and worry as to the double burden
which would be imposed upon them after the birth of the children.
Of course, auscultation will be without value in the diagnosis of plural
pregnancy if one of the foetuses be dead, but palpation might then be
of use. It is better, however, especially for the young practitioner, not
to depend exclusively upon either mode of examination, but rather com-
bine them, modifying the results obtained by one with those derived
from the other.
DIFFERENTIAL DIAGNOSIS OF PREGNANCY. Certain pathological
conditions may be mistaken for pregnancy, and the chief of these, with
the means by which error as to their character may be avoided, will now
be given.
First. Affections which Increase the Size of the Uterus.
PHYSOMETRA. Gas may be formed in the uterus from decomposi-
tion of retained secretions or of fragments of an ovum. This gas may
be retained if there be acquired atresia, or it may be discharged from
time to time in case there be only stenosis. When stenosis and dis-
charges of gas occurred Gooch called the condition flatus of the uterus.
Of course, there is little danger of confounding a case of either form of
the disorder with pregnancy. The uterus is but slowly and slightly
increased in size ; if it be large enough for percussion to be made, the
tympanitic sound evoked points to the nature of the enlargement, and
at the same time palpation and auscultation give negative results.
HYDROMETRA. A collection of watery fluid may take place in the
uterus when the os is occluded. Usually the uterus is no larger than
an orange, and the increase of size is slow ; it generally occurs in women
who have passed the childbeariug period, though Voisin met with it
in a patient only forty years of age. . Schroder has mentioned a case of
its occurrence in a woman in consequence of cervical atresia caused by
DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 205
the application of the actual cautery for sarcoma. ID hydrometra, too,
the development of the uterine tumor is slower than in pregnancy, and
the other usual signs of this condition are absent. Both physometra
and hydrometra are rare.
H^EMATOMETRA. Accumulation of menstrual blood in the uterus
has given rise to some most deplorable errors of diagnosis, errors that,
however, can be readily avoided by a careful study of the history of the
enlargement, followed by a suitable examination. Such an accumula-
tion results from either congenital or acquired atresia of some part of
the genital canal, and of course this atresia can be readily ascertained
by a direct examination. The history of the enlargement is that it has
lasted longer than pregnancy does, that it has taken place abruptly from
time to time, increasing periodically instead of continuously ; the periods
of abrupt increase, as a rule attended with more or less severe suffering,
usually occurred once in each month. Upon palpation the uterus is
found tense and resisting, not yielding and elastic as it ordinarily is in
pregnancy; no foetal parts can be felt, and auscultation is negative.
UTERINE FIBROIDS. The uterus is in most cases irregular in form,
and is hard and resisting, instead of elastic and yielding. Instead of
menstruation being absent, as is the fact in pregnancy, it is usually
irregular and profuse ; the mammary signs of pregnancy are as a
rule absent, and the umbilicus does not show the changes which occur
in the pregnant woman. The sympathetic disturbances of the early
months of gestation have not been observed, and the growth has been
much slower than the physiological development of the uterus; the
cervix does not present the changes characteristic of pregnancy. The
uterine souffle may be present, but the sounds of the foetal heart are
absent.
INCREASE IN SIZE OF ABDOMEN WITHOUT CHANGE IN SIZE OF
UTERUS OVARIAN TUMORS. Among the means that may be avail-
able in distinguishing these growths from pregnancy are the presence
of menstruation, and the enlargement having been first observed upon
one or the other side instead of in the median line, and its development
being slower than that of pregnancy. But amenorrhoaa is found in
quite a number of patients suffering with cystic ovarian disease either if
they have become anaemic, or iriternal hemorrhage has occurred ; as to
the place of origin of the enlargement, unfortunately many patients
observe badly or forget readily, so that this help often fails, and while
usually the enlargement of pregnancy is more rapid than that of an
ovarian tumor, exceptions to the rule may occur.
The deterioration of health and the emaciation, especially noticeable
in the face, will be marked if the tumor has attained great size. The
fluctuation is usually distinct in cystic disease of the ovary, absent or
very obscure in normal pregnancy ; in polyhydramnios the fluctuation
is quite marked, but it is especially at the upper part of the abdomen,
while in ovarian dropsy the fluctuation is commonly more general.
The results of touch and auscultation are negative, and the reflex dis-
turbances of pregnancy are generally absent. Nevertheless, there are
some cases in which a positive diagnosis should not be given at once;
delay and repeated examinations may be necessary to avoid a mistake.
206 PHYSIOLOGY OF PREGNANCY.
ASCITES. It seems strange, nevertheless it is true, that the abdomen
enlarged by ascitic effusion has been mistaken for the enlargement of
pregnancy. The shape of the former is different from that of the latter,
and fluctuation is always distinctly and everywhere present, whereas in
pregnancy fluctuation is not distinct except in polyhydramnios, and
then chiefly discovered in the upper part of the uterus. In ascites the
uterus is unchanged in form, size, and position ; the menstrual function
may be regularly exercised, and the reflex disturbances of pregnancy
are absent. The disease has in most cases an obvious cause in some
affection of the liver, kidneys, or heart. Palpation and auscultation
give negative results as to pregnancy.
ACCUMULATION OF FAT IN THE ABDOMINAL WALL OR IN THE
OMENTUM. Such an increase of size is more frequently observed in
women from forty to fifty years of age than at any other time of life.
The abdominal wall becomes not only prominent but pendent, and the
woman has, as Dr. Bailie expressed it, a double chin in the belly. In
such a subject it is generally easy, if she be lying down, for the phy-
sician, placing a hand on each side of the abdomen, to include between
them the entire mass, and partially lift it up, thus determining its true
character. There is entire absence of the signs of pregnancy furnished
by auscultation and touch. 1
PSEUDO-CYESIS, OR FALSE PREGNANCY. False, or nervous, preg-
nancy generally occurs in women who have married late in life, and
who are anxious for offspring, or who wish to give proof of their still
having the power of reproduction. They frequently present many of
the subjective and some of the objective signs of pregnancy, the intense
desire to be pregnant begetting many of the evidences of the condition.
In some of these subjects abdominal enlargement may be observed ;
menstruation may be absent, or scanty and irregular ; the breasts may
increase in size and contain milk ; the stomach may be irritable ; and,
finally, the woman is usually positive that she feels foetal movements.
The climax of the delusion of spurious pregnancy may be spurious
labor. The etiology of these cases is obscure. The women are honest
in their belief, they do not desire to deceive others, but they are them-
selves deceived. Nor can this self-deception and the phenomena of
false pregnancy and labor be accounted for by the action of the
imagination, for similar phenomena have been observed in some of the
inferior animals.
Over-fed bitches, which admit the dog without fecundation following, are
nevertheless observed to be sluggish about the time they should have whelped,
and to bark as they do when their time is at hand, also to steal away the whelps
from another bitch, to tend and lick them, and also to fight fiercely for them.
Others have milk or colostrum, as it is called, in their teats, and are moreover
subject to the diseases of those who have actually whelped. (Harvey On Con-
ception.)
Professor Haughton reported to the Dublin Obstetrical Society (February 7,
1880) an interesting case of phantom tumor observed in an ass that had been
covered by a zebra ; the appearance of pregnancy deceived an expert.
1 If the obesity is rapid in its development, if there are abdominal striae, and amenorrhoea is
present, the liability to error is increased. Such a case recently came to my knowledge, and the
diagnosis of pregnancy having been made, and false labor coming on, Csesarean section was done
the patient had a deformed pelvis and the increase in size was proved to be solely from deposit
of fat in the abdominal wall.
DIAGNOSIS OF PREVIOUS PREGNANCY. 207
In the diagnosis of pseudo-cyesis the physician must give little or no
weight to the subjective signs of pregnancy, or he will almost certainly
be misled. Let him, therefore, if the alleged pregnancy be far enough
advanced to make the objective signs available, trust to them, and in
the contrary condition wait until they ought to be plainly present in a
case of true pregnancy. Usually these patients, as has been frequently
observed, do not send for the physician until they have been, as they
think, pregnant for several months, and then they do not ask for a
diagnosis that they have made for themselves but for the relief of
some temporary indisposition, or to attend them in their approaching
labor. To undeceive such a one, proving that her hopes are false, is
generally a thankless and difficult task ; it ought not to be attempted
without first having conclusive evidence obtained by touch and auscul-
tation.
PATHOLOGICAL CONDITIONS RENDERING THE DIAGNOSIS DIFFI-
CULT. In case of pregnancy occurring in a woman suffering from an
abdominal enlargement the former is liable to be overlooked, the
pathological condition only being recognized. In some cases it is pos-
sible to remove the cause or condition hiding the pregnancy, and then
the latter will be discovered. Thus, if ascites be present, after
paracentesis the proofs of pregnancy may become evident. But the
chief means to avoid error from these sources are repeated examinations
and waiting until the signs of pregnancy become unequivocal. Pajot,
in referring to such difficulties, remarks that there is one distinct
characteristic of the gravid uterus by which it may be known from
ascites, fibroids, hsematometra, ovarian cysts, etc., that is, that it, in the
last third of pregnancy, is the only abdominal tumor in which there is
found a mobile solid body in a liquid.
The obstetrician should bear in mind that abnormal pregnancy, e. g.,
ectopic gestation, cystic disease of the ovum, or polyhydramnios, will
often present peculiar difficulty in diagnosis.
DIAGNOSIS OF PREVIOUS PREGNANCY. In some cases it is impor-
tant to know whether a woman is pregnant for the first time, or
whether she has been pregnant before, the pregnancy not ending in
abortion. In the primigravida the abdominal wall is smooth, tense,
and resisting and cannot be readily depressed ; the uterus is more
strictly confined to the vicinity of the median line, and especially does
not incline anteriorly so much as it does in the multigravida. In the
later part of pregnancy the stria usually found upon the skin of the
abdomen are not white or pearl -colored, but pink or purplish. The
mammary glands are round, full, prominent, firm, not relaxed, flabby,
and pendent. The vulval orifice is small, closed, the posterior com-
missure complete, the hymen may be torn, but the carunculae myrti-
formes are absent. The vagina is comparatively small, and the rugae
are distinct, prominent, and in intimate contact by the close apposition
of the anterior and posterior vaginal walls. The neck of the uterus
is conical, its orifice, which is closed, presenting a uniform rim or
border.
In the multigravida the abdominal wall is relaxed, not tense and re-
sisting ; possibly separation of the recti muscles is present, the striae,
208 PHYSIOLOGY OF PREGNANCY.
pearl -colored, of a former pregnancy may be present, and possibly, too,
with them there may be seen the purplish striae of the present gestation ;
a thinned abdominal wall permits more readily palpation of the uterus.
The breasts are less firm, the glandular portion can be defined ; they usu-
ally are somewhat pendent, and in many cases they are marked by old
stria3. The vaginal entrance is partially open, the labia rnajora relaxed,
pigment deposit is observed, and frequently there are varicose veins. The
hymen has given place to the carunculse myrtiformes, the presence of
cicatricial tissue at the perineum is not uncommon. The vagina is wide,
relaxed, its surface much smoother than is that of the primigravida, and
either the anterior or posterior wall may project into the canal. The
vaginal portion of the cervix is club-shaped or cylindrical, and the os
uteri is usually split, so that an anterior and posterior lip are distinctly de-
fined. In very rare cases this physiological tear of the os has not occurred,
so that to the touch it presents the character observed in the virgin or
of a woman for the first time in gestation. Again, tearing of the cervix
may be caused by the extraction of a large fibrous tumor from the uterus.
The possibility of error from either of these causes should be borne in
mind. Admitting that the woman has been previously pregnant, the
pregnancy may have ended in a miscarriage, and then, of course, the
diagnosis from physical examination may fail. So too, if a completed
pregnancy occurred some years before, .there may sometimes be difficulty
in the diagnosis.
DIAGNOSIS OF THE TIME OF THE PREGNANCY. In some cases it
is of importance to determine how far the pregnancy has advanced.
Independently of an estimate made of this time, by counting from the
supposed date of conception, an approximately correct conclusion may
be obtained by an objective examination. This examination gives more
satisfactory results in primigravidse than in multigravidae, because in the
former the changes caused by pregnancy are more characteristic and
typical. 1 The chief means in making this diagnosis are the changes in
the neck of the womb, including, in multigravidse, the patency of the
external os, and the progressive permeability of the cervical canal ; the
size of the uterus as learned by bimanual examination, and the distance
of the fundus above the pubes as measured on the abdominal wall ; the
changes in the umbilicus, and the formation of the secondary mammary
areola ; the time when the uterine souffle and the foetal heart-sounds be-
come audible, and the measurement of the length of the foetus. With
the exception of the last, measuring the foetal length, all these have been
considered. Ahlfeld's method of ascertaining the length of the foetus
is to put one knob of the calipers in the vagina, so that the head of the
foetus is touched necessarily through the thickness of the uterine wall,
while the other is placed at the fundus of the uterus, as near as possible
to the highest part of the breech, the abdominal and uterine wall, of
course, intervening. The length of the child is about twice this measure-
ment. Knowing what its length usually is at successive months, a con-
clusion may be drawn from the length of the foetus, ascertained by this
measurement, as to the time of the pregnancy.
. * Schroder.
DATE OF LABOR. 209
DURATION OF PREGNANCY/ Since pregnancy does not begin imme-
diately after coition or insemination, but with the actual union of the
spermatozoid and ovule, and as an uncertain time intervenes between
insemination and conception, it is impossible for us to know its actual
duration. We know in all cases when it ends, but in no case when it
begins. In those rare instances in which pregnancy was known to have
resulted from a single coition, the date of the coition does not corre-
spond with the beginning of gestation. It is probable that in any case
some hours, and in many several days intervened before the combina-
tion of the male and the female element occurred ; Schroder states that
the interval may be from one to fifteen days. Further, we do not know
whether the ovule that is fecundated 2 is the one liberated at the men-
strual period immediately preceding the sexual intercourse, or the one
corresponding to the succeeding menstrual suppression, or one escap-
ing from its ovisac in the menstrual interval. Hence a variation of a
few or of several days in the time when pregnancy actually begins.
While denied this certainty of knowledge, general observation agrees
in making the period of gestation nine calendar or ten lunar months.
Harvey said : " Unquestionably the ordinary term of utero-gestation is
that kept in the womb of his mother by our Saviour Christ, of men the
most perfect ; counting, viz., from the festival of the Annunciation in
the month of March to the day of the blessed Nativity, which we cele-
brate in December. Prudent matrons, calculating after this rule, as
long as they note the day of the month in which the catamenia usually
appears, are rarely out of their reckoning, but after ten lunar months
have elapsed fall in labor and reap the fruit of their womb the very
day on which the catamenia would have appeared had not impregnation
taken place." 3 Dr. Matthews Duncan speaks of Harvey's opinion here
quoted, as " very correct," and also states that his remarks tally with
the late Dr. Tyler Smith's ingenious views upon the question.
When pregnancy resulted from a single coition the average interval
between it and labor was two hundred and seventy-five days. The
average interval between the end of menstruation and labor is two
hundred and seventy-eight days. Variations from these averages will
be considered subsequently.
PREDICTING THE DATE OF CONFINEMENT. Tables for readily cal-
culating the time of labor are usually found in " Physicians' Visiting
1 Montaigne has the following remarks upon the duration of pregnancy : " Here, again, are the
physicians, the philosophers, the lawyers, and the divines, by the ears with our wives, about the
dispute, ' for what time women carry their fruit.' and I for my part, by the example of myself, side
with those who maintain that a woman goes eleven months with child. The world is built upon
this experience ; there is not so simple a little woman that cannot give her judgment in all these
controversies, and yet we cannot agree." .But Montaigne wrote in the sixteenth century.
Referring to the opinions as to the duration of pregnancy, there is found in Herodotus the story
of a Spartan king. Demaratus, born seven months after his mother's marriage, and in answer to the
charge of his illegitimacy she made this statement: "Women bring forth at nine months and
seven, and all do not complete ten months."
"His found by careful examination of 16 embryos that in 12 the stage of their development
showed them to be the result of impregnation at the time of the first missing menstrual period,
while the 4 others corresponded to the last preceding menses, and it only remains to prove by a
more extended series of observations which is of more frequent occurrence." Winckel.
3 Professor A. R. Simpson, referring to Harvey's statement fixing the duration of pregnancy as 275
days, remarks : "The dates are derived only from the teachers of the Roman Catholic Church, and
when their true meaning is investigated it is found that the 25th of March was held as Lady-day
in Pagan Rome, in honor of Cybele, the mother of the Babylonian Messiah, long before the era of
our Lord ; while the 25th of December was kept among many Gentile people as the birthday of the
Son of that " Queen of Heaven.' "
14
210 PHYSIOLOGY OF PREGNANCY.
Lists," and therefore it is unnecessary to insert any here. But, more-
over, there are simple rules by which the calculation can be made,
and therefore such tables and "periodoscopes" may well be omitted.
One plan is to count the number of days between the beginning of the
last menstruation and that of the one immediately preceding it, and
multiply the number by ten; labor comes on at what would have been
the tenth menstrual period had not pregnancy occurred. A much sim-
pler rule, given by Tarnier, is this: Count nine calendar months from
the cessation of the flow, and add five days. Or we may add five days
to the date when the flow stopped and count back three months. Thus,
a woman ceased to menstruate on the fifteenth of February, now adding
five to fifteen we have the twentieth of the month, and then counting
back from the twentieth of February three months, we find that the
twentieth of November is the probable day of labor.
An objection to the plan of counting the duration of the pregnancy
from the duration of the menstrual cycle arises from the fact that in
many women this is not a uniform period, often varying from one
month to another, and it certainly is very different in different individ-
uals. According to such plan, the woman who njenstruates every three
weeks ought to have her pregnancy end in two hundred and ten days,
while another whose period may happen to be thirty-one days would
have her pregnancy protracted to three hundred and ten days.
"Quickening" has been by some regarded as so uniformly occurring
at four months and a half that the time of the ending of pregnancy
might be determined from the date when this was observed. But, as
previously stated, this phenomenon is not so regular in its time of mani-
festation as to give accurate guidance. In some cases it may serve to
correct an error that has been made in regard to the date of the last
menstruation, and may assist in forming a probable conclusion as to the
time when labor will occur.
While it is usual to speak of predicting the day of confinement, it
should be remembered that the prediction is only a probable one, and
indeed that the day when labor occurs is most frequently either just
before or just after this.
PRECOCIOUS BIRTHS. La Motte has given the history of a woman
who was delivered of a child seven months after marriage ; her husband
suspected her chastity, but seven months after her convalescence she was
delivered again, greatly to the relief of the husband's mind ; her daugh-
ters married, and each of them was delivered at seven months. He
also mentions another case in which marriage took place the day that
the bride left the convent, and just seven months subsequently labor
occurred ; after recovery she again became pregnant, and this pregnancy
also lasted only seven months. Both children lived.
One of these cases was quoted by Depaul, and he observed that while
precocious births are generally admitted, the unanswerable facts proving
them are very rare. The late Dr. Hodge taught that in many instances
strong and healthy children are delivered before the usual time. The
same belief was expressed by Spiegelberg. Yet it seems improbable
that a child born, for example, at seven months will present the devel-
PROLONGED PREGNANCY. 211
opment of one born at nine months. 1 Ronaldson 2 has reported a case
of "early viability/ 7 the child being born six calendar mouths and nine
days after coition.
The French law recognizes as legitimate a child born six months (180
days) after marriage ; but while this is a legal viability, yet it is quite
exceptional for a child born before the completion of seven months to
live, and even if born then, very great care is generally necessary to
preserve its life. The nearer the time of birth approaches the normal
the greater the probability of the child living. While not claiming
that a child born at eight months will be as vigorous and as well devel-
oped as one born at full term, it is not unreasonable to believe that in
some cases the foetus may develop somewhat more rapidly, its growth
favored especially by abundant supply of nutriment, than in other
cases, just as seeds may germinate more rapidly, or plants have their
fruits and flowers earlier in one soil than in another ; in other words,
there may be precocious births, but the boundary within which this may
occur, though incapable of being defined, is probably a very narrow one.
A case recently under my care has convinced me that occasionally precocious
births do occur : Mrs. , six years married, pregnant three times, each
pregnancy ending in miscarriage, one in the fifth month, the others at earlier
dates. The patient first came under my care three years ago, on account of
retroversion of the uterus. In October, 1893, I attended her in a miscarriage.
In the spring of 1894 menstruation became somewhat irregular, and there were
occasional discharges of blood in the intervals. I thought these probably re-
sulted from an early and incomplete abortion, not included in the list of three,
and determined to curette the uterus. This curetting was done on the 18th of
June, and followed by an injection of Churchill's tincture. She left the hospital
the last day of the month, and menstruation did not reappear. Pregnancy was
soon believed to exist, the belief becoming a certainty in October. In consequence
of a severe fright, fire breaking out in her house, premature labor, no premoni-
tory symptoms whatever, especially no change in form, occurred on the 7th of
February, and after twenty-four hours she was spontaneously delivered of a
living female child, which weighed nearly seven pounds. The child, though not
so strong nor so active as one born at term, certainly greatly exceeded in vigor
that usually observed in a seven months' child : the fontanelles were much larger
than in a child born at term, and the cranial bones less firm. The infant was
kept in Auvard's incubator for three weeks. The pregnancy could not have
exceeded 226 days, or eight lunar months and two days, and the assurance was
given me that it was even less than this period. It is impossible to admit
that even if pregnancy was presenfat the time of the curetting it could continue
after it. I am, therefore, led to believe with La Motte, and some other of the
older obstetricians, in a more rapid development of the foatus in exceptional cases
than that usually observed.
PROLONGED PREGNANCY. Few questions in obstetrics have caused
more controversy than as to whether the period of utero-gestation can
be materially prolonged beyond 280 days. It is still unsettled. As
late as 1870, in a trial before the Court of Queen's Bench, upon the
charge of seduction, very contradictory evidence as to the prolongation
of the ordinary period of pregnancy was given by distinguished obstet-
ricians. In the United States obstetric authorities have generally up-
1 It is somewhat remarkable that we have comprised within a few lines in the nineteenth book 01
the Iliad, 115-119, not only a statement of the normal period of human pregnancy, nine months,
but also an example of the successful induction of labor at less than seven calendar months, and
of the prolongation of pregnancy beyond nine months in another subject.
2 Edinburgh Obstetrical Society's Transactions, vol. vi.
212 PHYSIOLOGY OF PREGNANCY.
held the view that gestation may be prolonged. Dewees asserted
that in each of four women under his observation pregnancy lasted ten
calendar mouths. Bedford stated that there is undoubted evidence that
pregnancy occasionally extends beyond 300 days. Dr. Hodge gave
from his own practice a case in which he regarded it as certain that
pregnancy continued 302 days. Warrington, apparently founding his
opinion upon the evidence in the Gardner Peerage case, says that some
women have been pregnant ten calendar months (311 days). Meigs,
after detailing Asdrubali's case, in which pregnancy was alleged to have
continued thirteen months and twenty-two days, and expressing his
belief in its truth, narrated the history of a pregnant woman under his
own care, whose pregnancy lasted 420 days. American physicians have
reported in medical journals a few instances of protracted gestation.
Among these is that of a case in which pregnancy was believed to have
continued 330 days. 1 Dr. L. A. Rodenstein has given four cases of pro-
longed pregnancy; 2 he suggests as the probable limit to this increased
duration, two mouths.
Rossie has published 3 a case in which pregnancy did not end until
317 days after coition. McTavish 4 gives a case in which he believes
pregnancy lasted 318 days, and Maur, 5 one of 334 days.
It has been in this country judicially decided that pregnancy may last
317 days.
Thomson has recently reported a case in which pregnancy lasted
317 days from the last menstruation, or 301 from the last coition. 6
Some of the most eminent of foreign physicians have held that pro-
longed gestation may occur. Naegele, in his well-known work, asserts
that there are undoubtedly cases in which the pregnancy has lasted 300
days and even longer. The late Dr. Churchill 7 said: "Dr. Mont-
gomery relates two cases in his work, one of which came under my
observation ; in the first, the gestation continued 291 days, and in the
second, forty-one weeks and two or three days at least." He adds to
this statement, that the question being one chiefly of authority, positive
evidence must infinitely outweigh mere negation. Spiegelberg 8 has
remarked that the variations in pregnancy lie chiefly between the 265th
and the 280th days ; cases in which a foetus has matured in a shorter
time are rare, somewhat more frequent are those in which birth took
place after 280 days. Individual conditions certainly have an influence
upon the pregnancy, thus primiparous and legitimate pregnancies end
earlier than their opposites. He also refers to the dependence of the
duration of the pregnancy upon the menstrual cycle, as pointed out by
Cederschojold and Berthold, and hence variations in individuals accord-
ing to their menstrual periods ; there may be also variations in the same
person in different pregnancies. Wiuckel, from his own study of cases
in which pregnancy followed a single cohabitation, and from the obser-
vations of others, reaches the following conclusion : The average dura-
tion of pregnancy is about 280 days ; it may vary, however, from 240
1 Boston Medical and Surgical Journal, May, 1859.
2 American Journal of Obstetrics, June, 1882. 3 Ibid., January, 1886.
* New York Medical Journal, April, 1889. * Ibid. ; May, 1889.
6 London Obstetrical Society's Transactions, vol. xxvii.
* Theory and Practice of Midwifery.^ 8 Op. cit.
PROLONGED PREGNANCY. 213
to 320 days, and perhaps even exceed this latter limit, and such excess
is by no means so rare as was formerly supposed, for in 6.8 per cent,
the duration is over 300 days. Ahlfeld states that pregnancy in women
varies from 220 to 330 days, counting from coition. He also quotes
the case reported by Sarwey in, which labor occurred 341 days after
the last menstruation, as doubtful because the date of impregnation was
not known. So, too, Olshausen 1 has said that the duration should not
be restricted to 300 days, but the limit ought to be advanced to 320 or
325 days. Hohl is quoted by Olshauseu, op. cit., to the eifect that pro-
longation to 308 days is not rare, and that even 321 and 336 (case of
von Rieche) may occur.
On the other hand, Stoltz takes the position that pregnancy cannot
be prolonged more than fifteen days ; Depaul, referring to the French
law making a child legitimate born 300 days after the departure or
death of the husband, considered the limit very large ; Kleinwachter
denies prolonged pregnancy ; Dr. Robert Barnes holds that a pregnancy
lasting 300 days is highly improbable ; and Tarnier states that it is
impossible to admit an iutra-uterine pregnancy passing the highest
limit of normal pregnancy unless some obstruction at the cervix prevents
delivery.
That labor may be delayed for a few weeks is the belief of many
obstetricians from their personal observations. Thus, in illustration,
it is not uncommon for a woman, in most cases a primigravida, who
passes the time at which her delivery, counting from her last menstrua-
tion, was expected, and then after a delay of two, three, or even four
weeks, falls in labor ; the labor is tedious, a large head, its ossification
further advanced than is usually found at birth, is to be moulded ; in
some cases the forceps must be used, but whether the child be delivered
spontaneously or artificially, it weighs considerably more than the
average, and not unseldom is stillborn. Delore mentions an instance
of a primigravida whose gestation lasted a month beyond the usual
period ; Duncan, one of a multigravida in whom the pregnancy also
lasted a month over time, the child weighed ten pounds and four ounces,
and the placenta two pounds. Schroder quotes the case reported by
Rigler, as " a very conclusive one " in proof of prolonged pregnancy.
A woman four weeks after the'expected term, give birth to a dead male
infant, weighing ten pounds and a quarter, the hair and the nails were
well developed, and the placenta weighed more than three pounds.
Cases of this kind will be admitted by most as proving the prolonga-
tion of pregnancy. Such facts, belonging so generally to personal ex-
perience, have more weight than an appeal to the uniformity of Nature's
laws. The argument drawn from occasional instances of prolonged
pregnancy in some of the inferior animals, also has weight in sustaining
the view that this is not impossible in the human female. For example,
the average duration of pregnancy in the cow is 282 days, but the time
may be prolonged to 321 days.
Reese, 2 in his excellent manual, takes the ground that it is possible
for human pregnancy to be prolonged beyond the usually admitted nor-
1 Centralblatt f. Gynakol., 1889.
2 Text-book of Medical Jurisprudeuce and Toxicology.
214 PHYSIOLOGY OF PREGNANCY.
mal period, but that the question how far beyond is more difficult to
answer, though the greater the amount of the deviation, the stronger
and more convincing should be the proofs. He further indorses the
statement of Taylor to the effect that we must " be prepared to admit
either that conception may in some cases be delayed for so long a period
as five to seven weeks after intercourse, or that there may be a differ-
ence of from five to seven weeks in the duration of pregnancy."
In regard to the question of a perfectly matured child being born
prior to the normal period of pregnancy, he criticises the evidence
given by the late Sir James Simpson in an English case, in which the
legitimacy of a child was made to depend upon the period of the
mother's gestation, 259 days, Sir James testifying that it was impossi-
ble for a child perfectly matured to be born three weeks before the
usual term.
I am indebted to James P. Baker, Esq., of Indianapolis, for the
following presentation from a legal standpoint of the duration of
pregnancy :
The period of gestation is frequently a matter of judicial inquiry, particularly
in bastardy proceedings and in controversies among heirs affecting legitimacy.
Lord Coke, who was one of the great masters of the common law, in his work
upon Littleton, written nearly three hundred years ago, held that nine months,
or forty weeks, is the longest time allowed. Mr. Hargrave, in his edition of
Coke upon Littleton, at page 123 b, carefully reviewed the law, and came to a
different conclusion. In summing up, he said :
" The precedents, therefore, so far from corroborating Lord Coke's limitation
of the ultimum tempus pariendi, do, upon the whole, rather tend to show that it
hath been the practice in our courts to consider forty weeks merely as the more
usual time, and consequently not to decline exercising a discretion of allowing
a longer space where the opinion of physicians or the circumstances of the case
have so required. In the course of our inquiries into the subject of this note
we were curious to know the general sentiment of that eminent anatomist, Dr.
Hunter, on three interesting questions. These were, What is the usual period
of a woman's going with child? What is the earliest time for a child's being
born alive ? and What is the latest f "
Dr. Hunter's answer was as follows :
" 1. The usual period is nine calendar months ; but there is very commonly a
difference of one, two, or three weeks. 2. A child may be born alive at any
time from three months ; but we see none born with powers of coming to man-
hood, or of being reared, before seven calendar months, or near that time. At
six months it cannot be. I have known a woman bear a living child, in a per-
fectly natural way, fourteen days later than nine calendar months, and I believe
two women to have borne children alive in a natural way, above ten calendar
months from the hour of conception."
Mr. Hargrave's note has been frequently quoted by the courts up to the present
time, and is still regarded as a sound exposition of the law. The question may
arise, Which Dr. Hunter gave the above reply ? Hargrave lived in London, and
wrote the preface to his edition of Coke in January, 1785. Dr. William Hunter
died in 1783. Dr. John Hunter, his brother, died In 1793. The note was prob-
able written near the time of the completion of Mr. Hargrave's work. It is
probable, therefore, from these facts, though not certain, that John Hunter was
the author of the reply. But a certainty seems to be established by Mr. Har-
grave referring to Dr. Hunter as " that eminent anatomist," a designation which
applied more especially to John than to William Hunter, for the latter was
more celebrated as an obstetrician.
Judges, like doctors, are liable to differ, and the decisions of courts have not
been entirely harmonious as to the period of gestation. In the case of O'Brian
v. The State ex rel. Swift, 14th Ind. 469, the Supreme Court of Indiana say :
PROLONGED PREGNANCY. 215
"Those who have investigated the subject know that in the course of nature
a child living and capable of surviving to the ordinary age of man may be born
in seven, and may not be born until the expiration of ten months from the ces-
sation of the catamenia indicating the time of its conception."
The case of Duck v. The State ex rel. Dill, 17th Ind. 210, was a prosecution
for bastardy. In such a case the question always is, " Is the defendant the father
of the child?" Any evidence tending to show that any other man is the father
is admissible. The child was born on September 18, 1858. On the trial the
defendant offered to prove that the relatrix had had sexual intercourse with
another person in the first week of November, 1857. The evidence was rejected.
The Supreme Court held that this evidence was rightly rejected, and said :
'* It is true, experience proves that the period of gestation is almost as variable
in individual cases, though within narrow limits, as that of the length of human
life, but the longest period we have ever known to be judicially allowed was 313
days. See the case of Commonwealth v. Hoover, 3d Clark, Pa. 514. In the
case at bar the evidence might have covered a period of 322 days."
A still longer time was judicially allowed, however, in the case of the United
States v. Collins, tried in the U. S. District Court for the District of Columbia in
1809, and reported inCranch's Circuit Court Reports, vol. 1, page 592. The case
was an indictment for not supporting a bastard child. The mother was received
as a witness. The attorney for the government objected to the cross-examina-
tion as to her connection with other men than the defendant. The Court over-
ruled the objection, but limited the time of inquiry to a period of not more than
twelve months nor less than six months before the birth of the child. This is
an extreme case. In Paul v. Padleford, 16 Gray (Mass.), 263, a bastardy prose-
cution, the Court refused to allow proof of acts of intercourse of the plaintiff
with other persons than the defendant, at a time more than ten months and
twelve days before the birth of the child. In Phillips v. Allen, 2d Allen (Mass.),
453, the Court said :
" The child was born in eight months after the marriage, and the fact that a
child is born thus soon after the husband had first access to the wife does not
prove beyond all reasonable doubt that the child is not his. There are ancient
decisions that gestation somewhat more than nine months after the husband
could have had access to the wife, does not disprove the legitimacy of the child.
See Hargrave's note to Coke's Lift. 123 b, where these decisions are cited, and
where in support of them the testimony of Dr. Hunter is introduced, expressing
his opinion that gestation often varies from one to three weeks from nine cal-
endar months, and that children are sometimes born in seven months from con-
ception, and live and grow to manhood."
In Eddy v. Gray, 4 Allen (Mass.), 435, which was a bastardy prosecution, the
Court below had admitted testimony tending to show illicit intercourse by the
complainant with other men than the defendant at a period of time more than
ten months before the birth of the child. The Court said :
" Such testimony, in the absence of proof that the period of gestation extended
beyond the usual duration according to the common and natural course of life,
which is recognized as well by legal as medical authorities, is inadmissible, and
should have been excluded. See Coke's Litt. 123 b, and note by Hargrave."
In the recent case of Ronan v. Dugan, 126 Mass. p. 176, a prosecution in bas-
tardy, the Supreme Court of Massachusetts say :
" In cases of this kind, the admissibility of evidence of illicit intercourse of
the complainant with any other man than the defendant depends upon the
relation to the time when the child was born. In Eddy v. Gray, 4 Allen, p. 435,
where the intercourse offered to be proved occurred more than ten months before
the birth, the evidence was held to be inadmissible without proof that the period
of gestation was prolonged beyond the usual duration. We see no reason why
the same rule should not be followed where the intercourse offered to be proved
took place less than seven and a half months before the birth, in the absence of
the proof that the birth was premature."
In such a case the Tennessee Code limits the inquiry between the first of the
tenth and the first of the sixth month next before the birth of the child. See
Crawford v. The State, 7, Baxter, 41.
Wharton, in his work on Evidence, at section 344, says :
216 PHYSIOLOGY OF PREGNANCY.
" The court will take judicial notice of the ordinary periods of gestation, so
as to assume the non-legitimacy of children born ten months after intercourse,
or when prior non-intercourse is proved five months after the act of intercourse."
At section 1300 he says :
" The time of conception is determined by the Roman practice by reckoning
backward from the time of birth ; and the rule is that there must be not less
than one hundred and eighty-two days and not more than ten months to estab-
lish legitimacy. German jurists have continued to maintain the minimum of
one hundred and eighty-two days. In our own practice the question of legiti-
macy, when a child is born on either side of the usual limits of parturition, is
determined on the testimony of experts ; though in cases beyond question, the
court may determine what is notorious as a part of the ordinary laws of nature."
After all, the light of the courts in this matter is reflected light. Physicians
must determine the matter ; and if the space between the minimum and maxi-
mum periods, hitherto allowed, is shown to be too long or too short, the courts
will readily follow the truth as it is made manifest.
MISSED LABOR. This term, introduced by Dr. Oldham, is applied
to those cases in which a foetus dying after the period of viability has
been reached is retained in the uterus for weeks, or even months, be-
yond the time when pregnancy ordinarily ends. In these cases nature
makes an effort at the normal time to expel the contents of its cavity,
but the effort fails, and the pregnancy continues an indefinite period
until those efforts are renewed successfully, or the contents are removed
by artificial means.
In some cases the failure to expel the contents of the uterus has been
from resistance of the os, e. g., the obstacle may be cancer of the cer-
vix. Other explanations given by Spiegelberg are an abnormally firm
connection of the ovum with the uterus, or anomalous degrees of
irritability.
In missed labor the amnial liquor may be absorbed and the foetus
become mummified ; in other instances a lithopaedion results. In rarer
cases suppuration of the foetus may occur, the purulent discharge
usually finding its way externally through the vagina.
It has been shown that some of the cases of supposed missed labor
were really instances of ectopic gestation, or of gestation in a rudi-
mentary uterine horn.
CHAPTER IX.
THE MANAGEMENT OF PREGNANCY.
WOMAN only escapes being sick twelve times a year by having an
illness which lasts nine months, was the assertion of a once famous
French litterateur. Though, of course, rejecting this statement and
denying that gestation is a disease, we must admit that it has many dis-
comforts, and in numerous instances causes great liability to pathological
conditions, and in some these conditions are manifested. The remark-
able changes that occur in the organism or in the organs of a pregnant
woman may open the way for maladies which are manifested during or
subsequent to the pregnancy. It is advisable, therefore, that all care,
and even precautions, be taken to ward off threatened dangers and to
conduct the subject safely through her pregnancy, both in her own in-
terest and in that of her offspring. 1
The conduct of pregnancy includes hygienic and medical care.
HYGIENE OF PREGNANCY. This relates to food, clothing, air,
exercise, rest, sleep, bathing, care of the breasts, and to the mental con-
dition.
FOOD. In many cases during the first months of pregnancy the
disturbance of the stomach, and the less active life often consequent
upon this disturbance, and in some the associated mental anxiety, lessen
the desire for food. Nevertheless it is better that an effort at least be
made to have regular meals, although the quantity of food taken may
not be as much as usual.
In some cases the morning sickness may be lessened, if not averted,
1 That special care of the pregnant woman was in early times regarded as important is
shown by the practices of many ancient people, and by the injunctions of old medical writers.
The following, for example, are the directions given by Susru-fa, the earliest known medical
writer of India, who lived at least fourteen hundred years before the Christian era. Many of
these directions are wise, while the reasorl for others cannot be understood :
" The pregnant woman should avoid becoming weary, indulging in coition, sleeping in the day-
time, watching at night, sorrow, climbing into a wagon, sitting upright, violent movements,
phlebotomy, and long-continued exertion. Her longings must be satisfied in order that she may
nave a strong and long-lived child. From the first day she must be cheerful, pious, and clean in
clothing and person. She should not touch dirty or deformed objects, nor eat any dry or spoiled,
food. She must not go out, or remain in an empty house, or go to the holy altar, or in graveyards,
or near trees ; she must avoid getting angry, carrying loads, or talking top loud."
Probably the first recorded example of the hygiene of pregnancy was given by Samson's mother
when pregnant with the Jewish Hercules ; she was to abstain from wine. There is reason for
believing that drunkenness among the Jewish women was not uncommon at that time, or not
long subsequently, as the interview between the priest Eli and Hannah, recorded in the first
chapter of Samuel, suggests. Furthermore, abstinence from intoxicating beverages in pregnancy
is certainly a rule of prudence, while great indulgence in them, according to excellent profes-
sional authority, is very mischievous. For example, Dr. Kirk, Glasgow Medical Journal, 1885,
remarks: "For my part I am convinced that indulgence in alcohol beyond the most moderate
extent is frequently in the last degree disastrous to a pregnant woman and her progeny."
Dr. Norman Kerr, in the second edition of his work upon Inebriety, London, 1889, says in ref-
erence to the influence of alcoholism of the parents upon the child : ' The mother probably is
the more important factor of transmission. She exerts an influence, not only with the father in.
the conception, but, in addition, during the whole period, of utero-gestation wields a special in-
fluence upon the unborn child." And again : " Considerable numbers of the children of female
inebriates succumb to intra-uterine death. Of those who reach the period of birth, a goodly
number have been so affected in the womb by the alcoholic cerebral and meningeal congestions,
and other pathological states induced by alcohol, that they die from hydrocephalus or convul-
sions."
218 PHYSIOLOGY OF PREGNANCY.
by the patient having a light breakfast an hour or two before rising. 1
When this disorder disappears the appetite usually returns, and in some
is greater than it was before pregnancy. The food should be both
animal and vegetable, and especially include digestible fruits in their
season ; for the latter will aid in preventing the constipation which so
generally attends the pregnant condition.
It occasionally happens that a women when pregnant desires articles
of food to which at other times she is indifferent ; and these desires
ought not to be refused, for they may express some need in her system
for certain materials which are thus supplied ; they are very different
from the perversions of appetite that by some are imagined or assumed.
It is important that the stomach be not overloaded at any time,
and especially in the evening. When the uterus encroaches most upon
the stomach in the latter part of pregnancy it is generally the case that
only a small quantity of food can be taken at a time, and then the
meals may be more frequent than usual.
Alcoholic liquors ought not to be used, but the drink should be
milk, water, or chocolate ; those who are accustomed to coffee and tea
will doubtless continue them, but these beverages should not be strong,
nor taken in large quantities.
CLOTHING. This should be such as will not hinder the development
of the abdomen and the breasts, and at the same time will protect from
cold. The word enceinte, meaning in Latin ungirdled or without girdle,
commemorates the custom of Roman women, who, when they became
pregnant, laid aside their girdle, the fascia mamittaris, and it suggests
avoiding all compression of the body. Baudelocque mentions the case
of a girl who sought to conceal her pregnancy by tight lacing, and thus
caused a dangerous hemorrhage. The corsets should be quite loose ;
the garters, if tight, may cause oedema of the legs, or varicose veins.
Insufficient or unseasonable clothing may lead to an acute affection of
the respiratory organs, attended with violent coughing, and the latter
cause abortion ; or sudden suppression of the perspiration occur from
exposure to cold and result in albuminous nephritis. The high-heeled
shoes so commonly worn by ladies tend to increase the forward inclina-
tion of the body, and thus render more difficult the position which a
pregnant woman must take to preserve the centre of gravity when
standing or walking ; they make her more liable to missteps, and thus
danger of falling, thereby injuring herself or the foetus, and of jars that
may case partial detachment of the ovum. If, as is often the case in
the multigravida3, the abdominal wall be greatly relaxed, permitting
decided anteversion of the uterus, a suitable bandage contributes very
much to the patient's comfort, and by correcting the malposition of the
womb assists in preventing an unfavorable presentation of the foetus.
AIR. Pure air is of especial importance to the pregnant woman, for
1 The late Professor Meigs stated : " Many of those examples that consist of nausea and
vomiting during the early part of the day, but which cease after the meridian hour, may be set
aside by the following method : Let a cup of coffee, with a toast, be brought to the bedside at the
earliest morning hour. The patient should be called from her sleep to take this preliminary
breakfast without rising from bed. As soon as it is taken let her lie down to sleep again, if pos-
sible. It appears useless to offer a rationale of this method. I am very confident, however, that,
in a considerable number of persons it will be found to put a sudden stop to the vomiting as well
as to the nausea. Certainly many of my patients have been speedily, as well as permanently,
cured by it, and that in very distressing instances of the nausea."
THE MANAGEMENT OF PREGNANCY. 219
she breathes for two, and is eliminating an increased quantity of toxic
matter. A confined atmosphere has an injurious influence both upon
her and upon the foetus, and breathing air poisoned by carbonic acid
may cause abortion. She should avoid all crowded halls, whether
theatres, concert or ball-rooms, or churches ; all poisons in the air, such
as that of sewer gas or of infectious diseases, should be carefully guarded
against; the room occupied in the day or in the night must be well
ventilated ; if possible, a part of each day ought to be spent in the open
air.
EXERCISE, REST, SLEEP. If a woman in the first months of preg-
nancy suifers much from nausea and vomiting, she is little disposed to
exercise ; she is weak from the less amount of food taken or retained,
and any movement may increase the gastric irritability. Again, toward
the close of pregnancy her great size interferes with facility of move-
ment; both her condition and instinct ask for repose more than for
active exertion ; J if we observe the conduct of pregnant animals, we
find that as parturition draws near they are indisposed to exertion and
spend much of their time lying down. But in woman during the
intervening time daily exercise in the open air, carried to the point of
slight fatigue, is one of the best means to increase her vitality and that
of her offspring ; her appetite is thus improved, her digestion better,
and refreshing sleep secured. The best exercise is walking, and without
some special reason against it, that should be chosen rather than riding.
All violent motions, whether active or passive, such as riding over
rough roads, equitation, dancing, ascending several flights of stairs, or
lifting heavy weights must be forbidden ; so, too, prolonged exercise,
causing great fatigue, and protracted journeys by land or sea, are to be
avoided. Regular hours of rest are to be observed ; from eight to ten
of the twenty-four may be given to sleep. In women liable to abortion
absolute rest is often necessary, especially at the time corresponding
with a monthly period, to guard them against the danger ; in some rare
cases, rest in bed during almost the entire pregnancy has been necessary
in order to avert this accident.
CONJUGAL RELATIONS. Obstetric writers agree in forbidding coition
when there is a liability to miscarriage, in advising it to be less fre-
quent in other cases, and abstained from at times corresponding with
monthly periods, especially the third and seventh, in one the danger
of abortion, in the other that of premature labor being greatest.
Klein wiichter remarks that coition is to be restricted the first half of
pregnancy, and unconditionally forbidden the second half. Dr. Ben-
jamin Ward Richardson directs that the bed of the pregnant woman
should be occupied by herself exclusively. Dr. Richard 2 says that if
the human race were guided by the example of animals, and if it per-
fectly conformed to the advice of nature, which most frequently inspires
the pregnant woman with complete indifference and even some aversion
to marital caresses, coition during gestation would be entirely abandoned.
Other writers have referred to the aversion which Richard mentions. Thus
Roederer 3 enumerated among the signs of pregnancy viri fastidium. It is re-
Stoltz. 2 Histoire de la Generation. 8 Op. cit.
220 PHYSIOLOGY OF PREGNANCY.
markable that among the signs of pregnancy given by Susru-fa the dread of
coition is mentioned. Stolz 1 states that women have told him that as soon as
they were enceintes they had horreur du mart, some of them by this sign first
knowing that they were pregnant.
If the relation between husband and wife had no higher purpose than perpetu-
ating the race, it is plain that sexual intercourse should cease when the vow of
nature is being fulfilled ; such indulgence may cause abortion, and has been
compared to ploughing the soil when the seed is germinating ; in many cases it
is painful, excites or aggravates leucorrhcea, and may cause more or less reflex
disorder. There is a moral side to this question. Many a wife must have less
love and reverence for her husband when she, sick and suffering, or at least often
wearied by the growing burden she bears, her mind a prey to anxious fears as to
the issue of her pregnancy, is the victim of lust, 2 a lust which has no excuse in
her desires, no demand for the continuance of the race. Man does not learn that
self-restraint which makes him purer and nobler, but nourishes a passion that
becomes more dangerous by such exercise than it could by any voluntary conti-
nence during his wife's pregnancy. Admitting that the state of society changes
the instincts of nature, and that the indulgence condemned, in many cases, brings
no immediate and obvious injurious physical results, it may well be questioned
whether most obstetric writers have not, either tacitly or explicitly, granted a
license which leads to evil rather than good.
Both Stoltz and Spiegelberg disapprove of sexual intercourse in pregnancy,
but the former states that such disapproval is preaching in the wilderness, and
the latter that it is preaching to the rocks. Nevertheless let the truth be spoken,
whether men will hear or not, and let the right way be pointed out, though a
multitude may choose to go in the wrong path.
Mantegazza, L' Amour dans PHumanite, says : "The origin of polygamy may be
purely hygienic. In many countries of Africa husbands cannot have any sexual
relation with their wives during the period of pregnancy, nor sometimes during
the period of lactation." ,
BATHING. The frequency and temperature of baths will depend
upon a patient's previous habits ; but usually once or twice a week is
as often as a bath, cold or warm, is advisable : 3 hot baths, whether of
the feet or of the entire person, must be forbidden. The external
genital organs should be bathed daily with cool water as a protection
from erythema, and to cleanse from increased secretion which retained
might cause irritation ; if leucorrhoea be troublesome, there is no objec-
tion to tepid vaginal injections of water, plain or medicated, e. g., with
common salt, creolin, chlorate of potassium, or borax ; the fluid should
be injected gently, used as a wash, not a douche.
The late Dr. G. W. Lawrence, for many years a distinguished prac-
titioner at Hot Springs, Arkansas, informed me that abortions have
frequently been caused by the use of hot baths at this famous health
1 Op. clt.
2 In Swift's terrible satire upon human beings, given in Gulliver's Voyage to the Houyhnhnms,
it is stated that " the she-yahoo admits the male while she is pregnant," and this is spoken of " as
such a degree of infamous brutality as no other sensitive creature arrives at."
For the following statements I am indebted to Floss's work, Das Weib :
In the majority of heatht-n nations sexual continence is observed during pregnancy. Among
many the abstinence from coition has arisen from the belief that the pregnant woman is unclean.
By the Medes and Persians cohabitation with a pregnant woman was severely punished. Among
some people polygamy is based upon abstinence from coition in pregnancy.
The old Hebrews and the Rabbis in the Talmud taught that coition during the first three months
of pregnancy was very injurious to both the mother and child. Whoever cohabited on the ninetieth
day did that which destroys human life, but the prudent Rabbi Abaja adds, " Since we cannot
know this day with certainty, God preserves the simple from injury."
The ancient Irans very severely punished cohabitation with the pregnant woman. The man re-
ceived 2000 lashes, and was compelled to carry 1000 loads of heavy and 1000 of light wood to the
fire. He must offer in sacrifice 1000 of the smaller domestic animals, and kill 1000 snakes, 1000 land
lizards, 2000 water lizards, and 3000 ants, and lay 30 bridges over flowing water.
s Warm hip-baths during the last week of pregnancy are by some thought useful in facilitating
labor.
THE MANAGEMENT OF PREGNANCY. 221
resort. Tardieu, 1 after referring to the universal use of baths under
all forms by those practising abortion, observes that he does not know
a single instance authorizing him to believe that abortion was its direct
consequence.
CARE OF THE BREASTS. It has been previously stated that the
clothing should be such that no compression of these organs, especially
of the nipples, is permitted. If the nipple be small, the woman should
be taught to use her thumb and finger to draw it out, giving it suitable
form and size ; this process begun some months before labor, and ex-
ercised for a few minutes each day, will often give very favorable results.
It is in the highest degree improbable that the action of the uterus could
be thus excited, causing abortion or premature labor. In rare cases it
may be advisable to use at first, but very gently, atmospheric pressure
by means of a breast-pump, and also to wear a firm nipple-shield which
protects the organ from pressure, and gives room for its development.
Keeping the nipple too constantly, too warmly covered, renders the skin
more delicate and sensitive, and therefore is to be avoided, while daily
exposure to the air has, according to Delore, the beneficial effect of ren-
dering the epidermic secretion more active. Cleanliness is important,
for the secretions from the nipple and that from the gland, which occur
during pregnancy in many cases, if allowed to collect, render the skin
beneath very liable to become excoriated when nursing begins ; the
nipples, therefore, are to be washed each day, generally with simple
water, occasionally soap may be added. Bathing the nipples daily with
alcoholic and astringent solutions is a common practice in pregnancy, it
being believed that thereby excoriations and fissures are prevented.
But it is doubtful whether the theory is wise, or the practice justified
by results. Such applications effectually remove the secretion and
probably lessen the activity of the sebaceous glands thereby in some
degree doing away with the protection nature gives to surfaces exposed
to contact with liquids and make the skin hard and rigid, which
nature meant to be soft and pliable. It would be better to use simply
tincture of arnica, bay rum, or Cologne water, one part to three of water,
if an alcoholic preparation is advisable; but in any case there should be
applied to the nipple at night a small quantity of cocoa butter. Cer-
tainly the prophylaxis of acute disease of the nipple in nursing women,
which so often leads to mammary inflammation, is better, more rationally
sought by the simple means just mentioned, than by those in common
use.
CONDITION OF THE MIND. Not only the pregnant woman's own
health, but that of her child is in some degree dependent directly or
indirectly upon her mental state. Her sensibility is increased, and
therefore she should be carefully guarded against injurious impressions ;
she should be saved all needless pain, all possible petty irritations, all
sudden fright or shock. The exercise of a cheerful temper should be
advised, as well as occupation of the mind in some useful work, in
reading or study, and the society of agreeable friends, with occasional
pleasant recreation.
1 Etude MMico-legale sur PAvortement.
222 PHYSIOLOGY OF PREGNANCY.
MATERNAL IMPRESSIONS. The question 1 as to the foetus being in-
juriously affected, whether by arrest of development, malformation, or
"marks," in consequence of impressions made upon the mother's mind,
is one of great interest, and probably of no mean importance. These
psychical conditions may be subjective or objective; that is, may origin-
ate in the patient's mind, or be made by an external cause; only in the
latter case is it correct, so far as strict use of language is concerned, to
speak of an impression. The belief in the former source is perpetuated
in the term ncevm maternus, while almost countless illustrations of the
alleged power of the latter may be found in professional literature.
Dr. Barker has called attention to the fact that three of the most dis-
tinguished writers of fiction in modern times Goethe, in his Elective
Aj/inities ; Sir Walter Scott, in the Fortunes of Nigel; and Dr. Holmes,
in Elsie Venner " have based incidents on this belief, in a way which
they would not have done if they had supposed that these incidents
would be rejected by their readers as improbable." It may be added
to this statement, that in Redgauntlet, Scott, 2 not so much by the inci-
dent narrated as by the accompanying footnote, indicates his faith in
this influence. 3
Quatrefages said it has been long observed that children begotten by
a man when intoxicated often permanently present the characteristic
signs of that state obtuse senses and almost entire absence of intellect.
The remark of Diogenes to a stupid youth is well known : " Young
man, your father was very drunk when your mother conceived you."
If the temporary state of the progenitor has such an immediately
powerful and permanent influence upon the germ, it is not probable
that the evolution of that germ is unaffected by the mental condition
of the mother. The belief in maternal impressions has that criterion
which one of the great philosophers* of the day regards as indicating
some measure of truth it is universal and perennial. Though prob-
ably the majority of physicians are either very skeptical in regard to
such influence or absolutely deny it, yet there is a large number of emi-
nent names that can be cited as believers in it. Very interesting con-
tributions to the subject have been made by Drs. Barker and Busey in
the eleventh volume of the Transactions of the American Gynecological
Society, and a valuable paper upon the question by Dr. Dabney will be
found in the first volume of the Encyclopaedia of Diseases of Children.
There is not space for even an imperfect discussion of the subject in
this treatise, and I shall merely adduce a few of many illustrative cases
1 " Up to the beginning of the eighteenth century physicians adopted the opinion of Hippocrates,
and the philosophers admitted with Empedocles, not only that strong emotions experienced by
pregnant women could cause deformities of the foetus, but also the desires or ' longings ' of these
women cause ' marks ' of infants." Bayard : Annales Medico-psychologiques, tome troisieme.
2 Lilias, in conversation with her brother, Darsie, exclaims : " See, brother," she said, pulling
her glove off, " these five blood-specks on my arm are a mark by which mysterious Nature has
impressed on an unborn infant a record of its father's violent death and its mother's miseries."
Sir Walter Scott adds the following footnote : " Several persons have brought down to these days
the impressions which Nature had thus recorded when they were yet babes unborn. One lady of
quality, whose father was long under sentence of death, previous to the rebellion, was marked on
the back of the neck by the sign of a broadaxe. Another, whose kinsmen had been slain in battle
and died on the scaffold, to the number of seven, bore a child spattered on the right shoulder and
down the arm with scarlet drops, as if of blood. Many other instances might be quoted."
3 The Medical Standard, Chicago, August, 1892, adds to the list of novelists the following
names : Dickens, in Barnaby Rudge ; Read, Put Yourself in His Place ; and Hawthorne, Scarlet
Letter.
4 Herbert Spencer: First Principles. Elsewhere, some years ago, I quoted Lotze, one of the
most eminent German philosophers of the century, as believing in the possibility of this influence.
THE MANAGEMENT OF PREGNANCY. 223
that have been communicated to me, and which have never been pub-
lished, suggesting to those who honestly doubt to consult the papers by
Dr. Meadows, 1 Drs. Barker and Busey, and by Dr. Dabney. Those
who deny maternal impressions of course, the expression is used to
avoid a circumlocution base a strong and unanswerable argument
upon anatomical and physiological grounds. But let it be remembered,
that when obstetric auscultation was made known, two of the most
eminent of French obstetricians Duges and Baudelocque denied the
possibility of hearing the foetal heart through the amnial liquor, the
uterine and the abdominal wall, and, so far as theoretical argument was
concerned, proved their thesis. Those who believe in such impressions,
acknowledge their ignorance of the way in which these impressions
act ; but if we exclude from belief all that we do not understand, our
minds will be kept within very narrow limits. 2
CASE I. Dr. H. Woodbury Coleman, of Trenton, N. J., has communicated to
me the following history of a case under his own observation: "Mrs. , of
this city, twenty-three years old, and about two months pregnant, was one day
very badly frightened by her son, two years old, nearly cutting off with a
butcher-knife his left thumb, the member hanging apparently by but a shred.
She was without any one to assist her, and dressed the injury as best she could.
In two hours I saw him, and she assisted me in that and subsequent dressing.
Her mind constantly dwelt on the accident, and in due time she gave birth to a
boy, who, to my great surprise, had his left thumb hanging to the hand by a thin
pedicle of flesh."
CASE II. I am indebted also to Dr. Coleman for the following case, occurring
under the observation of Dr. Elias March, of Paterson, N. J. : " In 1863 a married
private in the army came home on forlough ; his left arm had been amputated
near the shoulder-joint, a small stump remaining which had not yet healed, daily
dressing being required, which was done by his wife She became pregnant, and
during the early part of her pregnancy her thoughts were constantly dwelling
upon the condition of her husband. She was delivered at term of a child without
any left arm, only a small fleshy mass attached to the shoulder-joint, resembling
the amputated stump observed in her husband."
CASE III. Dr. W. H. Knipe, while a student at Jefferson Medical College
last winter, gave me the following statement as to one of the cases of confine-
ment he attended in connection with the Philadelphia Dispensary. "Mrs. A.
W., primigravida, burned herself with a poker upon the wrist of her right hand,
the burn being in a line with the index finger ; this occurred on March 5th. On
the 7th she burned herself again, but on the wrist of her left hand. She was
delivered on March 19th ; the chifd was a girl, and had on each wrist marks in
the same location and presenting the general characters of the burns upon the
mother's wrists."
CASE IV. One of the students of Jefferson Medical College, a young gentle-
man whom I believe perfectly reliable, showed rne a varicose left popliteal vein ;
the right vein was quite normal indeed, there were no varicose vessels to be
found except that mentioned. From his mother the following history was ob-
tained. When she was four months pregnant, her ninth pregnancy, she was
visited one day by a woman who told her how much she suffered from a swollen
vein behind the left knee, and, without invitation, at once exposed it to her view.
She was quite startled by the sight, and expressed her sympathy for the sufferer.
1 Transactions of the London Obstetrical Society, vol. viL
2 In Coleridge's Table Talk it is stated that Dr. Parr said to a person who asserted he would
believe nothing he could not understand : " Then, young man, your creed will be the shortest of
any man's I know."
In reference to this very question a famous physiologist, Burdach, once said : "If we wish to
deny a vital phenomenon, for the sole reason that it is impossible for us to say what are its mate-
rial conditions, we must also assert that it is impossible for any quality to pass from the grand-
father to the grandson, or that a child can inherit the traits, the stature, the constitution, the
morbid predispositions, the talents and inclinations of the father."
224 PHYSIOLOGY OF PREGNANCY.
When her child was born a precisely similar condition of the vein behind his
left knee was found, and, as I have said, has continued to the present. To these
cases I add the following, as showing a possible purely psychical influence :
CASE V. The case of Benjamin Hall Blyth, an arithmetical prodigy, is of
interest as illustrating the possible influence of maternal impressions in produc-
ing his peculiar gift. His mother, while pregnant with him, witnessed the
wonderful calculating power of the boy Bidder, once publicly and twice at her
home. She was greatly interested. Blyth, when about six years old, one day
walking with his father, asked: "At what hour was I born?" The reply was 4
A.M. He then asked: "What time is it now?" The answer was 7.50 A.M.
Walking on a few hundred yards, he turned to his father and stated the exact
number of seconds he had lived.
His brother, in narrating 1 this incident, adds : " It is, I believe, admitted by
physiologists that anything greatly occupying the mother's mind certainly may,
and frequently does, influence the character of her unborn child."
The five cases that have been narrated are more easily explained by
the hypothesis of maternal impressions 2 than in any other way. An
ancient poet, uttering the limited knowledge of his age, declared that it
was not known how the bones grew in the womb of her who was with
child, though now an explanation is at hand, so possibly the clearer
light of future science may make plain the mystery of the psychical,
action of the mother upon her unborn offspring.
But be this as it may, it is not wise to reject, as resting upon old
wives' fables, an opinion avowed by such men as Rokitansky, Stoltz,
Montgomery, Tyler Smith, and Meadows, and in this country by For-
dyce Barker, Busey, Spitzka, and Dabney.
Conception itself presents mysteries 3 the solution of which will prob-
ably always elude the research of man, so that we may continue with
Harvey to admire and marvel at this process.* But in recognizing the
fact that the foetus may be affected through the mother's mind, we must
beware of accepting most of the popular evidence given in its favor;
for example, a child is born with a deformity which the mother attrib-
utes to her having seen a similar deformity while she was pregnant, but
upon inquiry it is ascertained that she saw it after the stage of embryonic
development in her own child had passed when its deformity resulted.
Very many of the stories of the influence of maternal impressions are
absurd, 5 carrying with them their own contradiction, and are often sug-
gested, or even fabricated after the birth of the child.
In addition to the probable but occasional coarser proofs of the in-
fluence of maternal mental impressions upon the unborn child, as shown
1 Proceeding^ of the Society for Psychical Research. London, July, 1892.
* " The singular influence thus exerted by the mind of the mother on the growth of the foetus is
not one ' for which,' as has been remarked of other modes of action of the mind upon the body,
1 It is likely we shall ever be able to assign a reason, or which it would be any great hardship to be
obliged to regard as an ultimate fact in physiology.' " Dr. Alexander Harvey, op. cit.
8 " Is it not marvellous," says Montaigne, " that this drop of seed from which we are produced
should bear the impression not only of the bodily form, but even of the thoughts and inclinations
of our fathers? Where does this drop of water keep this infinite number of forms? and how does
it bear these likenesses through a progress so haphazard and so. irregular that the great-grandson
shall resemble the great-grandfather?" Had Montaigne lived after the important discovery made
by Ham, he would have substituted spermatozoid for "drop of seed," and declared the marvel
vastly greater.
* Bain has said : " The reproduction of each living being from one or two others through the
medium of a small globule which contains in itself the future of a definite species, is the greatest
marvel in the whole of the physical world ; it is the acme of organic complication."
5 Of course there have been, as there are many reported cases of " maternal impressions " that
only amuse by their absurdity. Burton, Anatomy of Melancholy, has mentioned several. Mon-
taigne narrates the following : " There was presented to Charles, the emperor and king of Bohemia,
a girl from about Pisa, all over rough and covered with hair, whom her mother said to be so con-
ceived by reason of a picture of St. John the'Baptist, that hung within the curtains of her bed."
THE MANAGEMENT OF PREGNANCY. 225
in monstrosities and in deformities, it is possible, nay probable, that very
important effects are produced by the condition of the mother's mind
in pregnancy which belong to the psychical 1 rather than the physical
nature, effects that are gradually made manifest in childhood, in youth,
and in adult life. It not unfrequently happens that children of the
same parents differ very greatly in mental and in moral qualities ; they
differ in the power of acquiring knowledge, in objects of desire and pur-
suit, in aptitudes and accomplishments. In some instances it is possible
to trace a probable connection between these differences, and, not only
the condition of the mother's health during the several gestations and
the surrounding circumstances, but also with the state of her mind dur-
ing those periods. Here is opened a wide field, not merely for speculation,
but for actual investigation. And the more the whole subject of human
reproduction is studied with regard to the physical and mental health,
and the happiness and usefulness of the offspring, the more grave and
solemn the responsibility of paternity and of maternity will be proved.
Enough is known, and enough has been said, to urge the importance of
the pregnant woman living as far as possible a calm, equable, and cheer-
ful life, avoiding all intense emotion and all great excitement. 2
Weissmann, in a lecture upon 3 "The Supposed Transmission of Mutilations,"
takes the ground that a single coincidence of an idea of the mother with an ab-
normality of the child does not prove a causal connection between the phenomena.
He maintains that " the present state of biological science teaches us that with
the fusion of egg and germ-cell potential heredity is determined." He further
asserts, " The tales of the efficacy of maternal impressions, and of the transmis-
sion of mutilations are closely connected, and break down before the present
state of biological science ;" and that " no one can be prevented believing such
things, but they have no right to be looked upon as scientific facts, or even as
scientific questions."
F6re, 4 incidentally discussing this subject, remarks : " The acute or chronic
emotions of the mother during gestation can without doubt have a noxious
influence upon the child in causing disorders of development," etc.
THE MEDICAL CARE. Under this head it is proposed to consider
briefly some of the most frequent, but usually minor, disorders of
pregnancy and their treatment.
NAUSEA AND VOMITING. The gastric irritability, occurring in most
cases only in the first half of pregnancy, is usually regarded as reflex.
The writer quite agrees with Vinay in considering the vomiting of preg-
nancy as the type of nervous vomiting, and presenting greater or less
intensity according to the condition of the nervous system. When we
observe cases in which before pregnancy there was hysteric cough that
is superseded by vomiting, when patients have been so often cured by
suggestion some trivial application to the cervix proclaimed as infalli-
1 In a paper by Dr. Robert J. Lee, entitled "Maternal Impressions," published in the British
Medical Journal, 1875, the following remark is made : " It would, on reflection, appear to be most
natural that maternal impressions should be more frequently followed by some unnatural condition
of the intellect of the child than by abnormalities of growth, and this point is worthy of particular
attention."
2 Plato, in the Seventh Book of Laws, after speaking of the susceptibility of the newly born
infant to impressions, remarks : " Nay, more, if I were not afraid of appearing to be ridiculous, I
would say that a woman during her year of pregnancy should of all women be most carefully
tended, and kept from violent or excessive pleasures and pains ; and at that time she should culti-
vate gentleness, and benevolence, and kindness."
'' Lecture before the Association of German Naturalists, Cologne, 1888.
4 Revue des Deux Mondes, November 15, 1894.
15
226 PHYSIOLOGY OF PREGNANCY.
ble, \ve must believe that the so-called remedy acted only by mental im-
pression and also other sufferers promptly relieved by the occurrence
of great danger, or fear, or anxiety, the conclusion seems just that the
disease is often a neurosis, and that we do not know its etiology, simply
hiding our ignorance under the term reflex.
Nevertheless, in a few cases an obvious uterine cause, either uterine
displacement or disease, has been found.
The grave form of the disease will be considered in the Pathology of
Pregnancy, and there will now only be presented the treatment of its
milder manifestations. If hygienic means should fail, such as taking
the morning meal in bed, iced drinks, lime-water and milk, etc., a com-
plete change of scene, if possible, may prove useful. As to medical
treatment, the means that have been advised are so numerous that their
recapitulation would occupy too much space; the fact of their being so
numerous is a probable proof of their uncertainty in action. Sir James
Y. Simpson strongly recommended oxalate of cerium, 5 to 10 grains three
or four times a day ; now the valerianate is given in preference to the
oxalate. Dr. Meigs and Dr. Hodge advised tincture of aconite root,
two drops three or four times a day. Among other remedies that have
been employed are tincture of nux vomica, 3 to 4 drops, four or five times
a day this sometimes is quite useful creosote, hydrocyanic acid, bis-
muth, wine of ipecacuanha, opium in connection with belladonna, mor-
phia, hypodermatic or endermic, chloral and potassic bromide by the
rectum, and, in recent years, menthol, antipyrin, and cocaine. Counter-
irritants to the epigastrium, ether-spray to the epigastrium, Chapman's
ice-bag to the spine, galvanization, and faradization. In regard to the use
of the faradic current, the following are the directions 1 of Olivier : one
electrode is placed at the lower part of the neck posteriorly, the other
upon the epigastric region ; it is usual to have the upper electrode nega-
tive, but if the effect is not satisfactory the poles may be changed. The
application lasts two to three minutes, and is repeated daily or once in
two days. Olivier states that this method is usually rapidly effective,
also saying that the beneficial result may be from a doubtful reflex action,
or from a feeble excitement of the splanchnic nerves, or be purely psy-
chic ; the last explanation seems the most probable.
SALIVATION. This is a less frequent disorder than the preceding,
but the two may be connected, and usually are when either is severe.
Washing the mouth out frequently with a cold astringent solution has
been commonly recommended, but is of doubtful value in a severe case.
A sudden suppression of the excessive secretion may be followed by
serious consequences. Baudelocque refers to a young woman who in
her first pregnancy suffered greatly from salivation, but was refused any
means for its relief; in her second pregnancy the same symptom re-
curred, and means were successfully used to arrest it, but the day fol-
lowing she died of apoplexy.
Schramm 2 has reported a case of sialorrhoea in a pregnant woman cured by
bromide of potassium, after the use of iodide of potassium, atropine, galvaniza-
tion of the sympathetic, and hypodermatic injections of pilocarpine without any,
or only temporary, benefit.
i Hygiene de la Grossesse. Paris, 1892. 2 Berlin, klin. Wochen., 1886.
THE MANAGEMENT OF PREGNANCY. 227
CONSTIPATION. If this cannot be prevented by suitable diet, an
injection of a pint of cool water may be used each morning. If medi-
cines must be resorted to, they should be mild laxatives, such as calcined
magnesia, compound licorice powder, Seidlitz powder, Rochelle salts, the
liquid citrate of magnesia ; a few prunes that have been stewed in an
infusion of senna, eaten in the evening, will in some cases prove an effi-
cient means of removing the constipation ; so too one of the mild ape-
rient waters, such as Huuyadi, may be used. All drastic purgatives
should be avoided. If the constipation be associated with hemorrhoids,
Dr. Fordyce Barker 1 advised a grain of aloes made into a pill with soap,
hyoscyamus, and ipecacuanha and given night and morning. Cazin 2
commends a pill containing one or two centigrammes of belladonna given
daily, as advised by Bretonneau.
HEMORRHOIDS. In addition to correcting constipation by the means
just mentioned, half a pint of cold water should be injected into the
rectum morning and evening, the injection being retained. When the
piles protrude and are painful they may be bathed with warm water
and laudanum, or the ointment of galls and opium may be applied.
Dr. Bartholow 3 speaks favorably of the following ointment, advised by
Oesterlen, for hemorrhoids : Pulv. gallse, 3j ; pulv. opii, grs. x ; ung.
plurnbi subacetat., 3ij ; ung. simplicis, 5ij. M- The protrusion should
be reduced as soon as possible.
(EDEMA OF THE LEGS VARICES. The former is in many cases a
consequence of the latter. It usually disappears after lying down for a
time, and is to be treated by position, by removing all constriction, as
from garters, and by bathing with cool water. Varices, according to
Budin, occur in twenty to thirty per cent, of pregnant women ; but in
many cases the dilatation of veins must be very slight if there be so
large a percentage ; my own observation leads me to believe that only
from five to ten per cent, of women are thus affected in pregnancy.
Varices of the lower limbs are treated by position and compression.
Cazin 4 advises the application first of an old linen bandage, and over
this one of flannel extending from the toes to a point above the enlarged
vessels. Some prefer an elastic stocking, but a flannel bandage is less
expensive, and properly applied^more comfortable. It is to be remem-
bered that too great compression has caused abortion. An accident to
which the patient is liable, either from violent scratching, from a blow,
or sometimes simply from the pressure of the column of blood in un-
supported vessels, is a rupture of one of them, permitting a hemorrhage
rapidly fatal if the flow be not promptly arrested. The patient is in-
formed of this danger, and told, if the accident occur, to lie down at
once and stop the flow by firmly pressing her finger upon the bleeding
point.
PRURITUS OF THE VULVA. Itching of the vulva is a symptom of
various conditions, such as oedema, follicular inflammation, eczema,
herpes, or prurigo, etc. It is not remarkable that the external genera-
tive organs, sharing in the increased supply of blood occurring in preg-
nancy, and in some cases the seat of passive congestion caused by the
1 Puerperal Diseases. 2 Archives de Tocologie, 1881.
3 Materia Medica and Therapeutics. < Op. cit.
228 PHYSIOLOGY OF PREGNANCY.
enlarged uterus, should be liable to some of the local affections men-
tioned, and which have as their most prominent symptoms a more or
less intense itching. The violent rubbing and scratching which the
pruritus may cause of course aggravate the disease. The irritation
sometimes extends to the vagina, but it usually occupies only the great
and less lips. The vulval inflammation from which the pruritus results
may be caused by a vaginal discharge.
The suffering of some pregnant women from pruritus is often very
great. Dewees has spoken of a woman under his charge thus afflicted,
who was confined to her room during three months of her gestation,
and whose only relief in her entire period was had by the nearly con-
stant application of ice- water.
He also described an aphthous eruption as present in some cases, and
for this he advised a strong solution of borax ; it may be used for bath-
ing the vulva, and also for injecting in the vagina, and frequently proves
quite beneficial.
Some patients find relief of the itching by applying to the vulva
cloths wrung out of hot water.
Dr. Tauszky recommends the application with a brush to the affected
parts eight or ten times a day of the following solution, first sug-
gested by Hufeland : two drachms of powdered gum-arabic, one of
balsam of Peru, one and a half of oil of almonds, and one ounce of
rose-water.
Bulkley advises an ointment, made by rubbing together one drachm
each of camphor and chloral, and then incorporating the mixture with
eight ounces of ointment of rose-water. Doubtless cocaine ointment or
solution would prove useful. Spiegelberg found the most reliable rem-
edy a solution of corrosive sublimate, applied 1 to 3 times (1 : 100-200
parts of dilute alcohol), followed by the application of tar- water, and by
chamomile hip-baths. Tarnier also prefers a solution of corrosive sub-
limate, 2 parts ; alcohol, 10 parts ; rose-water, 40 parts ; and distilled
water, 450 parts. This lotion is employed undiluted morning and
evening.
But, as observed by Olivier, 1 if the parts are inflamed, in some
subjects mercurial lotions cause great suffering. He also states that in
a series of cases he has had prompt success from the lotion of Del-
peyrou, which is composed of hydrate of chloral, boric acid, glycerin,
alcohol, and water. Unfortunately the formula for this lotion is not
given, and Mr. Morgan, a prominent pharmaceutist of this city, sug-
gests the following :' Chloral, 2 drachms; glycerin, 4 drachms; alcohol,
4 drachms; boric acid, 1 drachm ; and to these sufficient water is added
to make four ounces. The parts are first washed in water as hot as
can be borne, and then the lotion, diluted with an equal quantity of
water, is applied by absorbent cotton ; a thin layer of cotton, after being
dipped in the solution, is interposed between the labia. The application
may be made two or three times a day.
HERPES GESTATIONIS. Bulkley has described this affection as begin-
ning with clusters of vesicles upon the extremities, whence extension to
. i Op. cit.
THE MANAGEMENT OF PREGNANCY. 229
the trunk occurs. The disease does not disappear until after labor, and
may recur in subsequent pregnancies; the treatment does not differ from
that usually required by herpes.
GENERAL, PRURITUS. This, like the last, is a comparatively rare
affection. It is characterized by intense itching of the skin, without
any eruption being present to explain it. In a case narrated by Spiegel-
berg the pruritus began in the second month of pregnancy, and lasted
until labor, being only partially relieved by Fowler's solution. Stoltz
gives two cases. Probably arsenic or sulphur internally, and alkaline
or mercurial lotions, may effect slight mitigation in some cases. The
affection may be so serious, depriving the patient of rest, and causing
such rapid deterioration of health and so great emaciation, that the
question of ending the pregnancy is presented.
NEURALGIA. This is more frequent in pregnancy than in the non-
pregnant state, and may require the administration of tonics, especially
of quinine and iron, and the use of anaesthetics locally ; in some instances
the suffering demands morphine hypodermatically, but usually phenacetin
or antipyrin will relieve. Odontalgia is so common in pregnant women
and the pain may be so severe that extraction of an offending tooth is
too often done, and hence the familiar adage, "for every child a tooth."
Marshall states 1 that softening of the dentine is not uncommon in preg-
nancy, and caries may result. He holds that long, tedious operations,
like the restoration of form in decayed teeth with gold, are inadmissible
during gestation. " All operations upon the teeth at such times should
be as free from pain and fatigue as is possible, from the fact that in
certain cases miscarriage might be the result." He advises as means
preventive of caries a thorough and frequent use of the toothbrush and
floss silk at least three times a day, supplemented by tooth-powders and
antacid mouth-washes.
GINGIVITIS. Pinard first drew attention to gingivitis in pregnant
women. This affection is characterized by redness and swelling of the
gums, more especially of the anterior maxillary bones indeed, in the
vicinity of the molars the disease does not appear ; the swollen parts
readily bleed upon touch, and the corresponding teeth may become quite
loose. Gingivitis is manifested about the fourth month of gestation,
and having once appeared does not entirely go away until after the
pregnancy ends.
The treatment consists in the thorough cleansing of the teeth, the
removal of tartar, and the diligent use of the tooth-brush. Should
these means fail, the use of astringents, such as tincture of myrrh and
water, would be indicated. Tincture of iodine locally used has been
recommended. Pinard advises applying to the diseased gums a solu-
tion of equal quantities of hydrate of chloral and tincture of cochlearia,
the application being made every day or once in two days.
SLEEPLESSNESS. If this cannot be remedied by hygienic means
such as taking only alight supper, exercise in the open air, and a sponge-
bath before retiring and if caused by no obvious physical disorder which
can be corrected, one of the alkaline bromides may first be tried alone,
1 Journal of the American Medical Association, February 22, 1890.
230 PHYSIOLOGY OF PREGNANCY.
and should this fail chloral may be combined with it. Opium is in some
cases necessary, but great care must be takeu that it is not given so fre-
quently the habit of using it is formed. \
The obstetrician will visit the pregnant woman from time to time,
especially during the latter weeks of gestation, so that he may know
her condition is favorable for her approaching trial. Once a week,
during the last two or three months of gestation, the urine should be
examined with reference to possible albuminuria ; the examination must
be made earlier if any symptoms, hereafter to be mentioned, indicate
the probability of this disorder being present.
Few women, if a proper explanation be given, will object to an ex-
ternal examination made in pregnancy for obstetric diagnosis. Certainly
such examination is advisable in most cases ; and in some, if there is
the least suspicion of an unfavorable presentation, must be insisted upon.
Moreover, if the history of previous labors indicates any pelvic deform-
ity, or there may be other reasons for suspecting such condition, the
examination must be not only external but also internal.
In lying-in institutions careful pelvic measurements are made in the case of a
pregnant woman, and hence when serious deviations from the normal are dis-
co Yerecl in time, appropriate means to avert danger to mother and child are taken.
The pregnant woman in private practice, and her unborn child, are entitled to
quite as great prophylactic care. I know that occasionally a mother perishes in
labor, and her child, too, because of the failure of the obstetric attendant to know
in time the existence of a pelvic deformity.
SECTION II.
THE PHYSIOLOGY OF LABOR
CHAPTER X.
CAUSES OF LABOR PRECURSORY SYMPTOMS PHYSIOLOGICAL PHE-
NOMENA CHANGES IN THE FORM OF THE HEAD IN VERTEX
PRESENTATION CAPUT SUCCEDANEUM.
LABOR, the physiological end of pregnancy, is the process by which
the foetus and its appendages are separated from the mother ; it is
travail, bringing forth. Nature's design being the continuance of the
race, the foetus must have reached such development before its expul-
sion as to be viable, that is, capable of living external to the mother.
If, therefore, the product of conception be expelled before such capa-
bility, the process is not called labor, but abortion or miscarriage. If
labor takes place in the eighth or ninth month, it is called premature,
because the foetus has not attained its perfect development; if labor
be deferred beyond nine months, it is called postponed or delayed, if
the foetus is alive, but missed labor if it is dead. When parturition is
effected by the sole power of the maternal organism it is called natural;
but if art aid or replace that power., it is termed artificial labor. In
order that a labor may be natural the foetus must not exceed the normal
size and the presentation must be favorable ; the birth-canal must be
typical in size and form ; and, finally, the forces, voluntary and involun-
tary, of the mother must be able to dilate the birth-canal, mould the
presenting part, determine changes in its position so that shorter foetal
diameters are brought in relation with longer diameters of the mother's
pelvis, the passenger thus accommodated to the passage, and all resist-
ance overcome.
DETERMINING CAUSES OF LABOR. For a long time it was believed
that the foetus escaped from the uterus by its own efforts, just as the
chick leaves its shell, or the butterfly its cocoon. Harvey, for example,
held that " the foetus, with its head downward, attacks the portals of the
womb, opens them by its own energies, and thus struggles into day."
If the foetus made its own way from the mother's womb, the question naturally
arose as to the reason for its action, and various answers were given. The amniotic
liquor became acrid, and irritated the skin of the foetus ; Drelincourt said that the
intestine was filled with meconium, and hence a colic which disturbed the foetus,
and made it strive to get out, while others held that a distended bladder was. the
cause of this effort ; the womb became too hot for it, or it needed to breathe, or
232 PHYSIOLOGY OF LABOE.
sought different food ; Fabricius asserted that the weight of its head pressed open
the mouth of the iiterus. Some thought that obliteration of the utero-placental
vessels caused the child to leave, others that the uterus having reached a certain
distention, reacted and by its contraction incommoded the foetus ; narrowing of
the ductus arteriosus, of the ductus venosus, and of the foramen of Botal have
also been suggested as the causes of the action of the fcetus.
Those who believed that the foetus was an active agent in parturition
asserted that the delivery of a dead child was more difficult than that
of a living one. Admitting the assumption, Depaul has suggested three
answers : First, the living foetus by its movements may excite or increase
uterine contractions. Second, in case the foetus dies, some time may
elapse between the death and the expulsion, but the development of the
uterus ceasing with the former, its action in the latter may be less power-
ful than it is at the time of perfect development. Third, if the mem-
branes have been ruptured, the following foetal decomposition may have
a poisonous influence upon the muscular fibres of the uterus, weakening
their action.
Post-mortem births have been claimed as proof that the foetus could
escape from the womb by its own efforts. But when these happen soon
after death they result from the persistence of uterine contractility,
while the resistance of soft parts is lost ; occurring later, they are caused
by the pressure of gases formed in the abdomen external to the uterus.
Fatty degeneration of the decidua, by which the ovum is detached
from the uterus and becomes a foreign body, is alleged by some to be the
cause of labor. It is well known that artificial detachment of the ovum
is one of the most certain methods of inducing labor. But the fatty
degeneration which is supposed to excite natural labor is not a constant
fact.
The influence of the ovaries in exciting labor has been maintained.
Tyler Smith believed he had established that ovarian excitement is the
law of parturition in all forms of ovi-expulsion ; this excitement, this
nisus, he alleged, is active at monhly periods through the pregnancy,
becoming at the tenth so great as to cause labor. Probably the majority
of women are not conscious during their pregnancy of periodical ovarian
disturbance; in the order of nature ovulation is then suspended, the
ovaries, for the time being having fulfilled their work, now rest. Besides,
the tenth period varies in different women ; in one menstruating every
thirty days it is three hundred days, while in another who has her flow
every twenty days, it is only two hundred. Again, women may con-
ceive who never menstruated, or in the physiological absence of the flow
during lactation ; a nisus which fails to cause menstruation in the non-
pregnant state has not enough power to start the machinery of child-
birth. Single ovariotomy has frequently been done during pregnancy,
and labor occurred at the normal time. Double ovariotomy has been
done in a few cases in pregnant women, but this did not delay or pre-
vent the action of the uterus occurring at the normal end of gestation.
But if the determining cause of labor be not found in the foetus or
in changes in the decidua or in the ovaries, may it not be in the uterus?
It is held by some that when the muscular fibres of the uterus have
attained their perfect development, expulsive contractions result. But
CAUSES OF LABOR. 233
the contractile power of the uterus is manifested in premature labor and
in abortion. Others teach that the uterus may be distended to a certain
degree, and then reacts against the distention. But the thickness of
the uterine walls is different in different subjects, and in the same sub-
ject varies in different pregnancies, yet in each case the reaction occurs
just when the fcetus has reached maturity. In plural pregnancy and
also in polyhydramnios the uterine distention is greater than in single
or in normal pregnancy.
Brown-Sequard has shown that carbonic acid circulating in increased
quantity in the blood of a pregnant animal causes uterine contractions,
and the occurrence of labor is therefore attributed to the accumulation
of carbonic acid in the venous apparatus of the uterus. Dr. Robert
Barnes 1 has called attention to the fact that when the French army in
Algeria kindled fires at the mouths of caves in which, among others, a
number of pregnant women had taken refuge, almost all these women
miscarried. But it is possible that mental emotion had as much to
do with the accident as carbonic acid. The carbonic acid hypothesis
of the induction of labor fails, because it does not explain why the
uterine muscular tissue did not act sooner, but was indifferent to the
presence of carbonic acid until nine months ended, and then suddenly
resented and began the process of labor.
Leopold finds the source of the irritation which leads to uterine con-
tractions in the increased venosity of the blood in the maternal or foetal
placenta, resulting in venous thromboses of the serotina or in the uterine
walls.
Dubois and Depaul upheld a theory first advanced by Power in 1819.
According to it, the expulsion of the fetus is similar to that of the
feces or of the urine. Feces accumulate in the rectum, and after a time
by pressure on the sphincter irritate it, until reflex action determines
contractions which overcome its resistance, and the bowel is emptied.
So, too, the renal secretion does not at first excite vesical contractions ;
but when the reservoir is more or less completely filled the fibres of the
neck are stretched, causing irritation and dragging on the sphincter of
the organ, and this sensation reacting upon the body, contraction is
excited and its contents discharged. In pregnancy the upper part of
the uterus is developed first ; " little by little the lower segment takes
part in the general development of the organ, and the ovum gradually
occupies a larger space in this portion ; thus at the ninth month that
section of the uterus adjoining the internal orifice of the neck is
developed in turn, and causes stretching of the circular fibres ; this
purely mechanical irritation, by reflex influence, acts upon the upper
part of the womb." 2
But, as frankly acknowledged by Depaul, the theory of Power fails
to explain the access of labor-pains in extra-uterine pregnancy.
1 Transactions of the American Gynecological Society, vol. i.
* Depaul, op. cit. Garimond, Nouv. Arch. d'Obst4t. et de Gyn6col., 1887, in a study of the
determining cause of labor, referring to the analogy between the expulsive exertion action of the
bladder and that of the uterus, observes that it is not irritation of the sphincter, but excessive
tension of the entire cavity of the bladder that causes this organ to contract, expelling its con-
tents ; and thus in regard to the uterus : tension of the uterine walls is the cause of uterine action
beginning, and contractions occur, not in response to an elective sensibility seated in the body
or neck, but this sensation belongs to the entire physiological organ. This is simply an old
hypothesis in new clothes.
234 PHYSIOLOGY OF LABOR.
Ahlfeld 1 regards the irritation which determines uterine activity as
primarily originating in the lower uterine segment and cervix. These
are greatly stretched at the end of pregnancy. Moreover, the parts of
the birth-canal adjacent are rich in nerves, and especially at the ante-
rior and lateral periphery of the cervix large numbers of ganglia cells
are found. He refers to the inaugural dissertation of Kniipfer, at the
Dorpat Klinik, 1892, in which careful study of the bat has proved the
existence of vast numbers of ganglia cells in the peri-cervical tissue,
irritation of which caused expansion of the lower uterine segment.
Some writers, plainly seeing the weakness of each of the various
causes adduced as determining labor, have rested their explanation in a
combination of them. 2 It is better to refer the matter to a law of the
organism, a law the cause of which we do not know, for, as truly said
by Foster, 3 we are utterly in the dark as to why the uterus, after
remaining apparently perfectly quiescent, or with contractions so slight
as to be with difficulty appreciated for months, is suddenly thrown into
action, and within, it may be, a few hours gets rid of the burden it has
borne with such tolerance for so long a time ; indeed, none of the
various hypotheses which have been put forward can be considered
satisfactory.
THE EFFICIENT CAUSES OF LABOR. The chief agent in the expul-
sion of the foetus is the uterus itself. During the first part of labor the
uterine contractions act unaided ; but when the os uteri is dilated so as
to oifer little or no resistance to the descent of the part of the foetus
which presents, they are reinforced by the action of the abdominal
muscles. In exceptional cases, as in complete prolapse of the uterus, or
when the patient is paraplegic, or profoundly narcotized, uterine con-
tractions have alone effected delivery, but the labor under these cir-
cumstances is, as a rule, longer.
PRECURSORS OF LABOR. In some cases labor begins abruptly the
patient, for example, being wakened in the night by frequent and strong
uterine contractions. But in the majority a change in the form of the
abdomen, increased secretion from the external organs of generation at
first, and then from the glands of the neck of the uterus, swelling of
the labia, aud the hitherto painless contractions of pregnancy becoming
more frequent and causing some discomfort, prepare the way and
herald the coming of labor. The first of these phenomena is not con-
stant ; it results from the head of the foetus covered by the inferior
segment of the uterus and more or less of the expanded upper portion
of the cervical canal entering the pelvic cavity, while the superior por-
tion of the uterus inclines more in front and is lower. By this descent
or settling down of the uterus falling of the abdomen it is sometimes
called the patient's waist is not so large, her breathing is less interfered
with, she can take a fuller inspiration, aud her stomach, relieved from
pressure, receives more food ; on the other hand, the increased downward
pressure may cause irritability of the bladder or of the rectum, difficulty
1 Lehrbuch der Geburtshilfe, 1894.
- Their explanation has always seemed to me similar to the statement of the physician who
combined many medicines in his prescription, " so that the disease might take whichever it
liked."
8 Text-book of Physiology.
STAGES OF LABOR. 235
in walking, and greater swelling of the lower limbs. This change in
the form of the abdomen is marked in the primigravida, but may fail
in the multigravida, for the uterus and the abdominal wall of the latter
having undergone development in one or more previous pregnancies, yield
more readily, the uterus does not rise so high, and is more inclined for-
ward earlier in pregnancy. In cases presenting this phenomenon 1 its
value as a sign of approaching labor is not great, for while it usually
occurs from one to two weeks before, this interval may be only a day or
two, or it may be a month. It is a favorable indication as to the labor,
for it shows that the presentation is normal and the pelvis roomy.
Active hypera3mia and passive congestion, the latter resulting from
pressure, cause more abundant secretion from the glands of the cervix.
This discharge is viscid, yellowish, and in some cases toward the end of
pregnancy contains stria? of blood ; when thus stained, its color being
caused in the same manner as that of the sputa in pneumonia according
to Velpeau, it is known in the lying-in room as a u show," and is then
usually an indication of considerable advance in labor. It is caused,
whether occurring at the end of pregnancy or in the beginning of labor,
by partial detachment of the decidua near the mouth of the womb. The
strise of blood observed at the close of the stage of dilatation of the os
uteri result from slight lacerations of the cervix. An abundant dis-
charge from the cervical glands is a favorable indication as to the ready
dilatation of the os uteri.
The external organs of generation are swelled and moistened by their
own aud by the vaginal secretions. The painless uterine contractions
of pregnancy become more frequent, and begin to cause more or less
discomfort. In the parous especially it is not unusual for these contrac-
tions to become decidedly painful some days before labor ; they may
come on at night disturbing the woman's rest, and making her believe
labor is at hand, but disappear in the morning to be renewed the follow-
ing night. When the cervix is effaced, and uterine contractions recur
at regular intervals and cause dilatation of the os uteri, labor has begun.
STAGES OF LABOR. Although labor is one process from the begin-
ning to the end, yet it is usual to consider it as including three stages
or periods. The first stage, the uterine period, begins with dilatation
of the os uteri, and ends when that dilatation is so complete that the
head, or the greater part of it, can pass through the os uteri. The
second stage of labor, the utero-abdominal period, then begins, and
includes the expulsion of the child. The third stage, the placeutal
period, embraces the detachment of the placenta, its expulsion from
the uterus, and then from the vagina. While the boundary between the
second and third stages is well marked, that between the second and the
first is by no means so clear; theoretically, the line is as stated, but in
practice one rarely sees it so sharply and abruptly defined the first
oftener gradually passes into the second stage.
1 According to the investigations of Brill, in primigravidse the greatest circumference of the
foetal head was found to have passed the brim at the end of pregnancy in half the cases, but
in multigravidse in one-fourth only ; if the true conjugate is less than 10 centimetres, in only
one-third.
Prof. Muller, of Berne, directs in those cases in which the head has not thus passed the brim at
the end of pregnancy, to grasp the fretus through the abdominal wall and force the head as far as
possible into the pelvic canal.
236 PHYSIOLOGY OF LABOR.
PHENOMENA OF LABOR. These are usually divided into Physiological
and Mechanical. A third class has been added by some, and are called
Plastic Phenomena; by these are meant the foetal form-changes pro-
duced in labor, and dependent upon presentation and position ; they
are the deformations which the presenting part of the foetus undergoes
in its transmission through the birth-canal ; they disappear a few days
after birth.
PHYSIOLOGICAL PHENOMENA. First. Uterine Contractions. As the
contractions of the uterus are the chief power by which the foetus and
its appendages are expelled, their study is important.
CHARACTERISTICS OF UTERINE CONTRACTIONS. First. They are
involuntary, that is, independent of the will ; it can neither begin nor
stop them. But though not subject to volition, they may be affected by
mental impressions. Thus the presence of a person in the room of the
parturient who is disagreeable to her, one for whom she has an antipathy,
may interfere with their regular action and power, while they may be
immediately arrested by the arrival of a stranger who takes the place
of the expected family physician. Profound mental anxiety, grave
apprehension of disaster, and deep sorrow may lessen the activity of
uterine contractions.
Second. These contractions are peristaltic. The most probable view,
derived from observations of inferior animals, is that the peristaltic
movements begin at the fundus of the uterus.
Third. The contractions are intermittent. The periods of action and
of rest are different in different stages of labor. The contractions last
about twenty seconds at the beginning of labor, and the intervals are
twenty or thirty minutes ; toward the close of the second stage of labor
the former may last a minute or more, while the latter only two or three
minutes, sometimes less, but during it the intervals are about five minutes.
In some cases the uterus, after having manifested active contractions for
a few hours, pauses in its work, and a rest of some hours may follow,
after which its action is resumed with new vigor. Such a pause, there-
fore, neither the condition of the mother nor of the child indicating the
demand for interference, should not be considered pathological. The
ordinary intermittence in the succession of uterine contractions is im-
portant both for the mother and for the child ; the latter is saved by it
from a continuous pressure which would cause asphyxia, and the former
has her burden of suffering divided into many parts which can therefore
be endured, while united they would be too heavy for human tolerance;
and beside, such continuous and concentrated action would produce inju-
rious pressure upon her tissues, and render rupture of the uterus almost
inevitable. The iutermittence of uterine action corresponds with that
observed in other organs, e. g., the heart, the lungs, the intestines,
etc., and the noblest human organ, the brain, has a period of activity
followed by one of repose ; alternate work and rest seem to be the law
of life. The contractions do not begin and end abruptly, each gradu-
ally reaches its maximum and then declines- 1 - a climbing, and then a
falling wave; but in the latter part of labor this characteristic becomes
much less marked.
Fourth. The contractions of the uterus are associated with changes
FORCE OF UTERINE CONTRACTION. 237
iu its form and in its position. During a contraction the organ takes a
cylindrical form ; its transverse diameter is notably lessened, while both
the longitudinal and the antero-posterior are slightly increased ; the
shortening of the transverse diameter produces some extension of the
fetus, its curved form is lessened, and hence the slight increase in the
longitudinal diameter of the uterus. The broad and round ligaments
contracting simultaneously with the uterus press it toward the pelvis ;
the round ligaments contracting draw the organ forward, so that the
fundus rests upon the abdominal wall.
Fifth. The power of the contractions is in proportion to their fre-
quency and the resistance ; it increases with the progress of the labor,
the duration of contractions being inversely proportionate to the inter-
vals. The force and frequency of uterine contractions are not in all
cases in relation with the general vigor of the subject ; these contrac-
tions may be strong and frequent in feeble, delicate women, while weak,
and the intervals long, in the robust.
Sixth. The character of the contractions is related to the presentation.
Depaul has especially drawn attention to this fact, stating that the con-
tractions are usually more regular and effective in presentation of the
vertex. Uniform pressure upon the lower uterine segment and the
dilating os seems necessary in order to evoke the regular and strong
action of the body and fundus of the uterus ; this condition cannot be
met by presentation of the face, of the breech, or of the shoulder, and
hence the contractions present a manifest irregularity. The physiog-
nomy of the labor will in most cases give a valuable indication as to
the part of the foetus which presents.
It is not uncommon to find the contractions alternating in strength, a
vigorous contraction being followed by a feeble contraction, and vice
versa; they then come in couples. One of the characteristics of uterine
contractions is that they are painful, but the subject of pain in labor
will be considered in another connection.
FORCE OF UTERINE CONTRACTION. Many endeavors have been
made to ascertain the force exercised in labor. These have been by
measuring the bulk and extent of the voluntary and involuntary mus-
cles concerned in the function (Haughton} ; by determining the force
necessary to rupture the fetal* membranes (Poppel and Duncan) by
means of the tocodynamometer (Schatz) and by the tocograph (Poullet).
Haughton's estimate was 577.75 pounds, which exceeds that quoted
by Sterne in Tristram Shandy " 470 pounds avoirdupois acting upon
the head of the child." Poullet's conclusion 1 is that the maximum
force of expulsion is about 50 pounds. Duncan states that in easy
labor a force scarcely exceeding the weight of the child is necessary,
while only a few difficult labors require for their whole work a force
exceeding 50 pounds ; and admitting the force asserted by Haughton,
he adds the child would be shot out of the vagina at the rate of 36 feet
per second. Schatz's estimate is from 17 to 55 pounds. Ribemont has
repeated the experiments of Duncan, and has found that with the mem-
1 Poullet (Archives de Tocologie, 1880) refers to Tristram Shandy as an English author, and
speaks of Professor Haughton as " one of his corn patriots," a ludicrous mistake, into which more
recently Delore and Lutaud (Traite Pratique de 1'Art des Accouchements. Paris, 1883) have been
led.
238 PHYSIOLOGY OF LABOR.
branes presenting a surface of 10 centimetres, the pressure necessary to-
rupture them was 10 kilo.; the maximum, 11 kilo. Spiegelberg
regarded all estimates as liable to errors e. g., that derived from the
resistance of the foetal membranes in labor to this, that the water in
front of the presenting head is not subjected to the same pressure as
the other uterine contents, while the manometric method is liable to
mistakes in measurement. It cannot, therefore, be claimed that we
know the entire force, or that which is its chief element, the contrac-
tion of the uterus as exerted in labor.
ABDOMINAL CONTRACTIONS. When the mouth of the womb is so
dilated as to offer little or no resistance to the escape of the presenting
part, the first stage of labor ends, and the second, or the utero-abdominal
period, begins. The uterine contractions are now reinforced by volun-
tary contractions of the muscles of the abdomen. Preparing for one
of these efforts, the patient bends forward, fixes her body by pressing
the feet against a firm object, possibly grasps the bed or another's hands,
takes a deep inspiration, pushing the diaphragm down, and the glottis
is closed ; the abdominal muscles are now firmly contracted, thus lessen-
ing the size of the cavity ; the pressure from this contraction is exerted
uniformly upon the contents ; it is resisted above by the depressed dia-
phragm, and behind by the immovable spine; it acts uniformly upon
the uterus, forcing it downward, and. is transmitted to its contents.
This force not only assists that of the uterus, but also acts as a counter-
force to uterine contractions, which, when violent, might, were it
absent, cause rupture of the vagina at its uterine attachment.
While, during the greater part of the second stage of labor, the
action of the abdominal muscles is voluntary, it generally happens that
toward its close, just when the foatal head is about to be expelled from
the vulva, the patient cannot refrain effort, and the hitherto voluntary
action becomes purely reflex.
THE THIRD STAGE. In ten to twenty or thirty minutes after the
birth of the child uterine retraction, which detaches, and then uterine
contractions, which expel the placenta into the vagina occur ; they may
be assisted by voluntary contraction. So, too, these uterine and abdom-
inal contractions, assisted in some slight degree by the elasticity and
contractions of the vagina, may thrust the placenta without. Thi&
topic will be considered more fully hereafter.
PAIN. Labor begins, continues, and ends with pain: "childbirth
is the only necessarily and invariably painful function of the species."
While in very rare cases delivery is without suffering, yet these are
exceptional, for now, as of old, the law 1 is, "in sorrow thou shalt
bring forth children." But pain is relative ; there is no measure of
this phenomenon of vital sense which can be universally applied. One
patient will be in restless agony in childbirth, vexing the air with her
outcries, while another lies comparatively quiet and suffers in silence,
because sensation, power of endurance, and force of will so greatly
differ. Nevertheless, pain is not so great in the parous as in the prim-
ipara ; yet how often the former will declare that they suffer more in
1 Dr. Richert has said : Pain is an intellectuaT function so much more perfect as the intelli-
gence is more developed.
THE SEAT OF PAIN. 239
the present than in a previous labor, simply because of that beneficent
law of the economy which leads human beings to forget painful sensa-
tions. The occurrence of pains during uterine action in labor is so
constant that the name is generally, and in almost all languages, used
as a synonym for uterine contractions. But the duration of a contrac-
tion and of a pain is not the same ; while the former causes the latter,
the contraction can be readily recognized by the obstetrician with his
hand upon the patient's abdomen, or with his finger at the os uteri, be-
fore she complains of any suffering, and he likewise knows by the same
means that it continues after all complaint has ceased ; pain comes after
contraction begins, and goes before it ends.
CHARACTER OF THE PAINS. In the beginning of labor these are
felt as a disagreeable pressure downward in the pelvis, later they are
felt in the lumbar and sacral region, radiating thence to the pubes, so
that the patient is girdled with pain. At first they do not by their
frequency or their severity hinder a patient's being engaged in such
occupations as reading, sewing, conversing, etc., only when one occurs
she pauses for a minute or two, a slight change of expression is noticed,
a mere cloud passes over her face, she bends her body forward during
the brief suffering and then resumes her conversation, reading, or work.
The bending forward is instinctive, and is said to be an effort to with-
draw the ovum from pressing directly upon the lower segment of the
uterus ; but it is probable that the movement is made in response to
the anterior and downward positional change of the uterus, caused by
the contraction of the broad and round ligaments, and to lessen the pres-
sure upon the abdominal wall, just as more common abdominal pain
leads to a similar movement.
During the first stage of labor the pains are spoken of by the sufferer as
" cutting," " grinding," etc., but by the obstetrician as dilating, or pre-
paratory. As the frequency and intensity of the uterine contractions
increase so are the pains more severe ; the patient may become rest-
less, irritable, despondent, and discouraged, asserting that she suffers
in vain, " the pains do no good," " the child will never be born/' and
she knows she will die. After a time, when the os has become fully
dilated, and the birth-canal is thus prepared for the descent of the child,
expulsive, or " bearing-down," pains occur. The transition is not sudden
but gradual, the call for voluntary effort is at first indistinct, and partly
from this, and partly because the patient fears lest such effort may add
to her suffering, the response begins in a hesitating, tentative way, and
then gradually becomes equal to the demand. Hitherto the patient has
been without power to assist the progress of labor she has had only to
endure, to suffer but with the establishment of the second stage active
duty devolves on her, and she usually becomes hopeful and resolute;
no longer moaning and groaning, her lips are closed while voluntary
abdominal pressure combines with uterine contraction to drive the foetus
down the birth-canal, abrupt expiration occurs at the close of a pain,
with a sudden and guttural outcry. The practitioner soon learns to
know by a patient's cry whether she is in the first or second stage of
labor.
THE SEAT OF PAIN. Madame Boivin, who knew from personal
240 PHYSIOLOGY OF LABOR.
experience the suffering of childbirth, thought the pain was almost en-
tirely the result of stretching the os uteri. Depaul said that in the first
stage of labor it was in the lateral and lower parts of the uterus, but
afterward it arose from pressure of the foetus upon the organs and
tissues of the pelvic cavity. According to Spiegel berg, form-changes in
the uterus and of separate muscular fasciculi in its walls, permitting pres-
sure on nerves, are causes of 'suffering. The pressure upon the tissues
surrounding the vulval orifice made during its dilatation also causes
severe pain.
DILATATION OF THE Os UTERI. At the beginning of labor the
cervix has disappeared, only a slightly projecting border more pro-
nounced in multipart marking the boundary of the os uteri. This is
the first barrier to the escape of the foetus, and dilatation of the os, there-
fore, is the first part of labor. This dilatation is at once active and
passive ; the muscular fibres of the body and the fundus overcome the
resistance of the circular fibres of the os, and the pressure of the ovum
upon the os, made by the projecting membranes filled with amnial liquor
the bag of waters mechanically dilates it. Further, this uniform
pressure of the ovum upon the lower segment and mouth of the womb
evokes regular and stronger contractions from the body and fundus ;
and thus, in addition to its mechanical dilatation, assists labor. When
the uterus contracts the cavity lessens, its walls tend to approach a com-
mon centre ; but the ovum resists, and the resultant of the forces
developed by the contracting muscular fasciculi is transmitted in the
direction of least resistance, that is, to the os uteri, from which a part of
the ovum, this part increasing with the progress of the labor, protrudes.
As the os uteri expands the cavity lessens ; and the former, by the con-
traction of the longitudinal fibres of the uterus tends to ascend, drawn
up over the ovum or the presenting part. At the beginning of a con-
traction the rim of the os uteri becomes thicker, irregular, as if " puck-
ered/' and the opening smaller, but with the progress of the uterine
effort the border becomes thin, irregular, uniform in thickness, and the
opening expands ; with the advance of the labor the lessening of the os
at the beginning of a contraction is not observed, but dilatation alone.
In primi parse the border of the os uteri is at the beginning of labor
very thin, scarcely thicker than parchment, is closely applied to the foetal
head, and during a uterine contraction seems like a tense cord ; but with
the progress of the labor it becomes thicker and swelled, especially at
the anterior part, and it is more dilatable ; it never, however, becomes
so thin as it was at first.
The dilatation rapidly increases with the progress of the labor,
nearly as much time being needed for the os to be stretched to the
size of a silver dollar, as from this to reach complete expansion. The
process is more rapid in the parous than in the primipara. At the
beginning of labor the os is usually posterior and to the left ; but with
its progress it comes nearer the centre ; its form is at first circular, then
oval, the large end of the oval being to the left and somewhat behind.
The posterior lip generally yields before the anterior, the uterine orifice
being nearer to the sacrum than it is to the pubes ; if the labor be pro-
longed, the anterior lip in most cases becomes cedematous.
THE BAG OF W A TEES.
241
THE BAG OF WATERS. The ovum being equally pressed at all points
except at the os uteri projects there, and that portion of the membranes
containing amniotic liquor thus protruding, " making a hernia through
the more or less dilated os," is the bag of waters. The size and form
of this protrusion are usually dependent upon the degree of dilatation
and upon the presentation. When the os is but slightly dilated the
bag of waters is small ; so, too, in vertex presentation it is at first
little, and has the form of a watch-crystal, but as the dilatation ap-
FlG. 106.
THE BAG OF WATERS.
proaches completion it is large, and is hemispherical. The bag is great
in presentation of the face, of the breech, or of the shoulder, because
no one of these parts can be adapted to the cervico-uterine canal, but
permits the amnial liquor to pass freely by it ; the great size of the bag
of waters rather than the form is an indication of an unfavorable presen-
tation, especially when this is observed during the dilatation of the os
uteri, and the presenting part of the foetus does not readily descend. A
double bag of waters is observed in some cases of twin pregnancy.
16
242 PHYSIOLOGY OF LABOR.
The pouch is smooth and tense during uterine contractions, relaxed
and yielding in the intervals. Tarnier's experiments have proved that
the membranes are permeable by fluids, so that a moist condition of the
vagina is not a proof of rupture of the sac. The bag of waters acts as
a hydrostatic dilator of the os uteri, the best and the least painful one ;
and therefore care must be taken to guard against its premature rupture.
In some cases rupture takes place before labor, or as the first indication
that labor has begun, the patient being awakened from her sleep in the
night by a gush of water; this accident is more frequent in primi-
gravidse than in multigravidae, because in the former the uterine walls
are more resisting, and yield less readily to distention. When the waters
are evacuated before or at the beginning of uterine contractions the
labor is called a dry labor, and the first stage is generally quite tedious.
A collection of fluid between the ovum and the uterus or between
the amnion and the chorion may take place, and its discharge simulate
that of the amuial liquor ; when this occurs the flow is known as the
'' false waters," 1 and probably most of the cases in which it is thought
that the ovum was ruptured sometime before labor are thus explained.
This last statement, however, does not apply to all, for there are authen-
tic cases in which the rupture took place some weeks before labor.
Poullet, quoted by Tarnier, gives one instance of rupture six weeks,
another nine weeks before labor, and then a living foatus being born in
each case. Matthews Duncan mentions an instance in which the preg-
nancy continued for forty-five days after the first discharge of amnial
fluid ; he also states that a medical friend, mistaking pregnancy for an
ovarian dropsy, performed paraceutesis, drawing off a large quantity of
amnial liquor, when he desisted because feeling the fretus strike against
the can u la, and yet the pregnancy did not end for a month. If one is
in doubt whether the fluid discharged in a given case be liquor amnii,
and enough of it can be collected for examination, the presence or absence
of sebaceous matter promptly settles the question.
In rare instances, less rare in premature than in mature labor, the
ovum is expelled entire. Under these circumstances the membranes
were known as a child's caul, which once was in demand by sailors as
an amulet that would keep its possessor from drowning. Formerly,
when the child was born with a flap of membranes covering the head,
the fact was regarded as a favorably augury. 2
The bag of waters is usually spontaneously ruptured about the time
the os uteri is fully dilated ; in some cases, however, it may protrude
from the vulval orifice before being torn. As a rule, the rent is at the
most dependent part of the pouch, and the water escapes suddenly and
with noise ; but it may be above in the cervico-uterine canal, and the
flow is gradual and silent, while the part of the membranes in front
of the child's head being entire still forms a pouch. The quantity of
fluid discharged depends upon the presentation ; thus if the vertex pre-
sent, the head makes a ball-valve which, when pressed down during a
i These discharges are generally caused by catarrhal endoinetritis.
* Caul on the Head. In Dean Swift's Polite Conversations one of the female characters remarks to
a gentleman, " I believe you were born with a caul on your head, you are such a favorite with the
ladies."
DILATATION OF THE VULVA. 943
uterine contraction entirely arrests the flow, and permits only a slight
discharge in the interval ; no other part of the foetal ovoid which may
present can so well fill the cervico-uterine canal, but by its irregular
form readily permits the escape of the amnial liquor. It is often ob-
served in vertex presentations that when the head has descended so that
partial deflection a movement which some authors describe in the
mechanism of labor as levelling can take place, there is an increased
flow of liquor amnii, because the neck does not completely fill the canal.
It is very important for the obstetrician to know whether the mem-
branes are ruptured. Generally there is no difficulty in deciding this
question, but cases occasionally occur in which it is very great, and
some deplorable mistakes have been made ; thus the forceps has been
applied to the foetal head enclosed in the membranes, the distended
bladder has been thought the bag of waters and incised, causing a
vesico- vaginal fistula, and the foetal scalp similarly mistaken and treated
in like manner, the incision being the starting-point of a fatal erysipelas.
A knowledge of the fact that such errors have been committed, and
hence the possibility of their repetition, may prove a warning against
the hurried and imperfect examination in which they originate. In
doubtful cases the obstetrician should examine during a pain of course,
taking care to avoid rupture of the pouch if it be present for, however
closely the membranes may be applied to the head when the uterus is
at rest, there will then always be found some fluid interposed which
causes their projection. In the interval between pains the membranes
are flaccid, and the finger can press them in wrinkles or folds which
give a different sensation from that caused by directly touching the
foetal scalp. Finally, Charpentier advises carrying the finger as far as
possible between the head of the foetus and the cervix, thus opening a
way by which, if the membranes have been ruptured, the liquor amuii
will flow down into the palm of the hand.
MUCO-SANGUINEOUS DISCHARGE. A greater discharge from the
external genital organs and from the vagina is observed toward the
close of pregnancy, but with the beginning of labor an increased secre-
tion from the glands of the cervix occurs. The character of the latter,
as well as the significance of the blood often found mixed with it, has
already been stated ; the discharge of any considerable amount of blood
with it would indicate most probably either a serious rent of the cervix
or a partial detachment of the placenta.
DILATATION OF THE VAGINA. The upper part of the vagina is
dilated by the descent of the lower portion of the uterus containing the
foetal head, and by the stretching of the margin of the os uteri, so that
there is formed a complete utero-vaginal canal ample for the passage of
the head ; no resistance is presented until the inferior boundary of the
vagina is reached; in primiparge the hymen is an obstacle which is
removed by a series of rents. Budin has shown that the vaginal
orifice may present a resistance lasting some hours, which has been
commonly attributed to the perineum ; in one case in which there was
delay from this cause, he incised the vaginal orifice, and the labor
ended rapidly without injury to the perineum or to the vulva.
DILATATION OF THE VULVA. The head now enters the vulval
244
PHYSIOLOGY OF LABOR.
canal, the perineum is behind, the labia at its sides, and the uterine
contractions, whose force is increased with the partial emptying of the
uterus, and the abdominal, which are stronger from reflex irritation
caused by the head pressing on the perineum, drive the presenting part
like a wedge, widely separating the vulval walls. The perineum is
greatly elongated and so thinned that the bones of the fetal head may
be felt through it; it is converted into a glitter, externally from side to
side, and from before .backward ; its elastic tissue and muscles direct
the head upward. Each pain pushes the head further, but it recedes in
HEAD AT THE VULVAL OPENING.'
the interval between pains the parts are stretched and then relaxed ;
the anus is widely opened, and the anterior wall of the rectum exposed,
making a part of the external covering of the foetal head ; the labia are
separated by the head, more and more of this emerging at each con-
traction, which seems as if it were to be the last needed for its expul-
sion, until finally the parietal protuberances escape the rim of the vulva,
and there is no more recession, for the bearing-down effort seems almost
continuous, scarcely a pause for breath, until in a conquering agony and
with the most intense suffering the head is born. A brief pause fol-
lows, and returning pains expel the body of the child; immediately
following it the remaining portion of the liquor amuii, frequently some
blood from a partially detached placenta with it, is discharged.
DETACHMENT AND DISCHARGE OF THE PLACENTA. The separa-
1 "In this figure, copied from Smellie, the child's head, a, is seen separating the labia; the
extension, thinning, and protrusion of the perineum, b, caused by the head's descent, and called
by some the perineal tumor, are also well portrayed ; d marks the point of the coccyx ; c the anus
dilated, so that the inner membrane of the rectum is to some extent exposed to the contact of the
hand, when applied for the protection of the structures. This exposure is not injurious ; no harm
arises from it : and sometimes it is even greater than is represented here." Ramsbotham.
DETACHMENT AND DISCHARGE OF THE PLACENTA. 245
tion of the placenta from the uterine wall has been differently explained,
and probably does not always occur in the same manner, varying, too,
according to the part of the uterus to which it is attached. If the pla-
centa has its site at the fund us of the uterus, detachment may begin at
the centre, and effusion of blood occur which by pressure continues the
separation to the periphery of the organ. In one of Winter's frozen
sections this mode of separation is shown, and it is that which is known
as Schultze's. Necessarily there is inversion of the placenta in these
cases, and the organ presents at the os uteri with its foetal surface.
Ahlfeld 1 describes as the most frequent mode of separation, occur-
ring in about 75 per cent, of cases, the placenta being situated at the
anterior or posterior wall of the uterus, the central portion of the pla-
centa is lifted off, and the retro-placental hematoma presses the under
half of the placenta into the contraction -ring. The border of the pla-
centa, perhaps also the adjacent portion of membranes, enters deeper,
then the central part, finally the upper part of the placenta descends,
until the inversion and the pressing out from the uterine cavity is
completed.
Pinard and Varnier 2 state that the forces which cause placental de-
tachment are the elasticity, the retractility, and the contractility of the
muscular tissue of the uterus. "During and immediately after the ex-
pulsion of the foetus the uterus tends to recover its form, that is to
say, each part of its wall tends to approach the centre of the cavity.
That portion of the wall which corresponds to the insertion of the pla-
centa is more remote from this centre because of the presence of the
placenta and of its less elastic force, retractile and contractile, for its
wall is thinner. These muscular elements accumulated around the pla-
centa exercise their action upon the thinned part and lessen its surface.
It is easily understood that this action would be in direct proportion to
the acting muscular mass, that is to say, the detachment will be made
more quickly the thicker the uterine wall." The membranes remain
adherent, except in the lower uterine segment ; there they have been
detached during labor. The weight of the placenta and uterine action
determine the separation of the still adherent membranes. Pinard and
Varnier say that " the plate of Schroder and of Schatz and their own
conclusively prove that the placenta may be in the lower segment of the
uterus and even in the vagina, suspended, as it were, by the membranes
still retained and adherent in the uterine cavity." They add the im-
portant rule derived from this fact: Never begin or continue tractions
upon the cord during uterine contraction, even though the placenta is
already in the vagina or at the vulva. The consequence of such un-
timely traction will be the probable retention of fragments of the mem-
branes in the uterus.
Berry Hart 3 maintains that the separation of the placenta is accom-
plished, not by contraction, but by expansion of the area of uterine
attachment. "However much the area diminishes the placenta cannot
separate, because the disproportion necessary cannot take place. When
1 Lehrbuch der Geburtshiilfe.
2 Precis d'Obstetrique, by Ribemont-Dessaignes and Lepage.
3 Selected Papers in Gynecology and Obstetrics. 1893.
246 PHYSIOLOGY OF LABOR.
the uterus contracts to the amount it does after the child is born the
placenta fills the uterine cavity, and any further diminution in uterine
bulk never leads to a disproportion between placenta and the area of
the uterine muscle to which it is attached, but the two are always equiv-
alent. After the pain has died off the uterus relaxes, and, as a matter
of fact, has an increase in area in its anterior and posterior surfaces.
Now comes in a different phase in the behavior of the placenta. The
foetal blood has been aspirated from it; the iutervillous spaces are
empty, and, therefore, during the increase in the internal uterine area,
we have cut off the two factors in bringing about the equivalent ex-
pansion in area during the relaxation following the pains of the first
and second stages, i. e., we get the placenta smaller in area at the place
of separation than the placental site. This repeated disproportion in
area, i. e., slight excess of area of the placental site over the placenta
itself, tear the partitions in the spongy layer, i. e., separates the
placenta."
After the placenta is detached contractions of the body of the uterus
drive it into the lower segment, whence the same force compels its pas-
sage through the os uteri. In this passage the foatal face presented,
according to the observations of Pinard and Varnier, 789 times in 1000
cases, the border of the placenta 166 times, and the uterine surface 45
times.
FALSE PAINS. It sometimes happens that women during the latter
part of pregnancy have what are called " false labor pains." These
have been attributed to rheumatism of the womb, to local uterine con-
tractions, to contractions of the abdominal muscles, and to intestinal
irritation. The last is probably the most frequent cause. False are
distinguished from true pains by their not having been preceded by the
premonitory symptoms of labor; by their situation, for they are not
felt in the back, and from it extending in front, but in the abdomtn,
sometimes in one, and again in another part of it; by their being
irregular in recurrence, not increasing in severity, and not causing any
change in the os uteri. On the other hand, labor has begun when gen-
eral contractions of the womb and progressive dilatation of its mouth
occur.
THE EFFECTS OF LABOR UPON THE MOTHER. Parturition has an
influence upon various functions of the maternal organism. The desire
for food is lessened or lost; it is not unusual for nausea and vomiting
to occur, especially toward the end of the first stage, and these are
thought to facilitate dilatation of the mouth of the womb, a common
belief being that sick labors are easy labors. But while this gastric dis-
turbance is regarded as a good omen in the first stage, a very different
character belongs to the vomiting which may occur in the second stage,
with cessation of labor activity, and with exhaustion of the patient;
the symptom is then dangerous, and immediate delivery is required.
The pulse increases in frequency during a uterine contraction, lessening
at its close; as this contraction drives much of the blood from the uterus
into the general circulation, arterial tension is greater. Increased arterial
tension and nervous irritation cause a greater secretion of urine ; at first
this fluid has a less specific gravity than normal, but afterward the
DURATION OF LABOR. 247
quantity of salts is greater. A slight shivering is observed in some
patients at the beginning of each contraction. The respirations, less
frequent during a pain, are more frequent during an interval ; the tem-
perature of the body, as well as that of the uterus, is slightly increased.
In the second stage the face is usually red and swelled, and it, and
also the body and limbs, are bathed with perspiration. Patients in the
absence of pains frequently are drowsy and disposed to sleep, this con-
dition resulting in part from fatigue and in part from cerebral conges-
tion. In labor some women are irritable, restless, and lose all self-con-
trol; but the majority pass through the terrible ordeal with patience
and resignation, if not always with hope. A woman loses in labor one-
ninth of her weight ; the amount of loss is somewhat less in the primi-
parous than in the parous ; the loss is of course chiefly due to the
removal of the ovum, but the increased quantity of urine secreted, the
perspiration, and the blood discharged with the placenta, contribute to it.
THE EFFECTS OF LABOR UPON THE FOZTUS. Uterine contractions
cause temporary modifications in the foetal circulation ;* at the begin-
ning of a contraction there is a slight acceleration in the pulsations of
the foetal heart, then these become slower when the contraction is strong ;
and, finally, when the tension of the uterus lessens, the double pulsa-
tions increase in order to resume their ordinary rhythm. The slowing
of the foetal heart during a contraction of the uterus is probably due to
slight asphyxia from partial interruption of the placental circulation ;
it has also been attributed to greater intra-cardiac pressure, and to com-
pression of the head. Pressure upon the foetus may cause evacuation
of the bladder or of the rectum; discharge of the meconium is com-
mon in presentation of the breech. If the placental circulation be inter-
rupted, and hence the foetus threatened with asphyxia, instinctive efforts
to respire by the lungs are made. When the child is still unborn, if
air enter its respiratory organs, it may cry, and to this cry the name of
vagitus intra-uterinus has been given. The fact has been attested by
reputable observers, but of course is exceedingly rare.
DURATION OF LABOR. This varies with race, climate, place and man-
ner of living, heredity, age, organization, physical conformation, and
whether first or subsequent labor, and with the sex, presentation, and
position of the child. Labor is said to be shorter in warm than in cold
climates, in savage than in civilized races, in women in the country,
accustomed to plain food, out-door exercise, and regular hours of rest,
than in those leading opposite lives in the city. In primiparse labor is
longer than in multipart; it is longer also in face or breech than in
vertex presentations, in occipito-posterior than in occipito anterior posi-
tions, with male than with female children.
In primipara? the usual period of labor is, according to Depaul, fifteen
to twenty hours, but, according to Tarnier, twelve to fifteen hours; in
multipart six to eight hours. Hecker and Ahlfeld state that the aver-
age duration of labor in primiparse, thirty years old and more, is twenty-
one to twenty-seven hours ; Dieterlen's study of labor in 2369 primi-
par&3, the delivery being natural, shows that up to thirty-five years the
1 Depaul.
248 PHYSIOLOGY OF LABOR.
duration varies but little, aud is fifteen to sixteen hours, but that from
thirty-five it rapidly increases, so that in priraiparee above forty-oue
years it is thirty-three hours. The average of all labors is, according
to Naegele, twelve to fifteen hours. The second stage of labor is gener-
ally one-third that of the first. The majority of labors begin between
9 and 12 P.M. aud end between 9 P.M. and 9 A.M.
PLASTIC PHENOMENA OF LABOR IN VERTEX PRESENTATIONS. By
these phenomena are meant, not only, as previously stated, the changes
in the form of the cranium caused by labor, but also the production of
the caput succedaneum. The head delivered in an occipito-anterior posi-
tion presents a cylindrical form ; the occipito-frontal and occipito-mental
diameters are lessened, but the maximum diameter is increased ; the
suboccipito-bregmatic, the bitemporal, aud the biparietal diameters are
lessened. According to Dohrn, 1 there is an asymmetry of the two
lateral halves of the cranium, marked by the prominence of one of the
parietal bones, aud by the flattening of the other, which is sometimes
pushed farther in front, sometimes farther back than the one on the
opposite side, so that the parietal protuberances are not equidistant from
the occipital protuberance. In occipito-sacral delivery the head has the
appearance of being drawn out vertically from below above; the vertex
makes a conical projection, so that the head lias the form of a sugar-
loaf. The forehead and the anterior part of the parietal bone are almost
upon the same vertical plane ; the occiput is flattened and pushed in front.
CAPUT SUCCEDANEUM. This is the name given to a tumor com-
posed of asero-sanguineous infiltration of the connective tissue, situated
upon the presenting part of the foetus. The swelling occurs upon that
part which is not subjected to pressure. " In the course of labor, 2 after
the evacuation of the liquor amnii, the child is during pains subjected
to strong pressure from the parturient forces, and equally strong counter-
pressure from the resisting maternal passages. Every part of the child
is subjected to these forces, except that adjacent to the as yet uudilated
passage through which the child is being urged."
The caput succedaneum does not fluctuate, pits on pressure, and is
violet-colored. The longer and more difficult the labor, the larger this
swelling. By some it has been improperly termed cephalhaematoma ;
Bouchut describes it under the name of supra-periosteal cephalhgema-
toma, or pseudo-cephalhaematoma. Cephalhaematoma is an effusion of
blood between the periosteum and the bone; it is more frequently
found upon the right than upon the left parietal bone, in some cases
upon both, in others upon the occipital, upon the temporal, or upon the
frontal. The affection rarely occurs. Bouchut 3 describes it as an indo-
lent, distinctly circumscribed, soft, and fluctuating tumor, and attended
by no discoloratiou of the skin ; it may be as large as a pullet's egg.
The severity or great length of the labor has no influence upon its pro-
duction. There may be felt in many cases a bony circle at its base
separating it from adjacent parts.
In left occipito-auterior position the caput succedaueum is upon
the posterior and superior angle of the right parietal bone. In left
1 Tarnier. 2" Duncan. 3 Op. cit.
CAPUT SUCCEDANEUM. 249
occipito-posterior position it occupies the superior and anterior angle
of the right parietal bone. In right occipito-anterior position the caput
succedaneum is at the posterior and superior augle of the left parietal ;
and in right occipito-posterior position, at the superior and anterior
angle of the same boue. If in consequeuce of slight resistance the
labor be very rapid, no caput succedanum may be formed.
After the head has descended to the pelvic floor, and anterior rota-
tion occurred, if delivery be delayed, a secondary caput succedaueum
will be formed; but this will be always in the median line, and not
limited to one of the parietal bones.
While early rupture of the membranes, the labor being protracted,
causes greater size of the caput succedaueum, yet it may begin before
this rupture. In such exceptional cases Matthews Duncan suggests
" the liquor amnii must be in such minute quantity as to have no
hydrodynamical properties " But it seems a clearer explanation to say
the event occurs because of the minute quantity of this fluid in advance
of the head, for the statement quoted is at least ambiguous.
The caput succedaneum is not found if the foetus is dead, and Runge
suggests that this may be an important mark in doubtful cases as to the
life of the child.
This effusion in the connective tissue disappears in a day or two ;
while a subperiosteal hemorrhage, or true cephalha3matoma, will last
from ten to sixty days.
CHAPTER XI.
THE MECHANICAL PHENOMENA OF LABOR.
THE mechanical phenomena of labor are the passive movements
given the foetus in its expulsion. These phenomena are included under
the general term mechanism of labor. The efficient cause of labor is
the force of uterine and of abdominal contractions ; the final cause, that
is, the design, is birth ; but the former in accomplishing this end must
act by material and formal causes. Now, the material cause is the foetus
and the birth-canal, aud the formal cause includes the adaptations of
the former to the latter, adaptations by which its transmission is ren-
dered possible. Certain diameters of the foetal head are greater than
any of the pelvic diameters, and hence if the former be brought into
relation with the latter, the further movement of the foetus is impossi-
ble. The birth-canal presents an axis of emergence almost perpendic-
ular to the axis of entrance, and therefore the foetus going into that
canal in one direction must take another and very different direction in
order to pass out. The longest diameter of the pelvic inlet is an oblique
diameter, while that of the outlet is antero-posterior ; hence a diameter
of the foetal head, which requires the space given by the former for its
transmission, will, when it descends to the outlet, need to be placed in
relation with the latter in order that it can pass out. One word explains
these various passive movements of the foetus in birth, and that is,
accommodation; during the whole process of delivery there must be
adaptations and correspondences between the passenger and the passage
through which it is transmitted.
It will be seen in the study of the mechanism of labor that there is
a unity of character in all labors, no matter what the presentation or
position of the foetus ; provided the labor be natural, occurring at term,
and the foetus be living, there is but one mechanism. 1
Before studying the mechanical phenomena of parturition a few words
must be said in regard to presentation and position. As has been before
stated, presentation is that part of the foetus which is in relation with
the pelvic inlet that which presents, offers to the examining finger at
the mouth of the womb, or that part through which the pelvic axis
passes and our first inquiry is as to the number of presentations.
Baudelocque described twenty-three, making for these ninety-four posi-
tions ; but it is fortuuate for medical students that authorities do not
follow him. Madame Lachapelle was the first to show that the
foetus presented by the cephalic, or the pelvic extremity, or by the
trunk. But these presentations, which are apparently three, really in-
clude five. The foetal ovoid usually corresponds with the uterine
ovoid ; that is, the foetus occupies a longitudinal situation in the womb,
x i Pajot.
THE MECHANICAL PHENOMENA OF LABOR. 251
and hence one or the other end of this ovoid, generally the head, is at
the pelvic inlet. If the head be inclined forward with reference to the
trunk, that is, flexion be present, and this is the case generally, the
vertex summit or top of the head presents, and hence the presenta-
tion is cranial. On the other hand, if deflexion bending back of the
head, extension has occurred, the face presents, and the presentation
is called by this name or facial. The pelvis of the foetus may be in the
lower segment of the womb, and then the presentation is pelvic. This
presentation .is not changed by any change of position of the lower
limbs ; the pelvic wedge may be complete or decomposed a knee or
foot, both knees or both feet, 1 may come first, but no matter what the
.changes of position of these parts, none of the mechanical phenomena
of labor are needed to adapt them to the birth-canal, for they are small
and the space offered by the maternal pelvis is relatively large ; and on
the other hand such changes, such mechanism, are required for the ex-
pulsion of the breech. Those parts, therefore, are included under
pelvic presentation which may be defined as embracing all that part of
the fetus below a horizontal line passing from one to the other iliac
crest. The foetus lying transversely, or nearly so, may present some
part of the body at the inlet ; but the tendency in all cases is for one
or the other shoulder to descend first, so that presentation of the body
becomes that of the right or that of the left shoulder. We thus have
five presentations, cranial, or vertex, facial, pelvic, right and left
shoulder. The relations which the presenting part of the foetus has to
certain fixed points of the inlet give the position. For most obstetri-
cians these points are the sacro-iliac joints and the ilio-pectineal emin-
ences; they are the terminations of the oblique diameters of the inlet.
It follows, therefore, as some selected point of reference for each pres-
entation is in relation with one of these four points of the mother's
pelvis, sometimes called the cardinal points of Capuron, the position is
determined, and that there are four positions. The latter part of this
statement, however, only applies to the first three presentations ; each
shoulder presentation has only two positions, as will be explained here-
after.
It is important that the student should have clearly fixed in his mind
the essential difference between* presentation and position, never con-
founding them, never using one as a synonym for the other. Presen-
tation means an object, but position is a relation ; the former is part of
the foetus, the latter a temporary relation of that part to the mother's
pelvis; position is an accident, the property of a presentation, belonging
to it, while the reverse can never be true. Further, it is important not
to confound position as belonging to presentation with position as be-
longing to the foetus. The foetus is said to be in a longitudinal or a
1 Those born with the feet first were called Agrippas. Roederer, Elementa Artis Obstetricise, ob-
serves : Quando foetus pedes primi ad orificium decidunt, parlus agripparum oritur. In Pliny's
Natural History, Book Seventh, the following passage is found : In pedes procedure nascentem,
contra naturam est : quo argumento eos appellavere Agrippas, ut a>gre partos. This explanation
of the origin of the term has been accepted in the New Sydenham Society's Lexicon. But a more
probable origin is given by Kraus, Kritisch-etymologischeg medicinisches Lexikon ; agrippa is from
ay/wo? iTTTTOf , feminine aypia iTnra, for the nomadic tribes being more familiar with parturition
as it occurred in mares, gave this name to children born with the feet first. According to Schroder,
there was a superstition that those born thus would be injurious to themselves and to society, and
in confirmation of the belief the examples of Agrippa, Nero, Richard III., and Louis XV., were
cited.
252
PHYSIOLOGY OF LABOR.
transverse position in the uterine cavity ; but this use of the word is
very different from that in connection with presentation. The four
positions belonging to each of the three presentations cranial, facial,
and pelvic are generally designated first, second, third, and fourth.
Their relative frequency is not settled at least all authorities do not
agree and, therefore, the fitness of the term is questionable ; but as the
mechanism of labor presents some slight differences according as the
point of reference of the presenting part is in the right or left side of
the mother's pelvis, and as to whether it is anterior or posterior, tht'se
positions will be distinguished as right and left anterior, and right and
left posterior. In vertex or cranial presentation, for illustration, this
point of reference is the occiput, so that the four positions for this
presentation are left occipito-anterior, left occipito-posterior, right occi-
pito-anterior, and right occipito-posterior.
FIG. IDS.
PALPATION OF UTERUS, THE HANDS AT ITS SIDES.
DIAGNOSIS. The diagnosis of presentation and position is made by
auscultation, abdominal palpation, and vaginal touch. The first two
are most useful in pregnancy, the last in labor ; the former cannot be
made during uterine contraction, and the third, if then made, the mem-
branes being unruptured, must be done with great care to avoid their
rupture. Nevertheless, it is held that the practitioner who makes him-
self expert in obstetric palpation and auscultation, can reduce to a
minimum vaginal examinations, thus lessening the liability to septic
infection.
VERTEX PRESENTATION DIAGNOSIS. The vertex presents, accord-
ing to Naegele, in 93 to 95 per cent., according to Spiegelberg in 97 per
cent., of all cases ; the causes of this great frequency have been stated.
THE MECHANICAL PHENOMENA OF LABOR.
253
In making a diagnosis by external examination the practitioner should
first ascertain that the foetus is not placed transversely, but occupies a
longitudinal situation in the womb the foetal thus corresponding with
the uterine ovoid. He learns this by observing the general form of the
abdomen, and by his being able in palpation to circumscribe with his
hand the fundus of the uterus in its normal position. The next step is
to find which end of the foetal ovoid is in the lower segment of the
uterus. In doing this the obstetrician places his hands extended and
flat upon the lower part of the sides of the abdomen, pressing them
somewhat downward at the ulnar border within the iliac fossse; then
the hands, still pressed downward and moved toward 'each other, will in-
FIG. 109.
ASCERTAINING THE PRESENCE OF THE FCETAL HEAD IN LOWER PART OF UTERUS.
elude the foetal head if it be in the lower part of the uterus, and if it has
not entered the pelvic cavity. Instead of at first placing the hands upon
the sides of the uterus, they may be in contact with each other directly
in the median line of the uterine globe just above the pubes, then grad-
ually separated, pressing the ulnar edge of each downward upon the
abdominal wall in this movement until they pass deeper, when they
reach the borders of the uterus, and the lower portion of this organ is
then included between them. This manipulation, it should be observed,
is of chief value in the diagnosis during pregnancy. A single hand may
often be successfully used in abdominal palpation in order to determine
that the foetal head is in the lower part of the uterus. The distinguish-
254
PHYSIOLOGY OF LABOR.
ing marks of the foetal head in palpation are, its uniformity of shape,
roundness, hardness, and mobility; if the head be in the pelvic cavity,
the characteristic last stated fails. The fact that the presenting part is
in the pelvic cavity in the latter part of pregnancy, or early in labor,
is a strong proof that the presentation is neither the pelvis nor the face,
but the vertex. Further, in this situation one hand can be carried
deeper into the pelvis, while the hand on the other side of the pelvis
meets with resistance (Fig. 110); the occiput therefore is upon the one
FIG. 110.
PALPATION WHEN THE FCETAL HEAD is IN THE PELVIS.
side, the forehead upon the other, and the former being more deeply
situated allows the descent of the hand, while the latter prevents such
penetration. Further, when the occiput is found the position of the
back is known, for it must be upon the same side as the occiput. The
practitioner may then verify his diagnosis by exploring the fundus of
the uterus in which the pelvis of the foetus will be felt. This part of
the child is recognized as a large, firm, and somewhat round body, but
it lacks the uniform shape, the solidity, and the mobility of the head ;
moreover, there will be found near it small movable bodies, parts of one
or both lower limbs. The means by which a vertex is distinguished
from a face presentation will be given when the latter is considered.
AUSCULTATION. If the pulsations of the foetal heart are heard most
THE MECHANICAL PHENOMENA OF LABOR.
255
distinctly below the transverse line (see Fig. 105), the head is most
probably in the lower part of the uterus, and when heard to the left of
the median line the occiput is in the left side of the mother's pelvis, but
if upon the right, the occiput is in the right side.
INTERNAL EXAMINATION. The method of vaginal examination
has been given on pages 189-192. Again, let the practitioner be cau-
tioned against the danger of rupturing the membranes by pressure upon
the bag during a uterine contraction ; he should, therefore, usually
defer exploration of the presenting part until the contraction ceases. If
the head has descended into the pelvic cavity, the finger touches a
round, hard, projecting body, and the margin of the mouth of the
womb. If the head be high up, only a small portion of the cranial
vault is accessible to the finger, but a large portion may be reached if
the other hand is used to press firmly upon the hypogastrium so as to
force the head further into the pelvis. When theos is dilated the bones
may be plainly felt through the foetal membranes, and during a con-
traction the wrinkling of the scalp and the overriding of the bones.
If labor has been in progress some time, a large soft mass, the caput
succedaneum, may conceal the cranial bones ; but by pressing firmly
upon this mass it is possible the finger may detect beneath it a bony
surface, or else the finger should be passed within the os so as to touch
parts above the swelling.
FIG. 111.
LEFT OCCIPITO-ANTERIOR POSITION.
POSITION. Having ascertained that the presentation is cranial, the
position is next to be ascertained. The occiput being the point of refr
256
PHYSIOLOGY OF LABOR.
erence, in this presentation, the question is as to its relation to some one
of the cardinal points of the inlet. If it is directed toward the left
ilio-pectineal eminence, the position is left occipito-anterior ; if to the
right, right occipito-anterior ; if to the left sacro-iliac joint, left occipito-
posterior, but if to the right, right occipito-posterior.
The same means are available for the diagnosis of position as for the
diagnosis of presentation, viz., abdominal palpation, auscultation, and
vaginal touch. The application of these means will be considered with
each of the four positions given, following the diagnosis with a descrip-
tion of the mechanism of labor.
FIG. 112.
PLACE OF GREATEST INTENSITY OF FCETAL HEAET-SODNDS IN LEFT OCCIPITO-ANTERIOR POSITION.
FIRST. LEFT OCCIPITO-ANTERIOR POSITIONS (Figs. Ill, 112). As-
certaining that the back of the child is upon the leftside of the mother's
abdomen, we know that the occiput is anterior or posterior to the left
side of the pelvis ; and if the resistance given by the back lessens as
the hand is carried farther to the left side, the occiput, of course, which
is in the line of greatest resistance, points to the ilio-pectineal eminence
that is, the position is left occipito-auterior.
Upon auscultation the maximum of intensity of the foetal heart-
sounds is found about the middle of a line passing from the left ilio-
pectineal eminence to the umbilicus ; some, however, have the line start
from the left anterior spinous process of the ilium.
By vaginal touch the sagittal suture is usually felt crossing the pelvic
area obliquely, though it may be transverse, and a little nearer the pro-
monotory than it is to the pubic joint. Having found the suture, the
THE MECHANICAL PHENOMENA OK LABOR. 257
finger follows it either to the right or to the left until the anterior or
posterior fontanelle is felt. The anterior foutanelle is upon the right
side of the mother's pelvis, and necessarily the occiput is upon the oppo-
site side. If the finger follows the course of the sagittal suture to the
posterior fontanelle, the place rather than the presence of the latter is
recognized by its being at the apex of a depressed triangle, two sides of
which are made by the margins of the parietal bones overriding the
occipital bone, these sides corresponding with the bifurcation of the
sagittal suture. The occiput is at or near the left ilio-pectineal emi-
nence. This position, left occipito-anterior, has been generally called
the first, and it is the first in frequency, occurring in about seventy per
cent.
FIG. 113.
FIRST CRANIAL POSITION. OCCIPUT AT THE LEFT ILIO-PECTINEAL EMINENCE, FOREHEAD AT THE
RIGHT SACRO-ILIAC JOINT.
MECHANISM OF LABOR. In studying this mechanism it is con-
venient to divide it into stages, or times ; but it is to be remembered
that this division is arbitrary, for some of these stages may occur con-
temporaneously, or some may be absent, but in such cases the necessity
for them does not exist, the factors causing them are wanting. These
different stages are, in presentation of the vertex, first, flexion ; second,
descent, also called engagement, or progression ; third, rotation ; fourth,
extension .; fifth, external rotation of the head with internal rotation of
the body ; and, sixth, delivery of the body. Each of these mechanical
phenomena is to be studied as to its causes, its effects, and its diagnosis.
FLEXION. This is bending the chin toward the chest so that it rests
on it when flexion is complete; it is essentially rotation of the head upon
a transverse axis. In considering the causes of flexion the natural
position of the head must be regarded as predisposing to this purely
passive movement, for it is already somewhat flexed, and the flexion
occurring in labor is simply an increase in this state. It has been taught
by some that the articulation of the head with the vertebral column
being nearer the occiput than it is to the forehead, the force passing
through that column acts with greater power upon the occiput, causing
it to descend while the forehead rises, and thus flexion is increased.
But as long as the foetus is inclosed in the membranes, direct pressure
upon it does not occur ; uterine contractions compress the ovum at all
points equally, except at the lower segment of the uterus and the os
17
258
PHYSIOLOGY OF LABOR.
uteri j these are dilated by the pressure, and the force is transmitted to
the foetus through the intervening liquor amnii. Even after the rupture
of the membranes the fcetal head may so effectually plug the cervico-
uterine canal that only a small quantity of amnial liquor escapes, and
therefore direct pressure of the fundus of the uterus upon the upper
FIG. 114.
FIG. 115.
ILLUSTRATING THE DIFFERENT LENGTHS
OF THE FRONTAL ABM, F B, AND THE OC-
CIPITAL ARM, B O, OF THE LEVER MADE BY
THE FtETAL HEAD.
EQUAL RESISTING FORCES ACTING THROUGH
LEVERS OF UNEQUAL LENGTH.
portion of the foetal ovoid falls. It
therefore follows that the direction of
the uterine force cannot be deter-
mined by pressure of the fundus im-
mediately upon the foetus in the first
stage of labor, or, indeed, subse-
quently before the free discharge of
the amnial liquor.
The most generally received ex-
planation of this phenomenon of
labor is that it results from the un-
equal lengths of the two arms of a lever represented by the head, for
that part of the head in front of the vertebral articulation presents a
greater surface than that behind this articulation ; in other words, the
anterior arm of the lever is longer than the posterior that is, the dis-
tance from the occipital foramen to the forehead is greater than from
the occipital foramen to the occiput. Hence equal resistances applied
to these two arms necessarily cause the anterior or longer arm to rise,
the posterior or shorter to descend.
In the subjoined diagram (Fig. 114), taken from Hubert, let the line
F i represent the active force; N A and M B equal resistances ; the short
arm of the lever, A B, that is, B i, must descend, for the resistance, N A,
is the more powerful, because acting through the long arm, A i.
Fig. 115, taken from Ribemont, shows the much greater length of the
anterior than of the posterior arm of the lever represented by the head ;
F B is the frontal, and B O the occipital arm ; the sum of resistance-
THE MECHANICAL PHENOMENA OF LABOR. 259
pressure to which the former is subjected must much exceed that which
opposes the descent of the latter.
Another principle in mechanics has been brought forward by Hubert as con-
tributing to flexion. If a propulsive force be exercised centrally upon a mobile,
and there be resisting forces not directly opposite each other, but at different
levels, rotation of the mobile occurs ; thus, flexion of the head, which, as has
been before stated, is simply rotation of the head upon a transverse axis, is fre-
quently completed when the os uteri is almost entirely dilated so that the occiput
has escaped, and the resistance of the os acts upon the forehead and the face,
causing flexion.
According to Lahs, 1 the entire expulsive force of the uterus acts upon the
foetal head in a line perpendicular to the surface of what he terms "the girdle of
contact" that is, the part of the birth-canal for the time resisting the advance
of the head. "The head is a wedge, whose surfaces are found through the tan-
gents made on those points of the head's surface directly in relation with the
girdle of contact." That part of the head whose tangent makes the smaller
angle with the perpendicular line of expulsion must descend first. This smaller
angle is made at the occiput, and therefore this descends and flexion results.
Whatever theory of flexion may be adopted, the movement itself is
essentially one of accommodation, of adaptation of the foetal head to its
passage through the birth-canal. The head entered the inlet with the
occiput at the left ilio-pectineal eminence, and the forehead at the right
sacro-iliac joint, that is, the occipito-frontal diameter was in relation
with the right oblique of the inlet, and the bi-parietal with the left
oblique ; hence a circumference of the foetal head whose diameter is the
occipito-frontal is in relation with the circumference of the inlet. The
long diameter is not perpendicular, but oblique to the plane of the inlet;
besides this obliquity it was asserted by Naegele that the head entered
inclined on the anterior parietal bone, so that the right parietal protub-
erance was somewhat lower than the left, and this inclination was known
as Naegele's obliquity, 2 but most obstetricians reject it ; at least its con-
sideration may well be omitted in the study of the mechanism of normal
labor. The effect of flexion is not only to bring the long diameter of
the foetal head more or less completely in correspondence with the axis
of the inlet, but to present a less circumference of the head to the cir-
cumference of the inlet, for as the chin comes to the sternum, not the
occipito-froutal diameter, but a- shorter one, the suboccipito-bregmatic,
is in relation with the left oblique of the inlet. Remembering that
flexion is a movement of accommodation, it occurs when and where
such accommodation is necessary. It may, therefore, take place at the
inlet, in the lower portion or at the mouth of the uterus, or at the peri-
neal floor, or, finally, it may not occur because the small size of the
foetus, or the great size of the pelvis, the slight resistance of the os uteri,
or of the pelvic floor renders it unnecessary.
Flexion not only substitutes a less foetal head plane, but, according to
Pajot, 3 prior to its occurrence there is a great loss of force from its trans-
mission through a flexible, vacillating rod, to which he compares the
foetus, the mobility existing especially at the articulation of the head
Die Theorie der Geburt.
The obliquity of Solayi
imeters. and Roederer's tx
3 Dictionnaire Encyclopedique des Sciences Medicales.
2 The obliquity of Solayres refers to the head entering the pelvic inlet in one of its oblique
diameters, and Roederer's to the complete flexion of the head on the chest.
260 PHYSIOLOGY OF LABOR.
with the trunk; but when the head is firmly pressed upon the thorax
it is found favorably disposed to participate in the impulsion impressed
upon the general mass of the foetus. Further, flexion facilitates mould-
ing of the head so that it is adapted to the birth-canal. The diagnosis
of flexion is made by the recognition of the relative position of the fon-
tanelles; at the beginning of labor they are almost upon the same plane,
the anterior a little higher than the posterior; as flexion occurs, the
former recedes with the ascent of the forehead, but the latter descends
with the descent of the occiput, and when the anterior is very high, and
consequently the posterior very low, flexion is complete, but if the two
are equally accessible, it has not occurred.
DESCENT. The uterine, reinforced by abdominal, contractions now
compel the head to descend into the pelvic cavity; the axis of the uterus
corresponding with that of the upper part of this cavity there is no loss
of force, and hence if there be the proper relation between the fcetal
head and the canal, the latter presenting only its usual resistance, and
the driving force normal, there is no delay in the descent of the head.
The head planes are parallel with the pelvic planes during the first part
of the descent, and then in consequence of the greater resistance of the
posterior than of the anterior pelvic wall, this synclitism that is, the
parallelism between the planes of the child's head and the transverse
planes of the mother's pel vis ceases, though Dr. Hodge and some other
obstetricians taught that it continued during the entire descent.
A movement called levelling is described by some as occurring when the head
has descended so that the occiput is at the lower margin of the ischio-pubic fora-
men, : and the bregma is at the second bone of the sacrum; by this movement,
essentially a lessening of flexion, the anterior fontanelle becomes more accessible,
and the occipito-frontal diameter is in relation with the right oblique of the pelvic
canal. This phenomenon is not constant, does not contribute when present to
the progress of labor, and therefore may be dismissed from further consideration.
The progress .of the second stage of labor is ascertained by measuring
with the finger the distance of the head from the vulval opening. This
measurement is most conveniently made by using the thumb as an index
to the measuring-rod, the linger. Two errors are to be guarded against :
First, mistaking a caput succedaneum for advance of the head ; and,
second, the head may descend still inclosed in the uterus, whose lower
segment may be so thinned that without great care the examiner believes
he directly touches the head, and may conclude that the labor is much
further advanced than it really is.
ROTATION. This is a movement by which the occiput turns in front,
the entire trunk participating in the rotation. The expulsive power
driving the head down, the occiput is forced to escape, but only anteriorly
is there a gap in the pelvic wall, and to this gap the ischio-pubic ramus
bevelled, flaring invites ; the occiput descends with a pain, boring,
feeling its way, receding in the interval between pains, until finally driven
by a vigorous pain it passes the bony margin at the latero-anterior part
of the pelvis, and there is no subsequent recession, but it sweeps forward
toward the centre of the vulval opening, and the sub-occipital region
comes under the pubic symphysis. As observed by Dr. Ritchie, 1 in
1 Medical Times and Gazette, 1865.
THE MECHANICAL PHENOMENA OF LABOR. 261
some cases the head escapes all pivot movement in the pelvis, but comes
down obliquely upon the perineum, and suddenly wheels round when it
is on the point of escaping from the vulva, the rotation resulting from
the shape of the perineum which, attached on either side, yields most in
the median line, thus forming a gutter in which the head is best accom-
modated, lying not obliquely but antero-posteriorly. When rotation of
the head occurs in the pelvic cavity, while the occiput comes in front,
there is a reverse movement of the sinciput which turns into the sacral
cavity.
Obstetric authorities have devoted much attention to the study of the
causes of rotation, and have greatly differed as to them. Baudelocque
referred this phenomenon to the inclined planes of the pelvis, the anterior
determining rotation into the pubic arch, the posterior rotation into the
sacral cavity. This view probably has had more adherents than any
presented since ; some have modified it by changing the position of the
arbitrary lines, separating the anterior from the posterior planes, but
still essentially their teaching has been that of Baudelocque ; this was
true especially of the teaching of Hodge. But the accepted explanation
of the cause of rotation, while satisfactory so far as anterior positions of
the occiput are concerned, failed as to posterior positions, for in these, too,
as first proved by Naegele, the occiput in most cases rotates anteriorly.
Perinea! resistance, according to some, is the cause of anterior rotation;
but, as observed by Charpentier, this cannot be the sole cause, or the
movement ought never to fail in prirniparae, for in them the perineum
is remarkably resistant. The unequal lengths of the two arms of the
head lever is. according to others, the cause, for the occipital arm being
the shorter the occiput moves in the direction of least resistance.
The law of mechanics, which Hubert has applied to the explanation
of flexion, has its application here also. When a mobile is subjected to
resisting forces, which are not directly opposite, they tend to impress
upon it a movement of rotation. While some assert that this explana-
tion holds only for the rotation which occurs in anterior positions, it
may be shown in the discussion of the mechanism of labor in posterior
positions that the anterior rotation which then occurs can also be thus
explained. Pajot, rejecting all geometrical explanations, finds the just
idea of the causes of rotation in the immutable principle of mechanics
which has been formulated in what is known as his law (previously
stated) : " The indispensable condition for the execution of this law is that
the power, the volume of the content, and the capacity of the container
must be proportional." If the foetus be too large, insurmountable ob-
stacles are presented to its rotation ; if it be too small, there is no invita-
tion to turn, and when the foetus and the passage are in due proportion,
turning may fail for want of sufficient expulsive force. The results of
rotation are that the suboccipito-bregmatic diameter, which corresponded
with the right oblique of the mother's pelvis, is now in relation with
the antero-posterior of the outlet, and the biparietal with the transverse,
and the shoulders as the body participated in the rotation descended
in the pelvis with the bisacromial diameter in relation with its transverse
diameter. Rotation is known to have taken place by the position in
which the occiput is found that is, directly in front ; in some cases the
262 PHYSIOLOGY OF LABOR.
movement may be recognized during its occurrence by a finger placed
upon the occiput.
EXTENSION. The third of the mechanical phenomena of labor is a
movement of the head directly the reverse of the first; whereas the
head then rotated forward on its transverse axis, so that the chin came
to rest on the sternum it now rotates backward, and the chin recedes
from the sternum, that is, deflexion or extension occurs. In this move-
ment the nape of the neck presses the subpubic ligament, the shoulders
are transverse, and close behind the pubic arch, so that the occiput can
advance no further in a direct line ; meanwhile expulsive action continu-
ing is met by the resistance of the perineum, and the resultant diagonal
force is in the axis of the prolonged birth-canal ; the expulsive force
cannot act directly upon the occiput, but only upon the long arm of the
head lever, thus forcing the chin to descend ; according to Pajot, the
occipito-mental diameter represents a lever of the third order, the fulcrum
being at the pubic arch, the resistance at the pelvic floor, and the power
between the two, that is, at the occipital foramen. But extension or
rotation backward of the foetal head may also be explained as the result
of a driving force met by two resisting forces acting upon the foetal head
at different planes, or two unequal forces, even if acting in the same
plane. We have first the driving force of uterine and abdominal con-
tractions; the perineum resists, and -there is also resistance at the
pubic arch, but the former resistance being less than the latter, rotation
results the head is rolled out of the vulval opening, the bregma, the
forehead, and the face appearing successively from behind the perineum,
the occiput continuing to move in a curve over the pubic symphysis,
the successive radii of this curve being the several suboccipital diame-
ters. 1 The longest of these diameters is the suboccipito- frontal, and the
vulval opening is of course in greatest danger of being torn during the
passage of the head circumference corresponding with this diameter.
The progress of this stage of labor is known by the emergence of a
greater part of the foetal head at each expulsive effort, and its comple-
tion by the dropping down of the head in front of the anus, and by
the retraction of the perineum.
EXTERNAL ROTATION OF THE HEAD WITH INTERNAL ROTATION
OF THE BODY. In some cases just after the head drops down face
below, occiput above, there is a change of the head to an oblique posi-
tion : this movement is called restitution, and it takes place when in
internal rotation the body did not follow the head in this movement,
but a twist in the neck occurred, and now the head is restored to its nor-
mal position with reference to the trunk. Restitution is oftener seen in
occipito-posterior than in occipito-anterior positions, but even in the
former it is not frequent, for with perfect flexion the foetus is so com-
pacted together that head and trunk make one mass, and move together.
In most cases no such movement as restitution is recognized, but the
1 This hitherto generally received explanation of the expulsion of the foetal head has recently
been controverted by Berry Hart, who, denying extension, claims that progression, or translation
of the head, occurs, occiput and sinciput simultaneously advancing. He attributes that which he
calls the erroneous idea of extension to the fact that " the attendant, while the patient lay on
her left side, watched the passage of the fcetal head from behind, saw more of the anterior portion
of the head appear, and accounted for it by extension." Hart's opinion will be referred to on a
future page.
THE MECHANICAL PHENOMENA OF LABOR. 263
head remains motionless after dropping down with the end of the fourth
stage of labor, until a new expulsive effort occurs, and then it moves
through the fourth of a circle so that the occiput points to the mother's
left thigh, and the face to her right thigh. A simple law may be given
in this connection the occiput always points to that thigh correspond-
ing to the side of the pelvis in which it was before the delivery of the
head, and thus if the occiput was in the left side of the pelvis, no mat-
ter whether posterior or anterior, it will point to the left thigh. The
external rotation of the head indicates the internal rotation of the
shoulders; they descended into the pelvis, the bisacromial diameter in
relation with the left oblique of the inlet ; the body rotating with the
head the bisacromial became transverse, but as delivery in this position
is impossible, body rotation, which is indicated by external rotation of
the head, takes place, so that the right shoulder is behind the pubic
joint and the left is in the sacral cavity.
EXPULSION OF THE BODY. Expulsive efforts continuing, the pubic
shoulder passes out first it has the shorter distance to traverse, and
it represents the occiput which was delivered first and the superior
part of the trunk pivots upon the arm just below the shoulder, while
the sacral shoulder sweeps the sacral curve and follows the course of the
distended perineum, the perineal pressure and the direction of the canal
FIG. 116.
EXTERNAL ROTATION OF HEAD IN FIRST POSITION.
causing incurvation of the body upon its lateral plane; the sacral shoul-
der is finally delivered, and the arm quickly follows, and then the pubic
arm passes out, and the lateral curvature of the body is at an end. Just
as the nape of the neck was fixed at the subpubic ligament in delivery
of the head, so is the upper part of the pubic arm situated in delivery
of the superior portion of the trunk ; delivery of the head was effected
through extension, but that of the shoulders by flexion, the lateral in-
curvation of the body is simply the analogue of extension of the head.
Authorities differ as to which shoulder is delivered first, and some end the con-
troversy by asserting a simultaneous delivery. The illustration just presented
shows that the upper shoulder has passed the pubic arch, while the under one
264 PHYSIOLOGY OF PREGNANCY.
is still hidden by the perineum ; although Dr. Hodge, from whose work the dia-
gram is taken, taught that they escaped at the same time, the statement is con-
tradicted by it. Cazeaux held that in primiparre the delivery is as stated in the
text, but not in the parous when the perineum has been torn. But this is a con-
cession of the very point at issue, and we may say with Pajot that in the normal
mechanism of labor the pubic shoulder is first delivered.
The expulsion of the rest of the body rapidly follows that of the
shoulders, the trunk making somewhat of a spiral movement ; if the
hips are very large, there may be delay, and the same mechanism occurs
as in the delivery of the shoulders.
THE ROTATIONS. In the preceding description of the mechanism of labor
the rotations that have been stated are two, but there is also a third of the
mechanical phenomena of labor that is essentially a rotation, for flexion of
the head is simply the turning of the head upon a transverse axis ; so, too, the
head rotates in its expulsion, only the rotation is directly the opposite of that
which occurred in complete flexion.
Fritsch 1 describes five rotations. The first of these is the lateral turning of
the head in entering the pelvis, so that the anterior parietal is lower than the
posterior, the sagittal suture being nearer the promontory than it is to the anterior
pelvic wall. This position, known as Naegele's obliquity, according to him,
results from the projection of the promontory, and from there being no similar
resistance at the anterior pelvic wall.
But this obliquity, while a constant feature in the flat pelvis, is by no means,
according to most obstetricians, a frequent phenomenon in a normal pelvis, and
therefore its consideration may be omitted.
Of the other rotations, the only one considered in this note is the anterior rota-
tion of the occiput into the pubic arch. This rotation has given rise to much
discussion, many explanations have been offered, and by no means the last word
has been said. It is impossible to mention all the theories of its causes. Werth' 2
explains that this movement occurs because the anterior pelvic wall and the region
of the pubic arch offer no important resistance, while laterally and behind notable
obstruction opposes. Fritsch refers to the frontal bone pressing against the
anterior lateral part of one-half the pelvis, and there an oblique plane tends to
cause a movement posteriorly ; then the form of the horizontal pelvic plane is
such that there are two angles presented, one anterior and acute, the other pos-
terior and obtuse ; the forehead must turn into the opening of the latter.
Some have attributed, either wholly or in chief part, the turning of the occiput
forward to the action of the levatores ani ; this was the teaching of my prede-
cessor in Jefferson Medical College, the late Dr. Ellerslie Wallace, and it has
also been held by some of the most eminent among German obstetric teachers.
It is not remarkable that the rotation of the head internally, like its rotation
externally, has been by several authorities explained as resulting from a move-
ment of the body ; as external rotation of the head tells of internal rotation of
the shoulders or trunk, so it is claimed that this results from a similar movement
of the body. Many eminent obstetricians uphold this view ; among these may
be mentioned Litzmann, Kehrer, and Olshausen. The last has stated that in
consequence of the increased flattening of the uterus by contractions the back
of the child is pushed from a lateral to a front position, because of more room
anteriorly, necessarily then the child's head is turned so that the sagittal suture
is antero-posterior. Ahlfeld 3 criticises this view on two grounds : First, rotation
of the head occurs in the first of twins when the uterus is not flattened, and,
second, it occurs, too, in a head-last labor.
Ostermann, in a recent monograph, Die Cardinallebewegung des Geburtsmechan-
ismus, regarding previous explanations as not completely satisfactory, endeavors
to make good a new theory applicable to all cases. He starts with presenting
the three factors to be considered, namely, the expulsive force, the canal and its
1 Klink der Geburtshtilflichen Operationen. 1894.
MUller's Handbuch der Geburtshttlfe. I. Band. 1888.
8 Lehrbuch der Geburtshilfe. 18&4.
THE MECHANICAL PHENOMENA OF LABOR. 265
form, and third, the foetus and its form. The rotation which is being especially
considered, he attributes to the uterine contractions which place the shoulders
in a transverse position at the pelvic inlet.
The main factor in rotation depends chiefly upon the greater flexibility of the
antero-posterior and the less lateral flexibility of the vertebral column.
Osterman concludes his paper by saying : " We have endeavored to show the
influence of both factors, the simple flexion of the lower pole toward the opening
of the canal, and the invariable preponderance of the antero-posterior flexibility
of the vertebral column. It may seem that a more important influence is ascribed
to the foetus than is the actual fact. This appears to us to rest upon the natural
conditions. Should we wish briefly to describe the transmission of the foetus, we
would say : The foetus winds itself through the birth-canal throughout ; but this
expression must not be understood to suggest an active participation. In this
strong and general statement the assertion that the anterior rotation of the small
fontanelle is referred to the turning of the deepest part (Schroeder) seems un-
necessary, at least it is not lost in a chaos of details. Admitting the previously
considered factor, so we believe it may be applied for the explanation of all
cases of rotation. "
The anterior rotation of the occiput may occur, as many obstetricians have
observed, before the head rests upon the pelvic floor, and therefore this cause,
offered by many as explaining the mechanism of the movement, cannot be
admitted a constant factor.
RIGHT OCCIPITO-ANTERIOE POSITION. In this position, which is
the rarest of the four, the occiput is in the inlet, at the right ilio-pecti-
neal eminence, and the forehead at the left sacro-iliac joint, the child's
back is in the right and anterior portion of the uterus, and the limbs in
the left and posterior portion. By abdominal palpation the head is
found in the lower segment of the uterus, and the back in the situation
mentioned ; the hand passes more deeply in the pelvis upon the right
side than upon the left. Upon auscultation the maximum of intensity
of the fetal heart-sounds is found, according to Depaul, at the middle
of a line passing from the right ilio-pectineal eminence to the umbilicus
(see Fig. 105 ; this maximum is found at (7), but according to Ribe-
mont upon the median line, sometimes, indeed, a little to the left of it.
Digital examination confirms the diagnosis of a vertex presentation,
and the sagittal suture is found to be in the left oblique diameter of the
inlet, the occiput at the right ilio-pectineal eminence, and the forehead
at the left sacro-iliac joint.
The mechanical phenomena are the same as those which have been
described as taking place in a left occipito-anterior position. First,
flexion occurs, a process of accommodation, an adaptation of the pre-
senting part to the birth-canal, by substituting a smaller head circum-
ference to the pelvic area, a lessening of the foetal part which descends
first. Descent follows, and then rotation ; but the occiput, instead of
rotating from left to right, now rotates from right to left into the pubic
arch. Extension occurs next, for direct progression of the occiput is
impossible, because it is held back by the shoulders lying transversely,
but indirect advance occurs by the occiput tending to approach the back,
the chin departing from the chest, and the entire head is rolled out of
the vulval opening ; the head thus rotates backward upon its transverse
axis in deflection, just as it rotated forward in flexion. After the birth
of the head it rotates externally as the sign and the effect of internal
rotation of the body, but the occiput now is directed to the mother's
right thigh, the face to her left, which is the reverse of the situation of
266 PHYSIOLOGY OF LABOR.
these parts of the head in a left occipital position. By the direction in
which this external rotation occurs the student may correct or confirm
the diagnosis of position made at the beginning of labor. Finally,
delivery of the body takes place in the manner described for a left
occipito-anterior position.
RIGHT OCCIPITO-POSTERIOR POSITION. This is next in frequency
to the position first described ; it is that position reversed, and hence the
occipito-frontal and the biparietal diameters hold the same relations to
the two oblique diameters of the inlet that they did in left occipito-
anterior position. The former of these foetal diameters, which it will
be remembered is the longer, avoids the left oblique of the inlet, which
is practically the shorter of the two pelvic measurements, because of
the presence of the rectum upon the left side. The occiput is at the
right sacro-iliac joint, and the forehead at the left ilio-pectineal eminence ;
the back of the child is posterior and to the right, the limbs anterior
and to the left side of the mother's abdomen.
FIG. 117.
RIGHT OCCIPITO-POSTERIOR POSITION.
Palpation proves the presence of the head in the lower part of the
uterus; the hand can pass more deeply in the right side of the pelvis
than in the left ; in the latter it is arrested by the projecting forehead
at the ilio-pectiueal eminence. The dorsal plane of the foetus can be
more readily recognized if the woman lies upon her left side. The
maximum of intensity for the foetal heart-sounds is in a line passing
from the right sacro-iliac joint to the umbilicus. Digital examination
shows that the anterior foutanelle is in front and to the left, the posterior
fontanelle to the right and behind, while the sagittal suture is in the
right oblique of the inlet.
The mechanical phenomena of labor are in almost all cases the same
as have been described, and therefore need not be detailed. One of
these, however, requires special study that of internal rotation. In
occipito-anterior positions the occiput rotated only through a little more
than one-eighth of a circle in order to be placed in the pubic arch, but
THE MECHANICAL PHENOMENA OF LABOR. 267
now it must rotate through three-eighths. Moreover, it sometimes
happens that the shoulders do not rotate at all, or only partially, and
hence there results greater or less torsion of the neck, this torsion being
proved by the movement of restitution immediately following the
delivery of the head.
It is natural to ask why the occiput when in this position, so near
the sacral cavity, does not, as the forehead did, rotate, when in a some-
what similar location, into that cavity, instead of by a much longer
course seek the pubic arch. Dr. Hodge's answer was that the promon-
tory of the sacrum determines the whole head toward the anterior part
of the pelvis, and that when the point of the occiput strikes upon the
spinous process of the ischium rotation upon the right anterior inclined
plane necessarily occurs, but if the point of the occiput strikes posteri-
orly to this process, rotation into the hollow of the sacrum follows.
But the most satisfactory reply to the question as to the anterior ro-
tation of the occiput, and the posterior rotation of the sinciput, is, as
stated by Dr. Ritchie, that in both anterior and posterior positions the
former is lower than the latter when resistance begins ; in occipito-
anterior positions that resistance from the pelvic floor begins when the
occiput is level with the pubic arch, and the forehead with the cavity of
the sacrum, but in occipito-posterior positions the resistance begins when
the occiput is past the sacral cavity, and the forehead too high for the
pubic arch. There are forces of resistance presented to a progressive
mobile at different levels, and consequently they cause it to rotate, the
most prominent or advanced part of that mobile moving in the line of
least resistance.
In the further consideration of this mechanical phenomenon we must
bear in mind that unchangeable law which compels in all vertex deliv-
eries, whether artificial or natural, the occiput to pass out first. "When
the flexion is perfect, the head and neck make, with the upper part of
the thorax, according to the comparison of Dubois, a stiff, inflexible
rod. If the occiput rotates into the pubic arch, the neck more than
measuring the length of the pubic joint the occiput can pass out, and
extension of the head occur, and thus the rod becomes flexible, and the
trunk does not enter the pelvic cavity until the head is being delivered.
But the condition is very different in an occipito-posterior position ; the
neck is much shorter than the lateral wall of the pelvis with which it
is in relation, and hence the greatest diameter of the rod, the dorso-
frontal, must enter the pelvic inlet, so as to be in relation with its right
oblique diameter. But the descending back, curved and projecting,
cannot rest upon the promontory of the sacrum, and hence there is a
force of resistance which tends to throw the presenting part from an
oblique to a transverse position. This change is possible only when
flexion is perfect that is, when the chin is so firmly pressed upon the
chest that the head and upper part of the trunk make a unit, and thus
a movement communicated to the trunk also causes the head to move.
Meantime, on the other side of the pelvis the forehead is not adapted
to the pubic arch, is resisted more by the anterior than by the lateral
pelvic wall ; thus the two resisting forces determine rotation of the
head from an oblique to a transverse position, and then the rotation is
268 PHYSIOLOGY OF LAS OR.
continued until the position becomes right occipito-auterior, from which
the occiput finally turns into the pubic arch.
In rare cases probably once in fifty, Stoltz ; twice in fifty, Uvedale
West the occiput fails to rotate anteriorly, but turns to the sacral
cavity, and the head is in an occipito-sacral instead of an occipito-
pubic position. If this posterior rotation occurs, the head descends in
the axis of the pelvis ; but the occiput is not adapted to the concavity
of the sacrum, nor the forehead to the pubic arch, so that both in front
and behind space is lost. The straight, rigid rod cannot become flexi-
ble until the occiput has traversed the sacral cavity and the inner sur-
face of the perineum, so as to pass out over its anterior margin ; but
this end is not possible until the trunk has also entered the pelvic
cavity, for the longest diameter of the head is less than the distance
from the inlet to the vulval opening. When the occiput escapes, the
nape of the neck pivots on the anterior margin of the perineum, the
occiput passing backward extension occurring in like manner to that
observed in an occipito-anterior delivery and the anterior fontanelle,
the forehead, and the face are successively delivered, all the diameters
being suboccipital, just as in an occipito-auterior delivery.
After the head is delivered it drops down, and then follow in order
external rotation of the head with internal rotation of the body, and
delivery of the body. It is plain that the labor is slower in an occipito-
posterior delivery, not only from the great distance the occiput must
pass before it can escape from the vulval opening, but also from the
difficulties in that passage ; the suffering of the woman is greater, and
there is more danger that the perineum will be torn. The child is born
alive if it is not large and the pelvis is normal ; but if the latter be
small, or the former large, stillbirth is common.
In very rare cases, if the foetal head was small, conversion of a
vertex into a face presentation has occurred at the inferior strait, exten-
sion taking place, so that the chin instead of being born last is born
first, emerging at the pubic symphysis, and the delivery of the head
takes place by flexion.
It is unnecessary to give the diagnosis and describe the mechanism
of labor in left occipito-posterior position, for they can be readily under-
stood from the explanations already made, substituting left for right in
the description of the diagnosis and the mechanism of right occipito-
posterior position.
In concluding this exposition of the mechanical phenomena of labor
in vertex presentation, it must be remembered they all concur to one
end, the expulsion of the child, and therefore if one or another is not
needed for this end, it may be absent. In the main they are processes
of adaptation, of accommodation of the foetal head and body to the
birth-canal, and are the results of a driving and of resisting forces,
hence varying as these forces vary. In some cases the foetal head may
be so small, or the mother's pelvis so large, that any increase in the
head flexion is not needed for descent, flexion being essentially a lessen-
ing of size by placing a smaller head plane in relation with a greater
pelvic plane ; or, again, internal rotation of the head may not occur,
and the head be born in the same oblique position which it had upon
THE MECHANICAL PHENOMENA OF LABOR. 269
entering the inlet. These and other variations in the mechanism of
labor are not, as Pajot well says, violations of law, but occur because
some of the factors which carry out the law may be absent, or others
have more power. The phenomena as described always occur if the
foetal head, the birth-canal, and the driving force are normal. If, in a
given case, two of these phenomena are simultaneous, it does not follow
that their individuality as to causes, results, and diagnosis is lost, and
that they should be regarded as a single event.
PRESENTATION OF THE FACE. In order that the face may present,
the head must be extended instead of flexed, the occiput bearing the
same relation to the back that the chin does to the sternum in vertex
presentation.
FREQUENCY AND CAUSES. Authorities differ as to the frequency
of presentation of the face : 1 in 324, Spiegelberg ; 1 in 231, Churchill ;
1 in 217, Lachapelle; 1 in 247, Pinard ; 1 in 175, Depaul ; 1 in 276,
Galabin ; 1 in 250 or 300 cases, Hodge.
Winckel has stated that thirty-three different causes have been sug-
gested. One of the most remarkable was that given by Osiander, viz.,
that the foetus inherited a disposition from its parents to carry the head
back. Hodge 1 regarded as the best hypothesis that such presentation
resulted from the spontaneous movements of the child, the head being
fixed in this unusual posture by contractions of the uterus. Hecker
regarded dolicocephalia as a cause. According to him, the greater pro-
jection of the occiput in the dolicocephalic increased the length of the
posterior arm of the head lever, so that when uterine contractions
occurred it ascended, while the frontal arm descended. The answer
generally made by obstetricians to this explanation is that dolicoce-
phalia is a consequence of the delivery in a face presentation, not the
cause of such presentation, and that it disappears a few days after birth ;
further, even if this condition be present, the increase in the length of
the occipital is never so great as to make it longer than the frontal arm.
Spiegelberg met with a case of face presentation in a foetus having hydro-
thorax. Other instances are mentioned in which tumors of the neck
were the cause. But apart from these special causes, the general ones
are uterine obliquity, pelvic narrowing, and unusual size of the child.
The presentation occurs more frequently in multipart than in primi-
1 Dr. Meigs said " that dead and half-putrid children, in whose tissues there is scarcely any
resiliency or resisting power left, are not so unapt to come face foremost as living children, in
whom departure of the chin from the breast occasions such a great extension of the head as to be
painful, whence the living child instinctively opposes the wrong tendency, by acting with all its
strength to get the chin back, or the head flexed again." The statement by Dr. Meigs, and also
that by Dr. Hodge, suggest a voluntary movement of the foetal head in the one case causing and
in the other preventing presentation of the face, that is not unquestionable. Sir Thomas Browne,
whose Religio Medici all doctors read, among his many other literary works wrote a supposed
dialogue between twins in the uterus, which unfortunately has been lost. Imagining a conversa-
tion under such circumstances is, of course, a very wide step beyond, but is in the same direction
as the voluntary movements that have been suggested. Those who have observed how utterly
powerless the newborn are to move the head in any direction, and that it falls inert, according to
gravitation will hardly admit that the foetus can, against the force of gravitation, raise the head a
single inch from the chest, or that when it is removed from the chest by external causes that the
foetus, though " acting with all its strength," can replace it if the slightest force opposes.
Winckel indorses the criticism of the opinion of Drs. Hodge and Meigs I have made. In Preyer's
very interesting volume upon the Sord of tlie Infant the following statement is made upon the
authority of Dremme. giving additional confirmation : In 150 children the head may be held in
equilibrium if the infants are very vigorous toward the end of the third, or in the first half of the
fourth month ; in infants of medium force this is not seen until the second half of the fourth
month, and finally, in infants less vigorous, somewhat below the normal in nutrition, not until
the fifth or the beginning of the sixth month.
270 PHYSIOLOG Y OF LAB OR.
parae, the proportion being, according to Kleinwiichter, 1 of the former
to 2.23 of the latter. The presentation may be primary or secondary ;
the latter is much the more frequent. The duration of labor is in
primipane 34 hours, and in multipart 15 hours. The ordinary foetal
mortality in vertex presentation is 5 per cent., but in face presentation
15 per cent. 1 Premature rupture of the bag of waters, prolapse of the
umbilical cord, and tearing of the perineum, are among the accidents
liable to occur in face presentations.
MECHANISM. As in presentation of the vertex the occiput was
selected as the point of reference, so in presentation of the face the
forehead, following the example of Depaul, will be chosen. Most
obstetricians select the chin, naming the different positions of the pre-
senting part mento-anterior and mento-posterior, right or left, according
to the side of the pelvis in which the chin is placed. But let the student
imagine a case of vertex presentation with the occiput at the left ilio-
pectineal eminence, and then, while the foetus is unchanged in its gen-
eral position, let the head be extended instead of flexed, and it is seen
that the forehead at once takes the position which the occiput occupied ;
and this position is the most frequent in presentation of the face.
Further, in many cases, if not in the majority, presentation of the face
is a deviated vertex presentation, and such deviation can be better
understood with the nomenclature proposed. The various positions in
presentation of the face will therefore be called right or left fronto-
anterior and fronto-posterior.
DIAGNOSIS. Pinard 2 states that examination of the pelvis enables
us to recognize the presence of a large tumor at, above, or below the
inlet, according to the period of labor at which the examination is
made. Moreover, this tumor appears to occupy but one side, and is
wanting at the other. Let the hand be now at once placed upon the
fundus of the uterus, or both may be first put upon the sides of the
uterus until the fundus is reached, and then one of them applied to it,
and we find, usually upon the same side at which the lower tumor was
prominent, the pelvis, that may be recognized by its peculiar characters.
In order to follow and appreciate the resisting plane, it is indispensable 3
to depress slowly and deeply the abdominal wall, for this surface seems
to bury itself in the abdominal cavity, while the superficial parts are
readily felt. This is caused by the bending of the foetus upon its dorsal
plane. In operating properly one of the lateral planes can be examined,
and it is readily ascertained that the portion of the cephalic sphere most
accessible is in relation with the back. Moreover, between the back and
the head there is, especially early in the labor, a deep depression into
which the fingers sometimes readily enter. According to Budin, 4 one
can, in some cases, recognize on the side opposite to the accessible tumor
a clearly marked projection having the form of a horseshoe ; it is formed
by the inferior maxillary and the chin.
Charpentier regards the diagnosis by palpation alone as exceedingly
difficult, stating that special conditions must be present, relaxation and
thinness of the abdominal walls, and a non-irritable condition of the
1 Kormann, quoted by KleimvSchtef. 2 Abdominal palpation.
3 Pinard, op. cit. * Op. cit.
THE MECHANICAL PHENOMENA OF LABOR. 271
uterus, in order thereby to make such a diagnosis, but it can be made
by combining auscultation with palpation. The foetus occupies a higher
position than in vertex presentation, so that the maximum of the in-
tensity of the heart-sounds is heard at, instead of below, the transverse
line (Fig. 105) ; further, in consequence of the head being turned toward
the back, the latter is removed from contact with the uterine wall, so
that the sounds are heard better through the anterior wall of the chest ;
hence while the back is felt, for example, on the left side of the uterus,
the heart-sounds are heard most distinctly upon the right side. This
want of harmony between the results obtained by palpation and by
auscultation leads to the diagnosis of a face presentation, for palpation
would point to the conclusion that there was a vertex presentation, but
auscultation, both by the fact that the sounds are heard higher up than
in such a presentation, and on the opposite side to that upon which the
back is found, justifies at least the suspicion that the face presents. 1
After labor has begun, digital examination brings conclusive proof
of the presentation. There will be found upon one side of the pelvis
a round, hard part, divided in the median line by the beginning of the
sagittal suture, and bounded by the fronto-parietal suture, and in the
median line by the bregma ; while upon the other side of the pelvis
there is felt a smaller, softer, and irregular surface ; this surface imme-
diately next to the frontal bone offers two soft, round, small tumors,
the globes of the eyes; there is a depressed surface between them,
then from it there rises a projecting part which ends in two open-
ings, the nares ; below the nares and transverse to them is the mouth,
into which the finger may be introduced, and in some cases this intro-
duction is followed by efforts on the part of the infant to suck ; below
the mouth the chin is found, the direction in which it points being
plainly indicated by the opening of the nares. 2
If the labor has been in progress for some time, the membranes
having been ruptured, the face becomes greatly swelled and its form
changed ; one feature, however, remains comparatively unaltered, the
nose ; by this the diagnosis of the presentation can usually be made,
and when the nose is recognized the position is known, for the former
points in a direction opposite to, the forehead. The mouth should not
be confounded with the anus, for the projection caused by the point of
the coccyx is always readily found near the latter.
-f LEFT FEONTO-ANTERIOR POSITION. This is the most frequent
position. The back is found by palpation upon the left anterior side
of the uterus; the foetal heart-sounds are heard most distinctly upon
the right side. Upon vaginal examination the nose is found pointing
toward the right sacro- iliac joint, and hence the forehead must be at
the left ilio-pectineal eminence.
1. The first of the mechanical phenomena of labor is increase of
extension, the occiput turned against the back ; complete extension in
presentation of the face corresponds with complete flexion in presenta-
tion of the vertex. Its cause is the driving force met by the unequal
1 Fischel states the heart's action maybe felt in face or brow presentation, when the anterior
part of the chest lies in contact with the uterine wall, after rupture of membranes.
2 Winckel states that in the diagnosis of this presentation chief reliance should be made upon
recognizing the mouth and tongue.
272 PHYSIOLOGY OF LABOR.
resistance of the two arms of the face lever. In Fig. 119, A F, being
the long arm, necessarily offers more resistance than A M, the short
arm ; hence the chin descends and the forehead ascends. Further, the
head being already partially extended, prepares the way for complete
extension. The result of perfect extension is : There is a lessened area
of the head circumference brought in relation with the pelvic area, for,
prior to complete extension, that circumference corresponded with a
diameter passing from the chin to the bregma, the mento-bregmatic
diameter, while now the diameter whose circumference occupies the pel-
vic area is the frouto-mental. There is no loss of force, at least after
the waters have been evacuated and direct pressure upon the breech per-
mitted, for the foetus is no longer " a vacillating rod " in consequence
of the mobility at the cervical vertebrae, but compacted together by the
occiput being fixed upon the back. Complete extension is recognized
by the recession of the forehead, and by the advance of the chin toward
the centre of the pelvic cavity.
FIG. 118.
FRONTO-ANTERIOR POSITION IN PRESENTATION OF FACE.
2. Descent. This does not need to be defined nor its cause explained.
3. Rotation. It is essential, in order that delivery can take place, in
the ordinary relations of the size of the pelvis and that of the foetus,
that the chin rotate anteriorly; that must escape first before any flexion
of the foetal rod is possible. The descent is at an end as soon as the
length of the child's head has been measured upon the pelvic wall, for
then the chest tends to enter the pelvis, but the latter cannot accommo-
date both head and trunk. The length of the pelvic lateral wall is
three inches and a half, between nine and ten centimetres, while the
anterior wall is only one inch. and a half long (four centimetres), a dis-
tance readily measured by the neck. Ordinarily, therefore, it follows
THE .MECHANICAL PHENOMENA OF LABOR.
Fre. 119.
273
M
ATTITUDE OF THE HEAD IN PRESENTATION OF THE FACE.
that rotation of the forehead into the sacral cavity, and of the chin into
the pubic arch, occurs before the face reaches the pelvic floor.
ROTATION FORWARD OF THE CHIN.
18
274 PHYSIOLOGY OF LABOR.
Dr. Hodge, however, with Velpeau and Chailly, held that in many instances
"the chin will pass below the sacro-sciatic ligament, and will often distend the
perineum to a great degree." He justified this opinion by the following consid-
erations : First, the length of the neck is to be measured, not from the hyoid bone,
but from the chin to the chest. When the head is in a state of extension we
would have at least three inches and a half, and if the neck be elongated, probably
four inches from the chin to the sternum. Second, the neck can be elongated to
a considerable degree in these cases of great extension.
If these views were correct, we would probably have delivery of the
foetus in face presentation, without anterior rotation of the chin, as a
frequent occurrence. Admitting, too, the great elongation of the neck
claimed by Dr. Hodge, which, however, is of the anterior portion, this
does not obviate the difficulty arising from both the head and chest
occupying the pelvic cavity at the same time.
FIG. 121.
PASSAGE OF THE HEAD THROUGH THE EXTERNAL PARTS IN FACE PRESENTATION.
The bead is becoming flexed and sweeping over the perineum.
The reasons for posterior rotation of the forehead are that it offers a
more extensive surface, and the frontal arm of the face-lever is the
longer, and hence meets with greater resistance ; it finds more room and
can be better accommodated behind than in front. With the correspond-
ing rotation of the chin into the pubic arch the mental end of the face-
lever is free; it no longer meets resistance from the bony wall of the
pelvis, and the head is no longer pressed against the back, but can be
delivered, thus giving room in the pelvic cavity for the descent of the
body.
4. Delivery of the head by flexion. The chin escapes, and thus the
occipito-mental diameter is free to rotate partially. The head is, as it
were, rolled out of the vulval opening, flexion occurring, the throat
applied to the summit of the pubic arch, the chin ascending over the
pubic joint until the occipital end of the occipito-mental diameter
THE MECHANICAL PHENOMENA OF LABOR. 275
escapes over the perineum, when the head drops down toward the anus
as it did after vertex delivery. Here again we have illustrated the fact
that when one end of the long diameter of the foetal head enters the
pelvis, that end must pass out of it first.
5. External rotation of the head with internal rotation of the
shoulders. The conditions are the same as in vertex delivery, and the
causes of the rotations and the consequences are identical. The fore-
head, or the chin, always turns toward that thigh corresponding with
the side of the pelvis which it occupied ; thus, if the forehead was in
relation with the left side of the pelvis, it turns toward the left thigh.
6. Delivery of the body. This is the same as in presentation of the
vertex.
ANOMALIES OF MECHANISM IN FACE PRESENTATIONS. In some
cases there may be, in consequence of imperfect extension, presentation
of the forehead. But this rarely persists, for either flexion occurs and
the presentation becomes that of the vertex, or, and this is the more
frequent, extension is completed and there is simply a face presentation.
Sometimes, however, the forehead remains the presenting part, and is
delivered first. The anomalies of the third time, rotation of the chin
in front, are the most important. Not only may this rotation fail, but
posterior rotation by which the chin turns to the sacral cavity may
occur. Apparently spontaneous expulsion is impossible. Velpeau
thought that flexion of the head might then take place by which the
vertex would be substituted for the face. But this is impossible after
the head enters the pelvic cavity if the foetus and pelvis are of usual
size. Cazeaux suggested that the soft parts might be depressed at the
great sciatic foramen, " a depression permitting the chin to escape from
the bony canal," so that the long diameter of the foetal head might
turn, and presentation of the vertex be substituted for that of the face.
Another explanation was proposed by Dubois from two cases observed
by him. The chin was behind and to the right, descent to the inferior
strait occurred, and after the chin passed below the great sciatic liga-
ment it depressed the soft parts so that space was gained to permit
flexion of the head at the expense of the elasticity of the pelvic floor,
and labor ended with presentation of the vertex.
Pajot remarks that in directly posterior positions, which are so rare
that he has never seen one, that Chailly has suggested an analogous
mechanism theoretically probable, permitting spontaneous delivery.
The chin having reached the point of the coccyx, depresses the pelvic
floor so that rotation of the occipito-mental diameter can occur, and the
occiput is disengaged under the pubic arch. But whatever opinion may
be suggested as to the termination of the labor in mento-posterior posi-
tion, 1 practice demonstrates that they very rarely persist, and, moreover,
when rotation of the chin does not occur, difficulties ordinarily arise
requiring the intervention of art.
PLASTIC CHANGES. The form of the head is dolicocephalic ; the
longitudinal diameters are increased, the vertical and transverse
diminished.
The face is greatly swelled and discolored ; the eyelids likewise, and
i Pajot.
276 PHYSIOLOGY OF LABOR.
it is impossible for the infant to open them ; in some cases the lips are
so greatly swollen that the infant cannot nurse ; very often subcon-
junctival hemorrhage is present. 1 The caput succedaneum occupies the
inferior part of the malar region and the side of the mouth in fron to-
posterior positions; on the contrary, it is situated upon the superior
part of the malar region and even upon the eye in frouto-auterior posi-
tions. Mauriceau 2 has given a very graphic description of the appear-
ance of a child's face after birth with facial presentation.
Right fronto-posterior position is the reverse of left frou to-anterior ;
and just as the former might be considered a deviation of the most fre-
quent position of vertex presentation, extension taking the place of
flexion, so that instead of the occiput the forehead is at the left ilio-
pectiueal eminence, so, imagining first the next most frequent position
of vertex presentation, right occipito-posterior, we may suppose a devi-
ation to result from extension taking the place of flexion, so that the
forehead instead of the occiput is placed at the right sacro-iliac joint.
The mechanism of labor is the same as has been described. 1. Com-
pletion of extension. 2. Descent. 3. Rotation. As the chin is so
much nearer the pubic arch in this position than in left fronto-anterior,
this process occupies much less time. 4. Delivery of the head by
flexion. 5. External rotation of the head with internal rotation of the
shoulders. 6. Expulsion of the body. It is only necessary to mention
the names of the two other positions of face presentation, right fronto-
anterior and left fronto-posterior, for a description of the mechanism of
labor in these positions would be essentially a repetition.
PELVIC PRESENTATIONS. Presentations of the pelvis are next in
frequency to those of the vertex, and occur once in twenty to thirty
cases in single pregnancies, but more frequently in twin pregnancies.
Excluding cases of premature labor, pelvic presentations occur, accord-
ing to Pinard, once in sixty-two.
VARIETIES AND CAUSES. Usually the upper and lower limbs
occupy the same position with reference to the trunk that they do in
vertex or in face presentations. In some cases, however, not only are
the thighs flexed upon the abdomen, but the legs extended over the
chest. The knees may descend first, though, according to Spiegelberg,
such presentation is never primitive, one or both feet may descend, but
these various modifications do not affect the essential mechanism of
labor. Whether knees, feet, thighs, or pelvis present, all are included
1 A remarkable case of fatal hemorrhage from the conjunctiva in an infant born with face pres-
entation occurred, March, 1890, during one of my terms of service at the Philadelphia Hospital. Dr.
Frank R. Keefer, maternity resident, had charge of the mother in her labor, and has given me a
full report of the case, which I hope to publish with some comments at an early day. Suffice it
now to say that the child was delivered spontaneously after a not unusually long labor ; it seemed
quite well, weighed eight pounds, and had only the usual appearance of a child born presenting
the face. The bleeding began twelve hours after birth ; the oozing was first from the conjunctiva
of the right upper lid, and after a few hours from the palpebral conjunctiva of the left eye. In
spite of various local means, some of which temporarily arrested the bleeding, the child perished
of hemorrhage a little more than twelve hours after the first oozing appeared.
2 In Mauriceau's Diseases of Women with Child, etc., translated by Hugh Chamberlen, and pub-
lished in 1727, the great French obstetrician tells of a child being born face first, that " came with
the face so black and misshapen as soon as it was born, as usually in such cases, that it looked like
a blackamoor. As soon as the mother saw it she told me that she always feared her child would be
so monstrous, because when she was young with child she fixed her looks very much upon a black-
amoor belonging to the Duke of Guise, who always kept several of them. Wherefore she wished
that, or at least cared not though it died, rather than to behold a child so disfigured as it then ap-
peared. But she soon changed her mind when I satisfied her that this blackness was only because
it came faceling, and that assuredly in three or four days it would wear away."
THE MECHANICAL PHENOMENA OF LABOR. 277
under the general name of pelvic presentations. Multiparity, prema-
ture labor, polyhydramuios, plural pregnancy, the foetus being dead, or
of small size, or hydrocephalic, pelvic narrowing, uterine tumors, and
placenta praevia are the chief causes of pelvic presentations. In regard
to the last, it is probable that it is not the fact of the placenta being
prsevia which causes pelvic presentation, but they both result from a
common cause, the condition of the uterus.
FIG. 122.
PELVIC PRESENTATION. RIGHT SACKO-ANTERIOR POSITION.
DIAGNOSIS. Before labor the pelvic cavity will be found empty, aud
the lower portion of the foetal ovoid is partly in one or the other iliac
fossa usually, and partly over the inlet ; there will be found adjacent to
this portion, except when the legs are extended over the chest, small
movable parts ; the head is in the proper portion of the uterus, and in
the majority of cases at the right side, though in the illustration it is
represented in the left, aud cephalic ballottemeut may be made. Upon
auscultation the maximum of intensity of the heart-sounds will be
found above the horizontal line at Fig. 105.
Early in the labor before the presenting part has descended into the
pelvic cavity, and the foetal sac is entire, it will be difficult or impossi-
ble to make a diagnosis by vaginal examination. The bag of waters
is large, and is sometimes described as " pudding-shaped ;" such size
and shape, and difficulty in reaching the presenting part, render it
probable the presentation is pelvic. After the rupture of the sac and
the descent of the pelvis, there usually is no difficulty in making a
diagnosis. The finger touches a round object, but it is softer, less uni-
form in shape than the head, aud has neither sutures nor fontauelles,
nor the feeling of the scalp, wrinkled aud covered with hair. The
separation between the buttocks, the coccyx, the sacral crest, the anus,
278
PHYSIOLOGY OF LABOR.
and the sexual organs may be recognized ; if the child be alive, the anus
contracting resists the effort to introduce the finger, and the latter upon
withdrawal will be covered with meconiura. If the feet are pressed
against the thighs, so that one of them may be touched by the finger,
the diagnosis becomes easier. If the coccyx be felt, the position is at
once known, for its point is always directed toward the anterior
plane of the foetus. If a foot only is accessible to touch, it is dis-
tinguished from the hand by being at a right angle to the leg, by its
being thicker upon one side than upon the other, by the toes being
placed in the same line, by the impossibility of separating the great toe
FIG. 123.
DIAGNOSIS OF PELVIC PRESENTATION BY PALPATION.
from the second, and bringing the former in opposition to the other
toes, as the thumb can be separated from the index finger, and brought
in opposition to the fingers; the projection of the os calcis is also an
important mark by which the foot can be distinguished from the hand.
Presentation of a knee is very rare. The knee is broader than the
elbow, and the patella flat, while the olecranon is pointed ; the thigh
and the leg, between which the knee is felt, are thicker than the arm
and the forearm. If there still be uncertainty in the diagnosis, the
member may be extended, and then the foot will be recognized. When
the leg is extended the toes point to the anterior plane of the foetus ;
but if the leg be flexed upon the extended thigh, the toes point to the
posterior plane.
THE MECHANICAL PHENOMENA OF LABOR.
FIG. 124.
279
PELVIC PRESENTATION.
A, Place where sounds of foetal heart are heard most distinctly in left sacro-anterior position.
MECHANISM OF LABOR. The positions are named according as the
sacrum of the foetus is anterior or posterior, in the left or right side of
the mother's pelvis ; thus we have four positions for pelvic presenta-
tion : 1, left sacro-anterior, the sacrum being at the left ilio-pectineal
eminence, the most frequent position ; 2, right sacro-posterior, the sa-
crum being at the right sacro-iliac joint ; 3, right sacro-auterior ; and 4,
right sacro-posterior. Here, too, there are six stages, times, or processes
in the mechanism of labor, as have been given in presentation of the
vertex and in presentation of the face.
1. Compression of the presenting part. Just as a scattered crowd is
brought into a compact mass in order to go from a ferry-boat to the
landing-wharf, so the presenting part is compacted together, reduced to
the smallest dimensions, in order that it cau be transmitted through the
birth-canal. It is a process of lessening, of adaptation of the pas-
senger to the passage. In presentation of the vertex this process was
by completion of flexion, and in presentation of the face by completion
of extension ; in all the changes there is a lessening of the presenting
part, and the means by which the changes are effected are the same
driving and resisting forces, and in all the purpose of the change is
the same, the foetal region is reduced to a form and size corresponding
with the canal through which it must pass.
2. Descent. This needs no explanation.
3. Rotation of the anterior hip into the pubic arch, so that the bis-
trochanteric diameter is placed in relation with the antero-posterior
280
PHYSIOLOGY OF LABOR.
diameter of the outlet ; this rotation includes the trunk of the
child.
4. Delivery of the body. The anterior hip is at the pubic arch, and
the posterior at the other end of the coccy pubic diameter.
The pubic thigh remains fixed, forced against the subpubic ligament,
and makes the pivotal point upon which, by partial curvature, the hips
pass out ; the posterior thigh sweeps along the periueal gutter, and the
lower portion of the body is delivered, greatly latero-flexed. The
anterior shoulder now descends into the pubic arch, is fixed there, while
the posterior shoulder sweeps over the perineum and is delivered first,
meantime the arms and forearms remaining closely applied to the chest.
FIG. 125.
EXPULSION OF THE BREECH.
5. Internal rotation of the head and external rotation of the trunk.
This movement is designed to bring the occiput behind the pubic joint
and the face into the sacral cavity. It is essentially the same as that
which is observed in a vertex presentation, only it occurs last instead of
first. Its purpose is to place the head in the most favorable position for
expulsion, a suboccipital being brought in relation with the longest
diameter of the outlet.
6. Delivery of the head. The head is forced down, the chin closely
applied to the chest, the nucha pivots against the pubic arch, while the
chin is born first, then the face, forehead, bregma, and, finally, the
occiput emerge, the diameters presented being, as in head-first deliveries,
suboccipital.
ANOMALIES IN THE MECHANISM. The only one of importance is
that which may occur in the fifth time, arising from the failure of the
occiput to rotate behind the pubic joint, but it rotates into the sacral
cavity ; the back of the child, instead of being anterior, is now posterior.
The mechanism is different according as flexion of the head remains or
THE MECHANICAL PHENOMENA OF LABOR. 281
as extension occurs, the chin resting upon the chest in the one case, but
departing from it in the other. In the former the nucha presses upon
the anterior margin of the perineum, and the head is delivered by exten-
sion occurring, the chin, face, forehead, bregma, and occiput passing out
in succession, the back of the child being turned toward the mother's
back. But when the chin departs from the chest it is delayed above
the pubic joint, extension is completed so that the occipital end of the
occipito-mental diameter passes out first, then the rest of the head,
delivery occurring by flexion, the throat pivoting upon the pubic joint;
the abdomen of the child in the delivery comes toward the abdomen of
the mother.
FIG. 126.
EXPULSION OF THE SHOULDERS.
PLASTIC CHANGES. The caput succedaneum is usually found upon
the anterior thigh, but the swelling may also involve the external geni-
tals, which are often greatly discolored. The head is remarkable for its
round appearance ; this arises from the fact that it is pressed at all points
except at the top.
MECHANISM IN THE DIFFERENT POSITIONS. First. Left Sacro-
anterior: 1. Compression. 2. Descent. 3. Rotation. It is unnecessary
to give all the details. In this position the back is toward the mother's
left side anteriorly, the sacrum at the left ilio-pectineal eminence, the
bistrochanteric diameter is in relation with the left oblique, and the
sacro-pubic with the right oblique of the inlet. The anterior hip, here
the left, rotates from the right into the pubic arch.
4. Delivery of the body. The left hip is flexed at the pubic arch,
pressing against the subpubic ligament ; the right hip, passing over the
sacro-coccygeal concavity and the perineal floor, emerges at the anterior
perineal margin, the body of the foetus being curved upon its lateral
282 PHYSIOLOGY OF LABOR.
plane. The shoulders descend the bisacromial diameter has the same
relation with the coccypubic diameter that the bistrochanteric had and
the trunk is entirely born.
5. Internal rotation of the head and external rotation of the body.
The occiput turns from left to right behind the pubic joint, the chin
firmly pressed upon the chest.
6. Delivery of the head. This occurs by extension, the chin passing out
first, then the rest of the face, the forehead, the bregma, and the occiput
the back of the foetus is directed toward the abdomen of the mother.
Second. Right Sacro-posterior Position. In this position the sacrum
is directed to the right sacro-iliac joint. The right hip is anterior. The
only difference in the mechanism from that observed in left sacro-anterior
position is that the right hip turns from the right side in front. The
mechanism in each of the other positions can be readily understood
from the descriptions that have been given.
PRESENTATION OF THE SHOULDER. Either the right or the left
shoulder may present, and for each there are two positions, depending
upon the relation of the back of the fetus to the abdomen of the
mother, and hence known as dorso-anterior and dorso- posterior. Pres-
entations of the right shoulder are somewhat more frequent than those
of the left ; dorso anterior positions are at least twice as frequent as
dorso-posterior. Pinard, indeed, states that he never met, during preg-
nancy, with shoulder presentations unless occupying a dorso-anterior
position. Shoulder presentations occur once in about 125 labors, Pinard ;
6 to 7 in 1000, Kleinwiichter; 1 in 297 Galabin gives as the proportion
found from the statistics of Guy's Hospital Lying-in Charity.
CAUSES OF PRESENTATION OF SHOULDER. Smallness of the foetus,
its being dead, premature labor, polyhydramnios, peculiar shape of the
womb, plural pregnancy, relaxation of uterine and of abdominal walls,
FIG. 127.
TRANSVERSE PRESENTATION. DORSO-ANTERIOR. PRESENTATION OF RIGHT SHOULDER.
pelvic narrowing, and placenta praevia are given as causes. As to the
last, the remark made in regard to pelvic presentations being similarly
caused, is here also applicable.
DIAGNOSIS. 1. Before labor begins, according to Depaul, the
THE MECNANICAL PHENOMENA OF LABOR.
283
maximum of intensity of the foetal heart-sounds is at the level of the
line dividing the uterus in two equal parts, aud the line of decrease
of this maximum is horizontal, not vertical. This is shown in the
illustration, Fig. 129.
FIG. 128.
TRANSVERSE POSITION. DORSO-POSTERIOR. PRESENTATION OF RIGHT SHOULDER.
By abdominal palpation the form of the uterus is found very different
from the usual shape, being increased transversely ; but it is a mistake
to suppose, as is represented in some drawings, that the foetus will be
found lying with its head in one, its hips in the other iliac fossa ; for
FIG. 129.
A, POINT OF MAXIMUM OF INTENSITY OF SOUNDS OF FCETAL HEART IN PRESENTATION
OF THE SHOULDER.
apart from any other reason the distance between the fossa3 is much less
than the length of the foetal ovoid at or near term. The head is usually
lower than the hips, for the shoulder, in most cases, is in relation with
the pelvic area. Then by palpation the head is felt in one iliac fossa
284
PHYSIOLOGY OF LABOR.
while the breech is found in the opposite flank, and a resisting plane
connects the two ; cephalic ballottement is possible (Fig. 130). Vaginal
examination is without value prior to labor.
During labor auscultation remains the same. The head is pressed
nearer the inlet, and can be felt more distinctly, but ballottemeut is now
impossible. The pelvic extremity is brought nearer the fundus of the
uterus, toward the median line, and the resisting plane which unites the
two ends of the fetal ovoid is also brought nearer the vertical line. 1
FIG. 130.
SHOWING DIAGNOSIS OF SHOULDER PRESENTATION BY PALPATION.
Depaul has dwelt upon the " peculiar physiognomy " of labor in case
of shoulder presentation. The uterus does not contract with the same
regularity that it does in vertex presentation ; very frequently quite a
long time passes in which the contractions come, are suspended, and
then resume, without producing a marked effect; the os scarcely dilates,
and sometimes twelve, twenty-four, forty-eight hours, or even more
pass, without the part engaging in the inlet. The bag of waters is
unusually large, and sometimes reaches down between the labia. If the
presenting part cannot be reached by the two fingers, and auscultation
and abdominal palpation have rendered it probable that the shoulder
presents, it is better to introduce the hand into the vagina so that the
diagnosis may be made certain. The shoulder is round, and presents a
bony prominence, the acromion.; but the most characteristic feature is the
axilla, with the ribs parallel to each other, like the bars of a gridiron,
1 Charpentler.
THE MECHANICAL PHENOMENA OF LABOR. 285
called by Pajot the intercostal gridiron. The cavity of the axilla
formed by the arm and the wall of the chest represent an angle opening
toward the hips, and its apex pointing toward the head ; and hence
when this is recognized the side occupied by the head is at once known.
Next, the position of the breech is to be determined, whether anterior
or posterior ; this is done by feeling the scapula or the clavicle, the for-
mer corresponding to the posterior, the latter to the anterior plane of
the fetus; in some cases the spinous processes of the vertebrae may be
readily felt.
If the elbow presents, it is recognized by being smaller than the knee,
and the olecranon pointed while the patella is flat ; if there be doubt, the
forearm should be extended, and the hand will be readily recognized.
The elbow, before the forearm is extended, points from the head. Should
the hand descend, the means of distinguishing it from the foot men-
tioned in the diagnosis of pelvic presentation are to be used ; there is
usually no difficulty in making this diagnosis. But it does not neces-
sarily follow that there is a shoulder presentation because the hand
descends, for this may happen in presentation of the head, or of the
breech, and therefore it is necessary by auscultation, by palpation, and
by vaginal touch, to know that the prolapsed hand is not a complication
of either of these presentations. Supposing the hand to descend in a
shoulder presentation, it is important to know whether it is the right or
left hand. Two very simple ways are presented; by following either,
the question is answered. Put yourself in its place and shake hands,
That is, let the obstetrician imagine one of his own hands occupying
the same position, and he at once knows which hand. Or let him
apply one of his own hands to the projecting hand, the right, for exam-
ple ; if palm corresponds with palm, and the thumbs are directly applied
to each other, it is the right hand.
The hand 1 gives the shoulder ; the back of the hand the situation of
the head ; the direction of the thumb indicates the direction of the
breech ; when the breech is posterior, the thumb is directed above from
the side of the pubic joint ; if the breech is anterior, the thumb is
directed below, toward the anus.
Three modes of spontaneous^ delivery may occur in shoulder presen-
tations :
1. As observed by Roederer, Kleinwachter, and others, the foetus
may be delivered doubled ; but this is only possible when it is small,
very flexible, and compressible.
2. Spontaneous version, by which the head or breech is substituted
for the shoulder, may occur ; if the head take the place of the shoulder,
the change is known as cephalic version, but if the breech, pelvic ver-
sion. Spontaneous version has been attributed to the active movements
of the ftetus and to irregular uterine contractions. It would seem
more natural to explain the change as resulting from the uterus taking,
though tardily, its normal ovoidal form, and compelling the foetal ovoid
to occupy its corresponding position.
3. Spontaneous evolution is the term given to the delivery when, the
1 Charpentier.
286 PHYSIOLOGY OF LABOR.
shoulder still presenting, a series of changes, or mechanical phenomena
essentially the same as those that have been described in connection with
delivery in other presentations, take place. These are :
1. Compression, by which the presenting part is lessened and thus
adapted to the canal through which it must pass.
2. Descent. This stage requires no description.
3. Rotation of the shoulder into the pubic arch. These three stages
occupy considerable time, during which the foetus in most cases dies.
The shoulder is the smallest part of the foatal wedge, and hence advances
first, driven in the direction of least resistance. With the rotation of
the shoulder the head moves anteriorly and is fixed above the pubic joint.
4. Delivery of the body. The anterior shoulder remaining fixed at
the subpubic ligament, the posterior shoulder is forced down the sacro-
perineal curve, the body being strongly latero-flexed. By referring to
Figs. 131 and 132, it is seen that the right shoulder is anterior and
remains fixed, while the left or posterior shoulder is driven further
down ; the latter finally passes out at the anterior margin of the perin-
eum, and is followed by the chest, abdomen, and hips, and then the
anterior shoulder is delivered, the head only remaining in the pelvis.
FIG. 131.
SPONTANEOUS EXPULSION. FIRST STAGE.
5. Internal rotation of the head and external rotation oj the body.
This is the same as that which occurs in pelvic deliveries.
6. Delivery of the head. This, too, is the same as in pelvic deliveries.
CAPUT SUCCEDANEUM. This is situated upon the shoulder which
has presented ; when the arm prolapses, it also is swelled and dis-
colored, and frequently is the seat of phlyctenulse.
Of course, shoulder presentations are not trusted to spontaneous
delivery, but demand the intervention of art. Nevertheless, it was
THE MECHANICAL PHENOMENA OF LABOR. 287
FIG. 132.
SPONTANEOUS EXPULSION. SECOND STAGE.
important to present nature's method of dealing with these abnor-
malities. The student will recognize the truth of the statement
made at the beginning of this exposition of the mechanical phenomena
of labor, that there is a unity in this mechanism, one general plan, one
common end. That this may be made, if possible, still clearer, the
FIG. 133.
SPONTANEOUS EXPULSION. THIRD STAGE.
288 PHYSIOLOGY OF LABOR.
following table, including the different presentations, with the associated
mechanical phenomena of labor, is given :
Vertex Presentation. Face Pretentation. Pelvic Pretentation. Shoulder Presentation.
I. Flexion of the
head.
2. Descent.
3. Rotation of head.
4. Delivery of head.
5. Internal rotation
of body.
6. Expulsion of
body.
Extension of the
head.
Descent.
Rotation of head.
Delivery of head.
Internal rotation
of body.
Expulsion of
body.
Compression of pel-
vis.
Descent.
Rotation of pelvis.
Delivery of body.
Internal rotation of
head.
Expulsion of head.
Compression of
shoulder.
Descent.
Rotation of shoulder.
Delivery of body.
Internal rotation of
head.
Expulsion of head.
PROGNOSIS OP VERTEX, FACE, AND BREECH PRESENTATIONS.
Auvard gives as the mortality for infants, when the vertex presents, 1
per cent., in facial presentation 5 per cent., and in pelvic 10 per cent.
But this is too favorable. If the vertex present and the position is
occipito-anterior, the mortality, according to Winckel, is 2.5 per cent.
But in an occipito-posterior position, with rotation posteriorly, more
than 15 out of 100 perish. In presentation of the face 13 per cent,
are born dead, and 7.5 per cent, asphyxiated. Pelvic presentations
give a mortality of about 20 per cent.
In regard to the infant mortality in pelvic presentation, Runge states
that it varies, according to different authorities, between 9 and 37 per
cent.; Kaltenbach says it is 10, 20, even 30 per cent. Porak, on the
other hand, gives 1 infant dead in 9 primiparse and 1 in 30 multipart.
A proper conduct of the labor will certainly give a less mortality than
that which has been quoted from eminent German authorities.
CHAPTEE XII.
THE CONDUCT OF LABOR.
HAVING considered the phenomena of labor, its conduct or manage-
ment is now to be presented. Giving birth to a child, though a physi-
ological function, differs very materially from any other function of the
organism. These differences are duration, suffering, and traumatism.
Intelligent art may in many instances shorten the first, and lessen the
second and third. Even admitting that the savage woman 1 safely
brings forth alone, or with only an ignorant attendant, the civilized
woman is in many instances very far from being in a physiological
condition, and thus childbirth brings to her peculiar pains and perils;
her higher development renders her more susceptible to bodily suffer-
ing, and in many instances has been attained by the partial sacrifice of
physical endurance and vital force. Moreover, in cases of labor for a
time advancing favorably, sudden accidents imperilling the life of
mother or of child may arise, and professional knowledge and skill be
needed to meet them ; while the common role of the obstetrician is " to
observe, to control, to alleviate, and to protect," emergencies may come
which demand his promptest action and greatest ability, though it is
only in a small minority of births, not more than five per cent., any
other interference is required. It is, therefore, important, in her own
interest and in that of her offspring, that woman should have in labor
a qualified professional attendant.
Two important questions, the one relating to antisepsis, the other to
anaesthesia, may be considered at the beginning of this exposition of
the obstetrician's duties.
ANTISEPSIS. With our present knowledge of the gravest diseases
which affect the lying-in woman., it is very probable they are caused by
microscopic germs ; hence it is important that woman in labor should
as far as possible be protected from the presence of such germs, and
their entrance through the necessary or accidental traumatisms of labor
be prevented. 2 As part of the means for the attainment of this end, it
1 The following statement is made by Dr. Engelmann in his very interesting volume, Labor
Among Primitive Peoples, p. 7 : "Among primitive people, still natural in their habits and
living under conditions which favor the healthy development of their physical organization,
labor may be characterized as short and easy, accompanied by few accidents and followed by
little or no prostration."
If birth were as easy as that of Wenonah in Longfellow's song of Hiawatha, obstetricians
would never be needed :
" There among the ferns and mosses,
There among the prairie lilies,
On the Muskoday, the meadow,
In the moonlight and the starlight,
Fair Nokomis bore a daughter."
2 The testimony given by lying-in hospitals in regard to the value of antiseptics in greatly
lessening not only mortality but morbidity is so large and clear that no intelligent and con-
scientious practitioner can deny that system or wisely ignore the use of such agents. The
mortality has been reduced to one-half per cent, or less, and the statistics of Schuster, of
Innspruck, show that of the women delivered there, 93.1 per cent, did not have any febrile
temperature. Centr. f. Gynakol., 1888.
19
290 PHYSIOLOGY OF LABOR.
is important that the lying-in room be well ventilated and free from
disease germs or from the poisonous influence of sewer-gas. I have
seen in consultation a case of puerperal septicaemia in a multipara who
occupied a room in which three months before two of her children were
ill with diphtheria ; in another patient the lying-in room had a wash-
stand communicating with a badly drained sev/er ; in a third the dis-
ease apparently had its origin in connection with scarlet fever, the
husband, a physician, attending some malignant cases of the disease
immediately before and after his wife's confinement, and spending most
of his time in her room.
Thorough disinfection of the room which the patient is to occupy
should be made, if it has been previously occupied by one suffering with
scarlet fever, with erysipelas, or diphtheria, or with any disease attended
with suppuration, as uterine cancer in its advanced stages ; it would
be better, indeed, for her lying-in to be in another house or other
room. The room, too, should be free from the effluvia of decaying
animal matter. If there be any sewer communication in it, as, for
example, from a permanent washstaud, that communication should be,
for the time at least, cut off. The obstetrician must know that the
nurse has not recently been in attendance upon any of the forms of
disease that have been mentioned, and especially upon a case of
puerperal septicaemia.
ANTISEPSIS or THE PATIENT. It is advisable for a woman at the
beginning of labor to have a whole bath, or a hip-bath ; after this the
external sexual organs are washed with warm water and soap, and then
with a disinfectant solution, e. g., 3 per cent, of carbolic acid or 1J per
cent, of lysol, or a mixture of creolin and water may be employed.
Vaginal injection, or irrigation, is not indicated unless there be a puru-
lent discharge, or the labor is protracted ; the antiseptic used in the
former case may be one part of corrosive sublimate to two thousand of
water.
ANTISEPSIS OF THE OBSTETRICIAN. In addition to what has been
said on this subject, page 190, the peril of the patient being greater in
consequence of the traumatisms of labor, and the danger of infection by
the physician being increased, because it may be several examinations
are made instead of one, so his precautions must be more complete. It
his fingers have touched infectious matter, not only the thorough washing
with soap and water that has been previously mentioned here especially
the use of sand and green soap is one of the best means of mechanical
disinfection but before immersing them in the corrosive sublimate
solution they are to be washed with 80 per cent, of alcohol.
Ribemont-Dessaignes and Lepage say that there is not a single
obstetric antiseptic which is good on every occasion. Corrosive subli-
mate, which is a perfect microbicide in practice, is an agent that must
be prudently employed, because of its toxicity, and because of the acci-
dents which it produces when absorbed in considerable quantity. The
biniodide has been proposed as a substitute, but Tarnier states that it
has less antiseptic power and presents as great danger of poisoning.
Naphtaline, or the naphtolate of soda, is an excellent antiseptic, 4 to
1000 of water ; it has proved useful both as a vaginal and uterine
THE CONDUCT OF LABOR. 291
injection. But it must be freshly prepared, in order that it may have
sufficient solubility, and therefore it can hardly come in general use.
The sulphate of copper has proved useful, but it has also been found
dangerous. Boric acid has not great antiseptic value, but it is to be
observed that Kaltenbach, after suggesting a 5 per cent, mixture of
carbolic acid and oil, or vaseline free from germs, for anointing the
finger which is used in touching, commends lanolin, more especially
Graf's boro-glycerin-lauolin kept in tin tubes.
Potassic permanganate 1 in solution has been used as an antiseptic,
but the stains which it leaves have made it objectionable.
The use of antiseptics after labor will be considered in connection
with the management of the puerperal state.
ANESTHESIA. HISTORICAL. Early in 1847 the illustrious Sir Jarnes Y.
Simpson proved that inhalation of sulphuric ether could be safely and success-
fully used for the relief of pain in childbirth, and later in the year he established
the same fact as to the inhalation of chloroform. Obstetric anaesthesia soon
found a few in Great Britain and on the Continent to advocate and practise it.
In the United States, Dr. N. C. Keep, of Boston, was the first American physi-
cian to administer an anaesthetic in labor. But Dr. Walter Channing was the
most distinguished of American physicians advocating the practice ; his treatise
on Etherization in Childbirth was published in 1848. The late Professor Henry
Miller, of the University of Louisville, gave chloroform to a woman in labor on
the 13th of March, 1848 ; this was the first time that chloroform was thus used
west of the Allegheny Mountains. Dr. Miller remained faithful to anaesthesia
in labor the rest of his honored life ; he strongly advocated the practice, and with
his well-known ability answered the arguments adduced against it. Channing
and Miller are the two names that in this country shine with the most lustre in
connection with the early advocacy of obstetric anaesthesia.
On the other hand, three of the most eminent obstetric teachers, Meigs, Hodge,
and Bedford, strongly opposed the use of anaesthetics in normal labor, and their
influence was more powerful than that of its advocates. The controversy here
was but the reflex of that which was occurring in Great Britain. Simpson
asserted that it was only a question of time as to the general adoption of anaes-
thesia in parturition. On the other hand, Dr. Ashwell, who, with Tyler Smith
and Eamsbotham, were the most prominent London obstetricians opposing the
practice, declared that "unnecessary interference with the providentially
arranged process of healthy labor is sure, sooner or later, to be followed by
injurious or fatal results," " that chloroform need only be extensively used to
insure its entire abandonment," and that it was " a duty to urge every plea against
its further use." More than thirty-five years have passed since these words of
Simpson and of Ashwell were uttered ; the prophets are dead, but the prophecy
of neither has been fulfilled ; chloroform has not been generally adopted, nor
has it been entirely abandoned in obstetric practice.
Doubtless the influence of Drs. Meigs, Hodge, 2 and Bedford did much in this
country to prevent the use of anaesthetics in labor. It is certain that the great
majority 3 of women in the United States endure the martyrdom of maternity
without anaesthesia. On the other hand, it often happens that a brief surgical
operation, in many instances much less painful than childbirth, is not done until
the subject is anaesthetized.
1 In Dr. Hunter Robb's useful volume, Aseptic Surgical Technique, the author, in describing
the process of sterilizing the hands, advises after they have been immersed in a warm saturated
solution of permanganate that they should be next washed in a warm saturated solution of
oxalic acid, and adds: " Experiments made by Dr. Mary Sherwood, in the Pathological Labora-
tory of the Johns Hopkins University, have shown that in this process the oxalic acid and not
the permanganate of potassium is the essential disinfecting agent."
2 And yet Dr. Hodge, while refusing the parturient the relief to be had from chloroform, indi-
cates the severity of her suffering by saying that she is " agonized and serai-delirious."
3 For example, in the Summary of Obstetric Cases reported by members of the East District
Medical Society, and compiled by Dr. Samuel W. Abbott, Boston Medical and Surgical Journal,
Jaly 6, 1882, in only twelve per cent, were anaesthetics used ; as showing the great preference by
New England physicians for ether, it was used in 323, and chloroform in only 2 cases.
292 PHYSIOLOGY OF LABOR.
ANAESTHETIC MEANS. Chloroform 1 is preferred by most to ether,
because of its pleasanter odor, its prompter action, and the less quan-
tity required. Though various means have been recommended to pro-
duce obstetric anaesthesia, not one is perfect. If there could be found
some agent Avhich, while annulling pain, would have no injurious effect
upon uterine contractions, lessening their force and frequency, invariable
in its action, and leaving no unfavorable conditions, it would be the best
boon to women enduring the martyrdom of maternity. Chloroform and
sulphuric ether come nearer meeting these requirements than any other
of the various means that have been recommended. The bromide of
ethyl, according to Kaltenbach, 2 only exceptionally has a favorable
action, and is transitory, and moreover is liable to leave irritation of
the respiratory mucous membrane. The combination of laughing-gas
and oxygen, 4 : 1, cannot often be readily had, and a sufficient supply
would be cumbersome. Hypnotism is uncertain, only few readily and
completely yield to its influence, and seldom does the obstetrician pos-
sess hypnotic power ; moreover, neuroses may follow its employment.
Chloral is warmly recommended by some obstetricians, fifteen to twenty
grains every thirty minutes until pain is lessened, and it may be given
by mouth or rectum ; but it is slowly absorbed, and it cannot be as well
regulated according to the needs of the case as anaesthetic inhalation.
The local application of cocaine is very limited in its adaptability, the
exposure of the genital canal in pencilling the cervix, for example, is
not a matter of indifference so far as the future safety of the patient is
concerned. The effect is transient, and, finally, an injurious amount of
the drug may be absorbed.
Kaltenbach objects to chloroform on the ground that it lessens the
number, duration, and force of the uterine contractions. Ahlfeld 3
states that hemorrhage in the placental period is more liable to occur if
chloroform has been used, partly from the feebleness of uterine con-
tractions, and partly from the lessened coagulability of the blood. He
also believes it dangerous to the child. Since the first of 1893 Ahlfeld
has used ether, and is quite satisfied with it.
Kaltenbach believes that ether has a less unfavorable effect than
chloroform, and that acting as a cardiac stimulant it is of service in the
anaemic. Ribemout-Dessaigues and Lepage, 4 considering only chloro-
form in labor, observe " that in the great majority of cases women
ought to be delivered without chloroform ; but that in some whose
nervous system is too excitable, or if the uterus contracts with too much
violence, resort to chloroform analgesia may be made, especially if the
patient insists upon it." Martin 5 says that the severe suffering can be
blunted by superficial narcosis without interfering with the abdominal
pressure, and that a few drops of chloroform may be given by inhala-
tion at the beginning of each pain in the second stage of labor; but if
this stage is long, the energy of the abdominal pressure is occasionally
thereby injuriously affected.
It is quite evident from the statements of authors referred to that the
1 The late Dr. Fordyce Barker informed me that he always used chloroform, and that he used it
in all cases of labor.
2 Op. cit. ' Op. cit. Op. cit.
5 Lehrbuch der Geburtshilfe, 1891.
THE CONDUCT OF LABOR. 293
employment of anaesthesia in labor is far from general, and is even
hesitatingly employed.
The writer knows but little from personal experience of the employ-
ment of chloroform, but he has frequently used ether, and his belief is
that the latter may be safely 1 and beneficially employed in the second
stage of labor in the majority of women. But the practitioner should
remember that the anaesthesia must be neither continuous nor profound ;
intermittences in the administration are important, and at no time must
the intelligence and will of the patient be suspended.
Dr. J. C. Reeve, in his contribution to the American System of Obstetrics,
"On the Use of Anaesthetics in Labor," denies that ether is a safer anaesthetic
than chloroform, and after a careful study of accidents from chloroform in labor
makes the following statements :
1. But one well-authenticated case of death is on record where the adminis-
tration was by a medical man, and in that case no autopsy was held.
2. Dangerous symptoms have occurred but a very few times, and then almost
always from violation of the rules of proper administration.
3. The danger when chloroform is used only to the extent of mitigation or
abolition of the suffering of childbirth is practically nil ; when carried to the
surgical degree for obstetric operations, the danger is far below what it is in
surgery.
4. No proof can be furnished that the parturient woman enjoys a special im-
munity from the danger of anaesthetics, although facts seem to indicate that such
exists. Her best safeguard lies in the care and watchfulness of the administrator.
If chloroform be employed, it may be inhaled from a handkerchief
or small napkin, upon which half a teaspoonful is poured at a time ;
the napkin or handkerchief is held close to, but not touching, the
patient's nose. For the administration of ether an extemporaneous in-
haler may be made by first making a cone of a stiff towel, then this
cone is surrounded at the sides and covered upon the top by thick, firm
paper ; a sponge as large as the fist is pressed into the cavity of the
cone and saturated with ether, being careful that the quantity is not so
great as to drip upon the patient's face when the instrument is used.
The hollow base of the cone is now placed so as closely to encircle the
patient's mouth and nose. The anaesthetic is not to be used except just
before and during a " pain," .the purpose being not to cause uncon-
sciousness, but to lessen or remove suffering while intelligence and will
remain in full exercise.
Anaesthetic inhalation is used in the second, rarely in the first stage
of labor. It may, however, exceptionally be of value in the latter ; for
example, in the case of a primipara if the " pains " are unusually
severe and the os dilates very slowly, the new experience wearies,
weakens, and disheartens her, and great nervous irritability ensues ;
but now blunt the sharp edge of her suffering by an anaesthetic, and a
happy change may occur in her mental and physical condition. In
general, the indication for anaesthesia is great suffering, no matter
whether this occur in the first or in the second stage of labor. Dr. J.
C. Reeve, of Dayton, Ohio, whose name is so well known in counec-
1 Porak, Societe Obstetricale et Gynecologic, of Paris, 1890, stated that chloroform appears to
offer the least uncertainty as an obstetric anaesthetic, but he also said that the more rapid elimin-
ation of ether probably renders it less dangerous.
294 PHYSIOLOGY OF LABOR.
tion with the subject of anaesthesia, states 1 that " the periods of labor
to which it is best adapted are two : when distention is greatest of the
os, and of the vulva. The kind of labor where it does best is that in
which energy of contractions is great and expulsive force is in excess
of dilatation."
In all cases the practitioner will be guided by the effect of the anaes-
thetic, withholding, lessening, or increasing, as may be indicated ; he
will never carry the anaesthesia so far as to suspend consciousness, unless
during the birth of the head, and after it is born the use of the auses-
thetic should stop.
SPECIAL DIRECTIONS. Prompt attendance is important when called
to a case of labor, for though in most instances the call comes earlier
than necessary, yet occasionally the presence of the obstetrician may
enable him easily to correct an unfavorable presentation, which later
may prove difficult or impossible, or arrest a dangerous hemorrhage, or
avert an attack of eclampsia.
The following articles should be carried by the accoucheur: A stetho-
scope, a flexible catheter, a preparation of ergot, a solution of morphine,
or tablets for preparing such solution for hypodermatic use, and syringe,
sulphuric ether, two or three long needles with silk, silkworm-gut, or
properly prepared catgut, to be used if the perineum is torn, and, if
the patient lives at considerable distance, an obstetric forceps. 2
If the patient has not already been provided with a fountain syringe,
with an antiseptic solution, and an anaesthetic chloroform, or ether, or
a solution of chloral the obstetrician should carry these too ; on the
other hand, if the anaesthetic selected be ether, and she has a supply,
it will be unnecessary to include it in the list first mentioned. Upon
arrival it is better that he should not immediately enter the patient's
room, even if previously knowing her ; especially if a stranger, and
taking the place of her expected attendant, his coming should be first
announced, for an abrupt entrance may have an unfavorable effect upon
her. Admitted to her room, it is rarely necessary for him to make an
immediate examination, or even at once to inquire as to her present
condition ; for a time at least, it is better for him to get his information
indirectly, by observing the character of her pains, their frequency,
regularity, and the apparent suffering they cause. Let him so guard
his words and acts that no offence be given to woman's modesty, which
is at once her ornament and defence. Physical suffering hushes the cry
of shame, and until this occurs many a woman will shrink from a vag-
inal examination, especially if abruptly proposed. The obstetrician
should be a gentleman, gentle in his ways and words, and yet firm in
conduct ; he among all men must have the suamter in modo as well as
thefortiter in re.
Two questions are to be decided by the professional attendant when
in the presence of a patient supposed to be in labor. First, is she preg-
nant? Second, has labor begun? A woman is very rarely deceived as
to the fact of her own pregnancy, but occasionally she may have a false
1 Private communication.
2 The conservatism of Blundell did not permit taking instruments. " Lead not yourselves into
temptation ; if you put your instruments into your pocket, they are very apt to slip out of your
pocke's into the uterus."
THE CONDUCT OF LABOR. 295
instead of a true pregnancy, and the physician must have the possibility
of such occurrence in his mind. Provided the professional attendant
does not already know, inquiry is made as to the date of the last men-
struation, and as to that of "quickening;" so the question may be asked
as to the premonitory symptoms of labor; if she has been previously con-
fined, the character of the labor or labors should be ascertained. Next,
inquiry may be directed as to her present condition, how long she has
been sick, whether the "pains" are regular in recurrence, whether in-
creasing in frequency and severity, and where they are felt; whether
she has other suffering than that of labor, headache, for example, and
whether there have been recent and free discharges from the bladder and
rectum. The necessity for an examination, if she does not already know
FIG. 134.
EXAMINATION IN LABOR WITH INDEX FINGER OF RIGHT HAND. THE Os UTERI JUST OPENING.
i
it, is explained to her, and as a rule her consent is readily given. The
physician retires from the room while the nurse makes the necessary
preparations by arranging the person and the clothing of the patient.
Very commonly, upon his return, the woman will be found lying upon
the side with the hips near the edge of the bed, this position being taken
as less offensive to modesty. Though a vaginal examination can, in
most cases, be made more satisfactorily if the woman be in the dorsal
position, and this position is essential for abdominal palpation, an imme-
diate change need not be required, but after examining while she is
lying upon the side, she may be requested to turn upon the back, and
the exploration continued and completed. After the examination, exter-
nal as well as interual, the methods and purposes of which have been
fully explained, and the physician finding a normal presentation with
favorable position, vigorous and regular action of the uterus, and good
296
PHYSIOLOGY OF LABOR.
condition of the birth-canal, he should frankly tell the woman and her
friends that "everything is right," according to the stereotyped expres-
sion, or make some equivalent statement.
FIG. 135.
EXAMINATION* IN LABOR WITH Two FINGERS OF THE LEFT HAND, THE Os UTERI MORE DILATED.
Possibly the patient, after being informed of the favorable condition
of affairs, asks how soon the labor will be over. The question is sure
to come sooner or later, and to be anxiously and wearily repeated if the
labor be long. Let the obstetrician beware of a positive answer, espe-
cially if it be the first stage of labor, and if a primipara, for the
remorseless clock may contradict his prediction at the sacrifice of all her
hopes and of her confidence in him. Velpeau remarked :
The accoucheur who, in order to make a show of vain wisdom, thinks himself
capable of telling exactly when the labor will terminate, not only exposes his
ignorance or his bad faith, but he compromises the honor of his art and the safety
of his patient. Gooch, referring to parturition in a primipara, said, " I am never
fool enough to state any time within which the labor will be over."
It sometimes happens that the first stage is brief and the second pro-
tracted ; or, again, the first unusually long and the second very short ;
and hence any answer as to the duration of the labor, founded upon
the presentation and position, the primiparity or the multiparity of the
patient, the condition of the soft parts, the proportion between the pre-
senting part and the birth-canal, derived from observing the rate of
progress in a definite time, can only be a probability and an approxi-
mation to the truth, and should be so stated. Here, as in the general
THE CONDUCT OF LABOR. 297
relations of physician and patient, the laws of truth must be observed*
not that in all cases the patient is to be informed of any great peril
that threatens her, but, on the other hand, let no falsehood ever be told
her. Lying to patients, though the motive may be a kind one, never
brings any good in the long run ; and he who does it leads himself into
temptation to be untruthful upon other occasions, even if he does not
forfeit his claim to be believed in all matters, and loses his own self-
respect and also that of those who know him.
It is well to explain to her, if this is her first experience, the dif-
ferent stages of labor, the value of voluntary effort in the second, and
its inutility and injury in the first period. Better, too, that she 1 should
know what she has to endure, and the greatness of her suffering be
acknowledged, rather than treat it as being slight ; and never try
to cheat her with false hopes and promises that will not be fulfilled.
We are dealing with a rational being, and intelligent faith, will, and
conscience are a stronger support in the endurance of great suffering
than blind hope and unfulfilled predictions.
PREPARATION OF THE BED AND OF THE PATIENT'S PERSON.
These duties are generally attended to by an intelligent nurse ; but
sometimes the nurse is not intelligent, or the patient may be too poor
to employ one, or the labor ends before her coming, and in such emer-
gencies the practitioner must direct or make the necessary preparation
of the bed. The bedstead should not be close to the wall, but accessible
at each side ; a firm mattress is laid upon it, and over the mattress a
piece of rubber sheeting, oilcloth, or tarred paper to protect it from
the patient's discharges, 2 for these absorbed by it would cause both
discomfort and danger. Above the protective material an old quilt or
comforter, first folded lengthwise, and then transversely, is placed on
that part of the bed where the patient's hips will rest, and above this
a sheet similarly folded. Now let a sheet be spread in the usual man-
ner upon the bed, then folded from below above so that the fold will
come higher than the quilt and sheet which have been put in place ;
this sheet is thus arranged that it may be protected from being soiled
during labor, and after that has ended, and all wet clothes have been
removed, it can be drawn down under the hips and to the foot of the
bed, thus securing, with the least disturbance of her person, a dry,
clean, and warm sheet to lie upon.
Instead of the method just given, it is very common to have the under sheet
extend over the rubber cloth to the foot of the bed, then upon this there will be
placed a draw-sheet, made by folding a sheet four times in its length, and put
1 The great poetess of the century, Mrs. Browning, who knew from her own experience what
the suffering of childbirth was, has thus described it :
"I appeal
To all who bear babes ! In the hour
When the vail of the body we feel
Rent round us, while torments reveal
The motherhood's advent in power."
There might be added the words that Euripides has put in the mouth of Medea :
" Thrice would I stand on the rough edge of battle
Ere once bear the pangs of childbirth."
2 Dr. T. G. Davis, Bridgeton, N. J., informs me that instead of a quilt he uses ne\yspapers,
more likely to be aseptic, and over them a sheet ; the papers are readily had, absorb discharges
well, and afterward are burned.
The expression used by old English writers, among others Lord Bolingbroke and Dean Swift, for
lying-in was "being in the straw." Should the practice suggested prevail, there might be sub-
stituted " being in the newspapers," a condition to which not only many women, but also men,
including some doctors, are not averse !
298 PHYSIOLOGY OF LABOR.
upon that part of the bed where the patient's hips rest, and secured by safety-
pins. Rubber cloth now is placed so as completely to cover and protect the
draw-sheet; next there may be laid upon the rubber a folded blanket, or com-
forter, and finally a sheet also folded. After the labor is over every article down
to the draw-sheet is removed, and that is changed from day to day when it be-
comes soiled.
In some parts of the country it is customary to prepare a large muslin sac
and half-fill it with bran, which is placed under the hips of the parturient, and
readily absorbs all fluids that are discharged ; it is removed after the labor.
When the patient lies down, in the second stage of labor, her chemise
and nightdress should be drawn up above the hips, and a twice-folded
sheet pinned around the latter; this is far preferable to the skirt which
is often worn at such a time, for the latter is not so easily removed, and
its removal almost inevitably causes some soiling of the lower limbs.
A piece of old carpet or of oilcloth is spread on the floor at that side
of the bed upon which the patient lies.
MANAGEMENT OF THE FIRST STAGE OF LABOR. During this
stage, the presentation being normal, and the general condition good,
the patient ought not to be in bed ; sitting, walking, or standing is
more favorable for the entrance of the head into the pelvic cavity than
lying ; moreover, if she is up now, the necessary confinement to the
bed in the second stage of labor will be less irksome. She may be
encouraged to engage in some light occupation or in cheerful conversa-
tion, so that the time will not drag, and her mind will in some degree
be diverted from her suffering. Few persons should be in the room,
and those only who are agreeable companions to her, and who will
abstain from exciting her fears by the manifestation of great anxiety,
by gloomy looks and untimely forebodings, or by narrating the mis-
fortunes of other women in labor or in childbed. Her sympathies and
her antipathies ought to be consulted in regard to those who are with her,
and the obstetrician who knows how wisely to observe and judiciously
to act can often regulate this matter to the great benefit of the patient.
CONDITION OF BLADDER AND RECTUM. If these organs have not
been recently, and cannot be spontaneously, emptied, artificial means
must be used. It very seldom happens that there is urinary retention,
but accumulation of feces is common ; the best means for the relief of
the latter will be an enema of water, or of soap and water.
FOOD, DRINK. Usually there is very little desire for food during
labor, but if it be protracted the patient should take nourishment in
some form lest she become exhausted ; she may have any simple food
she desires, care being taken that the stomach is not overloaded. The
most grateful drink will be cold water, and that may be taken freely.
On the other hand, hot teas, so often in the country urged in domestic
practice upon the parturient by injudicious friends with the purpose of
" making the pains stronger,' 7 as well as alcoholic stimulants, ought to
be forbidden.
ACTIVE INTERFERENCE WITH THE PROCESS OF DILATATION.
There is a notion 1 on the part of some women .that the doctor can and
i Some years ago I saw a woman who had a torn cervix and perineum, and she explained her
condition as resulting from the fact that " the doctor opened " her " up too much " when she gave
birth to her child.
THE CONDUCT OF LABOR. 299
ought to render important assistance in the physiological processes of
childbirth by mechanical or other means. Some doctors, too, advocate
and pursue this practice. Dr. Barnes has justly characterized digital
dilatation of the os uteri as "old and bad."
The danger of septic infection by manual dilatation, and by all unnecessary
examinations, has been strongly presented by Spiegelberg in considering the
prophylaxis of puerperal septicaemia : " Care must be taken that labor go on as
simply as possible ; manipulations in the genital passages are to be made only
when absolutely necessary. . . . Nothing is more objectionable and more
repulsive than the almost incessant exploring and manipulating in the vagina,
the os uteri, and the vulva, which most midwives are in the habit of doing when
the labor does not progress as rapidly as they desire. . . . The danger in
this for the puerpera cannot be too strongly emphasized."
The young practitioner may be assured that digital dilatation of the
as uteri, or of the os vulva?, is rarely necessary ; in most cases does no
good, and in some may do much harm.
Among the other means resorted to for shortening the first stage of
labor may be mentioned the administration of ipecacuanha in an emetic
dose, a practice which was never common and which is now becoming
almost unknown, and the application of belladonna to the cervix, or, as
advised by Horton, 2 the injection of a solution of atropine into its sub-
stance. I can say nothing in favor of any of these means from per-
sonal experience, but in normal labor they are unnecessary.
It may be added that an 8-10 grain solution of cocain applied to the
margin of a resisting or rigid os often proves useful.
PRESENCE OF THE PHYSICIAN. It is not advisable for the physi-
cian to remain constantly in the room during the first stage of labor ;
an occasional absence gives the patient an opportunity to evacuate the
bladder, to make changes in her clothing, or attend to other matters
which might be prevented by his presence. Further, if he constantly
stays in the room she may anticipate a speedier termination of her
labor than is possible, or she may think her condition serious ; beside
this, he may be appealed to by her or by her friends to render some
supposed assistance, which may be very injudicious or even injurious.
In many cases it is not necessary^ for him even to remain in the house,
and he may take the opportunity to visit other patients ; but it should
always be known where he can be found, if any emergency arise de-
manding his immediate presence. A physician may exhaust his strength
by too constant attendance and too assiduous attention during the first
stage of labor, and by denying himself needed sleep, so that when some
serious difficulty arises in the second or third stage he may lack the
clear head, the firm hand, and the physical endurance upon which the
salvation of his patient or of her child rests.
MANAGEMENT OF THE SECOND STAGE OF LABOR. The uterine
contractions are reinforced by voluntary efforts, and the first usually
passes into the second stage of labor by a gradual transition. The pa-
tient now goes to bed, her clothing being arranged as has been mentioned ;
but if a primipara, or if the labor be slow, it is not necessary for her to
1 American Journal of Obstetrics, 1878.
300 PHYSIOLOGY OF LABOR.
remain constantly lying down ; occasional sitting up, or taking a few
turns in the room, will give her some rest, and also may hasten de-
livery.
At the beginning of this stage the bag of waters usually ruptures ;
and it is not advisable to rupture it if the labor is progressing favorably.
Should this be necessary simply pressing the finger against it during a
uterine contraction will generally answer ; if such pressure does not suc-
ceed, a few notches may be cut in the finger-nail 1 making a saw of it, which
may then be thus used against the tense membranes. Immediately after
the escape of the amnial liquor a vaginal examination must be made, in
order to confirm, in some instances possibly to correct, the diagnosis of
presentation and position that has been made, or to make this diagnosis
if it has hitherto been impossible, and to ascertain any change of posi-
tion, or any increase in descent of the presenting part, which in a multi-
para may sometimes become very rapid immediately after the evacua-
tion of the fluid; so, too, this, examination is now necessary, in order to
ascertain whether prolapse of the cord, or of one of the upper or lower
limbs, has occurred.
POSITION OF THE PATIENT. It varies in different countries, but
with us she usually lies upon the back, or upon the left side. Until
the head rests upon the pelvic floor the most favorable position during
a pain is one between sitting and lying, the feet pressed against a firm
object, or the bent knees fixed by the pressure of the hands of one of
the attendants, the upper portion of the trunk drawn forward by the
patient grasping the hands of the nurse or a sheet or towel fastened to
the lower part of the bed for this purpose, and the chin turned to the
chest. A kneeling 1 or squatting position is the most favorable for the
expulsion of the child, but the child may be injured, the perineum can-
not be protected, the liability to hemorrhage is greater, and it is impossi-
ble to manage properly the third stage of labor, as well as difficult to
put the patient in bed. When lying upon the left side the usual right
obliquity of the uterus is corrected, and in this regard the uterine force
acts more advantageously ; the abdominal pressure, however, is less,
and the general force is directed too much in the direction of the axis
of the inlet that is, toward the fundus of the pelvic cylinder whereas
the line of exit for the foetus is nearly at a right angle to that of en-
trance. Many women prefer the side position because of the relief to
pain in the back which firm pressure of the hand upon the sacrum
gives; such pressure, of course, cannot be made when the patient lies
on her back. Schroder has proved that rupture of the perineum is
more frequent in women delivered upon the back than in those delivered
upon the side, and therefore the latter position should be taken in all
cases in which there is danger of such rupture as soon as the head
begins to press upon the pelvic floor. In this position, too, visual ex-
amination of the perineum, should it be necessary, is possible.
1 It has been objected to this method that in these days when the obstetrician must have short
finger-nails, to avoid furnishing a refuge for septic stuff, this cannot be done, and instruments have
been invented for piercing the membranes a matter of ingenuity to make and of money to buy !
A bodkin, which can be found in every house, after disinfection, may be used, if the finger-nail is
too short ; or a probe or director from a pocket-case will answer.
2 Kleimvachter.
THE CONDUCT OF LABOR. 301
WALCHER'S POSITION. A Venice physician, in 1738, advised the patient in
labor to be placed horizontally on a table or bed, so that her lower limbs would
hang over its edge. It has recently been claimed by Walcher that this position
increases the true conjugate 8-18 mm. ; Klein states that the increase is only
5-6 millimetres.
My friend and colleague, Dr. Forbes, assures me that such increase is very
doubtful. Certainly the force thus resulting cannot be compared with that
exerted by the wedge-like action of the foetal head when driven or drawn through
the pelvis. It is possible that Walcher's position will pass into oblivion, as did
that of which it is merely the echo.
[f CONDITION OF THE CHILD. Occasional inquiry may be made of the
patient as to her being conscious of the movements of the child. But
a more certain way of learning its condition, either in the first or second
stage of labor, is by auscultation. The first indication 1 of the suffer-
ing of the child is shown by a greater rapidity of the cardiac pulsa-
tions ; then, if this state continues, to the acceleration which appears at
first there succeeds a slowing, which becomes more and more decided as
the foetal life is more and more compromised. At the same time that
these variations are observed and irregularities are produced, the inten-
sity of the bruits lessens. Whenever, says Depaul, the cardiac pulsa-
tions fall below 100, and especially below 80, the condition is a very
serious one, and if possible the accoucheur ought to intervene and end
the labor.
CONDITION OF THE Os UTERI. As has been stated, the rule is that
in the first stage of labor attempts to dilate the os uteri by the fingers
should not be made ; so, too, they are usually not required in the second
stage. But as it sometimes happens that in the former the force of the
uterine contractions is in part lost in consequence of the os being directed
too far posteriorly and to the side, and it may be then advantageous to
hook the fingers into the os during the absence of a pain, and draw it
toward the centre of the pelvic cavity, keeping it in this position during
a contraction, so in the second stage the anterior margin of the os may
be found closely applied to the foetal head, while the posterior has
receded, hence liberation of the former is indicated. The part of the
foetal head in front descends at each contraction, hooded by the anterior
portion of the dilated cervix, and this portion thus compressed between
the head of the foetus and the pelvic wall is liable to become swelled
and oedematous. Therefore, by the advice of the most conservative
obstetricians, this part may be pressed up, in the intervals of contrac-
tions, by one or two fingers, and thus held during a uterine effort ; some-
times the head immediately passes the obstruction, but in others it may
be necessary once or oftener to repeat the proceeding. Let it be remem-
bered that this manoeuvre, which is seldom necessary, must be done
without violence.
CRAMPS IN THE LOWER LIMBS. Cramps affecting the thighs or
legs sometimes cause great suffering ; they occur in the second rather
than in the first stage of labor, and are attributed to pressure and drag-
ging upon certain nerves of the pelvis, branches of the sacral plexus,
the sciatic, the obturator, etc. Rubbing the affected part with the hand,
change of position, or the use of an anaesthetic will give relief.
1 Depaul, op. cit.
302 PHYSIOLOGY OF LABOR.
FOOD, DRINK, ETC. PREPARATION FOR DELIVERY. Unless the
second stage be unusually long the patient rarely desires or needs nourish-
ment ; a full stomach will hinder the needed voluntary effort during a
uterine contraction ; if food is given, only a small quantity is advisable,
and it should be simple and easily digested. Now, as then, cold water
may be taken as desired. Frequently bathing the patient's hands and
face with cool water will in most cases be both agreeable and refreshing.
When the second stage approaches its end, hot and cold water, an
alcoholic stimulant, scissors, and a string for tying the cord are to be at
hand.
Pressure of the head upon the rectum often causes a factitious desire
to empty the bowels, and the patient insists upon getting up for this
purpose ; but she must be refused, for the child might be born while she
was on the commode or in the water-closet.
CARE OF THE PERINEUM. Usually the most important of the ob-
stetrician's active duties in the second stage of labor is protection of the
perineum from being torn during the delivery of the head and shoulders
of the foatus, or, if a tear is inevitable, cause that to be as slight as pos-
sible.
Matthews Duncan and Schroder have shown that in primiparas some
tearing of the vaginal orifice is inevitable, and the rent may involve the
perineum, only 39 per cent., according to the latter, escaping rupture of
the fourchette. Not only injury of the posterior portion of the vulva,
but also of its anterior may occur, and the rents in some cases cause
serious hemorrhage. The perineum is especially liable to tear from the
direction of the force which propels the child through the birth-canal ;
it is a resisting wall designed to direct the foetus toward the opening in
the anterior portion of the dynamic pelvis. When the perineum gives
way the rent generally occurs in the median line, for there the disten-
tion is greatest and the tissues are furthest from their points of attach-
ment. Even if the perineum receives no injury immediately apparent,
it may have been subjected to pressure for so long a time and been so
greatly stretched that, though entire for some days after delivery, it
finally gives way, and the condition is then similar to laceration. Hib-
berd 1 has reported two cases of the kind, and Duncan 2 previously
directed attention to the fact, but a case of such injury was first described
by Dewees. 3
FREQUENCY OF RUPTURES OF THE PERINEUM. Taking hospital
statistics rather than any derived from private practice, it is probable
that the perineum is more or less torn in 20 to 30 per cent, of primi-
parse, and in 5 to 10 per cent, of multipart.
CAUSES. Without referring to special conditions of the parts creating
a liability to the accident, or the form of the pelvis, or certain presenta-
tions and positions, it may be in general stated that the great majority
of perineal tears occur from too rapid deliveries, the child being expelled
before there is sufficient dilatation of the vulvo-vaginal opening; the
force is too great, and the time too short, so that soft parts are not
stretched but ruptured.
1 American Practitioner, 1881. - Papers on the Female Perineum, 1879.
8 System of Midwifery, eighth edition, p. 287, 1837.
THE CONDUCT OF LABOR. 303
PREVENTION. It follows from the statement just made that, to pre-
vent a tear of the perineum, or to make the tear as slight as possible if
some injury be inevitable, the most important means are to hinder abrupt
expulsion of the foetus, and to promote gradual dilatation of the part it
traverses. In attaining these objects one of the first things to be done
is to have the patient lie upon her side, preferably the left side. The
advantages of the lateral position are lessened voluntary effort, prevent-
ing the wide separation of the thighs, and in this position the condition
of the perineum may be known, if necessary, by actual inspection.
There must be no pressure against her knees, and any object against
which her feet may push should be removed ; she should be directed
to take frequent respirations, and to refrain from all bearing-down
efforts ; if such efforts cannot be thus prevented, chloroform may be
given. A doubled pillow or a quilt made into a roll is placed between
her knees. If the dilatation of the vulval opening be insufficient, the
head must be held back by direct pressure, and, when it is finally
expelled, it should be guided during the expulsion in the axis of
the opening. Hohl directed grasping the head, after the occiput has
passed under the pubic joint, with the hand, the thumb above, the
fingers below reaching to the anterior margin of the perineum, and
thus holding the head back during a pain. Others apply pressure to
the head with one hand, while the other is used to support the per-
ineum. 1
Supporting the perineum is, as Matthews Duncan has remarked, a
practice upheld by the majority of obstetricians, both now and in past
times.
In many cases the condition of the perineum as to ready dilatability
is such, the expulsive force acts so regularly and moderately, and the
relation of the object to be expelled is so adapted to the outlet of the
birth-canal, that there is no danger of injury, and therefore no effort
should be made to support it; the obstetrician's only duty then is to
receive in his hand the head of the child as it is expelled. But in other
cases the following plan may be followed: Supposing the patient to be
lying upon her left side, and her hips quite near the edge of the bed, the
practitioner places his right hancl so that the concave palm receives the
convexity formed by the bulging perineum; the thumb is upon the
right, and the four fingers upon the left labium majus, while the fold
between the thumb and index finger corresponds with the anterior mar-
gin of the perineum. Moderate resistance is made to the force driving
the head against the perineum, and at the same time the head is gently
pressed toward the pubic symphysis ; strong pressure is to be avoided,
because if the perineum be very thin, such pressure at this thinned part-
may cause a central tear. No napkin should be interposed between the
hand and the perineum ; the hand is not applied until perineal distention
begins, and the application is only during a pain. The left hand is
passed over the patient's upper thigh, and grasps the foetal head in the
manner directed by Hohl, holding it back when necessary, and at the
proper time guiding its exit in the axis of the vulval orifice.
1 In the first edition I gave various means for saving the perineum advised by different authori-
ties Siebold, Bernati, Ritgen, Smellie, Goodell, Keamy, Price, and others.
304
PHYSIOLOGY OF LABOR.
A clearer understanding of the mechanism of permeal tears, aud of
their prevention, will be had by examining the subjoined diagram taken
from Varnier, and in connection with it the suboccipital diameters as
shown in Fig. 93. In Fig. 136 it will be seen that the parietal protu-
berances have just cleared, or are about clearing, the vulval ring, aud
that the stiboccipito-bregmatic diameter lies directly antero-posteriorly.
But in order that the head may be born a longer diameter, and conse-
quently a larger circumference, must be in relation with the ring; this
change, as has hitherto been generally taught, occurs by a partial rota-
tion of the head, the beginning of deflection, or as taught by Berry
Hart his views will be more fully presented in a moment by a pro-
gression, and thus there is not even the least deflection of the head, no
pivoting of a fixed point of the nucha upon the pubic joint. But
without reference to either view just given, the danger of perineal rup-
FIG. 136
HEAD ABOUT TO PASS THE VULVAL OPENING.
ture comes with the rapid advance of the head before retraction of the
perineum can occur, for the perineum does not need to be elongated at
this stage elongation means delay or rupture, length is not required,
but breadth ; its own elasticity determines retraction, aud in the retrac-
tion diminished length gives increased breadth. By moderating abdom-
inal and uterine action, and by retarding the abrupt exit of the head,
letting the perineum withdraw from the head rather than the latter
advance from the former, we best preserve it from injury. If this view
be correct, then many of the methods advised for protecting the perineum
are useless, and some are most unn'atural and mischievous, proceedings
that thwart rather than assist nature's method. Give the perineum
time to draw back when the greatest strain upon the vulval opening
comes, aud it can be better protected than in any other way.
Support of the perineum must be continued during the passage of
the shoulders lest a new rent be made, or a slight one caused by the
expulsion of the head be increased.
THE CONDUCT OF LAS OR. 305
Hart denies 1 that the chin leaves the sternum while passing the perineum, and
that during the anterior fixation of the occiput under the pubic arch antero-
posterior and increasing diameters of the foetal head form the antero-posterior
diameters of the girdle of resistance. His method of " protecting the perineum
from undue tear " is this : "All the attendant can do, apart from the familiar
means of relaxing perineal spasm by chloroform and hot applications, is to pre-
vent the sinciput being forced down in advance of or faster than the occiput.
He restrains the foetal head from passing too rapidly. He thus has always to
get the occiput to lead, and to get it fully born if possible. So far as I can judge,
the best way of doing this is as follows : With the patient lying, of course,
upon her left side, the attendant places the thumb of his right hand, guarded by
a napkin soaked in hot sublimate, in front of the anus and presses it gently
there. The pressure is not in the direction of a line joining his thumb and the
pubic arch, but nearly in that of the pelvic outlet. By this, descent of the sin-
ciput is hindered, and that of the occiput favored. When the latter is beginning
to pass under the pubic arch the fingers of the same hand are placed between it
and the apex of the arch, so that when the occiput has cleared the arch the
fingers are passed toward the nape of the neck, and the head thus grasped in
the hand, ^:ie thumb lying over the sagittal suture. This gives one complete
command over the head which is now engaging in the diameters between the
nape of the neck, and forehead and face, and allows the whole passage with as
little tear as possible."
EPISIOTOMY. If a serious tear of the perineum seems inevitable,
many advise that an incision or incisions be made to prevent this acci-
dent. This practice, though generally credited to Michaelis, 1810, was
recommended by Ould 2 1742.
Opinions differ as to the necessity for incisions, and also on the part of those
who approve of the operation as to where they should be made. The late Dr.
A. H. McClintock stated that he had so often seen the perineum escape lacera-
tion, where this accident seemed inevitable, he was led to doubt the possibility
of recognizing the cases in which incision is an absolute necessity. Playfair
asserts that when a distended perineum ruptures its structures are so thinned
that the tear is always linear ; and, as a matter of fact, the edges of the wound
are always as clean and as closely in apposition as if the cut had been made
with a knife. This statement may be received with some doubt, even by those
who have never examined a recent tear of the perineum.
The incisions usually recommended are lateral. Tarnier, however, states that
they do not always prevent even quite extensive tears, and they may leave de-
formity and a painful cicatrix, or the duct of one of the vulvo-vaginal glands
may be divided and a fistula result. He therefore advises an incision of the per-
ineum, beginning at the raphe, and then not passing directly back, but turning
obliquely to one side, so that if a laceration follow, it cannot involve the same
sphincter. He cautions against episiotomy, unless ft is quite indispensable, for
1 Edinburgh Obstetrical Society's Transactions, vol. xii. It must be conceded that extension is
impossible while the perineal band is stretched over the frontal bone that band must hold the
chin upon the sternum ; but once the forehead clears the perineal margin, or, which amounts to
the same thing, the perineum retracts over the forehead, extension canl>egin very slight indeed
at first, but increasing until the head completely emerges, its perfect delivery being followed by a
dropping down of the head, a return of partial flexion, which would be impossible if there had
not oeen some extension.
2 " It sometimes happens, though the Labour has succeeded so well that the Head of the Child
has made its Way through the Bones of the Pelvis, that it cannot however come forward, by reason
ox the Extraordinary Constriction of the external Orifice of the Vagina ; so that the Head, after
it has passed the Bones, thrusts the Flesh and Integuments before it, as if it were contained in a
Purse ; in which Condition, if it continues long, the Labour will become dangerous, by the Orifice
of the Womb contracting about the Child's Neck ; wherefore it must be dilated if possible by the
Fingers, and forced over the Child's Head : if this cannot be accomplished, there must be an In-
cision made toward the Anus with a Pair of crooked Probe-Sizars ; introducing one Blade between
the Head and Vagina, as far as shall be thought necessary for the present Purpose, and the Busi-
ness is done at one Pinch, by which the whole Body will easily come forth." A Treatise on Mid-
wifery. By Fielding Ould, Man-Midwife. Dublin, 1742. Ould also advised stitching the wound
if the incision be made so near the " Rectum as to weaken its Contraction."
20
306 PHYSIOL OG Y OF LABOR.
he has sometimes seen the incised parts covered with eschars, and become the
medium of grave infectious accidents.
Delore, in referring to the lateral incisions advised by Dubois, states that he
accepts in extreme cases this slight operation, but in ordinary cases it is prefer-
able to have a median rent, which cicatrizes uniformly, than two lateral ones,
which result in deformed cicatrices.
It may be stated that episiotomy will very seldom be plainly indicated, and in
private practice will rarely be done.
Dr. Broomall 1 regards episiotomy as a safe and justifiable procedure when the
perineum is threatened, and where the danger of deep laceration is evident, as
the proper and indispensable means to be used with the hope of meeting that
danger. She advises a probe-pointed curved bistoury to be used ; the blade is
slipped between the foetal head and the lateral margin of the vaginal orifice, and
its cutting-edge directed during a pain toward the tuber ischii ; the incision is
made at a point one-third the distance from the posterior commissure to the
clitoris; the length of the incision never exceeded 1.5 centimetres. A similar
incision is made, if necessary, at the opposite side ; after the labor, the edges of
the wounds are united by silk sutures. Dr. Manton 2 strongly advocates episi-
otomy, claiming that it diminishes the frequency of perineal rupturesjto a mini-
mum. He also operates with a probe-pointed bistoury, and makes an incision
from 1 to 3 centimetres long, first on one, and then, if necessary, on the other
side ; he thinks it better not to include the external skin in the incision, although
no harm is done should this be done.
DELIVERY OF THE SHOULDERS. Immediately after the head is
expelled and rests in the hand of the accoucheur a finger is passed to
the neck of the child to find if the cord encircles it, an accident occur-
ring once in rive cases ; if this be the case, the loop must be enlarged,
and an attempt made to draw it over the head ; if this fails, the shoulders
are to be delivered through the loop. In some cases the cord encircles
the neck not only once but even three or four times, and the coils may
be so tight that dividing the cord is necessary ; if this be done, it is
advisable, unless the fetus is immediately delivered, to tie the fetal end
of the severed cord.
Moderate pressure is made upon the patient's abdomen during the
expulsion of the body, the hand so placed that it " follows down " the
uterus as it descends, with the discharge of its contents, in the abdominal
cavity. The shoulders are usually delivered soon after the head ; any
delay can generally be remedied by moderate manual pressure or friction
of the uterus through the abdominal wall ; it may be advisable in some
cases to turn the head of the fetus with the occiput toward the mother's
left or right thigh, according as the position was left occipital or right
occipital, thus having the external rotation of the head invite and cor-
respond with the internal rotation of the shoulders; then let the head,
still held in the hand, drop down so that slight traction is exercised
upon the anterior shoulder, which may be thus liberated. After the
anterior shoulder comes in the pubic arch the head is to be carried up
toward the mons veneris, slight traction being made, when the posterior
shoulder will be delivered ; the injunction is repeated, during the
delivery care must be taken that the perineum escapes injury.
DIFFICULT DELIVERY OF THE SHOULDERS. In some cases, however, the
delivery of the shoulders cannot be thus accomplished ; the body is very large,
and the fcetal circumference of the shoulders and chest much greater than usual,
1 American Journal ol Obstetrics, 1878. 2 Ibid, 1885.
THE CONDUCT OF LABOR, 307
while the vis a tergo, the uterine and abdominal contraction, may fail. The diffi-
culty may be increased by the child's breathing, for thereby the circumference
of the chest is increased. Danger comes to the child from compression of the
chest, or of the cord, which may encircle the body, and death is inevitable unless
speedy delivery can be effected. One of the ways which may be quickly tried is
to exert traction with the hands applied to the sides of the child's head. Even
if we cannot complete the delivery of the shoulders in this way, we may advance
it so far that a finger can be readily introduced into the axilla of the perineal
shoulder, and then pull with this finger; or traction may be made with the
fingers in each axilla. Jacquemier, who gave special study to this difficulty in
labor, and found that in 26 cases 20 of the children died, 1 advised bringing down
the arms, upon which traction can be made, and beside, when they are disen-
gaged the size of the chest is lessened. Although the practice is indorsed by
Charpentier, he acknowledges that in one case he fractured the humerus : if
there be room for this manipulation, there is room, as Spiegelberg taught, for
delivery by other methods, and it may be rejected. Hodge advised pushing the
anterior shoulder in behind the pubic joint, then bringing the neck of the child
in the pubic arch, so that its side presses against the subpubic ligament ; by this
means the posterior shoulder is brought to the margin of the perineum ; when
such change has been effected the head is carried backward and the anterior
shoulder again comes just outside the pubic arch, and delivery is usually easily
effected. This plan was also advised by Spiegelberg. Occasionally it may be
necessary to use a blunt hook, instead of the finger, to exert traction from the
axilla ; one must be careful, however, not to act upon the humerus on account of
risk of detachment of the epiphysis ; after either traction by finger or blunt
hook temporary paralysis of the arm may occur. Of course, the patient should
be urged to " bear down," and uterine action stimulated by friction and assisted
by external abdominal pressure.
DELIVERY OF THE REST OF THE BODY. After the delivery of the
shoulders the remaining portion of the body is in general very promptly
expelled ; but if it is not, and immediate delivery is necessary, the hands
should grasp the thorax, and with gentle traction the process is com-
pleted. It is very much better, however, in most cases, to trust the
expulsion of the child to the uterus.
ATTENTION TO THE CHILD. The child is laid upon the bed at the
side, not so near that by any sudden movement it may roll off, and not
so far from the mother that there is any dragging upon the c< >rd ; it is
placed where it can get air, and in a position in which it will not be
bathed in the fluids that often make a pool about the mother's hips. It
usually at once breathes freely and cries vigorously ; if respiration be
hindered by accumulation of mucus in its mouth, the secretion must be
wiped away by the linger covered with a little soft muslin. In case
respiratory efforts are feeble or absent, they generally may be quickened
or excited by dashing one or two teaspoonfuls of cold water upon the
chest, or friction of the chest may be made by the obstetrician with one
of his hands upon which a small quantity of spirits of camphor has
been poured.
It was the custom of Mauriceau, Clement, La Motte, and Deventer,
indeed, of the old 2 obstetricians generally, not to tie the cord until the
placenta was expelled ; Zweifel has revived this practice, and he uses
1 I have met with this hindrance to delivery in three cases in which the child could not be
extracted soon enough to prevent death. The method advised by Hodge and Spiegelberg I think
the best. In some instances the delivery is impossible until the size of the chest is lessened.
2 Denman, without reference to the expulsion of the placenta, stated that " the navel-string of
a newborn infant ought not be tied or divided till the circulation iu it has ceased spontaneously."
308 PHYSIOLOGY OF LABOR.
but a single ligature. Most obstetricians, however, are in the habit of
ligating the cord as soon as the child breathes freely.
Some experiments, made by Buclin 1 in 1875, in immediate and late ligation of
the cord, proved that when the latter plan was followed the infant received a
large quantity of blood, the average was 92 grammes, and thus immediate liga-
tion deprived the infant of this. In March, 1885, he stated that almost all con-
tributions to the subject, published in different countries, confirm the general
conclusion which he had previously reached, viz., ligation and section of the
cord should not be done until after complete cessation of the vascular pulsations
of the cord. Not merely is the child by late ligation secured a notable amount
of blood otherwise left in the placenta, but its subsequent condition is more
favorable, it loses less weight in the first days following birth, and acquires
weight more rapidly than a child in whose case immediate ligation was done.
These were the conclusions not only of Budin, but also of Blbemont, Schiicking,
Zweifel, and of most who investigated the subject. The matter has been studied
anew by Engel. 2 He observed that the pulsations in the cord continue for some
minutes, or even for a quarter of an hour, after birth. He found that late liga-
tion secured to infants born at term 70 grammes, but to premature infants 90
grammes. Engel failed to discover any relation between loss of weight in the
first days after birth, but his statistics prove that late ligation secures increased
vitality to the infants. Thus the mortality of premature infants when immediate
ligation was done was 18.88 per cent, but with late ligation only 9.45 per cent.
The reserve blood which the foetus obtains in late ligation has been explained
as entering partly through thoracic aspiration and partly through pressure upon
the placenta while it is squeezed out of the uterus. But Cariglia 3 has proved
that respiration has no effect in this process, and it is therefore solely due to the
pressure mentioned.
In regard to waiting until all pulsation has ceased, one might, in some cases,
wait until all patience as well as pulsation had ceased ; for example, La Motte 4
mentions going to a woman who had been delivered trois grosses heures before his
arrival ; the child was lying between the mother's thighs, the placenta un-
delivered, and " the beating of the cord was of a marvellous force."
It is not necessary nor advisable to make an absolute rule that pulsa-
tion must cease before tying ; when the child cries vigorously, breathes
freely, and the pulsation lessens in force, one usually need not wait.
Various material has been used for tying the cord. The late Dr.
Bedford preferred tape, believing that if a round string was used the
child was more liable to trismus. Dickson 5 first advised the elastic
ligature, and Tarnier uses it in addition to the ordinary one. A few
strands of hemp thread answer the purpose very well ; but my prefer-
ence is for the Chinese silk used in tying the pedicle in ovariotomy, for
it is strong, and a tight knot can be made without any danger of either
cutting the cord or the obstetrician's fingers. Whatever is used, it ought
not to be so thin as to risk cutting the cord, or cutting the physician's
fingers when he is drawing the knot. The ligature is placed about
three fingers' breadth from the umbilicus; the string or tape is passed
under the cord, the ends brought above and tied, gradually and firmly
compressing the cord so as to force away at the place of constriction
the gelatinous portion, with a surgeon's knot and then a single knot. 6 In
i Obstetrique et Gynecologic, Paris, 1886. * Centralblatt fur Gynakol., 1885.
3 Gazet. deg. Hosp., 1892.
4 Observation ccxxx.
6 Proceedings of Edinburgh Obstetrical Society, January 14, 1874.
6 It is generally recommended that a second ligation of the cord be made, partly upon the
ground that thereby the clothing is protected from the soiling caused by escape of blood from the
placental end of the funis, and chiefly because it was believed that if this escaping blood was
retained in the placenta, the detachment of the latter occurred more promptly. But Budin and
THE CONDUCT OF LABOR. 309
plural pregnancy a second ligature is required because of the possible
vascular connection between the circulation of the two foetuses in the
placenta. After ligation the cord is divided, care being taken to leave
a large button-like projection at the foetal portion, so that the ligature
cannot slip off; blunt-ended scissors are best for making this section,
and the obstetrician must be watchful lest a finger or some other part of
the foetus be included with the cord between the blades. After the sec-
tion press a soft rag upon the cut surface to dry it, and then watch for
a minute or two to see if there be any oozing of blood ; if there be,
another ligature must be immediately applied.
The obstetrician now hands the child to the nurse, who has a small
blanket or shawl, which has been warmed for its reception. In hand-
ing it to her he either places the right hand under the shoulders, the
thumb and index finger supporting the head, and the left hand holding
the ankles ; or, as taught by Dr. Hodge, he embraces the thorax of the
infant with the right hand extended so that the palm is over the ster-
num, the thumb under the right axilla, and the fingers under the left,
and the head falls toward the sternum ; this is a natural position for the
child, the practitioner has a firm hold, and the left hand is left free for
any required assistance. Trivial as these directions may seem to the
student, yet in practice he will find that attention to the little things has
much to do with the obstetrician's success.
WASHING THE CHILD AND DRESSING THE CORD. Though wash-
ing the infant and dressing the cord are usually done by the nurse, yet
occasionally one or both of these duties may devolve upon the doctor,
and even if this be not the case, he ought to know how they are best
done. There are needed for the washing a soft sponge, a piece of old
linen or cotton cloth, water at a temperature of 100 F., some oily sub-
stance, such as unsalted butter, lard, sweet oil, or vaseline or, instead
of any of these, the yelk of a fresh egg and Castile or some one of
the finer soaps ; transparent glycerin soap is good. The oily matter, or
the egg-yelk, is used for the purpose of facilitating the removal of the
vernix caseosa, and the body of the child is first rubbed with one of
these substances. The face is now washed with warm water simply, no
soap being used, lest some of t"he soapy water should get into the infant's
eyes, causing pain, and possibly a conjunctival irritation which may
result in inflammation ; children of a larger growth will strenuously
object to soap-water for washing their eyes, and let the infant be treated
as kindly. After washing and drying the face, the body and limbs are
washed with soap and water, and well dried ; the washing of course
must be done in a warm room, quickly, avoiding prolonged or unneces-
sary exposure of the child, and with gentleness, care being taken not to
irritate the sensitive skin by rude rubbing, even though some portion of
the vernix caseosa may remain, for it will dry up in a day or two, and
be spontaneously detached, or can be removed at a subsequent washing.
After drying the infant, powdered starch is dusted over the surface, espe-
cially at the flexures of the knees, thighs, and elbows, and in the axillae.
Ribemont-Dessaignes have experimentally proved that the blood escaping from the placental end
of the cord, in lessening the volume of the placenta, facilitates its separation, permitting uterine
retraction which little by little reduces the surface of placental attachment. Unless, then, in cases
of plural pregnancy a single ligation is advisable.
310 PHYSIOLOGY OF LABOR.
If the mother has had a purulent vaginal discharge, even if there is
any suspicion of her having had a specific vaginitis, the child's eyes
having been first carefully washed with warm water, should have ap-
plied to them a drop or two of a 2-g-rain solution of nitrate of silver.
The common method of dressing the cord is this : A square piece of
old linen, a little more than twice the length of the attached cord, is
slightly scorched, a hole cut in its centre, and mutton suet put upon its
under surface; the cord is passed through the hole, then the linen folded
first transversely, and afterward from side to side, over the cord so that
the latter is completely wrapped. lodoform or creolin gauze may be
used for wrapping the cord, absorbent cotton or cotton-wool is objection-
able because the drying of the cord cannot, when thus covered, occur so
readily. Goodell advised squeezing out Wharton's jelly from the cord,
and this certainly seems to me best. When the duty of caring for the
cord devolves upon the practitioner, he may pursue the following plan :
Let him take a piece of soft cotton rag, place it upon the cord, and grasp
the latter just below where it has been tied with the thumb and fingers
of the left hand ; now cut off the cord at the point of ligation, and then
squeeze out all of Wharton's jelly upon the rag, and in a minute or two
the cord is reduced to half its former size, and, instead of being a solid
cylinder, is a limp, ribbon-like body. A new ligature is now applied,
and bleeding is impossible. A little iodoform, or a powder of starch
and salicylic acid, may be sprinkled upon the stump of the cord, and
then it may be encircled with a few turns of a linen or muslin bandage,
an inch to an inch and a half in width, which is fastened by a silk
or hemp thread ; no subsequent dressing is needed ; the cord and
bandage will fall off together in a few days. The advantages of this
plan are the comfort of the child, absolute security from hemorrhage,
and the lessened mass to be detached.
DRESSING THE CHILD. The " belly-band," which is almost uni-
versally used, should not be tight, for the increase in pulmonary capac-
ity in the newborn is chiefly due to descent of the diaphragm, and the
bandage must be sufficiently loose to permit this increase ; a bandage
that is loose immediately after birth may often after a few hours cause
injurious compression ; it will be the duty of the obstetrician to see
that no mistake is made in this matter. The fewer pins used in fasten-
ing the clothing of the infant the better, and as far as possible tapes
should replace them.
APPARENT DEATH OF THE NEWBORN. The child born apparently
dead does not cry, does not breathe, or only at long intervals gives a
faint gasp, there is absence of reflex movements, but pulsations of the
heart still occur, though they are very weak. The most frequent cause
is asphyxia, and this asphyxia may result from compression of the
cord, for example, in prolapse, or from coils about the child's body, or
in head- last labor Further, the asphyxia may be caused by premature
separation of the placenta, or from continuous uterine contraction, or
from the mother's blood failing to furnish oxygen to that of the child,
as in grave hemorrhage, eclampsia, and various diseases which cause
accumulation of carbonic acid in her blood. The child in utero threat-
ened with apparent death may have a discharge of meconium, and the
THE CONDUCT OF LABOR. 311
discovery of this excretion in the amnial liquor during labor when the
pelvis does not present justly awakens suspicion of peril, though fre-
quently this accident occurs and birth of a perfectly healthy child fol-
lows. More important is the condition of the pulsations of the foetal
heart as indicating asphyxia ; these either are greatly increased in fre-
quency or fall below the normal in each case they become feeble, less
distinct. The failure of placental respiration, the foetus being thus threat-
ened with asphyxia, causes in many cases the effort at pulmonary respira-
tion, and hence there may be drawn into the air-passages amnial liquor,
mucus, blood, etc., aggravating the original affection and making the
treatment more difficult. In apparent death from asphyxia the color is
almost purple ; the features, especially the lips, swelled ; the cord is
large and full of blood ; the limbs are not flaccid, but even may be
somewhat rigid. It has been described as blue asphyxia, and some-
times, too, spoken of as apoplectic. A rarer form of failure of respi-
ration in the newborn has been called pale asphyxia. The child's sur-
face is remarkably white ; the limbs limp and relaxed; the cord small,
thin, apparently almost bloodless. The condition is very much more
unfavorable than that previously described. It has been called syn-
cope, and probably that is the best designation. Its origin seems to be
most frequently pressure upon the brain, and is oftenest observed after
labor in case of a contracted pelvis, or after the application of the for-
ceps ; intra-cranial hemorrhage may be present instead of hypersemia,
and then recovery, if recovery occurs, is very slow. Depaul has spoken
of pale asphyxia occurring in premature birth, and also in case of want
of nourishment from disease of the placenta, for certain changes in this
organ may produce a progressive inanition which does not kill, but the
child is born thin, emaciated, and feeble.
TREATMENT. Division of the cord is made at once, but in pale
asphyxia Depaul advises pressing toward the child's body all the even
scanty supply of blood in the cord before cutting it ; and it has been
the custom in blue asphyxia to let a teaspoonful of blood escape from
the foetal end before ligating, though now most authorities assert this
is useless. I have often done it, still do it, and am glad to find that
Winckel approves the practice. Immediately after separating the
child from the mother the mouth and fauces are cleansed of mucus by
means of the little finger wrapped with mull, and also the nares with
a feather (Ahlfeld). It may then be put in a hot bath, and while lying
supported by the obstetrician a little cold water thrown upon the ex-
posed breast. If respiration still fails to be made after -two or three
minutes, other means must be employed. Faradization of the phrenic
nerves has been successful, but the means for employing this are rarely
at hand. Artificial respiration comes next. The readiest way of effect-
ing this is by the Sylvester method : The infant has hot, dry flannel
applied to it, is placed upon its back, the head slightly raised by a small
pillow, then the arms are raised and brought by the sides of the
child's head, then to the sides of the child's chest ; these alternate
movements one promoting inspiration, the other expiration are con-
tinued for a few T minutes. The removal of mucus from the air-passages
is in some cases of essential importance. This removal may be effected
312 PHYSIOLOGY OF LABOR.
by the position of the child, as will be explained in describing Schultze's
method of resuscitation, by introducing a flexible rubber catheter in the
trachea and sucking out fluids, or by means of Ribemont-Dessaigues'
instrument, probably the best of aspirators and insufflators ; the laryn-
geal tube of Depaul may be used in a similar manner to that of the
rubber catheter. The instrument of Ribemont-Dessaignes consists of
a laryngeal tube and of a pear-shaped rubber bulb, readily attached
and removed from the tube. To introduce the tube, let the child be
FIG. 137.
INSUFFLATOK OF RlBEMONT DESSAIGNES .
upon the back, its head supported by a pillow ; the index finger is
introduced in the child's mouth and directed so that its pulp touches
the arytenoid cartilages, and then the tube is guided by it into the
larynx ; thence it is gently buried in the trachea and brought to the
median line. For the removal of secretions that have entered the air-
passages, let the compressed bulb be applied to the tube, and upon
removing the compression the fluids are promptly aspirated. Remove
the bulb, and, having its opening dependent, press it so that everything
escapes from it. Next filled with air, it is applied to the tube, and
gentle compression drives this air into the lungs. The insufflations
may be practised once in eight or ten seconds. If respiratory move-
ments are made, the period intervening between insufflations is length-
ened. Artificial respiration should be employed as long as the heart
continues to beat. Ribemont-Dessaignes, after describing his instru-
ment and its application, says that it is sometimes not until the end of
half an hour, or even three-quarters, that the infant makes the first
respiratory movements, and it may not be until the end of an hour or
more it first cries.
French obstetricians are partial to the means previously mentioned,
while by most German authorities "Schultze's swinging" is generally
regarded as the most valuable means of resuscitation. This is done as
follows: The operator stands with his lower limbs somewhat widely
apart, and his body slightly inclined forward, the arms and forearms
extended. The infant is now held, its anterior plane in front, by the
index finger of each hand entering the axilla? from behind, thumbs
supporting the face laterally, and their ends resting upon the upper and
anterior part of the thorax. This is the position of inspiration. After
a moment the operator very quickly raises his arms until they pass the
horizontal line and become oblique with reference to his body, and the
child is made to revolve upon the index fingers as an axis, so that its
THE CONDUCT OF LABOR. 313
head is now lowest, and its hips highest, its lower limbs falling upon the
anterior aspect of the body which is directly before the operator's face ;
the child's weight in this position rests upon his thumbs, which are
placed upon the anterior face of the thorax. If this movement of par-
tial revolution be made too rapidly, the child's back is bent too much
in the dorsal vertebrae, whereas it is designed the bending shall occur
in the lumbar vertebrae. While the head is in the dependent position
the movement of expiration occurs, and any fluids that may have entered
the air-passages flow out. The operator now lowers his arms, swing-
ing the child back into the first position, when all pressure of the thumbs
upon the chest is relaxed so that they may give no impediment to inspi-
ration. These movements are repeated at suitable intervals.
Ahlfeld, after mentioning several accidents that have occurred from the
"swinging," such as pulmonary hemorrhage, hemorrhage in the supra-renal
capsules and into the abdominal cavity, rupture of the liver and of an enlarged
spleen, fracture of the ribs, states that the method is not to be recommended
for employment by the unskilled, consequently by most midwives.
In Forrest's method 1 of artificial respiration the child, after being turned upon
its abdomen, the head lower than the pelvis, and pressure made upon the back
to cause escape of any fluid that has entered the mouth and trachea, is placed in
a sitting position in a bucket half- full of hot water, "the water being just above
the infant's heart." The arms of the child are carried upward and a little back-
ward by the operator's left hand, until the weight of the body comes upon the
shoulders. The operator takes an inspiration bending forward, applies his
mouth to that of the child, and "blows the air directly in the lungs." Expira-
tion is made by doubling the child's body forward upon itself, its arms brought
to the sides, and pressure downward and backward made upon the chest ante-
riorly. Dr. Forrest states that " artificial respiratory movements should be made
at the rate of forty per minute, instead of twenty, as usually taught."
Winckel says that this method is "not sufficiently energetic for severe cases."
Moreover, it is amenable to the just objection to all modes of mouth-to-mouth
insufflation, that it is probable tuberculous disease may thereby be communi-
cated, as the facts of Reich, quoted by Kaltenbach, go far toward showing.
Directly breathing into an infant's lungs ought not to be admitted as a common
way of resuscitation.
Dew's 2 method is this : " Grasp the infant with the left hand, allowing the
neck to rest between the thumb and forefinger, the head falling over backward,
straightening the mouth with the larynx and trachea, thereby serving to raise
and hold open the epiglottis ; the upper portion of the back and the scapulae
resting in the palm of the hand, the other three fingers to be inserted in the
axilla of the baby's left arm, raising it upward and outward.
" Then, with the right hand, if the baby is large and heavy, grasp the knees in
such a way as to hold them with the right knee resting between the thumb and
forefinger, the left between the fore and middle fingers. This position will allow
the back and the thighs to rest in the palm of the operator's hand. If the
infant is small and light, it will be found more convenient and easier to hold it
in the same way by the ankles instead of the knees, allowing the calves instead
of the thighs to rest in the palm of the hand.
" The next step is to depress the pelvis and lower extremities, so as to allow the
abdominal organs to drag the diaphragm downward, and with the left hand to
bend gently the dorsal region of the spine backward. This enlarges the thoracic
cavity and produces inspiration.
" Then, to excite expiration, reverse the movement, bringing the head, shoulders,
and chest forward, closing the ribs upon each other, and at the same moment
bring forward the thighs, resting, them upon the abdomen. This movement
arches the lumbar region backward, and so bends the child upon itself as to
1 New York Medical Record, 1892.
2 New York Medical Record, March, 1893.
314 PHYSIOLOGY OF LABOR.
crowd together the contents of the thoracic and abdominal cavities, resulting in
a most complete and forcible expiration. While this movement is a powerful
one, the operator can, by his manipulations, accomplish it without shock and
render it as gentle as he pleases."
ATTENTIONS TO THE MOTHER. Immediately after the birth of the
child the mother is placed upon her back, if she was delivered lying
upon her side, with but a single pillow, or only the bolster under her
head. From the time of the birth the hand of the assistant, which was
placed upon the uterus, following it down during the expulsion of the
child, is kept there until replaced by that of the obstetrician. It must
be borne in mind that the hand is applied, not flat, but with the fingers
and thumb so flexed that a concave surface is formed corresponding
with the convexity of the uterus, and that the purpose of this normal
application is to assist uniform uterine retraction, thus securing early
delivery of the placenta, and guarding against hemorrhage. It is the
custom of some practitioners to administer from a half to a teaspoonful
of fluid extract of ergot immediately after the birth of the child, while
others defer it until after the delivery of the placenta, and still others
omit its use altogether in physiological conditions. Ergot given after
the removal of the placenta probably cannot interfere in any way with
normal processes ; it certainly is one of the most important means in
prophylaxis of post-partum hemorrhage, and possibly it assists uterine
involution. But unless there are plain indications, it is better to omit it.
PLACENTAL EXPULSION. The delivery of the placenta is one of
the most important of the accoucheur's duties. The patient is anxious
until this final act in the drama ends; she cannot have the soiled clothes
removed from her person and from the bed, nor parts that have been
bruised bathed, nor secure that repose which her exhausted condition
needs; a delay is sometimes the source of fear to her at least, according
to the popular expression, that "the after-birth has grown fast to her
side." Therefore it is unwise, so far as her immediate comfort is con-
cerned, to do as practitioners in ancient times did, leave the delivery of
the placenta to nature, pursuing a merely expectant treatment. The
time of the practitioner also gives an argument against expectation. He
canuot wait hours at the bedside, as would be necessary in some cases
for nature to expel the placenta, when a little manipulation on his part,
simply assisting nature, will accomplish this delivery in a few minutes.
The following table of 100 cases in which the delivery of the placenta
was left to nature is given by Kabierske : l
24 times 30 minutes. 5 times . .5 hours.
20 " 1 hour. 3 " . 6 "
25 " 2 hours. 2 " . 8 "
11 " 3 " 1 time . . . 12 "
9 " 4 "
These figures are conclusive against trusting to purely spontaneous
delivery of the placenta. The method more or less closely followed by
most obstetricians is known as that of Credo", and briefly stated is this :
Frictions, at first gentle and then more or less vigorous, of the fund us
and of the body of the uterus are made through the abdominal wall.
When a uterine contraction occurs the obstetrician applies his hand to
i Centralblatt fur Gynakol., 1881.
THE CONDUCT OF LABOR. 315
the organ, the palm upon the fundus, the four fingers upon the poste-
rior and the thumb upon the anterior \\all, and exerts a moderate pres-
sure, which is soon followed by the expulsion of the placenta it is
thus expressed, squeezed out " as the seed from a ripe cherry compressed
between the thumb and fingers." It is necessary in some cases to re-
peat this manipulation once or ofteuer before successful. Crede's method
has not escaped criticism. Riol 1 justly states that if practised with too
much rapidity and energy, and immediately after the delivery of the
foatus, it may cause tearing the membranes and retention of fragments.
It would be better in physiological cases not to hurry uterine action by
friction, but simply to keep the hand applied to the uterus, as first
directed, acting in the beginning as a sentinel to warn of danger and
advise of condition, and then as an ally of uterine contractions when
they normally occur, a reinforcement to uterine power, not usurping its
place, but simply assisting it. Delivery of the placenta by expression
is certainly preferable to that by traction ; it is nature's way to have
the deliverance made by a vis a tergo, not by a vis afronte, and untimely
pulling upon the cord can cause inversion of the uterus, or serious
hemorrhage. But granting all this, haste and great force in expression
are an evil ; Nature should be the guide, give the signal for action, and
art be the follower and servant.
Pajot advises, after grasping the cord, at first to exercise a prolonged tension
during some minutes, and subsequently moderate tractions in the pelvic axis.
Ribemont-Dessaignes 2 claims that this tension is as rational in principle as it is
fortunate in results. Pajot's method, instead of trying to increase the size of
the uterine orifice, seeks to reduce the volume of the placenta ; and this reduction,
favored by the special structure of the organ, is easily obtained if the latter is
permitted to mould itself little by little to the passage it must traverse in a
word, to accommodate itself.
" No teaching as to the delivery of the placenta can be scientific which does
not direct attention to the character of the preceding labor ; and as the character
of labors varies, so must the management of the third stage. If the pains have
been frequent and energetic, and the birth of the child rapid, the placenta may
be delivered very soon ; if the labor has been tedious and the delivery slow, or
if the uterus has been exhausted by long continuous effort, time must be given
for the recuperation of its contractile force and nervous energy." 3
It is generally advised that in removing the placenta from the vagina
the former should be rotated so as to twist the membranes into a rope,
as it is supposed there is then less danger of their tearing and fragments
being left behind. Such an accident is not likely to happen if they
have been completely detached from the uterus, and the manoeuvre is
hardly necessary, simple, gradual withdrawal being sufficient. When
removed, the placenta and membranes are put in a vessel brought by
the nurse, which should be turned upon its side, and put with its rim
as near the vulva as possible, so that they can be slid in rather than
lifted, thus avoiding, as far as possible, soiling the clothes or the person
of the patient. After this the obstetrician removes clots that may be in
the bed, and puts them into the vessel, when it is taken away, but kept
1 Etude Critique et Clinique de la Deliverance par Expression.
2 De la Deliverance par Traction et par Expression. Paris, 1883.
3 Reeve : Transactions of the Ohio State Medical Society, 1884.
316 PHYSIOLOGY OF LABOR.
uneraptied until he has an opportunity to examine the uterine surface
of the placenta, and be sure that no fragments have been left in the
uterine cavity. Before removing the hand which has been applied to
the uterus through the abdominal wall, the size, position, and firmness
of the uterine globe should be found to be normal.
APPLICATION OF THE BANDAGE. After the removal of soiled
clothes the abdominal bandage may be applied. The value of this has
often been disputed, nevertheless most patients think themselves more
comfortable with it, and desire it to be used ; indeed, some are not
satisfied unless their professional attendant applies it.
Confirmation of the value of the abdominal bandage has recently
been given by Prochowuick. 1 It should be worn not merely while
lying in bed, but for some time after beginning to sit up. Usually a
bandage made for the occasion is at hand ; but if not, a bolster cover,
as suggested by Leishman, or, better than it, a moderately coarse crash
towel may be used. The bandage is rolled one-half its length, and the
roll carried under the patient's back to the opposite side, when it is
unrolled, drawn so as to be smooth, and arranged to extend from the
chest somewhat over the hips. It is then pinned as tightly as is com-
fortable, the pinning being begun, as taught by Warrington, 2 above,
though of course this is not very material. To prevent the bandage
from slipping a layer of cotton wadding may be placed upon the abdo-
men, if the weather be not so warm that this addition will cause dis-
comfort. Some place a pad, formed of one or more folded napkins,
upon the abdomen before the bandage is fastened, for the purpose of
producing compression of the uterus : if small, it does neither good nor
harm; but if thick, it may press the uterus out of place. A better
plan of securing uterine compression, should this be thought necessary,
is the following : Make three firm rolls rather thicker than the wrist,
of as many towels ; then place one of them transversely just above the
uterus, and the other two at its sides, and let the bandage be pinned
firmly over them ; thus the uterus is as it were included in a box, the
lid of the box being the portion of the bandage in front of the abdo-
men.
A warm vaginal injection of a 3 per cent, solution of carbolic acid, or
a 1 J per cent, solution of lysol, or a teaspoonful of creolin to a quart of
water, may be used, and with this solution the external sexual organs
and adjacent parts are washed.
If there be the slightest suspicion of any injury to vulva or peri-
neum, it is the duty of the obstetrician to make a careful inspection of
the parts after the washing. As a rule, should there be any serious
tear of the perineum sutures must be at once introduced. Slight tears
there or elsewhere may be 'covered with an antiseptic powder, as of
iodoform. Then an antiseptic napkin or pad is applied to the vulva,
the chemise and night-dress drawn down, and the patient prepared for
that rest which her exhausted state so much needs.
Dr. Fullerton, in her excellent work upon Obstetrical Nursing, gives the follow-
ing description of the antiseptic dressings used in the Woman's Hospital, Phila-
1 Op. cit. 2 Obstetric Catechism.
THE CONDUCT OF LABOR. 317
delphia : " They consist of a piece of dry patent lint, six by eight inches, which
has previously been rendered antiseptic by saturation in a solution of bichloride
of mercury 1 : 1000. This is placed, doubled in its width, so as to make a dress-
ing three by eight inches, directly over the external organs of generation.
This lint is covered by a piece of gutta-percha tissue, four by nine inches, which
is wet in a 1 : 4000 solution of bichloride of mercury. These dressings are kept
in place by a napkin of sublimated cheese-cloth, eighteen inches square, folded
to form a diagonal five inches in width, within whose folds a pad of oakum is
enclosed. The napkin is tightly fastened to the abdominal bandage, both ante-
riorly and posteriorly, by means of safety-pins, and the access of air to the
vagina is thus prevented. These dressings are changed at least once in three
hours, the dressing removed being at once burned. It is seldom necessary to
continue the dressings longer than two weeks."
In my own practice I direct, instead of this " occlusive dressing," simply a pad
of absorbent cotton that has been dipped in a 3 per cent, mixture of creolin and
water, and dried ; this pad will be retained without the napkin if placed between
the thighs closely upon the external genitals, or the napkin may enclose it, and
be fastened in front and behind to the abdominal bandage. Of course, the pad
will be removed as soon as soiled, a fresh one applied, the old one burned.
Winckel advises a pad of salicylated cotton, and Auvard says that " it is the
best and most simple barrier against the entrance of microbes."
Kaltenbach directs the application of sterilized cotton or jute to the genitals.
The practitioner remains with the patient for an hour after the labor
has ended, and then, if she be comparatively free from suffering, the
uterus well contracted, and the pulse and flow normal, he need not
hesitate to leave.
The woman is now, in the strict sense of the term, a puerpera, and
the puerperal state has succeeded that of labor. The phenomena and
management of puerperality will be studied hereafter.
CHAPTER XIII.
THE CONDUCT OF LABOR (CONTINUED) OCCIPITO-POSTERIOR POSI-
TIONS FACE, BROW, AND PELVIC PRESENTATIONS TWINS.
THE MANAGEMENT OF OCCIPITO-POSTERIOR POSITIONS. As has
been stated, in almost all cases of right or of left occipito-posterior
positions the occiput rotates in front and the head is delivered as in an
original occipito-anterior position. The labor is longer and the suffer-
ing greater. In exceptional cases, when by perversion of rotation the
occiput turns into the sacral cavity, the delivery of the head causes in-
creased danger to the perineum, and the long and difficult labor greatly
endangers the life of the child.
The tediousness of auterior and the possibility of posterior rotation
have led many obstetricians to urge the importance of manual or even
of instrumental means to effect or assist the former.
Smellie was among the first to claim that such rotation could be effected by
the hand or by an instrument. He stated, referring to the former means, that
" turning the forehead into the hollow of the sacrum might be assisted by intro-
ducing some fingers or the whole hand into the vagina during a pain, and mov-
ing it to the right position." Portal and Leroux advised pressing with the hand
upon the abdominal wall so as to withdraw the face from the anterior pelvic
wall. Velpeau taught that when the head had descended into the pelvic cavity,
almost immediately after the escape of the waters, two or three fingers should be
placed just before the sacrum, in order to push the occiput in front or behind
the pubes, upon the side of the forehead, in order to press the latter backward.
Meigs, referring to delay in labor from failure of anterior rotation, directed that
two fingers should be placed upon the child's head, just behind the ledge formed
by one of the parietal bones overriding the occipital, and then drawing the ver-
tex down, thus increasing flexion; he added, "If such gentle measures will not
succeed, we have the powerful resource of half the hand, which may be intro-
duced into the vagina, and sometimes within the cervix, and which, taking the
head in its palm and fingers, can place the vertex wherever it may be desirable
to fix it." Hodge's view was that anterior rotation could generally be caused by
pressing on the temple during a " pain " and also in the interval ; the pressure
should be made upon the left temple in right occipito-posterior, upon the right
temple in left occipito-posterior position. Mattel believed that he had often
succeeded in effecting anterior rotation of the occiput by acting upon each pole
of the foetal ovoid, the fingers of the right hand being used to draw the occiput
in front, while the left hand was applied to the fundus of the uterus to cause a
corresponding rotation of the trunk. Tarnier advises this plan : When the os
is nearly or quite dilated introduce the index finger the left one in right occi-
pito-posterior position and apply it to the cranial surface immediately behind
the left ear of the foetus, thus securing a good purchase ; at the beginning of a
uterine contraction the finger is pressed firmly, but without violence, at the same
time bringing the head toward the pubes, then to the joint, and finally to the
opposite side, so that the occiput is directly in front. The first attempt often
succeeds, but if, after being repeated two or three times, there is still failure, it
is better to desist.
Angus MacDouald 1 held that in all persistent occipito-posterior
positions we may safely assume we have some pelvic peculiarity or
i Transactions of the Edinburgh Obstetrical Society, vol. iii.
THE COND UCT OF LABOR. 319
disproportionately large head to deal with, and, as a rule, all attempts
at rectification of the position of the head will prove abortive, and are
even dangerous if attempted by means of levers, forceps, etc. Not dis-
similar was the teaching of Cazeaux ; he regarded all manoeuvres to
effect anterior rotation as quite useless. So, too, Charpentier looks upon
manual efforts as in vain, and when they appear to succeed the rotation
would occur without them.
THE MANAGEMENT OF FACE PRESENTATIONS. The older obste-
tricians advocated in presentation of the face either changing it into that
of the vertex or podalic version. Louise Bourgeois, 1710, remarked
that when the chin advanced first in the passage delivery was impossi-
ble, and the hand must be introduced to push back the chin upon the
chest. Baudelocque advised the same method, and if it failed only
podalic version or instrumental delivery remained. Smellie said that
when the " face presents resting upon part of the pelvis, the head ought
to be pushed up to the fundus of the uterus, the child turned and
brought by the feet." He admitted, however, that in some instances -
spontaneous delivery occurred. Paul Portal, 1685, nearly a century
before Smellie made the statement I have quoted, was contented with
" anointing the woman's parts with butter in order to soften and relax
them, thus making the escape of the infant easier : " he stated that the
accoucheur should be careful not to produce any irritation with his finger,
otherwise he will cause a thousand times more injury to the mother and
to the child than the accouchement, which has no more mystery than a
natural labor. It was not, however, until Lachapelle asserted that these
labors terminated as easily as those with vertex presentation that the
profession generally abandoned interference, leaving the delivery to
nature. Nevertheless the affirmation of the perfect safety of labor in
presentation of the face is somewhat an exaggeration, and the profession
is not unanimous in regard to the uselessness of intervening. Hodge
held that when the practitioner was called early, and recognized a face
presentation, he should, after the os is dilated and before the presenting
part has passed this opening, substitute the vertex, for under these cir-
cumstances, especially in multiparous women, the operation can be easily
and rapidly performed without much suffering to the mother.
Partridge has also advocated this plan of treatment, stating the conditions
favorable to it and the method, as follows: "An os nearly or quite dilated; a
face not engaged in or at least capable of being lifted from the pelvic brim ; an
unruptured bag of waters ; a capacious vagina. In the majority of labors a
stage is reached when these conditions are present. Chloroform to relax the
structures of the parturient canal, to quiet the movements of the patient, and to
obviate pain caused by the introduction of the hand into the vagina, is of pri-
mary importance. The manipulation requires the presence of the fingers only
in the uterus, and does not involve any laceration of the cervix. Passing the
palms of the fingers over the occipital bone, and pressing them firmly against it,
traction downward should be made. In our endeavors flexion of the head almost
immediately commenced and quickly became complete. The other hand aided
greatly by external manipulation." 1
Schroder; referring to conversion of a face into a vertex presentation, stated
that Thorn succeeded in 9 cases of 24 in accomplishing this change without diffi-
culty ; and further, he is correct in asserting that a good result is not to be had
1 American Journal of Obstetrics, 1884.
320 PHYSIOL OGY OF LAB OB.
by external and internal manipulation of the head alone, still less as Schatz
proposes by external manipulation of the head and shoulder, but that the half
or the whole of the hand should be used internally to turn the head, while the
external hand is employed to press it toward the chest, and finally pushing the
breech to the other side so as to change the position of the body.
Penrose's 1 method of treating face presentations is as follows : "The assistance
which I advise in all cases of face presentations of mento-anterior positions is,
as soon as the mouth of the uterus is dilated and the face has fairly engaged, to
apply the hand, the lever, or the blade of the forceps to the posterior cheek, to
bring artificially a force of resistance to bear on the face, inasmuch as the face
cannot secure this force of resistance from the muscles of the pelvic floor, as the
vertex does in vertex presentations, and therefore the chin does not rotate, or
does so slowly and uncertainly, to that part of the pelvic cavity where a spon-
taneous termination of labor is alone possible. If the medical attendant apply
this force of resistance at the time and in the manner I have directed, rapid rota-
tion will be secured and the labor will terminate speedily and safely."
In case the chin is posterior and is seen in time that is, before the face has
passed the mouth of the uterus he urges prompt employment of cephalic or of
podalic version.
Pinard, too, advises changing a face into a vertex presentation. His method
is acting upon the forehead with two fingers introduced into the vagina, pressing
the forehead up, while the other hand is used through the abdominal wall to
press the occiput down ; the manoeuvre is generally successful. Most obstetri-
cians will agree that if the head has not escaped from the os, and if the chin
is posterior, that the effort should be made, especially by the method of Pinard,
to convert the presentation into that of the vertex. Kunge takes the ground
that the treatment of this presentation should be expectant. 1
In conducting the labor, the presentation remaining unchanged, the
obstetrician must exercise great care in digital examination lest injury
be done, especially to the eyes. It is better frankly to tell the patient
that the labor will be protracted, but at the same time she may be as-
sured that it is almost certain to have a fortunate issue both for herself
and for her child. Friends who are with her ought to be informed of
the probably very great disfigurement of the child's face, the statement
being also made that this is sure to disappear in a few days. Great
danger comes to the child in the disengagement of the head, for during
this the throat is pressed against the pubic arch, and if delay occurs it
may be necessary actively to assist the delivery.
MANAGEMENT OF BROW PRESENTATIONS. As extension of the
head gives preseutatiou of the face, so partial extension results in pre-
sentation of the forehead or brow. Upon digital examination the apex
ot the forehead is found to be the lowest part of the head, the suture
between the two halves of the frontal bone can readily be traced to the
anterior fontanelle, and in the opposite direction the different parts of
the face are found. Now it is almost certain that the presentation of
the forehead will be only temporary ; for either flexion occurs, and the
vertex presents, or, and this is the more frequent, extension becomes
complete, and the final presentation is the face. If the head be small,
spontaneous delivery is possible without change of presentation. Klein-
wachter takes the ground that when the head is in the pelvic cavity an
attempt to substitute the vertex for the face is not to be made, for even
if successful the head, which has already been more or less moulded
into the form necessary for delivery, must undergo a new configuration
1 American System of Obstetrics, vol. i. 2 Op. cit.
THE CONDUCT OF LABOR 321
for delivery with a new presentation, and thus time is lost, to the dan-
ger of both mother and child. Hodge taught that a brow presentation
should be converted into that of the vertex as soon as the os uteri is
sufficiently dilated for the passage of the hand of the practitioner.
Even when the head has passed the os he thought this could be done
in many cases. Possibly his advocacy of an early active interference
arose from the fact that he did not recognize the almost unexceptionally
spontaneous change of presentation, for he cautiously observes, " per-
haps in the majority of cases " this change occurs. Hildebrandt directs
that in persisting brow presentation the woman should be placed upon
her side across the bed, and the practitioner then apply two fingers of
the right hand, at the beginning of a uterine contraction, upon the
forehead and exert a pressure directed toward the occiput if a facial
presentation is desired, or toward the face if descent of the occiput is
preferred. Long advises the same method, but urges the importance
of conversion into a vertex presentation. He adds : " If this is unsuc-
cessful, the whole hand should be introduced into the vagina and the
fingers passed up over the occiput, pushing the head up first if neces-
sary, and then drawing downward upon the occiput, and with the
thumb pushing up the brow as well as possible, so that the head should
be completely flexed. Assistance can sometimes be had by external
manipulation with the other hand, and sometimes by having the woman
in the knee-chest position. Anaesthesia should always be induced in
order to relax the parts and render the manipulation painless." 1 Thorn's
method, previously stated, may be employed in this as well as in pre-
sentation of the face.
THE MANAGEMENT OF PELVIC PEESENTATIONS. The practitioner
must guard against an early rupture of the membranes, and even
though the first stage of labor is protracted it is well to have the
woman lying down most of the time. No effort should be made to
hasten delivery during the expulsion of the lower half of the body ; no
traction upon the trunk is to be exerted, for it may cause not only de-
parture of the chin from the chest, but also of the arms to the sides of
the head or even behind it. If k the patient be anaesthetized, great care
must be taken that the anaesthesia is not to such a degree as to lessen
either voluntary or involuntary expulsive power when those forces are
essential for the prompt expulsion of the upper part of the trunk and
of the head. One hand protects the perineum during the expulsion of
the breech, which is received by the other. As soon as so much of the
body is born that the umbilical cord comes within reach, a loop must
be drawn down to guard against stretching and pressure, and also to
know by the pulsation the condition of the child ; if the cord be around
one of the limbs, it should be removed from this position ; next it must
be placed in such position that it will be least liable to pressure ; that
is, where there is the most room for it, and this will generally be upon
one or the other side of the sacral promontory. If the arms have
departed from the chest, an accident which is not likely to occur
unless traction has been made upon the trunk, they are to be brought
1 American Journal of Obstetrics, 1885.
21
322 PHYSIOLOGY OF LABOR.
down, the sacral arm first, by passing two fingers up to the shoulder,
and along the inner side of the humerus, if this be possible, to the
bend of the elbow, and then by gentle pressure drawing the forearm
over the breast, causing the dislocated member to be returned by a
movement the reverse of that which displaced it. But if it is impos-
sible to reach the elbow, the finger or fingers must be passed over the
acromion and pressure made directly upon the upper part of the
humerus, and gradually carried further toward the elbow, until both
are drawn down. Rotation of the face into the sacral cavity next occurs,
the shoulders now being transverse with reference to the vulval orifice ;
it may be assisted by making external rotation of the shoulders.
DELIVERY OF THE HEAD IN HEAD-LAST LABOR. Although plac-
ing here much which would be properly presented in the chapter upon
obstetric operations, it seems to me best now to consider the different
manual means used in the delivery of the head when it comes last.
FIG. 138.
ARTIFICIAL DELIVERY OF THE HEAD IN PELVIC PRESENTATION.
1. Continued flexion of the head is sought by assisting uterine con-
traction with manual abdominal pressure, and by passing two fingers
of one hand into the vagina which press upon the superior maxillary,
while two fingers of the other hand push the occiput up. This method
is illustrated in the subjoined figure.
Smellie 1 employed it, and it will usually be successful.
2. That which is called the Prague method, though probably origin-
ating with Puzos, is traction upon the child by grasping the ankles
with one hand, while the other is placed over the shoulders, three fingers
on one side of the neck, the thumb and index finger upon the opposite
side ; the pull is at first downward and backward until the head has
i Smellie performed traction upon the lower jaw in these cases, and it was oiuy when he " was
afraid of overstraining it " that he changed the pressure of his fingers to the supeiior maxillary.
THE CONDUCT OF LABOR.
323
entered the pelvis, then upward and forward, the back of the child
coming nearer the mother's abdomen as the head emerges from the
vulva.
3. A better method is represented in the annexed illustration. It
was employed by Mauriceau, but is commonly known as the Veit-
Smellie method. It will be seen in the illustration that two fingers of one
FIG. 139.
MANUAL EXTRACTION OF THE AFTER-COMING HEAD : COMBINED TRACTION UPON MOUTH
AND SHOULDERS (VEIT'S METHOD).
hand are passed into the mouth to exert traction upon the lower jaw,
while the fingers of the other hand pull upon the shoulders ; flexion is
secured partly by the direct force exerted upon the inferior maxilla,
and partly indirectly By the resistance furnished at the pubic joint to
the descent of the occiput. 1 The trunk must be lifted up as the head
descends further into the vulvo-vaginal canal.
4. This, known as the Wigand-A. Martin method^Js the best 2 of all
in a difficult delivery, and when it is important it shall be quickly
effected. It is seen that two fingers of one hand are introduced into
the child's mouth which pull upon the lower jaw, while the other hand
is used to press through the abdominal wall upon the head ; traction
and expression are thus combined.
While as a rule in head-last labor the face rotates into the sacral
cavity, the reverse rotation may occur, and the occiput is found pos-
teriorly, deflection may follow and the chin rest over the pubic joint.
It is necessary in such condition that the occipital end of the occipito-
1 Litzmann, Centralblatt f. Gynakol., 1887, referring to the method commonly "known as the
Veit-Smellie, which ought to be called the Mauriceau-Levret," modifies it according to the sug-
gestion of d'Outrepont thus : The nucha is seized, between the index and ring-finger, the medius
is placed against the occiput behind the pubic joint, and is used to press it upward ; later, when
stronger traction upon the shoulders is to be made, the medius is replaced by the ring-finger.
2 Eisenhart, assistant at the Munich Frauenklinik, has published a paper, Archiv f. Gyna-
kol., 1889. contrasting this with the Veit-Smellie method, and from comparing the results of
the two in a large series of cases arrives at this conclusion : The delivery of living children, and
of children that continue living, is at least seven times greater when pressure is made upon the
after-coming head by the Wigand-Martin-Winckel method than when the Mauriceau-Lachapelle
(Veit-Smellie) method was employed. Herzfeld, Centralblatt f. Gynakol., 1890, comparing the
results from the Mauriceau (Smellie-Veit) method in head-last labor, gives preference to this over
the Wigand-Martin, and considers that it may replace the forceps. His statistics show a slight
preponderance of the Mauriceau method in favorable results.
324
PHYSIOLOGY OF LABOR.
mental pole pass out first, and therefore in the delivery of the child
the body is carried upward and forward, abdomen of the infant toward
the abdomen of the mother.
In any of these methods in which the fingers are introduced into the
mouth great care must be taken lest injury is done with a nail to the
delicate mucous membrane ; I have seen one child bleed to death from
injury thus inflicted, and while I know that the obstetrician usually
comforts himself with the reflection that the child was u a bleeder," I
am not sure that the explanation is always true ; the hemorrhage may
occur when there is not the slightest proof of any hereditary influence.
FIG. 140.
WIGAND-MARTIN METHOD. (WINCKEL.)
As to the amount of force that may be safely exerted in traction upon
the lower jaw, Matthews Duncan from his experiments states 1 that
fifty-six pounds may be applied, in some cases, by dragging the lower
jaw without producing any easily discovered injury of parts.
A serious source of delay in the delivery of the head arises in some
cases from contraction of the os uteri around the neck of the child,
causing a dangerous compression of the throat. Depaul, who has de-
scribed the occurrence of this obstacle, advised the use of the fingers,
introduced into the os to dilate it, and, if resistance continues, incisions.
PEESENTATION OF THE HIPS. Delay in the delivery of the pelvis
in the usual form of pelvic presentation may require, in the interest of
the mother or of the child, manual assistance, and there is usually no
difficulty in bringing down one foot, or both feet, so that traction can
then be readily exerted. There is, however, an unusual form of pre-
1 London Obstetrical Society's Transactions, vol. xx.
CONDUCT OF LABOR. 325
sentation in which not only are the thighs flexed upon the abdomen,
but the legs extended upon the chest ; it is described by French obste-
tricians as presentation des f esses or as presentation du siege dcomplete,
mode des f esses. The lower limbs iu this position act as a splint to the
body, and make it rigid and inflexible. The diagnosis of presentation
by abdominal palpation presents a peculiar difficulty from the vicinity
of the feet to the head, for, as a rule, when a solid, round body is felt
with small mobile parts near it, the conclusion justly drawn is that the
body is the hips, so that in a case of this variety of pelvic presentation
the error of believing that the head is in the lower part of the uterine
ovoid can be very readily committed. It may be, too, that the hips
have entered the pelvic cavity before the labor begins, and hence new
difficulty and increased liability to error in diagnosis by abdominal pal-
pation. These cases are the most unfavorable variety of pelvic pre-
sentation, and, as a rule, assistance is necessary.
Lefour, in an interesting! paper, 1 refers to primitive cases of this anomalous
position of the lower limbs as distinguished after birth by the fact that though
the limbs be drawn down, immediately when they are free from constraint they
return to the position they had in the uterus. Fig. 141 shows this peculiarity.
FIG. 141.
POSITION OF LOWER LIMBS IN CHILD BORN WITH PRESENTATION OF THIGHS.
TREATMENT. There will be presented not only the means necessary
in this, but in other cases of difficult and delayed pelvic delivery.
The forceps may be rejected as a most uncertain, and possibly unsafe,
means if there is really a serious delay in the delivery of the hips. I
do not believe this instrument can be safely used to overcome any great
resistance under such circumstances.
The blunt hook applied over the anterior thigh is frequently used.
Fig. 142. There is danger of fracturing the thigh ; Bitot has shown
that the femur will be fractured by a force of fourteen to fifteen kilo-
grammes acting perpendicularly to the axis of the femur. By consult-
ing Fig. 143 it will be seen that any traction upon the anterior hip is
Contribution a 1' Etude des Presentations du Siege decompleW, mode des Fesses.
326
PHYSIOLOGY OF LABOB.
FIG. 142.
BREECH PRESENTATION. APPLICATION OF THE BLUNT HOOK.
not made directly, only indirectly, upon the part which ought to be
first advanced, the posterior hip, and therefore there is loss of force.
THE CONDUCT OF LABOR. 327
Nevertheless the blunt hook may prove useful ; that of Delore is to be
preferred.
The fillet as advised by Galabiu may be tried. A soft, oiled hand-
kerchief may be used for the fillet ; a knot is tied in it at two opposite
corners. By means of the forefinger the corner is to be passed from
without inward over the flexure of the groin till the knot can be
reached between the thighs and drawn down. In the same way the
opposite end of the fillet is to be passed from within outward over the
other thigh. The centre of the fillet is then slipped up over the but-
tocks till it surrounds the sacrum, and traction is made by the ends. In
this way the pressure is distributed over both groins and the circumfer-
ence of the pelvis.
FIG. 143.
BUDIN AND LEFOUK'S METHOD OF TRACTION.
With such a fillet traction is not only exerted over a great extent of
surface, and therefore with less danger of injury, but the pull may be
made approximately in the line of resistance. If the fillet be placed
over either thigh, the danger of its slipping, and producing fracture
of the femur, is not slight. Moreover, the application of the fillet
when the hips are firmly pressed in the pelvic canal, possibly consider-
ably swelled, is by no means easy, and may be impossible.
Traction with the finger in the anterior groin may not be difficult,
but the force exerted is not great, and, as previously explained, works
at a disadvantage ; much of it is lost. If the hand is introduced pos-
teriorly to carry a finger over the periueal hip, traction upon which will
obviously be much more advantageous, very probably the hips will be
pushed up by the entering hand.
328 PHYSIOLOGY OF LABOR.
Budin and Lefour advise passing one finger in the anus of the patient,
and through the anterior wall of the rectum hooking it over the pos-
terior groin, while the index finger of the other hand is passed over the
anterior groin, and traction then exerted by the two fingers, as shown
in the illustration. This method has succeeded.
Finally, the method advised by Barnes is to be commended, and in
general it may be stated that when the obstetrician in a pelvic presenta-
tion brings down a foot, he is, as Dr. Goodell happily expressed it, com-
mander of the situation, able if delay occurs efficiently to assist the de-
livery.
Barnes 1 decomposes the wedge by bringing down a foot, stating that
he has on several occasions brought a live child into the world after
forceps, hooks, and various other means had been tried in vain for many
hours, by passing his hand into the uterus and bringing down a foot.
His directions are as follows : u Place the patient on her left side ; pro-
duce anaesthesia to the surgical degree ; support the fundus of the uterus
with your right hand on the abdomen ; pass your left hand into the
uterus, insinuating it gently past the breech at the brim, the palm being
directed toward the child's abdomen, until you reach a foot the anterior
foot is the better to take; a finger is then hooked over the instep, and
drawn down so as to flex the leg upon the thigh. Maintaining your
hold upon the foot, you then draw it down out of the uterus, and thus
break up the wedge."
The importance of the proper management of pelvic presentation, more espe-
cially of that variety which is being here considered, and which it seems to
me deserves a distinct name, and I therefore call it femoral, is so great, that I
introduce here directions which otherwise would be included in Obstetric Opera-
tions : it seems to me that the difficulty and the means of remedying it should
be in immediate connection.
When the obstetrician decides in a pelvic presentation to bring down
a foot, two questions are to be first answered : Which is the good hand?
and, Which is the good foot ? The good hand is that which corresponds
with the anterior plane of the fetus. The good foot is that which be-
longs to the anterior hip of the fetus. In the subjoined drawing, Fig.
144, the operator instead of seizing the anterior foot has brought down
the posterior, and consequently the anterior hip is caught upon the pel-
vic girdle in front, and delivery becomes impossible, unless the second
foot is also brought down.
The next illustration shows that the anterior foot is brought down,
and hence no difficulty in the hips entering the pelvis.
But how are we to accomplish what Barnes advises, decompose the
wedge, in what the French term mode des fesses, or what I have called
the femoral variety of pelvic presentation ? The hips, let us suppose,
are fixed in the pelvic entrance, the amnial liquor discharged, the uterus
closely embracing the fetus, it is impossible, as Farabo3uf and Varnier
state, to execute the plan of Barnes, carrying the hand along the ven-
tral face of the fetus, and seize a foot which is at the same level as the
head in the fundus of the uterus. But as shown in Fig. 146, the index
1 Obstetric Operations.
THE CONDUCT OF LABOR.
FIG. 144.
329
THE WRONG FOOT BROUGHT DOWN. (FARABCEUF and VARNIER.)
and medius can be passed along the surface of the anterior thigh, press-
ing it outward and backward, making flexion and abduction complete ;
the inevitable consequence is flexion of the leg, and the foot descends so
FIG. 145.
THE RIGHT FOOT BROUGHT DOWN. (FARABCEUF and VARNIER.)
330
PHYSIOLOGY OF LABOR.
that it is readily caught between the fingers. This is one of the sim-
plest, most satisfactory, and useful of all obstetric 1 manoeuvres.
FIG. 146.
PINAKD'S METHOD OF BKINGING DOWN THE FOOT. (FARABCEUF and VARNIER.)
It should be remembered, too, that this manoeuvre readily secures a
foot, and may be successfully employed in those cases in which there
has not been complete ascension of the legs, that occurs in the femoral
variety, and without violence ; the entire hand is not passed into the
uterus only two fingers. If this method were generally adopted, I
believe the infant mortality in pelvic presentation would be materially
lessened, and there would be fewer instances of fractured femur.
THE MANAGEMENT OF LABOR IN TWIN PREGNANCIES. Tarnier's
statistics show that in more than two-thirds of pregnancies with twins
labor is premature. The reason for this fact is the very great disten-
tion of the uterus. The labor is usually longer in both the first and in
the second stage. The causes are : the changes in the cervix, belonging
to the last period of pregnancy, have not occurred in the majority of
cases, and hence increased resistance is to be overcome, the great disten-
tion of the uterus lessens its contractile power, and the force distributed
over so large a surface is less efficient.
The statistics of Depaul and Tarnier, embracing 316 twin labors, show
that in 131 cases each foetus presented by the vertex; 81 times the ver-
tex of one foetus and the pelvis of the other presented, and 47 times
i Pinard's method is simply a development of that of Madame Lachapelle. Those who will con-
sult the second volume of her "Pratique des Accouchmens," 1825, pp. 88, 89, will find that her
practice suggested the method of Pinard.
THE CONDUCT OF LABOE. 331
the pelvis, and then the vertex, while the remaining presentations were
of the vertex and of the shoulder, of the pelvis and of the shoulder,
vertex and face, face and vertex, etc. Kleinwachter makes vertex pre-
sentations 69.58 per cent, pelvic presentations 25.25 per cent., and trans-
verse 5.17 per cent. Most frequently both fetuses are born with vertex
presentation, 49.29 per cent., more seldom one vertex, the other pelvic,
34.49 per cent. Still more seldom does the birth of both occur with
pelvic presentation, or of the first with pelvic and the second with
shoulder presentation, or both with the latter, 6.23, 6.11, 3.55, 0.33.
FIG. 147.
FIRST CHILD PRESENTING BY THE VERTEX ; SECOND BY THE PELVIS.
B and A, points of maxima of intensity of sounds of the fcetal heart.
While usually the twins lie longitudinally in the uterus, placed beside each
other, as represented in the illustration, in some cases they may be either one
above, or one in front of the other. A full description of the last two anoma-
lous positions of twins has been given by Budin. 1
In more than one- half the cases the second child is born within twenty
minutes after the first. In one of 212 cases given by Collins the inter-
val was twenty hours ; twelve hours and forty minutes in 1 out of 188
cases observed in the Paris Maternity ; Reuss gives an instance in which
the interval was twenty- six hours. When the presentation of the first
child is favorable, the rule is no interference is advisable in the first
stage of labor ; after the os is dilated the membranes may be ruptured
and the labor conducted as usual. After the child is born the practi-
tioner, in most cases, knows for the first time that the pregnancy has
i Op. cit.
332 PHYSIOLOGY OF LABOR.
been plural ; he finds the uterus firm, nearly as large as it was before
the birth of the child, and upon digital examination ascertains that there
is a second one within the womb. In all cases a second ligature of the
umbilical cord is imperative, for while there probably is no vascular con-
nection between the placentae, the possibility of its existence requires
guarding against destroying the life of the second child by hemorrhage.
All traction upon the cord to remove the placenta from the uterus is
especially forbidden. If the mother desires to know if she is to have
another child, a knowledge which in many cases is by no means pleasant,
let the truth be frankly told ; she may at the same time be assured that
the labor will almost certainly be easy and brief, for not only has the
birth-passage been fully dilated, but the second child is generally smaller
than the first. If the presentation is normal, the sounds of the foetal
heart distinct, and the mother's condition favorable none of the grave
accidents of labor, such as eclampsia or hemorrhage, present it is better
to wait untill expulsive pains return, and not cause immediate delivery.
Supposing that the labor is premature, the child expelled feeble or dead,
and the placenta discharged, it is possible, as suggested by Depaul, that
the second child may be carried to the full period of gestation, and
therefore interference would be forbidden. But wheu the placenta re-
mains in the uterus there is no ground for this hope, and the practitioner
should not leave the patient until she is delivered. As soon as decided
pains occur the membranes are to be ruptured, and contraction of the
uterus secured by manual abdominal pressure during and for a time
after the expulsion of the child ; ergot may be given immediately after
the delivery of the placenta.
SECTION III.
PHYSIOLOGY OF THE PUERPERAL CONDITION
CHAPTER XIY.
THE PHYSIOLOGY AND THE MANAGEMENT OF THE PUERPERAL STATE.
PUERPERALITY, or the puerperal state, follows labor, and continues
until the genital organs return to their condition prior to pregnancy,
and is generally regarded as including a period of about six weeks.
But here a qualification of fact and one of time should be stated. There
is never an entire restoration of the genital organs, especially in the
primipara, to their ante-pregnant condition, the changes caused by ges-
tation and labor are not completely effaced ; and, as will be seen in the
study of uterine involution, some of the phenomena in this process last
much longer than the period mentioned.
While pregnancy was marked by extraordinary hypertrophy, a re-
verse process especially characterizes puerperality ; construction distin-
guishes one, demolition the other. There was a building up, and now
there is a tearing down and removal of structure no longer needed.
Moreover, in the early part of the puerperal state a new function is
called in exercise, that of the mammary glands; these organs, designed
to supply nourishment for the infant during the first eight or ten
months of extra-uterine life, enter into action while the ovaries and the
uterus rest ; ovulation, gestation, and lactation are the three character-
istic functions of the female organism, and they are exercised in succes-
sion.
It is important to know the physiological phenomena of childbed,
so that deviations from them may be at once recognized, and, if possible,
promptly arrested. The condition of a woman after delivery has been
compared to that of a person who has undergone a grave surgical oper-
tion ; neither is laboring under disease, but each is more or less ex-
hausted, and each has undergone a traumatism which opens the doors
for the entrance of disease-germs, and both need intelligent and constant
care to guard against danger and to guide to perfect recovery.
The woman who has just passed through childbirth usually enters
into a period of calm rest. The stormy struggle, the severe physical
suffering, and the anxiety are happily ended for most in quiet and
peaceful joy. Generally the puerpera is disturbed by conversation, or
by movement of her body ; her replies to questions are usually in a
low tone of voice and brief, and she desires above all things mental and
334 PHYSIOLOGY OF THE PUERPERAL CONDITION.
physical rest. In some cases there is very great nervous prostration,
presenting, as far as frequency of pulse and somewhat difficult respira-
tion are concerned, the characteristics of post-partum hemorrhage, aud
the heart's action is very feeble, but an error of diagnosis is easily
avoided by finding the uterus well contracted and the flow quite nor-
mal. Perfect rest, the administration of a stimulant, or a hypodermatic
of sulphuric ether with digitalis may be required. But these are quite
exceptional cases, and much more frequently a chill occurs. In about
one-third of parturients there is a chill during labor, or soon after ; the
latter is the more frequent. This chill, which is oftener observed after
a rapid labor, lasts from a few minutes to a quarter of an hour ; it is
not attended with any change in the pulse or in the temperature. The
most probable explanation of this phenomenon is that the organism
suddenly loses a mass to which it had been progressively accustomed,
and this rapid depletion of the abdomen causes immediate cessation of
compression of the viscera, the blood leaves the exterior to fill the space
left in these organs. But, whatever the explanation, the chill is physi-
ological, and portends no danger.
AFTEK-PAINS. A still more frequent cause disturbing the rest of
the newly delivered woman, if she be a multipara, is the occurrence of
painful contractions of the uterus. These are more severe after a rapid
labor ; indeed they may be absent if it has been slow, they only excep-
tionally occur in primiparse, and they are more frequent, too, if the
uterus has been greatly distended. They generally begin a short time
after the expulsion of the placenta, recur at intervals of five, ten, fif-
teen, or twenty minutes, and disappear after twenty-four hours ; they
are excited or increased by the application of the child to the breast ;
exceptionally they continue for two days, or even somewhat longer.
"When after-pains are very close together, and continue thus for some
hours, the fact is cause for anxiety, as they may indicate the beginning
of a metro-peritonitis, aud the temperature of the patient should be
carefully watched.
Expulsion of clots is usually caused by these painful contractions of
the uterus, and when they are moderate in severity their occurrence is
favorable, for they show a uterine activity which is a safeguard against
hemorrhage. The diagnosis ought not to present any difficulty, for the
hand placed upon the abdomen recognizes the contraction of the uterus.
But there may be very severe attacks of " uterine colic " occurring within a
few days after birth, in some cases even causing marked temporary elevation of
temperature, which are purely nervous ; just as there may be vesical or rectal
tenesmus, so there may be a similar disorder of the uterus, and in each case the
organ affected be quite empty.
Prochownick has shown 1 that in some cases of diastasis of the abdominal
muscles the intestine may protrude through the opening, and pain result, which
may be mistaken for after-pains, and probably is thus mistaken in many cases.
A careful examination will recognize the cause of suffering.
THE PULSE. During labor the pulse usually increases from 70 or
75 to 90 or 100 ; but a short time after delivery its frequency lessens,
sinking below the normal in from eight to forty-eight hours ; usually
i Op. cit.
MANAGEMENT OF THE PUERPERAL STATE. 335
the pulse oscillates between 50 and 60, but, according to Blot, between
44 and 56 ; Olshausen makes it between 40 and 50, and in rare cases
says it falls below 40 ; the lowest that I have observed was 46.
The lessened frequency of the pulse was attributed by Marey to increased
blood-pressure, but others assert that this is diminished ; by Olshausen to ab-
sorption of fat from the uterus, but, as will be presently shown, fatty degener-
ation of the uterine muscular tissue does not occur ; to the position of the woman,
and to complete mental and bodily rest. Winckel states that the experiments
of G. V. Liebig make it very probable that there is a causal connection between
the slowing of the pulse and the increase of the vital capacity of puerperal
women.
The slowing of the pulse is justly regarded as a favorable indication,
and the slower the more favorable. The duration of this condition is
usually several days, and the period when it is greatest is from the fifth
to the seventh day (Olshausen) ; Louage 1 states it is the morning of the
seventh day. Buffet says the slow pulse lasts in multipart from five
to seven days, but in primiparse only from three to four.
THE TEMPERATURE. During labor there is generally some increase
in the temperature, and this increase may continue for twelve hours or
more after; it is a little greater in primiparse, and may amount to two or
three degrees F. But within twenty-four hours the temperature declines
and remains stationary during seven or eight days, there being only the
usual morning and evening variations. The following table gives the
result of the average temperatures of twelve patients in whom puer-
peral convalescence occurred without disturbance ; the first temperature
was taken twenty-four hours after delivery. 2
Morning. Evening.
First day . -98.4 98.8
Second day 98.4 98.8
Third day 98.2 98.8
Fourth day 98.2 98.4
Fifth day 98.2 98.9
Sixth day 98.4 98.8
Seventh day 98. 98.4
Eighth day 98.2 98.4
The highest temperature observed in any one of these twelve women
was 98f , and this occurred on the fifth day. Transient elevation of
temperature may arise from mental causes, from disorders of the diges-
tion, or from getting up too soon. But, as Tarnier remarks, these
momentary elevations do not generally involve an unfavorable prog-
nosis ; it is not the same with those that are progressive and continued ;
especially when the thermometer placed in the axilla ascends above
100.4, some complication ought to be feared.
RESPIRATION. The pulmonary capacity, according to Dohrn's in-
vestigation, increases in the majority of cases ; the respirations are from
14 to 18 per minute.
PERSPIRATION. Increased action of the sudoriparous glands occurs
in the first week of the lying-in ; the perspiration is especially abund-
ant during sleep. It has been asserted that if the patient have good
1 Le Pouls Puerperale Physiologique, par Pierre Louage. Paris, 1886.
2 I am indebted to Drs. Phillips and Randall, resident physicians in the Obstetric Department
of the Philadelphia Hospital during one of my terms of service, for the preparation of this table.
336 PHYSIOLOGY OF THE PUERPERAL CONDITION.
nourishment, if she be lightly covered, and if the room be well venti-
lated this increase of secretion may not occur.
The congestion of the skin of the scalp, according to Naegele, causes
exudation in the hair-follicles, and hence falling out of some of the
hair is not uncommon. ||
RENAL SECRETION. The quantity of urine in the first eight days,
Kehrer states, is increased in comparison with that of the non-pregnant,
but lessened in comparison with that of the pregnant woman. Milk-
sugar is found in the urine from the third day, especially if there be an
abundant secretion of milk. This is known as a resorption glycosuria
the sugar being received into the blood from the milk glands and
eliminated by the kidneys ; it would be more appropriately called
lactosuria.
Peptone, according to Fischel, is found almost without exception in
the urine from the second to the tenth day ; it is derived from metab-
olism of albuminous elements of the uterine muscle. The urine in a
limited number of cases contains albumin ; this albuminuria may be
simply that of pregnancy, or that originating in labor, continued, or
may now first appear. The urine also contains small quantities of
acetone. (Winckel.)
f RETENTION OF URINE. Inability to evacuate the bladder is not
uncommon, especially in primiparse, if the labor has been protracted.
The causes of the urinary retention are the ample space given the bladder
to resume its spherical form, while during the latter part of pregnancy
it was flattened, the swelling of the urethra and the neck of the bladder
from severe compression in labor, the loss of abdominal pressure, and
the unaccustomed position the patient occupies while attempting to
urinate, that is, horizontal. If the bladder be distended with urine, the
uterus is carried higher up in the abdominal cavity ; such distention,
too, may cause secondary hemorrhage.
CONDITION OF THE DIGESTIVE ORGANS. The desire for food is less
in the first two or three days, but in consequence of the activity of
various secretions, especially of the kidneys and the sudoriparous glands,
the thirst is great. Evacuation from the bowels is delayed, partly
because of their having been so thoroughly emptied in labor, and partly
because of the character of the food usually taken, and because of the
woman being in entire rest.
PSYCHICAL CONDITION. The newly delivered woman is peculiarly
nervous and sensitive, and disturbed by causes to which she would be
ordinarily indifferent.
LocHiA. 1 This name is given to the flow from the genital organs in
childbed. The discharge comes chiefly from the placental site, and
there are mixed with it fragments of the uterine decidua ; in normal
cases it is free from germs. Passing through the cervix glandular
secretion of the latter is added, and in its further progress the secretions
of the vagina and of the vulva. The uterine lochia are free from germs
1 Ao^/. or Ao^e/a was one of the names given to Artemis or Diana, from her helping presence
at childbirth. From the adjective /lo^eZof , belonging to childbirth, we have the words used by Hip-
pocrates, ra hoxta and -fj /W^a, the discharge after delivery. It would seem, therefore, that
lochia may be used in the singular or in the plural.
MANAGEMENT OF THE PUERPERAL STATE.
337
in a normal puerperium ; injected beneath the skin no abscess or fever
results in human beings or in animals; the flow is alkaline. For the
first four days the lochial secretion is composed largely of blood, and
receives the name of lochia cruenta. (Fig. 148, from Winckel.) It
then becomes lighter in color and thinner, and is called lochia scrosa.
(Fig. 149, Winckel.)
FIG. 148.
FIG. 149.
LOCHIAL DISCHARGE ON THE SECOND DAY.
A FEW ISOLATED Cocci AND STREPTOCOCCI.
LOCHIA CRUENTA.
a. Decidua cells, b. Red blood-corpuscles.
c. White blood-corpuscles, d. Epithelia.
FIG. 150.
LOCHIAL DISCHARGE ON THE FOURTH DAY.
a. Cells of the decidua. 6. White blood-cor-
puscles, c. A few red blood-corpuscles, d.
Epithelial cells without nuclei from the vernix
caseosa, with nuclei from the parturient canal ;
numerous clusters of cocci, partly in cells
without nuclei, which are stained blue by
Gram's method. X 330.
FIG. 151.
LOCHIA, SEVENTH DAY. No ELEVATION or MAMMA IN LACTATION. X 330.
TEMPERATURE. a Colostrum . 6 . Milk .
a Blood-corpuscles. 6. Diplo- and Mono-
cocci, c. White blood-corpuscles, d. Epithe-
lial cells, e. Decidual cells.
The eighth day it becomes yellowish and creamlike ; it is known as
lochia alba. The above illustration from Winckel shows the micro-
scopic appearance of the lochia on the seventh day (Fig. 150).
The chemical character of the fluid, according to Doderlein, in the
vagina favors the development of saprophytes, streptococci, and staphy-
lococci ; inoculation causes fever and abscess. (Scherer, Rokitausky,
Kehrer, Karewski.)
22
338 PHYSIOLOGY OF THE PUERPERAL CONDITION.
The discharge is greater and lasts' longer in women who do not
nurse. In normal cases the quantity is, in the fourth week, very small,
and then usually ceases, presenting before its cessation somewhat the
appearance of uncoagulated albumin. The amount in all is about three
pounds and a quarter, the flow of the first three days being about two-
thirds of this weight.
During the establishment of the milk secretion the lochia temporarily
lessen as a rule, and, on the other hand, increase from great exertion too
early after labor, or getting up too soon.
The odor is not offensive, and should it become so the obstetrician is
watchful lest puerperal infection occur.
Artemieff 2 states that the lochia of healthy women consist of blood-corpuscles,
pavement-epithelium, mucous corpuscles, fatty degenerated cells, and cells which
he designates locheiocytes. In the first few days after labor red blood-corpuscles
predominate, which gradually diminish, while the locheiocytes become more
numerous. With a mixture of pavement-epithelia, mucous corpuscles, and fatty
degenerated cells, the locheiocytes constitute the lochia alba. Locheiocytes are
larger than pus-cells in the proportion of one to two-thirds.
De la Motte, in his Traite des Accouchemens, 1726, gives two cases in which the
lochial flow entirely ceased the fifth day, no injurious consequences being
observed. But my friend, Dr. Darrach, of Germantown, Philadelphia, has told
me of a more extraordinary case, the lochia not appearing at all. Dr. Darrach's
patient was a primipara, twenty-seven years old. After some discharge with the
delivery of the placenta no flow occurred ; she had a normal temperature through-
out complete puerperal convalescence.
CHANGES IN THE GENITAL ORGANS. INVOLUTION OF THE UTERUS.
A woman immediately after labor has more or less soreness of the
external organs of generation. They are tender, and there is the feeling
of their having been bruised ; if a primipara, there is more or less
tearing of the vulval orifice, such injury affecting the fourchette, some-
times the nymphse, less frequently the labia majora, and in some cases
the anterior margin of the vulva. These various parts may become
oadematous, but this condition usually disappears in two or three days,
and they gradually approximate their condition before pregnancy. The
vagina becomes shorter and narrower, but its columns and rugae never
are so distinct as before labor ; its muscular tissue is atrophied, while
the superficial epithelium of its mucous covering is exfoliated ; during
the continuance of the lochial discharge there is a catarrhal vaginitis.
The layers of the broad ligaments, separated by the growing uterus,
re-unite, and the ovaries and oviducts take their usual position in the
true pelvis.
But the most remarkable change occurs in the uterus. This organ,
which weighs soon after delivery 2.2 pounds, two days later only weighs
26J ounces. At the end of a week it weighs about one pound, and at
the end of two weeks its weight is about 12 ounces (Spiegelberg). In
six or eight weeks it has returned to nearly its size before pregnancy.
1 According to the law of the ancient Hebrews, Leviticus XII., a woman was unclean for thirty-
three days after giving birth to a male child, but for sixty-six days if the child was female.
Kehrer, referring to this, makes it equivalent to the statement that the lochia continued these
respective periods. (See Miiller's Handbuch der Geburtshiilie, vol i.)
Hippocrates taught that the flow lasted twenty to thirty days after the birth of a boy, and after
the birth of a girl twenty-five to forty-two days.
2 Zeitschrift f. Geburt. und Gynakol.
MANAGEMENT OF THE PUERPERAL STATE. 339
The process by which this change is effected is called involution. The
uterus was progressively evolved in the course of pregnancy to meet the
requirements of the new being, and now that gestation has ended, there
being no further use for such size and capacity, the organ is involved. 1
As Klein wachter remarks, uterine involution begins with the first
labor-pains. He further states that the contraction of so large a muscle
must go hand-iu-hand with a change of matter, increasing to a high
degree, and although the production of heat is by the consumption of
non-nitrogenous substances, yet long-continued and increased action leads
to the destruction of the functionally active contents of muscle-cells.
Besides, the formation of new protoplasm is interfered with by the com-
pression of bloodvessels during uterine contractions, and the involution
of the muscle is thus in part affected.
In regard to the degree and the character of the changes that occur in the
ultimate muscular tissue authorities are not agreed. According to Spiegelberg,
the uterine muscular substance, pale at delivery, becomes yellowish from the sixth
day, the color being due to a granulo-fatty degeneration of its fibres. But Robin
has stated that the presence of minute drops of fat can be seen from the third
month of pregnancy ; he adds that the diminution of volume of the muscle-fibres
is made solely by atrophy which occurs after labor, and he insists that the fatty
infiltration lessens as the muscular fibres atrophy. Heschl's view, adopted by
most obstetric authorities, attributes very great importance in uterine involution
to fatty degeneration. This degeneration begins about the fourth or sixth day in
the form of minute fat-drops, which by degrees extend so as to fill the fibre-cells,
and soon effect their destruction. From the fourth week a new formation is evi-
dent in the external muscular layers, appearing first as nucleated cells which soon
become fibre-cells ; destruction and regeneration march side by side, and toward
the eighth week, the latter is complete. Mayor's 2 investigations led him to con-
clude that fatty degeneration of the "muscular fibres was more marked than Robin
thought, but still had not the importance attributed to it by Heschl. From the
fact that it was at its maximum at the points where these elements most rapidly
resume their primitive volume, he regarded the degeneration as only a momen-
tary transformation of the protoplasm of the cells designed to favor absorption,
and the disappearance of the materials which constitute the gravidic hyper-
trophy.
The doctrine that there is a complete regeneration of the uterus certainly seems
improbable. Admitting the truth of Aristotle's statement, that nature does noth-
ing in vain, it seems utterly unnecessary to destroy the whole, in order to remove
a part. Moreover, it is somewhat remarkable, that if there is such entire regener-
ation, a new uterus in fact created, the organ in another pregnancy, and after
another labor, behaves so differently from the primitive one ; the new uterus is
more readily distended, and preserves its typical form less completely ; after labor
it fails to contract perfectly, and thus permits the accumulation of blood-clots,
and consequent after-pains. Nature may go on constructing a new uterus a dozen
times even, and the oftener she tries, the more the product of her work deviates
from the original pattern.
Sanger, 3 from his studies of the regressive metamorphosis of the muscular tissue
of the uterus, arrives at a result directly contrary to the statements of Heschl
and of Kolliker, the former asserting entire, and the latter partial, destruction of
the muscular tissue. He has found that the muscular fibres during uterine in-
volution lessen in length and thickness until restored to their primitive form and
size. The fatty degeneration of the muscular parenchyma has simply the signifi-
1 Numerous experiments have been tried using ergot daily during the puerperal period, and the
conclusion of most observers, not of all, is that involution of the uterus is thus hastened, but some
have found that the secretion of milk was lessened. Involution is a physiological process, and
ergot is a medicine its administration presupposes a pathological condition ; the healthy puer-
pera does not need ergot.
2 Siredey, Les Maladies Puerperales.
Central blatt f. Gynakol., 1888.
340 PHYSIOLOGY OF THE PUERPERAL CONDITION.
cation of nutritive phenomena. There is never found external to the muscular
fibrillee fatty detritus ; the combustion of fat-molecules takes place in the interior
of the cell, so that the lipoemia to which Olshausen attributed the slowing of the
pulse of the puerpera does not exist. Dittrich, from a study of the involution
of the uterus in pathological states of puerperal women, embracing 92 cases, 1 has
confirmed the view of Sa'nger.
The restoration of the raucous membrane proceeds at the same time
as the involution of the uterus. Normally, the superficial layer of the
mucous membrane, the decidua vera of Hunter, is detached and expelled
with the placenta and membranes ; but no small part of it may be re-
tained, passing off by fatty degeneration with the lochia. The uterine
glands retain their lining; these are brought closer together by the
retraction of the uterus, from the glandular cul-de-sacs epithelium is
formed, which extends toward the uterine cavity these proliferations
about the end of the third week, according to Leopold, reaching the
surface, and at the end of the fifth week this investment is complete;
that is to say, a new mucous membrane, formed from that lining the
glands, covers the uterine wall. Very important changes occur at the
site of the placenta. In the eighth month some of the venous sinuses
are closed by thrombi, and after the expulsion of the placenta the re-
maining ones are closed in the same way ; the thrombi degenerate and
are gradually absorbed, but the process is not completed until four or
five months after labor.
CHANGES IN THE BLOODVESSELS. It is generally thought that many
of these vessels are so firmly compressed by the contraction of the
uterus as to undergo fatty degeneration and absorption. The larger
arteries are partially obliterated by proliferation of the connective tissue
of the intima; the media is destroyed by fatty degeneration ; new mus-
cular elements take the place of the degenerated ones where the vessels
are to remain ; other vessels are simply narrowed, and continue. Accord-
ing to Balin, the regressive metamorphosis begins later and lasts longer
than the same process in the muscular structure of the uterus, occupy-
ing several months.
POSITION AND FORM OF THE UTERUS. Immediately after delivery
the uterus is a round, hard body reaching a little more than four inches,
eleven centimetres, above the pubic symphysis, and very nearly the same
distance from side to side. A few hours later, either from relaxation or
from the bladder being filled, it reaches somewhat higher ; subsequently
a more or less continuous diminution goes on, so that by the tenth day
the fundus is at the superior margin of the pubic joint; the daily de-
crease in the height of the fundus above the pubic symphysis being from
two-fifths to four-fifths of an inch, or from one to two centimetres.
During this time its position varies with the position of the patient, but
it inclines toward one or the other side, and does not occupy the median
line. The puerperal uterus is often auteflexed, and in some cases this
anteflexion is so great that an obstruction to the passage of the lochia is
caused, and the condition known as lochiometra results.
Depaul gave the following as the approximate relative positions of the fundus
of the uterus in the first days of the puerperal state. The first day it is a finger's
i Centralblatt f. Gynakol., 1889.
MANAGEMENT OF THE PUERPERAL STATE.
341
breadth above the umbilicus ; the second day at the level of the umbilicus ; the
third day a little below ; the fourth day but little variation from the preceding ;
the fifth and the sixth clays two fingers' breadth below ; the seventh, eighth, and
ninth days three or four fingers' breadth above the pubic joint; the tenth, elev-
enth, and twelfth days at the level of or a little below the pubis.
FIG. 152.
PUERPERAL UTERUS THE FIRST DAYS OF THE LYING-IN. (After a frozen section by WYDER.)
The following is a table given by Ahlfeld as to the position of the
uterus above the symphysis, and its width in the first ten days :
After the discharge of the placenta
End of the first day
End of second day
End of third day
End of fourth day
End of fifth day .
End of sixth day
End of seventh day
End of eighth day
End of ninth day
End of tenth day
CHANGES IN THE NECK OF THE UTERUS. Directly after birth the
neck of the womb is relaxed and soft, and has been compared by Klein-
wachter to the vulva ; the canal admits three or four fingers readily,
but slight resistance is offered by the internal os ; the length of the
cervix is about 2.7 inches, or 7 centimetres. At the tenth day the canal
no longer admits even one finger, and by the twelfth the neck is only 3
centimetres, or a little more thau an inch long, according to Lott.
Height above
Syinphysis.
Greatest Breadth.
11 cm.
10 cm.
10.8
10
10
9.6
9
8.9
8.4
8.6
7.7
8
7
7.4
6.6
7.4
6.2
6.6
5.8
6.6
5.5
342 PHYSIOLOGY OF THE PUERPERAL CONDITION.
Loss OF WEIGHT IN LABOR AND DURING LYING-IN. Gassner
states that the body increases during the last three mouths of pregnancy
about one-thirteenth of the entire weight ; this increase is proportionally
less in prirnipane than in multipart ; during labor a woman loses one-
ninth of that she had at the end of pregnancy, the loss being chiefly
due to the expulsion of the foetus and its appendages and the amnial
liquor, but also to the blood lost in the discharge of the placenta, to
fecal matter expelled, and to pulmonary and cutaneous excretions.
During the first eight days of lying-in the woman loses 1 one-eleventh,
the loss resulting from the lochial discharge, the increased action of the
kidneys and the skin, and the mammary secretion. This loss, how-
ever, is not so great if a good diet be given, as the statements in foot-
note show. Further, Baumm, in Winckel's clinic at Munich, has
proved that with generous food the loss of weight is about one-fourth
less than that observed by Gassner. The total weight lost in labor and
in the puerperal state amounts to about one-fifth that of the body. At
the end of three or four weeks after labor the loss has ceased, and gen-
erally a gain begins.
THE SECRETION OF MiLK. 2 During the latter part of pregnancy
and immediately after labor a fluid called colostrum is found in the
breasts, and often spontaneously exudes or can be pressed from the
nipple ; to this fluid, as found in the cow immediately after calving, the
name of biestings is given. An abundant secretion of colostrum in
pregnancy indicates a large supply of milk. Colostrum differs in color,
specific gravity, and composition, and morphologically from milk. It
is yellowish-white, is richer in fat and sugar than milk, and contains
albumin instead of casein; it has a larger supply of salts than milk,
and hence, according to most authorities, proves a laxative to the new-
born child, assisting in carrying oif meconium ; but this excess in salts
is not great, and it is more rational to attribute the laxative property of
the fluid, as De Sinety does, to its richness in glandular elements, which
produce indigestion. The following is Marchand's statement as to the
composition of the two fluids :
In 100 parts of each
Colostrum. Milk.
Proteine elements 17.20 1.90
Lactine 630 5.30
Butter 4.50 4.50
Salts 0.25 0.18
Water 71.63 81.12
The liquid portion of milk is simply a transudation from the blood,
while the morphological constituents proceed from the gland cells.
Colostrum corpuscles are remarkable for their size, contain fat granula-
tions, and are probably detached glandular elements; either the cell-
wall is broken down, and the contents set free, or, as De Sin6ty holds,
the cells have contractile movements, and by these the fatty particles
are expelled. These minute fat granules unite together to form larger
masses and of different sizes ; their mixture with the trausudatiou from
1 " Klein wSchter, however, by means of better nourishment, arrived at a different result ; he
noted only about half the loss of weight reported by Gassner, and Klemmer, in my Dresden clinic,
by means of meat diet, succeeded in obtaining not only less falliug-off in weight, but in some cases
the patient gained up to the tenth dav." f Winckel )
2 See Fig. 151.
MANAGEMENT OF THE PUERPERAL STATE. 343
the blood makes a fine emulsion, and this is milk. The casein of milk
is probably formed from the albumin of the blood, and the sugar of
milk from the glucose.
PHENOMENA ASSOCIATED WITH THE ESTABLISHMENT OF THE SE-
CRETION OF MILK. The current of blood which has been flowing to
the uterus for nine months now turns to the mammary glands, and on
the second, or oftener on the third day, these organs enlarge and their
sensibility increases ; the skin covering them is smooth and tense, the
nipples are less prominent, and very frequently some pain is felt in the
axillary glands ; in consequence of the swollen condition of the breasts
the arms cannot be brought close to the sides of the chest. The general
phenomena attending upon the beginning of the milk flow are restless-
ness, thirst, headache, occasional neuralgic pains, loss of appetite, and
possibly slight increase in temperature and in the frequency of the pulse.
But that which the old authors called milk fever is not now admitted ;
in very rare exceptions decided fever, even preceded by a chill and last-
ing twenty-four hours, has been observed in cases in which no compli-
cation was present, but the almost universal rule is that there is no milk
fever ; as Lorain remarked, it is a vague tradition which does not rest
upon classic observation. Siredey, collecting in one year 360 observa-
tions as to changes in temperature, states he can assert that in every case
in which the temperature in the axilla exceeded 100.4, he found the ex-
planation of the febrile movement independent of the lacteal secretion.
ChantreuiPs investigation led him. to conclude that the morbid entity called
milk fever very rarely occurred ; that in entirely normal cases the pulse did not
rise above 76, and consequently there could be no question about fever, and that
the temperature followed the variations of the pulse. In normal cases the tem-
perature did not rise during the secretion of milk above 100.4 or 100.2, figures
which have been adopted as expressing the mean temperature by all authors
who have been occupied with the study of thermoinetry.
The secretion of milk continues from 8 to 12 mouths. The quan-
tity increases until 6 or 7 months, and decreases from the 8th mouth.
The casein increases until the 2d month, and decreases from that to the
9th, and so also the butter ; the sugar lessens the first month, then
increases ; the salts increase the first five months, and then diminish. 1
If the woman does not nurse, the milk disappears in about a week.
Menstruation is, as a rule, absent during lactation, but ovulation may
occur, and it is not uncommon for women to conceive while nursing ;
should conception occur, the supply of milk lessens and finally ceases.
THE MANAGEMENT OF CnrLDBED. There will be considered under
this head not merely the care of the mother, but also that of the child.
ATTENTIONS TO THE MOTHER.* After the thorough cleansing of
1 Zuelzer, quoted by Kleinwachter.
2 In some parts of the world it appears that attentions to the father are of great importance,
thus
Peschel, The Races of Men, pp. 24-25, refers to paternal lying-in as having been observed by in-
habitants of the four quarters of the globe in Borneo, for example, the father of the newborn
child is for eight days allowed to eat nothing but rice, must take care not to expose himself to the
sun, and must give up bathing during four days ; and states such coincidence of error can be ex-
plained in one or the other of only two ways either all the varieties of our race once dwelt
together in a narrow home when the error originated, or the mental faculties of all these families
even in their strongest aberrations are the same.
The significance of couvade, or male childbed, is thus given by Dr. Poy, of Dublin, in the
British Medical Journal, September 26, 1891 : The writer states that " there are good grounds for
344 PHYSIOLOGY OF THE PUERPERAL CONDITION.
the external sexual organs by a warm antiseptic solution and a similar
injection in the vagina, the necessary care of injuries, 1 if any have
occurred, and proper arranging of the bed and body clothing, the
patient may have some nourishment if she desires, and should have if
she needs it.
REST. In the great majority of cases, a few hours' sleep will be
the most important restorative, and, therefore, means that conduce to
this end should be used. Generally a quiet room and moderately dark-
ened will be all that is required ; but in some cases there are such rest-
lessness and nervous excitement that an opiate must be given. So,
too, if after-pains are so severe and frequent that she cannot sleep, and
external applications, e. g., of cloths wrung out of hot whiskey, with
compression of the uterus, fail to relieve, opium and camphor, or auti-
pyrine, may be given ; quinine in a dose of ten grains is used by some
practitioners.
The practice which old obstetricians had of preventing a woman's
sleeping during the first hours following labor, lest flooding might
occur, had no just foundation either in reason or in experience.
Of course, visitors are not admitted, and if the baby's cries disturb
the mother it should be taken for a few hours into another room. She
should lie the first few hours chiefly upon her back, and then occasion-
ally upon either side, for it is better she should not be restricted to one
position.
The question as to absolute rest in bed for some days after labor is not a new
one. Sydenham's wise observation taught him that of those who died after
childbirth the result in the great majority of cases was from getting up too soon,
and he said he did " not suffer a woman to get up before the tenth day." That
sagacious and successful obstetric practitioner, the late Dr. Churchill, stated that
for one evil result from an error in diet he had seen ten from assuming an up-
right position or leaving the bed too soon. White, 2 on the other hand, had the
puerpera sit up in bed a few hours after delivery, and the sooner she got out of
bed the better ; this was not to be deferred beyond the second or third day.
Goodell had the patient sit up the day after labor, while her bed is making ; this
sitting up is repeated once or twice a day, until the fourth or fifth day, when
she, if so disposed, gets up and dresses herself. Solovieif 3 sustains the practice
of Goodell.
Kunge, 4 who insists upon the woman remaining in bed at least nine days, says
that in the first two days she should be upon her back, and then cautious move-
ments and the side position are permitted. Sitting in bed, for example, while
the conclusion that by the act of couvade the husband accepts the paternity of the child, declares
himself its author, and symbolizes by his acts that his conduct is directed by a desire for its pros-
perity, and the attention given him by his -rife and friends is an acknowledgment that they recog-
nize his claims and facilitate his design."
1 The following statistics of one of the residents during my term of service in 1889 are here in-
troduced, having been omitted in their more appropriate connection. They show that injuries of
the perineum in childbirth are more frequent 'than practitioners who never make examinations
after labors assert.
PHILADELPHIA HOSPITAL, March 12, 1889.
DEAR DR. PARVIN : I am very happy to send you the following report on the condition of the
perineums in the last one hundred primiparse and last one hundred multiparae delivered in the
maternity department :
Primiparse : Perineum intact, 58 Multiparse : Perineum intact. 84
Lacerated, 41 Lacerated, 16
Episiotomy, 1
100 100
Very respectfully, F. W. TALLEY.
Treatise on the Management of Pregnant and Lying-in Women.
8 Archives de Tocologie, February, 1881.
* Lehrbuch der Geburtshulfe.
MANAGEMENT OF THE PUERPERAL STATE. 345
nursing, eating, and urinating is positively forbidden during the first five or
six days.
While some nurses and doctors think that the sooner a woman after
confinement is up and dressed, apparently well, the greater their credit,
it must be admitted that very seriously injurious consequences of too
early getting up may not be immediate but remote, such as uterine dis-
placement or subinvolution, and that prolonged rest is a less evil than
the former ; better keep a woman in bed a week too long than have
her get up a day too soon. Again, every woman is a law unto herself;
one may convalesce much more quickly than another, and uterine invo-
lution be more rapid. The condition of the patient is a better criterion
as to the fitness of getting up than the number of days after labor ;
so, too, the effect produced by being up ought to be considered in
deciding as to permitting it to be continued, and, therefore, if, for
example, the woman has a return of the red lochia, or if abdominal
pain be caused, the indication is very plain for immediate return to
bed. It is probably best for most women not to sit up out of bed until
ten or twelve days have passed, and then only for a short time, though
sitting up in bed while taking their meals may be permitted in most
cases after the third day ; it is better for the puerpera to remain in her
room for at least three weeks.
FOOD. In regard to this question the most diverse opinions have
been held. Dionis referred to the popular notion of his day, that a
woman has lost so much blood in labor, and so much, too, is lost by
the lochia, she ought to eat more abundantly than at any other time, in
order to repair the loss, and condemned it, because the woman was in
u a state of fever," and the fever was sure to come on the second or
third day. Dewees would not allow any animal broth until after the
fifth day, or any animal substance until after the fifteenth ; he gave for
the first few days oatmeal gruel, tapioca, sago, mush and milk, rice and
milk, tea, coffee, or very thin chocolate. In recent years, however,
there has been a reaction against the absolute diet once insisted upon by
obstetricians. But there is a just mean between famishing and feasting,
between restricted and generous diet, which the practitioner will best
follow. Those who have seen how well a patient, upon whom ovari-
otomy has been performed, gets on for the first few days with water,
barley-water, and lime-water and milk, will hardly believe that the
puerpera on the first day needs either chops for breakfast, or abundance
of roast beef for dinner, but rather that she will convalesce more rapidly
if liquid food is chiefly given. l Indeed, her often temporarily enfeebled
digestion and her little desire for solid food point very plainly to proper
dietetic practice ; her thirst is usually much greater than her hunger.
At this time the simpler articles of food, such as tea and toast, the
lighter animal broths, milk toast, or soft-boiled eggs will be most accept-
able ; let her gradually resume her usual diet. On the other hand,
there are women whose digestion is perfect, and whose appetite from
the first craves more liberal nourishment, and there can be no objection
to giving them, from the beginning, the more easily digested animal
foods. Or again, there may be a patient so greatly exhausted that beef-
tea, milk-punch, or eggnog must be given at frequent intervals. There-
346 PHYSIOLOGY OF THE PUERPERAL CONDITION.
fore, no absolute rule as to the diet of the first days can be given ; each
case must be judged by itself, and the food directed according to the
condition. Cold water will usually be found the most acceptable drink,
and can be given at frequent intervals. If, however, the secretion of
milk l>e too abundant, it can be diminished by lessening the quantity of
fluids taken, and under these circumstances it is well to have the patient
quench her thirst by pieces of ice rather than by copious draughts of
water or of other fluid.
THE CONDITION OF THE BLADDER. The puerpera should be
directed to empty the bladder twelve hours after delivery, for unless so
advised she may be unconscious of the accumulation of urine, and it
may continue until the organ is so greatly distended that spontaneous
evacuation is impossible, even in case there be no obstruction of the
urethra from swelling. If urine is not passed within twenty-four hours,
the catheter 'must be used, and its use repeated in from eight to twelve
hours until the patient recovers the lost power ; the instrument must
be carefully disinfected before and after use, and the parts adjacent to
the urethral orifice washed with an antiseptic solution, e. g., 5 per cent,
solution of carbolic acid, before the instrument is introduced, for a
cystitis may result from neglect of these precautions ; in some instances
the inflammation passes from the bladder to the ureter and the kidney.
In order to run no risk of carrying from the external genitals septic
matter into the bladder, it is advised by some to trust to sight and not
to touch in catheterizatiou ; but unless the nurse uses the instrument,
this is not expedient. In some instances there is dribbling of urine
from a very full bladder, and both the patient and nurse insist that the
organ is completely emptied when in fact it contains a large amount' of
urine ; in all doubtful cases the practitioner should carefully palpate the
abdomen, and if doubt remains remove it by introducing the catheter.
By abstaining from the use of the catheter, unless the indications are
plain a distended bladder and suffering, and inability to empty it, not-
withstanding external applications and moderate pressure we have the
best prophylactic of puerperal cystitis. 1
CONDITION OF THE BOWELS. On the third or fourth day a free
alvine evacuation is to be had either by a warm-water enema, by a dose
of calcined magnesia, by Rochelle salts, a Seidlitz powder, liquid citrate
of magnesia, one of the mineral waters, as Hunyadi Janos, or by castor
oil, which remains, notwithstanding all prejudices and reproaches, one of
the safest and most certain laxatives for the puerperal woman. In case
she does not nurse her infant a saline is preferred, as the watery opera-
tion to some extent lessens the determination of blood to the mammary
glands. After the first free evacuation the bowels should be moved
every day, or every other day.
THE LOCHIA. CARE OF THE EXTERNAL GENITALS. VAGINAL
INJECTIONS, ETC, Napkins or antiseptic pads are usually applied to re-
ceive the lochial flow ; if the former, they should be sprinkled with a warm
antiseptic solution before application, or absorbent cotton, prepared as
has been stated, may conveniently replace the latter. Kaltenbach advises
1 Schatz, of Rostock, advocates in ischuria which persists in lying-in women, dilatation of the
urethra to an extent admitting the little finger rarely, a second dilatation is necessary.
MANAGEMENT OF THE PUERPERAL STATE. 347
either cotton or jute, which after use may be hurued. During the first
week the external genital organs are to be bathed twice a day with a warm
antiseptic solution, e. g., 1-2 per cent, creolin mixture in water, and if
there be the least offensive odor of the lochia a similar solution should
be injected in the vagina twice or oftener in twenty-four hours ; but
unless there be this indication vaginal injections are not given. Raw
surfaces at the vaginal entrance or upon the external genitals are to be
carefully and gently washed twice a day with the creoliu mixture, and
then they may be dusted either with iodoform or with one part of sali-
cylic acid and ten of starch. Sponges should not be used in bathing,
but absorbent cotton or perfectly clean cloths, the cotton or cloths being
afterward burned. The temperature of the room should be from 60
to 65; the room must be well ventilated, but the patient is to be pro-
tected from drafts of cold air ; all soiled clothing, napkins, etc., and
urinary or fecal evacuations must be promptly removed so as not to
poison the air by their exhalations. While care is taken that the pa-
tient is not chilled, the active state of her skin making her peculiarly
susceptible to any sudden reduction of temperature, she ought not to
be so carefully and heavily covered with bed-clothing as to make her
uncomfortable and increase the perspiration. The room is generally
kept moderately darkened, in the interest of the mother to promote her
rest, and in that of the child to prevent the supposed injurious effect of
light upon its eyes.
Changes in the clothing of the puerpera are made from day to day as
cleanliness and comfort require ; it is important that all clothing, and
especially garments that come in direct contact with the skin, be dry
and warm, though few would direct the method to secure this end
advised by Hubert. 1 The exclusion of visitors during the first week
materially assists in the convalescence of the patient.
LACTATION. Moralists and obstetricians agree in urging the impor-
tance of the mother nursing her infant. 2 As a rule, she thus best secures
her own and its health, she obejs nature's law and design, promotes the
closest mutual attachment, and has an important influence in fashioning
the first mental and moral development of her offspring. The preva-
lence of wet-nursing has been said to be the proof of a people's decline.
Maternal nursing was once held in such high honor by some of the
Romans that it appears no greater praise could be inscribed upon a
1 Hubert says that the chemise should be worn a day by the mother or the sister, or placed dur-
ing a night in the husband's bed, before she wears it. Upon the page containing this suggestion
he narrates from Djonis the well-known story in regard to Clement using for the dauphiness after
her first labor the fleece of a black sheep, this fleece being placed jusc after its removal from the
living animal upon the naked abdomen of the puerpera, and his not using it in her subsequent
confinements. The butcher brought the fleece carefully folded in his apron to the bedside of the
patient, but unfortunately had left the door open, and the fleeceless sheep, bleating and bloody,
followed him, greatly to the consternation of the dauphiness and of the ladies present ; this acci-
dent prevented the repetition of the remedy. Clement's and Hubert's practice may be placed
side by side.
Another curious fact is related by Dionis which shows that a medical sect of the present day have
at least an illustrious example in the belief that odors, as flowers, have an unfavorable effect upon
the sick. " It is claimed that odors have a very injurious influence at this time ; and persons who
are perfumed are not allowed to enter the room or princesses or of ladies of rank. In the case of
the dauphiness, the usher had orders to examine the ladies who came, and to send away any who
were perfumed or had flowers." Traite General des Accouchements, 1718.
2 The late Mr. Darwin, in his Descent of Man, suggests the probability that during " a former
prolonged period male mammals aided the females in nursing their offspring, and that after-
'ward from some cause, as from a smaller number of young being produced, the males ceased giv-
ing this aid ; disuse of the organs during maturity wo'uld lead to their becoming inactive."
348 PHYSIOLOGY OF THE PUERPERAL CONDITION.
mother's tomb than that found, according to Hubert, upon the tombs of
many women dying in Hadrian's time: Filios suos propriia uberibus
educavit.
In the Spectator, No. 246, there will be found an excellent article by the cele-
brated essayist, Steele, advocating maternal nursing. So, too, in Richardson's
Pamela there is a valuable discussion of the subject. Surely, argument upon
this theme is better than the Zolaism which infects so many novels now-a-days,
and which even enters medical literature with needless pictures of woman's
external sexual organs and her nude form, and such exhibitions are almost as
odious as the egoism which parades upon every occasion, and without occasion,
the photograph of the doctor !
OBSTACLES TO THE MOTHER'S NURSING. Nevertheless there may
be circumstances or obstacles arise which will forbid the mother nurs-
ing. First. The child may be illegitimate, and the mother, to hide her
shame or to save it from disgrace, must part, with it. Nevertheless it is
better to nurse it during the first few weeks. Second. The poor quality
or scanty secretion of milk may discourage the mother from nursing.
But means may be used to increase the secretion and to improve the
quality of the milk ; and, at any rate, mixed, nursing is better than a
diet exclusively of artificial food that is, let the child get all it can from
the mother, then make up the deficiency by artificial food. Third.
Vices of conformation of the nipple, or changes in the structure of the
gland, the latter generally resulting from inflammation in a previous
confinement, may render lactation difficult or impossible. Fourth. Dis-
eases of the mother which are aggravated by nursing, or will injure the
infant through the milk, forbid her nursing. Thus if the mother be
exhausted by anaemia, or if she be suffering from phthisis, she ought not
to nurse; indeed, a marked predisposition to the latter is a reason for
not nursing, since the statistics of Flint show that in 13.5 per cent, of
married women under forty years who are phthisical the disease is de-
veloped during lactation. If syphilis be recent, the mother should not
nurse, for then the probability is the child is not infected ; but other-
wise, that is, if the mother was syphilitic when she conceived, or acquired
the disease in the first half of pregnancy, she may. It is criminal to
employ a wet-nurse for a syphilitic child.
As far as the infant is concerned, it may have been born prematurely,
and be so feeble it cannot nurse at first ; or it may be so deformed as,
for example, by harelip or it may have been so injured in natural or in
artificial delivery that it is unable to do so. In some cases the disability
is only temporary.
TREATMENT IF MOTHER DOES NOT NURSE. If a woman is not to
nurse, let her have a less liberal diet until the secretion of milk disap-
pears, and until then, too, a saline laxative may be given each day, be-
ginning with the third; the breasts are covered with a layer of cotton-
batting, which is to be frequently changed as it becomes wet with the
mammary secretion or with that of the sudoriparous glands ; in this, as
well as in other cases, the gland may be supported when greatly enlarged
by a properly applied handkerchief, the ends of which are tied over the
opposite shoulder. Various popular as well as professional remedies
have been recommended to stop the secretion of milk ; among the former
MANAGEMENT OF THE PUERPERAL STATE. 349
may be mentioned a piece of flannel saturated with spirits of camphor
applied to each breast, and among the latter iodide of potassium intern-
ally and belladonna locally. Generally all local treatment, except that
which comforts the patient, is unnecessary, as the secretion stops if the
milk is not required, for the great law of political economy is as true
here as in the department of manufactures if there is no demand, there
will be no supply and possibly some if not all the remedies advised to
arrest the secretion have no more virtue than one which Mauriceau 1
mentioned as being employed in his day.
If the breasts are greatly increased in size, the application of a band-
age is important ; it contributes to the patient's comfort, and in lessen-
ing the supply of blood by compressing the breasts, of course diminishes
the secretion of milk.
CARE OF THE BREASTS IN NURSIXG. In case the mother is to nurse,
the child is not put to the breast until twelve hours after labor. Some
advise the first application to be made as soon after delivery as the
woman has had the necessary attentions, while others would wait until
the secretion of milk is established, alleging that an earlier application
is vain in securing nourishment, that it wearies the mother and renders
her more liable to sore nipples. Immediate application is to be rejected
because the mother is so fatigued and needs rest, and a late one because
of the difficulty of the child's nursing then, from the breast being so
swelled that the nipple cannot be readily seized by it. While it is true
that the infant gets little nourishment during the first twenty-four or
forty-eight hours, yet it does get the colostrum which nature seems to
have designed as a suitable laxative ; moreover, it is usually satisfied
with it, and is saved from having its stomach filled with improper food.
It is probable, too, that the early and frequent removal of the con-
tents of the breasts not only secures a proper formation or drawing out
of the nipple, but also leads to a gradual secretion of the milk, and thus
local and constitutional disturbances from this cause are prevented. Cer-
tainly, if we follow the rule observed by the young of inferior mam-
mals, the child will be put to the breast within a few hours after birth :
but the rule of twelve hours, as given above, is better.
The breasts are carefully protected from cold by covering them with
soft flannel or linen, which much be changed when it becomes moist.
The infant, as a rule, should not be applied to each breast at one nurs-
ing, but to them alternately, thus giving the nipples as long a rest as
possible between the times of nursing, until liability to inflammation
has passed. The infant must got be allowed to sleep with the nipple
in its mouth, for then it sleeps and sucks alternately, and its digestive
organs, kept in almost constant exercise, are liable to become disordered ;
this practice is very fatiguing to the mother, and the nipple being kept
constantly moist and heated, softening and desquamation of the epi-
dermis follow, with consequent erosions and fissures of the nipple, and
thus the doors are opened for the entrance of germs, causing, finally,
inflammation of the breast.
1 " I know some women who held it for a very great secret, and most certain to drive the milk
effectually back and that is, to put on her husband's shirt yet warm, immediately after lie had
taken it off, and wear it until the milk be gone." (Op. cit.) Of course, the value of the remedy is
indicated in the last words, " wear it until the inilk be gone."
350 PHYSIOLOGY OF THE PUERPERAL CONDITION.
Before aiid after each nursing the nipple as well as the mouth of
the child should be washed with clean water, and twice a day a little
cocoa butter may be applied to the former ; if it becomes sensitive,
and especially if the slightest rawness or excoriation 1 appears, the
surface may be pencilled once or twice a day with compound tincture
of benzoin ; if this treatment does not suffice, there may be conjoined
with it, lightly touching the tender surface, a twenty-grain solution
of nitrate of silver, and the use of a nipple-shield the best is Need-
ham's ; after the application of the tincture of benzoin the nipple is left
exposed until the tincture dries, and especially there must be no lint or
a rag placed upon the surface, which of course can be removed only
with the greatest difficulty at the next nursing.
Boric acid in a 3 per cent, solution has been employed as a lotion,
and also used for saturating compresses laid upon the nipple in order to
prevent mammary inflammation ; the success was certainly great. A
very weak solution of corrosive sublimate, as advised by Tarnier, has
also been employed with somewhat greater success. 2
During the first two or three days the infant, if comfortable, sleeps
almost all the time, and once in five or six hours is as 'often as it needs
to nurse ; with the perfect secretion of milk the intervals must be
shortened to two or three hours, endeavoring, however, to have the
child nursed only twice in the night, so as to secure the mother as long
periods as possible of uninterrupted rest. The infant ought to get an
ample supply from nursing fifteen to twenty minutes ; if it continue
nursing longer, there is almost certainly insufficient secretion of milk.
AGALACTIA. If the milk be scanty, it may in many cases be increased
by giving the patient a liberal diet, 3 especially by having her take ani-
mal broths, chocolate, and milk freely ; if the last can be drunk at the
temperature it is furnished by nature, it is best ; some women find that
malt liquors increase the flow of milk when all other means have failed,
and only under those circumstances may they be advised.
Various galactagogues have been recommended, such as the leaves of the
castor-oil plant applied to the breast, and drinking certain vegetable infusions,
as of anise and of fennel ; faradization of the breasts has in some cases produced
remarkably beneficial results. Kaltenbach says that the laity attach great
importance to the so-called milk-powder: Pulv. sem. fcenicul., cort. aurant.,
sacch. alb. aa. g. 2, magnes. ca'rb. g. 4. But these are not to be compared with
suitable and sufficient food conjoined with regular rest and as entire freedom
from care as possible, the use of moderate but not fatiguing exercise in the open
air, and avoidance of anxiety ; mental worry, bodily fatigue, and loss of sleep
notably lessen the supply of milk.
GALACTORRHCEA. Galactorrhoea may occur when there is polyga-
lactia or excessive secretion of milk, and also when the secretion is
normal in amount. As usually seen in the puerpera it is the former
variety of the disorder, is only temporary, and generally yields to mod-
erate compression of the mammae, a restricted diet, and saline laxatives.
De Sine'ty refers to cases in which the supply of milk is so abundant that sev-
eral infants could be nursed, and weaning does not arrest the exuberance. Very
1 At the maternity, Brussels, Hagermann advises in excoriation or fissures of the nipple 1 part
each of tincture of benzoin and of balsam of Peru, and 8 parts of simple cerate.
- See Pingat's monograph, De la prophylaxie des abces du sein.
3 An objection has recently been made to milk, on the ground that it acts as a diuretic, and does
not increase the mammary secretion.
MANAGEMENT OF THE PUERPERAL STATE. 351
great inconvenience results from this condition, for the breasts are painful and
the constantly flowing milk requires several napkins a day for its absorption ;
finally the subject may become exhausted by the discharge, a condition formerly
called tabes lactea resulting. Marvellous stories have been reported, especially
by Puzos, 1 as to the abundance of the secretion of milk. Borelli stated that a
nurse had so great a supply she not only suckled two infants, but sold a large
quantity to an apothecary who from it made butter for the phthisical. Ridley,
a physician, said of his wife that she nursed twins, several small puppies, and
then had enough milk escape from her breasts in twenty-four hours to make a
pound and a half of butter. 2
DIAGNOSIS OF RECENT DELIVERY. Very important questions in medical
jurisprudence may arise in connection with childbirth. One of these relates to
the evidence of recent delivery. If a priinipara, the fragments of the torn
hymen will be visible at the entrance of the vagina ; the frsenulum will almost
invariably be found torn, and very probably more extensive injury to the peri-
neum ; the external genital organs are swelled, red, sensitive to the touch, and
show various recent injuries ; there is a bloody discharge from the vagina, and
this organ will have injuries involving its mucous membrane, its rugae are absent,
and its calibre is so much increased that the hand can be introduced. In multi-
parse all these signs may be wanting except the discharge and the capaciousness
of the vagina, and the absence of rugse, though there will be almost always
swelling and redness of the external genitals. The uterus is a round, hard body,
readily felt by abdominal palpation ; the abdominal wall has its central line of
pigmentation, and laterally the bluish cicatrices of pregnancy may be seen,
while if the woman be a multipara white cicatrices are usually found. The breasts
are swelled, the areola discolored, and colostrum or milk may be pressed out of
the nipple. After seven or eight days external injuries of the genitals will be
healed, but the lochial discharge remains, and the characteristic striae and the
pigmentation may be observed upon the abdomen and the breast; the uterus
will be found enlarged. Korrnann states that after the third week the question
of recent delivery can hardly be answered with certainty. When the delivery
was premature the difficulty increases with the length of time that may have in-
tervened before the completion of pregnancy, and if there are no external
injuries the diagnosis will chiefly rest upon the lochial discharge and upon the
increased size of the uterus.
May the second stage of labor be so rapid in its progress or so sudden in its
termination that a woman is taken by surprise, as it were, so that she cannot lie
down upon the bed or on the floor, and the child, born while she is standing,
falls on the floor, receiving serious or fatal injury ? Kleinwachter's answer is,
that it may happen with a multipara whose soft parts are greatly relaxed and
offer little resistance, the labor-pains very strong, the basin of normal width, or
somewhat greater, and the foetus of the usual size ; for several cases of this acci-
dent in which there was no question of medical jurisprudence involved have
occurred. He regards it, however, as hardly possible in the case of a primipara.
Yet it may be conceived as not impossible that a primipara alone, or without
any intelligent person being present, may be deceived by the factitious desire to
empty the rectum when the child's head is very low down, causing her to leave
the bed for the water-closet, and the child being born there perish for want ot
proper immediate attention. Again : May a woman give birth to her child while
she is in bed, and she be in such condition that the child perishes for want of
proper attention, smothered it may be by the bed-clothes or in consequence of
its face falling directly into a pool of liquid between the mother's thighs ? The
answer generally made to this question is that such an event may happen in the
case of a primipara, but not in that of a multipara. Yet it would be going too
far to say that while exceedingly improbable in the case of the latter, it is neces-
sarily impossible.
ATTENTIONS TO THE CHILD. The care of the infant immediately
after birth in case it should be in a normal condition has been considered.
1 Traite des Accouchmens. Paris, 1759.
2 It would appear from these Illustrations that it is possible for a wet-nurse, contrary to the
opinion expressed in a recent poem, " Glenaveril," to be a table d'hote.
352
PHYSIOLOGY OF THE PUERPERAL CONDITION.
But if labor be premature or from other cause the infant is very feeble,
it may be necessary to postpone the washing and dressing, and simply
wrap it in warm cotton and surround it by bottles of hot water, or use
other means to secure for it a normal temperature ; it is then too feeble
to suck, and must be fed with milk from the mother's breast for some
days.
The results which have been attained in Paris by means of the couveuse and
gavaye in prematurely born infants are very remarkable. By these 30 per cent,
of children born at six months have been saved, 63.6 per cent, of those born at
seven, and 85 7 per cent, of those born at eight months. The couveuse, or incu-
bator, will rarely be used outside of maternities ; its purpose being to secure for
the infant a uniform temperature of 85-95 F., this end must be obtained in
private practice by the means previously suggested. But gavage is available to
the practitioner. The apparatus used by Tarnier is shown in the subjoined illus-
tration. The practitioner can easily improvise a simpler apparatus ; all he needs
is a small glass funnel to which a rubber tube is attached the red rubber cathe-
FIG. 153.
'ft/
50
40
30
]
TARNIER'S APPARATUS FOR THE ARTIFICIAL FEEDING OF PREMATURE OR FEEBLE INFANTS
(GAVAGE) ; LUER'S MODEL.
ter is advised. The food being ready, preferably milk from the mother's breast,
the infant is placed, with its head slightly raised, upon the knees of the nurse ;
the free end of the tube is moistened, then passed to the base of the tongue, and
the infant by the instinctive efforts at swallowing will carry it to the entrance of
the oesophagus, when the nurse by gentle pressure pushes the" end into the stomach ;
the distance is about six inches from the part which enters the mouth to that
which is in the stomach. The milk is now poured into the funnel, or receiver,
and gravity quickly carries it through the tube into the stomach ; the tube must
be promptly withdrawn after the funnel is empty, lest the child vomit. The
MANAGEMENT OF THE PUERPERAL STATE. 353
quantity and the frequency of the feedings will depend upon the age and strength
of the infant. A very feeble infant, born some time before the end of pregnancy,
must be fed every hour, and between two and three teaspoonfuls of milk given at
each meal. (This description has been condensed from Tarnier's directions.)
DISCHARGES FROM THE BLADDER AND BOWELS. Some time in the
first twelve hours the infant usually urinates. The urine during the
first few days has a low specific gravity, and is quite pale. Apparent
retention is generally non-secretion ; for when the infant takes little or
no food the quantity of urine secreted is necessarily very small. If
there be actual retention and no urethral obstruction, a warm bath, fol-
lowed by the application of cloths wrung out of warm vinegar to the
hypogastrium, has been recommended ; the use of the catheter is very
rarely necessary. Meconium, so named from its resemblance to the
juice of the poppy, is usually passed a few hours after birth ; but if the
anus be not imperforate, a delay of a day or two in this evacuation need
give no anxiety ; in case of longer delay a simple enema of warm water
or of flaxseed tea may be used, or a little sweet oil given by the mouth.
The third or fourth day the meconiura usually disappears from the
stools, and these gradually become a light canary-yellow.
THE UMBILICAL CORD. In three-fourths of infants born at term
the stump of the umbilical cord falls off within five days, but in prema-
ture infants the time is longer.
Ahlfeld has recently employed secondary section of the navel cord, and the
prevention of disease of the navel and adjacent parts he believes is thereby
secured. His method is, the third or fourth day after birth, to cut off the stump
of the cord, it previously having been disinfected ; the cut surface is sprinkled
with boric acid.
The raw surface left by the detachment of the cord does not cicatrize
for eight or ten days ; it may be washed daily with carbolized water,
and afterward a carbolized ointment applied, or it may be dusted with
calomel or with a simple absorbent powder.
UMBILICAL HEMORRHAGE OR OMPHALORRHAGIA. It has some-
times happened that a woman has given birth to her child while stand-
ing, and the infant falling to the floor the cord has been torn, or a
similar tearing has occurred in forceps delivery, the cord being abnor-
mally short, and in either case more or less serious hemorrhage may
follow. But the most frequent variety of umbilical hemorrhage ob-
served is that which may happen several days after the birth and sub-
sequent to the detachment of the cord. In forty-one cases collected
by Miuot 1 the average time was eight days ; in four the hemorrhage
began before the separation of the cord, in three immediately after, and
in the others at periods varying from one to thirteen days. Grandidier,
quoted by Marduel,* states that in one case it did not begin until the
fifty-third. In a large proportion of cases jaundice was present ; in
some the hemorrhage was evidently dependent upon a hemorrhagic
diathesis. The prognosis is quite unfavorable, for a great majority die
in a time varying from a few hours to some weeks. In the treatment
1 American Journal of the Medical Sciences, 1852.
2 Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, vol. xxiv.
23
354 PHYSIOLOGY OF THE PUERPERAL CONDITION.
it is useless to trust to astringents and compression. The only plan
which holds out hope of success is to pass a harelip pin or a needle
through the skin of the umbilicus upon one side, then beneath the
bleeding surface, and have its point emerge from the skin on the oppo-
site side, and a second pin is passed beneath and transverse to the first ;
a figure-of-8 ligature is made around the projecting parts of each pin,
and the entire mass ligated. The pins are removed on the fifth day,
but the ligatures are undisturbed and left to fall off with the ligated
mass.
SECRETION OF MILK. The enlargement of the breasts in male as
well as in female children, which with secretion of milk is sometimes
observed a few days after birth, has been mentioned. This irritation
almost always spontaneously disappears in two days ; probably suppu-
ration does not occur except in those cases in which the organ has been
accidentally bruised, or if injudicious nurses have rudely squeezed it in
efforts to force the fluid out.
CHANGES IN THE SHAPE OF THE HEAD CAPUT SUCCEDANEUM
CEPHALH^MATOMA. The alterations in the form of the cranium
occurring in childbirth disappear in the course of a week, or a some-
what longer time, and Nature is quite able to restore the original form
without efforts on the part of the physician or the nurse to mould the
head. The caput succedaneum, unless very large, usually disappears
in a few days, and meantime, if anything is done, it may be occasion-
ally bathed with a solution of muriate of ammonium. It is only
rarely that suppuration occurs, and then if the collection of pus be
large it must be opened. In cephalhsematoma absorption may occur in
from ten to sixty days ; suppuration is an occasional consequence, and
recovery may follow the discharge of the matter ; but sometimes ne-
crosis of the bone and even perforation, with resulting hernia of the
brain, are observed. Bouchut suggests in case of a large tumor which
does not diminish in ten or twelve days under the application of a
solution of muriate of ammonium, or of camphor, or of an alcoholic
mixture, the evacuation of its contents by an aspirator.
Winckel from the sixth to the eighth day incises the tumor, unless
it is quite small, following the incision by pressure on the detached
periosteum with salicylated cotton ; cure occurs in a few days. If an
abscess forms, it is opened, the cavity washed out with one-half per
cent, creolin mixture, and gentle compression with salicylated cotton,
previously advised, employed.
CHANGES IN THE SKIN OF THE NEWBORN DESQUAMATION
JAUNDICE. About the third day after birth desquamation of the epi-
dermis begins, and usually ends within a week.
About two-thirds of children have what has been called physiologi-
cal jaundice, first appearing two to four days after birth, and continu-
ing for a week or ten days. This is more marked in feeble infants, in
those born prematurely or who have been exposed to cold, as is the
fact frequently in foundlings. Various explanations have been given
of the affection, but none is .satisfactory. Active treatment is not indi-
cated, as spontaneous recovery occurs.
The grave form of jaundice, or pathological jaundice, often septic in
MANAGEMENT OF THE PUERPERAL STATE. 355
its origin, is generally, if not always, fatal. It is also more frequently
observed in children born with pelvic presentation.
According to Hofmcier, 1 every infant lives for a time upon its own organism
on account of insufficient nourishment being provided immediately after birth ;
this is accompanied with degeneration or decomposition of albumin and red
corpuscles. Bile-pigment is formed from the pigment of the latter. At the
same time the activity of the intestinal canal causes a great increase in the
amount of bile secreted, so that the quantity is larger than that excreted after
a certain degree of intensity has been reached, and icterus neonatoruiu results,
or, if the skin be not colored, bile may be found in the urine.
Bouchut 2 regards hepatitis, of which one of the manifestations is jaundice, as
very common in the newborn, its causes being compression of the body, or con-
tusion of the liver in labor, the impression of air upon the external surface, and
umbilical phlebitis caused by ligating the cord, and extending to the hepatic
veins. In eight or ten days the jaundice disappears.
Winckel adopts Birch-Hirschfeld's opinion that in consequence of swelling of
Glisson's capsule, resulting from lessened pressure in the portal system following
division of the cord, the bile-ducts are compressed, and therefore the jaundice.
But in the malignant form of jaundice there are fever, swelling of the abdo-
men, and tenderness in the right hypochondrium with enlargement of the liver ;
there may be nausea and vomiting, and in some cases epistaxis, purpura, or
haematemesis. The respiration is difficult, hiccough frequent, and as M. Richard
points out, when this state is prolonged or increases, a profound change of ex-
pression follows, the eyes are fixed, convulsions affecting the muscles of the face
and of the limbs occur, the infant sinks into collapse, becomes cold and dies.
BATHING SLEEPING NOURISHMENT. An infant should have a
bath once in twenty-four hours, in order to insure that perfect cleanli-
ness upon which its health and comfort so greatly depend. It should
not be accustomed to sleep in the nurse's arms, nor in the mother's
bed, but in a separate one. As previously stated, it ought to be ap-
plied to the mother's breast twelve hours after birth. It ought, as as-
serted by Kleinwiichter, to be subjected to a definite order in sucking
from the beginning. After the secretion of milk has become abundant,
generally the third day, " the child may be put to the breast every two
hours, for at that time the capacity of the stomach is not great ; after
four or five days once in three hours, and at night there should be an
interval of six or seven hours ; later on six applications in twenty-four
hours will suffice."
The child, as a rule, loses weight during the first few days ; the loss
is from 150 to 200 grammes, and is to be attributed to discharge of
urine and of meconinm, and also to the scanty supply of nourishment ;
at the end of the first week the child weighs nearly or quite as much
as it did at birth.
The best proof of the good quality and of the sufficient quantity of
the milk, whether of wet-nurse or of mother, is given by the thriving
of the infant. If the child grows well, is plump and healthy, it must
have good and abundant food ; the old law, " by their fruits ye shall
know them," is here quite applicable. Nevertheless, other means may
be mentioned. When the infant is at the breast it can be known that
it is getting milk readily by the movements of the cheeks alternating
with those of swallowing ; the last is often accompanied by a sound
1 Kormann. .. 2 Op. cit.
356 PHYSIOLOGY OF THE PUERPERAL CONDITION.
which Hubert compares to that made in uttering the French word
glou-glou. So, too, if the milk is abundant it is found in drops 1 at the
angles of the mouth or upon the adjacent part of the cheek, after the
child has finished nursing.
It sometimes happens that the mother has apparently a sufficient supply of
milk, but its inferior quality is shown not only by the child's failing to thrive,
but by disorders of digestion, attacks of colic, and the abnormal character of the
stools. It may be that one, two, or three meals of artificial food each twenty-
four hours will work a happy change in the infant's condition, and the mother,
less worried and her rest less disturbed, and at the same time less frequently
nursing the infant, secretes a better milk, and therefore she may continue to
nurse, her deficient supply being thus supplemented.
Weighing the child from time to time is an excellent test of the quantity and
quality of milk : the increase in weight ought to be about one ounce a day.
SELECTION OF A WET-NURSE. The most desirable age for a wet-
nurse is from twenty-two to thirty-five years. If a married woman, it
is better that she should be a multipara, for the milk is then not only
more abundant, but she is less liable to suffer from disease of the nipple,
or mammary inflammation, and, moreover, has acquired useful experi-
ence in the care of an infant. If unmarried, she ought to be a primi-
para, for, as suggested by Hubert, 2 while the first fault might be
excused, after the commission of a second there would be no guarantee
that a third might not occur while she was nursing.
Delore states that from the time of Ambrose Pare blonde women were consid-
ered inferior nurses, and indicates that brunettes are generally preferred as
habitually more vigorous. Dionis asserted that the best nurses were those of a
sanguine temperament, and who have black or brown chestnut hair. Bad nurses
were those of a bilious or melancholic temperament, and who have blonde or
red hair.
She must be free from syphilis, tuberculosis, or exanthematous dis-
ease. There ought not to be a difference of more than two months
between the birth of her own and that of the infant she nurses. The
breasts should be of medium size, and the nipple free from excoria-
tions, of such size that the infant can readily grasp it with its mouth,
and the milk be easily drawn. As a rule, a woman who menstruates
regularly ought not to be taken as a wet-nurse. Supposing everything
favorable as to the supply of milk and the physical health, considera-
tion should be given to her moral character and disposition, for while
it is true that the milk of the nurse 3 can transmit no intellectual or
1 The most gifted poetess of the century, if not of all centuries, Elizabeth Barrett Browning, has
alluded to this where she speaks of the babe " knowing all things by their blooms, not their
roots," etc. :
"And human love, by drops of sweet
White nourishment still hanging round
The little mouth so slumber-bound."
! The remark of Hubert suggests quoting the following observation by Goldsmith :
' ' For the first time the very best may err ; art may persuade, and novelty spread out its charm.
The first fault is the child of simplicity, but every other, the offspringof guilt." Vicar of Wakefiled.
The belief that the milk which nourished the newborn had much to do with the formation of
the character is an old one ; even to this day it is not uncommon to hear one speak of having
sucked in with his mother's milk certain beliefs or principles, especially those of a religious char-
acter ; but the expression is used more as a figure of speech to indicate how completely and thor-
oughly those beliefs or principles are interwoven with his spiritual nature, having been taught
him in the very dawn of his intelligent existence, than that they came by the nourishment de-
rived from the mother. The famous Cato, however, did believe that affection might be thus com-
MANAGEMENT OF THE PUERPERAL STATE. 357
moral qualities to the nursling, yet it is also true that with the devel-
opment of the infant's intelligence it will receive in its plastic nature
impressions more or less profound and permanent from one with whom
it is so intimately and constantly associated as the nurse. Moreover,
the question as to her disposition is an important one, siuce for the time
being she is to some degree a member of the family ; taking the child
to her own home to nurse is quite exceptional. 1 Further, it is generally
admitted that the milk may at once undergo important modifications in
consequence of profound mental emotion. Devilliers remarks that it
would be easy to adduce examples of nurses in whom violent passions,
especially anger, changed the qualities of the milk so as to disturb the
health of the infant, and even cause severe convulsions. And he adds :
"A thousand times better a woman somewhat stupid, of an impassive
character and almost insensible to passions, than a nurse with intelli-
gence more developed, but of a passionate and choleric character."
ARTIFICIAL FEEDING. In case the mother cannot nurse her infant,
and it is impossible to obtain a suitable wet-nurse, artificial nourish-
ment must be used. Condensed milk is a very convenient form of food,
especially in cities and in hot weather, when it may be difficult to obtain
pure milk from the cow. Babies like it, and rapidly fatten taking it,
and they are free from constipation. The liability to rhachitis in chil-
dren living on it exclusively has been stated by Fleischmaun, Lusk,
Galabin, and Starr. Runge remarks : " The condensed Swiss milk
contains 39 to 48 per cent, of sugar, and therefore is not to be employed
exclusively." The milk of the cow is that which, as a rule, can be
best used for the nourishment of the infant ; it has been the practice to
select the milk from one cow ; Winckel, however, advises that of sev-
eral mixed together. In order to remove all possible infectious matter
the milk ought to be boiled before using it; recently there have been
invented apparatuses for sterilizing milk ; milk after being subjected to
this process may be kept for several days without change ; the great
lessening of infant mortality in hospitals since the introduction of ster-
ilized milk is conclusive proof of its value.
Cow's milk, after sterilization, will be diluted with two parts of water
that has been boiled, and sweetened with milk sugar, for the infant during
the first four weeks. Then the proportion of water is gradually less-
ened until at the end of eight weeks equal quantities of water and milk
are given. At four mouths the milk is given undiluted.
But cow's milk, even with these additions, differs from human milk,
and various methods have beei\ employed to make an artificial fluid of
which the former is the base, which shall be more nearly like that which
mothers provide for the infant. The following is a formula approved
by Dr. Fullerton :
municated, for, according to Plutarch's statement, he had his wife, whenever she nursed her son,
also give her breast to the infants of her slaves, so that sucking the same milk they might have an
affection for him. Cruelty of disposition was also thought to be derived from the first nourish-
ment. Thus among all the bitter reproaches which the deserted Dido cast upon the escaping
2Eneas, one of the severest, as indicating his cruel nature, was that he had nursed the breasts of
Hyrcanian tigresses. Gardien quotes the statement that if young lions are nourished by cow's
milk they are gentle, and, on the other hand, that if puppies are brought up by wolves they are
fierce.
1 This seems not to have been extraordinary among the Egyptians, as the story of Moses' in-
fancy suggests.
358 PHYSIOLOGY OF THE PUERPERAL CONDITION.
Milk fgij.
Cream f |iij.
AVater f.5x.
Milk-sugar 3vj:|.
" Put iu a flask in the steamer and steam for twenty minutes ; then
remove the flask from the steamer, and when still slightly warm add
lime-water f 5j. It may be placed on ice, and a sufficient quantity taken
from it when needed."
DIFFICULTY AND PAIN IN URINATING. It occasionally happens
that male children have great pain before, and some difficulty in urina-
tion; upon examiuation it will be found that the trouble arises from
stenosis of the orifice in the prepuce. Of course, circumcision is a cer-
tain and permanent cure, but dilatation will also be successful, and it
will generally be preferred ; dilating may be done by drawing the pre-
puce over the closed blades of a suitable forceps inserted in its orifice,
and then opening the blades until about one-half of the glans is ex-
posed; cold water is applied for an hour, and the dilatation may, if
necessary, be repeated after one or more days.
THRUSH/ SPRUE, MUGUET. These different names are applied to
an affection of the mouth of the infant characterized by the appearance
upon the tongue and upon the inner surface of the cheeks, thence pos-
sibly extending to other or to all parts of the buccal mucous membrane,
of small, white curd-like patches. The affection is much more frequent
in the hand-fed than in the breast-fed, and is not so much a disease as
indicative of a diseased condition of the mucous membrane and of the
secretions, furnishing a suitable soil for the growth of the fungus, sac-
charomyces albicans, formerly called by Robin o'idium albicaus. The
occurrence of such a growth is usually an indication that proper care of
the child's mouth has not been taken in regard to washing it, or that in
artificial feeding either the food is not in suitable condition, or the vessel,
the tube, and the nipple are not thoroughly cleansed. The best local
application is borax ; it may be used as a solution in water, twenty
grains to the ounce, freely pencilled three or four times a day upon the
patches, or, as advised by Winckel, a mixture iu syrup may be used, of
which half a teaspoonful is given one to three times a day, the child by
the movements of its tongue making a better application of the remedy
to the diseased places than can be done with a brush.
1 Thrush, probably from the same root as thrust and sprue, spelled by some lexicographers
sprew, from the same root as sprout.
SECTION I.
INTRODUCTORY. The pathology of pregnancy includes :
First. The abnormal position occupied by the ovum completely or
partially. Thus, if the ovum be outside the uterine cavity, it is out of
place, a condition commonly known as extra-uterine gestation, but which
has been more appropriately called by Barnes ectopic.
Further, the placenta, instead of having its site in the upper portion
of the uterus, may in whole or in part be in the lower uterine segment,
that is, be prsevial.
These are the gravest deviations from normal pregnancy.
Following the consideration of placenta prsevia, of which the domi-
nant symptom is hemorrhage, that has been called unavoidable, there
will be presented the subject of accidental hemorrhage, or bleeding from
premature detachment of the placenta occupying its normal site.
Second. The woman may suffer from exaggeration of a physiological
change incident to gestation, or disease of an organ may otherwise be
consequent upon the pregnant condition ; if she were not pregnant,
neither morbid manifestation would occur. In illustration, the common
nausea and vomiting of pregnancy may be so aggravated that peril to
life is imminent. Again, albumiuuria may be caused by gestation.
Third. The woman when she becomes pregnant may be laboring
under some chronic disease, as pulmonary tuberculosis, or syphilis.
Fourth. Gestation does not exempt her from acute diseases; these,
then occurring, as erysipelas, variola, scarlatina, cholera, pneumonia, etc.,
may be injuriously affected by the pregnancy, or on the other hand have
a deleterious influence upon the. latter.
Fifth. Diseases of the sexual organs are necessarily included in the
pathology of pregnancy.
Sixth. Surgical operations, or iujuriesand accidents occurring in preg-
nancy, are to be considered.
Seventh. Diseases of the ovum make an important part of the path-
ology of pregnancy.
Eighth. As a result usually of causes included in some of these classes,
the pregnancy may be arrested, and therefore such interruption, whether
by abortion or by premature labor, must be here presented.
CHAPTEK I.
ECTOPIC DEVELOPMENT OF THE OVUM OR OF THE PLACENTA.
ECTOPIC PREGNANCY DEFINITION AND ETIOLOGY. The normal
place in which the ovum is developed is the uterine cavity, and there-
fore if this development occurs in the tube, in the ovary, etc., the
ovum is ectopic, that is, out of place, and the pregnancy is so called.
While the causes, as Martin has said, 1 are obscure, this is true in general,
for there are instances in which the etiology is certain, though in many
others we must be coutent for the present with probable explanations.
1. The body of the uterus having been removed, impregnation may
occur. This happened in a patient of Koeberle, the uterus having been
amputated because of a myoma ; there was a fistula in the cervical cica-
trix, and through this spermatozoids entered. Kaltenbach suggested
that a similar event might happen in case of removal of the inverted
uterus, 2 or after a Porro operation.
2. The ovum may escape into the abdominal cavity, from the uterus,
through an opening in the latter which remained after a Csesarean sec-
tion ; this occurred in a case reported by Lecluyse.
3. Absence of ciliated epithelium from the tube. This absence is ex-
plained as the result of catarrhal inflammation. Those who hold that im-
pregnation normally occurs in the uterine cavity claim that these cilia by
their movements toward the uterus prevent the spermatozoids from
ascending the tube, but if they have been destroyed no obstacle is
offered. On the other hand, admitting impregnation in the external
portion of the tube, the belief generally held, ciliated action is necessary
for the transfer of the ovum to the uterus. The result is the sam,e,
whichever theory is adopted.
4. Narrowing of the tube. The lessened diameter of a part of the
oviduct may be the result of perimetritic adhesions, of twisting, of
cicatricial contraction following inflammation, of a polypus, or of a
fibroid tumor of the uterus in the vicinity of the uterine entrance of
the duct.
5. Impermeability of the oviduct. An ectopic gestation thus caused
must be explained by the hypothesis of an external migration of the
spermatozoids or of the ovule after its impregnation. Thus, supposing an
atresia at some part of one tube, the other being normal, the spermato-
zoids passing through the latter, the ovule liberated from the ovary of
the opposite side is impregnated, and entering the other tube is arrested
by the obstruction. Or, an impregnated ovule may, it is supposed, pass
over to the opposite tube. But these explanations are chiefly hypo-
1 Congrfcs PSriodique International de. Gynecologic et d'Obstetrique. Bruxelles, 1894.
* MUller reported a case of ectopic gestation in a hernial sac ; A. Martin- Wend ler, in the am-
pulla of a tube that after the extirpation of a cancerous uterus had been pushed into the vagina,
and J. Veil a similar case. Ahlfeld.
ECTOPIG PREGNANCY. 361
thetical, and there must in some cases be a doubt as to whether the closure
of the tube preceded or followed the impregnation. The last observation
also may sometimes apply to those cases in which iutra-uteriue migration
of the ovum has been observed. In this migration the ovum entering
through the pervious tube is found developed in the partially closed tube
of the opposite side.
6. Accessory tubes and tubal ostia may be causes of ectopic gestation,
as recently l maintained by Siinger.
Dr. Joseph Price, of this city, has had 108 cases of ectopic gestation,
and all of them, he states in a recent communication to me, were pri-
marily tubal with one exception, possibly two, the ovary involved form-
ing part of the sac.
He regards the following as causes : " Catarrhal troubles and dis-
torted positions of the pelvic viscera ; emotional disturbance is no small
factor."
The abnormal situation of the ovum has occurred in many cases after
a period of sterility, or after an attack of gonorrhoea, or after a child-
birth followed by pelvic inflammation. The great majority of cases
are observed in women who have previously borne one or more children.
Several cases are recorded of ectopic associated with normal pregnancy,
and a few of double ectopic gestation. 2 It is quite possible that some of
the cases reported as double ectopic gestation were really single, for
hsematosalpinx is not infrequent, affecting the tube not occupied by the
ovum.
FREQUENCY. It is impossible even to approximate an accurate state-
ment as to how often ectopic gestation occurs in comparison with normal
pregnancies. The statements of authorities widely vary. Thus Wiuckel
saw ectopic gestation in 16 cases to about 222,000 births, while Bandl
had only 3 in 60,000 births ; Ahlfeld speaks of only one case observed
by him in twelve years at Giessen and Marburg, and, on the other hand,
Dr. Price has met with so large a number of cases, as stated above,
that he regards the accident as occurring once in 1000 pregnancies.
In arriving at a probable conclusion as to the frequency of ectopic
pregnancy, it must be remembered that the late Matthews Duncan, justly
as I believe, said, " There 3 are many cases in which the disease is never
suspected ; the foetus dies, and is, so to speak, entombed." Kaltenbach
speaks of hemorrhage into the tube which, in part with the ovum, finds
its way into the abdomen, where the embryo is quickly absorbed, while
the amnion itself and especially the chorial villi with their characteristic
epithelium remain a longer time between the blood-clots. So, too, in
some of the cases of tubal abortion in the first weeks, the developing
ovum occupying a place near the pavilion, and expelled into the abdomi-
nal cavity by the contractions of the oviduct, it is quite probable the
1 Monatschrift f. Geburtshiilfe und Gynakologie, January, 1895. It is of interest to observe in
this connection that Kossmann states, Zeitschrift filr Geburtshiilfe und Gynakologie, 1894, that
accessory tubes and tubal ostia are found in 4 to 10 per cent, of women.
2 One of the most remarkable explanations of an ectopic gestation is given in the Philadelphia
Medical Museum, vol. i., new series, 1811. Dr. W. B. Smith, of Jamestown, Va., describes the
autopsy of a colored woman, in which he found double ovarian pregnancy, one ovary containing
a ftetus four inches, and the other one eight inches long. The tubes were diseased, so that the
" male semen " could not have passed through either, and hence he suggests that impregnation
resulted from the semen being taken up by the blood, and thus carried to the ovaries.
3 London Lancet, July 13, 1889. The statement by Duncan, quoted above, is confirmed by Ahlfeld.
If the fostus " dies early, the sac may atrophy without the woman having any observable injury."
362
THE PATHOLOGY OF PREGNANCY.
expulsion may take place without any serious symptoms, and the patient
soon recover.
I therefore repeat the statement made in the second edition of this
work, that probably there is one case of ectopic gestation to 500 of
normal pregnancy. Those who make their estimates from abdominal
sections and from post-mortem examinations probably omit of the entire
number of ectopic pregnancies quite as many as they record.
VARIETIES. These are primary and secondary, and of each there are
two. Primary ectopic gestation is either tubal or ovarian, with the sub-
varieties tubo-uterine, also called interstitial, tubo abdominal, and tubo-
ovarian. The secondary varieties are abdominal and subperitoneo-
pelvic, or pregnancy in which the developing ovum is between the layers
of one of the broad ligaments, the result of a ruptured tubal pregnancy.
PREGNANCY IN THE EXTERNAL THIRD OF THE LEFT TUBE. (After WINCKEL.)
a. Ovary, b. Left tube. c. Tubal gestation cyst. d. Adhesion.
TUBAL PREGNANCY. This is by far the most frequent variety of
ectopic gestation. Some indeed contend that it is the only one, Dr.
Doran, for example, stating that he is inclined to believe that all are
tubal.
One of three events occurs : Tubal abortion, rupture of the tube, or
completion of pregnancy ; the second is the most frequent, 1 rupture
generally taking place within six to eight weeks, and the last is the
rarest. That the development of the ovum may continue until term is
proved by a few cases, among them one of Spiegel berg's, and in publish-
ing it he added five similar cases reported by others, and one reported
by Dr. Joseph Eastman, of Indianapolis, in which he operated at terra,
saving both mother and child. Kaltenbach admits it, stating, however,
that it is exceedingly rare.
DEVELOPMENT OF THE OVUM IN TUBAL GESTATION. The ovum 2
has the same deciduous membranes formed from the mucous membrane
1 Abortion is about as frequent as tubal rupture, according to some observers. Ortbman, indeed,
Zeitschrift f. Geburtshlilfe und Gynakologie, 1894, of 124 cases of tubal pregnancy in the first four
months, found 61 each of abortion and of rupture ; in 2 each accident occurred.
2 Lederer : Beitrage znr Anatomic der Tuberschwangerschaft. Berlin, 1888, and Berlin Thesis,
by John von Glahn, 1888.
ECTOPIC PREGNANCY.
FIG. 155.
363
TUBAL PREGNANCY. RUPTURE OF GESTATION CYST. (From RAMSBOTHAM.)
of the tube that in normal pregnancy are contributed by the lining mem-
brane of the uterus. The muscular fibrillse of the tubes during the
first two mouths hypertrophy, and then a retrogressive metamorphosis
begins, caused by a pressure-atrophy from the growing ovum. The
ACTUAL VIEW OF PLACENTAL VILLA. (Drawn by E. TEICHELMAN from section made by BERRY HART.)
c. Encroaching upon and causing thinning of the muscular wall (a) of the Fallopian tube.
b. Maternal blood sinuses.
364
THE PATHOLOGY OF PREGNANCY.
chorial villi, forerunners of the foetal portion of the placenta, enter the
connective tissue ; their penetration into the muscular layer, observed in
one case by Leopold, was not found in the examination made by Diihrs-
sen. The preceding illustration, Fig. 156, is from Tait's lectures on
" Ectopic Pregnancy."
In Zucker's 1 case of tubal pregnancy rupture with fatal hemorrhage
occurred when the gestation was only between two and three weeks.
The rupture is generally into the peritoneal cavity, and very rarely be-
tween the layers of the broad ligament. In many cases the mother,
unless saved by a surgical operation, perishes within a few hours. But
if the rupture should occur in that portion of the tube not covered by
peritoneum, the danger is much less, for the connective tissue uniting
the two folds of peritoneum not yielding readily, in some degree restrains
the bleeding, and its meshes facilitate coagulation. In the great majority
of cases the embryo dies, and a haematoma results, which remains for a
time; this may be gradually absorbed, or suppuration with the forma-
tion of an abscess occurs. 2 But in exceptional instances the develop-
FIG. 157.
FIG. 158.
DIAGRAMMATIC SECTION OF FALLOPIAN TUBE REPRESENTING THE Two DIRECTIONS OF RUPTURE.
1. INTO THE PERITONEAL CAVITY. 2. INTO THE CAVITY OF THE BROAD LIGAMENT. (From TAIT.)
a. Clot at point of rupture. 6. Wall of the Fallopian tube. c. Cavity of the broad ligament,
with (3) folds separated by hsemic effusion, o.
ment of the ovum continues, and there is an extra-peritoneal, broad
ligament, or intra-ligamentous pregnancy. The usual course of this
pregnancy will be described hereafter.
The possibility of a development of the ovum in the tube and liga-
ment should be borne in mind ; then there is a tubo-ligamentous preg-
nancy. Some authorities regard those rare cases in which a tubal
pregnancy has gone to term as oftener instances of a gestation in
1 Centralblatt f. Gynakol., 1888.
a It is incorrect to speak of intra-peritoneal and extra-peritoneal haematocele. An encysted
collection of blood in the peritoneal cavity is a hsemalocele, and a corresponding blood tumor in
the connective tissue is a hrematoma.
ECTOPIC PREGNANCY.
365
which the ovum occupies the tube and the space between the separated
layers of the broad ligament. It would seem probable that as a rule,
in such a variety originally of tubal pregancy, no violent rupture, such
PREGNANCY OF THE RIGHT TUBE. PARTIALLY INTRA-LIGAMENTOUS. (From ZWEIFEL.)
a. Right tube. b. Ovary, c. Gestation cyst.
as is represented in Fig. 158, occurs, but a gradual entrance of the
ovum takes place.
FIG. 160.
./*
DIAGRAMMATIC REPRESENTATION OF INTERSTITIAL TUBAL PREGNANCY AT TIME OF RUPTURE.
(From TAIT.)
INTERSTITIAL PREGNANCY. Mr. Tait asserts that this variety of
ectopic gestation is uniformly fatal by primary intra-peritoneal rupture
before the fifth month. The assertion, however, ignores the case of
366 THE PATHOLOGY OF PREGNANCY.
Braxton Hicks, 1 which in the sixth month of pregnancy ended by the
discharge of the foatus through the natural passage ; the placenta was
retained, and four days subsequently violent pain occurred, and the
patient died in two hours m collapse. The post-mortem proved that
there had been an interstitial pregnancy, and that while the fostus es-
caped through a rupture into the uterus, a subsequent rupture of the
gestation cyst into the peritoneal cavity had occurred with fatal hemor-
rhage. It ignores the case of Maschka, in which a double rupture of
an interstitial pregnancy took place, the body of the fetus being ex-
tracted through the uterus, while the head escaped into the abdominal
cavity. Spiegelberg has asserted that in rare cases the pregnancy may
go to term, and there have been several cases reported in which the
FIG. 161.
TUBO-UTERINE, INTERSTITIAL OR MURAL GESTATION.
a. Cavity of uterus clothed with decidua. 6. Broad ligament, c. Tubo-uterine sac which
contained embryo, d, d. Thicker part of cyst- walls, e. Placenta.
ovum was entirely expelled through the natural passage. While con-
fessing to skepticism in regard to many of these reported cases, in some
denial of the accuracy of the statements made by reputable and able ob-
servers would be unjust. That such an event is frequent is in the highest
degree improbable, independently of the fact that interstitial is an ex-
ceedingly rare form of ectopic gestation, and that many of the cases
should be credited by the reporters and by the profession only illus-
trates the old adage that opinion travels the world without a passport.
Interstitial pregnancies are more frequent in medical journals than they are
in autopsies or in abdominal sections. Careful and impartial study 1 of reports
1 London Obstetrical Society's Transactions, vol. ix.
ECTOPIC PREGNANCY.
367
of some of the unverified cases of interstitial pregnancy will convince any one
that they were in all probability normal pregnancies, and meddlesome treat-
ment caused abortion. It should be remembered that some of the best authori-
ties regard the diagnosis of interstitial pregnancy impossible. A few years since
a former pupil and medical friend in a distant city wrote me of a double inter-
stitial pregnancy occurring in one of his patients ; she was being treated by a
gynecologist for subinvolution of the womb, the sound having been more than
once introduced, and applications to the endometrium made. Miscarriage of
one embryo occurred, and within a few days, of the second. Both of the medi-
cal gentlemen who examined the patient prior to the abortions were confident
that the uterine cavity was empty, and they alike believed, after these occurred,
that there had been double interstitial pregnancy.
OVARIAN PREGNANCY. This is very rare, but cannot be reason-
ably doubted after the cases of Leopold, Martin, Walter, Maokeurodt,
and others. Martin's case, reported at the Brussels Congress, was one
in which the subject of ovarian pregnancy had cancer of the cervix.
The explanation of the origin of this form of ectopic gestation is that
an ovisac rupturing the ovule did not escape, but through the rent in
the follicle a spermatozoid entered and fecundation followed. The liga-
ment of the ovary is distinctly shown and the tube does not participate
in the formation of the gestation cyst.
FIG. 162.
OVARIAN PREGNANCY, LEFT SIDE, ONLY PART OF THE OVARY PARTICIPATES IN THE
GESTATION CYST. (From WINCKEL.)
a. Ovarian pregnancy, b. Left tube. c. Uterus.
TUBO-OVAEIAN. Tubo-ovarian pregnancy may result from congeni-
tal or acquired union between the abdominal mouth of the tube and the
ovary ; a cyst existing, the rupture of an ovisac into it, fecundation
follows. Such pregnancy has in rare cases gone to term. The usual
course of an ovarian gestation is that of a tubal pregnancy.
1 That my skepticism in regard to some of the cases of interstitial pregnancy which have been
reported is not peculiar is shown by the fact that Winckel has referred to one of them " as more
than improbable," and some years before his death Dr. Fordyce Barker requested me to write a
criticism of another, in which he was convinced that a normal gestation had been ended by abor-
tion from the erroneous diagnosis of interstitial pregnancy. Yet both these cases, occurring in
this country, are still quoted as true.
368
THE PATHOLOGY OF PREGNANCY.
ABDOMINAL PREGNANCY. A primary abdominal pregnancy is de-
nied by Mr. Tait on the ground that, even if an impregnated ovule
drop into the peritoneal cavity, the digestive power of the peritoneum
is so great that it would have no chance of development. Neverthe-
less, if spermatozoids can live for months in the abdominal cavity of
the frog, is it not possible that an ovum may defy peritoneal digestion,
and its development take place in the peritoneal cavity ? Moreover,
what happens to the embryo of a ruptured ovum does not necessarily
occur if the ovum be intact. Hart and Carter, however, whose re-
searches will be referred to in connection with intra-ligamentous preg-
nancy, state that a purely intra-peritoneal variety of abdominal preg-
nancy is yet to be demonstrated. Virchow said at a meeting of the
Medical Society of Berlin that he could not believe with Olshuusen
that all extra-uterine pregnancies were tubal ; that such an opinion was
especially difficult to admit for large lithopsedions, and that he had
seen one lasting twenty-six years which was completely outside an in-
tact tube.
What is called secondary abdominal pregnancy includes those cases
in which an ectopic gestation cyst, usually tubal, at least primarily,
opens into the peritoneal cavity, and the development of the foetus
continues. Mr. Tait asserts that this pregnancy results from rupture
of an intra-ligamentous cyst. In such case there were two ruptures,
one primary, that is, a tubal pregnancy becomes intra-ligamentous, and
the other secondary, so that the latter, rupture again occurring, is con-
verted into abdominal.
Kaltenbach suggests that some of the cases called abdominal are
only partial that is, tubo-abdominal.
FIG. 168.
UTERUS AND FCETUS IN A CASE OF ABDOMINAL PREGNANCY.
It is generally stated that in abdominal pregnancy (Fig. 163) the
developing ovum causes irritation of the adjacent parts, and a cyst is
formed of pseudo- membranes. "In rare instances the cyst atrophies,
or is not formed, and the ovum is free in the abdominal cavity ; such
ECTOPIC PREGNANCY. 369
cases have been seen by Leeluyse, Matecky, Schreyer and others." If
a sac is formed, it usually contains some muscular elements derived
probably from the muscles of the subserous layer of the pelvis. The
placenta has been found attached to the uterus, to the bladder, or to die
ovary ; " Sivard 1 has seen it attached to the mesentery and colon of
the left side; Courtail to the omeutum and stomach; Clarke to the
kindneys and intestines; Tilt to a great part of the mesentery, meso-
colou, portions of the small intestine, and to the two or three superior
lumbar vertebrae ; Baldwin, Wilson aud KoeberlS to the anterior ab-
dominal wall in the line of incision made either at the post-mortem
examination or during an operation for gastrotomy."
Abdominal gestation lasts longer than any other ectopic form. In
some instances the foetus develops during nine months, then dies, and
it may be retained for many mouths, or even many years ; in one in-
stance the pregnancy lasted fifty-four years ; a still longer retention is
given below.
The great danger of ectopic gestation, as has been pointed out, is
hemorrhage, and if the patient does not die from this, subsequent peri-
toneal inflammation may lead to a fatal result.
The death of the embryo or foetus, which is a favorable event in all
ectopic gestations, is followed by changes similar to those which occur
after death in intra-uteriue pregnancy; but in addition to these changes
the foetus may be converted into adipocere, or into a lithopsedion ; 2 the
formation of a lithopsedion has been observed in pregnancy in a rudi-
mentary uterine horn, the foetus dying at five months. The most widely
known of the last is the lithopsedion of Leinzell, which was found in
one of the tubes upon post-mortem of a woman ninety-two years old,
who had carried it forty-six years. In August, 1883, Sappey presented
to the Paris Academy of Sciences the membranes and foetus which had
been retained fifty-six years; calcareous incrustations were limited to
the wall of the cyst, but the foetus was in a natural attitude, and the
skin, superficial organs and those of the cavities, the muscles, and in
fact all parts of the body, preserved their consistence, suppleness, and
normal color.
Inflammation and suppuration may occur in the foetal cyst, ending in
the discharge of the foetus by the abdominal walls, by the bladder, the
vagina, or the rectum. According to Mattei, the first is the most fre-
quent; according to Parry, the last. In one instance the cyst commu-
nicated with the stomach ; it was reported by Darby ; " the cavity
which contained the child hac\ opened through the abdominal wall ;
1 Parry on Extra-uterine Pregnancy.
* Lithopsedion, literally a stone child, is a name given to the fcetus when calcification has oc-
curred. Barnes states that this change is limited to the membranes and sac, the shell thus formed
preserving the fcetal structures but little changed. But this is only one of three forms. Kuchen-
meister states (Archiv fur Gynakql., 1881) that the ftetus falling into the abdominal cavity, in con-
sequence of rupture of the cyst, is mummified, and by degrees covered by a calcareous layer
deposited immediately beneath the epidermis ; this is a true lithopjedion, and it is the second form.
The third form is when an incrustation involves both the membranes and the fcetus. Sarraute
(Archives de Tocologie, March, 1885), in a contribution to the microscopic study of lithopsedions,
states that most frequently all the cavities are found filled with calcareous salts, or salts derived
from fat ; the cartilages and bony cavities and the vertebne are infiltrated with calcareous masses.
" The oldest known case of lithopffidion is that reported by Sens, in 1582 ; it was carried twenty-
eight years. This case inspired Rousset to make a curious poem, in which he presented the fol-
lowing questions : cur nasci potuerit t cur per vigenti octo annos in utero retentus non putruerit 1 cur
in lapidem obdurueril?" Maygrier.
24
370 THE PATHOLOGY OF PREGNANCY.
when Dr. Darby enlarged the orifice and extracted the fetus, immedi-
ately after the entire contents of the stomach emptied themselves into
the cavity of the cyst through a ragged, jagged opening, two inches in
width."
INTRA-LIGAMENTOUS PREGNANCY. The origin of this variety of
ectopic gestation has been given, and its possible termination in a sec-
ondary abdominal pregnancy by rupture into the peritoneal cavity,
should the fetus live, has been stated. While in a great majority of
cases the embryo or fetus perishes, the tube rupturing between the folds
of the broad ligament, in a few pregnancy may continue for some
weeks, the fetus then dying and suppuration follow, or it may continue
until term. The changes that occur in the developing ovum in regard to
the peritoneum are of great interest, and were first made known 1 through
the study of frozen sections by Hart and Carter ; these sections were of
two specimens the one a four and a half months' extra-uterine preg-
nancy, in situ in the bony pelvis ; the other an entire cadaver with
advanced abdominal gestation. From the report of this examination
the following passages are taken :
" The consideration of these two sections shows, therefore, a special phase in
the development of extra-uterine gestation. They demonstrate that a Fallopian
tube pregnancy may develop between the layers of the broad ligament, and may
continue this extra-peritoneal growth, stripping off the peritoneum from the
uterus, bladder, and pelvic floor until it becomes in great degree surrounded by
a peritoneal capsule derived from these organs. All this is done without any
actual intra-peritoneal invasion. The placenta in the advanced gestation case
is attached in front to the extra-peritoneal connective tissue, the veins there en-
larging and acting like uterine veins.
" In this special cadaver, therefore, the gestation began probably in the right
Fallopian tube, developed into the layers of the broad ligament, and grew extra-
peritoneally, lifting up the peritoneum on the right side of the middle line both
anteriorly and posteriorly, and also stripping the posterior uterine wall and upper
part of the anterior wall.
"We have here what may be termed a slow displacement of the placenta. At
first it lay in the Fallopian tube, but the growing ovum has slowly pushed it up
(a process attended with blood extravasation) from the pelvis to the abdominal
cavity, until at last its upper edge is about ten inches from its original site.
Part of this is due to growth, of course."
The authors suggest that this variety of pregnancy should be termed
subperitoneo-abdominal.
DIAGNOSIS. It is by careful study of physiological and pathological
symptoms that the diagnosis of ectopic gestation is made. In the first
place, the fact of probable pregnancy is to be established ; it is not nec-
essary to detail local changes in the sexual organs and the reflex phe-
nomena indicative of this condition. Next, we endeavor to learn that
the uterus is not the seat of this pregnancy. This organ, though as a
rule increased in size, is not so large as it would be at the supposed
period of gestation. Hecker has stated that the uterine cavity may be
increased to fifteen centimetres, or more than five inches. There is
found adjacent to it a growing, usually pear-shaped, somewhat sensitive
tumo'r, not solid, and with little mobility. Menstruation having been
suppressed at one period, possibly two, there occurs a profuse and pain-
1 Transactions of the Edinburgh Obstetrical Society, vol. xii.
ECTOPIC PREGNANCY. 371
ful flow with the discharge of fragments of decidua, microscopic exam-
ination of which will be necessary to determine their character. Gus-
serow, in a case reported by Glahn, in order to assist in the diagnosis,
used a curette for the removal of decidua from the uterus. Should the
pregnancy continue until the sounds of the foetal heart can be heard,
and ballottement is available such prolongation of ectopic pregnancy,
it must be remembered, is exceptional the question is more readily
answered. So, too, if the practitioner has sufficient evidence to justify
dilating the cervical canal, and the use of finger and sound to explore
the cavity of the uterus, the absence of intra-uterine pregnancy can be
conclusively proved, and therefore the ovum, provided the woman is
pregnant, must be ectopic.
The diagnosis of ectopic gestation in the first months has been a subject of no
little controversy. Spiegelberg has said that a diagnosis is all but impossible
during the first three or four months, and can only be arrived at in exceptional
cases ; and Bandl suggests that the practitioner will do well not to make an
absolute diagnosis of extra-uterine pregnancy until he can appreciate the certain
signs of foetal life, active movements and the heart-sounds. On the other hand,
it has been claimed that the early diagnosis of an ectopic is easier than of a
normal pregnancy. The question is very fully discussed by Strahan, whose valu-
able monograph 1 can be consulted by the practitioner with benefit. Winckel
gives the following as probable symptoms which " in their entirety permit a cer-
tain diagnosis, especially if their progressive increase is established by repeated
observations :"
1. The cessation of previously normal menses.
2. Hyperaemia and secretion of the breasts.
3. Hyperaemia and livid coloring of the vulva and vagina, which increases
toward the portio vaginalis.
4. The strongly pulsating arteries in the vault of the vagina.
5. The softening, enlargement and displacement of the uterus.
6. The clearly defined and growing tumor.
7. The vascular murmur or souffle above the symphysis, which is heard at
rather an early period.
Dr. Reeve in an article 2 upon the subject, in which it is asserted that a diag-
nosis " can be made at an earlier period than in a normal pregnancy," refers to
cases of its having been made as early as the eighth and fifth week, and gives
the following classification and enumeration of symptoms :
" I. Suggestive. a. The general and reflex symptoms of pregnancy, especially
if the pregnancy had occurred after a considerable period of barrenness.
" b. Disordered menstruation, especially metrorrhagia coincident with symp-
toms of pregnancy ; gushes of blood accompanied with severe pelvic pains.
"c. Severe pain in the pelvis ; attacks of pelvic pain followed by tenderness in
either iliac region, and other symptoms of pelvic inflammation.
" II. Presumptive. a. The existence of a tumor : this tumor presenting the
characteristics of a tense cyst, sensitive to touch, actively pulsating; steady and
regular growth of the tumor to be ojbserved.
"b. The os uteri patulous, the uterus displaced and empty.
" III. Certain. a. Paroxysms of violent and overwhelming pain in the pelvis,
with general symptoms of collapse.
" b. Expulsion of the decidua." .
The employment of the uterine sound is permitted only when there is a proba-
ble evidence of ectopic gestation. Kaltenbach warns, if the sound is used,
against the danger of perforating the uterus because of its tissues being less firm.
The abdominal tenderness may be so great, especially in an advanced ectopic
gestation, that no satisfactory conclusion can be reached without the patient
is anaesthetized.
1 The Diagnosis and Treatment of Extra-uterine Pregnancy, 1889.
2 American Journal of the Medical Sciences, July, 1889.
372 THE PATHOLOGY Of 1 PREGNANCY.
DIAGNOSIS OF RUPTURE. The diagnosis of rupture of a tubal preg-
nancy is made by learning of severe pain in the lower part of the
abdomen or pelvis, suddenly occurring, possibly when the patient was
making some exertion, straining, stooping, lifting a weight, etc., and
this is followed by faintuess or fainting and collapse ; the skin is cold,
the pulse feeble and frequent, and there is acute anaemia. " The diag-
nosis of tubal pregnancy at the time of rupture may be made with
certainty seven times out of eight, and may be guessed at in the eighth
instance. The symptoms are too serious to be lightly regarded at any
time, and are practically coincident with those of pelvic heematocele.
If the rupture takes place into the broad ligament, they are the symp-
toms of extra-peritoneal hsematocele. If the rupture takes place into
the peritoneal cavity, they are the characteristic and most serious group
which belongs to iutra-peritoueal hsematocele." (Tait.)
PROGNOSIS. Martin 1 states that the prognosis of ectopic gestation
has materially improved uuder the influence of a better diagnosis and
treatment. He gives the following statistics : 255, expectant treatment,
36.9 recoveries, 63.1 deaths; 515, operative treatment, 76.7 recoveries,
23.3 deaths.
TREATMENT. Admitting the diagnosis of an ectopic pregnancy,
almost certainly tubal, before rupture, what course should be pursued?
Foeticide, or by abdominal section removal of the gestation cyst? The
foeticidal means which have been used are evacuation of the amnial
liquor, morphine injection, and electricity. The first is uncertain and
dangerous, and is now without an advocate. Joulin in 1863 2 proposed
injecting strychnine or atropine into the foetal cyst, and Friedrich in
1864 3 injected a solution of morphine in a tubal pregnancy. Since
then the method has been employed by Koeberle, Rennert, 4 Taruier 5
and Wiuckel. Winckel always injects 0.03 gramme, under the usual
precautions, through the abdominal wall, at intervals of six to eight
days; two or three injections generally suffice. He claims that this
method of killing the foetus may be practised successfully up to the
end of the fourth and even during the fifth month ; and also that it is
very easy of performance and perfectly innocuous to the mother.
Winckel states that there are now, 1893, sixteen cases of ectopic ges-
tation, ten of them his own, treated by injection of morphine into the
gestation cysts, three of the patients dying, or 19 per cent. He re-
gards the treatment as easy, and without danger to the mother ; he
states that the swelling perceptibly lessens in a short time, and as a
rule completely disappears in from six to twelve months.
THE USE OF ELECTRICITY. According to Depaul, Dubois first ad-
vised electricity to kill the foetus in normal pregnancy when grave acci-
dents threatened the life of the mother. Bachetti, of Pisa, in 1857, suc-
cessfully employed electricity in a tubal pregnancy of the third month ;
two long needles connected with an electro-magnetic machine were in-
troduced into the cyst. In 1865 Braxton Hicks attempted to destroy
the foetus in an extra-uterine gestation of three months and a half by
i Proceedings of Brussels Congress. 2 Traite corap'.et d'Accouchements.
Virchow's Archiv, 1864. i Arch. f. GynSkol., 1884-5.
5 Both in the priginal and in Dr. Edgar's translation of " Wiuckel," this name is given as Four-
nier evidently a typographical eiror.
ECTQPIC PREGNANCY. 373
two applications of the galvanic current at an interval of ten days, but
failed. In 1869, J. G. Allen, of Philadelphia, succeeded by faradiza-
tion in arresting pregnancy.
This treatment of ectopic gestation has been so frequently used by
American practitioners, so little by others, that it is often called the
American method. The galvanic current has been selected in some
cases, and abroad not in this country, I believe, a single time gal-
vano-puncture, but general preference is given to the faradic current.
An ordinary battery, with single cell, is employed ; the negative pole
is introduced in the vagina or in the rectum as near the tumor as it can
be, while the positive pole, connected with a dampened sponge, is placed
upon the abdomen. A current, not so strong as to cause the patient
any great distress, is passed through the tumor for ten minutes ; this is
repeated each day until the tumor ceases to grow ; four or five applica-
tions probably will be necessary. Blackwood, of Philadelphia, who
has had a large experience with this mode of destroying the life of the
embryo or foetus, prefers a strong current continued for an hour, but he
is probably alone in this preference. The galvanic current has been
advised by Rockwell, and has been successfully used in New York in
several cases, though the method has differed, in some the interrupted
and in others the continuous being employed. Rockwell 1 prefers the
former, the strength being from 10 to 20 milliamperes.
No impartial reader of the reports of cases by competent and reput-
able men can doubt that some ectopic gestations have by this means
been conducted to a favorable termination ; that is to say, the preg-
nancy was arrested, and the patient suffered no subsequent or serious
inconvenience.
Malcolm McLean asserts 2 that "in a vast majority of cases the
results of electrical treatment are good, and do not leave the woman in
a worse condition."
Brothers, of New York, an ardent advocate of the electric treatment
of ectopic gestation, has recently said 3 that " beyond one death in seventy-
eight cases no injury has ever been done by the use of electricity, and
when it has been abandoned for laparotomy no harm was done by the
previous treatment."
Those who substitute death of the ovum for death of the foetus seem
to assume a point in dispute, denying the possible growth of the placenta
after fbeticidal means have been successfully used. That in some cases
the placenta continues to grow does not rest alone upon Mr. Tait's as-
sertion. The same statement is made by Hart and Barbour, Manual
of Gynecology. Champneys and Thornton concede the fact, London
Obstetrical Society's Transactions, vol. xxix. Bandl, in his well-known
monograph on extra-uterine pregnancy, refers to the placenta develop-
ing for some time after the foetus is dead. Dole'ris, Nouv. Arch.
d'Obstet. et de Gyn., 1888, says that when the foetus dies in ectopic ges-
tation "the placenta in these cases often continues to vegetate, for
habitually it does not atrophy until the term of gestation has been
passed or attained."
1 American System of Gynecology. 2 American Journal of Obstetrics, 1892.
8 Ibid., 1894. The writer also asserts that in five cases electricity caused the transfer of the ovum
into the uterine cavity. In regard to some of these cases skepticism is wiser than faith.
374 THE PATHOLOGY OF PREGNANCY.
Doubtless too much has been claimed for electricity, and even some
of its earnest advocates abate their zeal and positiveness of utterance.
One of them, well known for his honesty and ability, in 1887 stated
that ' it was safe to predict that electricity will yet become the only
method of treatment in ectopic gestation prior to the rupture of the
cyst, and that through this means the dreadful mortality from gestation
of this nature will be reduced by fully three-quarters." He also stated
that the method is applicable to every form of ectopic gestation prior
to the middle or end of the fourth month, and prior to rupture of the
cyst. In 1889 the same gentleman said : " Electricity, then, under
the third month, with absence of symptoms of rupture, I would advo-
cate. At most it can do no harm, and it may do good."
^-TREATMENT BY ABDOMINAL SECTION. Tait remarks that " If I
ever should make a diagnosis of tubal pregnancy before rupture, I
should advise its immediate removal by abdominal section." Strahan
asserts that " the proper treatment of extra-uterine gestation in the pre-
ruptured stage, whenever diagnosed, or suspected with great probability
rather, is instant abdominal incision and removal of the entire trouble."
Werth 1 believes that an ectopic pregnancy ought to be regarded as a
malignant tumor demanding prompt removal ; in an interstitial preg-
nancy a pedicle should be made of the lower part of the uterus, and
hysterectomy done.
When one realizes by witnessing how suddenly in the midst of ap-
parent health a gestation cyst may rupture, and how swiftly death
follows in almost all cases not rescued by a surgical operation ; and then
upon opening the abdomen he finds sometimes from a rent compara-
tively small copious bleeding has occurred, he will hesitate to advise
in an ectopic gestation, the diagnosis of which is clear, any delay in its
removal, even though the pregnancy may not have lasted a month.
TREATMENT OF RUPTURE. Absolute rest in a horizontal position,
sulphuric ether hypodermatically, alcoholic stimulants and the ice-bag,
or a sack of sand to the lower part of the abdomen, constitute the most
important part of the treatment, which seeks to arrest the flow of blood
and to bring about reaction. As soon as the patient reacts, the general
rule is to perform laparotomy ; some, indeed, would operate immedi-
ately.
But take the case of a patient who has passed some days since the
accident, all symptoms being favorable, the retro-uterine haematocele
gradually lessening, the temperature normal, and only slight discom-
fort or none at all felt. I believe with Winckel, Ahlield, and some
others that operative treatment under such circumstances is not in-
dicated. If, however, suppuration occur, then this treatment must be
promptly employed.
It should be remembered that laparotomy, now so generally resorted
to in rupture of an ectopic pregnancy cyst, 2 was advised many years ago
by the late Dr. Stephen Rogers, of New York.
When gestation has been half-completed, the child living, most
advise immediate operation, having regard only for the mother's life.
1 Beitrage zur Anatomic und zur operativen Behandlung der Extrauterin-Schwangerschaft,
Stuttgart, 1887.
2 Transactions of American Medical Association, vol. xviii.
ECTOPIC PREGNANCY. 375
This position has recently been controverted. Thus G. Rein, 1 of Kieff,
who believes primary abdominal pregnancy sometimes occurs, asserts
that the conservative principle should be applied in some cases of
ectopic gestation, and that we have not then the moral right to destroy
the infant. If the pregnancy has passed one-half, and the proof that
the child is living is certain, the conservative method is absolutely
indicated, and we ought not to regard the ovum as a dangerous, still less
a malignant disease. Placing our patient in the most favorable circum-
stances for immediate laparotomy, if this should be necessary, we wait
until the infant has the best chance of living outside the maternal
organism that is to say, the ninth month of pregnancy.
If the normal period of pregnancy has been reached, abdominal
section is done for saving the child's life, and there is also a reasonable
probability of saving the life of the mother with certain improvements
in the method of operating and subsequent treatment certainly her
chances of recovery are probably not lessened but rather improved by
a properly performed operation. The treatment of the placenta has
presented the most serious difficulty. Of course, if it can be removed
with the foetal cyst it is a fortunate thing for patient and operator ; it
is rare, however, that perfect heemostasis can be secured, as in Eastman's
case, or as in the cases of Martin and of Breisky.
Tait in two cases was able to remove the placenta, tying a large
pedicle, the remains of the tube and broad ligament, which contained
the chief blood supply to the organ, and in each case the mother as
well as the child was saved. But such cases are probably exceptional.
There may be no fcetal cyst, and then after the removal of the foetus
the cord is tied and divided, and its placental end is left hanging out
of the abdominal wound, a draining-tube being placed by its side.
Tedious suppuration follows this method, and the woman may perish
of septic infection more than a month after the operation, as in Champ-
ney's case, the disease occurring when convalescence seemed established.
Tait proposes cutting off the cord near the placenta, closing the sac, and
thus leaving the placenta to be absorbed.
Should the foetus be dead, perishing in the latter half of pregnancy
or after false labor, which occurs in cases of ectopic gestation at the
normal period of pregnancy, the chances of its conversion into a harm-
less lithopffidion are slight, and the probabilities of painful and pro-
longed suppuration with the passage of foetal debris through the rectum,
the vagina, the bladder, or the abdominal wall, imperilling the mother's
life in many instances she parishes are so great that active inter-
ference is indicated. Therefore by abdominal section, rarely by ely-
trotomy, removal of the foetus is advisable. Unless the indications
are urgent, the operation is delayed until the placenta has probably
undergone such changes that its removal may be accomplished without
serious hemorrhage.
Elytrotomy in ectopic gestation Winckel restricts to cases in which
suppuration has occurred and perforation of the vagina is threatened.
Nevertheless he quotes two cases in which the posterior vaginal vault
1 Proceedings of the Brussels Congress.
370
THE PATHOLOGY OF PREGNANCY.
was opened, and in each case a child extracted by forceps ; one of the
children lived.
Kaltenbach advised in case of suppuration in the cyst of an Sutra-
ligamentous pregnancy, treating it as an open wound, and filling it with
cotton covered with tannin and salicylic acid.
A similar treatment was employed by him in those cases in which the
foetal cyst and placenta could not be removed. The placenta under this
treatment shrinks into a dry leather-like mass, and in eight or ten
days can be removed without bleeding.
FIG. 164.
GESTATION IN A RUDIMENTARY HORN OF THE UTERUS.
A. Developed right horn. B. Rudimentary horn, with a rent through which the embryo had
escaped. 1. Right Fallopian tube. 2. Left Fallopian tube. 3. Left ovary. 4, 5. Right ovary and
corpus luteurn. 6. Round ligament.
PREGNANCY 1 IN A RUDIMENTARY HORN OF THE UTERUS. The
symptoms of cornual pregnancy are those of tubal, and the treatment
in 'no respect differs.
ECTOPIC DEVELOPMENT OF THE PLACENTA Vicious INSERTION
OF THE PLACENTA PLACENTA PRJEVIA. Benjamin Pugh, in his
treatise upon Midwifery, 1754, remarked that "the placenta sometimes
loosens before the membranes, which contain the waters, are broke, and
by the child's turning itself, it is sometimes found to present at the
mouth of the womb," etc. This was the explanation generally given
by obstetricians of those cases in which the placenta was found at the
mouth of the womb previous to the birth of the child. Nevertheless,
Paul Portal, in 1685, had spoken of firm adherences between the pla-
centa and parts contiguous to the mouth of the wornb ; and Schlacher,
in 1709, had given an anatomical demonstration of this condition upon
the body of a woman dead from uterine hemorrhage. Rigby, whose
admirable Essay 2 was published in the latter half of the eighteenth
1 An interesting report of a case successfully operated upon by the late Dr. Angus MacDonald
will be found in the tenth volume of the Edinburgh Obstetrical Society's Transactions. Dr. Mac-
Donald with the report has also given a good resume of the cases observed up to that time.
2 An Essay on the Uterine Hemorrhage which precedes the Delivery of the Full-grown Foatus,
illustrated with cases. The fourth edition was issued in 1789.
ECTOPIC
century, made a distinction which is still recognized, between accidental
and unavoidable uterine hemorrhage, the former occurring when the
placenta occupies its normal position, the latter when u it is fixed to that
part of the womb which always dilates as labor advances." It Avill be
observed by the words just quoted from Rigby that those authors who
have attributed unavoidable hemorrhage, occurring in pregnancy, to the
abnormal situation of the placenta, have no authority from him for such
use of the word unavoidable. Rigby's definition of placenta pnevia is
that which is in accordance with the most recent knowledge. For ex-
ample, Spiegelberg has said that the placenta is pris 2 has narrated
a case in which the labor was protracted in consequence of the cord
forming a double coil about the lower limbs of the foetus at the ankles ;
hence the cord was much shortened, and the fcetus, presenting by the
vertex, was as it were suspended by the feet.
This case illustrates one of the dangers that arise when the cord is
coiled around the foetus, relative shortness, which of course may cause
the same difficulty in labor as absolute shortness does.
It is possible, in some very rare cases, if the abdominal and the
uterine walls are thin, to feel the pulsating cord when it encircles the
body. Schatz 3 claims that the diagnosis of the cord encircling the neck
i All the world knows, remarked Depaul, that the celebrated Beclard was the result of a hyda-
tidiform pregnancy. The possibility of a viable child being born, therefore, is the reason for ab-
staining from active interference in case of this disease, unless symptoms demand such interference.
- Archives de Tocologie, 1882.
* Revue Medico-chirurgicale des Maladies des Femmes, 1885.
DISEASES OF THE OVUM.
455
can be made during pregnancy by auscultation ; at first, moderate pres-
sure with the stethoscope is made at the part corresponding with the
depression of the neck, and the pulsations of the foetal heart are normal
in frequency; but when strong pressure is made their frequency is less-
ened to one-half.
KNOTS. In one out of two hundred infants there will be found at
birth one or more knots in the umbilical cord. They result from the
fetus passing through a loop of the cord, and according to most authori-
ties may be formed in pregnancy or during labor ; Read, 1 however,
asserts that they cannot be formed except by the passage of the child
through the lower portion of the uterus, for a loop must fall to the
vicinity of the os, it cannot remain in any other part of the uterus, and
hence they can be formed only during labor ; but this view is not gen-
FiG. 180.
FIG. 181.
KNOT IN THE STAGE OF FORMATION.
P. PLACENTAL END.
As IT WAS FOUND AT BIRTH.
erally accepted. Admitting the formation of knots in pregnancy, it is
exceptional for the vessels to be so constricted as to interfere with the
circulation of blood. Depaul has found in one instance five knots in
the cord, quite near together, but the fetus was living and well nour-
ished. On the other hand, Martin Saint-Ange has seen death of the
fetus result from a single knot, and many similar cases have been re-
ported. Great length of the cord predisposes to this accident, and a
relatively great size of the uterus facilitates its occurrence in pregnancy.
1 American Journal of the Medical Sciences, October, 1861.
456 THE PATHOLOGY OF PREGNANCY.
The knot is sometimes double, as in a case observed by Dr. George H.
Lyman, of Boston. Read gives the representations 1 of the successive
stages in the formation of the knot in Ly man's case. (See Figs. 180,
181, and 182.)
EXCESSIVE TORSION. Twisting of the cord upon its axis generally
occurs, according to Spiegelberg, in the second half of pregnancy, espe-
cially in the seventh lunar month. He refers to torsions as u praBmor-
tal" and " postmortal." The first are caused by the active movements
of the foetus, or by a severe fall received by the mother. Wiuckel
suggests that the movements of one of the two foetuses contained in a
single amnion may cause twisting of the cord of the other. The " post-
mortal" torsions are caused by the movements of the mother. Dancing
is mentioned by Kormann as a cause of torsions of the cord. They
occur more frequently in male than in female foetuses, the proportion
being 13 to 9. Excessive movements of the fetus, causing torsions of
the cord, were attributed by Billi (quoted by Hecker) to disease of the
brain. The facility of active and of passive movements, too, in the
foetus of the multigravida being greater than in the primigravida, these
torsions are more frequent in the former. It is said that a division of
the cord may be caused in a short, tense cord by twisting, it being thus
separated from the foetus, so that the latter is unattached in the uterine
cavity. The torsions are mcst numerous in the vicinity of the umbilicus,
and next at the attachment of the cord to the placenta. Torsions of
the cord may cause occlusion of its vessels, or only stenosis. Death of
the foetus follows occlusion or great stenosis. In some instances tine
thrombi are found in the vessels ; these indicate that the torsions occurred
suddenly. Fritsch has observed that in some cases torsions occur in
successive pregnancies.
I have seen a case in which there were forty-six twists in the cord ;
the foetus had died in the seventh month, and was macerated. A re-
markable illustration of very numerous twists of the cord is shown in
Fig. 83.
Narrowing of the vessels may occur independently of torsions. These stenoses
are usually found in the vein near its placental end ; " they were first observed by
Oedmanson and Winckel, and their anatomical description given by Birch-
Hirschfeld." They have been described as sharply defined proliferations of the
intima, partly of fusiform, partly of round cells, and forming a fibrillated tissue,
as a granular matrix with oval and globular nuclei. Beginning in the intima, the
adventitia becomes affected ultimately, and shows an accumulation of lymphoid
elements. Birch-Hirschfeld found circumscribed stenoses involving the intima
of the arteries in the vicinity of the navel and of the placenta ; he regards them
as resulting from syphilis, stating that the microscopical examination agrees in
every particular with those changes which Heubner described as syphilis of the
vessels of the brain. According to Spaeth, atheromatous changes may occur in
the arteries. Stenosis may be the consequence of periphlebitis, according to
Hyrtl. Cysts found in the cord are remnants of the urachus lined with epithe-
lium.
Martin Saint- Ange 2 narrates a case of a dead foetus being expelled at seven
months, the death caused by complete strangulation of the cord lying between
the legs, which crossed each other and were firmly applied together by a convul-
sive condition.
1 Charpentler in using these illustrations has substituted Leyman for Lyman.
2 Op. cit.
DISEASES OF THE OVUM. 457
ANOMALIES OF THE AMNION AND OF THE AMNIAL LIQUOR. The
question as to inflammation of the amnion, amniotitis, is undecided.
The formation of amniotie bands, resulting in amputation of foetal mem-
bers, or in the production of foetal malformations and adhesions be-
tween the amnion and different parts of the foetal surface, seems to indi-
cate that inflammation of this membrane does occur. According to
some, acute polyhydramnios is the consequence of inflammation of the
foetal membranes ; this was the theory taught by Mercier more than
fifty years ago.
The narrow space which the foetus occupies prevents its proper development.
Certain deformities, such as talipes valgus and t. varus, occur more frequently
in connection with scanty amnial liquor so, too, some forms of single mon-
strosity, as symmelian and syrenian.
Dareste 1 has shown the important connection between certain fcetal
anomalies and the condition of the amnion. The formation of amnial
bands may result from oligohydramnios that is, deficiency of the
amnial liquor as follows : The amnion is in contact with parts of the
foetus, not kept separate by fluid, and adhesions result ; but with in-
crease of fluid these adhesions are stretched, and thus cords or bands are
formed. Another result of deficiency of amuial liquor is superficial
adhesions between the members of the body. 2
POLYHYDRAMNIOS. The most frequent anomaly relating to the
amnion and its liquor is that which consists in an excessive production
of amnial fluid, incorrectly designated as hydramnios or hydramnion,
for neither of these words means excess of this fluid. Polyhydramnios
exists whenever the quantity of amnial liquor exceeds two and one-half
pints. Baudelocque stated that the excess might reach to sixteen litres,
or even to twenty-five, about thirty-three to fifty-two pints.
The affection occurs oftener in the multigravidse than in primigra-
vidse according to McClintock, 23 to 5 ; it is more frequent in twin
than in single pregnancies, and in the former case the children are
oftener of the female sex. The production of monstrosities occurs
more frequently in polyhydramuios. Syphilitic disease of the mother
has been observed in many cases of polyhydramnios. In some cases
Depaul has reported one the affection occurred in an ectopic preg-
nancy. In twin pregnancy polyhydramnios may be present in one
ovum, with oligohydramuios in the other.
ETIOLOGY. Polyhydramnios has been attributed to various causes.
According to Jungbluth, the vasapropria, which usually become obliter-
ated in the last months of pregnancy, remain open, and hence the dis-
ease. The open condition of these capillaries is favored by obstruction
to the foetal circulation, as from congenital defects of the heart (Lebed-
jew), and diseases of the liver (Kiistner). Support 3 is given the hy-
pothesis by the greater frequency of malformations and death of the foetus,
and a large and oedematous placenta with polyhydramnios. It has been
attributed to excessive activity of the renal function. It has also been
thought to result from disturbances in the mother's circulation, as shown
by great oedema or by dropsy. In some cases the decidua is greatly
1 ArchivdeTocologie, 1883. 3 Kormann. Kleinwachter.
458 THE PATHOLOGY OF PREGNANCY.
hypertrophied, and the chorial villi are swollen. Gervis 1 attributes the
affection to inflammation of the amnion, to a diseased condition of the
decidua, and to dyscrasia of the maternal blood.
In two of several cases of diabetes mellitus in pregnancy, 2 collected by Dr.
Matthews Duncan, there was excess of amnial liquor ; one of the two occurred
in his own practice and the other in that of Dr. W. L. Reid, of Glasgow.
FOEMS OF THE DISEASE. Polyhydramnios occurs in two forms,
chronic and acute. The former is the more frequent, and does not
usually appear before five or six months of pregnancy. It is char-
acterized by a move rapid increase in the size of the abdomen than occurs
in normal pregnancy, the foetal movements are not readily felt by the
mother, nor can the sounds of the fcetal heart always be distinctly heard
by the obstetrician ; the uterus has a more spheroidal than ovoidal form,
the respiration is interfered with, and the patient may be unable to lie
down. It is difficult or impossible to recognize the foetus by palpation,
and fluctuation is very well marked. By vaginal examination the lower
segment of the uterus is found drawn up into the abdominal cavity,
and the neck of the uterus is more or less effaced.
The acute form, which may suddenly appear in a case in which the
accumulation has hitherto been proceeding gradually, or may be primi-
tive, is characterized by symptoms similar to those mentioned. But
the discomfort is greater, for when the collection is gradual the system
is more tolerant ; but, beside, there is often fever, and also there are
nausea and vomiting in the acute form.
It is more frequently observed in case of twins.
Dr. John S. Miller, of Philadelphia, has given me the notes of a case of poly-
hydramnios which I saw in consultation with him : " Mrs. E , thirty-five years
of age, had previously given birth to six healthy children. At four months in
her seventh pregnancy was larger than in any previous pregnancy at term. No
fever, but persistent vomiting after fourth month. Circumference at umbilicus,
fifty-three inches. Miscarried at six months with male twins ; one large, well
developed, and lived for a few minutes after birth ; the other small, flattened,
only about six inches long ; the excessive quantity of fluid came from the sac
occupied by the larger foetus. The quantity actually measured was thirty-one
pints, but a considerable amount escaped in the bed."
Bar 3 maintains that as great pressure affecting the portal vein causes
ascites in the adult, so increased pressure in the umbilical vein produces
excess of amuial liquor. Mantel 4 asserts, from a very thorough study
of the subject, that there is an undeniable frequent coincidence between
the insertion of the placenta at the lower part of the uterus and poly-
hydramnios, and explains the latter as resulting from the former in
consequence of the pressure which the placenta thence undergoes, and
the modifications of circulation in the cord ; an obstacle to the normal
course of the blood is presented, and hence blood-stasis and a consider-
able osmosis into the amnial cavity.
Polyhydramnios occurs probably once in 150 labors. The acute
1 St. Thomas's Hospital Reports.
2 Transactions of the London Obstetrical Society, vol. xxiv.
s Journ. de M6d. de Paris, January, 1889. 4 Arch, de Tocol., 1888.
DISEASES OF THE OVUM. 459
form is very rare. The prognosis for the foetus is unfavorable ; in
McClintock's cases, out of 33 children 9 were stillborn and 10 died
within a few hours after birth ; 25 of the 33 children were females.
Spiegelberg has remarked that he knew "a number of instances in
which the hydramuiotic uterus was mistaken for a simple ovarian cyst,
and tapped ; this has happened once in my own maternity. Greater
care in making the diagnosis will prevent making such mistakes."
Nevertheless, Winckel states that a definite diagnosis in some cases is
impossible, and it might be advisable then to resort to exploratory
abdominal section. This was done by Wilson, 1 of Baltimore.
Errors in diagnosis are to be avoided, first, by establishing the fact
of pregnancy by subjective and objective signs ; among the latter,
Braxtou Hicks's will in some cases be of great value ; second, by recog-
nizing the enlargement as being in contact with the abdominal wall in
the median line; third, by finding the lower segment of the uterus very
high, and more or less complete effacernent of the cervix ; fourth, by
carefully studying the history of the enlargement as to position, as to
progress, and as to symptoms produced. Runge advises in doubtful
cases examination during anaesthesia.
TREATMENT. This is palliative and expectant, unless grave symp-
toms arise from the excessive distention ; when these occur the pregnancy
should be ended. It has been advised to puncture the membranes high
up, and to use the hand as a tampon to check the rapid discharge of the
amnial fluid. Of course, if a transverse presentation occurs, turning
must be resorted to, otherwise it is better to leave the labor to nature ;
it should be remembered that atony of the uterus may result from its
very great distention, and hence there is a liability to post-partum hem-
orrhage, which should be carefully guarded against.
In some cases puncture of the uterus through, the abdomen has been employed
to relieve the excessive distention. Even if premature labor or abortion re-
sult, this could hardly be regarded as an evil. But in two cases, one reported
by Tillaux and the other by Lepage, the pregnancy did not end until a month
after the operation. 2 In a case mentioned by Brouardel the condition was mis-
taken for an ovarian cyst, puncture followed by free evacuation of the amnial
liquor was done, and the pregnancy continued three months. Schatz recom-
mended puncturing the uterus from time to time with a fine trocar, drawing off
a portion of the fluid, so that premature interruption of pregnancy may be pre-
vented.
THE PATHOLOGY OF THE FCETUS. The pathology of foetal life
includes malformations, usually arising from arrests of development,
teratogeny, or the formation of monstrosities, constitutional and local
diseases, injuries, and death. So far as any of these cause difficulties
in delivery, they will be considered in connection with the pathology of
labor.
Vices of conformation are, as previously stated, usually arrests of
development. Thus there may be harelip, or spina bifida, and the
origin of each has been presented. An imperforate anus or vagina was
normal at a certain period of evolution, and only its permanence
1 American Journal of Obstetrics, 1887.
2 Revue Medico-chirurgicale des Maladies des Femmes, December, 1889.
460 THE PATHOLOGY OF PREGNANCY.
renders its pathological ; so, too, in regard to duplicity of the vagina
and of the uterus. In some instances there may be defective for-
mation of one or more members, and hence one kind of monstrosity
known as ectromelic ; l in the gravest form the monstrosity is without
members that is, an amelic. 2 Occasionally there may be excess of mem-
bers, superfluous development ; thus there may be six fingers on each
hand, an anomaly so common among the Romans that they gave the
name of Sexdigiti? to persons having six fingers. In many cases the
anomaly has been found hereditary.
ACUTE INFECTIOUS DISEASES. The fact that the foetus may suffer
from variola has been established in numerous instances. So, too, there
have been a few cases reported of children born with the eruption of
rubeola. Thomas stated in 1874 that there were only 6 cases of certain
transmission of the disease to the foetus ; but 3 have been reported
since, one of them being by Lomer. 4 In more frequent cases the child
has been attacked with measles shortly after birth, but so soon that the
intra-uterine transmission of the disease cannot be questioned. The
proof that the poison of scarlatina may affect the foetus rests upon a
few cases. It cannot be doubted that the child while in the uterus may
suffer from malarial fever, and the observations of Dr. Bemiss, pre-
viously given, render it probable that it may also have yellow fever.
Hirst 5 quotes an instance in which the specific bacilli of typhoid
fever were found in the foetus, the mother having had the disease. A
similar fact has been reported by Eberth. 6 Vinay, accepting the trans-
mission of the typhoid bacillus to the foetus, suggests that if the latter
is dead at birth it has been killed by the typhoid germ or by the toxiues
it secretes. Recognizing pneumonia as an acute infectious malady, it
was thought 7 probable that pneumococci might pass from a mother
suffering with the disease to her foetus, and such transmitted affection
was in some cases the cause of foetal death; the intra-uterine trans-
mission of pneumonia is now admitted. Instances showing the prob-
able infection of the foetus with erysipelas from the mother have been
published.
CHRONIC INFECTIOUS DISEASES. A few instances of congenital tuber-
culosis have been observed. (See page 422.)
Foetal syphilis is very frequent. The changes caused in the foetus
by syphilis "are found in its skin, thymus, lungs, liver, spleen, supra-
reuals, pancreas and intestine, on its serous membranes and in its bones ;
they are most constant in the latter and in the spleen." In the spleen
no pathological products have been found, but the organ is greatly
enlarged. An osteo-chondritis is the special manifestation of syphilis,
and is found in the tubular bones, the lowest end of the femur usually
showing the most striking changes. The disease " begins with an
excessive proliferation of the cells at the margin of the epiphysis, which
is rapidly followed by an irregular calcareous infiltration and sclerosis
i From "E/crpwCTif , abortion, and [iho, a member. * From a privative, an
3 Probably the first historical reference to a person having supernumerary fingers and toes is in
the Bible, 2 Samuel, chap, xxi., ver. 20. -
* Centralblatt f. Gynakol., 1889.
* American System of Obstetrics, vol. i. 6 Arch, de Tocologie, 1889.
f De la Pneumonic pendant la Grossesse, Annales de GynScol., 1889.
DISEASES OF THE OVUM. 461
of the newly formed tissue." If the child is born living, it is usually
feeble, under-sized, its skin presenting syphilitic eruptions, pemphigus
and impetigo, and there are buccal and genital mucous patches. Its
cry is weak, and it suffers from obstinate coryza.
RHACHITIS. Intra-uterine rickets produces similar deformities to
those caused by the disease occurring after birth. Fractures of bones
are not uncommon, and the limbs are not developed in proportion to
the trunk, but are short.
SPONTANEOUS AMPUTATIONS. These may concern the upper or the
lower limbs, more frequently, however, the latter; they are caused
either by amniotic bands or by the cord encircling the member that
becomes mutilated, producing a constriction which prevents the part
below the constricted place receiving any blood ; if the bone be carti-
laginous, there is no improbability in the statement that complete section
FIG. 183.
SPONTANEOUS INTKA-UTERINE AMPUTATION.
may occur, but in some cases at least of spontaneous amputation the final
separation of the member, after constriction of the soft parts, has resulted
from a fracture. Cases of amputation cannot be confounded with those
where there has been deficient development, for the amputated member has
been expelled with the foetus from the utecus. Generally those foetuses
to whom this accident has happened are stillborn.
SPONTANEOUS AND ACCIDENTAL FRACTURES. Chaussier saw one
foetus with 43 fractures in different parts of the skeleton, and another
with 113. The late Dr. Hodgeu, of St. Louis, reported the case of a
child which at birth had 65 fractures ; he attributed them to muscular
action during intra-uterine life. 1 Branfoot 2 reports delivering a foetus
with the femurs and both bongs of each leg fractured. Fractures may
be caused by external violence to the mother. Packard 3 gives cases in
which the broken bones were firmly united at birth, but others in which
there was no union. Brinton has reported two cases of intra-uterine
fracture, one of the tibia, the other of the clavicle, occurring from in-
iuries received by the mothers. 4
LUXATIONS. Dislocations of bones, more especially of the femurs,
1 St. Louis Medical and Surgical Journal, 1882.
2 British Medical Journal, 1888.
3 International Encyclopaedia of Surgery, vol. iv.
* Transactions of the American Surgical Association, vol. ii.
46 2 THE PA THOLOG Y OF PREGNA NCY.
occurring in the foetus are not absolutely rare, though their etiology is
obscure. They are observed more frequently in females than in males.
In some instances they may be the result of external violence, but in
most no such cause can be adduced ; and, therefore, they are attributed
to "anomalous development of articular cavities."
TUMORS. In addition to the tumors caused by spina bifida, ompha-
locele, meningocele, or encephalocele, various other tumors, fluid or
solid, may be found upon different parts of the body. Some of these
are pedunculated ; others attached by a broad base; sometimes they are
so large as to render parturition difficult or impossible without operative
means.
DEATH OF THE FOZTUS. The foetus having perished from disease or
injury, whether affecting it directly or mediately, we have next to study
the diagnosis and the consequences of its death.
DIAGNOSIS OF THE DEATH OF THE FCETUS. The previous recogni-
tion of the foetus being alive facilitates the inquiry as to its being dead ;
by the continued absence of those signs which gave conclusive proof of
its life, we have a strong probability of its death ; this absence must be
ascertained by a most careful examination indeed, it is safer to repeat
the examination once or oftener. The death may have occurred prior
to the time that positive proofs of life were available, or they may not
have been ascertained. We inquire as to whether any injurious influ-
ences, paternal, maternal, or directly acting upon the foetus, the common
result of which is death, have been present. Thus, the father or the
mother may be affected with syphilis, the mother may have had an
acute infectious disease, or received some severe injury. The absence
of foetal movements, which the mother had certainly recognized; the
deterioration of her health; the breasts, after having been full, and
possibly secreting milk, becoming flaccid ;' she is pale or sallow, has
occasional chilly sensations, the abdominal wall somewhat relaxed, and
she may complain of what seems a dull weight in the abdomen, falling
from one to the other side, in correspondence with changes of position
in bed. The temperature of the uterus, being greater than that of the
vagina in pregnancy, will noV show no such change; but this examina-
tion is rarely made. There is one sign constantly available which,
I believe, is a positive proof of the death of the foetus, and that is, if,
with the negative evidence furnished by auscultation and palpation,
there is found regular diminution in the size of the abdomen, the
woman not suffering from any disease explaining this change, we are
justified in concluding that the child is dead.
There may be conjoined with examination by measurement of the
abdominal circumference, weighing the patient from week to week ; if
the child be dead she will probably lose in weight, whereas if it be alive
there will be a constant gain.
CONSEQUENCES OF THE DEATH OF THE FOZTUS OK EMBRYO. These
are remote or immediate. The only remote consequence is the expulsion
of the uterine contents, and this will be first considered very briefly,
however, because the subject must be presented elsewhere. The expul-
1 One of the aphorisms of Hippocrates is that, if the mammae of a pregnant woman suddenly
begin to lessen in size, she will abort.
DISEASES OF THE OVUM. 463
sion usually takes place within two weeks, and if delayed beyond that
time the name given is missed abortion. There may be delay for a few
weeks, or even for several months. In the case of one of twins dying
during pregnancy it is not unusual for it to be retained until the normal
end of pregnancy, and then it is expelled along with the living child.
Such cases, improperly interpreted, have furnished an argument for
superfcetation. So, too, in a single pregnancy, a three-months' fcetus,
for example, may be expelled at the end of nine mouths' gestation, and
this ought to be borne in mind by the practitioner, lest a wife, her
husband having been absent for some months before such expulsion, may
suffer unjust suspicion or reproach.
THE IMMEDIATE CONSEQUENCES OF DEATH OF THE PRODUCT OF
CONCEPTION. Certain changes follow this event ; they are liquefaction,
mummification, maceration, and putrefaction.
1. Liquefaction. This may occur during the first two months at
least, the embryo being dissolved so completely that no trace, or only a
trace, of it is left. The amnial liquor becomes thick and opaque, some-
times having a milk-like appearance like an emulsion. Important
changes meanwhile occur in the fcetal appendages. If myxomatous
degeneration of the chorial villi has already begun, it continues. But
more frequently the formation of what has been termed a fleshy mole 1
follows. This is composed of the deciduous membranes, and the mem-
branes of the ovum, with a central cavity occupied as mentioned, of
the placenta in process of formation, and of blood which is infiltrated
between the chorial villi and between the membranes. The separation
between the mass and the uterus being incomplete, the former is nour-
ished, and growth of its elements continues, the clots are absorbed, or
the fibrin, according to Scanzoni, becomes organized, the amnial cavity
grows smaller, and finally a nearly solid mass results. The " fleshy
mole " may be retained in the uterus for some weeks, giving rise mean-
time to occasional attacks of uterine " pains" and hemorrhage.
In 1892 I published 2 a brief study of fifty-four cases of molar pregnancy.
Only four occurred in primigravidse, and the mean duration of the pregnancy
was three to four months. In that paper I attributed chief importance to disease
of the chorial villi, as indicated by microscopic examination. But the fact of
almost all the cases occurring in multigravidse leads me now to the conclusion
that usually the primary factor is disease of the deciduse.
2. Mummification. This has been compared to the change which
a fruit undergoes when kept in alcohol. The soft tissues of the foatus
become condensed, contracted, Hardened, dried up, and thus it is less-
1 Depaul has remarked that (Dictionnaire Encyclop&dique des Sciences Mfidicales, second series,
vol. ix.) " nothing is yet more obscure to-day than the etymology of the word mole. The most
natural is that which derives it from the Latin word moles, which signifies mass." I think that
Depaul was mistaken. It seems that both Hippocrates and Aristotle applied the word Mi/b?
which originally meant a mill, to " a hard formation in a woman's womb." From this word the
Romans had mola, also primarily meaning a mill ; Pliny certainly applied mola to such an intra-
uterine formation as has been mentioned. But both fii^h] and mola mean secondarily the stone
which was essential for grinding. Hippocrates undoubtedly had observed calcified fibroids dis-
charged from the uterus, and it was quite natural that such a formation should be called fivty,
The application of the term to other solid masses expelled from the uterus would obviously
follow. And, therefore, the derivation of the terra mole from moles is unnecessary, for it seems
properly to originate from the Greek pmkr]^ the Latin mola.
2 American Journal of the Medical Sciences, October.
464 THE PATHOLOGY OF PREGNANCY.
ened in size and presents a shrivelled appearance ; its color becomes a
dull gray or yellow. The amnial liquor finally disappears, leaving as a
residue an earthy, grayish sediment " similar to the deposit left by a
stream after an overflow of its banks." Mummification, of course,
does not occur if the membranes have been ruptured, nor is it usually
seen except in a foetus of three to four months.
3. Maceration. The macerated foetus is larger than corresponds
with the period of intra-uterine life at which it perished ; it is swollen,
its form changed, the abdominal cavity is often greatly distended ; its
tissues are softened, the bones lose their firm attachment, and especially
those of the cranium move freely upon pressure ; the skin presents
numerous blebs, and the epidermis comes off in large flakes, showing
the derm beneath of a dusky red ; the serous cavities contain blood-
stained serum, and the blood escaped from its vessels contributes its
coloring-matter to dyeing the tissues; it is sometimes known as, foetus
sanguinolentus. Runge states that in 70 to 80 per cent, of cases the
macerated foetus presents evidences of syphilis.
Ribemont-Dessaignes, 1 after referring to the generally admitted view that the
external signs of maceration the formation of blebs and the detachment of the
epidermis are not manifested until the third day after the death of the foetus,
holds that these lesions may appear much earlier, a few hours after death, and
even upon the living foetus, and adduces cases in illustration.
4 Putrefaction. This occurs when the membranes have been rup-
tured, and thus air gets access ; air with moisture and warmth furnishes
the essential conditions for putrefactive changes. Putrefaction occurs
very rapidly, and McClintock 2 stated that he had seen the uterus be-
come quite tympanitic from this cause after the accession of labor and
before delivery. The abdomen of the foetus is distended by gas, the
connective tissue emphysematous, crepitating upon pressure, the entire
body and members greatly swelled, so that serious difficulty in delivery
may be presented, and a horrible odor exhales from the foetus. In
some cases gas accumulates in the uterus, a condition known as physo-
metra, and the organ is greatly distended and tympanitic. Generally
the eifect of foetal putrefaction upon the mother is more or less grave ;
she has chills, fever, diarrhoea, and death may result from the infection
of her system, unless the decomposing foetus be promptly removed, and
appropriate local antisepsis be employed.
ABORTION. Abortion is the expulsion of the product of conception
before the foetus is viable. Miscarriage is commonly used as a synonym,
though by some it is restricted to an abortion occurring after three
months ; 3 the reason for this distinction is that the treatment of the acci-
dent varies at these different periods. But such distinction is purely
arbitrary. Further, abortion has been divided into ovular, embryonic,
and foetal ; the first is applied to an abortion in the first three weeks,
the second to that which happens between the end of the three weeks
and of the first three months, and foetal is used to designate the acci-
dent from the end of three to that of six months.
1 Annales de Gynecologic, July, 1889.
2 Note to Sydenham's Society's edition of Smellie's Midwifery.
3 Miscarriage in this restricted sense is also called partus immaturw.
DISEASES OF THE OVUM. 465
CLASSIFICATION. Abortion has been divided into spontaneous, or
natural, and accidental ; by the former a miscarriage occurring from
obscure or latent causes is designated, and by the latter one that has an
obvious cause. But this distinction is in many cases impossible to be
made. A better division is into spontaneous and artificial. The latter
class is divided into therapeutic and criminal ; therapeutic abortion is
that which is done by the physician in the interest of the mother's life
or health, while criminal abortion is without this or any other justifica-
tion. The term incomplete, or imperfect, is applied to abortions in
which the entire ovum is not expelled. Missed abortion has been pre-
viously defined.
FREQUENCY. There are, and there can be, no data by which the
absolute or relative frequency of abortion can be ascertained, for many
cases occur without the subjects knowing it, and many other abortions
are self-produced, or performed by professional abortionists, and, there-
fore, kept secret ; in only exceptional instances when a fatal result fol-
lows do medical men or the public know of them. Whitehead's statis-
tics 1 show that 87 per cent, of women living in wedlock until after the
menopause had aborted at some time in their married life. Priestley 2
estimates the number of abortions as one to four labors ; Ahlfeld, one
in five. But even the former proportion, though greater than given by
most Avriters, is probably too small. The sterility of prostitutes as well
as that of many newly married women may frequently be attributed to
early abortion.
TIME OF ABOETION. The greater number of miscarriages occur in
the first three months of pregnancy. There is an exception to this rule,
however, given by those cases of criminal abortion which become sub-
jects of judicial inquiry. Tardieu 3 has shown by statistics collected by
himself and others that criminal abortion is more frequent from the
third to the sixth month than in the first two months. The explana-
tion of this fact is, that up to three months a woman hopes there is
simply a delay in the appearance of the flow, but when this hope fails
she is ready to resort to active means to end a pregnancy which has
now become almost certain ; on the other hand, when six months have
elapsed the life of the child has become so manifest that she shrinks
from its destruction foatal movements make successful appeal to the
mother's conscience, if not to her love also, for the salvation of the new
life which dwells within her womb as its sanctuary. The great majority
of spontaneous abortions occur at a time corresponding with a monthly
flow ; Boerhaave made the proportion nine out of ten.
CAUSES OF ABORTION. Very trifling causes may produce miscar-
riage in some women. La Motte has said that a misstep, raising the
arms too high, a strong odor, as of musk, amber, or civet; a bad odor,
as from a dead animal in the road, from a charcoal fire just kindled, or
from a lamp or candle imperfectly extinguished, may end the pregnancy
in some. On the other hand, the most active exercise, the severest
injuries, grave surgical operations, the most cruel violence, or the use
of enormous doses of irritant medicines reputed abortive, have not
caused miscarriage in others.
1 Abortion and Sterility. 2 Op. cit. 3 Etude Medico-legalesurl'Avortement.
30
466 THE PATHOLOGY OF PREGNANCY.
Instances of frequently recurring abortion are not uncommon ; one
has been mentioned of a woman who miscarried twenty-four times at
three months. These have been termed habitual abortion. But, as re-
marked by Kleinwiichter, habit is not to be regarded as a cause; it
would be more rational, since habit did not begin the series, to attribute
the abortion, in most cases, to the still acting original cause. Dr. Meigs
ascribed so-called habitual abortions to excessive irritability of the
uterus ; others have held that they were caused by a want of nutritive
material in the uterus for its complete development, the organ growing
for a time, and then the growth ceases and abortion follows. Neither
hypothesis rests upon established facts, but each indicates the incorrect-
ness of the view that habit is its cause.
The causes of miscarriage do not, in all cases, act separately, but very
frequently two or more are combined. Some simply predispose to the
accident, while others are the efficient agents. In their further consid-
eration, it is convenient to divide them into paternal, maternal, and
those belonging to the ovum.
PATERNAL CAUSES. According to Deviliers, the procreative power
being distinct from that of development, the evolution of the product
of conception is almost entirely under the influence of the degree of
vitality of the mother. Nevertheless, the father being syphilitic, the
foetus may be infected and perish, though the mother remains healthy.
It is quite possible, too, that in addition to syphilis other diseased con-
ditions of the father, such as alcoholism and phthisis, may result in a
fcetal malady which is incompatible with the continuance of pregnancy.
The injurious influence of lead-poisoning acting through the mother
upon the foetus has been shown by Constautin Paul, 1 Roque, 2 and Ren-
nert. 3 But Lefour 4 has also taught that if the father be a worker in
lead, the mother not being exposed to lead-poisoning, there is great
liability to abortion.
MATERNAL CAUSES. These may be divided into external and in-
ternal, or those coming from without and those acting from within.
Among external causes are violent exercise, as running, dancing, jump-
ing, riding on a hard trotting horse or over a rough road; lifting heavy
weights, falls, blows 5 upon the abdomen, compression of the body by
clothing or by corsets, compression of a varicose limb, the use of the
uterine sound, applications to the cervix, leeching the cervix or the vulva,
and surgical operations, especially if involving the genital zone. Fre-
quency of coition is not unseldom a cause of miscarriage. Whitehead 6
has stated that there can be little doubt that a great number of cases of
uterine disease, attended with vaginal discharge, and frequently result-
ing in abortion, may be attributed to intemperate sexual intercourse
1 Arch. Gen. de Medecine, 1860. - Paris Thesis, 1873.
3 Arch, fiir Gynakol., 1881. Gaz. hebd. des Sqi. Med. de Bordeaux, 1887.
6 History gives us two noted instances of husbands causing abortion by kicking their wives.
One of these was Cambyses, the son of Cyrus: he is referred to in "Ezra" as Ahasuerus. He
subjugated Egypt more than 500 years before the Christian era ; while living in that country,
according to Herodotus, he married his sister, and one day, becoming enraged at her just rebuke
of some of his many evil acts, kicked her, she being pregnant at the time, and death, preceded by
miscarriage, resulted.
In Fleury's Histoire Ecclesiastique, Paris, 1722, it is stated that one of the crimes of Novatus, an
heresiarch of the Carthage Church, about the year 258 A.D., was kicking his pregnant wife, causing
miscarriage.
Op. cit.
DISEASES OF THE OVUM. 467
during pregnancy. Depaul held that two-thirds of spontaneous abor-
tions were caused by coition, while Miquel, of Tours, makes the pro-
portion still greater nine out of ten.
Great altitudes are said to be a cause, and it is asserted that in certain
mountainous countries pregnant women descend to the valleys to escape
the accident. Hot climates are thought by some to cause it. This effect
has also been attributed to hot baths. The opinion is confirmed by the
statement of Kormann 1 that when used to excess they are apt to pro-
duce a miscarriage.
Among internal causes are acute infectious diseases. Chronic infec-
tious diseases differ in their influence upon pregnancy, phthisis compara-
tively seldom arresting it, while syphilis frequently does. Olshausen
regards syphilis and retroflexiou of the uterus as the most frequent
causes of spontaneous abortion. Cardiac disease may cause abortion.
Lydeu 2 states that cardiopathics frequently miscarry, and this is the
means taken by nature to avoid accidents. Some of the sporadic dis-
eases produce the same result, as has been previously mentioned; so
may lead-poisoning and albuminous nephritis. It is by some held that
a pregnant woman working in a tobacco factory is thereby rendered
liable to miscarriage. 3 Abortion may result from violent sneezing,
coughing, or vomiting; likewise from diarrhoea or dysentery. Adhe-
sions of the uterus from former peritoneal inflammation may prevent
the development of the organ, and thus end the pregnancy; so, too,
rigidity of its body, or relaxation of the cervix, are regarded as causes.
Abdominal tumors external to the uterus may occupy so much space
that there is no room for the pregnant uterus, and hence its contractions
resulting in expulsion of the ovum may be evoked. Positional and
structural diseases of the uterus are causes. Among the former pro-
lapse and posterior displacements are of especial significance; among
the latter malignant diseases, particularly of the fundus, polypi and
fibroid tumors; a lacerated cervix may cause repeated abortion. Strong
mental emotions, as fear, sorrow, joy, or anger, are occasionally causes.
Whitehead and Duncan, among others, have mentioned the fact that
the last pregnancy in the childbearing period is quite liable to end in a
miscarriage.
ABORTION FROM THE USE OF MEDICINES. It sometimes happens
that abortion is caused by the use of drugs, as, for example, active
cathartics, or even laxatives or emetics. It may be that in some cases
the administration of quinine has been followed by miscarriage, and
while in almost all instances the .event is justly attributed to the disease
for which the medicine is given, yet possibly the latter, in a few, was,
from some peculiarity of constitution of the individual, the efficient
agent. Nevertheless, neither this nor any other drug can be regarded
as an abortifacieut ; there must be some tendency to miscarriage, some
abnormal condition which renders those who thus suffer after taking
any of these agents liable to miscarry. 1 have known two pregnant
married women take an infusion of May-apple in such large quantity
1 Op. cit. 2 Berlin, klin. Wochenschrift, 1893.
3 The testimony of medical men who have investigated this subject differs, but I think the
weight of authority is in favor of the statement made in the text. See article by Dr. Pradel, Journ.
de Med. de Paris, August 5, 1888.
468 THE PATHOLOGY OF PREGNANCY.
as to produce violent catharsis and eraesis with great prostration, yet in
neither was the pregnancy interrupted.
CAUSES BELONGING TO THE OVUM. Velpeau, after examining the
ova from two hundred abortions occurring under three months, found
one-half were diseased. The various diseases of the decidua that have
been mentioned, and its premature atrophy, are frequent causes ; also
placental apoplexy and the different degenerations of the placenta.
Polyhydramnios in most instances causes the pregnancy to be arrested,
in consequence of the great disteution of the womb. The uterus, too,
in many cases reacts prematurely in consequence of similar excessive
distention in plural pregnancy. Abnormal site of the placenta may
cause miscarriage. The foetus may be affected by the same disease as
the mother, or suffer independently of her, and its death result in abor-
tion. Disease of the umbilical cord, or its compression, may have a
like fatal effect upon it, and thus upon the pregnancy.
SYMPTOMS. In some cases of abortion premonitory symptoms may
be observed. These are alternate flushes of heat and chilliness, a feel-
ing of languor or feebleness, lumbar pain, a sensation of pelvic weight,
of fulness of the lower part of the abdomen, some irritability of the
bladder, and possibly of the rectum also.
The characteristic symptoms are hemorrhage and painful contractions ;
contractions are, indeed, the efficient cause of abortion. In the first
weeks abortion may be readily mistaken by the woman herself, especially
if she has had other early miscarriages, and by the physician for an attack
of dysmenorrhcea. But the rule is, that in the latter pain precedes the
flow of blood, whereas, in the former, the phenomena occur in the re-
verse order, or else they are simultaneous. Some cases have early in their
progress a gush of watery fluid slightly discolored with blood ; this
discharge does not necessarily indicate rupture of the ovum, and hence
that miscarriage is inevitable, for it may occur from catarrhal endome-
tritis. But no such discharge occurs either before or during menstrua-
tion. Usually the flow of blood is very much greater than that which
occurs in menstruation. Further, it is possible some of the reflex
disturbances arising from pregnancy may have appeared ; and if so,
this fact will assist in making a diagnosis. The final proof of the case
being one of abortion and not of difficult menstruation would be find-
ing the ovum in the discharge, possibly surrounded by a clot of blood.
The ovum of an early abortion is generally entire, though the fact that
the sac is ruptured is not a proof, as claimed by some, that the miscar-
riage has resulted from criminal means. In some cases occurring from
the first to the second month, blood may not only be effused between
the decidua and the chorion, but also penetrate the chorion and then the
amnion, more or less completely filling the amuial cavity.
If the pregnancy has advanced to seven or eight weeks, or further,
but still not reached three months, the symptoms of abortion are usually
quite plain. The suffering, the regular recurrence of the pains, and the
marked hemorrhage, scarcely leave room for doubt. It is a labor in
miniature, at least so far as it relates to the expelling organ and to the
expelled product, but not in miniature in regard to the duration of the
process and the attendant suffering. The ovum is in the majority of
DISEASES OF THE OVUM. 469
cases expelled entire if there has been no improper interference. The
chorial villi are very distinct, and, as Pajot has said, the entire external
surface of the ovum is placenta. The deciduous membranes are usually
discharged afterward at least a considerable portion of these does not
pass off with the ovum.
If the pregnancy has advanced to three months or beyond that is, if
the abortion be foetal the ovum is usually ruptured in the process, and
the foetus is expelled first and its appendages afterward ; in this respect
the course is similar to that of labor. A delay of many hours, or even
of several days, may occur in the expulsion of the foetal appendages ;
and during this retention the patient is liable to attacks of hemorrhage,
or she may have a bloody and purulent offensive discharge.
It happens in some cases that after severe pains, and more or less hemorrhage
with dilatation, so that the finger can touch the ovum, even, too, with discharge
of a fragment of decidua, as has been observed by Spiegelberg, Matthews Dun-
can, and others, the symptoms of miscarriage gradually cease, and the preg-
nancy is completed. More frequently, however, the cessation is temporary ; it
may last some hours, or even days, and then uterine action is renewed, and the
usual result follows. In those cases of threatened abortion in the early months
in which the symptoms permanently cease, though there has been considerable
hemorrhage, the discharge came from detachment of the ovum at its lower seg-
ment ; such cases are usually seen before the placenta is completely formed.
In the fourth month, and on to the seventh, the course of abortion is
similar to that of premature or of mature labor, the process being,
however, longer than in labor, because the cervical changes which pre-
cede the latter must be effected, and because the uterine muscular struc-
ture is imperfectly developed. Hemorrhage is less to be feared as the
seventh mouth is approached ; the uterine decidua is more readily cast
off in late than in early abortions. Before the formation of the pla-
centa the hemorrhage comes from the entire internal surface of the
uterus, but after this has taken place only from the site of placental
attachment. Very little discharge follows an abortion in the early
months if it be complete ; but if a portion of the ovum be retained, the
hemorrhage may be great. Milk is usually secreted after miscarriage,
in some instances even when that occurs quite early in pregnancy.
Prognosis. If the abortion be inevitable, of course the foetus dies,
or is already dead, and the practitioner is concerned with the interests
of the mother alone. The chief immediate dangers are hemorrhage or
septicaemia, 1 which may be general, or be limited to a local pelvic in-
flammation. Tetanus has occasionally followed. Putrid decomposi-
tion of fragments left in the uterus, according to Kleinwachter, is less
common than generally believed, because of the difficult entrance of air,
and because manual intervention is less frequently resorted to than in
birth at the normal time.
The fatality following criminal abortion is very great. Hippocrates
said that abortion was much more dangerous than labor, because the
product of conception could not be destroyed except by violent means ;
but this remark is especially applicable to criminal abortions.
1 In a paper upon Midwifery Among the Burmese, the author, Dr. Pedley, states that " puer-
peral fever is recognized by Burmese midwives, and seems to be more frequent after abortion."
Transactions of the London Obstetrical Society, vol. xxix.
470 THE PATHOLOGY OF PREGNANCY.
Tardieu states that in 116 of this class, in which the termination was certainly
known, death occurred more or less promptly in 60. He refers to cases of sud-
den death which may be caused by embolism, by syncope, either from excessive
pain or from the moral shock created by the consciousness of crime. Other
causes which conduce to the fatality of criminal abortion are the secrecy with
which the operation is done; usually the unhappy victim goes to the house
of the abortionist,^ and he or she, for women are also engaged in the wicked
work, endeavors to puncture or detach the membranes, possibly wounding the
uterus in these efforts, in many instances " made by an ignorant or brutal hand,
or one that trembles with conscious guilt." After the operation the subject
walks or rides probably a long distance to her home, and there, in order to conceal
all knowledge of her condition, engages in her usual avocation or work, until grave
symptoms compel her to rest, and possibly to send for a physician.
The remote dangers of abortion are chronic parenchymatous metritis,
very often spoken of as subinvolution, and positional disorder of the
uterus ; a portion of the placenta may remain and be converted into a
placental polypus, or hypertrophy of undetached decidua may occur,
and either be the cause of uterine hemorrhage. These dangers may be
prevented in most cases by proper care during and after abortion. Unfor-
tunately too many women look upon miscarriage as a trivial matter,
and do not take the rest after it that they ought.
Treatment. The treatment may be considered under three heads,
prophylaxis, that required in threatened or commencing abortion, and
that of inevitable abortion.
Prophylactic Treatment. This includes a recognition of the causes
of miscarriage in individual cases, and their removal. It is not neces-
sary to repeat the etiology of this accident, nor the treatment required
in different cases. In habitually recurring abortion the probability is
that syphilis, or uterine retroflexion, or an endometritis is the cause.
The late Professor Henry Miller, of the University of Louisville, who was one
of the first American physicians to teach and to practise the local treatment of
uterine diseases, regarded inflammation of the lining membrane of the uterus
as one of the most frequent causes of miscarriage, and urged the importance of
properly treating the former in order to prevent the latter.
When a woman who has previously aborted becomes pregnant she
should be advised to avoid all exercise at the time in the new pregnancy
corresponding with that in the former when abortion occurred. So, too,
rest at the times corresponding with " monthly periods " should be en-
joined. Sexual intercourse ought to be forbidden.
The late Sir James Y. Simpson advised the potassic chlorate, ten to twenty
grains three times a day, as a preventive ; he gave it for placental disease and
also as a means of arterializing the blood ; it is impossible for it to produce the
effect upon the blood suggested. Priestley states that many practitioners have
testified to its utility as well as to its harmlessness, and suggests that it may act
successfully as an alkaline salt in preventing the formation of congestive and
fibrinous deposits in the placenta. A preparation from the bark of the black
haw ( Viburnum prunifolium) was recommended by Phares, in 1866, as useful in
preventing miscarriage ; since then it has been occasionally indorsed for this
purpose by others ; Wilson and Campbell 1 have recommended it very highly,
sustaining the claims previously made for this medicine, that it is a tonic and
uterine sedative ; pills of two to four grains of the solid extract were given three
or four times a day ; Wood 2 states that we have no exact knowledge of the action
i British Medical Journal, 1886. * U. S. Dispensatory, 1883.
DISEASES OF THE OVUM. 471
of the remedy, and its value must be considered at present apocryphal. The
dose of the fluid extract, the only preparation of viburnum which is officinal, is
from half a teaspoonful to one or two teaspoonfuls, three times a day.
Some physicians, chiefly in Italy, have recently recommended asafoetida, given
twice a day, in threatened abortion. The most important means, however, will
be the removal of the causes which produce abortion.
In most cases, if four months have passed without abortion occurring,
that is, if a previous one -were before this time, the probability is that
pregnancy will not be disturbed, and the patient may gradually resume
a moderately active life.
TREATMENT OF BEGINNING ABOETION. Here the characteristic
symptoms, to wit, hemorrhage and uterine contractions, are present ;
under only three conditions is the abortion inevitable; the first is the
death of the embryo or foetus; the second, detachment of a large por-
tion of the ovum ; and the third, rupture of the ovum. But it is in
exceptional cases the physician can know at the beginning that any one
of these conditions is present, and therefore his duty in all cases is to
endeavor to arrest the miscarriage. The patient should at once lie
down, her clothing being quite loose, the bed moderately hard, and she
should be only lightly covered ; her drinks should be cold iced lemon-
ade is very commonly given. Twenty drops of laudanum with half a
teacup of warm water should be at once injected iuto the rectum, or an
equivalent amount of opium in the form of a suppository may be used.
The purpose sought to be accomplished by the opiate is to lessen the
irritability and arrest the contractions of the uterus ; it is claimed by
some that the pregnant woman bears this remedy much better than when
not pregnant. If the contractions have not decidedly abated in one
hour, the injection or suppository is repeated, and again if necessary at
the end of the second hour, and still again at the end of the third hour.
If the patient is very nervous and restless, twenty to thirty grains of
chloral may be added to one of the opiate injections, and then the vehicle
should be, not warm water, but the yelk of an egg and some warm
milk. When opiates are given freely, it is quite possible that retention
of urine will follow, and if this is the case the catheter must be used
as needed, twice or thrice in the twenty-four hours ; the employment ot
the instrument is preferable to allowing the patient to sit up to urinate.
The opium may be continued from day to day as long as there is any
hope of arresting the abortion. Meantime, once in two days the bowels
should be opened by a warm-water injection, or by a mild laxative.
Supposing the pain and hemorrhage to cease, it is better for the patient
to remain in bed for three or four days after this cessation ; when she
gets up she should only gradually resume her usual habits of life, even
then as an experiment, and prepared to return to bed at the first recur-
rence of the former symptoms. Unfortunately, in the majority of cases,
the pains and hemorrhage do not cease, or having stopped they return,
and the abortion is apparently inevitable, or the flow may be so great
that its arrest is necessary without regard to the continuance of the
pregnancy.
TREATMENT OF INEVITABLE ABORTION. Two indications are pre-
sented stop the bleeding and empty the uterus. The application ot
472 THE PATHOLOGY OF PREGNANCY.
cloths wrung out of ice-water, to the vulva, to the lower part of the
abdomen, and to the upper part of the thighs, has been recommended;
but apart from the uncertainty of this use of cold, such applications
may chill the patient, and will make her uncomfortable, and may cause,
if there be liability to either, an attack of bronchitis or of rheumatism.
Vaginal injections of very hot water are to be preferred, both for
hsemostasis and exciting uterine action. If the os be sufficiently dilated
to permit immediate and complete evacuation of the uterine cavity, it
should be done. And to this end firm pressure is made with one hand
through the abdominal wall upon the uterus, while in some cases one
or two fingers may be introduced into the uterine cavity to assist in the
delivery of its contents, the greatest care being taken to avoid rupture
of the ovum, if this be still entire.
In case, however, the os is but little open, some advise dilatation, especi-
ally by means of Barnes's dilators ; Dr. Murphy, of Sunderland, for
example, rejects the vaginal tampon, and uses them as a most efficient
uterine tampon, not only arresting the hemorrhage, but making possible
and hastening a complete delivery.
The most valuable, the safest, and most certain means of arresting
the hemorrhage generally available is the tampon. Of course the tam-
pon can be best applied by using Sims' s speculum, but this is not essen-
tial. The following method may be satisfactorily employed in almost all
cases. The vagina should be washed out with an antiseptic injection
and the bladder emptied ; let the patient lie on her back with flexed
legs and thighs ; the practitioner having provided a number of balls of
absorbent cotton about the size of a hulled walnut, and some iodoform
in powder, or a solution of carbolic acid, now separates the labia with
two fingers of one hand, then by means of an ordinary dressing- forceps
in the other hand, carries one and then another of the cotton balls up
into the vaginal vault, firmly pressing them around the cervix ; the
balls first introduced should be covered with iodoform or dipped in
the carbolized water. After filling the vaginal vault with the cotton,
another layer of balls is firmly placed beneath the first, and still one
or two beneath that, until at least the upper third of the vagina is com-
pletely filled, and the os uteri covered over. The use of an astringent
solution, such as one of the salts of iron, is unnecessary, for by no
possibility can one drop of fluid come in contact with the bleeding
surface, and needless irritation, even inflammation and sloughing of the
vagina, may occur if a concentrated solution is employed.
Instead of balls of cotton, strips of iodoform or of creolin gauze .may be used.
I have in some instances made a vaginal tampon by taking a strip of absorbent
cotton, 10 or 12 inches long and about 2 inches broad ; let one side of the strip
be covered with a 4 per cent, creolin ointment ; then seizing one end of the cot-
ton with forceps, while the vulval orifice is kept open, it is carried up to the
anterior portion of the vaginal vault, and from this as a starting-point alternate
folds made posteriorly and anteriorly until the upper part of the vagina is com-
pletely packed, a second and a third strip being used if necessary. The special
advantage of this method of using cotton as a tampon rests upon facility of appli-
cation and of removal.
In only rare cases will it be necessary to tampon the entire vagina,
and secure the packing by a T-bandage. The tampon is a perfect safe-
DISEASES OF THE OVUM. 473
guard against hemorrhage, but it must be of suitable material and
properly applied ; let no practitioner in this or any other case of uterine
hemorrhage delude himself by trusting a tampon of sponge. The ad-
vantages of the tampon in abortion are, not only in the arrest of external
hemorrhage, but its pressure evokes uterine contractions, and the small
quantity of blood escaping from the detachment of the ovum is now
shut up in the womb, and passes between the former and the uterine
Avail, perfecting the separation, and thus facilitating complete discharge.
The tampon may be left in place twelve or twenty-four hours, perfect
antisepsis having been observed in its application. Upon its removal
the ovum will in many cases be found in the upper part of the vagina,
or it may have entered the cervical canal, and so completely fill it that
a repetition of the tampon is unnecessary ; in the latter case firm com-
pression of the uterus may finish the expulsion of the ovum ; even
before the descent into the canal, delivery by expression is sometimes
successful.
The general practice is to give ergot when there is much hemorrhage;
but if the cervical canal is undilated, it is claimed by some that the
medicine contributes quite as much to the imprisonment as to the expul-
sion of the ovum. This objection is completely removed if the tampon
be used when ergot is administered. Ergot and the tampon are reme-
dies that act admirably when associated in these cases. The practitioner
in cases of miscarriage in the first three months must be especially
careful not to rupture the ovum, for if the amnial sac be opened there
is great danger of the abortion being incomplete. In case hemorrhage
persists or returns, the abortion not yet having taken place, the tampon
is to be repeated, and with the repetition ergot may also be used.
While in the great majority of cases under this treatment the ovum
is expelled entire, in some the embryo or the foetus is discharged, but
the appendages retained ; or the case may be one in which the abortion
was begun by perforating or puncturing the membranes. If the
pregnancy has continued as long as four months, usually expression will
cause the expulsion of the placenta and membranes ; if necessary, this
expulsion may be facilitated by digital or other dilatation of the os uteri.
These cases as a rule do not present serious difficulties, though there may
be delay and difficulty in completely emptying the womb.
But if a miscarriage occurs in the period from seven to ten weeks,
and immediately after the expulsion of the embryo the cervical canal
closes, what practice is to be pursued ? Some insist upon immediately
emptying the uterus by means', if necessary, of instruments, either
forceps, curettes, 1 or Simon's spoon. Certainly when miscarriage is
incomplete, there is a possibility of serious dangers, but, on the other
hand, hasty interference is not free from peril ; the appendages are re-
tained either because still attached to the uterus, or because of the ob-
stacle presented by the narrowed cervix. If attachment prevents their dis-
charge, they are a living part of the uterus, and tearing them away in
itself is a traumatism, while rude efforts in this process may inflict ad-
ditional traumatism, and as fragments are almost inevitably left behind,
1 I am glad to read the recent statement of Ahlfeld : Curetting is almost always unnecessary.
Wounds from the curette are unavoidable.
474 THE PATHOLOGY OF PREGNANCY.
the detachment is incomplete ; moreover, their presence in the uterus
may for a time give rise to no symptoms. 1 But, on the other hand, if
partial or complete detachment has occurred there will be hemorrhage ;
or if retention is permitted for a day or two, in addition to the hemor-
rhage there may be an offensive discharge. Now, the indications for
active interference are unequivocal, and delay is perilous. In these cases
gradual dilatation of the os may be effected by tupelo tents or a rapid
dilatation by Hegar's hard-rubber dilators, and this is the preferable
plan, the patient being anesthetized if thought best. After the dilata-
tion the uterine cavity is disinfected by washing it out with a 3 per cent,
solution of carbolic acid in warm water, and one or two fingers made
aseptic and dipped in an antiseptic fluid one teaspoonful of creolin, for
example, in a pint of water are passed into the uterine cavity, while
the other hand upon the hypogastrium presses the uterus down upon
the internal fingers ; or, as advised by Dr, Alexander R. Simpson, the
uterus is drawn down to the mouth of the vulva by the volsellum, and
then one or two fingers introduced. In either case the membranes are
detached by the fingers and brought down to the os ; in some instances
the finger and thumb may be used like a crab's claw, as Mauriceau
expressed it, to seize them and draw them out.
But if digital detachment fails to remove the remains of the ovum, I
have found the following an excellent plan The practitioner has at
hand a basin of warm carbolized water, Churchill's tincture of iodine,
Emmet's curette forceps, a uterine tenaculum, one or more applicators,
a uterine probe, absorbent cotton, and a bivalve speculum Neugebauer's
answers admirably. The patient now has her hips brought to the edge
of the bed, and the thighs and legs strongly flexed ; after the introduc-
tion of the speculum and exposure of the os, the tenaculum is inserted
into the anterior lip from below and firmly held, so as to fix the womb,
and also used to straighten any flexion that may be present ; next the
uterine probe is introduced to ascertain the size and direction of the
uterine cavity, after which the blades of the curette forceps, first being
dipped in the carbolized water, are passed into the uterus, then opened,
the ends pushed on until touching the uterine wall, when they are firmly
closed and withdrawn ; upon withdrawal they will be found to contain
fragments of membranes which may be removed by opening them and
moving them to and fro in the carbolized water ; the process is repeated,
and all parts of the uterine cavity, especially the vicinity of the
entrance of the oviducts, thoroughly explored, and membranes detached
and removed. After completing the removal of membranes, or placental
fragments, the uterine cavity is swabbed out with the iodine solution,
or, better, an injection of iodine made with Braun's syringe ; iodine is
both an excellent antiseptic and uterine haemostatic.
1 Charles says : We do not advise immediate efforts for the removal of the after-birth in abor-
tions before four months, wliLe after this period we recommend acting as soon as possible in the
artificial delivery as after labor at term. The conditions are different. 1. The danger from reten-
tion is much less. 2. The introduction of the hand is impossible because of the narrowness of the
cervical canal and the smallness of the uterine cavity. 3. The dilatation of the orifice and the
introduction of instruments designed to extract the placenta are dangerous, difficult, and painful ;
these instruments act blindly, contuse,-lacerate the uterine walls, and rarely succeed in removing
all the secundines, but almost always cause metritis. In a word, the danger from retention is
much less than that of extraction. Journal d'Accouchements, June, 1885.
DISEASES OF THE OVUM. 475
Doubtless some will think that the practice advised in incomplete abor-
tion of the earlier weeks, when there is closure of the cervical canal after the
expulsion of the embryo or foetus, and no symptoms demand interference, too
conservative. But I can fully adopt the words of that wise obstetrician, the late
Dr. Churchill, " Longer experience has made me less fearful of leaving these
cases to nature, and more unwilling to interfere hastily." The probability is,
that they will end within a few days by the spontaneous expulsion of the uterine
contents ; meantime the practitioner carefully watches the case, directs antisep-
tic vaginal injection twice a day, and is ready to meet any dangerous symptom
and to assist nature's process ; his position is not that of simple expectation, but
of armed expectation, as a French obstetrician has expressed it.
It is satisfactory to the writer to know that the conservative treatment con-
servative in opposition to the radical methods advocated by many authors in
recent years presented in previous editions of this work and now repeated, is
in perfect correspondence with that of Winckel in his work upon obstetrics.
This eminent and able practitioner, with an experience which is the fortune of
few, uses the following language : l " I maintain that if, in an abortion or imma-
ture labor, fragments of foetal membranes or placenta have remained behind, we
are justified and obliged to proceed to operative interference only when there are
severe hemorrhages from the uterus, or fever or sloughing occurs. In the absence
of these indications I am strongly opposed to cleansing the uterus, either by
hand or by instruments, because this method furnishes no guaranty against small
fragments being left behind and against direct inoculation of sanious matter into
existing lesions. If the placenta remain behind and the inetrnal os closes, or
permit at most the introduction of one finger, or even if an exudation can be
detected in the neighborhood of the uterus, we must desist from any attempts at
entering the uterus, but should administer ergot, irrigate the uterus daily through
a Fritsch or Budin catheter with an antiseptic fluid, such as solutions of boric
acid, carbolic acid, or of potassic permanganate, or chlorine-water, and as a rule
we will find that in from two to ten days the placenta is completely and safely
expelled."
The course in incomplete abortion 2 advised by Tarnier and Budin is also con-
servative.
Last year Professor Schauta, of Vienna, made a valuable contribution to the
subject of the treatment of abortion ; some of his directions in the manage-
ment of abortion will now be presented. He condemns active intervention at
first, so strongly advised by some authors, and is content with meeting the first
symptom, hemorrhage, by a vaginal tampon of iodoform gauze ; it is not neces-
sary to use the speculum. If after introducing the tampon the pains are severe
enough to cause the expulsion of the ovum, the latter will be found upon re-
moval of the former. But the contractions not having effected this expulsion,
the tampon is removed at the end of twenty-four hours, and after its removal the
neck is found dilated or not, and the hemorrhage has ceased or continues It
the neck is not dilated and the hemorrhage has ceased, no immediate interven-
tion, but wait possibly abortion may not occur.
But if the neck is partially dilated, and bleeding continues, a fresh tampon,
and this, if necessary, is replaced by another at the end of twenty-four hours.
In acting thus the ovum is completely detached and is entirely expelled. Occa-
sionally, after tamponing several days, it may happen that the neck will admit
two fingers, nevertheless the ovum Remains. This fact shows that the ovum is
adherent, and its adhesions must be artificially ruptured ; for this end two fingers
are passed into the uterus, pressed down so that the fingers reach to its fundus,
and then they are carefully used to detach the ovum, when the hand is with-
drawn and simple pressure upon the uterus usually causes expulsion of the ovum ;
if this does not occur, use forceps, and if bleeding follows tampon the uterus with
iodoform gauze, the tampon remaining twenty-four hours. In those cases to
which the practitioner is first called, when the uterus has lessened in size, the
neck not dilated, and hemorrhage continues, there are fragments of the mem-
branes retained, and dilatation is necessary, preferably by Hegar's dilators. Let
the finger be used after this dilatation to remove the retained fragments, and if
1 Edgar's translations.
- Trait6 de 1'Arte des Accouchements, tome deuxieme.
476 THE PATHOLOGY OF PREGNANCY.
not thus succeeding, then the curette, guiding the instrument by the finger and
using it only upon those parts where there are such adherent fragments ; he con-
demns blind general curetting the endoinetrium. I am very glad to introduce
this condensed statement of Professor Schauta's method ; I hope his practice and
counsel will do something toward checking the radical treatment of abortion,
which has, in my opinion, come too much in vogue.
AFTER-TREATMENT. The patient remains in bed at least a week
after a miscarriage, for frequently permanent invalidism is caused by
neglect of proper care at this time.
MISSED ABORTION. Sinclair, 1 in a paper upon this subject, classifies
cases of missed abortion as follows : (1) those in which expulsion occurs
spontaneously before the end of pregnancy ; (2) those in which expul-
sion takes place at or about the full period of pregnancy ; and (3) those
in which the ovum is retained beyond the full period of pregnancy.
He shows from statistics that the accident is very rare in primigravidae ;
he also calls attention to the fact that while in a large number of cases
the expulsion of the ovum is apparently spontaneous, in others a slight
disturbance, in one instance a vaginal examination, determines the ex-
pulsion, remarking " It would seem as if there was a kind of equilibrium
between the retentive and expulsive forces, and that this equilibrium
could be readily upset by any influence capable of slightly increasing
the force of the uterine contractions."
The indication in missed abortion is to empty the uterus. In some
cases, as in one reported by Matthews Duncan, the introduction of a
bougie will be sufficient to excite the uterine contractions ; in others
it may be necessary to dilate the os uteri with tupelo, or with Hegar's
dilators.
In concluding the subject, a single word upon criminal abortion.
The temptations to this offence probably come to every physician. He
will be appealed to by the unfortunate victim of man's passion and
perfidy to save her and her family from disgrace, and his sympathies will
unite with the teaching of some utilitarian theories of morals to stifle
the voice of conscience ; family friendship will be plead by the married
woman already a mother, who does not wish to have any more chil-
dren ; or finally, the baser motive of avarice will be invoked, and he
may be promised a far more liberal sum than led Judas to be chief
contributor to the crime of the ages. But he must turn a deaf ear to
all these appeals. " Heart's blood weighs too heavily," and let him
beware of violating both human and Divine law, no matter how great
the temptation.
1 Journal of the British Gynecological Society, 1887.
SECTION II.
THE PATHOLOGY OF LABOR.
INTRODUCTORY. The pathology of labor includes anomalies of the
forces that expel the ovum and secure subsequent normal contraction of
the uterus ; anomalies of the passage through which the foetus is trans-
mitted, and anomalies of the foetus itself, whether deviations in position,
in size, or in form ; finally, the accidents which may occur in a labor,
or immediately follow it, such as rupture of the uterus and post-partum
hemorrhage, must be considered. Of course, anomalies of the passage
will embrace deformities of the pelvis, just as the therapeutics required
in certain pathological conditions will include obstetric operations.
I. Anomalies of the Forces concerned in Labor. These anomalies
relate chiefly to the uterine force. This force may be abnormal by
excess, by deficiency, or by perversion.
a. Excess of uterine force. In those cases in which the uterine con-
tractions are strong and recur rapidly the labor has a speedy 1 end with-
out danger to mother or child, provided the latter present favorably,
and the birth-canal offers no serious obstruction, and suitable precautions
are taken. But in the absence of proper care delivery may surprise the
woman while she is standing, or while 2 she is upon a commode or in
the water-closet, and the child be injured, the cord torn, the uterus
inverted, or relaxation follow the violent uterine action, and hemorrhage
result. Again, if the os or the perineum does not yield readily, a tear
in one or both may occur from excessive uterine action ; an injury to
the former is less likely to occur than to the latter.
Emphysema of the Neck, Face, and Chest. If voluntary efforts in labor are very
great, especially in primiparse, it sometimes happens that rupture of some of the
air vesicles occurs, and emphysema of the neck, face, and chest follows. Blundell 3
has spoken of the condition as follows : " It is not frequently that a disruption
of the larger air-tubes occurs in the progress of laborious parturition ; yet this
accident is sometimes observed, the*trachea or bronchi giving way. After much
exertion, the neck and face swell, from the hurrying of the circulation, an ery-
thematous flush of the integuments is produced, and at first glance the patient
appears to labor under a sudden attack of erysipelas ; the nature of the swelling
manifesting itself on making an examination by the. usual crepitus perceived on
compressing, and lightly shampooing the skin with the tips of the fingers.
Should emphysema occur, delivery is desirable. To retain the breath and force
down is likely to aggravate the disease, so that the emission of the voice may be
1 The old authors described it as partus prxcipitalus, precipitate birth.
2 If a woman is delivered standing, it is rare that the child is seriously injured by falling on the
floor, because the force of the fall is broken by the limbs of the mother and by the resistance of the
cord, though the latter be ruptured by the sudden strain.
3 Principles and Practice of Obstetricy.
478 27/7!,' PATHOLOGY OF LABOR.
recommended. After delivery, if I may judge from the single case brought
under my notice, the aperture, seldom capacious, heals spontaneously, and with-
out inflammation the air is absorbed."
The swelling and the characteristic crepitation clearly indicate the nature of
the accident. The emphysema, if not very great, disappears spontaneously in
five or six days. Of course, the patient is not permitted to continue any volun-
tary effort, but the labor must be terminated by the sole force of uterine con-
tractions, or by instrumental delivery. 1
As has been previously stated, very active uterine contractions are not
to be regarded as pathological in a normal condition of the birth-canal,
and normal presentation and size of the foetus, and, therefore, usually
require no direct interference. The woman must be in bed, and lying
upon one or the other side ; she is advised not to make any bearing-
down efforts, but keep her mouth open, refrain from pressing against
any object with her feet, or grasping one with her hands during a
uterine contraction. But if the unyielding condition of any portion of
the birth-canal renders tearing probable from the rapidity of the labor,
free inhalation of chloroform must be used to moderate the uterine
force. Care must be taken in the third stage of labor to see that the
uterus undergoes its normal retraction.
In some cases violent contractions of the uterus may be the consequence of
too early rupture of the membranes, or frequent and rough examinations, or
improper efforts to dilate the os with the fingers or other mechanical means, in
short, of " meddlesome midwifery "; to mention the origin of the evil is to sug-
gest its prevention.
b. Deficiency of uterine force. Here the uterine contractions fail in
intensity, in duration, and in frequency; this condition results in
" tedious labor." Feebleness of uterine contractions is much more fre-
quently met with than the condition just described, and it may occur
in any one of three stages of labor, though most frequent in the first.
It varies in degree and continuance, and may end in an actual cessation
of uterine activity, which is commonly known as inertia of the uterus.
The immediate danger to the mother from weak uterine contractions is
greatest in the third stage of labor for then, hemorrhage is the inevitable
consequence. Delay in the first stage of labor if rupture of the mem-
branes has not occurred is not attended with risk to the child, or
immediate peril to the mother ; indeed, in very many cases she suffers
no injury, immediate or remote, from this delay. But if the amnial
liquor has been discharged some risk comes to the foetus, though prob-
ably this is not usually so great as has been thought, for complete empty-
ing of the liquor is exceedingly improbable ; especially if the vertex pre-
sents, there usually remains filling up the interstices in the ftetal ovoid
a considerable quantity of the fluid, so that the cord is protected
from injurious pressure. Most practitioners of even a few years'
obstetric experience have met with cases in which spontaneous rup-
ture of the membranes occurred twenty-four hours, or even three or
1 Tn the British Medical Journal, October 24, 1885, a case of emphysema in labor is reported, in
which the entrance of air into the connective tissue of the neck and upper part of the chest, is
supposed to have occurred through a small denuded surface about the middle of the right cheek
in the cavity of the mouth certainly a very singular hypothesis.
INTR OD UCTION. 479
four days before labor began, yet in most instances it ended in the
birth of a living child. Delay in the second stage of labor is serious
for both mother and child, for supposing the head to have entered the
pelvic cavity, it may produce by continued pressure upon the mother's
soft parts inflammation and sloughing, with consequent rectal or
vesical fistula? ; even if these accidents do not happen, the injury to
tissues opens the door for septic infection ; the child suffers from pro-
longed pressure, and fatal asphyxia is the not uncommon consequence.
The mother's life is endangered by the exhaustion which follows long-
continued powerless labor.
In some cases at the close of the first stage of labor, and immediately after the
evacuation of the liquor ainnii, a pause occurs in the labor ; there is an absence
of uterine contractions, or these are very feeble, and this condition may, though
it is not common, last some time unless means are used to evoke the languishing,
or the delayed uterine force. The patient, usually a multipara, is herself sur-
prised that the pains have ceased ; the practitioner, upon making a vaginal
examination, finds the head still within the uterus, the cervix perfectly relaxed,
and its walls hanging in loose folds, and a perfectly normal condition of the
remaining portion of the birth-canal ; a few vigorous pains, assisted by abdominal
efforts, are apparently all that is needed to effect the expulsion of the child.
Longer labor-pauses sometimes occur before the discharge of the amnial liquor ;
labor has come on, and some degree of dilatation of the os been accomplished ;
then uterine action, which has been manifest for hours, gradually ceases, and the
patient goes to sleep, often to the surprise, if not the disappointment, of attend-
ants, who expected that in a short time the labor would be over ; twenty-four
hours may pass before the labor is resumed. Such cases are not to be regarded
as pathological ; the cessation of uterine contractions is very different from that
observed when the uterus has for hours vainly struggled against some invincible
obstacle, until its force is exhausted. The condition last mentioned is most
frequent after the rupture of the membranes, and in the second stage of labor.
Voluntary force may be feeble, the abdominal contractions failing to contribute
their part to the progress of the foetus. This failure, in the majority of cases,
occurs when uterine contractions are attended with much suffering ; the patient
refrains from effort lest she may add to that suffering. Again, voluntary effort
may fail from the general weakness of the patient or from her being profoundly
narcotized.
CAUSES OF WEAK PAINS. Failure of uterine force may arise from
previous exhaustion, or from that caused by protracted labor ; the uterus
has grown weary in its work, and falls into a condition of inertia. It
may be the result of deficient uterine innervation, or it may be caused
by excessive uterine disteution, as from polyhydramnios, or from the
presence of more than one foetus ; the upper portion of the uterus being
thus thinned, it cannot triumph over the normal resistance of the os.
A full bladder or a loaded rectum may hinder normal uterine action.
Kleinwachter has drawn attention to the fact that failure of uterine
contractions may result from an artificial cause, as, for example, if
during the course of labor the forceps is applied and unsuccessful
attempts at extraction are made, the labor-activity may be permanently
interrupted. Mental influences may, temporarily at least, cause the
labor to lag, the uterine contractions becoming weak and inefficient. A
woman depressed by fear or anxiety, or offended by the presence of
someone to whom she has an antipathy, or wounded by the unkindness
of another the nearest to her, and to whom she ought to be the dearest
480 THE PA THOLOQ Y OF LABOR.
iu this her hour of sore trial, and possibly of great peril, may have
weak uterine contractions thus caused.
PROGNOSIS. This depends upon the stage of labor in which feeble
pains occur ; upon whether the membranes have been ruptured or are
still entire ; upon the causes of the condition ; upon the general state of
the mother, and upon that of the child. In the first stage of labor, the
membranes being unruptured, as a rule the child does not suffer ; but
the prolongation of the first stage is iu many cases not a matter of indif-
ference as far as the mother is concerned, for she may be deprived of
sleep, become discouraged by the delay, and exhausted by her fruitless
suffering, which exceptionally continues for several days. Charpentier
mentions a case in his practice in which dilatation was not accomplished,
notwithstanding all means employed, until five days ; the delivery was
then made by forceps. In Greek mythology a case in which labor
lasted nine days is given. 1
The gravity of the condition, if it occurs in the second or in the third
stage of labor, has been sufficiently pointed out.
TREATMENT. Here we must carefully distinguish between physio-
logical and pathological labor-pauses, for in the former we abstain from
active interference, while in the latter it may be imperative, and often
must be prompt. Again, for their wise treatment a recognition of the
causes of weak pains is essential, and also the period in labor of their
occurrence, and the condition of mother and of hild. If the con-
tractions are attended with excessive suffering, we have in chloral
one of the best agents for its relief. If feeble uterine contractions
occur in the first stage, wearying and exhausting the patient, while
dilatation of the os almost, if not quite, fails, the membranes being
unruptured, we. may imitate nature's action in many cases, and create
a temporary labor-pause by the administration of morphine; after a
sleep of a few hours it is not unusual for uterine action, thus tem-
porarily suspended, to return with normal vigor. The practitioner
should know that the bladder and rectum are completely emptied.
When uteriue contractions fail from deficient iunervatiou of the uterus,
a change of position, especially from the recumbent to the erect, or
walking for a time, may produce a favorable effect. Similar action
may be accomplished by a stimulating rectal injection, or by hot-water
vaginal injections ; taking a moderate quantity of food, a cup of hot tea,
or a glass of hot lemonade is in some cases followed by increase of uterine
action. If the uterus fails to contract because of its excessive distention,
rupture of the membranes is indicated, though the os is only partially
dilated, but dilatable. Even if there may not be obviously great
uterine distention, partial evacuation of the amnial liquor is often fol-
lowed by vigorous uterine action. But this should only be doue if the
presentation is normal and the position favorable, and the os at least half-
dilated and dilatable. Hasty intervention is, in the majority of cases,
1 Latona, pregnant by Jupiter, and her labor at hand, was pursued by jealous Juno, and at last
found secure retreat in the island of Delos. Her labor lasted nine days and nine nights, when,
seizing hold of a palm tree, she gave birth to Apollo, the god of medicine and of music. The posi-
tion she took to end a protracted and difficult labor might be adduced as an argument in favor of
delivery being effected while the woman is erect or leaning forward. It may also be mentioned
that from the legend we learn that Artemis, the twin sister of Apollo, was born twenty-four hours
after an interval that, as has been previously stated, may sometimes occur in the birth of twins.
ANOMALIES OF FORCE. 481
more dangerous than expectation. The introduction of Braun's colpeu-
ryuter into the vagina, or of a flexible bougie into the uterus, placing it
between the ovum and the uterine wall, has been used for the purpose
of exciting uterine action, and each has sometimes been successful. But,
of course, if these means are used very strict antisepsis must be observed.
Friction of the uterus by the hand upon the abdominal wall may sometimes
be useful. Runge commends an entire bath, temperature of 95 F.,
continued for one-half to three-quarters of an hour in cases of prolonged
labor, especially if the temperature increases, the general condition being
thereby improved and the uterine activity revived.
The use of the forceps in the first stage of labor after the rupture of the mem-
branes, not for the purpose of extraction, but simply to bring the head down so
as to press upon the os uteri during uterine contractions, and effect dilatation,
has been advocated, in this country especially, by the late Albert H. Smith, 1 and
by Professor Isaac E. Taylor. 2 The former has given the following directions as
to this use of the forceps : When the os uteri is sufficiently dilated to allow the
introduction of the blades, they may be carefully applied, and during each
uterine contraction the head may'be drawn down gently, and with as little com-
pression as may be required to keep the blades in place. We have then nature's
own dilator, supplemented by art simply for the increase of its powers, without
any change in the method of action, no new plan of operation being introduced.
The application of the forceps before the os is dilated can only in exceptional
cases be proper. Digital dilatation of the os uteri will generally prove in cases
demanding intervention, after spontaneous and premature rupture of the mem-
branes, a better method than the use of the forceps, at least in the hands of the
majority of practitioners. Dilatation by means of rubber bags may in some
cases be substituted for that by the fingers. Artificial dilatation can, as a rule,
be more readily effected if chloral be first given. In labor delayed by insufficient
uterine contractions foetal expression has been proposed by Kristeller, 3 and
advocated especially by him and by Suchard, 4 though Kleinwachter states that
it accomplishes no more than friction of the fundus of the uterus.
The following are the directions given by Kristeller for the applica-
tion of this method :
The patient lies upon her back, near the side of the bed ; by percussion and
palpation the limits of the uterus are defined, the neighboring organs are
isolated, and the intestinal folds separated. If the uterus incline too far ante-
riorly or laterally, it is brought into the axis of the inlet. It is then embraced
by the hands, their cubital border being directed toward the pelvis, and their
palmar face applied to the sides and to the fundus of the uterus, the thumbs
being upon the anterior face. The fingers are now directed as far as possible
behind the uterus ; this succeeds very easily in the case of a multipara whose
abdomen is relaxed and yielding, and in a pluripara after the birth of one child.
Next press gently the abdominal walls against the uterus thus embraced at the
superior part ; gradually increase the pressure ; after keeping up this pressure
for a certain length of time, it should be gradually diminished. The pressure
upon the fundus of the uterus should be directed from above below, while that
upon the sides converges toward the axis of the organ. The duration of the
compression will vary from five to eight minutes; it may be repeated at intervals
of from one-half a minute to three minutes during a period of ten, twenty, or
forty minutes, according to the urgency of the case, the period of labor, and the
sensibility of the patient. In the succession of intermittent compressions thus
made, it is sometimes necessary to act upon the fundus, sometimes upon the
upper and lateral portion of the uterus, never forgetting that when the os is but
1 Medical and Surgical Reporter, 1877.
2 Transactions of the American Gynecological Society, vol. iv.
3 Monat. f. Geburt., 1886. * De I'Expression Uterine appliquee au Foetus.
31
482 THE PATHOLOGY OF LABOIl.
slightly opened, not readily dilatable, and its diameter not more than five centi-
metres, nearly two inches, the pressure should be less upon the fundus, more
upon the sides of the uterus. On the other hand, when the os is more dilated
and yielding, compressions of the fundus produce the best effects. In difficult
cases a longer pause, from ten to fifteen minutes, should be made after ten or
fifteen compressions. Toward the end of the labor the place of applying pressure
should not be changed ; it can scarcely be made except at the fundus of the
uterus. Kristeller directs that, as a rule, if twenty to thirty compressions
properly made produce no result, it is better to desist.
Electricity, whether faradism or galvanism, is not so uniformly effi-
cient in exciting uterine contractions, nor are the means for employing
it usually available, that it can be advised.
INTERNAL MEANS. Medicines may be administered for increasing
uterine contractions ; the chief of these are quinine and ergot. It is
asserted by reputable observers that the former given in doses of ten to
twenty grains has this effect. Wood 1 attributes the result not so much
to a specific action of the remedy upon the uterus as by its arousing
the general nervous forces of the system. Klein wachter explains the
apparently beneficial effect of quinine as resulting from reduction of
abnormal temperature; after the fever abates the pains frequently
increase spontaneously, and succeed each other rapidly, but not in con-
sequence of the quinine.
The late Dr. Albert H. Smith stated 2 that in forty-two women, to each of whom
he gave fifteen grains of quinine after actual labor-pains had begun, he observed
within fifteen minutes a decided increase in the frequency and vigor of the con-
tractions, a rapid progress of the labor, and, where there was no obstruction, a
speedy termination. He claimed that quinine not only increased the activity of
the normal uterine contractions, but that it promoted permanent tonic contrac-
tion of the uterus after the expulsion of the placenta, that it lessened the lochial
discharge in those who previously had it in excess, and that it also lessened
after-pains in the majority of cases. Still, beneficial results from it are by no
means constant.
Ergot has been more generally given than any other agent to increase
uterine contractions. Wernich's investigations show that it lessens
venous tension, and while the blood in the veins increases, that in the
arteries diminishes ; anaemia of the uterus and its nerve-centres occurs,
and hence the uterine contractions become more powerful and longer.
According to Wood's statement, 3 if ergot be given in small doses during
labor, the natural pains are simply intensified ; but if the dose be large
enough to have a decided effect, their character is altered ; they become
not only more severe, but much more prolonged than normal, and
finally the intervals of relaxation appear to be completely abolished
and the intermittent efforts are changed into one violent, continuous
strain.
Ergot was introduced into American practice in 1807, 4 and received the name
o{pulvis ad partum; but as fatal results at least to the child followed its use, Dr.
Hosack suggested that it should be called pulvis ad mortem. Many reputable
obstetricians to-day reject the use of ergot during labor, some indeed insisting
1 Therapeutics, Materia Medica, and Toxicology.
* Transactions of the College of Physicians of Philadelphia, 1875.
3 Op. cit. Medical Repository, 1807.
ANOMALIES OF FORCE. 483
that it should be banished from obstetric practice. It is believed that this is a
mistake, and it is unjust to conclude that because there has been gross abuse in
the administration of the agent it has been given in unsuitable cases, at im-
proper times, or in too great quantities it should therefore not be used at all.
Siixinger found good results from it in weak pains, and never any injurious
effect upon the child. Schutz 1 maintains that ergot, in suitable doses, excites
normal contractions.
The form in which it is most frequently given is that of fluid extract, each
minim of which represents one grain of powdered ergot. A preparation called
ergotine, though Squibb denies the right to this name, is also used ; each grain
of ergotine is supposed to represent five minims of the fluid extract. The remedy
is given by the mouth, and also used hypodermatically, in the latter case a watery
solution of ergotine usually being preferred.
Ergot is not to be given in the first stage of labor. Exceptions to the
rule are very few. Next, it should not be given unless the labor be so far
advanced, and the conditions of presentation and of the birth-canal are
such that an early delivery may be reasonably expected if the uterine force
be made normal. The most important rule in regard to its administra-
tion is that it must be given in such amount that the normal contrac-
tions of the uterus shall be increased ; the use of large doses, so that
continuous action is excited, may be followed, and too often has been,
by rupture of the uterus, of the vagina, or of the perineum, and by
the death of the child from asphyxia. Ten drops of the fluid extract,
or an equivalent quantity of the infusion, or of ergotine, once in fifteen
minutes, is a suitable dose when the remedy is required during labor;
if given for uterine inertia after labor, the dose should not be less than
a teaspoonful. Kleinwachter advises combining Wernich's ergotine
with tincture of cinnamon, a teaspoouful of the latter at each dose,
stating that it then acts more efficiently ; it might be well, therefore, to
give ten drops, for example, of the fluid extract with a teaspoouful of
the tincture of cinnamon in two tablespoon fuls of water.
If after the rupture of the membranes and complete dilatation of the
os labor does not advance, instrumental delivery will in many cases be
best, both in the interest of the mother and of the child.
Feeble and inefficient uterine contractions in the third stage of labor
usually have as their consequence placental retention and uterine hem-
orrhage, and will hereafter be considered.
Dr. Duff, of Pittsburg, advises that strychnia be given, beginning six or
eight weeks before labor, to women suffering from general debility and relaxed
muscle, and who have suffered in previous deliveries from feeble and irregular
uterine contractions, causing tedious parturition, and, moreover, to those who
have had post-partum hemorrhage and failure of uterine contraction and
retraction.
c. Perversion of uterine force may be manifested by continuous gen-
eral or by partial contraction ; the former is sometimes called tetanic,
while the latter causes what is known as spastic stricture. Tetanic or
continuous contraction of the uterus occurs oftener in old primiparse;
it may be caused by ergot given at an unsuitable stage of labor, or in
too large a quantity ; by irritation of theos from frequent examinations
or other interference with the progress of labor, or result from dispro-
1 Deutsch. Gesellschrift t. Gynakol. Congress, 1890.
484 THE PA THOLOO Y OF LA B OR.
portion between the size of the foetus and the pelvis, or from a mal-
presentation, as of the shoulder, the uterus struggling to overcome great
or invincible resistance. The condition is generally attended with
severe suffering. This condition, too, makes difficult or impossible the
introduction of the hand into the uterus for rectifying an unfavorable
presentation or position. It usually occurs after the rupture of the
membranes, and hence may interfere with the utero-placental circula-
tion or produce direct pressure upon the cord, and in either case the
child perish from asphyxia ; premature detachment of the placenta is
not uncommon.
Chloroform given until deep anaesthesia is produced will be necessary
in cases demanding an obstetric practice, e. g., podalic version in pre-
sentation of the shoulder. Friinkel advises a hypodermatic injection of
morphine and of atropine to be given before the chloroform inhalation ;
in five or ten minutes the uterus relaxes, and the introduction of the
hand can be readily made.
One of the dangers from tetanic contraction of the uterus is rupture ;
and if this contraction cannot be abated, Kaltenbach advises delivery of
the child even by embryotomy.
SPASTIC CONTRACTION. Partial uterine contraction is usually an
accident of the third stage of labor ; in its most common form it is
known as hour-glass contraction. In the great majority at least of these
cases the condition is not pathological ; there is general contraction of
the uterine body, while the cervical canal remains relaxed, and the
apparent stricture is the normally contracted internal os, while the
placenta remaining in the uterine cavity prevents the complete approxi-
mation of its walls.
Kleinwachter denies the existence of partial uterine contractions or partial
uterine spasms, but asserts that in consequence of the relations of the muscular
fibres to each other the uterus must contract as a whole. The so-called spas-
modic contraction of the external os uteri is nothing more than a condition in
which the upper part of the uterus has not manifested enough power to over-
come resistance ; the os is only slightly dilated, and it presents sharp edges, but
as soon as the contractions have become more vigorous it opens, and the so-
called spasm ceases. Again, in the third stage of labor, the placenta may not
be detached spontaneously, in consequence of adhesions, and the uterus takes
the form of an hour-glass The relaxed lower uterine segment represents a
funnel, the narrowest portion of which is above. The upper portion of the
uterus contracts around the remaining placenta, and immediately below the
walls of the body meet, as nothing intervenes ; but the lower segment is found,
as after every normal birth, in a condition of partial paralysis that is, it is
relaxed. The so-called stricture, therefore, is not a pathological phenomenon,
but is the normal condition after the delivery of the child. While this is the
most frequent form of stricture, and, as Kleinwachter states, is not a pathological
condition, yet the recent investigations of Bayer 1 seem to prove that from the
anatomical construction of the uterus strictures may occur at various parts of
the organ. Clinical observation, too, confirms this view, though the occurrence
of such cases is exceedingly rare.
But this ring-like stricture at the os may occur in head-last as
well as in head-first labor, so that it acts as a cord around the neck of
the foetus, preventing in the one case the delivery of the head, and in
i Op. cit.
ANOMALIES OF THE SOFT PARTS. 485
the other that of the body. Incision of the unyielding band may be
necessary, if digital dilatation fails, for saving the child's life.
Kaltenbach narrates a case which he regards as of importance in a forensic
point of view : In a woman twenty-four years old, in her fourth labor, the head
of the child on the pelvic floor ; delivery with forceps was necessary from delay,
and a dead child extracted with difficulty. The head and upper part of the
throat showed a deep, bluish-red discoloration, at the middle of the throat a fur-
row ; there was no coil of the cord about the neck. Such a condition might have
been mistaken, under other circumstances, as proving infanticide from strangu-
lation.
GREAT PAIN. Excessive suffering in labor may be caused by very
great distention of the uterus, by peritoneal inflammation, by mal-
presentation or great size of the foatus, or it may arise from a general
hypereesthetic condition. It does not interfere with the action of the
uterus, but it does prevent the assisting action of the abdominal mus-
cles in the second stage of labor.
In the treatment of excessive pain, of course, the cause must be
ascertained, and, if possible, removed ; but in many cases remedies must
be given directly for the suffering ; thus we may use chloral or lauda-
num by rectal injection, or morphine hypodermatically, or anaesthetic
inhalation.
ANOMALIES OF THE SOFT PARTS. These will include not only
anomalies of the uterus as to development and position, as to the con-
dition of the os and the cervix, and as to neoplasms, but also certain
deviations of adjacent organs from the normal.
ANOMALIES OF FORM AND OF POSITION OF THE UTERUS. The
arrest of pregnancy in a rudimentary horn of the uterus has been stated
in connection with the subject of ectopic development of the ovum. But
in the cases in which the pregnancy has occurred in the fully developed
horn, either of a uterus unicornis or bicornis, its course has been unin-
terrupted and the labor normal ; nevertheless, in some instances of the
latter malformation it is stated that the unimpregnated horn has inter-
fered with the entrance of the foetus into the vagina, and that there is a
greater liability to a transverse position of the foatus. Instances have
occurred in which both horns were pregnant, the labor taking place in
each at or near the same time ; in other cases there has been an abortion
from one horn, while the pregnancy in the other was completed.
Cruveilhier has mentioned a curious instance of double uterus with duplicity
of the vagina also, the woman being pregnant ; she was visited by one physician
who asserted that she was not pregnant, and then by another who found her in
labor ; the difference of opinion arose from the fact that one practitioner made
a digital examination through the vagina, which communicated with the non-
pregnant half of the womb, while the second, making his through the other
vagina, recognized the dilatation of the os and the presenting part of the foetus.
Latero-positions of the uterus, though usually rectified by uterine
and abdominal contractions bringing the uterine in correspondence with
the pelvic axis, can easily be corrected, if necessary, by having the
patient lie upon the side opposite to that of the displacement. Ante-
version or anteflexion is remedied simply by the dorsal position or by
486 THE PATHOLOGY OF LABOR.
the abdominal bandage ; Dr. Barker 1 stated that in some cases of pendu-
lous abdomen he has been obliged to place the patient in the dorsal
position, her head and shoulders being considerably lower than her hips.
Prolapse of the uterus can only occur in case of a very large pelvis ; very
rarely the head passes out still inclosed in the lower uterine segment.
OCCLUSION AND NARROWING OF THE Os UTERI. Conglutination
of the external orifice is occasionally met with. The labor is tedious,
the lower uterine segment greatly thinned, and upon digital examination
no os can be felt, but usually a slight pit or depression marks its place,
though sometimes this may fail ; the closure in most cases is simply
from a thickened secretion, but may be consequent upon a superficial
endometritis. During a contraction of the uterus pressure should be
made with the point of the finger or with the uterine sound at the
depressed place, or if this be absent, at that which is most thinned, and
the os w T ill open ; it may be widened simply by the finger, or, as in a
case 2 reported by the late Dr. Albert H. Smith, by means of a uterine
dilator.
In rare cases it happens that the union between the maternal and foetal mem-
branes in the immediate vicinity of the external orifice is so firm that the lower
segment of the uterus cannot retract over the ovum. Should this be the case,
detachment of the membranes or rupture of the sac is indicated.
Cicatricial closure of the os may have resulted from an inflammation following
a previous labor, or from the application of powerful caustics to the cervix. It
is rarely complete, and if there be atresia, of course, it must have originated
subsequently to impregnation.
Undoubtedly, in some of the cases in which atresia of the os was diagnosed
there had been only stenosis. Failing with the finger to discover the os, the next
step will be to expose, by means of a speculum, the parts, and then there will
usually be seen at the os a little mucus projecting, or, if the membranes have
ruptured, and especially during a uterine contraction, there will be discovered
a small stream of water escaping.
Of course, if it be a simple stenosis, or conglutination, pressure with the knob of
a uterine sound will open it so that dilators or the finger may be used. But if
atresia is present an incision is necessary ; Winckel advises a superficial crucial
incision ; antisepsis must be carefully observed. In a case of this kind, seen two
years ago with Dr. Markley, of Hatboro,Pa., neither he nor I could discover the
os, and I made with scissors a cut through the thin tissue where I believed the
os ought to have been; this opening readily dilated, and the labor was ended by
forceps.
RIGIDITY OF THE Os. Under the different names of anatomical,
simple, or mechanical rigidity of the os, a condition is met with, espe-
cially in old primiparse, which causes great delay, and in rare cases
presents an invincible obstacle to labor. The cervix has not been com-
pletely effaced, and the borders of the os are thick, resistant, hard, but
not sensitive. In some instances the neck is hypertrophied, and in
these it is not unusual to find, after labor has continued for some time,
a thrombus involving the anterior or posterior lip. At first warm
baths, warm vaginal douches, and a laudanum injection into the rectum
may be tried, then artificial dilatation ; Schroder advises incisions freely
made by curved scissors or by a probe-pointed bistoury.
1 Transactions of the American Gynecological Society, vol. v. p. 274.
Medical and Surgical Reporter, 1877.
ANOMALIES OF THE SOFT PAIITS.
487
Remarkable results have been recorded by Farrar 1 as resulting from
the application of a 10 per cent, solution of cocaine to a rigid os ; it is
probable that Dr. Farrar has made a most valuable addition to the
means for treating this condition.
Dr. Robert Barnes, from whose work the subjoined illustration is taken, nar-
rates a case in which the labor was impeded by a hypertrophied cervix : " A
primipara, aged twenty-two, was in labor. The cervix protruded through the
vulva about three inches, forming a mass equal to a man's wrist in circumference.
After reducing the cervix in the vagina the head could be felt. The cervix had
a hard, gristly feel. Free incisions in the os externum were made, so that the
os externum was freely opened up to meet the natural expansion of the os
internum. She was then delivered after an anxious labor of fifty-two hours."
FIG. 184.
ILLUSTRATING LABOR WITH HYPERTROPHIC ELONGATION OF THE CERVIX.
NEOPLASMS OF THE UTERUS. The injurious influence of uterine
fibroids upon labor depends upon their size and their position. If the
tumors are small, or subperitoneal, they may present no complication,
and, indeed, may not be recognized in some cases until the labor is over.
1 Transactions of the London Obstetrical Society for 1894.
488 THE PATHOLOGY OF LABOR.
Tumors of the neck, when large, prevent the presenting part from
entering the pelvis ; interstitial tumors of the body may be the cause
of rupture of the uterus, or of post-pa rtum hemorrhage, especially if the
placenta be attached to the part of the uterine wall which they occupy.
The relative proportion of fibroids of the neck to those of the body is
much greater in pregnant than in non-pregnant women. Thus, while
there are twenty cases in which these tumors are situated in the body
to one where such a growth occupies the neck of the uterus in the non-
pregnant, the proportion is only five to one in the pregnant, as ascer-
tained by Chahbazian from the study of 310 cases of uterine fibroids
complicating pregnancy. 1
Chadwick 2 has reported ten cases of pregnancy and labor complicated
with fibroids, with the following results : 1 miscarriage, 7 recoveries
of mother and 7 living children, 2 deaths of mothers and 2 stillborn
children. Fortunately in one-half of cervical fibroids observed in preg-
nancy or labor the tumors are pedunculated, 38 out of 76, according to
Chahbazian's statistics. Another notable fact is that transverse and
pelvic presentations are greatly increased, so that the two nearly equal
the number of vertex presentations. In Chadwick's cases there were
in 9 labors 7 head presentations and 2 transverse.
In the treatment of fibrous tumors of the uterus complicating labor,
Lefour advises at first to wait, letting Nature accomplish all she can,
but this delay must be determined by the interest of the mother and
child. Next, act upon the tumor by its removal, or by pushing it up
from the pelvis. Extirpation of the tumor was first performed by
Michellacci in 1791. 3 The operation has been repeatedly done since,
and with almost unvarying success as far as the mother is concerned,
but with a very large foetal mortality. As in a large proportion of
cases the tumor is cervical, and as in one-half of these it is pedunculated
(see Fig. 185), its removal will, under such circumstances, usually be
neither difficult nor dangerous. If the tumor has no pedicle, it must
be enucleated. But other tumors may occupy such a position that they
cannot be removed, as, for example, a subperitoneal growth with a long
pedicle that has dropped into the pelvis, or a tumor involving the neck
and the lower part of the body of the uterus. Here an effort must be
made to push it above the pelvic inlet. The patient is put in the knee-
chest position, and the fingers or the entire hand introduced into the
vagina and used to press the tumor out of the way ; of course, pressure
is made only in the intervals between contractions. If it is impos-
sible either to extirpate the growth or to remove it from the pelvis,
and space permit, the forceps or podalic version may be tried. The
results from the former are very much more favorable than those given
by version, and therefore it is to be preferred. In absolute narrowing
of the pelvic cavity, Cffisarean section is indicated ; the supra-vaginal
amputation of the uterus, Porro's operation, may be done. If abdom-
inal section is forbidden, embryotomy is the only resort; but while, of
course, all the children are lost, it gives a fearful mortality for the
1 Des Fibromes du Col de 1'Uterus au point de vue de la Grossesse et de 1'Accouchement.
2 Boston Medical and Surgical Journal, July 30, 1885.
3 See Chahbazian, op. cit.
ANOMALIES OF THE SOFT PARTS.
489
mothers, 66 per cent, of them perishing. No one can hesitate, if the
child is dead, in performing embryotomy, provided the mother does not
run a greater risk than from abdominal section.
FIG. 185.
A POLYPUS OCCUPYING THE PELVIC CAVITY IN LABOR. (From RAMSBOTHAM.)
Cancer of the uterus gives a very unfavorable prognosis ; Cohustein
found that of 126 mothers only 54 survived, while 72 died during
labor or in the puerperal period. If the disease partially affects only
the lips of the uterus, labor may go on without special difficulties, and
there may be no great hemorrhage. But if the entire cervix be affected,
and especially if the disease has extended to the adjoining part of the
body of the uterus, it is impossible for the diseased tissue to dilate, and
the expulsion of the foetus can only occur after rupture of the unyielding
ring, which causes such a serious hemorrhage that may be difficult or
impossible to arrest. Incisions of the cervix thus degenerated are
dangerous because of consequent hemorrhage, and, according to Klein-
wachter, because they must be carried through the entire wall and thus
injure the peritoneum ; nevertheless, Charpentier advises them, and
directs that they be followed by the application of the forceps. Her-
mann 1 states that " when labor has actually come on, expansion of the
1 London Obstetrical Society's Transactions, vol. xx.
490
THE PATHOLOGY OF LABOR.
os uteri should bo aided by making numerous small incisions in its cir-
cumference." He also says that when dilatation is in progress, if it is
necessary to accelerate labor the forceps is preferable to version. When
the disease, however, involves the entire cervix, the timely performance
of the Csesarean operation is generally considered as indicated, both in
the interest of the mother and of the child.
Winckel, considering the large mortality of the Csesarean operation in cancer
of the uterus, and the great uncertainty of the child living, prefers perforation
and extraction of the lessened foetus through the vagina, thus securing to the
mother, it may be, several months of life. He takes the ground that delivery of
the lessened child is more humane. Certainly "Winckel's advice deserves very
serious consideration, though in this he is not in accordance with the majority
of authorities.
Abdominal extirpation of the uterus in labor has been employed in a few
cases, but the fatality of the operation is great. Vaginal removal a few weeks
after labor has given good results, for the time at least.
ANOMALIES OF ADJACENT ORGANS. Chief among these which may
interfere with labor are tumors of the ovary, the danger or difficulty
FIG. 186.
AN ENLARGED OVARY BLOCKING UP THE PELVIC CAVITY IN LABOR. (From RAMSBOTHAM.)
depending upon their size., position, mobility, and nature. Thus, an
immobile, solid tumor in the pelvis is more serious than a fluid cystic
tumor. Even if the turner furnished no obstacle to the birth, there may
ANOMALIES OF THE SOFT PARTS.
491
be, as Kleiuwachter states, twisting of the pedicle during labor, and
this be followed by rupture of the cyst in childbed, with fatal peritonitis.
Dermoid cysts give a more unfavorable prognosis than those which are
liquid, because they are fixed and their contents solid, so that they as
a rule cannot be pushed out of the way nor their size lessened by
puncture. Fibroid tumors of the ovary, especially if calcareous change
has occurred, may cause great difficulty by descending into the pelvis in
advance of the presenting part of the foetus, and thus preventing its
progress ; on account of their hardness, it is very difficult when they
have thus become fixed to distinguish them from pelvic exostoses. 1
In disturbances of labor caused by ovarian tumors, reposition is the
first thing; if this fails, puncture, usually by the vagina; if this is
impossible, the Csesarean operation.
EECTOCELE AND CYSTOCELE. Obstruction of the vagina from pro-
jection of the rectum loaded with feces, or of the bladder filled with
FIG. 187.
CYSTOCELE COMPLICATING LABOR.
urine, can scarcely offer a serious hindrance to childbirth, especially if
the obstetrician gives heed early in the labor to having each of these
organs thoroughly evacuated. Ramsbotham, however, has stated that
he has seen many instances of the bladder prolapsing before the head,
Kleinwachter, op. cit.
492 THE PATHOLOGY OF LABOR.
and mentions two cases in which it was punctured, one practitioner
mistaking it for a dropsical head, and the other for the bag of waters.
Such errors can only result from culpable ignorance or carelessness.
Dr. Busey 1 is the author of a paper upon cystocolpocele complicating preg-
nancy and labor ; by cystocolpocele is meant prolapse of the bladder into the
vaginal passage; and if the sac occupies the cavity of the pelvis, filling the hol-
low of the sacrum, pushing the os uteri beyond reach, and occluding the vaginal
passage, it is complete. One of the most marked results of this displacement of
the bladder is lingering labor. The diagnosis is made by introducing the catheter
into the bladder and evacuating it. This displacement of the bladder in relation
to pregnancy and labor was very fully considered by Broadbent, in 1863, in a
paper read before the London Obstetrical Society. In referring to the diagnosis
he states: "The prolapsed condition of the bladder is readily recognized on
examination, especially when it contains urine in any considerable quantity.
The cavity of the pelvis is found to be occupied by a bag of fluid, easily dis-
tinguished from the ftctal membranes by the fact that it springs from the pubis,
and does not permit the finger to pass between it and the symphysis. As this
sac, the bladder, fills up the hollow of the sacrum, the os uteri cannot be reached
until the urine is evacuated ; and if this is done by the catheter, the instrument
can be felt from the vagina and followed to every part of the bladder. When
the bladder is perfectly empty the displacement may be overlooked, but the
finger, instead of circumscribing the lower segment of the uterus readily, meets
anteriorly with the bladder, passing from the symphysis pubis to the uterus, and
usually disposed in ruga? ; the introduction of the catheter at once makes the
case clear."
Whether called cystocele, prolapse of the bladder, or cystocolpocele,
the obvious indication is to empty the organ and press it out of the
way of the descent of the presenting part of the foetus.
Vesical calculi have in very rare cases obstructed the birth-passage.
It will generally be easy to push a tumor thus formed up out of the
pelvis ; if not, an opening may be made into the bladder from the
vagina, and the stone or stones removed, after which sutures are to be
introduced as in the operation for vesico- vaginal fistula.
The vagina may present an obstacle to labor from congenital or
acquired circular stenosis, the former being very rare, or from cicatricial
bands. Patient artificial dilatation, dividing bands with blunt-ended
scissors or probe-pointed bistoury, will generally prove sufficient to
secure delivery.
In rare cases a resisting hymen may be an obstruction ; of course,
incisions remove the resistance.
Still rarer are the cases in which vaginismus prevents delivery ; Beu-
neke saw such a case, in which even craniotomy was necessary (Kalten-
bach); usually the difficulty is overcome by deep anesthesia.
1 Transactions of the American Gynecological Society, vol. xii.
CHAPTER VII.
ANOMALIES OF THE PELVIS.
ANOMALIES of the pelvis may be conveniently divided into those of
position, of size, and of form.
The first division includes two varieties. The pelvis has a normal
inclination or obliquity, and the deviations from this obliquity may be
by excess or by defect ; that is, the inclination may be increased or
lessened.
So, too, the second division includes two classes : 1, that in which
the pelvis undergoes uniform increase, pelvis cequabiliier justo-major ;
and, 2, that in which similar decrease occurs, pelvis cequabiliier justo-
minor. The latter is described as a pelvis uniformly contracted ; in
order that a pelvis may be called contracted the true conjugate must be
lessened one centimetre and a quarter, but if there be a uniform lessen-
ing of all the diameters one centimetre, or about four-tenths of an inch,
then general contraction is said to be present.
The third division includes those characterized by change in the
pelvic form ; in the second class there are simply changes in size, the
pelvis remaining symmetrical, but in this it becomes asymmetrical its
form perverted, or the pelvis is said to be deformed, and, so far as the
injurious resu/ts in relation to labor are concerned, vitiated. Such
deviations from the normal may involve the vertical diameters with
reference to the transverse, or the latter with regard to each other, and
these constitute the chief ones to be considered. The last presents three
classes: 1, that in which the antero-posterior diameter is lessened; 2,
the transverse diameter is lessened ; and, 3, the diminution is in the
oblique diameter.
These various pelvic anomalies will now be considered in the order
that has been given.
1. Anomalies of Position. As already stated, deviations from the
normal obliquity of the pelvis are two ; this obliquity may be increased
or lessened.
Lobstein, 1 in an unpublished memoir presented to the Society of Medicine of
the Faculty of Paris, 1817, first directed the attention of obstetricians to the
consequences of too great or too slight inclination of the pelvis. The anterior
obliquity may be so exaggerated that the axis of the inlet is horizontal. Moreau
narrates a case in which the plane of the inlet was vertical, and there was also
associated with this vicious inclination of the pelvis narrowing from rickets,
which compelled the Csesarean operation. Naegele has described the case of a
married woman in whom the inferior strait was turned directly behind ; the
pubic symphysis and the upper part of the sacrum were directed horizontally,
and consequently the plane of the superior strait was vertical ; the venereal act
never took place but in a position opposite to the natural one. She became
1 Dictionnaire Encyclopedique des Sciences medicates, t. viii.
494 THE PATHOLOGY OF LABOR.
pregnant, but the pelvis being normal no difficulty occurred at labor; six other
consecutive pregnancies occurred, and ended with the same facility as the first.
By so-called posterior obliquity a true obliquity in a backward direction of
course is impossible is generally understood a marked lessening of the normal
obliquity, that may go to such extreme that the plane of the inlet becomes hori-
zontal. This obliquity is usually associated with deformed pelvis, but it has been
observed independently of such vitiation.
In cases of posterior obliquity or pelvic retroversion " the vulva is directed
much more in front than usual, and the pubic syinphysis presents a direction
more or less approaching the vertical. The superior half of the sacrum has
become parallel to the axis of the trunk, and the lumbar region is more or less
without its posterior concavity a flat back. Finally, the point of the coccyx is
always found in the vertical position either at the level or beneath the summit
of the pubic arch, and the last false rib is generally nearer the iliac crest than in
the normal state."
In addition to these obliquities, Lenoir has given a description of
lateral obliquity of the pelvis. According to Depaul, lateral obliquities
are very frequently found in connection with rhachitic skeletons, and
even in cases of shortening, atrophy, or old luxations of the abdominal
members.
Naegele, in referring to inclination of the pelvis, makes the following remarks :
" Even when this inclination is normal, it quite often happens in cephalic pre-
sentation that the head presses upon the superior border of the pubic symphysis,
and thus to some degree its entrance into the pelvic cavity is retarded. If in
such cases the other conditions of the mechanism of labor are normal, this re-
sistance is overcome soon by the efforts of nature, and delivery is accomplished
without special difficulty. But if at the same time there is a more or less great
disproportion between the head and the basin, the resistance presented by the
anterior wall of the latter exerts a very injurious influence. This influence is
much worse still when at the same time the inclination of the pelvis is too great.
If, as frequently happens, an inclination exceptionally great coincides with nar-
rowing of the pelvis, obstetric operations may be rendered much more difficult.
For this reason it appears necessary in all cases where the head of the foetus
strikes against the pubic symphysis at entering the pelvis to have the woman lie
in such a way that the lumbar vertebrae may be strongly flexed ; that is to say,
give her a half-sitting posture by raising the hips and the upper part of the
trunk, or have her lie upon the side, her back bent forward, and the thighs
strongly flexed upon the pelvis."
2. Anomalies of Size. This division, which includes uniform increase
and uniform lessening of the size of the pelvis, might also be distin-
guished as symmetrical anomalies in contradistinction to the third class,
in which the anomalies are chiefly asymmetric.
The illustration, Fig. 188, taken from Depaul, represents the justo-
major and the justo-minor pelvis, while the line marked B is the measure
of the distance between the iliac crests in a normal pelvis.
a. The justo-major pelvis. In the pelvis marked A the distance be-
tween the antero-superior spinous processes was 28 centimetres, more
than 11 inches, and that between the iliac crests 32 centimetres, more
than 12 inches. The antero-posterior diameter of the inlet was 13 cen-
timetres (5 inches), the transverse 16 centimetres (6.3 inches), and the
oblique 15 centimetres (5.9 inches). The justo-major pelvis has been
justly compared to the pelvis of a giantess found in a woman of ordi-
nary size.
Schroder taught that the generally enlarged pelvis did not disturb
ANOMALIES OF THE PELVIS.
495
the course of labor, causing this to be rapid, and, in short, that it
should not be regarded as pathological unless the same conditions were
present, as might be observed in the case of a normal pelvis. On the
other hand, most obstetricians believe that such a pelvis contributes to
precipitate birth by the ampler bony canal through which the foetus is
transmitted.
b. The pelvis junto-minor, or the generally-contracted pelvis. This
pelvis, as has been before stated, is characterized by a uniform lessening
of its diameters ; it is one of the most important anomalies of the pelvis.
A. Justo-major pelvis. B. Normal distance between the iliac crests. C. Justo- minor pelvis.
At least three varieties of this pelvis have been described. In the first
the pelvis has the form characteristic of the sex, but seems to have been
arrested in its development ; the bones are frailer and smaller, and,
though it is usually found in women whose stature is under the normal,
it may also sometimes belong to tall women who are with this exception
perfectly developed. While in another variety to be mentioned, there
usually is a departure from the strict definition of the justo-minor
pelvis uniform lessening of the pelvic measurements this corresponds
496 THE PATHOLOGY OF LABOR.
quite accurately. The second variety, the dwarf's pelvis, presents the
usual characteristics of the normal female pelvis, only it is under size;
there is a correspondence between the pelvis and the height, and the
bones of the former correspond in their development as to size and
firmness with those of the rest of the skeleton. The third variety is
the masculine pelvis. This may have the external form of the female
pelvis, but in some very strongly resembles the male. The bones are
thick and strong ; the sacrum is narrow ; the ilia are straighter than
normal ; and the ischia are nearer each other. The external measure-
ments may vary but slightly from the normal, and the contraction may
not be uniform, but may concern the inlet, the cavity, or the outlet ; in
the latter case the pelvis becomes funnel-shaped.
The equally-contracted pelvis is not frequently seen; of its three
varieties the masculine basin is the least, the dwarf's the most rare.
The causes of the justo-minor pelvis are generally obscure. In some instances
the anomaly may result from rickets. This origin has been generally accepted.
Zweifel states that he has seen one typical instance of generally equally con-
tracted pelvis which was caused by rickets, though this disease usually produces
another abnormal form. Muller has mentioned the frequency of this pelvis in
crelins and semicretins. Still, there remain the great majority of cases of this
partial pelvic development which cannot be attributed to any constitutional
disease either hereditary or acquired.
Before giving the diagnosis of the generally-contracted pelvis, study-
ing the mechanism of labor in such pelves, and the treatment of labor
there occurring, it is necessary first to consider the means by which
deformities of the pelvis are known a subject the importance of which
cannot be exaggerated.
Kleinwachter observes, no error in diagnosis is so terribly avenged
upon the mother and the child as one relating to contracted pelvis.
It might be added that the vengeance falls, too, upon the obstetrician, for he
can never escape self-reproach if, suitable opportunity having been his, he has
failed to recognize the deformity in time to ward off at least some of its conse-
quences, or possibly saving both mother and child by means appropriate to the
emergency. A primigravida, for example, is in labor at the normal end of
pregnancy ; her form is apparently perfect, her health excellent, and there is
not the least suspicion that the pelvis is abnormal. The first period of labor is
somewhat longer than usual ; the second is protracted until instrumental inter-
ference is demanded in her interest, if not in that of the child. One or more
consultants come, and the forceps is tried, first one pattern, and then another,
but all in vain, Meantime, serious inroads upon the patient's strength have
been made, and disappointment at the delay in delivery almost brings her to
despair. The next step is a craniotomy, the attendants now fully convinced that
it is impossible for a living child to pass through the narrowed inlet. But before
craniotomy and extraction of the mutilated foetus can be completed she dies.
Examination of the pelvis after death proves that the antero-posterior diameter
of the inlet is barely two inches and a half. A timely Csesarean operation would
probably have saved both mother and child, or, this being refused, the mother's
salvation might have been secured if the embryotomy had not been deferred until
she was exhausted.
DIAGNOSIS OF PELVIC ANOMALIES. This is made by the recog-
nition and appreciation of signs which may be classified as probable and
certain. The former are ascertained from the history of the patient,
from her general appearance, carriage, walk, stature, etc., while the
ANOMALIES OF THE PELVIS. 497
latter are sought by direct examination of the pelvis. In the history we
learn as to sickness during infancy and childhood ; as to the period
when walking began ; whether there was any bodily deformity observed
at birth or any manifested since ; whether any injury to the pelvic
joints or dislocation of one of the femurs occurred in early life or in
adolescence; whether one hip is higher than the other, or either femur
is ankylosed. The vertebral column is examined for deformity, whether
apparent or latent ; if it presents a deforming curvature, the period of
its first manifestation is inquired for, such curvature, if appearing in
infancy, was most probably caused by rickets ; and this origin will be
confirmed by finding the lower limbs notably curved. In this case the
pelvis is in almost all cases deformed. But if the spinal curvature
began during adolescence, the cause is not rickets and the pelvis may be
normal. The woman is lame, the first manifestation and cause of that
lameness should be ascertained. 1
If the woman has previously been delivered, we inquire as to
whether the labor was natural or artificial, whether the child was born
living or dead, and in case of instrumental delivery what means were
employed. If possible, too, ascertain further as to the cause of the
difficulty in the previous labor or labors, for that may have been from an
abnormal presentation or from excessive size of the child. It should
also be remembered, on the other hand, that though the first labor may
have been spontaneous, there might still be some narrowing of the
pelvis, which would render subsequent ones difficult from the increasing
size of the children.
CERTAIN SIGNS. As before stated, the positive proofs of pelvic
deformities are obtained by measurements of the pelvis, or pelvimetry.
These measurements are made by an instrument called a pelvimeter,
by an ordinary tape-measure, and by the hand or fingers. The
pelvimeter most generally employed is that of Baudelocque or that
of Martin ; the latter instrument has the recommendation of being
quite portable, and is represented in use in Fig. 189. In using the
pelvimeter the woman should be lying upon her back, and the lower
portion of the body exposed, or at least covered with only one thick-
ness of very thin material. Before beginning to measure, the obste-
trician applies his hands externally to the pelvis, ascertaining whether
one hip is higher 2 than the other, finds out whether there is decided
narrowing of the hips, the thickness and size of the iliac bones, the
1 Peu, La Pratique des Accouchemens, Raris, 1695, makes the following statement, which is
interesting as one of the earlier obstetric references to deformed pelvis, and as also showing that
this wise observer could not be beguiled by beauty, intellect, wealth, and social position into
marrying a young lady whom he believed, from her lameness, had a deformed pelvis : " I remember
that at the time of the second Paris war, having recently settled, it was proposed to me to marry
a beautiful young lady, rich, very spirituelle, and one whose father I greatly honored ; but she
was small and lame in one lower limb. The consequences of the lameness which I apprehended
prevented me from making this alliance. One of our aspirants in surgery, braver than I, or per-
haps more unfortunate, fell in love with her and married her. Unfortunately, she became preg-
nant. Shortly her abdomen touched the ground, and she fell from the slightest misstep. Her
frequent falls compelled her to lie in bed. Her child died, and she also when about eight months
pregnant."
Further reference to lameness as indicating deformity is given by Dionis, Traite general des
Accouchemens, 1718. He has remarked that " the lame who have one of the hip-bones higher
than the other sometimes have great difficulty in labor, because the basin formed by these bones
is not exactly round, and the infant is obliged to redouble its efforts in order to go through the
2 Want of symmetry in this respect is so common as to be the rule, and it is only a marked
deviation that should" awaken the suspicion of the examiner.
32
498 THE PATHOLOGY OF LABOE.
depth of each iliac fossa, the breadth and curvature of the sacrum, and
the height of the pubic joint. Next the external measurements are
made : first, the distance between the anterior superior spinous processes
of the iliac bones, one of the knobs of the pelvimeter touching the one
processs, and the other placed upon that of the opposite side ; this
is usually 25 centimetres, or about ten inches ; second, the greatest
distance between the iliac crests at their external margin is similarly
ascertained; this diameter is 28 centimetres, or 11 inches. 1 The third
measurement made is that between the great trochanters ; this, in case
of a normal pelvis, is 31 centimetres, or 12^ inches. If these three
diameters are normal, we know that there is no lateral narrowing of
the pelvis. The fourth measurement is taken from the spinous process
of the last lumbar vertebra to the middle of the anterior surface of the
pubic joint. This diameter, known as the external conjugate or the
diameter of Baudelocque, enables us to approximate the probable antero-
posterior diameter of the pelvic inlet, or the true conjugate ; the former
measures 20 centimetres (7.9 inches), and by deducting from it 8 cen-
timetres 2 (3.1 inches) the latter is approximately ascertained ; such
deduction is supposed to correspond with the combined thickness of the
pelvic walls, anteriorly and posteriorly. But the only absolutely certain
fact which we reach by measuring this diameter is, that if the distance
be notably diminished the true conjugate is less than normal. 3
Litzmann asserts that sometimes the measurement of the distance between the
posterior-superior iliac spines may be useful in the diagnosis of the form of the
pelvis. The relation between this and the distance between the antero-superior
iliac spines varies in the normal and in the uniformly contracted pelvis between
1 to 3 and to 3.3 ; in the flat rhachitic pelves, 1 to 3.5 ; in rhachitic flat and
generally-contracted pelves, 1 to 3.9 ; and in the simply flat rhachitic pelves, 1
to 4.3.
The diagonal diameters extend from the postero-superior iliac spines to the
antero-superior spines, passing from the right to the left, and from the left to the
right; if the pelvis be symmetrical they are equal, or the difference is very
small. They are each about 22.5 centimetres, and if normal indicate that the
corresponding diameters of the inlet are also normal.
Lohlein has sought to learn the transverse diameter by measuring from the
inferior margin of the subpubic ligament to the upper angle of the sciatic notch
and adding to it 20 mm. While this method gives a correct result in the normal,
it is without value in the abnormal pelvis.
In the great majority of cases the obstetrician will be content with measuring
the distances between the iliac crests and the antero-superior iliac spines, and
the external conjugate, so far as external pelvimetry is concerned. Pershing, in
a valuable paper* published a few years ago, after urging the importance of ex-
amining the pelvis of every pregnant woman, adds: ''The examination should
consist in measurement of the external conjugate, and anterior and posterior
iliac spines, and iliac crests. If these external measurements indicate a normal
pelvis, the examination may end with them. But if contraction is suspected,
i Litzmanu, Die Geburt bei Engen Becken, states that in 200 women with a large pelvis, he
found these measurements 27 and 29. 5 centimetres. Winckel states them to be 26 and 28, while
Zweifel gives the numbers in the text.
8 Litzmann states, op. cit, that in 30 cases in which he had an opportunity of comparing the
external conjugate measured upon the living with the true conjugate measured upon the cadaver
or upon the dried pelvis, he iound a mean difference of 9.5 centimetres, with a maximum of 12.5
and minimum of 7 centimetres.
8 If the external conjugate measures less than 16 centimetres the pelvis is always narrowed
antero-posteriorly ; if below 19 centimetres there is narrowing in one-half the cases, between 19
and 21.5 scarcely once in ten, and above 21.5 almost never. (Litzmann.)
4 Pelvic Measurements and their Importance in Obstetric Practice, American Journal of the
Medical Sciences, February, J889.
ANOMALIES OF THE PELVIS.
499
the diagonal conjugate and oblique ascending diameter of Lohlein should also
be taken."
The circumference of the upper or false pelvis is formed by applying
the end of an ordinary tape-measure to the spinous process of the last
lumbar vertebra, and carrying the tape along the iliac crest of one side,
and thence to the median line at the pubic joint; similarly, the other
half is measured, the results added, and thus the entire circumference is
ascertained. Evidently, if the one measurement is greater than the
other, the pelvis is asymmetrical. The normal circumference of the
false pelvis is 90 centimetres = 35.5 inches.
FIG. 189.
MEASURING THE EXTERNAL CONJUGATE WITH MARTIN'S PELVIMETER.
Next, the diagonal conjugate that is, the distance from the lower
margin of the pubic joint to the promontory of the sacrum is found
usually by means of one or twd fingers. In the following illustration
the index and medius of the left hand are extended, the thumb ab-
ducted, and the third and fourth fingers folded upon the palm ; the
extended fingers are carried up and backward in the pelvic cavity
until the promontory is touched ; then, still keeping up this contact,
the hand is brought upward until its lateral margin, just below the
index finger comes in contact with the subpubic ligament. Next, this
last point is marked by the nail of the index finger of the right hand ;
then the left hand is withdrawn, and the measurement made from this
mark to the tip of the finger. Kleinwachter holds that the introduction
of the index and medius at the same time ought not to be permitted,
500
THE PATHOLOGY OF LABOR.
except perhaps in the case of a multigravida, because the stretching of
the soft parts by two fingers will cause pain ; but he adds that in very
difficult cases the half or the whole hand may be used. There is diffi-
culty in reaching the promontory if the pelvis is normal, but, of course,
it is more accessible as the true conjugate is lessened.
MEASURING THE DIAGONAL CONJUGATE.
If the basin be normal, the true conjugate may be found by sub-
tracting 15-16 millimetres (-fa- fa of an inch) from the diagonal con-
jugate. " It is evident that this subtraction will vary according to
the angle which the true conjugate makes with the pubic symphysis,
and as to the height of the symphysis. It is increased with the
obtuseness of the angle and with . the elevation of the symphysis.
Hence, with the various pelvic deformities the subtraction will vary.
Though the height and thickness of the symphysis may be ascertained,
but not the angle which it forms with the true conjugate, the latter can
only be estimated, and hence slight errors may be made. Nevertheless,
with proper skill the length of the true conjugate may be determined
within a few millimetres, and the error is so slight that it may be
regarded as of no importance."
Measurements of the diameters of the pelvic outlet are of much less impor-
tance ; nevertheless, they may be required in some cases. To obtain the antero-
ANOMALIES OF LABOR. 501
posterior diameter, the woman lies, for example, upon her left side, and the
obstetrician with the thumb and index finger of the right hand the former
externally, the latter in the vagina finds the sacro-coccygeal joint, and includes
it between them. The end of the finger is fixed at that point, while the body of
the finger is carried forward and upward until its lateral surface is brought
against the subpubic ligament, and while held firmly in that position is marked
by the nail of the index finger of the other hand, as in ascertaining the diagonal
conjugate. Upon withdrawing the finger the distance from the mark to the tip
is measured, and this will give the desired diameter. Breisky places one of the
knobs of the pelvimeter externally at the sacro-coccygeal joint, while the other
is put at the lower margin of the pubic joint; now subtract from the measure
thus obtained 1 to 1.5 centimetres, and we then have the antero-posterior
diameter. Breisky recommends for measuring the transverse diameter of the
pelvic outlet Osiander's pelvimeter. The knobs are placed upon the ischial
tuberosities, and from the measure thus obtained of the intervening distance
between the tuberosities, 1-2 centimetres must be subtracted for the thickness
of the soft parts. Frankenhauser's method is to place the thumbs, their nails
being directly opposite, upon the most prominent surface of the inner margin of
the ischial tuberosities, and then with Osiander's pelvimeter measure the dis-
tance between the nails.
Barbour 1 states that the transverse diameter of the outlet is best estimated
by ChantreuiPs method: "Place the patient in the genu-pectoral position or in
that of lithotomy, though the former facilitates the measuring ; pass the index
fingers into the vagina, and turn them back to back so that the pulp of the finger
rests on the inner surface of the ischial tuberosities ; an assistant lays the points
of the calipers on the palmar surface of the fingers just outside the vulva, the
distance intervening corresponds to the inside measurement between the tuber-
osities. This allows us to use the ordinary calipers."
DIAGNOSIS OF THE JUSTO-MINOR PELVIS. The distances between
the iliac anterior superior spinous processes and between the iliac crests
are found less than normal in all cases, an exception being made for the
masculine pelvis, for in it, in consequence of the increased thickness of
the bones, these differences may be very slight or even absent. The
pelvic circumference is lessened, as is also the true conjugate. Contrac-
tion at the outlet will be suggested by the apparent approximation of
the ischial tuberosities and spines, and be confirmed by ascertaining
that the antero-posterior and the transverse diameters are under the
normal.
LABOR AND ITS TREATMENT IN THE GENERALLY-CONTRACTED
PELVIS. 2 Labor begins with the fnetal head at the pelvic inlet, for there
is not, as there is in the majority of primigravidse 3 having a normal
pelvis, descent of the head into the pelvic cavity during the last weeks
of pregnancy. The resistance of the lessened inlet compels strong
flexion of the head upon the chest, and thus, with the occiput below,
the head enters, the biparietal diameter corresponding with the con-
jugate, and the suboccipito-bregmatic with the transverse ; the sagittal
suture is at first usually in the transverse diameter. The uniformity of
the pelvic contraction shows itself by the strong resistance to any less-
1 Spinal Deformity in Relation to Obstetrics.
2 Lizmann, in considering the question what should be understood by a contracted pelvis,
states that for the simply fiat pelvis, and perhaps also for the generally-contracted flat pelvis,
shortening of the true conjugate to about 9.7 centimetres constitutes the boundary line between
the contracted pelvis and the pelvis of normal size, while for the pelvis uniformly contracted the
limit of the true conjugate is 10 centimetres.
3 Litzmann found partial entrance of the head in 8.1 per cent, at the end of pregnancy, and that
in scarcely one-fourth of the cases after labor had begun did descent of the head occur before
rupture of the bag of waters.
502 THE PATHOLOGY OF LABOR.
ening of flexion, there being such constant and great pressure upon the
frontal arm of the head- lever.
Zweifel, in describing the mechanism of labor in generally-contracted
pelves, says the sagittal suture may sometimes be in the transverse or
in the oblique, or even in the antero-posterior, pelvic diameter, and
hence the child's head becomes elongated. This elongation, however,
cannot be in the occipito-mental diameter, but rather in that described
by Budin as the maximum diameter, for the squamous portion of the
occipital bone is pushed under the parietal bones, this movement being
permitted by the cartilaginous connection between it and the basilar
portion. So, too, the equally strong compression to which the head is
subjected on all sides compels overriding of the frontal by the parietal
bones, while the posterior of the latter overrides the anterior. The
caput succedaneum is large and long, even in some cases protruding
from the vulval opening while the head is in the cavity.
FIG. 191.
MARKED FLEXION OF THE HEAD ENTERING A GENERALLY-CONTRACTED PELVIS.
The duration of labor is about one-third longer than if the pelvis is
normal. From the head remaining so long at the pelvic brim while
strong uterine contractions are going on, there is danger of injury to
some portions of the lower uterine segment, resulting in subsequent
inflammation, or actual perforation caused by long-continued attrition.
So, too, exhaustion may come on to such degree that the life of the
mother is imperilled, the uterus falling into a state of atony. The
long continuance of the labor carries danger to the foetus, and injury
may also result from the strong compression of its head.
Delay in rupture of the membranes until the os is fully dilated,
descent of the occiput rather than of any other part of the foetus,
moderate size of the foetus, yielding character of the bones of the head,
and on the part of the mother a slight degree of pelvic contraction and
vigorous uterine and voluntary action, have been correctly stated to be
propitious, the labor under these circumstances usually terminating
favorably for both mother and child.
On the other hand, early rupture ot the membranes, great size of the
child, unyielding nature of the cranial bones, and unfavorable presenta-
tion as, for example, of the pelvis (usually a knee or foot descends
ANOMALIES OF THE PELVIS. 503
first because of the difficulty of the pelvis entering the inlet), of the
brow, or a shoulder make the prognosis unfavorable.
The mortality of children Litzmann states is 9.5, and that of mothers
a little more than 6 per cent.
The forceps 1 is not applicable in general contraction of the pelvis
until the head is completely moulded. So, too, podalic version is not
indicated if the head presents, for extraction after turning cannot be
effected soon enough to save the child's life ; the head must be moulded
to the passage in a few minutes a process which Nature's forces require
hours to accomplish. Further, if craniotomy should finally become
necessary, the difficulties of the operation are increased because of the
head coming last. Another objection to delivery by podalic version is
the danger of ascension of the arms in consequence of the pelvic con-
traction. In those cases in which the contraction is chiefly at the inlet
the mechanism of labor after the head has entered the cavity is the same
as in a normal pelvis, and the treatment also corresponds.
3. Anomalies of the pelvic form or asymmetrical changes in the pelvis.
Two divisions of this class are made, the first including changes in the
depth of the pelvis :
a. That in which the vertical diameters of the pelvis are increased,
without a corresponding change in the horizontal. Such change in-
creases the depth of the pelvis, but, alone, does not to an important
degree modify the course of the labor; the latter will be longer, and in
some cases its protraction may require the use of the forceps.
6. The second class embraces those pelves whose depth is lessened.
But this change is in almost all instances associated with what are com-
monly called pelvic deformities. If occurring independently, all the
horizontal diameters being normal, other conditions being favorable, the
duration of labor is shortened.
The second division is much more important, and includes those
changes which deform, render asymmetrical, or vitiate the pelvis. It
embraces three varieties: 1, those characterized chiefly by shortening
of the antero-posterior diameter; 2, a like change in the transverse;
and, 3, the same in the oblique diameter.
The following subdivisions are made of these three classes of pelvic
deformities. These subdivisions are those adopted by Zweifel :
I. Pelves chiefly contracted in the autero-posterior diameter :
a. The flat pelvis ;
6. The rhachitic flat pelvis ;
c. The generally-contracted flat pelvis ;
d. The spondylolisthetic pelvis;-
e. The pelvis flattened by double luxation ;
/. The lumbo-lordotic pelvis.
The last originates in lordosis of the lumbar vertebrae, which is com-
pensated by a deeply situated kyphosis. In consequence of the lordosis
the lumbar vertebrae may project over the pelvic entrance, causing the
deformity known as pelvic obtecta, or roofed pelvis. In the osteomalacic
pelvis, to be described in the next class, there is also considerable con-
traction in the antero-posterior diameter :
1 Kleinwachter.
504 THE PATHOLOGY OF LABOR.
II. Pelves chiefly contracted in the transverse diameter :
a. The osteoraalacic pelvis ;
6. The ankylotic transversely contracted pelvis ;
c. The kyphotic transversely contracted pelvis.
In 6 and c the narrowing is only in the pelvic outlet.
III. Pelves chiefly contracted in their oblique diameter :
a. The ankylotic obliquely contracted pelvis ;
6. The coxalgic pelvis;
c. The scoliotic pelvis.
Neoplasms originating in the pelvic walls constitute a final class of
pelvic deformities.
THE SIMPLE FLAT PELVIS. This pelvis may be found in women
who present no other anomaly of form which would awaken the slightest
suspicion of its presence. They are usually of normal stature and appar-
ently of perfect development. There is no history of disease of the
bones in infancy or childhood, or of injury to spine or pelvis or lower
limbs in adolescence. How often has this anomaly led to the most
deplorable results in childbirth ! Even in Europe this pelvis is found
a little more frequently than the rhachitic, while the American obste-
trician will meet with it oftener than any other pelvic anomaly, and thus
forewarned ought to be forearmed.
The cause of the deformity is not clear. The deformity consists
essentially in an approximation of the sacral promontory to the anterior
pelvic wall, and the sinking of the sacrum has been attributed to walk-
ing too early, to sitting too long at a time in infancy, and also simply
to the weight of the body, when neither of the other causes can be justly
adduced. Still another explanation of the etiology has been suggested
the carrying of heavy weights in childhood ; but the occurrence of the
anomaly in women who were never subjected in childhood to severe
toil renders necessary the explanation that has been given viz., the
simple weight of the body may cause the deformity.
The descent of the sacrum is without any rotation upon its transverse
axis, and the approximation of this bone to the pubic bones, and the
shortening, involve only the antero-posterior diameter of the inlet, or if
those of the cavity and outlet are lessened the diminution is very slight.
The descent causes strong tension upon the ilio-sacral ligaments, which
would result in separation of the iliac bones if it were not for the re-
sistance of the pubic joint ; and the consequence is that the transverse
diameter undergoes slight increase and the pubic joint is brought nearer
the sacrum.
Schroder states that in very rare cases a flattened pelvis is also nar-
rowed in the transverse diameter of the outlet. In a practical point of
view, this is a very important complication of the flattened pelvis,
sometimes the articulation of the first with the second sacral vertebra,
which remains unossified, forms that which is called a double promon-
tory ; that is to say, the two vertebrae meet at an obtuse angle poste-
riorly, and the articulation makes in contracting a projection in the
pelvic cavity. 1 If a line bp drawn from this projection to the pubic
1 Schroder. Nevertheless, Zweifel remarks in reference to the name given this pelvis, that we
use the expression simple, einfach, in contradistinction to rhachitic. By this term Michaelis first
expressed the difference between the single and double promontory.
ANOMALIES OF THE PELVIS.
505
symphysis, it is as short as, or even shorter than, the true conjugate
itself, and, as this anomaly has an essential obstetric importance, it must
be included in pelvic measurements.
The diagnosis of the flat, non-rhachitic pelvis is readily made by
measuring. The transverse measurements are normal or slightly in-
creased ; the circumference is normal or slightly decreased, but the two
sides of the upper pelvis are symmetrical ; the external conjugate is
always diminished, and by this diminution, combined with that of the
diagonal conjugate, the true conjugate is found, which, of course, is less
than normal, and in the great majority of cases at least 8 centimetres
(3.1 inches).
RHACHITIC FLAT PELVIS. This deformity results from pressure
upon the base of the sacrum chiefly, causing not only descent of the
bone, but also a partial anterior rotation upon its transverse axis ; thus
the promontory is brought nearer the pubic joint, and the true conjugate
necessarily shortened. In a flat rhachitic pelvis in the Museum of
FIG. 192.
FLAT RHACHITIC PELVIS (Mutter Museum, College of Physicians, Philadelphia).
Jefferson Medical College I find the following measurements of the
pelvic inlet: Oblique diameter, 5 inches; transverse, 5J inches; and
true conjugate, 3 inches. The measurements of the outlet are: antero-
posterior, 3f inches, and the transverse 4 inches. The depth of the
pelvis at the pubic joint is 1J inch, at the sides 2f inches.
Eickets is a disease occurring in infancy or early childhood, chiefly charac-
terized by a disorder of nutrition and development of bony tissue, the disorder
involving various deformities of the skeleton, swelling of the epiphysis, bending
or fractures of the diaphysis, important changes in the shape of the pelvis, and
frequently curvatures of the spine. While in almost all cases it is a disease of
extra-uterine life, yet there have been instances in which it occurred in utero,
probably the first recorded one being given by Glisson in 1650.
506 THE PATHOLOGY OF LABOR.
It is a disease especially of poverty, and is found most frequently in the large
cities of the Old World, where the poor abound and the children of the poor
often so greatly suffer from want of sufficient food, fresh air and sunshine, and
proper clothing. Arnott 1 speaks of its being frequent in India, though he also
states that, so far as his experience goes, osteomalacia is, relatively to rickets and
also absolutely, more common in India than in Europe.
The child suffering from rickets does not walk so early as healthy children,
but is much of the time in a sitting posture ; the pressure of the body's weight
causes not only the changes in the position of the sacrum previously stated, but
also, through the resisting tension of the ilio-sacral ligaments, drawing of the
innominate bones, so that they would separate if it were not for the resisting
pubic joint ; this separation being impossible, the bones yield, and hence the
transverse diameter of the inlet is increased, "just as a long bone may be frac-
tured in the shaft by a force applied at one end, the other end resisting." In
consequence of the weight of the body resting upon the ischial tuberosities, and
by the action of muscular traction, the former are more widely separated, and
also the pubic rami, and the pubic arch is broadened.
If the child walks during the disease, the pelvic deformity is greatly increased,
there being superadded the changes caused by pressure upon the acetabula.
" The parts adjacent to the acetabula are pressed into the basin by the resistance
of the heads of the femurs, and thus the sacro-cotyloid diameters are lessened.
In consequence of the approach of the ilio-pubic tubercles the ischial spines are
pressed in the pelvis ; the approximation of the former causes a beaked protru-
sion of the pubic joint." In the highest degree of the deformity the lumen of
the pelvis is almost closed, and with bending of the sacrum and iliac bones the
pelvis may take a triangular form and is known as the pelvis triloba, or the
pseudo-osteomalacic pelvis.
Turning from these graver deformities of the pelvis caused by rickets,
we will now consider the diagnosis of the simply flat rhachitic pelvis.
The history of rickets is learned, and many of its obvious consequences
FIG. 193.
PSEUDO-OSTEOMALACIC PELVIS (Mutter Museum, College of Physicians, Philadelphia).
in other parts of the pelvis may be present. The distance between the
antero-superior iliac spines is equal to, possibly exceeds, that between
the iliac crests; the external conjugate is always lessened ; the true con-
jugate is shortened ; in some instances the second sacral bone protrudes
into the pelvic cavity, making what is called the false promontory, and
1 Transactions of the Edinburgh Obstetrical Society, vol. x.
ANOMALIES OF THE PELVIS.
507
this may be more prominent than the true, when, of course, it becomes
one of the terminal points of the conjugata vera. The antero-posterior
and transverse diameters of the outlet are unusually large in comparison
with the contraction at the inlet.
THE MECHANISM OF LABOR IN THE SIMPLE FLAT AND IN THE
RHACHITIC FLAT PELVIS. In consequence of the narrowing of the
pelvic inlet, the head of the foetus not only does not enter the pelvic-
cavity, as is the rule in the last weeks of pregnancy in primigravidse,
but it may be turned aside at the brim, and hence the proportion of
transverse presentations is increased. Another factor 1 in causing such
malposition of the foetus is found in multigravidse in the relaxed abdom-
inal and uterine walls, which permit anterior displacement of the
uterus, though a pendulous abdomen, as Litzmann observes, is especially
frequent in pelvic contraction, and in these cases there is not simple
anteversion, but auteflexion of the uterus. If the pelvis be below, its
descent through the narrowed aperture does not occur, but the feet are
prone to enter. Supposing the head to be at the inlet when labor
begins, it, as a rule, takes a transverse position ; that is, the sagittal
suture instead of being oblique lies directly from one side toward the
other of the pelvis. Resistance to the descent of the occiput compels a
partial deflection, and the anterior and posterior fontanelles may be in
the same pelvic plane ; thus the transverse diameter of the foetal head
is in the pelvic conjugate, and the occipito-froutal in the pelvic trans-
verse. But in this accommodation the anterior parietal is somewhat in
advance of the posterior, and therefore the sagittal suture approaches
the sacral promontory. (See Fig. 194.)
FIG. 194.
HEAD PASSING THROUGH THE INLET IN FLAT PELVIS.
The anterior parietal bone, pressed against the anterior pubic wall,
according to the description of Kleinwachter, becomes the fixed pivotal
point around which a partial revolution of the posterior parietal occurs
in the descent until the promontory is cleared. But in order that this
descent can occur, the transverse diameter of the head must be lessened ;
1 Kleinwachter.
508 THE PA THOL O G Y OF LA B OR.
this lessening is in part accomplished by the lateral margin of the pos-
terior parietal passing under the corresponding part of the anterior
parietal. In some instances the revolution is reversed ; that is, the
posterior parietal is fixed at the promontory, while the anterior moves
down ; then the relations of the parietals are changed, in that the pos-
terior overrides the anterior. Further diminution of the head trans-
versely may be effected by indentation, deep depressions, or even frac-
tures or fissures of the revolving parietal. After the head has passed
the inlet the subsequent mechanism is the same as in normal labor, and
often then the delivery is more rapid from the ampler space furnished
by the cavity, and especially by the outlet in the pelvis flattened by
rickets, as has been previously mentioned. Nevertheless, as stated by
Litzmann, often the uterine contractions fail in force in consequence of
exhaustion from the prolonged effort made in forcing the head through
the inlet, so that the delivery must be completed by art.
In exceptional cases the sagittal suture is placed so near the pubic or
the sacral wall of the inlet that what is termed a parietal presentation
results ; if this presentation is not rectified, delivery is impossible with-
out craniotomy. Descent of the frontal bone first may occur in great
narrowing ; then the two halves of the bone play a corresponding part
to that of the parietals in relation to the pubic and the sacral wall of the
pelvis. Whether the parietals or the frontal halves pass the strait first,
the posterior bone has a distinct pressure-mark from its being so strongly
forced against the promontory.
In pelvic presentation one or both feet usually descend first ; if the
contraction is slight, the body passes through it without serious diffi-
culty ; then the head may pass also of course, it must be in a trans-
verse position for this passage flexion being continued ; the posterior
parietal bone suffers from pressure in descending the promontory. In
more decided narrowing departure of the chin from the chest is ob-
served.
The mortality of mothers is more than 7 per cent., and of children
50 to 60 per cent. The prognosis is more favorable in the case of
female than of male children, and it is also more favorable if the
woman be a multipara thau if a primipara, provided the head presents.
In the management of the labor care should be taken to keep the
membranes unruptured until the os is dilated, and hasty intervention
while the head is being moulded to pass through the narrowed inlet
must be avoided. If nature is unable to effect the passage of the head
through the inlet, resort to the forceps is not indicated, but podalio
version. In regard to the former means, Zweifel observes that the
application of the forceps to the movable head is not impossible, but to
seize it firmly is purely accidental ; an application of the blades over
the parietal bones is absolutely impossible; and even if the head were
thus grasped, it could not be drawn through the conjugate. Version
comes only in those cases in which the forceps cannot be used ; and
even then the question, as Schroder has framed it, is, Shall we turn, or
wait? " Whenever we perform version in contracted pelves we decide
in favor of this operation without knowing, in case this is not done, how
the head would enter the true pelvis and how it would pass through.
ANOMALIES OF THE PELVIS. 509
This renders the question as a practical one so difficult, and will prob-
ably thus keep it for a long time, probably forever."
The usual rule is to wait after rupture of the membranes and dilata-
tion of the os, with the hope that the head may enter and pass the
inlet ; but if after a reasonable delay this does not occur, podalic version
is to be employed.
GENERALLY-CONTRACTED FLAT PELVIS. In this variety there is
a greater degree of descent of the sacral promontory than is found in
the generally -contracted pelvis, and the deformity rarely occurs except
as a consequence of rickets. Not only all the pelvic diameters are below
the normal, but the true conjugate especially is shortened.
Litzmann states the mortality of mothers with this pelvic deformity
is between 8 and 9 per cent., and of children delivered dead or dying,
there are 66 per cent.
THE SPONDYLOLISTHETIC PELVIS (from a7r6i>6vhog, probably, more
correctly, c6v6v^, vertebra ; and oMcdr/aif, a slipping or gliding).
This deformity arises from a gliding or slipping forward of the last
lumbar vertebra, so that it no longer rests upon the upper surface of the
first sacral vertebra completely, but only partially ; or even, in an
excessive degree of spondylolisthesis, the posterior wall of the body of
the former vertebra maybe fixed to the anterior wall of the body of the
latter, a synostosis occurring. Sometimes, indeed, the lumbar vertebral
column glides down to the body of the second sacral vertebra. The
lumbar vertebrae thus sinking, lordosis results, and the lower edge of
the fourth lumber vertebra, or the union between the third and fourth,
or even that between the second and third, is opposite the pubic joint.
This pelvis was first described by Rokitansky. The question as to the cause
of the deformity has been much discussed. From the firmness of the transverse
processes of the normal vertebrae it would seem impossible for a dislocation of
one of the bodies to occur ; and the view generally held as to its origin in the
majority of cases is that it results from a fracture of the vertebral arch anterior
to the articulating processes this fracture caused by a fall upon the sacrum
and hence dislocation becomes possible. " If a person should thus fall with the
body bent forward, the sacrum being fixed at the moment of the accident, the
force will mainly act upon the body and arch of the last lumbar vertebra, and a
fracture of the acrh would very probably occur." Zweifel remarks that we can-
not overlook the weak side of this, F. L. Neugebauer's theory, which is, that
hitherto the traces of such a healed fracture have been found in only one case. 1
Nevertheless, he also states that a traumatic, and hence extra-uterine, origin of
spondylolisthesis must be admitted for the majority of cases. There may also
be congenital spondylolisthesis, the origin of the disease, from the failure of
coalescence of ossification-centres in the vertebral arches, thus permitting dislo-
cation of the vertebral body. This 'deformity is rare ; Kleinwachter, writing in
1882, states that only fourteen cases have been observed.
The diagnosis is made by the increased distance between the posterior
superior iliac spines ; by the marked lordosis just above the sacrum ;
by the shortening of the abdomen, its contents sinking so much between
the ilia; by the peculiar " rocking gait" of the pregnant woman, by the
absence of any history or present manifestation of rhachitis or of osteo-
malacia ; by an account of a fall such as would result in fracture of the
1 Winckel mentions two cases under his observation, in which the probability was that the
deformity had its origin as Neugebauer has stated.
510
THE PATHOLOGY OF LABOR.
arch of the fifth lumbar vertebra; but, above all, by internal examina-
tion, counting the bodies of the sacral vertebrae, and recognizing the
projecting lumbar vertebra by finding the sacral vertebrae complete, and
by the absence of the alee in this, which belong to the first sacral. In
Olshausen's case, the bifurcation of the aorta could be felt on the deeply-
sunken lumbar vertebral column.
FIG. 195.
SPONDYLOLISTHETIC PELVIS, SHOWING DISLOCATION INTO THE PELVIC BRIM OF THE LUMBAR
VERTEBRA (KILIAN). THE " PRAGUE PELVIS."
4. Fourth vertebra. 5. Fifth lumbar vertebra.
The Csesarean operation is unavoidable in a severe spondylolistnesis.
Slight degrees of the deformity are much more common than was at
first supposed, and the prognosis is, according to Zweifel, no more
unfavorable than it is in the flat rhachitic pelvis.
THE PELVIS FLATTENED FROM BILATERAL DISLOCATION OF THE FEMORAL
BONES. Whether the double dislocation be congenital or occur early in child-
hood, the heads of the femurs pressing above and posteriorly to the acetabula,
" great traction is exerted upon the round and upon the ilio-femoral ligaments ;
the muscles of rotation passing from the inner side of the pelvis to the femur,
the obturators and gemelli are also made tense Hence traction in a transverse
line at the pelvic outlet and its partial eversion. By the tension of the ilio-
femoral ligaments passing from the capsule to the anterior inferior spinous pro-
cess, and in consequence of the place of support of the trunk, the heads of the
femurs, being placed further back, the centre of gravity is thrown anterior to the
plane of support ; continual care is necessary to prevent falling forward, and this
is exerted by the dorsal muscles drawing the body backward, the consequence of
which is, the inclination of the pelvis is lessened, and there is a lumbar lordosis.
Tension upon the pelvic ring causes increase in the transverse diameter of the
inlet and flattening of the pelvis, with necessary shortening of the conjugate ;
the latter diminution is also increased by sinking of the sacrum." Not only the
conjugate is lessened, but usually the corresponding diameters of the cavity and
of the outlet, though, according to Kleinwachter, this lessening becomes less at
ANOMALIES OF THE PELVIS.
511
the outlet in consequence of the recession of the lower part of the sacrum, while,
on the other hand, it may be that resulting from tension upon the ligamentous
connections between the ischial tuberosities and spines upon the lower portion
of the sacrum, the latter is drawn forward, and then there necessarily follows
lessening of the antero-posterior diameter of the outlet.
The true conjugate rarely falls below nine centimetres, but in some it has been
reduced to seven. The characteristics of this pelvis are, in addition to the les-
sened conjugate, the increase of the transverse diameter, the fact of the double
luxation, the greater breadth of the pubic arch, the lessened pelvic depth, and
the flattening of the pelvic inlet. The diagnosis in the living subject is greatly
facilitated by observing the duck-like gait. This pel vie anomaly, if we know the
peculiar walk of those having such a basin, Zweifel states, can be diagnosed at
a distance of two hundred steps.
This variety of pelvic deformity is quite rare ; according to Kleinwachter, only
nine of such pelves have hitherto been observed. The labor usually ends favor-
ably both for mother and child ; after the head once passes the inlet the progress
is quite rapid.
The Second Class includes Pelves chiefly Narrowed in the Transverse
Diameter.
a. The osteomalacic pelvis. Osteomalacia (from barlov, bone, and
nahaxbt, soft mollities ossium, softening of the bone) is a disease of
which the essential cause is a diminution of the earthy salts of the
bones, this diminution being such that these salts are two, three, or even
five times less than normal, and of which the most marked results are
FIG. 196.
OSTEOMALACIC PELVIS, SHOWING THE BEAK-LIKE SHAPE OF THE PUBES.
changes in the forms of the bones in consequence of their great flexi-
bility. It is not a disease belonging exclusively to adult life, nor to
the female, nor to childbearing. Nevertheless, the statistics of Col-
liueau indicate very clearly the frequent origin of the disease in conse-
quence of changes of the organism caused by pregnancy. He found
only 14 of 43 women suffering with osteomalacia who had never been
pregnant, and of the other 29, 14 who had had from four to ten preg-
51 2 THE PA THOLOG Y OF LABOR.
nancies, 6 one to three, and 4 who had been pregnant but once. Thus
it is seen these statistics prove that the majority of cases of the disease
are connected with pregnancy. It may appear during gestation or in
the puerperium ; once begun, the disease is aggravated by succeeding
pregnancies, especially if the intervals are short.
It is impossible to explain satisfactorily the anomaly of nutrition which is
essential to the disorder. " While true that the disease has never been observed
in women comfortably situated in life, even the lack of good nourishment, mis-
erable and damp dwellings, a diet exclusively of potatoes or of rice, cannot be
regarded as the absolute cause of the disease, though the conditions just stated
are undoubtedly predisposing causes. If deficient nourishment of the bones in
the large majority is the sole cause, so that the bones, losing their earthy
elements, are softened, then osteomalacia would be much more frequent. A fact
that is inexplicable is, that the disease occurs usually only rarely and sporadically,
but in some countries very frequently, so that it may be called endemiUCIS, ap-
plied by Hippocrates to a bowing or curving of the spine, so that one
was humpbacked) means an abnormal convex curvature of the spine.
The origin of the kyphotic pelvis is found in an abnormal posterior spinal cur-
vature, for a compensating curvature lower down results from the former ; and in
order that the pelvis may be affected by the spinal anomaly, the latter must be
situated in the lumbar vertebrae, or in these the sacral vertebrae must be affected,
the one known as lumbo-dorsal, the other is lumbo-sacral, kyphosis. Further,
the sacrum is pushed downward and backward : just as in a pelvic deformity
previously considered this bone is pressed downward and forward, lessening the
conjugate, a rotation of the bone upon its transverse axis forward, so that the
sacral promontory is brought nearer the pubic joint, so now a corresponding rota-
tion backward is claimed to occur.
Barbour gives the following summary of the peculiarities of the kyphotic pel-
vis based upon his examination : " The iliac crests are drawn out from before
backward; the arching of the crests is diminished and their sigmoid curve
lessened. The anterior superior spines are thrown apart. The pelvis is funnel-
shaped. The conjugate diameter is greatly increased, while the transverse is
relatively, and sometimes absolutely, lessened. The linea terminalis is less
arched at the sides. In the cavity the conjugate is increased, but to a less ex-
tent than at the brim. Sacrum narrowed transversely and elongated vertically ;
its vertical curvature is diminished throughout, its transverse in the upper por-
tion of the bone. At the outlet the conjugate is not usually altered. The trans-
verse may be contracted, and that to an extreme degree. The pubic arch is
narrowed."
The most characteristic anatomical peculiarity of the kyphotic pelvis is an
increase in the antero-posterior diameter of the brim. The contraction in the
transverse diameter of the outlet, which is the feature of obstetric importance,
is not so constant.
Further, Barbour, in opposition to the teaching of Breisky, states as the result
of the study of the preparations he has had that there is not, as a rule, a rota-
tion of the sacrum upon a transverse axis, and that the contraction at the outlet
is not related to the elongation at the brim. He further maintains that the con-
traction at the outlet implies a rotation of the innominate bones ; and this is
shown by the fact that the approximation of the tuberosities is related to separa-
tion of the crests.
The most characteristic indication of the kyphotic pelvis is found in the pres-
ence of a lumbar kyphosis, and next in the peculiar walk of the subject, the
movement being as if carrying some heavy load before her and a constant effort
to avoid falling. By pelvimetry we find the true conjugate increased ; the trans-
verse measurements of the false pelvis are normal, but that between the posterior
iliac spine is lessened.
The distinction just given is the direct opposite of the conditions observed in
the osteomalacic pelvis, with which this may be confounded, for in that the
anterior transverse diameters of the false pelvis are lessened, while the distance
between the posterior iliac spine is increased. The pubic arch is narrowed in
the rhachitic and also in the osteomalacic pelvis, while no narrowing is present
ANOMALIES OF THE PELVIS. 515
in this. Besides, the first two occur in persons whose history points to one or the
other disease. In such a pelvis, too, the promontory is quite accessible.
Of course, the prognosis rests chiefly upon the degree of contraction.
It is of especial importance in this connection to know the transverse
diameter of the outlet. Further, it is important to know if " the ischial
tuberosities move upon being pressed apart. Korsch has demonstrated
that even in the normal pelvis the transverse of the outlet can be thus
slightly increased, this movement being accompanied by a diminution
in the conjugate." 1 But before this observation both Mattel and La-
borie had asserted that an increase in the transverse diameter of the
outlet resulted from the wedge-like pressure of the ftetal head.
In consequence of the lessened abdominal capacity arising from a
lumbar kyphosis, the uterus may be strongly anteverted, and, hence,
difficulty in the head entering the inlet. Bnt the most frequent fact as
to the position of the child in the abdomen that has been observed is
that the fetal back is posterior that is, toward the mother's spine
" probably in consequence of the pendulous abdomen generally present,
the limitation of abdominal space, and the compensating lordosis of the
upper portion of the spinal column, through which the anterior plane
of the fetus can be better adjusted to the anterior abdominal wall."
This explains the frequency of occipito-posterior positions. Accord-
ing to Barbour, the shape of the pelvis favors posterior rotation of the
occiput.
He gives a table of 32 cases of kyphosis and 52 labors ; there were
33 recoveries from these 52 labors, but of the 32 mothers, 19 ultimately
died after labor. He thus finds in his collection of cases that there was
a fetal mortality of 52 per cent, and a maternal mortality of 36.5 per
cent., according to the number of confinements, or 59.4 per cent., accord-
ing to the number of cases of kyphosis.
The extreme limit admitted by Barbour for the application of forceps
is 3.25 inches, and if this diameter is less he advises craniotomy. There
were 7 cases of Csesarean section, 6 mothers dying ; 9 cases ended spon-
taneously, and 7 mothers recovered. Zweifel regards the prognosis as
more favorable in this than in other pelvic contractions, because the nar-
rowing is at the outlet. But he adds that Csesarean section has been
necessary, and as spontaneous rupture of the uterus has occurred, and
even after the use of the forceps death rapidly followed, it is advisable
in a given case to keep this possibility in mind.
RHACHITIC KYPHOSIS." While th changes in the pelvis caused by rickets are
in the main directly opposed to those caused by kyphosis, on the other hand,
should kyphosis result from rickets, the pelvis may present a similar form to that
observed if the kyphosis has a different etiology. The kyphosis, in order to
change the form of the pelvis, must, as in the account of the kyphotic pelvis just
given, concern the lumbar vertebrae. The diameters of the outlet are lessened,
and the diminution is greatest in the antero-posterior.
The Third Class includes Pelves chiefly Contracted in the Oblique
Diameter.
a. The ankylotic obliquely-contracted pelvis. Dionis was credited by
1 Barbour, op. cit. 2 Zweifel.
516
THE PATHOLOGY OF LABOR.
Naegele with having first alluded to the pelvis contracted in an oblique
diameter. Certainly, this distinguished French accoucheur does refer
to difficult labor caused by spinal deformities, and also to changes in
the pelvis caused by rhachitis, but his reference to the pelvis now to be
considered is by no means clear.
The oblique-oval, or Naegele's basin, was first described by Naegele
in 1839. It is distinguished by the fact that one sacro-iliac synchon-
drosis has been ossified, and, as a consequence, one-half of the basin
becomes narrower.
The part of the sacrum belonging to the ankylosed side is imper-
fectly developed, and its union with the innominate bone is made by a
FIG. 199.
OBLIQUELY-DISTORTED PELVIS, OB NAEGELE'S PELVIS.
narrow ledge of greatly condensed osseous tissue instead of by a broad
articulating surface. There is slight scoliosis involving the lumbar
vertebra. In Kleinwachter's case there was also rhachitis. The iliac
bone of the affected side is raised and projects further back than its
fellow. The sciatic notch is lessened in consequence of the ischium
being pressed upward and inward, and the ischial tuberosity and spine
approach the sacrum.
The absence or rudimentary condition of the sacral wing upon the
affected side finds its most rational explanation in the absence of ossifi-
cation nuclei, and, therefore, the deformity may have an intra- uterine
origin ; this was the view favored, though not exclusively, by Naegele.
But it is also held that the deformity may result from pathological con-
ditions of the joint in infancy or childhood; in other words, inflamma-
tion lies at the beginning of the change. The theory of an inflammatory
origin in some cases after- birth does not exclude that possibly this
inflammation may begin in intra-uterine life; if the inflammation occurs
after birth, its cause may be simply pressure of the trunk, which will
ANOMALIES OF THE PELVIS. 517
be greater upon that side corresponding with an imperfectly developed
sacrum. It is impossible for disease of one of the sacral joints in adult
life to cause the deformity.
Thomas, 1 in 1861, from a study of the 50 cases of oblique oval basin up to that
time described, classified them as to their etiology as follows :
a. Oblique pelves found in women who during their infancy, or in all cases
before the ankylosis was recognized, had suffered from disease of the pelvic
bones, 9 cases.
b. Oblique basins with fracture of the pubis on the same side as the ankylosis,
2 cases.
c. Oblique basins with traces of periostitis or exostosis of the hip-bones, 3 cases.
d. Oblique basins in which there was found, beside the ankylosis, a coxal
arthritis of the same side or of the opposite side, 5 cases.
e. Oblique basins without any other trace of disease, of which, nevertheless,
the history was too imperfectly known to permit the absolute statement that in
the women to whom these pelves belonged there was nothing observed, especially
in youth, indicating a morbid state of the pelvic bones, 27 cases.
/. Oblique basins without visible traces of disease of the pelvic bones in women
whose history was sufficiently well known, so that it could be affirmed they had
never suffered from any affection of the bones.
Whatever or whenever the origin of the deformity, the latter presents
a most characteristic form which is well shown in the illustration that
has been given. The pelvic inlet is asymmetrical, and presents the
form of an obliquely placed oval with a point projecting to the ankylosed
side. The antero-posterior diameter is increased, but the transverse is
lessened, and there is a continued lessening of this diameter through the
cavity and to the outlet.
Most of the cases of obliquely-contracted pelvis have been diagnosed
after death ; the entire number of cases observed is given as about fifty,
but probably this is too small. Zvveifel states that with a great differ-
ence between the two sides of the pelvis the diagnosis during life cannot
be difficult. Should there be delay during labor in the entrance of the
head into the pelvis, the possibility of this deformity will be suggested
if we find it impossible to reach the sacral promontory. The limping
gait of the subject may not be observed, but it is important to learn
whether there is any history of inflammation of the joint in infancy or
childhood, and whether any evidences of suppuration following such
inflammation can be found in healed sinuses. Freund claimed that, an
examination being made per rectum, the woman standing alternately on
one and then on the other foot, some movement would be detected in an
unaffected joint, while the ankylosed one would be immobile.
Internal examination should be made with the half or with the whole
hand, and thus the want of correspondence in the position of the ischial
spines, the distortion of the promontory, and the displacement of the
pubic joint will be learned. The most important external measurement
in order to prove that the basin is asymmetrical is the distance between
the trochanter major of one side to the iliac crest of the other, and
vice versa.
Naegele directed the following measurements to be made :
1. From the posterior superior spine of one side to the anterior superior spine
1 Das SchrSgverengte Becken, quoted by Naegele and Grenser.
518 THE PATHOLOGY OF LABOR.
of the other side from the right side behind to the left side in front normally
21.22 centimetres.
2. From the trochanter major of one side to the posterior superior spine of the
other 22.25 centimetres.
3. From the middle of the inferior margin of the pubic joint to the posterior
superior spine of each side 17.25 centimetres.
4. From the ischial tuberosity of one side to the posterior superior spine of the
other 17. 5 centimetres.
5. From the spinous process of the last lumbar vertebrae to the anterior supe-
rior spine of each side 18 centimetres.
These oblique diameters, as Naegele termed them, must show a difference
between each two corresponding ones of more than one centimetre in order to
make the diagnosis of obliquely-contracted pelvis.
In this pelvis, if the ankylotic contraction be great, the passage of
the child is necessarily made through that portion of pelvic space corre-
sponding to the healthy side, for that which belongs to the ankylotic
side is so contracted that no part of the foetus can be admitted. The
space, then, that is available is quite similar in form to that given by
the justo-minor pelvis ; and if labor be possible the mechanism is the
same, the occiput descending first, as has been described in the course
of labor occurring in that pelvis. Presentation of the breech is very
unfavorable, because of the great difficulty in, or impossibility of, the
passage of the head.
The prognosis as to the mother of course depends upon the degree of
the deformity, the vigor of labor-forces, the size and degree of resistance
to moulding of the foetal head, and the size of the child; the maternal
mortality given by Litzmann and Thomas is 80 per cent. But this
high percentage is to be attributed to the fact that in most of the cases
the deformity was not recognized soon enough for the use of appropriate
therapeutic means, and in some instances, according to Kleiuwachter,
the means employed directly caused the death of the mother. Zweifel,
too, regards Litzmann's statistics as being too unfavorable. He advises
the forceps if the head enters the pelvis, but if this entrance be impos-
sible the Caesarean operation, especially as in cases of such difficulty
uterine rupture is liable to occur.
6. The coxalgic obliquely-contracted pelvis. This pelvis is similar to
that just described, but there is this remarkable difference in manifesta-
tion : While in the Naegele pelvis the arrest of development or the
inflammation of the sacro-iliac joint affects the side of the basin in which
it occurs, in this deformity the coxitis and subsequent ankylosis are
upon the side of the pelvis which remains comparatively normal, and
the healthy side becomes misshapen.
The pelvis, represented in Fig. 200, was taken from a negress upon whom Dr.
R. G. Curtin performed Caesarean section, and it exhibits very clearly the fact
of the pelvic deformity being manifest upon the healthy side, while that upon
which the coxitis occurred is normal. The history of the usual development of
this pelvis is that a child suffers from coxitis so severely that the corresponding
lower limb for example, let the affection be upon the right side becomes use-
less, and the weight of the body rests upon the left femur. This pressure causes
similar changes in form in the basin to those observed in the Naegele. The left
acetabulum is pressed upward, and it comes more in front ; the innominate line
is bent in front at an acute angle, and the left ilium is higher and less inclined ;
the left half of the sacrum is narrowed, so that the entire bone loses its symmet-
ANOMALIES OF THE PELVIS.
519
rical form ; the left ischial tuberosity and spine move backward and outward,
and the pubic joint is placed opposite the right side.
There are several modifications of the coxalgic oblique basin according to the
period in adolescence when the disease of the joint began and as to the degree of
use permitted by the diseased limb. Thus, the earlier in childhood the disease
occurs and the more the limb is used, the greater the deformity. On the other
hand, if the coxitis is first manifested after complete development of the basin,
the obliquity may be completely absent.
FIG. 200.
A COXALGIC OBLIQUELY-CONTRACTED PELVIS (Mutter Museum, College of Physicians, Philadelphia).
So, too, the obliquity may involve first one side, and then it may change to
the other. Zweifel gives the following illustration : A child has coxitis of the
right side, ending in firm ankylosis, the right lower limb being shortened. It
necessarily limps, and the concussion in walking will be greater than on the left
side, this jar being felt not only at the hip-joint, but also in the corresponding
sacro-iliac synchondrosis ; hence, ascension of the iliac bone. If now a chronic
inflammation in the sacro-iliac joint is superadded, the corresponding sacral
wing will be retarded in its growth ; hence the right half of the pelvis becomes
smaller than the left half, the pubic symphysis is pushed to the left, and the
oblique diameter of the pelvis from the left anteriorly to the right is shortened.
Suddenly, however, all this may be changed, so that by muscular traction a
pelvis presenting an opposite contraction may be developed. For if the child
ceases to use the right lower limb, the plane of support is exclusively given by
the left femur. But it is not necessary to follow the changes that then result in
the form of the pelvis, the diseased side furnishing comparatively a normal con-
dition of the corresponding side of the pelvis, and the healthy side becomes in
this regard abnormal.
Paralysis of a lower limb or amputation of a leg is rarely followed
by any great change in the form of the basin, because in the great
majority of cases this has attained complete development before either
occurs.
The coxalgic pelvis so gravely deformed as seriously to interfere with
labor is rarely seen. The recognition of the deformity will be made,
520 THE PATHOLOGY OF LABOR.
first, by having a history of coxitis in early life, and finding its effect
in a useless abdominal member, and then by a direct examination of
the pelvis. In slight cases of the deformity labor needs no assistance,
while in the ga\ne ones labor and its treatment are the same as advised
in similar circumstances in the Naegele pelvis.
c. The scoliotic obliquely-contracted pelvis. This deformity arises from
a scoliosis involving the lumbar vertebra, there being thus caused a
greater pressure upon that half of the upper articulating surface of the
sacrum corresponding with the side toward which the spinal curvature
occurs. By the connection of the sacrum with the innominate bone
this increased pressure is transmitted to the femur of that side. But
the resistance of the latter causes leaning inward of the parts adjacent
to the acetabulum, and hence that side of the pelvis becomes greatly
lessened. A scoliosis of the vertebrae toward the right diminishes and
deforms the right half of the pelvis, while the left is similarly affected
by a scoliosis with its curve directed to the left.
Should the scoliosis be limited to the dorsal vertebra, a compensating
curve of the lumbar vertebra may prevent any influence upon the pelvic
form.
This deformity renders one side of the pelvic canal useless, so far as
furnishing space for the transmission of the child. The mechanism of
labor is that described as occurring in the justo-minor pelvis, and the
assistance to be given by the obstetrician, provided the contraction be
not so great as to forbid the passage of a living child, is by forceps,
remembering, however, that this instrument is not to be used until the
head has been sufficiently moulded.
DEFORMITIES OF THE PELVIS CAUSED BY FRACTURES OR BY NEO-
PLASMS OF THE PELVIC BONES. Fracture of the horizontal ramus of
one of the pubic bones may result in serious deformity of the pelvis,
because of the impossibility of keeping the broken ends of the bone in
apposition during healing. Eugene de Saint-Moulin 1 narrates the case
of a girl sixteen years of age who, while working in a coal-mine, was
injured by the falling of a large mass of coal upon the lower portion of
her back; after several months she recovered so that she could walk,
though with some difficulty, and there was slight spinal deformity.
Five years afterward she became pregnant, and the diameter of the
superior strait being only three centimetres six millimetres, the Caesa-
rean operation was successfully done at the end of the pregnancy.
Seven years after she was again pregnant, and at seven months rupture
of the uterus occurred, the tear being in part of the uterine incision
made in the previous operation, and the rupture ended fatally. The
autopsy showed that, in addition to marked lumbar lordosis, the second
sacral vertebra was crushed, so that the first was directly buried in the
pelvic cavity, and there was a synostosis between its inferior border and
the superior border of the third sacral vertebra. The spondylolisthesis
had thus a very rare origin in this case.
Various neoplasms enchondroma, sarcoma, carcinoma, exostosis,
fibroma may, originating from any part of the internal surface of the
1 Journal d'Accouchements, 1885.
ANOMALIES OF THE PELVIS. 521
pelvic bones, encroach so greatly upon the bony birth-canal that the
Csesarean section is necessary.
Deventer, who was the first obstetrician to give any clear exposition of pelvic
deformities, regarding the position of the coccyx as sometimes causing a serious
obstacle to labor, occupied several pages of his well-known work with the sub-
ject, and gave directions as to pushing the head back and thus enlarging the
pelvic outlet. Since then other obstetricians have urged the. hindrance in labor
from sacro-coccygeal ankylosis. The pressure of the child's head in labor is
sufficient to overcome the resistance.
EFFECT OF INCREASED AND OF LESSENED PELVIC OBLIQUITY
IN PREGNANCY, AND IN LABOR. If the inclination of the pelvis be
notably increased, a pregnant woman will especially sufler from pendulous
abdomen, and in labor delivery may be impossible when she is lying
upon her back, and therefore it will be necessary for her to be upon her
side.
If the inclination of the pelvis be much lessened, and labor rapid,
rupture of the perineum is almost inevitable. According to Ahlfeld, if
with lessened pelvic inclination there are associated narrow vagina and
a broad perineum, this rupture may be central, the child delivered
through the rent, while the anal and the vulval openings remain intact.
CHAPTER VIII.
ANOMALIES OF THE FCETUS AND OF THE FCETAL APPENDAGES.
ANOMALIES of the foetus include those of size, form, and presentation
the last may be complex instead of simple, or may be abnormal in
other respects other foetal anomalies may be malformations and mon-
strosities, single or double. The cord may be relatively or absolutely
shortened, or it may prolapse, and the membranes may be unusually
resistant.
ANOMALIES OF THE SIZE OF THE FGETUS. These may be general
or partial, physiological or pathological.
Great Size of the Foetus. This may relate to the head only, or the
body also. The diagnosis of great size of the fostal head prior to birth
is uncertain ; abdominal palpation previous to, or during labor, and
by touch finding the distance between the anterior and the posterior
fontanelle to be greater than usual, are thought by some to furnish use-
ful information. Could we know the sex of the child we might be
assisted in the diagnosis of the size of the head. In multiparse advanced
in age it is usual to find that the child if male has a very large head.
In primiparse more than thirty years of age the children are larger than
in young prirniparse. Possibly the patient's previous labors have been
protracted in consequence of the great cranial development with prema-
ture ossification of the bones of the head, and they all may have ended
in the birth of dead children. In case of prolonged pregnancy, as a
rule, the development of the foetus, especially of the head, is greater
than if the labor occur at the normal time.
Blake takes the ground that it would be a very judicious rule of practice in
any dystocia caused by a large and prematurely ossified foetal cranium not to con-
sider the question of forceps delivery. " We may resort to the perforator with
less than our usual repugnance to its use if we bear in mind the fact that quite a
proportion of children born with closed or partially closed fontanelles and ossified
sutures will, if not early cut off with symptoms of brain irritation and pressure,
be epileptic and idiotic." 1
Jacobi states that premature ossification of the sutures and fontanelles occurs
particularly with the first child, and in the milk of young mothers the phosphates
are predominant as compared with the milk of mothers later in life. 2
The induction of premature labor is clearly indicated in the case of a
pregnant woman whose previous pregnancies have ended in stillbirths
from the great cranial development of the children. One of the most
frequent causes for the application of the forceps is the necessary dispro-
portion which exists between the head and the normal pelvis ; if the
former be unusually large, turning is not advisable, but in some instances
craniotomy may be necessary.
i American Journal of Obstetrics, vol. xii. s Ibid., p. 358.
ANOMALIES OF F(ETUS AND POSTAL APPENDAGES. 523
Jacquemier has said that after spontaneous or artificial delivery of
the head it was thought by some that the shoulders became too large by
development of the chest, and presented an obstacle to the escape of the
foatus so that it was impossible for the uterus alone or assisted by the
usual artificial means to expel it, at least as promptly as required by its
precarious situation thus suspended between intra- and extra-uterine life.
It is not, however, the great volume of the shoulders so much as that of
the chest which causes the delay, conjoined with some degree of uterine
inertia. When this difficulty is anticipated the practitioner must beware
of deep anesthesia, provided an anaesthetic be administered, during the
delivery of the head, lest, even if uterine inertia be not thereby invited,
the voluntary expulsive efforts of the patient may fail when they are
most needed.
Difficult delivery of the shoulder is considered on pages 306 and 307. Fracture
of the clavicle has occurred in some cases from direct pressure of the obstetri-
cian's fingers in endeavoring to extract the inferior shoulder.
PARTIAL INCREASE IN THE SIZE OF THE FCETUS. 1. Hydrocepha-
lus. By this is meant abnormal accumulation of serous liquid in the
cranial cavity. It is met with once in 3000 births. It has been attrib-
uted to syphilis, alcoholism, cretinism, and to marriages of consanguinity.
The mothers were, in many instances, past forty years of age, and lived
in bad hygienic conditions. Poullet 1 states there are cases in which
women have a predisposition of unknown nature to produce hydro-
cephalic offspring, and cites an illustration from Franck of one who had
in successive pregnancies seven children with hydrocephalus, and another
from Goelis of one who had six. He also directs attention to the investi-
gations of Dareste, who, in the artificial production of monstrosities, has
caused dropsy of the nervous centres in experiments upon the embryo
of the hen.
In hydrocephalus the cranial bones are usually much thinner than
normal, and more flexible ; they are flattened, are much more widely
separated, and the fontanelles larger, and in some cases the latter occupy
a greater extent than the ossified parts. In many cases of hydrocephalic
heads there is a supplementary fontanelle, known as the fontanelle of
Gerdy, situated between the anterior and the posterior fontauelles.
One of the characteristics of the hydrocephalic head is the marked
triangular form of the face, the base of the triangle being at the forehead,
which is broad and prominent, and presents a distinct suture, and the
sides of the triangle rapidly approach, meeting at the chin.
The great development of the head interferes with the normal accom-
modation of the fostus, and hence there is a much larger proportion of
presentations of the pelvis. 2 Poullet found in 106 cases 30 in which
the pelvis and 8 in which the shoulder presented. So far there has
been no example of face presentation in hydrocephalus.
If the enlargement be not very great, spontaneous delivery occurs
1 De 1' HydrocSphale Foetaledans ses Rapports avec la Grossesse et 1' Accouchement. Paris, 1880.
2 G riffith suggests t hat the hydrocephalic head is more frequently in the upper part of the uterus,
because the fluid it contains has a less specific gravity than that of the amnial liquor. London
Obstetrical Society's Transactions, vol. xxix.
524 THE PATHOLOGY OF LABOR.
after a more or less difficult and tedious labor : " But in the largest
number of published observations the efforts of nature were entirely
powerless to effect the expulsion of the hydropic head, and after alter-
natives of contractions and inertia from exhaustion of the uterus, final
inertia supervened, or uterine rupture occurred, the woman dying unde-
livered ; this, at least, is the course of spontaneous labor without more
or less able intervention, when the head was large." l In some instances,
however, delivery may occur by the fluid passing from the interior to
the exterior of the cranium, or it may become infiltrated in the connec-
tive tissue of the neck, of the chest, and of the abdomen, thus producing
a general oedema. A still more singular lessening of the size of the
hydrocephalic head may result from the fluid passing into the pleural
or into the peritoneal cavity, and then the labor spontaneously ends. In
some instances rupture of the head occurs, more frequently in presenta-
tion of the pelvis than of the head, and with the free evacuation of the
fluid the obstruction to labor ends. If the slow labor demands the
application of the forceps, the introduction of the blades and the locking
are difficult, the handles are wide apart, and efforts at traction usually
end in the blades slipping. It should be added, however, that if Tar-
nier's forceps is used, this accident is much less likely to occur. I have
with it delivered a hydrocephalic head when a Hodge's instrument had
been unsuccessfully tried.
PROGNOSIS. This is most unfavorable for the child. The statistics
of Chassainat 2 show that in 60 cases of foetal hydrocephalus 41 died
before or during labor, and only 19 were born alive ; only 4 of the 19
lived for several years. Poullet regards this result as too favorable,
stating that he has been unable after diligent search to find a case in
which hydrocephalus caused dystocia and the child lived.
DIAGNOSIS. If there is not an excess of liquor amnii, it may be
possible to recognize the great disproportion between " the round and
voluminous tumor made by the head, and the other tumor at the oppo-
site extremity of the fetal ovoid, and which may be distinguished as the
pelvis." Upon auscultation when the head is below, contrary to that
which is usual in head-first labor, the sounds of the foetal heart are
heard most distinctly higher than the umbilicus. Combining digital
examination, after labor has begun and the membranes have ruptured,
with abdominal palpation, it has sometimes been possible to perceive
distinct fluctuation between the touching finger and the palpating hand.
By vaginal touch alone a large surface, less rounded than the normal
foetal head, is felt ; it seems like the bag of waters at first, but a more
careful examination proves that its walls are thicker and more resisting
than those of the foetal sac, and possibly the hair may be felt ; during
a uterine contraction instead of the scalp being wrinkled it remains
smooth and tense ; it may be difficult to recognize the fontanelles or
sutures, for the membranous spaces intervening between the bones are
wide, but it will be possible to touch one of the cranial bones which will
usually be found thin and quite yielding, and it is more flat and has a
greater mobility. A macerated head, when the death of the foetus has
i Poullet, op. cit. z Quoted by Poullet.
ANOMALIES OF FCETUS AND FCETAL APPENDAGES. 525
occurred some time before, may give similar increase of mobility, but
there is no increase in the size of the head ; the bones override during a
uterine contraction, the sounds of the foetal heart cannot be heard, and
the mother has not recognized foetal movements for some days.
If the diagnosis is not clear using one or more fingers in the vaginal
examination, the entire hand is to be employed.
The diagnosis of hydrocephalus in head presentation is sometimes
difficult, but the difficulty is still greater in presentation of the pelvis ;
in most cases of the latter it is not made until after the body is delivered,
and then a delay arises from the difficulty or impossibility of the head
entering the inlet. During this unexpected delay it is not unusual for
the child to die. Possibly if a finger be now introduced so as to feel
the occipital bone it will be found thinner and less resisting than nor-
mal ; by abdominal palpation it will be ascertained that the uterus is
much larger than it should be after the delivery of the body of the
foetus ; if there be difficulty in disengaging the arms, the great distance
to which the finger must be carried to effect this disengagement is a
probable indication of a hydropic head.
TREATMENT. There is but one thing essential, and that is, lessen
the size of the head. Schroder and some others have advised puncture
by a fine trocar with the forlorn hope that the child may survive,
although he stated in 1880 that he knew no instance in which such sur-
vival occurred. The advantage of perforation is that the finger can be
introduced into the opening, then curved so as to exert slight traction,
thus, in some cases, speedily effecting delivery. Some obstetricians have
recommended delivery by podalic version immediately after the evacua-
tion of the fluid, but if the uterus be retracted it may be ruptured dur-
ing the operation, and most obstetricians prefer delivery by the head ;
the extraction may be made with the forceps, if the instrument does not
slip, or if it does, with the cephalotribe; Pajot 1 suggests extraction by
taking a rod of wood two inches and a half long, to the middle of which
a cord is attached, it is passed into the cranial perforation, which should
be made through a bone and not in one of the sutures or fontanelles,
given a transverse direction, and then pulling on the cord.
Perforation is advisable, too, in most cases if the pelvis presents,
though in some the delivery may be effected by traction upon the
lower limbs conjoined with supra-pubic pressure; this traction, however,
has, in a few cases, torn the body away from the head, leaving the latter
in the uterus, and therefore the force thus exerted should never be so
great as to run this risk. Perforation has been made through the pala-
tine vault, at the occipital bone, behind the ear, or through a lateral
fontanelle.
The almost insuperable difficulty in reaching the head with an instrument led
Van Huevel to suggest an easier method of evacuating the dropsical fluid, and
it has in some cases been successfully employed. The spinal canal is opened as
near the body of the mother as possible by a transverse incision two inches long ;
then a rubber sound with a firm mandarin is easily made to pass through the
opening and up to the cranium ; upon the withdrawal of the mandarin the fluid
1 According to Poullet, this method was first suggested by Augier about the middle of the last
century.
526
THE PATHOLOGY OF LABOR.
readily escapes through the catheter, and the head lessened in size may be read-
ily withdrawn by traction on the body or lower limbs. (Fig. 201.)
FIG. 201.
EVACUATING FLUID IN HYDROCEPHALUS BY OPENING SPINAL CANAL.
FIG. 203.
FIG. 202.
MENINGOCELE.
LARGE SPINA BIFIDA.
Sir James Simpson, in the case of a woman who had in her two pregnancies
hydrocephalic children, the delivery of each being possible only by cranial per-
foration, in her third pregnancy induced premature labor, and she gave birth to
a living child.
ANOMALIES OF FCETUS AND FCETAL APPENDAGES. 527
Encephalocele and Hydromeningocele. The tumor formed by an eu-
cephalocele may be hydropic, though it is not often that the enlargement
from this cause is so great as to furnish an impediment to birth, but if
it should the treatment is puncture, but some treatment of hydromenin-
gocele may be necessary.
Increase in the Size of the Body of the Foetus. The body of the foetus
may be greatly increased in size by hydrothorax,
ascites, accumulation of urine in the bladder from
closure of the uretha, cystic degeneration of the kid-
neys, tumors of the liver and of the spleen, fcetal in-
clusion, aortic aneurism, and spina bifida.
The foetus dying and air having ready access, and
expulsion being delayed, emphysema may result from
decomposition, and the foetus be greatly swelled.
Tumors appearing more frequently at the sacrum
and coccyx than at the upper part of the trunk may
interfere with labor.
It may be stated in general that when fluid collec-
tions, either in cysts or in normal cavities, cause
dystocia, evacuation by puncture is indicated ; solid
tumors producing the same result may be lessened by
knife or scissors.
SINGLE MONSTERS. Acardia, Acephalia, Anencephalia, Hemiceplia-
lia. An acardiac monster is described by Schroder as originating from
anastomosis of the vascular systems of twins contained in the same
chorion, consequently of the same sex, the blood-pressure being greater
in one than in the other ; in the latter the circulation becomes too feeble,
as a consequence the heart, the lungs, and a greater or less part of the
trunk atrophy, and the monstrous foetus is nourished at the expense of
the one which is normally developed. The stasis thus produced in the
umbilical vein which leaves it, may have as its consequence considerable
hypertrophy and an oedematous tumefaction of the subcutaneous connec-
tive tissue. He adds that the acephalous monster is born frequently by
the feet half an hour or three to twelve hours after the well-developed
child. The hypertrophy of the trunk may render extraction necessary,
and if this hypertrophy is very great make it exceedingly difficult;
Mayer in such a case had to lessen the size of the trunk by the perfora-
tor. In hemicephalia or anencephalia there may be a large collection
of serum in the ventricles, so that there is hydrocephalus. Difficulty
in labor may come from the great development of the shoulders, espe-
cially if the head presents, for this is so small, unless enlarged as just
mentioned, the way is not opened for the descent of the trunk. Delivery
by podalic version is indicated ; if version cannot be done, the hand
may be applied to the head, or the finger introduced into the mouth, or
the blunt hook used to make traction ; if these means fail, the arms
should be brought down.
Double Monstrosities. Such monstrosities are found four times oftener
in multiparae than in primiparae, thus corresponding with the relative
frequency of labors in these two classes. In a decided majority of cases
the labor ends spontaneously, partly from the fact that frequently it is
528 THE PATHOLOGY OF LABOR.
premature, and partly because the mother in most instances has pre-
viously given birth to one or more children.
C. Veit 1 divides in three classes double monsters with reference to their ob-
stetric relations.
I. Incomplete double formation. The union of the two is very intimate :
Diprosopus, two faces (npdcuirov, the face) ; dipygus, two pelvic ends (^vyy,
rump).
Kephalothoracopagus, double face, double rump (pagus, from irfyvvpi, to
unite).
The mechanical difficulty depends upon the circumference of the double-
formed parts. Frequently the forceps, or perforation, will be necessary in dip-
rosopus.
IL Two developed foetuses are united to a great or less extent at the upper or
at the pelvic part :
Craniopagus.
Ischiopagus.
Pygopagus.
These double formations lie in a continuous line or can be so placed. The
fetuses pass through the pelvis without great difficulty.
III. Both fetuses are united together by their bodies :
Thoracopagus, dicephalus.
In these there must be more or less great mobility of each body, or of the
parts upon each other, in order that delivery can be effected.
The diagnosis of a double monstrosity will not be made until the labor be-
comes protracted, and the obstetrician, finding neither a narrow pelvis nor
hydrocephalus to explain the delay, introduces his entire hand in seeking to dis-
cover the cause.
FIG. 205.
DIPROSOPUS.
In regard to monsters results are as a rule more favorable if the lower
part or parts descend first, and therefore, should the diagnosis be made
during labor, podalic version is usually indicated. So, too, podalic ver-
sion has been successfully done after the spontaneous delivery of one of
the heads of united twins, the feet of both twins brought down, and
then the bodies, and the head that was unborn delivered.
Of course, the mother's life is of the greater importance, and there-
fore the obstetrician will have in the case of a monstrosity less hesita-
tion in resorting to mutilating operations upon it. The Caesarean
operation is never indicated for the purpose of saving the life of single
or double monstrosity.
1 Sammlung klin. Vortrage von Volkmann.
ANOMALIES OF F(ETUS AND FfETAL APPENDAGES. 529
FIG. 206. FIG. 207.
DERODYMUS.
Museum College of Physicians, Philadelphia
CEPHALO-THORACOPAGUS. Front view. (STERLEY.)
34
530
THE PATHOLOGY OF LABOR.
There are two instances of children born with three heads, and in one the
child was born alive, and continued to live three days, sucking and crying with
each of the three mouths.
Kirchhof l describes a thoracopagus found after the death of the mother, in a
tubal pregnancy.
FCETAL ANOMALIES IN PLURAL LABOR. Interference of one
fostus with the delivery of the other is a rare complication of twin
labors. Among predisposing causes Besson 2 mentions the great size of
the pelvis, the small size of the fetuses, and their occupying a single
sac ; and among the determining causes the use of ergot, untimely rup-
ture of the fretal sac, and other interferences with the natural course of
labor. This interlocking of the foetuses may occur in every one of the
different varieties of presentations observed in labor with twins. Delay
may be caused by both heads presenting at the inlet, but this must be
very rare, for Besson gives only one example. More frequently when
the heads are first, one descends into the pelvis slightly in advance of the
other, then the latter is forced down so that usually the neck of the
first child is pressed upon. In some cases the first head is delivered
FIG. 209.
o
SHOWS HEAD-LOCKING, BOTH CHILDREN PRESENTING HEAD-FIRST.
spontaneously or by forceps, and then it is impossible to effect delivery
of the trunk, or the arrest in labor may come before this. The illustra-
tion, Fig. 209 (from Barnes), shows very well this form of interlocking.
In case the first infant presents by the pelvis and the second by the
head, the body of the former is delivered, and then the labor stops from
the two heads entering the pelvis or coming to its inlet together. One
form of this difficulty is -presented in the accompanying illustration
(also from Barnes). In some cases the head of the second child is fixed
1 Cent. f. Gynakol., 1894.
2 Pystocie specielle dans les Accouchements multiples.
ANOMALIES OF FCETUS AND FCETAL APPENDAGES. 531
upon the thorax of the first. When the heads are locked together this
may not be, as in the illustration, by the chins, but by the occiputs, or
by a chin and occiput, or simply by one side of each head.
When the first child presents by the head, the second by the pelvis,
the bag of waters of the former has descended so as to interfere with
the transmission of the latter, and the labor been delayed until the
obstetrician ruptured the obstacle. Besson quotes a case of this
difficulty occurring in the practice of Mauriceau. When both
foetuses present by the pelvis, difficulties may occur from the simul-
taneous descent of the feet ; and in one case of this kind, reported by
Armand, the midwife exerted such powerful pulling that she brought
away the trunk of each child, leaving the heads in the uterus. Schultze
delivered a woman pregnant with twins, four feet and one hand present-
ing, by drawing upon the feet of the child which was lowest. Cazeaux
gives a case from Pleissman, which was probably the first example in
which difficult labor from the interlocking of foetuses was treated by
raising the woman's pelvis higher than her chest, a treatment which has
within a few years been successfully resorted to by Galbraith 1 the
principle but not the plan used.
" Pleissman states that on one occasion he found the orifice plugged up by the
parts that had become engaged, and which at first sight appeared to him to be a
quantity of hands and feet. A more careful examination enabled him to distin-
guish four inferior extremities, which were delivered as far as the ham and one
arm." " At first," he says, " I was in great perplexity because I could find no
way of introducing my hand into the womb for the purpose of distinguishing
and seizing the two feet belonging to each child, and because all my efforts to
make even one of these extremities go back again proved abortive ; besides
which, in drawing any two of them, I might confound them, and bring down
the feet of two different foetuses at the same time ; and lastly, even if I succeeded
in seizing the feet belonging to the same child, I might, by drawing upon them,
engage the other parts, and thus augment the difficulties. Being greatly embar-
rassed as to the proper course, and yet obliged to act, the employment of a meas-
ure suggested by Hippocrates, under different circumstances, happily suggested
itself; it was to suspend the patient by her feet, hoping that the heads and bodies
of the children would, by their weight, draw one or more of the extremities
toward the fundus of the womb, which was still distended by the waters. The
husband and brother-in-law of the woman passed their hands under her hams
and thus held her suspended, so that only the head and shoulders rested on the
bolster. I intended, as soon as I mounted on the bed, to press back one or more
of the free extremities into the womb, but two had already returned from the
mere position of the mother, and the other three followed by the aid of my
fingers. Immediately afterward I was enabled to introduce my hand into the
uterus, and to withdraw successively therefrom three children by the feet."
The first child may present by the head and the second be transverse.
Jacquemier has narrated the post-mortem condition found in a woman
pregnant with twins who died undelivered ; the head of the first fretus
was in the pelvic cavity, but the neck of the second was below the
shoulder of the first, and formed a half-ring about its neck. 2
The first child may present by the pelvis, and the second be trans-
verse. Here the feet and trunk of the former may pass the latter, and
then the head is arrested by the body which obstructs the inlet.
1 American Practitioner, 1880, and American Journal of Obstetrics, 1880.
2 Manuel des Accouchements, tome ii. p. 131.
532 THE PATHOLOGY OF LABOR.
The last variety given by Besson is that in which the first child is
transverse and the second presents by the pelvis. An illustrative case
is quoted from Bartscher, in which the feet of the second child were in
the vagina, but the hand introduced into the vagina proved that the
first was presenting by the shoulder and the second was upon it a cheval,
that is, a lower limb had descended upon each side of its body.
The treatment of dystocia from interlocking of twins is directed
first to saving the mother, next to saving both, and if this cannot be
done, to saving one of the twins. The first effort of the obstetrician
should be to unlock the head or other parts causing the obstruction.
This may be done in some cases by combined external and internal
manipulations. Since Galbraith's 1 success, certainly the knee-chest
position should be tried. He was called to a case of labor with twins,
first child with pelvic presentation, and delivered except the head, which
could not be extracted ; the second child with vertex presentation. He
had the patient take the knee-chest position, while he supported the life-
less body of the partly delivered child. On introducing his hand he
found the obstructing head quite movable, and readily pushed it out of
the way ; In a few minutes the head of the first child was brought
down and its delivery effected. If unlocking is impossible and it may
be, in a case in which both heads present the next step is to
apply forceps to the head of the first child and endeavor to deliver it.
Barnes advises to have an assistant during this effort apply his hand
and push away the second head, but this supposes a very capacious
pelvis and a mobile head. Tarnier advises, if delivery cannot be
effected by the forceps, and the state of the mother requires action,
especially if the child be dead, crainiotomy. Decapitation of the first
child has been practised by several obstetricians.
Eeimann in his paper, 2 " Simultaneous Entrance of Both Heads of Twins Into
the Pelvis," mentions, among the number who have performed decapitation under
these circumstances, Meigs, and Besson repeats 3 the statement. It may be a
matter of no great consequence, but Meigs 4 said expressly that he never saw a
case of the kind, afterward stating that one of his " brethren " in Philadelphia
did meet with the difficulty " a few years since," and decapitated the first child,
when the second was easily delivered.
Reimann lays down the rule that in all cases " the forceps should be
applied without delay to the second head ; every other measure is unsuit-
able and useless." This statement seem s too absolute.
Considering now those cases in which the first child presents by the
pelvis and the seccond by the head (Fig. 210), Barnes states that the
first child whose trunk is partly born encounters by far the greater
danger, and having discovered that there is but a faint or no hope of
saving it, attention should be turned to the best means of securing the
second ; the wedge may be decomposed by detaching the head of the
first, or craniotomy be done. Decapitation of the first child, too, is advo-
cated by Besson. Referring to the rule of most obstetricians to apply
the forceps to the head of the second child, a rule which in this particu-
1 Op. cit. 2 American Journal of Obstetrics, 1877.
8 Op. cit. * Op. cit., 3d edition, p. 500.
ANOMALIES OF FCETUS AND FCETAL APPENDAGES.
533
lar variety of locking of heads corresponds with that which Reimaun
lays down for all cases, he says that it is irrational. Either the first
child is living or it is dead. If it is dead, why not decapitate in order
to facilitate the passage of the second, and lessen the pressure which the
head of the other child and the soft parts of the mother are undergoing?
If it is living, which is very improbable after the trunk has escaped, is
SHOWS HEAD-LOCKING, FIRST Cnitto COMING FEET-FIRST; IMP ACTION OF HEADS
FROM WEDGING IN BRIM.
D, Apex of wedge. E C, base of wedge which cannot enter brim. A B, line of decapitation
to decompose wedge and enable head of second child to pass.
there any chance of saving it? Craniotomy upon the second infant is
to be rejected because it destroys a life which might be saved by other
means. Reimann admits decapitation of the first child if the forceps
applied to the second does not effect delivery, and if the latter shows
distinct signs of life. Now in 34 cases collected by Besson in which
the first child presented by the pelvis and the second by the head, there
were only 4 in which the former was born living, and therefore because
534 THE PATHOLOGY OF LABOR
the probabilities of saving the life of the first are so small, our efforts
should be chiefly directed to saving that of the second child, and when
the former presents an insuperable obstacle to the delivery of the latter,
it should be got out of the way as soon as possible.
Mai-presentation and Complex Presentation. The child presents
badly, that is, there is a mal-presentation, when some portion of it
descends first which offers such disproportion to the pelvic canal that
spontaneous delivery is impossible. The most frequent mal-presenta-
tions are those of the shoulder ; that is, the child, instead of being
longitudinal in the uterus, and one or the other end of the fetal ovoid
lying in the lower uterine segment, is in a position approximating a
transverse line, and hence some portion of the side of the ovoid is in
relation with the pelvic inlet ; but as, in the course of labor, one or the
other shoulder ultimately takes this position at the superior strait, the pre-
sentation is called by this name. In addition to shoulder presentations,
there may be, when the head comes first, a latero-flexion of the head
upon the trunk, and hence the side of the head or of the face for a
time present. Should this inclined lateral position of the head occur,
nature, in almost all cases, rectifies the error, and the position becomes
normal.
Dr. Hodge has narrated the case of a primipara, to whom he was called after
she had been in labor five days, first under the care of a midwife, and then
under that of physicians, and who had been given ergot freely ; he found the
superior strait " completely occupied by the head of the child, but an accurate
diagnosis could not be made, owing to bloody tumors and infiltrations in the
presenting part. The blades of the forceps were carefully passed on the sides of
the pelvis to the superior strait, and, without difficulty, a firm grasp was made
upon the child's head, which, however, was found perfectly immovable. Crani-
otomy being now determined on, the head was punctured, the forceps, which had
not been removed, were now used as compressors, their handles being approxi-
mated by means of a strong fillet ; the head yielded to this compression, and was
gradually brought down and delivered externally. It was now found that it had
been originally a presentation of the right side of the head, and that one blade
of the forceps was over the face, and the other over the occiput ; so that the long
diameter of the head had been, by means of the forceps, so diminished as to
allow the transit of the head through the outlet of the pelvis, with the face
toward one ischium and the occiput toward the opposite. The patient recovered
without any special difficulty."
The case just narrated illustrates some of the evil effects of ergot ; for, had it
not been given, the mal-presentation would almost certainly have been corrected
by nature, and the labor probably terminated spontaneously with the birth of a
living child. Nevertheless, in case the lateral inclination of the head persists,
the indication is plain, as urged by Dr. Hodge, to rectify it by manual means ;
but in some cases, version or the forceps will be indicated, with a final resort, as
in the instance given by Dr. Hodge, to craniotomy.
The management of shoulder presentations will be considered in
" Obstetric Operations."
Complex or complicated presentations are those in which two or more
unrelated parts of the foetus as, for example, the head and a foot or a
hand descend. It is convenient, also, to consider in this connection
prolapse of the cord ; that is, a presentation of the cord with presenta-
tion of some part of the foetal ovoid, for the same causes which usually
produce prolapse of members are also in general those of a similar
accident to the cord.
ANOMALIES OF FfETUS AND FCETAL APPENDAGES. 535
As an illustration of a complex presentation, the following case from La Motte
is of interest. On the 27th of October, 1711, he was called to the wife of a car-
penter at Montebourg, who had been in labor since the preceding day, and
whose child occupied such a position that the sage-femme could not explain it.
He found the woman very much exhausted, and, upon touching, he distinguished
two hands, the head, a foot, and the cord, the last being cold and without pulsa-
tion. He introduced his hand, pushing the head away, and carried it to the
fundus of the uterus, where he found the second foot, which he drew into the
passage, in order to have the two feet together ; as he drew the feet out the arm
ascended, thus leaving the passage free, and in fifteen minutes the woman was
delivered.
Frequency and Causes of Prolapse of Members. Depaul found in
16,613 labors 163 in which there was prolapse of the members alone or
with the umbilical cord ; the proportion is, then, 1 to 102. The upper
limbs more frequently prolapse than the lower. In some cases a hand
or the arm may descend by the side of the head ; in others a hand is on
each side of the head, or a hand or arm descends with the pelvis.
These complex presentations occur more frequently when the vertex or
face, rather than the pelvis, presents. In some cases a foot has de-
scended with the shoulder, but the descent of a hand or arm when the
shoulder presents does not complicate the presentation any more than
the descent of a foot complicates that of the pelvis, since in each case
the prolapsed member belongs to the part with which it descends.
Madame Lachapelle, and all authors who have written upon the subject
since, says Depaul, have admitted as predisposing or occasional causes
the small size of the foetus, the abundance of the amnial liquor, its
rapid discharge, oblique presentation of the foetus when, for example,
instead of being directed in the middle of the superior strait, it is rather
directed obliquely toward one of the sides of the circumference of the
strait and, finally, vices of conformation of the pelvis. Charpentier
gives, in addition, rupture of the membranes when the woman is stand-
ing, and unskilful or untimely attempts to perform version.
Diagnosis. We have not only to recognize the fact that the presenta-
tion is complicated, but also the cause of the complication ; in other
words, know that a member has prolapsed, and what that member is.
The diagnosis before rupture of the membranes is usually difficult, and
may be impossible. Perhaps a member may be found near the head,
and then the former may be pressed against the latter, so that an exam-
ination will determine whether it is a hand or foot. In case the head
or other presenting part of the foetus is too high for this to be done,
Depaul suggests pressing the member against the pelvic wall, and thus
fixing it momentarily for examination. Of course, the probabilities are
that a member found near the head is a hand. After the rupture of
the membranes the diagnosis is generally easy. Sometimes 2 it is a hand
that is applied upon one of the sides of the head, in front or behind,
but almost always resting upon one of the parietal bones, and in others
it descends lower than the head, and is then readily distinguished. The
forearm may be upon the side of the head, as if the child were resting
on it. If the pelvis presents, of course we know that the prolapsed
1 Observation CCXCII. a Depaul.
536
THE PATHOLOGY OF LABOR.
member must be a hand. In some cases this has descended into the
vagina, and even projects from the vulva ; then there is no difficulty in
recognizing what this member is, but there may be in deciding with
what presentation it is associated, for it is not uncommon at once to
conclude from the hand being in this position that there is a shoulder
presentation ; but to avoid error the practitioner should always follow
up the member until he reaches the presenting part. So, too, if a foot
be found in the vagina the conclusion that the pelvis presents is not a
necessary one, for the former may have descended by the side of some
FIG. 211.
HAND PROLAPSED BY THE SIDE OF THE HEAD.
other presenting part. A foot seldom descends low in the vagina, and,
being larger, delays the descent of the presenting part much more than
a hand does.
TREATMENT. In very many cases when a hand or foot is at the
side of the fetal head before the rupture of the waters it is, as it were,
pushed up by the descending head, or at least the former is crowded
out of the pelvic inlet by the entrance of the latter. Or, again, if the
prolapse be slight and space be sufficient, the head comes down, bring-
ing the prolapsed member with it. If descent of one or more members
be ascertained .before the rupture of the membranes, the patient should
lie down, and other precautions be taken to preserve them entire
until the os uteri is completely dilated. If the prolapsed member in-
ANOMALIES OF FCETUS AND FCETAL APPENDAGES.
537
terferes with the entrance of the head into the pelvis, it should be
replaced by the hand introduced into the vagina, after which it may
be advisable to use forceps, or if the contractions are vigorous it is
possible that the entrance of the head into the pelvis, when the obstruc-
tion is pushed aside, takes place readily, and its rapid descent will render
artificial delivery unnecessary. So, too, in some cases, especially in one
like La Motte's, podalic version is indicated. If reduction of a pro-
lapsed member or members fail while the patient is recumbent, an
attempt may be made when she is in the knee-chest position.
FIG. 212.
FIG. 213.
DORSAL DISPLACEMENT OF THE
ARM.
DORSAL DISPLACEMENT OF THE ARM IN FOOTLING
PRESENTATION.
DORSAL DISPLACEMENT OF THE ARM. 1 This has occurred in vertex
as well as in pelvic presentations. In the former variety Sir James
Simpson, who first described the displacement, advised bringing the arm
down, thus making a complex presentation, that of the hand and head.
The following is an extract from a lecture upon La Motte, given by me more
than three years ago, and the criticism made by this great practical obstretrician
upon Mauriceau's advice is of interest in connection with the observation of Sir
James Y. Simpson : In case the hand descended with the head, if the labor was
well advanced, and could end without help, La Motte's rule was no interference ;
1 Illustrative cases of this anomaly will be found in Dr. Alexander R. Simpson's Contributions
to Obstetrics and Gynecology. and in a paper by Dr. Freeland Harbour, Edinburgh Obstetrical
Society's Transactions, vol. xii.
538 THE PATHOLOGY OF LABOR.
he absolutely rejected any attempt to restore the arm, believing it futile and
injurious ; if necessary, he performed podalic version. He quoted Mauriceau
as stating that in a case of this kind, " I reduced the arm behind the head," and
criticised it as follows : " It is not necessary to be a good accoucheur to see that
a woman could not be delivered without the arm thus reduced being twisted and
broken," etc. Of course, the so-called dorsal displacement of the arm would
inevitably result. It is remarkable that Simpson did not mention Mauriceau's
advice, and La Motte's criticism.
Playfair thinks it better to perform podalic version, and has done it
successfully after having failed to deliver with the forceps. If the dis-
placement occurs in head-last delivery, Barnes advises rotating the child
in the opposite direction to that rotation which he believes caused the
difficulty. "By rotating the child back in the contrary direction, so as
to restore the original position, you may possibly liberate the arm. At
any rate, you will render more easy the further proceeding that may be
necessary. You carry the trunk well backward, so as to give room to
pass your forefinger in between the symphysis ptibis and the child's
shoulder ; and hooking on the elbow draw this downward, and then
forward. It may be useful, as a preliminary step, to gain room by first
liberating the other arm." 1 Barnes further states that if the arm cannot
be liberated, craniotomy may be necessary.
ANOMALIES OF THE CORD. Presentation and Prolapse. When
the cord toward the end of pregnancy is in the vicinity of the os uteri,
or descends at the beginning of labor, or only during the period of
dilatation, between the presenting part and the membranes, there is
said to be a presentation of the cord ; the term prolapse is applied to
the descent occurring after rupture of the membranes, the prolapse
being complete if the cord protrudes from, but incomplete if remaining
within, the vagina.
FREQUENCY AND CAUSES. Churchill's statistics show that prolapse
of the cord occurred in British, French, and German practice once in
23 1J cases. In the Dublin Lying-in Hospital, in 50,061 cases it hap-
pened 304 times, or 1 in 168. Charpentier gives the proportion of
1 in 227.
Naegele, in explaining the accident, attributed great importance to
the lower uterine segment not being completely occupied by the fetal
part ; if this application be perfect, the cord is retained in the womb by
the same cause which prevents the flow of all the amnial liquor and
only that which is between the head and membranes is discharged.
The accident is nearly four times more frequent in multipart than in
primiparse. Among other causes usually given are : excess of the am-
nial liquor, premature rupture of the sac, smallness of the fetus, face,
shoulder, and pelvic presentations, 2 great length and weight of the
cord, its marginal attachment, the placenta, being situated in the lower
portion of the uterus, oblique position of the uterus, pelvic deformity,
and prolapse of one of the foetal members.
DIAGNOSIS. The recognition of the cord being by the side of the
presenting part may be difficult in the early stage of dilatation when
1 Obstetric Operations.
2 Massman, quoted by Winckel, estimated the frequency, in head presentations at 1 in 150 ; in
breech presentations, 1 in 21, and in shoulder presentations, 1 in 12.
ANOMALIES OF FCETUS AND FCETAL APPENDAGES. 539
the membranes are entire; if the cord can be readily touched during
the interval of a uterine contraction, its characteristics may usually be
determined ; it has not the size, shape, or consistence of foot or hand,
and beside, it is not suddenly withdrawn as a member often is when
touched ; possibly by pressing it against a resisting part pulsation may
be recognized.
FIG. 214.
THE FUNIS PROLAPSED BY THE SIDE OF THE HEAD.
After the rupture of the membranes, if the cord has escaped from
the os uteri, diagnosis is easy, especially if the pulsations can be felt.
The absence of pulsation in the cord does not necessarily indicate'that the
foetus is dead, for it may be only temporary ; Charpentier delivered a living child
by podalic version ten minutes after no beating in the cord could be felt. On
the other hand, as observed by Naegele, very often the pressure need be for only
a few minutes to kill the foetus. It is better, in a doubtful case, to listen for the
sounds of the fcetal heart.
PROGNOSIS. The accident does not affect the mother, but is very
dangerous to the child. Engelmanu states that of 365 cases of pro-
lapse 171 of the children, 47.7 per cent., were saved ; in foot presen-
tations 71 per cent, of the children were saved ; in pelvic, 40, and in
vertex, 36.7. Hecker had a mortality of 43 per cent, in head presen-
tations, and in pelvic 17 per cent. ; including all cases the mortality
540 THE PATHOLOGY OF LABOR.
was 37.6 per cent. The statistics of Scanzoni gave a mortality of 55
per cent., and those of Churchill 53 per cent.
TREATMENT. Formerly it was thought the chief danger to the
child occurred from the cord becoming cold in case of complete pro-
lapse Velpeau, indeed, attributed the danger partly to this and hence
the advice was given to restore it to the vagina or to have it wrapped in
warm cloths. Some have held that the arteries only were compressed,
and hence the danger was from plethora, while others thought the com-
pression affected the vein exclusively, and therefore the child was auasmic.
But partial compression is rendered impossible by the arrangement of
the vessels. It is easy to understand that compression of the umbilical
cord in suppressing hamatosis causes asphyxia in the same manner as
during extra-uterine life ; suffocation, strangulation, or pulmonary em-
bolism determines death in suppressing respiration.
Recognizing the danger of death, we endeavor to avert it by prevent-
ing pressure upon the cord. If presentation of the cord be recognized
in the first stage of labor, the woman should be lying down, and great
care taken to preserve the bag of waters unruptured until this stage is
completed.
After the rupture of the membranes if the cord prolapses in front
of the child's head, and thus the life of the foetus be endangered by
pressure upon it, the advice given by Smellie still remains the best.
He said : u If the navel-string comes down by the child's head, and
the pulsation is felt in the arteries, there is a necessity for turning
without loss of time ; for, unless the head advances first and the de-
livery is quick, the circulation in the vessels will be entirely obstructed,
and the child consequently perish. If the head is low in the pelvis,
the forceps may be successfully used." 2 McClintock, in a note upon
this passage, has stated that of all modes of treatment recommended,
the most successful, as regards the child, is turning. " Thus of sixty-
four cases, in the practice of La Motte, Mauriceau, Lachapelle, Boivin,
Giffard, and McClintock, when turning was resorted to solely on
account of the funis presenting, fifty-two of the children were born
alive."
It happens in some cases that after the membranes have ruptured,
and the cord prolapses so as to be subjected to pressure, the head is
expelled so rapidly there is no necessity for applying the forceps, the
cord being compressed for so short a time that there is no risk to the
child.
Prior to the rupture of the membranes turning is not indicated if the
cord presents, for we do not know that after the discharge of the amnial
liquor it will certainly prolapse so as to suffer compression.
REPLACEMENT OF THE COED. Neither turning nor the forceps
being employed, we may endeavor to, partially at least, protect the cord
from pressure by putting it in that part of the pelvis where the most
room is found, and that will be opposite one or the other sacro-iliac
joints according to the position of the head. But it is better in most
cases to replace the cord^ and this reposition may be manual, instru-
1 Depaul. 2 Op. cit.
ANOMALIES OF FCETUS AND FCETAL APPENDAGES. 541
mental, or postural. Mauriceau directed that an effort should be made
to carry the cord by the fingers of one hand behind the head, and keep
it there until the latter had descended, so as to prevent its prolapsing
again ; he added that a compress might be placed between the head and
the uterus, to sustain the cord after it was replaced. For Mauriceau's
compress other obstetricians substituted a sponge, and still others sought
to put the cord around one of the foatal members. Dr. William Harris,
of Philadelphia, in a presentation of the breech, returned the cord over
the knee, and the child was saved. 1 Boer thought so unfavorably of
manual reposition because of the fact that generally the cord prolapsed
again and again after repeated replacement, that he compared it to the
task of the .Dana'ides. 2
In consequence of the liability to prolapse again after manual replacement,
various repositors, that are designed not only to facilitate the replacement, but
also to prevent the recurrence of the accident, have been devised. A simple and
long-known method is to attach a piece of whalebone, or an elastic bougie or
catheter, to a small bag or purse, into which the cord may be placed, and then
be restored. As soon as the head descends, the whalebone or bougie may be
safely withdrawn. 3 A repositor may be improvised of an ordinary rubber
catheter and stylet, with a piece of tape or string. A loop of the tape or string
is passed into the eye of the catheter, and the stylet then introduced so that it
holds the loop ; the cord is fastened by the free ends of the tape, and by the
catheter carried into the uterus as far as desirable, and the stylet withdrawn.
Charpentier speaks favorably of the following method used by him successfully
in one case : " The cord is encircled by a loop of silk, and the ends tied so that
the cord will be firmly held but not compressed ; the ends are now firmly
fastened around the end of an olive-shaped elastic or wax bougie ; the cord is
now carried within the uterus until the lower end of the bougie is at the os. The
bougie is left in the uterus, there is no tendency to recurrence of the prolapse,
and the instrument excites uterine contractions, and thus hastens, which is
always desirable, the termination of the labor."
Nearly two hundred years ago a famous Holland obstetrician, Deventer,
advised the position on the knees and elbows in the treatment of prolapse of the
umbilical cord : " The advantages of this position have been shown in later
years, especially by Ritgen, Kiestra, Thomas, and Theopold." 4 Winckel states
that he has never used the knee-chest position, and has never failed to replace
the cord. This position, if maintained for some time, is quite wearisome, and
certainly causes the uterine force to act at a great disadvantage. Deventer also
advised a lateral position in the treatment of prolapse of the cord ; and Galabin
states that if the patient cannot be readily induced to adopt the knee-elbow
position, the semi-prone position may be used from the first with almost as much
advantage.
Even when the pulsations in the cord are feeble and separated by
long intervals, hope of saving the child should not be abandoned ; the
less near the end of pregnancy the' longer the child survives interference
with the circulation. But when no pulsation has been discovered for
fifteen minutes, examinations being made in the intervals of contractions,
it may be concluded the fo3tus is dead, and the delivery conducted with-
out reference to its interests.
SHOETNESS OF THE CORD. Brevity of the cord may be absolute or
accidental, the latter resulting from circulars around the body, or mem-
1 Hodge, op. cit.
2 Depaul used the same apt comparison. Recently an able and distinguished writer deserts the
Dana'ides and seeks Sisyphus. No one has yet called upon Hercules, or upon Briareus.
3 Hodge. 4 Schroder.
542 THE PATHOLOGY OF LABOR.
bers. While examples of either form are rare, so rare that a few obste-
tricians have doubted the existence of this anomaly, yet instances are
not wanting to prove the fact, e. g., Rigby saw a case in which the
cord was only two inches ; Werner, less than four inches ; Malgouyre,
a little more than two inches. Of course, the site of placental attach-
ment and the place of insertion of the cord must be considered in the
question of shortness; and thus the cord must be longer to permit the
delivery of the child if the placenta is at the fundus than in the lower
portion of the womb, longer too, if the insertion of the cord be central
than if it be at the inferior margin of the placenta. Negrier states that
the genital canal at the time of foetal expulsion is 22 centimetres (8.69
inches) and, therefore, Lamare asserts that the cord becomes too short
if less than 25 centimetres (9.87 inches).
The diagnosis of brevity of the cord is from lingering labor, not
otherwise explained, slight flow of blood immediately after a contraction,
depression of the uterus at the place of placental attachment during a
contraction, and great recession of the presenting part when the con-
traction ceases. King, who has given much study to the subject and
written several valuable articles upon it, regards as an important sign
the strong desire of the patient to sit up, and " the judicious Denman "
advised, if labor was delayed from this cause, that the patient should
stand or kneel by the side of the bed, or sit upon the lap of one of her
assistants.
The dangers from shortness of the cord are, delayed labor, rupture of
the cord, premature detachment of the placenta, and inversion of the
uterus. ,
Delivery by expression is regarded as preferable to extraction with
the forceps, and, after the child is partially born, should delay result
from a tense cord then only can a certain diagnosis be made this is
to be cut.
ABNORMAL, RESISTANCE OF THE BAG OF WATERS. As very thin
membranes have as their consequence premature rupture of the bag of
waters, so if these membranes are very thick and resisting rupture may
be delayed, and partial placental detachment occur, especially if the
quantity of amnial liquor is small. The remedy for this condition, of
course, is artificial rupture.
CHAPTER IX.
INJURIES OF THE MATERNAL SOFT PARTS.
INJURIES OF THE VULVA. Tears involving the nyrnphse some-
times occur in natural as well as in instrumental labor ; one of these
organs may be divided longitudinally, or partially detached from its
base. There may be a tear involving the inferior margin of the vesti-
bule, and it may extend upward to the side of the clitoris, possibly
involving the corpus cavernosum, or it may be prolonged inward by
the side of the urethra. In some instances, especially if the corpus
cavernosum be injured, the bleeding is great; indeed, cases of fatal
hemorrhage from such injuries of the vestibule have been reported. 1
If hemorrhage is observed following the birth of the child's head, the
body being undelivered, it must necessarily come from an injury of the
vulva.
Arrest of hemorrhage can generally be accomplished by compression,
but it would be better, should a serious tear be found, to use catgut
stitches ; so, too, such stitches may be used in tears of the nymphse for
the purpose of preventing deformity of the part ; moreover, the more
completely closed these wounds are the greater the protection of the
patient from infection, for if an injury be external or near the exterior,
there is more danger of the absorption of poison than if it be high up
in the vagina or of the uterus.
In addition to the stitching, the injured parts may be freely dusted
with iodoform ; so, too, in cases in which sutures are not used, a similar
application should be made.
TEARS OF THE PERINEUM. According to Olshausen, unavoidable
tears of the perineum occur in at least 15 per cent, of primiparse.
Wiuckel confirms this statement. The former regards tears ot the
perineum in multipart as generally preventable.
Rents of the perineum usually begin at its anterior margin in the
median line, and are divided into partial and complete ; by the latter is
meant a tear which extends through the anal sphincter. In some cases,
however, the tear begins in the 1 vagina on one side of the posterior
column, and thence passes obliquely to the median line and ends in a
tear of the perineum. A superficial rent involves only the skin and
subcutaneous fascia. A rent beginning with the expulsion of the head
may be increased by the shoulders.
The accident is more liable to occur in old primipane. The perineum
has sometimes been torn by the introduction of the hand to perform
podalic version. To the forceps must be attributed a large number of
1 Young : Transactions of the Edinburgh Obstetrical Society, vol. viii. , gives two cases of tears
of the vestibule followed by serious hemorrhage seen by him ; one of the patients died from the
bleeding.
544 THE PATHOLOGY OF LABOR.
complete ruptures of the perineum. Thus Leopold and Wehle 1 state
that in 105 cases of this injury the forceps had been used in 70.
The majority of obstetric authorities hold that, as a rule, a torn peri-
neum should be stitched as soon as practicable after the injury, or, at
least, that the operation be not delayed longer than sixteen hours.
When performed immediately it arrests hemorrhage, which, in some
cases, is considerable; in all cases an early operation lessens the danger
of septic infection taking place through the raw surfaces ; and though
an incomplete rent that seems great at first become comparatively small
in the course of three days, yet spontaneous restoration is not the rule,
while restoration is, after perineorrhaphy, and, therefore, this ought to
be done unless there are some strong contra-iudications.
The stitches can be introduced most conveniently with the patient lying
upon her back, and her hips near the edge of the bed. A hot antiseptic
vaginal injection is first used, the parts being thus thoroughly cleansed
and oozing of blood lessened ; an antiseptic tampon of gauze or of cotton
is placed in the vagina to prevent uterine discharge from obscuring the
field of operation. Supposing the rent to be incomplete, the obstetrician,
after threading his needle, which may be curved or straight according
to his preference, with silkworm-gut other material may be used, silk,
wire, horsehair, if the first-mentioned be not at hand introduces one
or two fingers of the left hand into the rectum ; then with the right
hand enters the point of the needle half an inch from the margin of the
tear at the lowest part of the latter, on the one side, and carries it across,
buried beneath the tissues, unless the tear be complete, in all its course,
until it emerges at a corresponding point upon the opposite side ; in
case the tear be complete, the needle will be entered into the tissues a
little below the anal rent so as to secure the torn fibers of the sphincter
and, carried across, appears in the median line, as does the following
suture, and then passes out on the opposite side at a similar point to
that in which it was introduced. After placing the first suture, the
second and then the third are introduced rarely will a larger number
be necessary ; in some cases only one is required. The sutures are then
tied, or, if of wire, twisted. Of course, instruments, sutures, and the
hands of the operator are properly antisepticized ; the silkworm-gut is
rendered more pliable by being first soaked for a few minutes in very
hot water. In some cases it is necessary before stitching to cut away
loose shreds of tissue. If the tear extends up the recto- vaginal wall,
internal stitching will be required before employing the external sutures,
the material for the former being catgut, and a curved needle being used
for the suture, which, as a rule, should be continuous ; so, too, let similar
suturing of the vaginal surface be made. Finally, the perineal stitches
are placed.
AFTER-TREATMENT. By some it is hel$ important to tie the knees
together, to use the catheter at regular intervals, and to keep the bowels
confined for a week or more. By no probable movement of the limbs
can there be any strain upon the perineal tissues now sewed together
tissues that have undergone the very great stretching in labor and,
therefore, the bandaging of the knees is unnecessary ; moreover, the
1 GeburtsMlfe und Gynakologie, Band ii. , 1895.
INJURIES OF THE MATERNAL SOFT PARTS. 545
bandage increases the discomfort of the patient and helps to imprison the
lochial discharge in the vagina, and is thus an injury. Hildebrandt
objects to the use of the catheter because vesical catarrh is very liable to
result, and thinks it better for the urine to be discharged spontaneously,
if possible. Once in twenty-four hours the vagina should be carefully
washed out with a warm antiseptic injection. On the third or fourth
day the bowels may be moved by castor oil or by compound licorice
powder, assisted by an enema of warm water or an infusion of flax-
seed ; subsequently evacuation should be had at least once in forty-eight
hours. The diet need not vary from that usually given after labor.
The common practice is to remove the sutures in from eight to ten
days.
CENTRAL RUPTURE OF PERINEUM/ Central rupture of the peri-
neum has occasionally occurred, and the head and then the body of the
child have passed through this opening, the anterior and posterior portion
of the perineum being uninjured; in other instances the rent has been
caused by the foot or elbow of the child.
Duncan 2 asserts that the passage of the child through such a rent rarely hap-
pens that this is probably sometimes believed in after the event, but is not care-
fully observed during the process. Reeve 3 has reported a case of central rupture
of the perineum, without implication of the vulva, occurring in a multipara.
" The rent began on the right side, near the junction of the upper fourth with
the lower three-fourths of the labiuin, followed the outer boundary of the labium
downward, and crossed the perineum to the rectum ; both the anal sphincters
were divided, the laceration extending upward quite an inch and a half. The
part of the perineum remaining intact at the posterior commissure and along the
lower part of the right labium was about -the thickness of a man's thumb."
Duncan 4 has called attention to the fact that central perineal rupture may in-
volve only the skin, or the mucous membrane of the vagina, or both of these
with their subjacent tissues, while there remains entire some tissue intervening
between the skin and the vagina.
Obstetricians agree that if the beginning of a central rupture is
observed, the tissues between the tear and the vulvar orifice should be
at once divided, thus preventing the extension of the rent into the rec-
tum ; but if the injury is not discovered until after delivery, then
division of the anterior bridge is not advisable ; the tear is to be stitched
by interrupted sutures, preferably of silkworm-gut.
INJURIES OF THE VAGINA. It is proposed under this head to con-
sider not only lacerations, but also contused and perforating wounds of
the vagina received in labor.
It is convenient to divide these jnjuries into those of the upper, of the
middle, and of the lower part of the vagina. Vaginal tears are fre-
quently associated with corresponding injuries of the uterus. Never-
theless, McClintock, 5 from the statistics of the Rotunda Lying-in
Hospital, found 35 of 108 which involved the vagina only, or merely
1 In the following passage, narrating the labor of Tamar giving birth to twins, we have,
according to Luther and some other commentators, medical as well as theological, an instance or
central rupture of the perineum : " And it came to pass, when she travailed, that the one put out
his hand ; and the midwife took and bound upon his hand a scarlet thread, saying, this came out
first. And it came to pass, as he drew back his hand, that, behold, his brother came out ; and she
said, How hast thou broken forth? the breech be upon thee; therefore, his name was called
Pharez." (Pharez, it may be added, means breech.) Genesis xxxix. : 28-29.
'- Transactions of the American Gynecological Association, vol. i. 3 Ibid, vol. lii.
4 Op. cit. Dublin Journal of Medical Science, May, 1866.
35
546 THE PATHOLOGY OF LABOR.
the os uteri with it ; it is thus seen that the cases of vaginal injury
alone are nearly one-third of the entire number.
Spontaneous tears of the vaginal vault are more frequently transverse than longi-
tudinal, while those in the middle portion of the vagina are generally longitudinal.
In some instances the vagina has been, by a circular rent, partially or even
completely separated from the uterus. Johnson and Sinclair 1 give the case of a
patient in whom a fatal injury of this kind occurred ; the woman was a multipara,
but delivery being impossible because of cicatrices in the lower part of the
vagina, even after division of the cicatricial tissue was made with a bistoury,
craniotomy was performed ; death occurred the next day. An instance of per-
foration of the posterior cul-de-sac by a vaginal douche, used to induce labor at
the eighth month of pregnancy because of pelvic deformity, is given by Budin. 2
So, too, the vaginal vault has been torn by the badly directed blade of forceps
or cephalotribe. Both spontaneous and artificial rents of the upper posterior
portion of the vagina are especially liable to occur in case there be a pendulous
abdomen permitting anterior displacement of the uterus, for by this displacement
the tissues are stretched and thinned. Hart 3 has shown that the posterior
vaginal wall is structurally weak at its upper half-inch, while it is more elongated
than the anterior wall in labor. Rupture is most common where the posterior
vaginal wall is covered by peritoneum, and when it occurs is a tension tear like
cervical rupture. Instances of injury to the vagina anteriorly and posteriorly
have occurred from the use of the perforator ; in one case 4 the practitioner,
wishing to open the child's head, made a rent in the bladder, permitting the
introduction of three fingers, and in another case 5 the obstetrician, attempting
the same operation, thrust his instrument through the tissues, aud applied it to
the sacral promontory, mistaking it for the foetal head. Kupture of the vaginal
vault has oeen caused by forcible introduction of the hand into the uterus for
the purpose of performing version. 6
Prolapse of the intestine through the rent has been observed in several cases.
Danyau* in 1850 collected 17 cases of rupture of the vagina in which the fcetus
passed into the abdominal cavity ; 4 of these patients recovered. Others, too,
nave recovered, though the injury permitted prolapse of the intestine. Moysant
has reported a case in which a woman being in labor the forceps was vainly
applied, and then delivery by podalic version tried ; the trunk was extracted,
but the head left behind ; the woman died in a few hours, and at the post-mortem
the foetal head was found in the left side of the abdominal cavity, having entered
through a rent which extended from the uterine junction to the vulva.
Schroder refers to a peculiar case recently reported by Battlehner, of rupture
of the anterior vaginal vault with prolapse of the bladder into the vagina.
McClintock 8 gives as the causes of spontaneous rupture of the vagina in the
cases which he collected 1, diseases of the vagina ; 2, disproportion between
the size of the foetal head and the maternal pelvis ; and 3, osseous irregularity
upon the inner surface of the pelvis. While, according to the same authority,
the recoveries after uterine rupture are only 4| per cent.; they are after similar
injury to the vagina 12 per cent.
The symptoms that have been most frequently observed in ruptures
of the vagina are cessation of labor-pains, hemorrhage, recession of the
presenting part, which, however, is slight unless the ftetus enters the
abdominal cavity ; prolapse of intestine or of omentum is a not infre-
quent complication. Shock, too, has been observed in many cases.
TREATMENT. The treatment is essentially that required in a similar
injury to the uterus. Prompt delivery is indicated, and usually this
i Midwifery.
3 Des Lesions traumatlques chez la Femme dans les Accouchements artiflciels. Par Pierre
Budin. Paris, 1878.
3 Edinburgh Obstetrical Society's Transactions, vol. viii.
* Provincial Medical Journal, 1843. . 5 Budin, op. cit.
Spiegelberg, op. cit. 7 Bulletins de la SocifitS anatomique, 1857.
s Archiv. Med.
INJURIES OF THE MATERNAL SOFT PARTS. 547
will be made through the vagina ; arrest of bleeding will be accom-
plished by hot- water injections, by sutures, and in only exceptional cases
need a tampon, of iodoform or creolin gauze for example, be em-
ployed ; a lateral rent or one involving the peritoneum usually re-
quires a drainage-tube.
RENTS OF THE MIDDLE PORTION OF THE VAGINA. These are
generally superficial ; they may be caused by careless use of the perfo-
rator or of the crochet, or the vagina may be torn by sharp fragments of
bones of the foetal head in extraction after craniotomy. Injury may be
done in the introduction of the blade of the forceps, this being forced
instead of caused gently to " feel " its way to the desired point ; so, too,
a tear may be made in the extraction, especially in case the blades are not
accurately applied to the side of the child's head and kept in such close
relation, for the foetal head ought to be a protection to the vagina from
injury by the borders or by the ends of the forceps blades. Deep tears
of the middle portion of the vagina may occur if there be structural
change in its tissue, whether from malignant disease or from cicatricial
contraction. Contused wounds of the vagina most frequently result
from prolonged impaction of the head in the pelvic cavity and as a
consequence subsequent sloughing occurs which, if involving the an-
terior wall of the vagina, may result in a vesico-vaginal fistula, or if
the posterior, a recto- vaginal fistula.
TREATMENT. It rarely happens that bleeding from wounds of the
middle portion of the vagina is considerable, and its treatment does not
differ from that required in similar injury of the upper portion. The
most important part of the treatment of the colpitis resulting from the
injury will be the use of warm antiseptic injections 1 part of corrosive
sublimate to 5000 of water, for example, or a 2 per cent, creolin mix-
ture and following the injection by introducing an iodoform supposi-
tory ; if a contused wound involving the anterior wall be present, great
care must be taken to prevent distention of the bladder ; after slough-
ing of any part of the vaginal walls, means must be used during the
healing to prevent contractions, metal, glass, or hard-rubber dilators
being introduced from time to time.
As showing the greater liability to injuries of the vagina in birth in
case the child be male, the fact stated by Spiegelberg is significant : that
in 12 cases of vesico-vaginal fistula at his clinic and polyclinic, in the
labors from which they resulted all the children were boys.
TEARS OF THE LOWER PORTION OF THE VAGINA. Though these
are in most cases associated with corresponding injuries to the perineum
or vulva, yet some are not, and therefore should be considered sepa-
rately. So far as spontaneous injuries of this class are concerned, their
most frequent cause is excessive stretching of the vagina; they are
usually superficial and situated at or near the median line ; in some
cases, however, they may have a diagonal course, or two diagonal tears
may be united with a median tear, having approximately the form
of a Y.
Contused wounds resulting from prolonged pressure by the presenting part
are also found here, and they may be followed by sloughing, which may end in
rectal or in perineal perforation. Improper use of the forceps is to be credited
548 THE PATHOLOGY OF LABOR.
with many injuries to the lower part of the vagina ; these injuries may result
from too rapid extraction, but probably their most frequent cause is turning the
handles of the forceps too soon toward the abdomen of the mother, and thus the
points of the blades are withdrawn from the child's head and brought directly
against the posterior wall of the vagina, making more or less deep furrows in its
tissues ; a similar accident has occurred from the attempt to withdraw the blades
just before the expulsion of the head, a violent pain suddenly expelling the
head, while the obstetrician, busy with the manoauvre mentioned, was powerless
to prevent the rapid delivery. Dupuy 1 mentions a case in which, the feet pre-
senting, one of these escaped by the vulval opening, while the other, pressing
strongly upon the vagina posteriorly, was forced through the perineum. I have
seen a somewhat similar case, only the foot inflicting the injury made a rent at
the lower portion of the recto-vaginal wall and protruded through the anus,
there being also a slight tear in the posterior perineum. Dr. Barker 2 has pub-
lished a case he was called to in which he found the perineum " enormously dis-
tended by the pressure of the head, and the left hand and forearm projecting
through the anus." He did not attempt to restore the member, but delivered
with the forceps. The patient's bowels were kept confined by opium for ten
days, and complete cicatrization followed.
TREATMENT. Bleeding from uncomplicated lacerations of the lower
part of the vagina is usually only slight, and therefore can only excep-
tionally require means for its arrest. While, too, in most cases these
tears are only superficial, and therefore require no treatment other than
cleanliness and the use of antiseptics, in others their extent is such that
not only to protect from septic infection and to secure their rapid heal-
ing, but also to guard against possibly permanent injury to the pelvic
floor, sutures are plainly indicated. Properly prepared catgut is the
best material for stitching the surfaces together, and the continuous
suture is employed.
THROMBUS OR H^EMATOMA OF THE VULVA OR OF THE VAGINA.
In addition to the injuries that have been mentioned, there may be tear-
ing of the vessels of the connective tissue of the vulva or of the vagina
without external opening, and the effused blood forms a mass known
as labial, or vulval, or vaginal thrombus or haematoma. This is not a
frequent accident. Deneux, 3 in a practice of more than forty years,
saw but three cases, and Dnbois a like number in 14,000 deliveries.
Winckel gives the proportion as 1 in 1600. It is at least relatively
more frequent in primiparse than in multipart. Varicose veins are not
a predisposing cause; Perrot's statistics, including forty-three cases,
show that this condition was present in only two ; Barker states that in
a very large proportion no such condition preceded the thrombus.
Among the causes of haBmatoma mental emotion, violent vomiting, and cough-
ing have been given. But laying aside this doubtful etiology, we may say with
Hervieux that the determining cause of this affection in labor is the prolonged
stay of the head in the pelvic cavity, the delay arising from narrow pelvis, from
resistance of the perineum, from size of the foetus, etc., and hence excessive
efforts on the part of the patient to overcome the obstacle to delivery. Perrot
has shown that there may be a gliding of the vaginal walls upon the peripheral
tissues, so that a partial detachment occurs from tearing of portions of the con-
nective tissue, and thus spaces are formed in which blood poured out by the
ruptured vessels collects. Or it may be that the walls of vessels are thinned by
the great pressure from the foetus, and when that pressure ceases, a new wave of
1 Considerations relatives aux DSchirures du Vagin a, la Suite de 1' Accouchement. Paris, 1822.
* The Puerperal Diseases, p. 42. 8 Maladies Puerp6rales, Hervieux.
INJURIES OF THE MATERNAL SOFT PARTS. 549
blood distending them, they give way. According to some authorities, the vessels
that rupture are venous, but Winckel says there is no question that the wound
of an artery, as well as of a vein, may give rise to a hsenmtoma, even though the
effusion is most commonly of venous origin. In 35 out of 43 cases collected by
Perrot the hemorrhage did not occur until after labor. Dewees 1 has given an
instance in which the tumor formed ten minutes after the birth of the first of
twins, and was ruptured by the descent of the second child, the patient recover-
ing. Madame Sasanoff, in connection with a case under her care in the Mater-
nity of Kolonna, St. Petersburg, has reported five others 2 that of Dr. Dewees
not being included as the only ones she could find published in which the
hsematoma formed in the interval between the birth of twins. Of these five,
four were fatal. She believes the rule of practice ought to be that, when there
exists the least appearance of the formation of a thrombus, the delivery should
be hastened, and that to this end version and extraction of the second child
should receive a large application, so much the more as the escape of the first
child favorably affects the dilatation of the orifice, and facilitates the intro-
duction of the forceps or the hand into the genital canal. If the delivery be
delayed, the haematoma rapidly increases in size, and rupture or incision maybe
necessary for the passage of the child, and such early rupture or incision makes
the prognosis quite unfavorable.
The tumor varying in size from a hen's egg to a child's head 3 usually
appears a short time after labor, but exceptionally several days may
intervene. Schroder refers to a case reported by Heifer in which it was
first seen on the twenty-first day ; in such instances the exciting cause
was violent bodily exertion.
Hsematoma of the vulva is more frequent than of the vagina. The labia
majora are oftener affected than the labia minora. The effusion may extend to
the connective tissue, making a vulvo-perineal thrombus : "The blood is gener-
ally extravasated into the subcutaneous cellular tissue in the perineum between
the superficial and median fascia, in the vagina into the submucous tissue, or
into the cellular tissue encompassing the vagina; yet there are cases (Cazeaux
and Hugenberger) in which it has extended along the vagina up to the perito-
neal cellular tissue, and posterior to the peritoneum up to the kidneys, anteriorly
in front of the peritoneum up to the navel, and on the sides as far as the sacrum." 4
The tumor is in the majority of cases unilateral ; and its formation
is usually preceded by severe pain ; the surface is smooth, discolored,
livid or violet, and it presents to the touch more or less elasticity with
or without fluctuation. If the hemorrhage be great, the symptoms of
acute anaemia are present ; but death does not follow unless the hasma-
toma ruptures, and then it may be very rapid. Recovery generally
takes place. Thus Winckel found only six that were fatal in fifty;
Barker met with two deaths, both from puerperal fever, in thirteen hos-
pital cases, while of nine in consultation and in private practice all
recovered. The prognosis will be* governed by the size of the thrombus,
and by whether it occurs before or after delivery : the larger the tumor,
of course the greater the danger; and, on the other hand, the case is
more favorable if the formation occurs after the labor than during it.
The termination may be by resolution, and this may happen even if
the tumor be as large as the fist, by suppuration, by rupture, or by
gangrene.
1 Diseases of Females: Of Bloody Infiltration in the Labia Pudendi
2 Annales de Gynecologic December, 1884.
3 An instance in which the tumor was the size of a,child's head, and interfered with the delivery
of the placenta, is given in the Centralblatt f. Gynakol., 1889, p. 526.
4 Winckel, op. cit.
550 THE PA THOL OG Y OF LABOR.
TREATMENT. During the formation of a hsematorua we endeavor to
lessen the effusion of blood by the application of an ice-bag and by com-
pression. If rupture occurs, an astringent tampon must be applied and
pressure also used. If a hsematoma appears during labor, and presents
an obstacle to the deli very of the child, even by forceps, though such con-
dition is quite exceptional, " incise at once, remove all the clots that have
formed, and then deliver by the forceps," and afterward compresses of
cotton batting saturated with the solution of persulphate of iron are to be
used and pressure made, constitute the directions of Barker. After labor,
incision may be rendered necessary by threatened gangrene ; but it is
always better if this can be delayed for three or four days after the
development of the hsematoma, for, as observed by Schroder, the longer
we can wait the less danger from consecutive hemorrhage ; nevertheless,
Chaussier mentions a case in which the incision was not made for a
week, yet hemorrhage occurred, and Baudelocque one in which the open-
ing was not made until three weeks after the tumor was formed, and the
following hemorrhage was so great as to require the tampon.
TEARS OF THE CERVIX. Lateral tears of the cervix almost inva-
riably occur in a first labor, that upon the left side being usually deeper
than the corresponding one upon the right. In some cases the tear
extends to the vaginal vault, more rarely above it so that the connective
tissue is involved, and still more rarely the injury may reach to the
peritoneum. In the multipara some tearing also may occur, but usually
the rents are not so deep, and less frequently lateral. The injuries
referred to occur not only in spontaneous, but also in artificial delivery,
both manual and instrumental ; the application of the forceps and ex-
traction of the foetus before complete dilatation of the os has occurred,
as well as rude and hurried dilatation of the os by the hand or rapidly
drawing out the child after podalic version, is very liable to cause this
accident ; when the placenta is prsevia, severe and even fatal laceration
of the cervix, the tear extending upward to the body of the uterus and
downward into the vagina, has been known to result from too rapid
dilatation of the os and too hasty extraction of the child.
Lacerations of the vaginal cervix are physiological in the great majority of
cases, neither immediately nor remotely demanding professional interference ;
so far as ulterior consequences are concerned, probably an exaggerated 1 impor-
tance has been attached to these injuries of the cervix, more especially in this
country, since Emmet has devised the operation known by his name, an opera-
tion very beneficial in suitable cases, but often done, as Emmet himself has
pointed out, unnecessarily.
In exceptional cases serious hemorrhage comes from the rent in the
cervix, and immediate arrest of the bleeding is demanded. This may
lie accomplished by copious injections of hot water, by the pressure of
properly applied iodoform gauze, but the surest means is the suture ;
for its application the cervix must be seized with suitable forceps, and
1 Some years ago the late Dr. Holmes pleasantly remarked that Mr. Huxley had given bioplasm
about all it could bear. I am quite sare that some practitioners have given a lacerated cervix a
good deal more than it can bear. The assumption that healed and innocent physiological tears of
the cervix require a plastic operation by which the os and cervix of the woman who has borne a
child shaJ be restored to their condition prior to childbirth, Is an error from which originates a
great deal of mere carpenter work of no profit whatever except to the operator.
INJURIES OF THE .MATERNAL SOFT PARTS.
drawn down to the vulva, when the stitches can be readily introduced
with the injured part thus exposed ; silkworm-gut is the best material
for stitches.
Transverse tears of the cervix are comparatively rare. They usually involve
only the anterior lip, and then result from its being forcibly held by the descend-
ing head against the anterior wall of the pelvis. Schroder refers to the accident
as more frequent if there is induration of the cervical tissue; he also mentions a
case of Martin's in which there was found a polypoid body formed by the par-
tially detached lip of the uterus.
ANNULAR LACERATION OF THE CERVIX.
A few cases of what has been termed annular separation of the cervix have
been recorded. This accident results from an unyielding cervix and strong
uterine contractions Barnes 1 refers to a case reported by Gervis in which ring-
form detachment was not complete. It was replaced without sutures, as the
patient was very prostrate. She recovered, and the ring reunited. Duparcque 2
mentions meeting with a case in which the entire anterior lip was detached, so
that at first it seemed as if there were a double os uteri.
RUPTURES OF THE UTERUS. Rupture of the uterus is one of the
gravest accidents that can occur to the pregnant or parturient woman,
for her child almost without exception perishes, and her own life is lost
in the great majority of cases.
FREQUENCY OF RUPTURE. This is variously stated by different
authors :
Collins found
McClintock .
Bandl .
Jolly .
Ramsbotham
Von Franque
1 rupture in 482 labors.
737
1183
3403
4429
3225
Winckel saw rupture of the uterus during five years in the Munich
clinic in 6 cases out of 4000 labors.
In some instances the rupture is what has been termed "silent," as will be
explained hereafter, and the woman perishes of hemorrhage, or of septic infec-
1 Obstetric Medicine and Surgery. A similar case will be found in the Transactions of the
Philadelphia Pathological Society, vol. i., reported by Dr. Keller.
2 Histoire complete des Ruptures et des Dechirures de FIT terns, etc.
552
THE PATHOLOGY OF LABOR.
tion, and only by accident, if an autopsy is made, is the injury known ; in the
absence of such autopsy death is attributed to one or the other cause mentioned,
the true condition being unknown. Hence it is probable the accident occurs
oftener than statistics lead us to believe.
RUPTURE IN PREGNANCY. This may be spontaneous or result
from external violence. The cicatrix remaining after the Csesareau
operation may give way, or the thinned wall of a rudimentary horn
yield to the pressure of the growing ovum, or a blow upon the abdo-
men, or a fall, causes a tear in the normal uterus.
Spontaneous rupture in pregnancy has followed dancing, vomiting,
lifting a heavy weight, and great fatigue. Barnes, op. cit., gives illus-
trative cases.
FIG. 216.
TRANSVERSE OR SEMI-CIRCULAR GRINDING THROUGH OF THE UTERUS. (From BARNES.)
RUPTURE DURING LABOR; ITS CAUSES. In considering the etiology
of this accident, it is convenient to refer first to the rarer cases of this
accident. Rupture may be consequent upon attrition, the uterine tissue,
usually cervical, being forced against abnormal bony projections from
some portion of the pelvic inlet, exostoses of pelvic bones ; and thus
usur, a wearing away of those tissues, results. Naegele states that
Kilian has drawn especial attention to a deformity of the ilio-pectineal
eminence in which this, instead of presenting its normal oval shape, has
a spine-like process ; similar sharp projections may occupy other parts
of the pelvis; to the basin thus deformed the name of Slachelbecken,
pelvis spinosa, was given ; and Kilian showed the injurious effect in
INJURIES OF THE MATERNAL SOFT PARTS. 553
labor resulting from this cause. Depaul has stated that four out of
twenty-four deformed pelves in his collection have exaggerated develop-
ments of particular parts, forming knife-like projections ; according to
his observation, this deformity was most frequent at the pubic crest.
The following remarkable case is quoted by Duparcque : l A woman
had been in labor twelve hours, the presentation being pelvic. The os
uteri was not yet completely dilated when all the anterior part of the
neck, from one side to the other, separated. Immediately the foetus
passed into the abdominal cavity, and it was extracted with great diffi-
culty in less than two hours; it was dead. The mother died five hours
after being delivered. The basin was found a little narrow ; the point
of the sacrum had passed through the posterior part of the uterus (was
this the sacro-vertebral angle?); the internal and salient border of the
pubis and of the iliac bones resembled somewhat the edge of a paper-
cutter, and had cut all the thickness of the uterus as if it had been
divided by a ligature. Breus 2 has published a case of injury done to
the uterus by its tissues being worn through in consequence of the pres-
sure of the head of the child forcing these tissues against the sharp pro-
montory of a rhachitic pelvis.
Not only may pelvic deformity cause such attrition, but I believe that it may
also result from an irregular bony surface of the foetal body being forced against
the uterine walls, hour after hour, by uterine contractions ; such a surface is
presented by the jagged margin of the imperfect arches of a spina bifida after
rupture of the sac has occurred. This belief depends upon my having several
years ago, in a judicial investigation, a midwife having been arrested for mal-
practice, examined the foetus and the ruptured uterus of the dead mother. The
rupture involved the cervix and the lower third of the body of the womb upon
the right side ; in the labor the pelvis presented with the sacrum to the right,
and the most rational explanation of the accident was, to my mind, that which
has been stated.
In rare cases no cause can be assigned for the accident. Thus
Winckel remarks that the cases of Alexander Simpson and of Hof-
meier are very remarkable and difficult to explain. "In Simpson's
case the laceration extended from the fundus uteri to the os on the left
side ; in Hofmeier's the laceration was of the same length, but on the
right side ; both occurred in pluriparae and the pains were not very
strong ; the former showed an abnormal fatty condition of the uterine
muscular structure, which was absent in the latter. The most remark-
able case of spontaneous rupture of an otherwise normal uterus is, how-
ever, the one which Ingersley observed in a 32-year-old VH-para in
the eighth month of pregnancy, in whom a rupture from the fundus to
within one-half inch of the internal os occurred without any external
violence ; the child escaped into the peritoneal cavity and the woman
died in two hours."
Passing from these rare and exceptional cases, we have now to con-
sider the causes of the accident as it most frequently occurs. So far as
immediate causation is concerned, it may be stated that rupture of the
uterus is spontaneous or from violence, and this violence may be done
by the instrument or by the hand of the obstretriciau. Duparcque, in
1 Op. cit. 2 Ueber perforirende Usur des Uterus, Wien. med. Blatter.
554 THE PATHOLOGY OF LABOR.
his well-known work, gives as his first conclusion that ruptures of the
uterus in labor are caused by the contractions of the organ. Trask, in
his, at the time of publication, exhaustive study 1 of the accident, said :
"Unless caused by direct violence, rupture must, in almost every case,
be the result of the contraction of the uterine fibres, whether the uterus
be healthy or diseased." Tyler Smith expressed the following opinion :
" Undoubtedly cases of rupture of the uterus do occur which are de-
pendent upon inflammatory action, either during or before labor, or
upon malignant diseases of the uterus ; but such cases are rare com-
pared with rupture from self-contraction of the uterus." Jolly stated
that the true cause is more or less violent uterine contraction. But con-
tractions of the uterus, though violent, could not rupture the uterus if
normal conditions are present, and therefore behind this cause there
must be others that predispose or otherwise contribute to the result, and
to these our attention will now be directed.
The accident occurs more frequently in multiparse 2 than in primi-
parse, the latter furnishing only 12 per cent, of the entire number. The
influence of multiparity is explained by Charpentier as causing thinness
of the wall of the uterus and changes in its tissue, with enfeebling of
power. Klein wachter and others, however, believe that healthy uteri
rupture more frequently, for they only contract powerfully. Scanzoni
suggests the greater frequency of shoulder presentations ; to this may
be added the greater size of the children. The accident is more fre-
quent in the births of male than of female children of 67 children,
48 were male, only 19 female. They are more frequent, according to
Baudl, among the poor than among the rich.
It is probable that the untimely administration of ergot, or using it in too
large doses, must be considered the chief factor in causing rupture of the uterus
in some cases. The late Dr. Hugh L. Hodge stated that he had never met with
this or seen a case of rupture, with perhaps one exception, in which ergot had
not been given. Dr. Meigs has referred to three, and Dr. Bedford to four cases,
in which it was believed that ergot was the cause. Similar instances are given
by Marot, and it would be easy to increase the list to large proportions, especi-
ally if cases were collected from the practice of midwives in this country, who,
usually attending cases of labor for low fees, too often endeavor to hurry the
labor by giving ergot in the first stage.
The injurious effect of ergot given with a free hand in the first stage of labor
can be readily understood when we remember that for the occurrence of spon-
taneous rupture of the uterus the chief immediate factors are active contraction
in the effort to overcome great or insuperable resistance. The undilated or par-
tially dilated os is a barrier to the passage of the foetus ; if time be given, the
tissues being healthy, gradually yield and perfect dilatation results ; but if the
uterus is stimulated to excessive activity the resisting os prevents escape of the
presenting part, and the force prematurely or unduly evoked is expended upon
the thinned lower segment of the uterus, and rupture follows.
In some cases of pathological change in the cervix, as from malig-
nant disease, rupture follows the vain effort to overcome the resistance.
1 American Journal of the Medical Sciences, 1848 and 1856.
2 Playfair states : " Tyler Smith contended that ruptures are relatively as common in first as In
subsequent pregnancies." Charpentier says that all authors, except Tyler Smith, admit the influ-
ence of multiparity. How these statements can be reconciled with the following language, let
others decide : " It is an interesting and remarkable fact that ruptures of the uterus seldom hap-
pen to primiparous women." (Lectures on Parturition and the Principles and Practice of Obstet-
rics. By W. Tyler Smith. Lancet, vol. ii. p. 495.)
INJURIES OF THE MATERNAL SOFT PARTS. 555
It must be remembered that in labor the uterus consists of two portions,
one active, the other passive ; an upper portion which seeks to expel
the child, and a lower portion which is stretched so as to permit that
expulsion. Now if, for example, there be a shoulder presentation, ex-
pulsion is impossible. So, too, if there be excessive size of the child,
as from hydrocephalus, the same element of disproportion between the
passenger and the passage is present. Schuchard 1 in 73 cases of uterine
rupture found hydrocephalus in 18.
Winckel describes the occurrence of spontaneous rupture as follows :
" Some obstruction, whether it be hardness or rigidity of the external os, or an
unusual size of the head (by hydrocephalus), or a faulty attitude (face presenta-
tion, prolapse of an arm), prevents dilatation and retraction of the cervix over
the presenting part, while it is continually forced by the body of the child under
the contraction-ring; hence the lower uterine segment becomes thinner and
thinner, until, finally, its fibres separate, by reason of the renewed force of the
pains, at the points which have been most tensely stretched and attenuated, the
laceration perforating rapidly from within outward."
SYMPTOMS OF THREATENED UTERINE RUPTURE. The premoni-
tory symptoms are the tense condition of the round ligaments, the great
thinning of the lower uterine segment, the ascension of Schroder's con-
traction-ring, so that from its normal position near the pelvic inlet it
may now be only the breadth of two or three fingers below the umbili-
cus ; this ring can be recognized by palpation, and during a uterine con-
traction can in some cases be seen making a somewhat obliquely lying
furrow across the abdomen, while, at the same time, that portion of the
uterus below this furrow " is prominent as if it were a distended blad-
der ; " but the use of the catheter will prevent, in a case of doubt, such
mistake.
The finger in the vagina passes readily between the presenting part
and the cervical wall, which is everywhere found extremely thin. The
general condition of the patient also foretells the accident. She is rest-
less and suffers not only during uterine contractions, but also in the
intervals ; the abdomen is tender f the suffering and the anxiety cause
an excited and frequent pulse, and there is some elevation of tempera-
ture ; her countenance expresses anxiety. Instances of this variety
of rupture that do not present premonitory symptoms are quite ex-
ceptional.
Tears of the uterus caused by the application of the forceps when the
os is not sufficiently dilated, or by the rude and rapid dilatation with
the hand, or by the manual extraction of the child in a case of partial
expansion of the os, have been previously mentioned. It only remains
to refer to this accident in case of threatened rupture in consequence of
obstetric manipulations. The shoulder, for example, presents, and the
vain labor has continued for hours ; the obstetrician performs podalic
version, and although accomplished with ease, it may be, as the last
straw that breaks the camel's back, so the introduction of fingers or
hand, even done with the utmost gentleness, may cause tearing of the
uterus.
1 Ueber die Schweirigheit der Diagnose und die Hauflgheit der Uterusruptur bei fotaler Hydro-
cephalie. Berlin thesis, 1884.
2 Spiegelberg.
556
THE PATHOLOGY OF LAEOR.
Before mentioning the symptoms of rupture of the uterus, a word may be
said of those cases in which there are no indications of the accident.
FIG. 217.
contraction-ring
't round ligament
contraction-ring
round ligament
internal os
external os
SHOULDER PRESENTATION. THREATENED RUPTURE OF THE STRETCHED LOWER SEGMENT
OF THE UTERUS AND CERVIX. (After SCHRODER.)
Hervieux 1 narrates a case from the practice of Dubois, in which he performed
podalic version on account of narrowed inlet ; the woman died the next day, no
symptoms of uterine rupture having been manifested, yet there was found at the
post-mortem an irregular rent involving a part of the anterior wall of the vagina,
the entire length of the neck in front, and a portion of the left side of the
uterus. He also refers to a case occurring in the Maternite in his service in
which Tarnier by external means changed a pelvic into a vertex presentation ;
the woman was delivered on the 9th and died on the llth of November, and
at the autopsy there was found a rent in the side of the neck a little more
than two inches long, extending from the internal os to the union between the
neck and the vagina. In a paper presented some years ago to the Philadelphia
County Medical Society, I narrated a case of uterine tear which was not sus-
pected during life, but, the woman dying of septicaemia, a post-mortem showed
that there was a complete rent involving the left side of the cervix and the lower
third of the body of the uterus. Since that time a medical gentleman of this
city brought me the uterus of a woman who died in labor from hemorrhage, so
reported, too, in the certificate to the Board of Health, and examination showed
that the cause of the hemorrhage was a tear extending from the external os
nearly as high as the contraction-ring. Hervieux remarks that in some cases
the uterine tear is made silently neither pain nor complaint nor crisis, and if
the patient dies, as is usually the case, one is astonished to find at the autopsy a
rupture which had not been even suspected.
Winckel, after referring to these cases, as given in the first edition of this
work, adds a similar one occurring under his observation.
Traitfi clinique et pratique des Maladies puerp6 rales.
INJURIES OF THE MATERNAL SOFT PARTS.
557
If we add to these silent tears, many of which remain unknown because
autopsies in private practice are not frequent, and a few in which death does
not follow the accident those cases which, though recognized by the practi-
tioner, are not made known it is probable, as has been previously stated, that
the accident, though by no means frequent, is less rare than published statistics
indicate.
POSITION AND EXTENT OF TEARS. Usually the rupture involves
the lower uterine segment and the cervix, but it may extend upward
into the contraction-ring or downward into the vaginal wall. Usually,
too, the peritoneum is torn, so that there is a direct communication be-
tween the uterine and abdominal cavities ; exceptionally the peritoneum
is not injured, and then the rupture is incomplete. The tears are rarely
longitudinal, but they may be transverse or oblique ; they may be lat-
eral, anterior, or posterior. A part of the foetus usually enters the
abdominal cavity, sometimes almost all or even the entire body ; and,
on the other hand, a portion of intestine may prolapse through the rent.
SYMPTOMS OF RUPTURE. It may be that during a pain of unusual
severity, or an obstetric manipulation, as the introduction of the hand
for the purpose of version, the patient has sudden suffering of the
greatest intensity, " totally different from the pain of uterine contrac-
tion." Trask said that she is conscious of something having given way
within her; "she feels a tearing or rending sensation, and in some in-
stances the noise accompanying the rupture is heard by those around
her." The last statement is now generally denied ; Depaul regarded it
as purely theoretical. The patient's face becomes anxious and pale, the
skin is covered with cold sweat, there are nausea and vomiting, the
pulse is rapid, threadlike, and irregular, the respiration is hurried, diffi-
cult, and sighing, the sight is obscured, and there is ringing in the ears.
There is severe pain in the abdomen, and the latter notably changes its
form if the foetus has entirely or partially entered its cavity, or if there
be large hemorrhage in it. The uterine contractions cease in almost all
cases. Upon vaginal examination generally some hemorrhage is dis-
covered, the presenting part has receded, or is replaced by another pre-
sentation, and possibly the rent can be at once felt. In the 580 cases
studied by Jolly the symptoms narrated were manifested as follows :
Abrupt cessation of contractions was observed in 218 cases.
Gradual
Change in the pulse
Prostration
External hemorrhage, slight in 33,
Retrocession of presenting part
Abdominal pain
Alteration of countenance *
Acute pain at the moment of rupture
33
179
151
148
146
133
115
62
Foetal parts felt immediately under abdominal wall in 77
These are the signs almost always presented, but others which may
occur should not be neglected. Thus a remarkable change in the form
of the abdomen is observed two tumors, one formed by the escaped
foetus and the other by the uterus, may be present. In some cases the
movements of the foetus that have been active suddenly cease, and the
sounds of its heart can no longer be heard. Hemorrhage may be ex-
ternal, internal, or both ; Charpeutier directs attention to the fact that
the blood may accumulate at a particular point, forming a hypogastric
558 THE PATHOLOGY OF LABOR.
tumor. Kiwisch, McClintock, Montgomery, Paully, Ross, Crighton,
and Schatz have indicated as a pathognomonic phenomenon the occur-
rence of emphysema at the level of the hypogastric region, very rapid
sometimes, and which results from the penetration of air through the
rent and its diffusion in the connective tissue.
But the emphysema referred to can be present only in those cases in which
the rent is incomplete. Spiegelberg has stated that the air either enters from
without through the tear during intra-vaginal manipulations, or else results from
putrefactive changes in the foetus. This symptom is always a very unfavorable
one, all cases in which its presence has been recorded having proved fatal.
Trask made the diagnostic marks two : recession of the presenting
part, and the ability to distinguish the limbs of the foetus beneath the
abdominal parietes. In regard to the cessation of the uterine contrac-
tion, Jolly found 37 in which this did not occur, or was only temporary,
and in some, indeed, the contractions retained their normal force.
PROGNOSIS. This is most unfavorable both for the mother and for
the child especially for the latter. In Jolly's 580 cases only 100
mothers were saved, and of 237 children in regard to whom the results
were stated, only 7.5 per cent, were born alive. The mother may die
very suddenly from shock, as in a patient of Churchill, 1 who lived but
five minutes after the accident, or one of Bluff, 2 who gave a scream of
suffering agony, vomited, and died. Instead of sudden death from
shock, there may be rapid death from hemorrhage ; or a fatal result
may occur from strangulation of a coil of intestine in the rent ; but the
most frequent cause of a fatal termination is septicaemia. In two cases
reported by Winckel death was caused by air embolism. The same
author regards the prognosis as improved 3 by the use of antiseptics.
While Jolly gave the percentage of recoveries as 17, Spiegelberg
thought 5 per cent., the result established by Hugenberger, as being
near the truth. Zweifel after quoting Trask as deriving from his
statistics that the mortality of expectant treatment was 78 per cent.,
after delivery by the vagina 68 per cent., and after laparotomy 24 per
cent., says these statistics cannot be correct. The suprisingly small
mortality when laparotomy was done is to be explained by the fact that
cases operated upon which recovered are reported, while the others are
passed over, and by the relative smallness of the figures.
TREATMENT. This comprises that advisable in threatened rupture
and that required after the accident has occurred. In the former imme-
diate delivery is demanded, and this must be effected without additional
stretching of the cervix. Hence, embryotomy is preferable to version,
for the introduction of the hand or fingers for the accomplishment of
the latter is liable to cause the accident immediately in such conditions,
i Diseases of Women. * Siebold's Journal, 1835.
3 Nevertheless this opinion meets with no support from the statistics of Schaffer, " Uber die
Behandlung der Ruptura Uteri mit kompleten Austritt des Kindes," Munich med Wochenschrift,
1889. He states that of 100 laparotomies for this accident, there were, before 1875, 48 cases with 31
recoveries 65.1 per cent.: antiseptic operations, 52 cases, 19 recoveries 36.1 per cent.
Freund, Central. 1. Gynak., 1892 : " The prognosis of uterine rupture has not improved ; the
chief conclusion of practitioners consists in prophylaxis. early diagnosis, and averting the rupture
by proper obstetrical operations, forceps, turning, and in their place, in most cases better, perfor-
ation and embryotomy. Csesarean section only in case of absolute indication.
"After rupture, immediate delivery, when possible per vias naturales, and drainage ; if the bleed-
ing is severe, not controlled by tampon, if prolapsed and irrestorable loop of intestine, laparotomy
and suture as soon as possible."
INJURIES OF THE MATERNAL SOFT PARTS. 559
no additional strain to the overstretched tissues being possible without
this injury following. If the child occupies a transverse position, ern-
bryotomy ; if the head presents in a contracted pelvis, craniotomy ; or
if there be hydrocephalus, perforation constitute the treatment advised
by Zweifel ; and he adds that transverse position, narrow pelvis, and
hydrocephalus are almost the sole complications of labor, bringing the
imminent danger of rupture of the uterus.
After rupture of the uterus, too, delivery must be made as soon as
possible. If the woman is greatly prostrated, stimulants especially
hypodermatics of sulphuric ether are indicated, and other suitable
means employed to bring about reaction. The modes by which delivery
is to be effected will depend upon the position of the child, the presen-
tation, and the special obstacle to labor which has been the chief cause
of the injury. The child is either in the uterus or in the abdominal
cavity, or partly in each. In the first case, supposing the head to pre-
sent, the forceps or the cephalotribe is indicated ; of course, the head is
first opened if the latter instrument is employed. If the head be not
accessible, delivery by podalic version is indicated. In the third case,
still, delivery through the natural passage is the rule if the part of the
fretus that has entered the abdomen can be easily brought into the
uterine cavity and without increasing the rent. But if such restoration
is impossible without this additional injury to the uterus, and in the
second condition that has been stated, abdominal section is required.
After delivery through the natural passage, a 3 per cent, solution of
carbolic acid is used to wash out the cavity thoroughly, and a drainage-
tube introduced. Frommel, 1 pursuing this method, had in 1880 three
successful cases, and the next year Hecker 2 reported a success obtained
in like manner. Schlemer 3 in 1882 had a case of rupture in which a
portion of intestine prolapsed through the rent, the fact of the rent and
of the prolapse being ascertained after delivery with the forceps ; the
bowel was restored, a drainage-tube introduced, an injection of carbol-
ized water employed ; the injection was repeated daily, and the woman
recovered.
Associated with drainage a compressive abdominal bandage is em-
ployed. The drainage-tube is of glass, and is T-shaped ; injections are,
as a rule, not made through it into the abdominal cavity, but the nozzle
of a syringe may from time to time be introduced into the tube,
and fluid drawn out ; the tube is removed in about a week. Zweifel,
after stating that Schroder, Frommel, Grafe, Hecker, and Morsbach
have had excellent results from this treatment, adds that he has also
had in his clinic a case that was successful by means of peritoneal
drainage.
In a case of rupture 4 reported by Rhinestadter, the peritoneal cavity
was washed out through the drainage-tube with a 1 per cent, carbolic
acid solution, an antiseptic vaginal tampon introduced, and an ice-blad-
der applied to the abdomen over the rupture. The vaginal dressing
was renewed the next day, the drainage-tube was removed four weeks
after the delivery ; the woman recovered.
1 " Zur Therapie der Uterusruptur," Centralblatt fur Gynakol., 1880.
2 Ibid., 1881. 3 Ibid., 1882. Op. cit.
560 THE PATHOLOGY OF LABOR.
Fleischman 1 has shown the greater mortality of ruptures of the anterior por-
tion of the cervix than of the posterior, for of 18 cases of the former all died,
while of 14 of the latter only 9 were fatal, and he suggests that in the former injury
the abdomen should be opened, while in the latter drainage should be used.
Douglas's cul-de-sac presents favorable conditions for drainage, while the vesico-
uterine does not. In one case successfully treated by drainage the abdominal
cavity was washed out with a 1 per cent, thymol solution, and a firm drainage-
tube passed posteriorly into the cavity, and retained in position by a loose tampon
of iodoform gauze.
Piskacek 2 claims that the most successful treatment for complete rupture is
drainage by iodoforni-wicking, the results being 12 per cent, better than from
laparotomy. Seven cases from Breisky's clinic are given, 5 of them treated by
drainage as stated, and 4 recovered. Leopold 3 emphasizes the importance of
delivering the child so that the mother's life may be least endangered, and of
having especially in view the control of hemorrhage by the promptest treatment.
He attaches more value to laparotomy than the previous authority.
Coe, in connection with a case of laparo-hysterectomy successfully done by
him for rupture of the uterus, 8 believes this the only method of treatment proper
after prolonged and unsuccessful attempts at delivery ; he gives a table including
13 cases by different operators, and the maternal mortality is a little more than
69 per cent.
In case laparotomy is done, it should be followed by hysterectomy if
the hemorrhage cannot be controlled by suturing the uterine wound,
and a tampon of iodoform gauze.
The methods of treating uterine rupture, given by Cholmagroff, 5 are five : a.
Expectant or antiphlogistic ; b, laparotomy, the uterus left, and the rent either
sutured, or not ; c, laparotomy with supra-vaginal amputation, or extirpation of
the uterus ; d, drainage of the uterus ; and e, sutures with, or without introduc-
tion of iodoform gauze.
The statistics of Merz 6 show that drainage counts a larger number of successes
than any other method. In 75 cases, the expectant plan being pursued, only 10
recovered, that is, 14.2 per cent. ; the percentage of recoveries when the tampon
was used was 40 ; after laparotomy, with or without suture, or Porro's operation,
48.1 per cent, recovered, while in drainage with tube, or iodoform material, the
recoveries were 66.6 per cent.
R. Braun v. Fernwald, Ueber TJterusruptur, Vienna, 1894, gives 19 ruptures in
38,000 deliveries, that is, 1 in 2000, incomparably more rare in primiparse than
in multiparse. In the 19 cases not one primipara. Age from 24 to 44 years.
Primary laparotomy in 4 cases; 2 rupture sutured, both died. In 2 Porro's oper-
ation, 1 fatal, 1 recovery. In 7 cases of complete rupture, the foetus entirely or
partly entering the peritoneal cavity, all died. 19 ruptures, 15 complete, 4 in-
complete, 1 complicated with rupture of the bladder; 7 recovered, 36.84 per
cent. 1 case resulted from high forceps improperly applied.
HEMORRHAGE AFTER THE BIRTH OF THE CHILD. Bleeding sub-
sequent to the delivery of the child may arise from tears at the vaginal
entrance, of the vaginal wall, or of the cervix, or it may be from the
interior of the womb. The treatment of vulval, vaginal, and cervical
hemorrhage has been presented, and there remains now only that
variety having its origin in the uterus to be considered.
1 "Bin Beitrag zur Casuistik der Collumdehnung und der Uterusruptur," Zeitschrift fur Heil-
kunde, 1885.
2 See abstract of Piskacek's paper in the American Journal of the Medical Sciences. November,
1889.
Archiv f Gynakol.. 1889. New York Medical Record. 1889.
5 Zeitschrift f. Geburtshtilfe und Gynakologie, 1894.
6 Zur Behandlung des Uterusruptur. Arch. f. Gynakol., Band 45.
INJURIES OF THE MATERNAL SOFT PARTS. 561
This hemorrhage is from the placental site, and, of course, is impos-
sible as long as the placenta is completely attached, but may occur in
case of partial detachment. It may occur when the placenta is partially
expelled, lying in the vagina, for example, or after its complete expul-
sion, an hour or more subsequent to the labor.
The essential cause of hemorrhage is deficient uterine contraction.
The reason for this failure may be previous excessive distentiou, as from
a plural pregnancy, or from polyhydramnios ; or it may be too rapid a
labor ; the uterus suddenly emptied of the fcetus does not contract as
promptly as if the labor had been of normal length, and, on the other
hand, a prolonged labor may exhaust the power of the uterus; the lia-
bility of albuminurics to post-partum hemorrhage has been previously
stated, while hemophilia is too obvious a cause to be more than men-
tioned.
In some cases of uterine fibroids retraction of the uterus is hindered,
but bleeding will not result unless the site of the placenta has happened
to correspond with the situation of one of the tumors.
Hemorrhage after the birth of the child is not a frequent, and in
almost all cases is a preventable accident ; it generally indicates some
sin of omission or of commission on the part of the obstetrician. Spiegel-
berg has said : " I certainly do not exaggerate when I say that severe
post-partum hemorrhage is almost without exception the fault of the
attendant. The value of his services can be estimated by the frequency
with which this accident occurs in the labors he conducts."
That the accident is not frequent is shown by the following statistics given by
Herman : l Guy's Hospital, 1 case of dangerous post-partum hemorrhage in 2040
labors ; St. Thomas's Hospital, 1 in 2172 ; and in Prussia, according to Hegar, 1
in 3131.
Veit 2 states that since Diihrssen recommended packing the uterus with iodo-
form gauze, he has sought to ascertain how often atonic bleeding occurs. In
analyzing the statistics of 20,378 births given in seventeen years in the Charite-
Annalen, the frequency of atony varies from to 25 : in all there were only two
deaths from atonic bleeding. Further, Veit combining these statistics of births
with those of Ahlfeld, Winckel, Derselbe, and of Chiari, Braun and Spath, and
Hecker, making 47,765 cases, finds there were only five fatal cases of atonic hemor-
rhage. Incidentally, it is stated by Veit that in one of the fatal cases packing
with iodoform gauze was employed ; a similar case is given by Strassman.
SYMPTOMS. There is generally observed an unusual frequency of
the pulse, but this increase is possibly only slight ; nevertheless its occur-
rence should put the practitioner upon his guard, even though he finds
the uterus at the time nearly normal in size and in firmness. The pa-
tient probably complains of great thirst, and she is somewhat restless.
But, it may be without any premonitory symptoms, the flow of blood is
suddenly manifest, trickling through or down by the side of the bed to
the floor ; the discharge may be so rapid and great that it is appropri-
ately called flooding, a flood upon which the patient's life is swiftly
borne away unless proper measures are promptly used ; now she is
usually restless, and her arms rise and fall, thrown to this side and to
that in a sort of aimless way, and agony of despair ; her respiration is
1 British Medical Journal, 1892.
2 Zur Pathologie und Therapie der Blutungen unmittlebar nach der Geburt. Zeits. f. Geburts und
Gynakol., 1894.
36
562 THE PATHOLOGY OF LABOR.
sighing, and she wants fresh air, and possibly she complains of the dark-
ness of the room, exclaiming, " I can't see !" while a deathlike pallor is
upon her face. You put your finger upon her pulse ; it is frequent,
thready, intermittent ; your hand upon her abdomen, and the small
hard uterine globe is no longer felt, but there is excessive abdominal
distention, and it is often difficult or impossible to define the boundaries
of the uterus a relaxed sac filled with blood.
TREATMENT. If ever there is one time more than any other in the
obstetrician's life when he needs to be calm and collected and to put
forth prompt and intelligent action, it is when he is brought face to
face with post-partum hemorrhage.
In addition to lowering the patient's head and the administration of
stimulants and of hypodermatic injections of sulphuric ether, etc., appli-
cable in other cases of bleeding with consequent exhaustion, we use direct
means to arrest the bleeding. First of these is uterine compression.
The usual method of doing this is to grasp the uterus through the ab-
domen with one hand, while the other is introduced into the uterine
cavity in order that its presence may evoke uterine contraction. 1 Pos-
sibly, too, the placenta may still be in the uterus, either free or par-
tially attached ; in the latter case the fingers are used, as the uterus les-
sens in size, to detach it, and in either case to remove it from the uterus
at the proper time. Probably the uterus is very sensitive when pressed
by the abdominal hand, but this arises from its great distention, and as
soon as the organ is emptied the excessive sensibility ceases ; possibly
the uterus cannot be felt at first by this hand it is so relaxed that it
has lost its form but then so much the more necessity for prompt
action.
Should this means fail in arresting the hemorrhage, compression of
the uterus, placed in a position of anteflexion, may be employed. Zweifel
says it ought to be possible to stop every atonic hemorrhage by energetic
use of this treatment. In it pass two fingers into the posterior cul-de-
sac, and press the cervix forward, while the other hand, upon the ab-
domen, is made to press upon the fundus posteriorly, bringing it also
forward as shown in the accompanying illustration.
Compression of the abdominal aorta may be made with the fingers of the left
hand, the obstetrician being upon the patient's right side ; the abdominal wall
is depressed just above the uterus and a little to the left of the median line until
the pulsations of the vessel are felt, and then slight pressure with the first three
fingers will arrest the current. An assistant will be needed, for the fingers be-
come too tired after twenty or thirty minutes to maintain efficient compression.
Compression of the abdominal aorta was probably first advocated by Rudiger, a
practitioner of Tubingen, in 1797. His method was with the hand introduced
into the uterus, pressing through its posterior wall. Ulsamer in 1825 introduced
the method of pressure through the abdominal wall, and it received the strong
indorsement, from personal experience, of Siebold and of Baudelocque. Gros*
has reported nine cases of puerperal hemorrhage in which it was successfully
employed. Zweifel holds this objection has been made by Jacquemier and
others that it is impossible to cut off by this means all the blood-supply to the
uterus, because the spermatic arteries pass off from the aorta above the part com-
1 Nevertheless, Veit (op. cit.) holds that never in the first hours is the hand to be passed into the
genital canal in treating atony. He further holds that manual detachment of the placenta is an
entirely superfluous operation.
* De la Compression de 1'Aorte dans les Hemorrhages apres 1'Accouchement.
INJURIES OF THE MATERNAL SOFT PARTS.
563
pressed, and that the chief benefit is in preventing cerebral anaemia, in this re-
spect being upon the same level as bandaging the limbs, or what is known as
auto transfusion.
Uterine contractility has been in some cases evoked by flapping the
abdominal wall with a wet towel, by pouring cold water from a height
upon the exposed abdomen, by the application of ice to it, by the intro-
duction of pieces of ice into the vagina or into the uterus, or by the
injection of cold water into each. In recent years, however, the general
preference has been for injecting the uterus with hot, rather than cold
water, the former being more efficient than the latter in producing per-
manent contraction, and stimulating rather than depressing. The water
should have a temperature of not less than 105 F., and an irrigator
used for its introduction, rather than a pump.
FIG. 218.
ARRESTING HEMORRHAGE BY COMPRESSION OF THE UTERUS IN A POSITION OF
ANTEFLEXION. (ZWEIFEL.)
The application of vinegar to the interior of the uterus was probably first ad-
vised by Leroux 1 in 1776. Since then many obstetricians have regarded this
remedy as of very great value. Dr. Penrose, 2 for example, states that he has
been using it alone as his last resort, both in hospital and private practice, in
1 Observations sur 16s Pertes du Sang des Femmes en Couches.
2 Transactions of the American Gynecological Society, vol. iii.
564 THE PATHOLOGY OF LABOR.
many apparently desperate cases of post-partum hemorrhage, and invariably
with successful results. His method is the following : " I pour a few tablespoon-
fuls into a vessel ; dip into it some clean rag or a clean pocket-handkerchief. I
then carry the saturated rag with my hand into the uterus, and squeeze it; the
effect of the vinegar flowing over the sides of the cavity of the uterus is magical.
The relaxed and flabby uterine muscle instantly responds." Similar stimulating
applications have been successfully made to the interior of the uterus e. 19
Charpentier states that he has seen, as a consequence of an application of the
forceps by an inexperienced operator, one of the branches pushed with such
violence that the blade penetrated the scalp near the occiput, passing as far as
the root of the nose, detaching in its progress the skin from the cranium ; the
child died at the end of forty-eight hours. I have observed a similar case ; the
operator had passed one blade on the outside of the scalp, but the other was
applied beneath the scalp, when the difficulty in making it penetrate far enough
led him to ask professional assistance ; fortunately, the child was dead.
Intra-cranial effusion of blood may occur, oftener, as suggested by
Spiegelberg, not from the direct compression of the forceps, but indi-
rectly from drawing the head rapidly through the narrow birth-canal.
Paralysis of the facial nerve, usually on one side only, in rare cases ou
each side, may occur from direct pressure by the forceps-blade upon
the nerve-trunk ; the compression may be of one of the branches only,
and then the paralysis is only of the parts supplied by it. Generally
this paralysis disappears in one or two weeks without treatment, but in
some instances it lasts for years, and then may be regarded as incurable.
So, too, the brachial plexus may be injured by the point of one of the
blades, and paralysis of the parts supplied by it result.
I have seen a case in which forceps extraction was made, one of the
blades being applied partly over the frontal bone, and exophthalmus
resulted ; the child was dead, and the mother perished a few days after
of septic infection.
Pincus 1 attributes some cases of injury to the sterno-cleido-mastoid
muscle to improperly constructed forceps and to torsion. The last fact
should be borne in mind before attempting to compel anterior rotation
in an occipito-posterior position.
While the obstetrician will neither resort to the forceps " from com-
plaisance, nor reject it from cowardice," he must be quite sure that the
interests of the mother or of the child, or both, demand the use of the
instrument, and that the conditions are present rendering that use safe.
THE VECTIS. This instrument is supposed to be, like the forceps,
the invention of Chamberlen. The instrument has been given different
FIG. 254.
forms, according as it was used chiefly or exclusively as a lever or as a
tractor; thus Roonhuysen's instrument was a plate of steel, slightly
curved, but the form preferred by the few obstetricians who use the
instrument is that of a fenestrated, curved blade, with a straight handle ;
Spiegelberg has briefly referred to it as being one blade of the forceps,
and therefore an unnecessary instrument. Lowder's instrument, of
which an illustration is given, is probably the best. It has been used
chiefly to increase flexion and to assist rotation, but is rarely employed
and by but few obstetricians at the present day.
1 Zeits. fur Geburt. und Gynak., 1895.
CHAPTER XII.
MANUAL KEMOVAL OF THE PLACENTA SYMPHYSEOTOMY.
MANUAL KEMOVAL OF THE PLACENTA. If the placenta is not
spontaneously expelled within two hours after the birth of the child, and
if by stimulating uterine contractions, by manipulation through the
abdominal wall, assisted by moderate traction on the cord, it is still
retained, its removal by the hand is usually indicated. In order to
guide the hand that is to enter the uterus into the os, and also to the
position of the placenta, the other hand pulls on the cord, so that it is
made moderately tense. The hand, after proper preparation washing
and antiseptics is passed in a cone-shape, the fingers and thumb
brought together so that the cone is formed, into the vagina, thence
into the uterus and the placenta found, and then the other hand, no
longer required to pull upon the cord, is placed upon the abdominal
wall, so. that the uterus is grasped by it. The placenta is detached,
partially detached, or completely adherent. In the first case the
operator includes as much as he can of it in his half-folded hand, not
instantly withdrawing placenta and hand, but rather invites by the
irritation of the hand within and by friction and compression of the
hand without, uterine contraction which tends to expel both hand and
placenta. In the second case, that is, in partial detachment of the
placenta, there is no hemorrhage if the womb be well contracted ; but
even if there be no bleeding, still more if there is, the placenta is to be
completely detached, this separation being effected by continuing the
separation from the part where it has begun ; in this manipulation,
supposing the right hand to be in the uterus and the placenta to be sit-
uated upon the posterior wall of the uterus, the ulnar border of the
hand is used with a sort of sawing motion, or like the continuous move-
ments made in using a paper-cutter, the back of the hand being toward
the uterine wall, and the external hand keeping the uterus in position,
and assisting in defining the uterine wall so that the internal fingers do
it no damage. If the placenta be situated upon the anterior wall, then
the radial margin furnishes the edge of the paper-cutter; but if the
attachment be to the fundus, the ends of the fingers must make the
separation, being careful that they turn toward the soft placenta rather
than toward the harder uterine wall, and thus harm to the latter is
avoided. Of course, all manipulations must cease during a uterine
contraction. If the placenta be completely adherent, the method of
removal does not differ, but is more difficult. It ought to be added that
an adherent placenta is very rare ; that is, pathological adhesion, in
consequence possibly of endometritis, is very seldom in occurrence.
Hildebrandt advised separation within the foetal membranes, these being
made to form a glove-like covering for the operating hand, on the
SYMPHYSEOTOMY. 621
ground that thus avoidance of injury to the uterine wall was secured,
and also danger of septic infection avoided. Spiegel berg found the
method successful only in case the attachment was not strong, and that
the assistance derived from tactile sensations was greatly diminished
by this method. Budin advises, if the hand has entered the foetal sac,
to tear the membranes at the border of the placenta, so as to begin the
separation there ; if this fails, then the placenta is penetrated near its
centre, and the fingers introduced into the button-hole thus formed, and
the separation made with them, making a circle from this starting-point
between the placenta and uterus. In case hour-glass contraction is
present, or a similar contraction at one of the uterine cornua holds the
placenta imprisoned, it may be the stricture can be overcome by a
hypodermatic of morphine and chloroform inhalation, then dilatation
with one, two, three, four fingers, until finally the hand enters, or dila-
tation with Barnes's hydrostatic dilators may be successful. If these
means fail, Budin's answer is antisepsis and patience. Certainly the
condition of the woman is one of imminent peril ; but by the use of
antiseptic washes and suppositories we can materially lessen that peril,
and, in many instances, the patient waiting is followed by the spon-
taneous detachment and expulsion of the placenta.
Chazan, 1 who, in correspondence with the views of obstetricians generally,
regards placental retention as in almost all cases failure of placental detachment,
this failure not indicating abnormal adhesion has for many years abandoned
the usual treatment, stating that he has been quite successful pursuing another
plan. A firm and continued pull upon that part of the placenta which has
been detached usually there is such a part will cause the detachment of the
entire afterbirth. In most cases it is not necessary to pass even the fingers
into the uterine cavity, for the separated portion will be found in the cervical
canal, sometimes indeed in the vagina. Exceptionally this portion is central
instead of marginal, and then the finger bores through that part of the placenta,
and using it as a hook detaches the rest of the placenta by pulling on it.
SYMPHYSEOTOMY. 2 By this is meant section of the pubic joint to
facilitate or render possible the birth of a living child in stenosis of the
pelvis.
HISTORICAL. Pare 13 stated he had heard it said that in Italy the pubic
bones were broken in young girls for the purpose of facilitating labor. It cer-
tainly was a strange rumor to be credited by the great French surgeon. Dela-
courvee, a French physician living at Warsaw, in the year 1655 divided the
symphysis in a woman who died after four days' labor undelivered, and thus
permitted the child, whose head Lad been wedged in a narrow pelvis, to be
extracted. A similar operation was done by Plenck, in Hungary, in 1766. A
French medical student J. E. Sigault made the subject of his inaugural thesis,
1773, a discussion of the question, whether in labor contra naturam, section of
the pubic bones would not be more prompt and safer than the Caesarean opera-
tion. Sigault was led to the advocacy of syraphyseotomy by a memoir read by
Louis before the Academy of Surgery, upon the separation of the bones of the
pelvis. In 1777 Sigault 4 performed his first operation on a woman who was the
1 Ueber Placenta retention nach rechtzei tiger Geburt., 1894.
2 In employing this word I have complied, so far as the use of e is concerned, with the com-
mon usage of recent French and English writers. Nevertheless, Kossmann, Pathologic unserer
Kuntsausdriiche, Monatsschrift f. Geburtshiilfe und Gynakologie, June, 1895, refers to it as a hor-
rible word, and, probably, were we to use an accurate designation we would choose Symphysitome.
3 For several of the facts here given I am indebted to Gotchaux's Monograph, De la Symphy-
seotomie, Paris, 1893.
4 Most authorities state that this was the first symphyseotomy upon the living subject; but Kal-
tenbach says that the operation was done in Naples in 1774, by Domenico Ferrara.
622 THE PA THOL OGY OF LAS OR.
wife of a soldier, and who had been pregnant four times previously, the children
being dead. Child and mother were saved, but the latter suffered many years
with a vesico-vaginal fistula. Four other operations were done by him, all of
the children perishing, and in the last the mother also. From his first operation
until 1800, that is, a period of twenty-three years, the operation was done thirty-
four times, nineteen of these being in France.
The mortality of the operation was very great, and obstetric authorities were al-
most unanimous in condemning it. Nevertheless, though rejected in the country
where it had its birth, symphyseotomy found occasional advocates in Italy during
the first half of the present century ; it is especially to the Naples school that the
profession ia indebted for the preservation and improvement of the operation.
Of that school, no one has done so much to establish the value of symphyseotomy
as Morisani, whose first operation was done in 1879. The next most prominent
Italian name connected with the revival of the operation is that of Mangiagalli,
of Milan. The operation has been received with much favor in France, and,
owing chiefly to the careful researches and contributions of Dr. Robert P. Harris,
also in this country ; many prominent German authorities accept it, but in
England its progress has been slow.
Morisani, at the International Congress, in Rome, 1894, asserted that
by symphyseotomy a well-developed foetus at term can pass through a
pelvis narrowed between the limits of 67 to 88 millimetres. These ad-
ditional statements were made by him. As a rule, the operation should
be done at term, after labor has begun and dilatation advanced. It is
not a good operation if the foetus is dead or seriously compromised ;
nor is it to be done in connection with induced labor ; the forceps may
be used, but it is not indispensable ; finally, in some cases it may be
done in connection with embryotomy if the foetus is dead.
So far for the position assigned symphyseotomy by its chief living promoter.
All do not accept the teaching of Morisani. Sanger, for example, with twelve
Csesarean sections and no death, believes symphyseotomy should be more re-
stricted, and greater extension given the former operation. Leopold would, if
possible, avoid it in primiparse; and in multipart, if the conjugate is only seven
centimetres, induce premature labor ; if too late, no interference at first, and if
the labor does not terminate naturally, version for it is possible in the flat pelvis
with a true conjugate of seven centimetres, and in a generally contracted pelvis,
the conjugate being seven and one-half centimetres, to deliver a child of mean
volume at term.
Of course, the extravagant claim for Walcher's 1 position, that by it in many
cases symphyseotomy will be superseded, can find but little acceptance.
Ahlfeld regards determining the indications as quite complex, and only pos-
sible for the most skilled obstetrician. He further believes that the operation
has been in late years often done unnecessarily and for the love of operating.
He also states that the next years must teach us how many women are injured
by the operation, and remain injured, and also as to the result in private, com-
pared with hospital practice.
In conversation with Professor Olshausen last summer he expressed the
opinion that the operation was one for the hospital.
Among the dangers of the operation are severe hemorrhage, tears of
the urethra, bladder, or vagina ; septic infection, inflammation of the
joint may follow, or there may be a failure of firm union. Yet, it is to
be remembered that such results are exceptional, and can usually be
averted.
MORTALITY. Neugebauer's statistics, from 1887 to the end of 1893,
1 Those who will read Varnier's criticism of the claim, Annalesde Gynecologic, December, 1894,
will accord small importance to Walcher's position.
SYMPHYSEOTOMT. 623
include 278 operations, and there were 31 deaths. Several died from
pneumonia, two from hemorrhage, and in a patient of Chrobak's the
record is " purulent endometritis, rupture of the urethra, of the vagina,
and of the neck of the uterus, septicsernia, amemia, and rupture of both
sacro-iliac joints." 1 Nevertheless, the majority of deaths were from
septic infection.
Harris 2 states that the operation has been done in the United States,
in fifteen years, 74 times; 10 women and 18 children perishing.
Uniting the American cases with those of Neugebauer for 1892 aud
1893, he finds the percentage of maternal deaths over 11 ; that of
symphyseotomies in Canada and the United States he states is more
than 12.
OPERATION. There are different methods of operating, but the chief
ones, those generally employed, are that of Morisani, and that of Pinard,
and these only will be described.
Morisani has the patient lying at the edge of the bed, in the position
for obstetric operations, while the operator is directly in front ; she is
anesthetized. Having shaved and carefully disinfected the genital
parts and the hypogastrium, a metallic female catheter is introduced
into the bladder; then an incision is made two to three centimetres long
vertically just above the symphysis ; the retro-pubic tissues are detached
after the incision has penetrated to the superior border of the articula-
tion ; in this separation of the tissues, the operator keeps his finger close
to the posterior surface of the symphysis. By the way thus made Gal-
biati's sickel-shaped knife, a strong bistoury, probe-pointed and curved
upon the cutting-edge, is introduced. The knob is passed below the
inferior border of the articulation, upon which the cutting curve of
the instrument is now brought ; then, by movements of the wrist, the
joint is divided from below above, and from behind in front. He
further states that he has sometimes, instead of Galbiati's knife, used a
probe-pointed bistoury, with a short, firm blade, and opened the joint
from before backward.
Pinard makes an incision eight to ten centimetres long, its lower end
being above the clitoris, and slightly deviating in order to spare this
organ and its vessels. Next the recti muscles are separated at the supe-
rior part of the wound, in order to permit the finger to enter into the
pre-vesical cavity to protect the bladder and to feel the projection of
the joint. "Then having a clear conception of the median line I cut
the symphysis from above belo'w, and from in front behind, by suc-
cessive strokes of the bistoury, reserving the sub-pubic ligament until
the last."
Arterial hemorrhage is met by ligature or torsion of vessels, and
venous bleeding by tampon of sterilized gauze.
The separation of the pubic bones will be 6 to 8 centimeters, or two
or three inches ; too wide a separation is prevented by assistants press-
ing the trochauters inward, lest serious injury be done the sacro-iliac
joints.
1 Jahresbericht iiber die Fortschrift auf dem Gebiete der Geburtshiilfe und Gyniikologie, i. for
the year 1893.
- The American Gynecological and Obstetrical Journal, June, 1895.
624 THE PATHOLOGY OF LABOR.
If labor paius are active, delivery may be left to Nature; in the
majority of cases, however, either version or the forceps has been em-
ployed. After labor is over the parts are thoroughly cleansed, and an
antiseptic employed ; then the divided parts are pressed together, and
stitches of silk or of silkworm-gut unite the superficial incision, some,
indeed, use silver-wire sutures to join the pubic bones, and an antiseptic
dressing is applied ; a firm bandage or adhesive straps are employed to
keep the divided parts in contact. Plaster-of-Paris bandage, Martin's
rubber bandage, or Esmarch's, and two bags of sand placed one on each
side of the patient, are among the many means that have been employed
to secure immobility of the separated bones.
The dorsal position is kept during the first week, and after that the
patient may be changed to either side, when she desires it. In favor-
able cases the joint is so well united in three weeks that she may be
permitted to sit up, and after a few days may walk.
FAEABEUF'S OPERATION, OR ISCHIO PUBIOTOMY. In an instance
of a pregnant woman having an oblique-oval pelvis, Naegele's pelvis, by
the advice of Farabeuf Pinard performed ischio-pubiotomy the bones
of the anchylosed sides were divided and a living child was born, the
mother perfectly recovered. This operation was done in 1892.
CHAPTER XIII.
THE (LESAREAN OPERATION AND ITS SUBSTITUTES.
BY the Caesarean section or operation is meant opening the abdomen
and the uterus, and extracting the foetus through the incision.
The operation performed after death is a very ancient one, having been estab-
lished by the Romans as a law centuries before the Christian era, its purpose
being to secure citizens to the State. The Christian Church strongly enjoined
the operation, even when the mother's death occurred quite early in pregnancy.
The first known operation upon the living subject was by Jacob Nuffer, a sow-
gelder, in 1500, the patient being his wife ; she recovered, and afterward bore
several living children. Kleinwiichter states that the next operations were by
Doring, 1531, .and by Donat in 1549, and that the first operation in Germany
was by Trautmann, in Wittenberg, in the year 1610.
TERMS DESIGNATING THE C^SAREAN OPERATION AND ITS SUB-
STITUTES. The term laparotomy 2 has been strangely perverted from
its etymological and original meaning, and applied as part of a compound
word to the Csesarean operation, to that of Porro, and to that known
by the name of Thomas. It will be better, while protesting against
this great perversion, to replace the various compounds of laparotomy
by correct terms, and thus the Csesarean operation will be called gastro-
hysterotomy ; gastro-hysterectomy is the proper designation for Porro's
operation, and gastro-elytrotomy, the name used by JBaudelocque, is the
appropriate one for the operation commonly called laparo-elytrotomy. 3
INDICATIONS FOR GASTRO-HYSTEROTOMY. These are absolute and
relative. When there is such obstruction of the birth-canal, whether
arising from uterine tumors or tumors of adjacent organs, or of the
pelvis, or from conditions of the cervix or of the vagina, or from pelvic
contraction, that even a mutilated fetus cannot be delivered through the
natural passage the operation should be done.
In regard to pelvic contraction as furnishing an absolute indication
for gastro-hysterotomy, we may accept the limits assigned by Winckel,
1 The earliest history of this operation which I have had the opportunity of reading is given by
Scultetus in his Armamentarium Chirurgicum, Frankfort, 1666. We have the picture of a woman
at the end of her first pregnancy some days in labor without relief from Nature's efforts, or from
the assistance of " thirteen midwives and several lithotomists." The husband, despairing of
help from these means, suggests others to his wife, and she consents. Next he procured a license
from the civil authority, and returning home, first addresses the midwives, exhorting them to be
brave, but advising the timid to retire, and, as a consequence, eleven withdrew, only two remain-
ing to assist him ; the lithotomists also remained. He places his wife upon the table, implores
Divine help, and then incises the abdomen non secus ac alicui porco. Almost immediately after
the incision had been made a living child was extracted uninjured, and the woman made a rapid
recovery.
2 Laparotomie (from /Mtrapa, flank, and TO//?}, section). Operation for lumbar hernia or for
artificial anus, practised in the lumbar regions. Litre and Robin's Dictionary of Medicine, Sur-
gery, etc-
3 Cosliotpmy has been proposed by Dr. R. P. Harris as an appropriate term for abdominal sec-
tion, and it has been generally accepted by the profession in this country and by many abroad.
Medical language so abounds with neologisms, that a new word, though correct and appropriate,
should not be introduced unless absolutely necessary. It has been stated that the Arabic has a
thousand names for a lion, but in science a synonyme, or an alias is seldom advisable.
40
626 THE PATHOLOGY OF LABOR.
and which have been quoted on a previous page, 2.6 inches conjugate
in a generally contracted pelvis, and 2.1 inches in a flat pelvis. Yet
embryotomy in pelves that approximate such narrowing will, in the
hands of those who are not expert and possessed of the necessary facil-
ities for operating, often if not usually prove more difficult and more
tedious than abdomino-uterine section, or exsection. Nevertheless let
these limits be recognized.
The relative indication is given by those pelves so contracted that a
living child cannot be delivered at term, or by the induction of pre-
mature labor, or if the pregnancy has advanced beyond the time for the
safe induction of labor. This question will be further considered under
the head of embryotomy.
TIME OF, PREPARATION OF PATIENT FOR, AND MODE OF OPER-
ATING. If a choice of time can be made, it is preferable to do the
operation about the end of pregnancy, but before labor begins. The
patient is given a bath the evening before, soap being used with the
water, and the skin thoroughly cleansed. The bowels are moved freely
in the morning of the day on which the operation is done, the vagina
thoroughly cleansed by an antiseptic injection, and immediately before
operating a catheter is introduced so that it is certain the bladder is
empty. The sub-umbilical region is shaved, the part washed with soap
and water, then with ether or antiseptic solution. The lower limbs are
each wrapped with a blanket or shawl, and the chest properly protected
from cold. The operator has ready a bistoury, several haemostatic forceps,
sponges or antiseptic gauze, scissors, needles, needle- holder, silk of two
sizes, rubber tubing for encircling the neck of the uterus, if he prefers
this method of preventing hemorrhage a funnel to which a rubber tube
is attached, and to the lower end of the latter a metal or hard rubber
canula, for washing out the abdominal cavity, iodoform, iodoform gauze,
antiseptic cotton, flannel bandage for the abdomen, safety pins, two hypo-
dermatic syringes, ether, brandy, solution of ergotin, or fluid extract of
ergot, and Tait's or other constrictor, as in preparation for hysterectomy,
should this prove necessary. He must have, also, wire, and two long,
thick needles. There must be at hand hot and cold water, basins and
towels. The operating- table should be narrow ; the operator is upon
the patient's right side, and his chief assistant upon the left. The ab-
dominal incision must be about six inches in length, and is made
through layer after layer in the linea alba there is no difficulty in
finding this when the tissues are stretched as they are in pregnancy
haemostatic forceps being used as required for bleeding vessels ; as the
peritoneum is approached, it is advisable for the operator and assistant
to lift up the tissues to be cut, each with forceps, and the incision is
made between the points of the two instruments. The abdominal
cavity having been opened, the incision if not long enough is increased
by scissors ; then the uterus is brought out through the opening, and
encircled below the ovaries and as close to the neck as possible by rubber
tubing, and constricted, or, instead of this method of guarding against
hemorrhage, an assistant compresses with his fingers the lower lateral
part of the uterus. If the uterus is opened outside the abdominal
cavity, a few sutures are introduced at the upper part of the incision so
CJESAREAN OPERATION AND ITS SUBSTITUTES. 627
as to close it partially, and thus prevent the escape of amnial fluid or
blood into the peritoneal cavity. Next, the anterior uterine wall is
incised in the median line if the organ be in situ, an assistant presses
it on either side of the abdominal wall so as to bring it close against the
cut in the abdominal wall, and also corrects any obliquity which there
may be. The operator will have in mind Leopold's statement as to de-
termining the position of the placenta (see page 383) ; Winckel states
we can distinguish previously, by the distinctness with which the ex-
tremities are made out, whether the placenta is attached in front or not.
If it should be found in this position, we may change the place of incising
the uterus. But if the discovery is not made until during the incision,
there will be a startling gush of blood ; this is only for a moment, and
the operator does not delay an instant. The incision of the uterus com-
pleted, an assistant places the palmar surface of each index-finger at the
ends of the opening, thus lifting up the uterus, and preventing its rapid
retraction. Next the operator ruptures the membranes, introduces one
hand into the sac, and the other hand assisting externally, brings the
child out of the uterus, usually drawing forth lower limbs and hips
first, shoulders and head last ] if the incision in the uterus is not large
enough for the child to pass through, it must be lengthened ; when the
child cries and breathing is established, the cord is divided, and after
this it is put in charge of an assistant. The placenta and membranes
are delivered through the wound ; if not spontaneously detached, they
are manually separated from the uterine wall. The open condition of
the cervical canal is next secured, and the uterine cavity is washed out
with a 1 to 2 per cent, solution of carbolic acid, or swabbed out, accord-
ing to Kaltenbach's direction, with a 5 per cent, solution of carbolic
acid, or 1 per cent, of lysol, or with chlorine water. Next the sutures
for the uterine incision are introduced, and here is the great merit of
Sanger's improvement in the Csesarean operation, an improvement
which has given the operation in recent years a marvellous success, con-
joining with deep, superficial sutures, carefully bringing the peritoneal
margins in close contact, and protecting against hemorrhage. Siinger
and others who employ these sutures use fine silk, much smaller than that
employed for the deep stitches. The deep sutures are made down to,
but do not include the uterine mucous membrane ; there may be five, six,
or seven of these, and then probably twice as many superficial sutures :
the material for the sutures is of antiseptic silk. 1 After the introduc-
tion of the stitches the constriction of the uterus, whether by fingers or
tube, is discontinued. If hemorrhage from the wound follows, addi-
tional stitches ; if from relaxed womb, uterine injections of hot water,
ergot hypodermatically, tamponing with iodoform gauze, and should
these means fail, supravaginal amputation of the uterus, known as
Porro's operation, may be required. But such hemorrhage is excep-
tional, and supposing it absent, the next step is " the toilet of the peri-
toneum," thorough washing out the abdominal cavity with water as hot
as can be comfortably borne ; for this purpose nothing is better than
the apparatus previously mentioned. Following the thorough cleans-
1 Schauta uses silver wire for the deep sutures. Fritsch rejects the double sutures, nor does he
avoid in the introduction of sutures the deciduous membrane, i
628 THE PATHOLOGY OF LABOR.
ing of the abdomiual cavity is the uniting the abdominal incision with
stitches, silkworm-gut being generally used ; these are chiefly deep,
including the peritoneum, and after they are introduced and tied super-
ficial sutures of catgut are employed at points where the skin gaps,
lodoform is sprinkled upon the line of incision, antiseptic gauze laid
next to the abdomen, then cotton batting, and finally a firmly fitting
flannel bandage applied. The after-treatment is that of abdominal
section in general, and therefore need not be given.
G ASTRO-HYSTERECTOMY, SUPRA- VAGINAL AMPUTATION OF THE
UTERUS, PORRO'S OPERATION. Porro, of Milan, in 1876, 1 having
come to the conclusion that the great mortality of gastro-hysterotomy
was due to leaving the injured uterus in the abdominal cavity, performed
supravaginal amputation after the extraction of the child. The suc-
cesses were superior to those obtained by the usual Csesarean operation,
but with the improvement in the method of doing the latter, introduced
by Sanger, the mortality of the two has been reversed, so that the pro-
fession generally prefer gastro-hysterotomy to gastro-hysterectomy in
most cases; nevertheless, all admit a limited field for the latter.
INDICATIONS FOR THE OPERATION. Parrish, 2 in his valuable con-
tribution to the subject, states that the operation should be done when,
through unwarranted delay, or by reason of unwarranted attempts at
delivery, the uterine tissues have been seriously injured, or when the
child is putrid, or when the patient is greatly exhausted by incipient or
established septicaemia, and when there is extensive fibroid or fibro-
cystic degeneration of the uterine body. Among the indications given
by Winckel are : Pregnancy in a rudimentary horn, the ovary on that
side to be also removed, in hernia uteri gravida bicornis iuguinalis, if it
cannot be reduced, in very extensive adhesions of the vault of the
vagina, and in echinococci of the uterine wall and of the pelvic con-
nective tissue, which cannot be removed in any other way and which
make the pelvic canal absolutely impassable, and in severe puerperal
osteomalacia. Schultze's removal of the uterus seven days after
delivery has been mentioned, as well as the indication given by uterine
hemorrhage after gastro-hysterotoray.
Supravaginal amputation of the uterus is also indicated after abdom-
inal section for ruptured uterus if the hemorrhage cannot be otherwise
arrested.
Porro's operation is, strictly speaking, partial hysterectomy. Bischoff, in
1879, removed the entire uterus. According to Auvard, 1890, Bischoff's opera-
tion has been done three times, always with a fatal result to the mother.
METHOD OF OPERATING : MULLER'S MODIFICATION. The prep-
aration and the abdominal section are the same as for gastro-hys-
terotomy ; so, too, the incision of the uterus and the extraction of the
child, as directed by Porro. Miiller, however, modified the operation
by having the abdominal incision so large as to permit eversion of the
body of the uterus, and encircling the lower portion with a rubber tube,
1 This operation, however, was first done by Dr. H. R. Storer in 1868.
2 First edition of this work.
C^ESAREAN OPERATION AND ITS SUBSTITUTES. 629
and then the uterus is rapidly opened and the child extracted. No
matter which method is employed, the placenta and membranes are
left in the uterus. After cleansing the abdomen the upper portion of
the abdominal incision is closed with sutures. Next the uterus is
amputated with scissors, knife, or by the thermo-cautery about three-
fourths of an inch above the constricting rubber. If the external
treatment of the pedicle is employed, and this is the general rule with
operators, the stump is encircled with a wire connected with a con-
strictor, Cintrat's, Tail's, or other, the wire tightened, the rubber
removed, and two long, thick needles passed through the stump ;
these transfixion needles hold the stump outside the abdominal cavity
after the incision is completely closed. The advantages in using wire
is that in case hemorrhage occurs, as may happen from shrinking of the
pedicle, a few turns of the screw tighten the wire so that the bleeding
is promptly arrested. Mr. Tait refers to the operation as the easiest
" in abdominal surgery, and every country practitioner ought always to
be ready to perform it. No special instruments are required nothing
but a knife, a piece of rubber drainage-tube, two or three knitting-
needles, and a little perchloride of iron." The stump is brushed over
with a solution of the perchloride of iron. The transfixion needles are
removed in ten to twelve days. In case the intra-peritoneal treatment
of the stump is selected, the operator begins by carefully stitching the
mucous membrane of the stump with silk sutures ; next the muscular
tissue is stitched over this, and finally the serous above it. If any
bleeding occurs upon removing the rubber tube, additional stitches are
taken, or the afferent vessels of the broad ligaments ligated. When all
bleeding is stopped the pedicle is dropped in the abdominal cavity.
GASTRO-ELYTROTOMY. This operation was first suggested by Jorg, in 1807,
attempted by Ritgen in 1821, advocated by Auguste Baudelocque in 1823,
twenty years later attempted twice by him, the first attempt a failure, but in the
second a dead child delivered and the mother perishing seventy hours afterward,
done in Italy in 1857, the child saved but the mother dying, was again brought
before the profession by Thomas in 1870. Whatever of fame and success the
operation had during the brief period of its limited acceptance is chiefly due to
T. Gaillard Thomas. But, as Winckel states, the operation rested on false
premises regarding the peritoneum. Its success, too, is inferior even to the
operation of Porro. Clark 1 gives the maternal mortality as 54 per cent., and the
foetal as 36 per cent. The special purpose of the operation was to avoid exposing
the peritoneal cavity, and it accomplished this by making an opening into the
vagina, beginning with an incision upon one side about an inch above Poupart's
ligament ; the tissues were divided to the peritoneum, and this was separated
until the lateral cul-de sac of the vagina was reached ; the wound was four and
a half to five inches long ; a small incision was made into the vagina, and the
opening enlarged by tearing ; the os was dilated, and child and placenta were
removed through the abdomino-vaginal wound.
" The operation has no future." Winckel, in condemning it, hopes that his lines
may hasten it once more to a silent burial, and that it may have no resurrection.
POST-MORTEM DELIVERY. The Csesareau operation was originally
done in case of women advanced in pregnancy dying undelivered. This
was the civil law in Rome 2 dating from the time of Numa Pompilius.
1 Contribution to k 1' Etude de la laparo-elytrotomie, 1887.
2 In Plutarch's Lives it is stated that Scylla having died, his wife, " Valeria was afterward
delivered of a daughter, named Posthuma ; for so the Romans call those who are born after the
630 THE PATHOLOGY OF LABOR.
But the fact that post-mortem delivery by an abdomino-uterine incision was
recognized in ancient mythology as is exhibited by the history of the birth of
Bacchus, the god of wine, and that of ^sculapius, the god of medicine renders
it probable that the operation is still older.
The Church, as Hubert remarks, merely reproduced the injunction of the
Roman law in the following degree of its Ritual : Si mater prsegnans mortua ait,
iructus quam primum caute extrahatur.
As has already been indicated, the method of delivery after the mother's death,
exclusively recognized in ancient times, and indeed that which has most gen-
erally been employed since, was the Csesarean section. Unfortunately, in some
instances in which it has been resorted to the woman was not dead, and more
than one operator has fled horror stricken. upon finding the manifestations of
life when he thought his incisions were made upon a corpse.
ThSvenot 1 has earnestly contended for delivery through the natural
passage, as successfully accomplished by the Italian school, especially
by Rizzoli, and asserts that the post-mortem Csesarean operation belongs
to another age and ought to disappear from our practice. Depaul, in
1861, said, " I cannot too strongly insist, with almost all those who have
studied this subject, upon the advantages which extraction of the infant
by the natural passage gives. One ought not to hesitate in the appli-
cation of a bistoury to the cervix and relieving resistance by multiple
incisions. There can be thus obtained in a few seconds sufficient dila-
tation to perform version or to apply the forceps." There have been
several successful deliveries effected in this way, 2 but, of course, it is
only applicable in normal conditions of the pelvis, and will be most
successful when the death of the mother occurs during labor. The
method is especially applicable in cases of apparent death, or when
there is doubt in regard to the question as to whether life is actually
extinct.
If the Csesarean operation is employed, the same precautions should
be used as if it were being done upon the living subject. Only a small
minority of children can be thus saved ; the successes generally occur
only in those cases in which the mother has died suddenly, and when
the operation is done within twenty-five minutes after her death.
father's death." It might be justly implied from this that the removal from a dead mother ot a
living child was unknown among the Romans. Readers of Shakspeare will be reminded in the
play of Cymbeline of the words spoken by the apparition of the father of Leonatus Posthumus :
Hath my poor boy done aught but well,
Whose face I never saw ?
I died whilst in the womb he stay'd,
Attending Nature's law.
By the way, the mother's words, following those of the apparition, point clearly to a successful
Csesarean operation:
Lucina lent me not her aid,
But took me in my throes ;
That from me was Posthumus ript, etc.
1 De 1' Accouchement artiflciel par les voies naturelles substitute a 1'opgration Cesarienne post-
mortem. Paris, 1878.
2 Dr. Barton C. Hirst has reported a case in which the post-mortem Caesarean operation was
avoided by dilatation of the os while the woman was dying ; the dilatation was accomplished in
a few minuies, and a living child extracted. Philadelphia Medical News, May 24, 1890.
According to Auvard, this method of delivery, accouchement forc6 pendant 1'agonie, was directed
by Costa in 1827. He states that unless there is an urgent indication, it is preferable not to
trouble the final minutes of the dying by an intervention which can be as well done after life
ceases. Nevertheless, in Dr. Hirst's case there does not seem to have been any disturbance of the
patient by the intervention. Millot, De I'Obstetrique en Italie, 1882, gives 14 cases, the first in
1858, the last in 1870. of this method of delivery, 5 of the 14 women suffering from pulmonary
phthisis. Only 3 of the 14 children were delivered alive.
CHAPTER XIV.
EMBRYOTOMY.
EMBRYOTOMY includes all operations employed to lessen the size f
the foetus, facilitating or rendering possible its transmission through the
birth-canal. These operations embrace, therefore, perforation of the
cranium and removal of its contents, cephalotripsy, cranioclasm, break-
ing up the base of the cranium as by transforatiou, the method of
Hubert, or by the basiotribe of Taruier, or by the basilyst of Simp-
son and the division of the head into sections, or lamination, decolla-
tion, evisceration, and spondylotomy.
Embryotomy is one of the oldest obstetric operations, directions for its per-
formance having been given by Hippocrates. All obstetricians recognize it as
not only a right, but also a duty in certain circumstances, to perform embry-
otomy upon the dead foetus ; while some, and the number is steadily increasing,
condemn its performance when the child is alive ; some, indeed, have had so
strong a repugnance to directly sacrificing the life of the child that they have
done it indirectly, waiting until it died before resorting to the operation, thereby
in no sense evading the responsibility for its death, and at the same time by delay
adding to the perils of the mother. The principle of morals upon which most
obstetricians rest the right to sacrifice the child for the sake of the mother is a
very old one, and has met with general acceptance ; that principle, clearly
enunciated by Cicero, 1 for example, and sustained in general by moralists of all
ages, is that if two lives are in such peril that both cannot be saved, but one
will be by the sacrifice of the other, let that life which is of least value to the
State, or to society, perish. It is unnecessary to show that the adult woman
with her various domestic and social duties, has a life of greater value than that
of the unborn child ; and, therefore, while the duty of the obstetrician is to save,
both when he can, if either is to be sacrificed let it be that of the latter in other
words, if in a given case embryotomy is a less risk to the mother than Csesarean
section, the former should be selected. This is a rule of obstetric ethics which
cannot be set aside. Fortunately the brilliant successes recently had by a few
operators in Germany render it highly probable that embryotomy upon the living
foetus will soon be restricted to very narrow limits.
Symphyseotomy, too, promises much in lessening the occasion for craniotomy
upon the living child. Nevertheless, there are conditions which clearly justify
it. For example, in case of hydroc'ephalus, or in that of a monstrosity, causing
an obstacle to delivery, we do not hesitate to sacrifice the life of the child for
the safety of the mother. Further, in case of threatened rupture of the uterus,
immediate delivery is imperative; and frequently this delivery can be most
promptly accomplished by lessening the size of the child.
Winckel admits craniotomy upon the living child, first, if its life is much en-
dangered so that its chances of being saved are improbable, in order to protect
the mother, as far as possible, from the dangers of a more difficult operation ;
and, second, if a relative indication for the Csesarean section exists that is, if
the child cannot be delivered through the pelvis as it is, and the mother firmly
refuses the operation. "The percentage of maternal deaths in the hands of
1 " Quid, si in una tabula sint due naufragi, hique sapientes, sibine utervis rapiat, an alter cedat
alteri? Cedat vero ; sed ei, cuius magis intersit vel sua, vel reipublicse causa, vivere. Quid, si
haec paria in utroque? Nullum erit certamen, sed, quasi sorte aut micando victus, alteri cedat
alter." (Cicero de Offlciis, Book III., xxiii. Pereya'sed.)
632 THE PATHOLOGY OF LABOR.
skilful operators is reckoned at after perforation and as at least 8.4 per cent,
after the Csesarean section. The former is entirely free from danger, and the
latter, especially in the hands of an inexperienced man, can only be designated
as quite dangerous; therefore, perforation of the living child will be considered
justifiable in many cases." 1 Winckel also states that craniotomy must not be
performed on a living child without the mother's consent.
Auvard says : " If the life of the child were as valuable as that of the mother
there could be no hesitation in giving the preference to hysterotomy ; but the
appreciations are different in this regard, and while the Caesareans say that the
life of a perfectly developed infant is more precious than that of a woman unfit
for procreation, the anti-Csesareans reply that the life of the newborn, sur-
rounded by so many dangers, cannot be regarded as equal to that of a healthy
woman.' 1
" If it were your wife or your child, what would you do? 1 ' The Csesareans
are embarrassed, for if obedient to their principles, they will be considered bad
husbands. On the other hand, the anti-Csesareans will seem to be bad fathers,
for they do not hesitate to sacrifice their child. In this question, which ought
to be purely scientific, it is better that sentiment should not enter, or it becomes
insoluble. However, in accepting that the life of the mother has a greater value
than that of the child awaiting birth, we may attempt to indicate the better
choice between the operations, though confessing that it is arbitrary and ad-
mits of discussion.''
Cancer of the uterus or of the vagina suggests hysterotomy rather than em-
bryotomy, is generally held by obstetric authorities. Again, if the pelvic con-
tractions be such that a living child may be born were premature labor induced,
and the pregnancy is at term, embryotomy is selected with the hope that a sub-
sequent pregnancy may occur and be prematurely terminated, is an opinion
expressed by Auvard. The more difficult cases for decision are those in which
it is impossible, on account of the pelvic deformity, for a woman to give birth to
a living child, though premature labor be induced, and embryotomy can be done
with little risk to the woman's life. Here Auvard, Winckel, and, indeed, the
majority of obstetricians, would leave the decision to the woman herself.
I think most practitioners will coincide with the opinion of Naegele, in saying
that if the indication is only relative and the mother, in sound mind and after
mature reflection, positively refuses to submit to the Csesarean operation, it
would be an unjustifiable cruelty to compel her to undergo it.
Dr. Jaggard has given, in the American Journal of Obstetrics, the
following as the expression of Carl Braun's views in regard to the rela-
tive indication for the Csesarean operation :
Ca3sarean section on the living woman, for the preservation of the living foetus
in pelvic deformity in which the child, dead and diminished in volume, can be
extracted through the pelvic canal, and the health of the mother can with prob-
ability be preserved by the perforation of the child's head is not permissible
under the following conditions :
a. When the parturient woman, in full consciousness and without any direct
coercion, declines Csesarean section.
b. When the parturient woman is rendered unconscious by disease (eclampsia,
meningitis, apoplexy, etc.), by medicines (chloroform, ether), by poisons, or in-
toxicating drinks.
c. When the child's life has been imperilled by uterine contractions, attempts
at version, or the forceps, or when the child is deformed or not viable.
For a series of years not a single parturient woman in the Vienna Lying-in
Hospital has determined to submit to Csesarean section upon the ground of the
relative indication.
INDICATIONS. Those relating to the pelvis or caused by cancer of
the uterus or vagina have already been stated. The operation has also
1 Runge gives the maternal mortality in general at 18 to 20 per cent.
EMBRYOTOMY.
633
been done iu hypertrophic elongation of the cervix and in cicatricial
contraction of the vagina. Excessive size of the foetus, and a neglected
shoulder presentation in which version is impossible or would be at-
tended with imminent danger of rupture of the uterus, are indications.
It may be necessary in a brow or parietal presentation, or in that of
the face when anterior rotation is impossible.
CRANIOTOMY. Most frequently reduction of the size of the foetal
head is necessary, and the first step is perforation. So, too, perforation
precedes the application of the cephalotribe, or its most recent modifi-
cation, the basiotribe, or of the crauioclast.
PERFORATION. Reduction of the size of the head, whether this
comes first or last, is necessary. Supposing the head presents, the first
step is perforation of the cranium. In order that this may be done
readily and safely, the head must be held by an assistant, who presses
upon it through the abdominal wall with his hand during perforation.
o
, -*
03
Atavism, infantile, 161
Atresia of os, 486
Atrophy, acute yellow, of liver, 424
Atrophy of the decidua, 448
Attitude of foetus in womb, 150
Auscultation in diagnosis of pregnancy, 197
in plural pregnancy, 203
Axes of the pelvis, 29
Axis-traction by Poullet's method, 604
BAG of waters, 241
Ballottement, 192
Bandage, application of abdominal, after labor,
316
Band 1's ring, 180
Barnes's treatment of placenta prsevia, 888
bags or dilators, 390
Bartbolin, glands of, 580
Basilyst, 634
Basiotripsy, 636
Basiqtribe, Tarnier's, 637
Bathing during pregnancy, 220
of the newborn child, 309, 355
Battledore placenta, 137
Bed, preparation of the, for labor, 297
Biestings, 342
Bifid uterus, 86
Birth-canal, genital portion, 43
Births, precocious, 210
Bladder, calculi in, obstructing labor, 492
condition of, in first stage of labor. 298
discharges from, of child, 353
distention of, in pregnancy, 437
in the puerperal state, 346
irritability of, during pregnancy, 187
Blastodermic vesicle, 121
Bleeding in eclampsia, 416
Blot's perforator, 633
Blood, changes of, in pregnancy, 416
Bloodvessels, changes in, of the uterus in puer-
peral state, 340
Blunt hook, 325
Body, delivery of, 307
Bowels, condition of, in puerperal state, 346
discharges from, of child, 353
Breasts, anatomy of, 87
anomalies of, 91
care of, during pregnancy, 221
during lactation, 349
changes in, during pregnancy, 182, 187
during puerperal state, 343
development of, 91
disease of, in pregnancy, 444
in the puerperal state, 343
enlargement of, in newborn child, 354
Breech-presentation (vide Pelvic), 276
Brim of pelvis, 25
Broad ligaments, 73
Bromide of ethyl, 292
Brow-presentation, 320
Bruit (vide Souffle), 197
Bregma, 146
Bulb of ovary, 76
Bulbs of vagina, 56
Busch's method for performing cephalic ver-
sion, 583
pACAO butter for nipples, 221, 350
L Csesarean operation, 625
indications for, 625
mode of performing, 626
preparation of patient for, 626
time for doing, 626
Calcareous deposits in placenta, 449
Calculi, vesical, obstructing labor, 492
Cancer of uterus complicating labor, 489
Capuron, cardinal points of, 26, 251
Caput succedaneum, 248, 354
changes in, after birth, 354
in shoulder-presentation, 286
secondary, 249
Cardiac disease in pregnancy, 420
Care of the breasts during pregnancy, 221
Carunculse myrtlformes, 49
Catarrhal decidual endometritis, 447
Catheter, introduction of, 49
use of, after labor, 346
Caul, 242
Causes of labor, 231, 234
Cavity of body of the uterus, 59
of neck of uterus, 59
of pelvis, 28
Central rupture of perineum, 545
Cephalic version, 581
Cephalhsematoma, 248, 354
Cephalotripsy, 636
Cervix uteri, 58
cancer of, in labor, 489
in pregnancy, 442
cavity of, 59
changes in, in pregnancy, 178
in the puerperal state. 341
portio yaginalis of, 53
lacerations of, in labor, 550
shortening of, in pregnancy, 178
softening of, in pregnancy, 178
tears of, in labor, 550
Child, condition of, during second btage of labor,
301
artificial feeding of, 357
attention to. 307, 351
bathing of, 355
breasts of, 354
caput succedaneum, 248, 354
cephalhsematoma, 248, 354
care of, 307, 351
changes in the shape of head, 354
circulation, 156
clavicle, fracture of, 307
discharges from bladder and bowels, 353
dressing, 310
dressing cord, 309
injuries to, by forceps, 618
jaundice of, 354
milk-secretion of, 354
muguet in, 358
newborn, apparent death of, 310
nourishment of, 355
skin-desquamation of, 354
sleeping of, 355
sprue in, 358
thrush in, 358
umbilical cord, 353
hemorrhage from, 353
urination, difficulty and pain in, 358
washing, 355
wet-nurse, selection of, 356
Childbed (vide Puerperal state), 333
Choc, foetal, of Pa jot, 200
Chloral in eclampsia, 417
in labor, 292
Chloroform in eclampsia, 417
in labor, 292
Cholera in pregnancy, 429
Chorea in pregnancy, 425
treatment of, 426
Chorion, 127
Chronic infectious diseases in pregnancy, 422
Cicatrices of vagina complicating labor, 492
of os, 486
Circulation at birth, 158
placental, 156
vitelline, 156
Circulatory apparatus, changes in, in pregnancy,
167
Clefts, visceral, 139
palate, 141
Clitoris, anatomy of, 48
length of, 48
Cloaca, 81
Clothing during pregnancy, 218
Cocaine, 487
Coccyx, recession of, 27
Cohen's method of treating placenta prsevia, 391
Coiling of umbilical cord, 454
Coitus during pregnancy, 219
Columnse rugarum, 54
Combination of male and female elements, 113
Combined turning in placenta prsevia, 389
Complex presentation of foetus causing dystocia,
534
INDEX.
681
Conception, 108
time of, 114
of year most favorable to, 117
Conduct of labor, 289
Confinement, prediction of date, 209
Constipation in pregnancy, 227
in puerperal septicaemia, 667
Contracted pelvis indicating induction of pre-
mature labor, 577
Contractility of uterus during pregnancy, 176
Contraction, uterine, force of, in labor, 237
Contractions, abdominal, in labor, 238
uterine, characteristics of, in labor, 236
nerve-centre controlling, 70
Convulsions, puerperal (vide Eclampsia), 406
Cord, umbilical (vide Umbilical cord), 134, 353
anomalies of, 454
pathological conditions of, 455
Corpora albicantia, 96
Corpus luteum, 96
false, 96
true, 96
Course of twin pregnancy, 165
Couveuse, 352
Coxalgic, obliquely contracted pelvis, 518
Cramps in lower limbs in second stage of labor,
301
Cranial presentation (vide Vertex), 252
Cranioclasm, 635
Cranioclast, Braun's, 635
Simpson's, 635
Craniotomy, 633
Cranium, foetal, 145
Credo's method of placental expression, 314
Crural hernia of uterus in pregnancy, 441
phlegmon in puerperal state, 664
Cystic decidual endometritis, 447
Cystocele complicating labor, 491
DEATH, apparent, in newborn, 310
treatment of, 311
oi foetus, 462
consequences of, 462
liquefaction, 463
maceration , 464
mummification, 463
putrefaction, 464
diagnosis of, 462
sudden, during or following labor, 672
from accidents of labor, 675
from different diseases, 675
from pulmonary embolism, 673
from syncope, 672
from the entrance of air into the uterine
veins, 674
Decapitation, 639
Decidua, atrophy of, 448
formation of, 119
reflexa, 119, 172
serotina, 119
syphiloma of, 450
yera, 119. 172
Decidual endometritis, 447
catarrhal, 447
cystic, 447
diffuse, 447
polypoid, 447
Decollation, 639
Deficiency of uterine force in labor, 478
Deformities of pelvis caused by fractures or by
neoplasms of the pelvic bones, 520
Degeneration, hydatidiform, of the placenta, 451
myxomatous, of placenta, 451
Delivery, diagnosis of recent, 351
difficult, of shoulders, 306
of body, 307
of head, in head-last labors, 322
of shoulders, 306
post-mortem, 629
preparation for, 302
Derotomy, 639
Descent of head in labor, 260
Desquamation of skin in newborn, 354
Detachment of placenta, causes of, 382
complete, in treatment of placenta prsevia,
Detachment, partial, in treatment of placenta
prsevia, 388
Determining causes of labor, 231
Development of embryo and foetus, 138
of female generative organs, 80
external organs of generation, 80
internal organs of generation, 81
of mammae, 91
| Diagnosis, differential, of pregnancy, 204
Diameters of ftetal head, 147
of maternal pelvis, 25-28
Differences in pelvis as to individuals, sex, age,
and race, 33
I Diffuse decidual endometritis, 447
I Digestive organs, condition of, in puerperal state,
i 336
Dilatation of os uteri in labor, 240
active interference with, 298
of vagina, 243
of vulva, 243
sacciform, of posterior wall of uterus during
pregnancy, 440
Dilators, Barnes's, 390
Directions, special, in labor, 294
Disease, malignant, of uterus, in pregnancy, 442
of breasts during pregnancy. 444
of mother as an indication for jnduction of
premature labor, 578
syphilitic, of placenta, 450
Diseases, accidental, occurring to puerperal
women, 645
acute infectious, during pregnancy, 427
of foetus, 460
chronic infectious, during pregnancy, 422
of foetus, 460
exaggerations of physiological conditions of
pregnancy, 395 et seq.
infectious, in puerperal state, 642, 647, 651
intercurrent, in pregnancy, 420
of heart during pregnancy, 420
of newborn, 675
acute fatty degeneration, 678
hsemoglobmuria, 678
erysipelas, 675
gonorrhoea, 677
melsena neanotorum, 678
sclerema neonatorum, 675
tetanus, 676
of umbilicus, 675
umbilical hernia, 67 9
of ovum, 447
of placenta, 449
of sexual organs in pregnancy, 433
of various organs of foetus causing dystocia,
522
sporadic, during pregnancy, 423
structural, of the uterus in pregnancy, 442
during labor, 489
Disinfection, 190
Displacement of foetal arm, dorsal, causing dys-
tocia, 537
Displacements of uterus during pregnancy (viite
Uterus).
Double vagina and uterus, 86
Douglas's cul-de-sac, 52
D'Outrepont, method of, performing cephalic
version, 583
Drink in first stage of labor, 298
in second stage of labor, 302
Dry labor, 242
Duration of labor, 247
of pregnancy, 209
Dynamic pelvis, 23
Dystocia, foetal, 530
from abdominal tumors, 487
from advanced ossification of the head of the
foetus, 523
from anomalies of adjacent organs, 490
from cancer, 489
from dorsal displacement of arm, 537
from double monstrosities, 527
from great size of foetus, 522
from great size of foetus from pathological
causes, 523
ascites, 527
diseases of various organs, 527
encephalocele, 527
682
INDEX.
Dystocia, from great size of fretus from patho-
logical cause hydrocephalus, 527
hydromeningocele, 527
hydronephrosis, 527
hydrothorax, 527
new growths and foetal inclusion , 527
retention of urine, 527
single monsters, 527
from prolapse of members, 535
or umbilical cord, 538
in complex presentations, 534
in malpresetHations, 534
in plural deliveries, 530
UCLAMPSIA, 406
LJ attack of, 407
Csesarean operation in, 418
diagnosis of, 414
essential cause of, 412
etiology of, 411
exciting causes of, 412
influence on pregnancy and labor, 414
mortality in, foetal and maternal, 409
pathological appearances in, 411
predisposing causes of, 411
premonitory symptoms of, 407
prognosis, 410
treatment, 415
medical, 415
obstetrical, 418
prophylactic, 451
Embryo, 123
formation of, 128
EmphjMema in labor, 477
EncepHalocele, 527
Episiotomy,305
Ergot in labor, 314. 483
Expulsion of body in labor, 263
Extension of head in labor, 262
FACE, anomalies of, mechanism in, 275
auscultation in, presentation of, 271
causes of presentation of, 269
descent of, in presentation of, 272
delivery of body in presentation of, 275
delivery of head in presentation of, 274
diagnosis of presentation, 270
external rotation of head, 275
frequency of presentation, 269
internal rotation of body in presentation of,
275
management of, presentation of, 319
mechanism of labor in, presentation of, 270
plastic changes in, presentation of, 275
presentation of, 269
prognosis of, 288
rotation of, 272
Fecundated ovule, changes in, 118
Feeding, artificial, 357
Flexion of head in labor, 258
Foetal appendages in plural pregnancy, 164
Fcetal head, 145
diameters, 147 '
fontanelles, 146
movements, 149
sutures, 146
Foetal heart, sounds of, 199
trunk, diameters of, 149
Foetus, anatomy of, 138
anomalies of, 522, 527
double monstrosities, 527
hydrocephalus, 523
single monsters, 527
size of, 522
attitude of, in womb, 150
development of. 138, 145
pathology of, 459
amputations of members, 461
fractures of, 461
infectious diseases occurring in, 460
luxations, 461
rachitis, 461
tumors, 462, 527
physiology of. 138
positions of, 431
Foetus, positions of, left fronto-anterior, 271
left occipito-anterior, 256
left occipito-posterior, 266
left sacro-anterior, 281
right occipito-anterior, 265
right occipito-posterior, 266
right sacro-posterior, 282
presentation of, 151
Forceps, application of, in head-first labor, r>14
to pelvis, 617
conditions necessary for use of, 604
historical, 589
indications for use of, 604
in face-presentation, 615
in head-last labor, 614
Ostermann's method in occipito-posterior
position, 614
powers of, 596
preparations for using, 606
varieties, 591
Funic souffle, 200
n ALACTORRH(EA, 350
U Gavage, 352
Gingivitis, 229
TT^MORRHOIDS, 227
U Hegar's sign of pregnancy, 193
Hemorrhage, accidental, 392
treatment of, 394
after birth of child, 560
secondary, 565
symptoms of, 561
treatment of, 562
Heredity, influence of, 115
Hips, presentation of, 324
application of blunt hook in, 325
fillet in, 327
Pinard's method in, 330
traction with fingers in, 327
treatment in, 325, 330
Hydrsemia during pregnancy, 400
Hymen, 49
Hyperemesis, 395
causes of, 396
treatment of, 397, 398
TNSOMNIA, 229
JAUNDICE of newborn, 354
V
T ABIA majora, 47
Jj minora, 47
Labor, anaesthesia in, 291
antiseptics in, 290
artificial, 231
conduct of. 289
delayed, 231
determining causes of, 231
diagnosis of, 252
discharges in, 243
duration of, 247
effects of, upon the child, 246
effects of, upon the mother, 247
efficient causes of, 234
first stage of, 298
condition of bladder and bowels in ,
298
food and drink in, 298
presence of physician in, 299
mechanical phenomena of, 250, 288
missed, 216
pathology of, 477
anomalies of adjacent organs, 490
anomalies of force in, 478
excess of force, 477
deficiency of force, 478
perversion of, 483
of soft parts, 485
of os uteri, 485
INDEX.
683
Labor, pathology of, anomalies of uterus, 480
injuries to maternal soft parts, 543
inversion of uterus, causes, 568
diagnosis, 569
prognosis, 571
symptoms, 569
treatment, 571
rupture of uterus, 551
symptoms of, 557
threatened, 555
treatment, 558
tears of cervix, 550
of perineum, 554
of vagina, 545
of vulva, 544
thrombus of vagina, 548
of vulva, 548
pain in, 238
phenomena of, 236
physiology of, 231
precursors of, 234
prediction of date of, 209
premature, 231
preparation of bed in, 297
of patient in, 97
second stage of, condition of child in, 301
os uteri in, 301
cramps in lower limbs in, 301
drink in, 302
food in, 302
management of, 299
of twin labor, 330
perineum, care of, 302
preparation for delivery in, 302
special directions in, 294
stages of, 235
Lactation, 347
obstacles to, 348
treatment of, 348
Levelling, 243, 260
MAMMAE, 87
develdpment of, 91
" Maternal impressions," 222
opinions of Barker on, 222
of Weissmann on, 225
Menstruation, 97
first causes of,, 101
genital sense, 102
heredity, 101
race, 101
residence, 101
theories of, 103
Mind, condition of, in pregnancy, 221
Mons veneris, 46
Morning sickness, 166
treatment of, 225
Mother, attention to, after second stage of labor,
314
VTAVICULAR fossa, 50
II Nervous system, changes of, in pregnancy,
170
Neuralgia, 229
It
fPDEMA of legs, 227
VJL Omphalorrhagia, 353
Operations, obstetrical, 573
anaesthesia in, 573
antiseptics in, 573
Farabeuf s, 624
induction of abortion, 574
indications for, 575
means of, 577
prognosis in, 577
induction of premature labor, 577
indications for, 577
means of, 579
prognosis in, 579
placenta, removal of, 620
symphyseotorny, 621
version, 581
bimanual, 583
cephalic, 581
Operations, version, podalic, 584
Os uteri, dilatation of, in labor, 240
Osteophytes, 171
Ovaries, 74
aspect of, 76
bulb of, 76
form, 76
hilum, 76
nerves, 78
size, 76
structure, 77
vessels, 78
Oviducts, 79
Ovisacs, 78
Ovulation, 92
PAIN, after labor, 334
character of, in labor, 239
false, 247
seat of, in labor, 239
Palpation, abdominal, 193
Parbvarium, 73
Pelvimetry, 497
Pelvis, anatomy of, 21
anomalies of, 493
ankylotic, 513
transversely contracted, 513
coxalgic, obliquely contracted, 518
deformity from neoplasms, 520
diagnosis of, 496
form, 493
generally contracted, flat, 509
justo-major, 501
justo-minor, 501
labor in, 501
kyphotic, 516
Naegele's, 493
osteomalacic, 511
position, 493
simple, flat, 504
spondylolisthetic, 509
axis of, 29
cavity of, 28
dynamic, 42
floor of, 39
inclined plane of, 28
inlet of, 25
joints of, 21
changes in, 172
inflammation of, 400
movements of, 23
relaxation of, in pregnancy, 399
rupture of, 400
treatment of, 399
uses of, 24
horizontal planes, 29
obliquity of, 29
differences of, 33
in individuals, 33
in races, 36
in sexes, 34
presentation of, 276
anomalies of mechanism in, 280
causes of, 276
compression of, in, 279
delivery of body in, 280
descent in, 279
diagnosis of, 277
external rotation of trunk in, 280
internal rotation of head in, 280
mechanism in different positions, 281
of labor in, 279
plastic changes in, 281
positions of, 281
rotation of anterior hip in, 279
segments of, 42
soft parts of, 37
varieties of, 276
Perineum, 41
care of, 302
central rupture of, 545
changes of, in pregnancy, 172
frequency of rupture of, 302
tears of, in labor, 543
Phenosalyl, 573
Placenta, 128
684
INDEX.
Placeuta, anomalies of, circumvallata,
strata, marginata. 449
of structure, 449
calcareous deposits, 449
my xomatous degeneration. 450
fibrous, 450
detachment of, '244
expulsion of, 314, 315
inflammation of, white infarcts, 450
position of, 130
prsevia, 376
causes of detachment in, 382
complications of, 380
diagnosis of, 383
etiology, 378
frequency of, 378
hemorrhage and its source, 381
prognosis in, 384
treatment of, 384
Barnes's, 388
Cohen's method in, 391
combined method in, 389
ergot in, 388
Ford's method, 392
Murphy's method, 390
Puzos' method, 391
Simpson's method, 388
tampon in, 385
varieties of, 378
syphilis of, 450
tuberculosis of, 451
uses of, 132
Pregnancy, 151, 255
breasts, diseases of, in, 444
cholera in, 429
chorea in, 425
cystitis in, 444
decidua, atrophy of, in, 348
diabetes mellitus in, 444
diagnosis of, 184, 201
differential, 204
diphtheria in, 432
duration of, 209
ectopic, 360
causes of, 360
diagnosis of, 370
frequency of, 361
prognosis of, 372
rupture of, 372
diagnosis of, 374
treatment of, 374
treatment, 372
abdominal section in, 374
electricity in, 372
elytrotomy in, 375
morphia in, 372
varieties, 362
abdominal, 368
intra-iigamentous, 370
interstitial, 375
ovarian, 367
tubal, 362
tubo-ovarian, 367
endometritis, decidual in, 447
catarrhal in, 447
cystic in, 447
diffuse, 447
polypoid, 447
epilepsy in, 427
erysipelas, 431
.fevers in, 428
intermittent, 428
typhoid, 427
yellow, 428
heart, diseases of, in, 420
hygiene of, 217
hysteria in, 426
influenza In, 431
jaundice in, 424
Kidney, 404
leucorrhcea in, 434
management of, 318
nephritis in, 444
pertussis in, 432
phenol in, 202
phthisis in, 422
pleurisy in, 424
fene- Pregnancy, pneumonia in, 423
prolonged, 211
rubeola in, 431
signs of, 186
scarlatina in, 431
syphilis, 422
traumatisms in, 444
tumors in, ovarian, 443
uterus in, 434
anteflexion of, 435
anteversion of, 435
hernia of, 431
prolapse of, 434
prociaentia, 434
retroflexion, 436
retroversion, 136
structural diseases of, 442
vagina, prolapse of, in, 433
variola, 430
vulva, vegetations of, in, 433
Pseudo-cyesis, 206
Puberty, 92
Puerperal fever, 651
clinical course, 666
prognosis, 667
treatment, 667
colpitis in, 658
endocarditis, ulcerative, in, 670
endometritis in, 658
treatment, 659
entrance of poison in, 656
influence of the air in, 657
mildness or severity of infection,
657
parametritis in, 660
perimetritis, 662
phlegmasia alba dolens, 663
prognosis, 664
symptoms, 663
treatment, 664
prophylaxis, 671
saprsemia, 665
severe forms of, 665
pyaemia, 668
septicaemia, 665
temperature in, 657
time of infection, 658
ulcers in, 658
state, 333
management of, 333
attention to child in, 351
to mother in, 343
care of genital organs during, 346
change in weight during, 342
condition of bladder and bowels in,346
digestive organs in, 336
food in, 345
lochia in, 336
perspiration in, 335
pulse in, 334
respiration in, 335
rest during, 344
retention of urine in, 336
secretion of milk, 324
temperature in, 335
pathology of, 641
breasts, diseases of the, 641
erysipelas, 646
insanity, 648
etiology, 649
prognosis, 649
treatment, 649
Insanity of lactation, 649
malarial fever, 645
mastitis, 642
treatment of, 643
melancholia, 648
neuralgia of the lower limbs in, 650
nipple, diseases of, 641
paralysis of the lower limbs in, 650
( vUICKENING, 187
RESPIRATION in pregnancy, 168
Rotation of head in labor, 260
INDEX.
685
Rotation, external, of head in labor, 262
of body in labor, 262
OALIVATION, 226
Banger's sign of pregnancy, 191
Scarlatina in pregnancy, 431
in the puerperium, 645
Seminal fluid, 109
Sex, prediction of, 200, 201
production, 115
Sexual organs, 46, 91
anomalies of, 80
changes of, in labor, 235
after labor, 338
involution of uterus, 338
neck of uterus, 341
position and form of uterus, 340
changes of, in pregnancy, 171
uterus, 172
vagina, 171
vulva, 171
development of, 80
Shoulder, presentation of, 282
auscultation in, 284
causes of, 282
compression in, 285
delivery of body in, 285
delivery of head in, 286
descent in, 285
diagnosis of, 282
external rotation of body in, 286
internal rotation of head in, 286
prognosis of, 288
rotation of shoulder in, 285
spontaneous delivery in, 285
Shoulders, delivery of, 306
difficult delivery of, 306
Skin, changes of the, in pregnancy, 169
Souffle, uterine. 198
Spermatozoids, 110
Striae gravidarum, 170
Super-fecundation, 163
-impregnation, 163
fcetation, 163
Synclitism, 260
^TETANUS in the newborn, 676
1 in the puerperium, 646
Touch, rectal, in labor, 192, 255
vaginal, 189
vesical, 192
TTMBILICAL cord, 134
U Uterine ligaments, 72, 73
Uterus, 57
bloodvessels of, 65
cavity of body of, 59
cavity of neck of, 60
lymphatics of, 68
mucous membrane of, 65
muscular coat of, 61
nerves of. 69
peritoneal coat of, 60
position of, 60
structure of, 60
\TAGINA, 51
V dilatation of, in labor, 243
Vaginal bulbs, 56
Varices, 227
Vectis, 619
Vertex presentation, 252
auscultation in, 254
descent of head in, 260
diagnosis of, 252
expulsion of body in, 263
extension of head in, 262
external rotation of head in, 262
flexion of head in, 257
internal rotation of body in, 262
mechanism of labor in, 257
position in, 255
prognosis of, 288
rotation of head in, 260
Vestibule, 50
Vulva, 50
dilatation of, in labor, 243
pruritus of, 227
general, 227
Vulval canal, 50
glands, 50
YlfET-NURSE, selection of, 356
Date Due
CAT. NO. 23 233 PRINTED IN U.S.A.
A 000 548 275
WQ100
P2T6s
1895
Parvin, Theophilus.
The science and art of
obstetrics
WQ100
P2?6s
1895
Parvin, Theophilus.
The science and art of obstetrics
CALIFORNIA COLLEGE OF MEDICINE LIBRARY
UNIVERSITY OF CALIFORNIA, IRVINE
IRVINE, CALIFORNIA 92664