THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY THE NEW SYDENHAM SOCIETY. Instituted MDCCCLVIII. VOLUME CXIX. TEXT BOOK OF MIDWIFERY. BY THE LATE OTTO SPIEGELBEKG. Professor of Obstetric Medicine in the University/ of Breslau. TRANSLATED FROM THE SECOND GERMAN EDITION J. B. HURRY, M.A., M.D., Cautah. AAOL. I. ^onbon : THE NEW SYDENHAM SOCIETY. MDCCCLXXXVII. 543 100- inrj OTTO SPIEGELBBRG- was born January 9, 1830, at Peine in Hanover, and after receiving his classical education at Hildeslieim, entered the University of Göttingen at the age of 18. There he began to study Midwifei-y under E. C. J. Von Sieboid, and soon {> PAET II. Physiology and Hygiene op Pregnancy, Parturition and the Puerperal State. CHAP. I.— PREGNANCY. Puberty, menstruation, corpus luteum, impregnation, duration of pregnancy 59 1. Changes in the maternal organism 67 a. In the generative organs and their vicinity 1)7 b. In the organism as a whole 83 2. The embryo, its membranes and appendages 90 a. The development of the ovum 90 b. The foetal appendages 95 <•. The foetus lir> (1.) In the different months of pregnancy 115 (2.) The mature foetus 121 (3.) Attitude, lie and position of the foetus in the uterus 127 (4.) Nutrition and circulation of the foetus 132 Xll CONTKNTS. TACJM 3. The diagnosis of pregnancy '3!* «. The obstetrical examination (uterine souffle, foutal pulse and umbilical souffle) HO b. Diagnostic value of the various sip;ns of pregnancy lf>2 (1.) The vaiions signs of pregnancy l'">2 I "2.) The diagnosis of the period of jiregnancy, the calculation of the date of deliver}' 158 (3.) The diagnosis tetwten a lirst and a subsequent pregnancy 162 (4.) The diagnosis betwteu a living and a dead foetus lö-i The diagnosis of .=cx 1(>5 4. The hygiene of jjregnanc}- 107 CHAP. II.— PAliTUiaTIOX. Determining cause of labour, nerve centres for the uterus? I 'I 1. ThecHnical progress of parturition ("paiii.s", action of abdominal muscles, stages of labour, constitutional symptoms, duration of labour) 1~ I 2. The mechanism of labour l«s a. The mechanism in general (expulsive forces, canalisation of the cervix uteri, of the perineum ; bag of membranes, rotations of the foetus, influence of "pains" on the distribution of blood) !>ii (2.) Face presentations ■ 2-2(> (3.) Brow presentations 2;H1 (4.) Presentations of the pelvic extremity 20;") 3. The management of labour 2.')t) The use of chloroform in labour 2()t> Multiple pregnancies and births (superfcetation and dystocia) 27U CHAP. III.— THE PtJEIlPERAL STATE. (Processes accompanying it.) I. The changes in the maternal sj'stem — a. Involution itsH b. The secretion of milk .-{ül c. The diagnosis of the puerperal state 305 *2. The new-born child 8u» 3. Management of the puerperal state — a. Care of the lying-in woman 31tJ b. Care of the new-born child :',->n PART III. PATHOLOGT and THEKAPEUTICS of PrK(;NASCV, I'ARTLKITION AND THK Puerperal State ( Definition op Ob.stetrical Operation^*). CHAP. I.— THE PATHOLOGY OF PHEGNANCV. 1. Disorders caused by a morbid intensity of physiological phenomena .VM'> (Alterations of blood, anomahes of the circulation and of digestion; urine, skin, neuroses.) 2. Complications due to intercurrent diseases .%(> I Acute infectious disease.s, malaria, icterus, diseases of the heart, diseases of the respiratory passages, syphilis, operations.) Death during pregnancy 3ß7 CONTENTS. Xlll PAGE 3. Anomalies of the sexual organs 371 n. Failures in development 372 b. Displacements 377 (I.) Prolapse of the uerus and vagina 377 (2.) Hernias of the uterus 381 (3.) Anteversion of the uterus 383 (4. ) Retroflexion and retroversion of the uterus 386 <: New formations 398 (1.) Fibro-myoma of the uterus 398 (2.) Cancer of the cervix uteri 402 (3.) Ovarian tumours 403 d. Inflammatory conditions (metritis, endometritis decidualis chronica et catarrhalis, leucorrhoca, abnormal softening and mobility of the pelvic articulations) 408 e. Injury and rupture 415 4. Diseases of the ovum 418 (t. Pregnancy outside the utetine cavity — extra-uterine pregnancy ... 418 h. Anomalies of the decidua (atrophy, aborted ovum and fleshy mole) 447 c. Anomalies of the chorion, myxoma of the chorionic villi, vesicular mole 451 d. Anomalies of the amnion 459 e. Anomalies'of the liquor amnii — hydramnios 460 /'. Anomalies of the placenta 465 (/. Anomalies of the umbilical cord 475 Hernia of the cord 482 ft. Anomalies of the foetus 483 Intra-uterine death (habitual death, maceration and mummifica- tion of the ovum, retained ovum, missed labour) 496 5. Haemorrhage from the uterus— premature termination of pregnancy 505 Menstruation during pregnancy 507 n. Haemorrhage during the first 28 weeks, abortion 508 Ij. HEemorrhage after the 28th week 528 (1.) Hemorrhage due to detachment of the normally inserted placenta 529 (2.) Haemorrhage due to insertion of the placenta at the lower segment of the uterus — placenta prajvia 534 Prolapse of the placenta 550 ILLUSTIIATIONS OP' VOL. I. KIG, PA«E 1. The pelvis ^ 2. Anterior half of pelvis (seen from behind) 10 3. Lateral view of pelvis (seen from within) 10 4. Ditto (without ligaments) 10 Ö. Pelvis from below 11 6. Pelvis (horizontal section) 12 7. Outline of pelvic inlet 14 •S. Outline of pelvic dilatation 14 'J. Outline of pelvic strait 14 10. Outline of pelvic outlet 14 1 1. Showing inclination and axis of pelvis Ifl 12. Posterior half of pelvis 11' 13. Uro-genital and anal regions 27 14. The parturient canal 2s 1 5. Vertical and transverse section of female generative organs 30 If). Median section through female pelvis 3ö 17. Posterior view of the genital tract and its surroundings 42 18. Venous plexus of the genital canal 44 19. Sagittal section through a parturient woman 72 20. Portio vaginalis directed backwards 7(1 21. Portio vaginalis directed forwards 7(! 22. Ovum showing the yolk-sack and the amnion in process of development 91 23. Ovum showing the amniotic folds about to coalesce aud the allantois at an earl}- stage 92 24. Ovum showing the subzonal membrane covered with villi, and the allantois which has undergone further development 92 25. Ovum in which the vascular layer of the allantois has come into contact with the subzonal membrane 94 26. Membranes of a human embryo in situ 9,'> 27. "^ ^ ,,q' [ Ovum becoming embedded in the decidua, and reflexa ia process of " ' t development 9« 30. Section through an incapsuled ovum 97 31. Section through the placental and uterine wall 105 32. Section through the placental and uterine wall IOC 33. "SVreath of capillaries at the margin of the skin and umbilical cord 112 34. Human ovum 12 — 13 days old 118 35. Human ovum at the end of the third or the beginning of the fourth week ... 1 H! 36. Human embryo I« *i7M within its membranes 4 weeks old 116 37. The embryo from fig. 30 magnified IIG .38. Human embryo of the 6th— 7th week magnified 2 diameters 117 39. Foetal head seen from the side 124 40. Fcetal head seen from above 124 ILLUSTRATIONS. XV FIG. PAGE 41. Foetal circulation 13i; 42. Expulsion of the placenta (according to Schultze) 184 43. Expulsion of the placenta (according to Matthews Duncan) 185 44. Section through the frozen body of a woman dying during the period of expulsion 194 45. The uterus and parturient canal of fig. 44, without foetus.... 195 46. Foetal skull 210 47. Shape of the head in vertex presentations (occipito-anterior position), with a well marked caput succedaneum 21,'» 48. Fcetal head born in the second vertex position (moderate pelvic con- traction) 215 49. Shape of head with an anterior parietal presentation 217 50. Face passing through the pelvic outlet and vulva 225 51. Face presentation with chin directed posteriorly 226 52. Shape of the head in face presentations 227 53. Head entering the brim as a brow presentation 231 54. Caput succedaneum of brow presentation 234 55. Shape of the head in a brow presentation 235 5(5. The lateral flexure of the trunk accompanying delivery in a breech presentation 239 57. Interlocking twins 283 58. Foetal circulation 300 59. Circulation in the new-born child , 309 60. Ch-culation in an adult 309 61. Uterus displaced backwards 387 62. Retroflexion of the gravid uterus, showing the distended bladder with the mucous membrane and a portion of the muscularis detached and in a state of gangrene 390 63. Diagram of an incomplete retroflexion 397 64. Tubal pregnancy of the left side 422 65. Pregnancy in a left rudimentary horn 424 66. Interstitial pregnancy 426 67. Interstitial pregnancy 427 68. Ovum with an imperfectly developed decidua ; external surface of the vera 448 69. Blood-mole with extravasations and blood-cysts on the foetal surface 450 70. Vesicular mole in the uterus 452 71. Portion of the uterine wall from fig. 70, showing the way in which the degenerated villi involve the muscular tissue 454 72. Torsion of the cord 479 73. Torsion at the foetal end 479 74. Amputation of the left fore-arm. with rudimentary formation of fingers 487 75. Uterus with the nucleus of a fibrinous polypus after abortion , 516 INTRODUCTION. § 1. The study of Midwifery, according to the meaning of the word, includes the science and art which relate to the act of parturition, both under normal and abnormal conditions. But parturition constitutes only one of a series of eventr, which begin with conception and end with the puerperal state. The various phenomena which accompany parturition can therefore only be fully appreciated when considered in relation to the development which has preceded them; their significance is often manifest only in relation to the puerperal state. The pro- vince of Midwifery must therefore be extended; pregnancy and the puerperal state must be included in its teaching. Thus Midwifery comes to be the Study of the Processes of Ttcpro- duction, of the Child-hearing Period in its wider sense ; indeed it forms a division of Gynaikology, of which another division deals with the remaining sexual functions under healthy and morbid conditions. § 2. The object of Midwifery is to render assistance to woman during pregnancy, childbirth, and the puerperal state, whether these events follow a normal or an abnormal course. Hence arises a natural division of the subject-matter of the following work. The first part comprises a description of the ordinary course of events and of the appropriate treatment to be followed ; the second deals with abnormal events and the assistance that can be rendered in such cases ; thus the physiology and hygiene, the pathology and therapeutics of the puerperal processes are all included. The means to be employed will of course vaiy greatly, being sometimes hygienic and pharmaceutical, sometimes mechanical and operative. The operative measures are for the most part special to Midwifery, and constitute a large share of its therapeutics. A special chapter will therefore be devoted to their description under the head of Obstetrical Operations. § 3. From this definition of the scope of "Midwifery," it at 1 2 INTRODUCTION. once becomes evident what preliminary knowledge the student of the subject must possess. Especially must he be familiar with anatomy, physiology (particularly that of the female sexual organs) and embryology, for Midwifery can no more include the latter amongst its branches of study, than it can pathological anatomy, general pathology, therapeutics &c. It can only refer to them as far as is requisite to make the whole subject intelligible. Nevertheless we cannot altogether exclude a consideration of the organs directly concerned in the puerperal processes, namely the generative organs and the pelvis, at any rate as far as their relations and proportions are of importance in regard to those processes, all the more as those characters are not specially considered in anatomical lectures, and above all are not studied from an obstetrical point of view. The same is true of the impregnated ovum. Such a description is therefore desirable as takes a knowledge of purely anatomical facts for granted, and only deals with them so far as they concern the gynaekologist. Thus a description of the female pelvis and its contents forms the introductory portion of Midwifery ^ ' The description of the embryo and its appendages can only be given in the second part, inasmuch as it assumes at several points a knowledge of the changes in the uterus brought about by pregnancy. PAPtT I. THE ABDOMINAL CAVITY, PELVIS AND GENERATIVE ORGANS (tHE PARTURIENT CANAL). § 4. As already stated in the Introduction, we cannot here attempt to give a lull account of the pelvis and its contents. We must however describe the relations of the organs which are concerned in childbirth, and indicate the peculiarities in their structure and arrangement, so far as these are directly connected with the development and expulsion of the embryo. This is necessary to enable the reader to start with a clear con- ception of the origin of the processes which he is about to study, both from a physiological and a pathological point of view, and thus to make them more intelligible. 1. The Abdominal Cavity. § 5. The abdominal cavity forms a more or less barrel-shaped cylinder, flattened from before backwards and terminated at both ends by a concave surface. The walls are formed mainly by soft parts, which above are attached to the ribs, and below are fixed and supported by the pelvic girdle and the vertebral column in such manner that they cannot collapse, but are always more or less tense. The superior and inferior walls, constituting the diaphragm of the thorax and the diaphragm of the pelvis, are formed by soft parts which present uniform concavities looking towards each other. The anterior wall, likewise concave, is membrano-muscular, except in its lowest portion. The side walls are everywhere bon}^, except in their middle portion, where they are soft. The posterior wall is altogether bony in the middle line, and on each side it is so also, except over a small area where the muscles attached to the spinal column (M. quadratus lumborum) take the place of bone. § 6. It is clear therefore that the shape of the abdomen must vary greatly according to the degree of its repletion and the 4 THE ABDOMINAL CAVITY. thickness of its parietes, so that any one familiar with the position of the organs, and the elastic and the solid structures bounding the cavities and tubes contained in the abdomen, will be able from a mere inspection to decide with a fair degree of confidence as to the nature of any change that has taken place. In the ordinary condition sections passing through the various planes of the abdomen will have some such relations as the following : — A coronal section will have an outline approximately resem- bling two circles intersecting each other, of which the larger lies below, the smaller above the anterior superior iliac spines. The better made the woman, the more obvious is this relation even to the ordinary observer in the curving waist and the moderate prominence of the hips. In the habitus of the child or the man the curve is converted into a straight line, while during pregnancy the interval between ribs and ilium becomes bulged, and the convexity of the line is directed outwards. A horizontal section has more similarity in its outline to that of a heart or kidney, according to the elevation at which it passes ; the higher the section, the more does the outline become heart-shaped ; the lower down, the more reniform. The trans- verse diameter is here larger than the sagittal or antero- posterior, and has its greatest width between the two anterior superior iliac spines. In pregnancy, on the other hand, the sagittal diameter measures more than the transverse, and is greatest at the level of the umbilicus. § 7. A section imssinfj through the median sagittal plane has in its upper and middle portion almost the outline of an ellipse, the regularity of the figure being chiefly disturbed by the S-shaped curve of the vertebral column, which is most marked in the lumbar and sacral regions, and is convex forwards. In a normal figure the curve in the lumbar region seen from behind, forms a gentle concavity, which passes gently into the convexities of the thoracic and sacral regions. Deviations from this normal appearance are so characteristic, that the presence of co-existing peculiarities of the pelvis may safely be inferred. Pregnancy necessitates a modification of this curve, for, as the centre of gravity is shifted forwards, the woman is obliged to lean back- wards in order to preserve her equilibrium, and in so doing she THE ABDOMINAL CAVITY. 5 causes an increase in the lumbar curve. Slight lateral curva- tures of the abdominal region of the vertebral column, compen- satory of the curve to the right side in the dorsal region, are present in almost all persons. § 8. The dimensions of the abdominal cavity are important. The height averages 40 — 45 cm. (15*5 — 17"5 in.), about a quarter of the length of the body ; the transverse diameter is about 35 cm. (13'5 in.). The capacity can be easily calculated from the weight of the contained organs, inasmuch as they entirely fill the cavity. Altogether they weigh 6 — 7 kilogrammes (13 — 15'5 lb.) ; their specific gravity varies from 1*02 — 1*07 ; we cannot therefore go far wrong in estimating the contents at from 6—7 litres (10—12 pints). § 9. As is well known, the alimentary canal and the large glands belonging to it, together with the spleen, kidneys and generative organs, form the contents of the abdominal cavity. These sets of organs are connected with each other and with the abdominal walls by the peritoneum, a membrane which lines the under surface of the diaphragm, is reflected from there on to the liver, stomach and spleen, enveloping these organs, and con- necting them closely together by means of the gastro-hepatic and gastro-splenic omenta. The two laminae of peritoneum derived from the anterior and posterior surfaces of the stomach, form a long aproulike fold which generally reaches to the entrance of the pelvis — the great omentum. From the first- mentioned organs the peritoneum also turns back towards the spinal column, adhering firmly to it and sending forwards from it the mesenteric folds to envelop the small intestine with their anterior borders. On either side it passes down in front of the fossa lumbaris as a smooth membrane, and meets here with the ascending and descending colon, which in the great majority of cases it only covers on the anterior surface. At the level of the iliac fossa it reaches the serous membrane lining the lateral and anterior abdominal wall, and on the right side partly covers the caecum. Lastly, it sinks into the pelvic cavity as a closed sac, stretching from the symphysis pubis to the middle of the first sacral vertebra, on a level with the ilio-pectineal crest, and at the upper border of the anterior wall of the pelvis it is continued on to the anterior abdominal wall. This pelvic pouch is partly inverted by the uterus with the Fallopian tubes, which 6 THE ABDOMINAL CAVITY. are set in it, and thus are formed two pockets, one lying in front of, the other behind the uterus, deepest in the middle and lined by a membrane which passes insensibly at each side into that lining the iliac fossfe. § 10. The serous membrane therefore divides the abdomen into two secondary cavities, an anterior or intra-peritoncal cavity, which contains the alimentary canal, liver, spleen, great omentum and mesenteries, and a posterior lower or extra-peritonenl cavity, containing the pancreas, supra-reuals, kidneys, part of the caecum, the lowest division of the rectum, the vagina and cervix uteri, the urethra and the lower part of the bladder. The peritoneal cavity may be looked upon as a great lymph-sac, closed everywhere except at two small spots where it communi- cates with a mucous surface, and thus with the outer vrorld (ovary and orifice of the Fallopian tube). These two cavities are so related to each other, that one of them can increase in size at the expense of the second, and an organ belonging to the posterior lower one, can for a time lie almost entirely in the anterior upper one, or at any rate project into it to an enormous extent. At the same time the separate viscera are in close contact and exposed everywhere to an equal pressure, though this will vary with the varying degree of distention of the abdominal cavity, with the different postures and attitudes of the body, and with the degree in which the latter is supported, also with the weight borne by the spinal column, and especially with any bodily exertion or abdominal straining ; this pressure is mainly supported by the floor of the pelvis. § 11. To assist the reader in obtaining a clear idea of the relative position of the abdominal viscera, I add a sketch of their topography. In the epigastrium are portions of the right and left hepatic lobes, and the middle and pyloric divisions of the stomach ; deeper down are the terminations of the duodenum and pancreas ; and still further from the surface, the aorta, inferior vena cava, solar plexus and the caeHac axis. The stomach when distended pushes the liver up, the transverse colon down and the anterior abdomi- nal wall forwards, but when empty it lies under the diaphragm, the liver and colon being in front of and almost entirely covering it. The right lujpochovdrium is filled by the right lobe of the liver, the edge of which, in women who have borne children, THE PELVIS. 7 usually projects somewhat beyond the edge of the ribs. Under the liver in this situation lies the right end of the transverse colon, further back the supra-renal capsule and sometimes the upper part of the right kidney. In the left hypochondi-ium is situated the cardiac end of the stomach, and the spleen still more to the left ; below this lies the left side of the transverse colon, the left supra-renal capsule with the upper part of the kidney. The mesogastnum contains in its middle portion the great omentum ; beneath this lie above the transverse colon, lower down the largest part of the coils of the small intestine ; beneath these are the aorta and vena cava, with their branches. On the right side lie some more coils of small intestine, further outwards the ascending colon, and behind it the kidney. The same is true of the left side, except that the descending colon is placed further outwards. The lumbar region has in its middle portion the vertebral column ; on the sides of the latter the lower end of the kidneys, outwards from which lies the posterior wall of the great intestine, generally devoid of peritoneal covering. The hypogastrium contains the lower half of the coils of small intestine, and the bifurcations of the aorta and vena cava which lie at the level of the pelvic brim ; in its deepest portion are the pelvic organs, which when distended project more or less into the hypogastrium. The only organ which is usually found in contact with the lower third of this region of the abdominal wall, is the bladder, provided it is not quite empty. In the iliac fossffi lie coils of small intestine, and somewhat higher up on the right side is the c»cum, on the left the commencement of the sigmoid flexure. (The description of the pelvic cavity will be given below.) LITERATURE. Xouveav- Dlctionn. de Died, ct de Chirurgie, Jaccoud, Article "Abdomen," vol. i., 1864, p. 36. Schatz, " Der Intraabdominelle Druck," Arch. f. Gyn., iv. cand v., 1872 — 1873. 2. The Pelvh. § 12. The pelvis is composed of the two ossa innominata, which are more or less hour-glass in shape and constitute the lower limb-girdle, and of the spadelike sacrum with the trian- 8 THE PELVIS. gular coccyx, the point of which is directed downwards. From an obstetrical point of view we must also add the two lowest lumbar vertebrte with their ligaments. Looked at as a whole, the pelvis resembles a deep plate mth a broad, flat, and in several places interrupted rim. The boun- dary between the latter and the deepened portion, is only well defined and sharp on the internal surface, and is there indicated by a line which passes from the symphysis pubis over the ilio- pectineal crest of the two ossa innominata, over the rounded border on the lateral portions of the sacrum, obliquely upwards to the middle of the synchondrosis, between the last lumbar and the first sacral vertebra {promontory), and is called the Unea innominata or terminalis. The plane bounded by this line is called the pelvic inlet, or upper pelvic aperture (fig. 1). Its Fig. 1. shape is somewhat elliptical, but according as the promontory projects much or little, approaches the outline of a kidney or a heart. The portion of the pelvis situated above the linea innominata is called the great (or false) pelvis, the canal below that line forms the small (or true) pelvis. The Great Pelvis. § 13. The great pelvis is mainly formed by the shoveUike expansion of the iliac bones and the two last lumbar vertebrae lying between them ; in a less degree by the aloe at the base of the sacrum and by the upper surface of the pubic bones. These bones contribute to some extent to the formation of the abdominal wall, the intervals between them being completed THE PELVIS. 9 behind by the muscular and tendinous structures which are in contact with the last lumbar vertebrae, and in front by the lower portion of the anterior abdominal wall. It is therefore only in its transverse diameter and depth that the ring thus formed can have constant dimensions. The distance between the two anterior superior iliac spines is called the small or anterior transverse diameter (Sp. I.), and measures 23 cm. (9 in.) . The gi'eatest distance between the two iliac crests is near their middle, and is called the great or posterior transverse diameter (Cr. I.) ; it measures 25 cm. (9^ in.). A line drawn from the last diameter perpendicularly to the pelvic brim (depth of the great pelvis) measures on an average 7*5 cm. (3 in.), and one carried from the highest points of the iliac crests to the brim, about 6 cm. (2'5 in.). The JvidtJi of the great pelvis diminishes from above down- wards, indeed the lateral surfaces converge so rapidly, that if prolonged below they would meet at about the level of the fourth sacral vertebra : the surfaces of the innominates are therefore oblique. The depth is almost uniform along the sides, but diminishes gradually both in front and behind, owing to the important gaps that are situated there. TJie Small Pelvis. § 14. The small pelvis — the pelvis of common parlance — forms an approximately cylindrical canal directed backwards and downwards, whose inlet and outlet are somewhat narrowed in comparison to its cavity. It is composed of the pubic and ischial bones, of the sacrum and coccj^x. Although the several walls that bound the cavity pass into one another by means of sloping surfaces without sharp boundaries, it is possible to distinguish an anterior, a posterior and lateral walls. The an-terior wall is bounded by two lines, which pass on each side from the ilio-pectineal eminence, along the outer edge of the foramen ovale to the middle of the tuberosities of the ischia (fig. 2) ; the posterior is formed by the anterior surface of the sacrum and coccyx. The lateral walls lie between these two ; a perpendicular line drawn through the base of the ischial spine on 10 THE pel\t:s. each side, divides them into an anterior half which is wholly bony and belongs to the ischium, and a posterior which is mainly membranous (fig. 3). Fig. 2. § 15. The small pelvis is not everywhere of uniform depth, owing to tbe great gaps in its inferior border. There are three such gaps, one antero-median, and two latero-posterior. The former is bounded by the lower edges of the rami of the ischial and pubic bones, which converge above and in front, the summit being at the lower margin of the pubic synchondrosis. It con- stitutes an arched interval rounded off by the subpubic ligament, and forming an angle of 95^ — 100^ {areas puhis). The pubic and ischial rami bounding this arch are called the pillars of the pubic arch ; their lower border is flat, be- coming convex in front, and excavated further down. The gap in the lateral wall is the incisura sacro • ischiadica, whose greatest diameter runs forwards and upwards. It is rounded off above, limited in front by the posterior edge of the OS innominatum, behind by the lateral border of the sacrum and coccyx, and is separated by the sacro- sciatic ligament from the lower pelvic aperture. The depth of the small pelvis is as follows (fig. 4) : behind (arc THE PELVIS. 11 of the curve between the promontory and the point of the coccyx), ca. 13 cm. (5 in.) ; at the sides, from the middle of the hnea innominata to the middle of the tuberosity of the ischium, 9'5 cm. (3"75 in.) ; in front, along the middle line (depth of the symphysis pubis), 4'5 cm. (1"75 in.). The depth of the whole pelvis, from the highest point of the iliac crest to the tuberosity of the ischium, is on its outside 19'5 cm. (7"5 in.). § 16. Inasmuch as the dimensions of the pelvic canal vary in its different regions, it is necessary to consider the latter one by one — viz., the upper aperture or inlet, the lower or outlet, and the cavity lying between them. The inlet of the pelvis is included within the linea terminalis. The outlet (fig. 5) is limited in front by the pubic arch and its Fig. r*. pillars, laterally by the tuberosities of the ischia, and behind by the lower border of the sacro-sciatic ligaments and by the borders and apex of the coccyx. Its boundaries are bony in front of the tuberosities of the ischia, but behind them are composed of soft parts, between which in the middle line the coccyx forms a pro- jection. The opening has a rhomboidal shape, and lies in more than one plane ; the lateral boundaries lying about 3 cm. (1'2 in.) deeper than a median line drawn from the anterior to the posterior margin, a fact which is of obstetrical importance. A horizontal line connecting the lowest points of the two tuber- osities divides the outlet into two triangles, the common base of which it forms ; the anterior triangle is directed backwards and downwards, the posterior forwards and downwards. The pelvic canal is widest at its middle, and becomes some- 12 THE PELVIS. what narrower towards the outlet. The widest iporiion— pelvic dilatation— is bounded by a hue running from the middle of the symphysis over the upper border of the obturator foramen, in the neighbourhood of the acetabu- lum, to the point of union of the second and third sacral vertebrae (fig. 6). Its outhne approaches that of an oval directed from before backwards. The nar- rowest portion — pelvic strait — is the almost circular region which T,. ^ is bounded bv the end of the sacrum, the spines of the ischia and the summit of the pubic arch. § 17. These various divisions have the following measure- ments : — ^ A. The pelvic inlet. 1. The sagittal diameter (fig. 1, a, h) from the middle of the promontory to the middle of the inner and upper border of the symphysis — antero-posterior diameter, conjugata vera" (C. v.) — measures 11 cm. (4'3 in.). 2. The transverse diameter (fig. 1, c, d) from the middle of the linea innominata of one side to that of the other (D. tr.) 13'5 cm. (5"3 in.). It lies a little nearer to the sacrum than to the anterior wall of the pelvis. 3. The oblique diameter {e, f) from the sacro-iliac synchon- drosis of one side to the ilio-pectineal eminence of the other — (D. obi.) 12-5 cm. (4-9 in.). That drawn from the right sacro-iliac synchondrosis is called the right or first, that drawn from the left is called the left or second oblique diameter. 4. The distance of the middle of the promontory from the upper and posterior portion of the floor of the acetabulum of ' These measurements are of course the averages obtained by different authors in measuring perfectly normal pelves. There is therefore a pelvis which is slightly smaller than the average, and yet must not be looked upon as abnormal. Thus in Breslau I find that the figures are as a rule somewhat smaller than those I used to obtain in Königsberg and Freiburg, a fact which is doubtless to be associated •with the striking differences in the physique and stature of the populations referred to. ^ A conjugate is the small axis of an ellipse. THE PELVIS. 13 each side (a, g) — distantia sacro-coti/loidea (D. s. cot.) — 9 cm. (3-5 in.). The circumference of the pelvic inlet measures about 40 cm. (15-5 in.). § 18. B. Th.Q pelvic dilatation (fig. 6). 1. The antei'o-posterior diameter, from the point of union of the second and third sacral vertebrae to the middle of the sym- physis {a, h) — 12*75 cm. (5 in.). 2. The transverse diameter, between those points of the aceta- bula which are highest in the erect posture (c, d) — 12 cm. (4"7o in.). 3. The oblique diameter, from the middle of the upper edge of one incisura ischiadica major to the upper circumference of the sulcus obturatorius of the opposite side — 13'5 cm. (5*25 in.). c. The 2)elvic strait. 1. The antero-jjostej'ior diameter from the point of the sacrum to the lower edge of the symphysis — 11'5 cm. (4*5 in.). 2. The transverse between the points of the two ischial spines (Sp. Isch.)— 10 cm. (4 in.). D. The pelvic outlet (fig. 5). 1. The anter -posterior diameter from the point of the coccyx to the lower edge of the symphysis {a, h) — ^9*5 cm. (3*75 in.). It can be increased during parturition by the recession of the movable coccyx in the direction of this diameter of the pelvic strait to 11*5 cm.^ (4*5 in.). 2. The transverse from one tuberosity to the other (c) — 11 cm. (4'25 in.). 3. The oblique diameters from the middle of one sacro-sciatic ligament to the opposite pubo-ischiadic synostosis — 11 cm. {4'2o inches). They may, when the ligaments are stretched, be increased by from 1 to 1*5 cm. (4 — "6 in.), and have therefore no special practical importance. § 19. If the measurements given above are tabulated, the reader will not only obtain a clearer conception of them, but the comparison will give a very instructive insight into the space- relations of the various regions of the pelvis ; especially if the ' According to Lang's investigations {Ueher die BewegVichkek des Steissheines und ihre Beziehung zu der Geburt, Diss. Bern, 1878), the average range of movement of the coccyx amounts in primiparte to l'(j5 cm. ("6 in.) before birth to 27 cm. (1 in.) after it. In the case of multiparas to 2 cm. ('S in.) and 27 cm. (1 in.) respectively. 14 THE PELVIS. conjiigata vera is taken as a standard which we will call 100, and the other diameters are compared with it. Antero-posterior. Transverse. Oblique. Sp. Iscli. Inlet llcm.=100 13-5cm.=122-7 125 cm.=113-6 Cavity(pelvicdilatation)12-75cm.=115-9 12cm.=109 13-5 cm.=122-7 10cm.=90-9 Outlet (fixed diameter) 11-5 cm.=104-5 11 cm.=100 This table shews that the pelvis offers most room at its inlet iu the transverse direction, in its cavity in the oblique and at its Fig. 7. Normal pelvic inlet. (After Hegar.) Fig. 8. Pelvic dilatation. Fig. 9. Pelvic strait. Fig. 10. Pelvic outlet. outlet in the antero-posterior direction, a course therefore which a bod}- passing through it and meeting with resistance will follow. At the same time it must be noticed that this resistance will gradually increase in a transverse direction, on account of a gi-adual diminution of the transverse diameter from above down- wards, and that the cavity and the outlet will afford most room THE PELVIS. 15 in an oblique direction, owing to the size of the oblique diameter of the first and the capacity for elongation (figs. 7 — 10) of the second. § 20. In order correctly to estimate the size of the pelvis, the following distances also are important and therefore to be noted : — The distance at which the point on the posterior edge of the symphysis lying nearest to the middle of the promontory, is from the latter — conjugata vera in the obstetrical sense — 10 — 10*25 cm. (3'9 — 4 in.). The anterior extremities of the anatomical and obstetrical conjugata vera are separated from each other by about 1 cm. ('4 in,). The distance of the middle of the promontory from the summit of the pubic arch — conjugata diagonalis (C. d.) — 12*5 cm. (4*9 in,). The distance of the spinous process of the last lumbar vertebra from the upper anterior edge of the symphysis — conjugata externa (CE.) or Baudelocques diameter (D.B.) — 19 — 20cm.(7"5 — 8 in.). The distance between the posterior superior spines of the iliac bones — 10 cm. (4 in.). The greatest distance between the trochanters when the thighs are adducted (Tr.) — 31 cm. (12 in.). The numerous other external pelvic measurements generally added by authors are mostly oblique, and drawn from definite points of the whole pelvis to definite points on the opposite side (external oblique measurements) ; they have only a relative value, inasmuch as they serve to compare the two sides of the pelvis. (Further remarks on this subject will be found under " Pel- vimetry.") § 21. Apart from an enlargement of the outlet caused by the recession of the cocc^^-x, no increase in the size of the i^elvic cavity is possible. The relaxed and swollen condition of the movable pelvic articulations, which sometimes accompanies pregnancy, and which may be developed to a pathological degree, is not of any assistance to the forces which during parturition act everywhere equally from within outwards, and tend to separate the pelvic bones from each other. Such a separation could only take place by the interspaces at the three articulations increasing in size, and for this an arrangement is wanting, by means of which the vacuum arising from the separation of the pelvic bones could 16 THE INCLINATION OF THE PELVIS. be filled'. The movement permitted at the ilio-sacral and pubic s3'uchondroses, has no other result than to break the force of the shocks to which the pelvis is exposed, and merely shows itself in a gliding of the surfaces over one another upwards and downwards, or forwards and backwards. If, however, the tissues become abnormally softened during pregnancy, an increased degi-ee of mobility may set in, which materially interferes with the steadiness and security of the woman when standing or walking. The Inclination of the Pelvis. § 22. The pelvis does not lie in the axis of the body, but forms with the vertebral column an angle of from 130^ — 140° ; its inlet lies therefore in a plane whose anterior edge is inclined downwards, and the degree of this inclination is defined by the angle which the antero-posterior diameter of the inlet forms with the horizon (x, fig. 11). This angle varies from 55° — 64°, but averages 60°. .._^ri\-A.^PL.=.ri:'j^'- Fig. 1'. The plane in which the antero-posterior diameter of the pelvic outlet lies has also this downward inclination, but to a much smaller extent, for the angle which it forms with the horizon (y) varies from 7°— 27° and averages 12°. THE INCLINATION OF THE PELVIS. 17 A plamb-line passing through the middle point of the pelvic inlet, would pierce the abdominal wall somewhere in the neigh- bourhood of the umbilicus, and below strike the end of the coccyx. A similar line starting from the middle of the outlet, would strike the promontory. The promontory is about 9'5 cm. (3"75 in.) higher than the upper edge of the symphysis ; the point of the coccyx about 1'7 cm. ('7 in.) higher than the top of the pubic arch. In order to give a pelvis its natural position in relation to the horizon, the anterior superior iliac spines and the two pubic tubercles must be in one vertical plane, or the posterior ends of the acetabular notches must look directly dow^uwards. § 23. Since the direction of the conjugate depends on all those influences which affect the position of its extremities, the degree of pelvic inclination must be subject to many alterations ; the position of the promontory is especially variable. According to Meyer's observations, the inclination of the pelvis in different individuals varies much more than had been previously supposed, and even in the same individual there are very great differences, dependent on the degi-ee of divergence or convergence, and on the amount of rotation of the thighs. The minimum inclination is 40"^ — 50"^ and is associated with slight divergence (25°) and slight inward rotation (10°) of the thighs ; the maxima are met with when extreme convergence and divergence of the thighs accom- pany strong inward or outward rotation and amount to 100°. When a person stands in an unconstrained manner with parallel legs, the pelvis is inclined about 55°. Parow believes that the direction and normal curvature of the vertebral column are affected by the inclination of the pelvis, and are no more constant than is the latter ; the inclination of the conjugate, according to him, has a definite but inverse relation to the inclination of the posterior surface of the sacrum, so that by measuring the inclination of the sacrum in a living person, that of the pelvis may be obtained. For estimating the great variations of the angle of inclination of the inlet, the so-called normal conjugate of Meyer seems most useful. It is a line whose posterior extremity is at the slight depression which runs transversely across the middle of the third sacral vertebra, and whose anterior touches the upper edge of the symphysis, between the two pubic tubercles (c, d, fig. 11) ; 2 18 THE AXIS OF THE PELVIS. it forms with the horizontal an angle of 30° (z). Its posterior end is the most unvarying spot of the sacrum, the angle z is fairly constant, and the variations of the angle formed hy the normal conjugate and C. v., are just as gi-eat as the variations of the angle between the horizon and the C. v., which proves the constant position of the normal conjugate. The inclination of the pelvic outlet is, as already stated, very variable. Its autero-posterior diameter may coincide with a horizontal line ; indeed it always does so during parturition, when the foetal head forces the point of the coccyx backwards ; the latter may lie as much as 2 cm. ('75 in.) below the inferior border of the pubic synchondrosis. Lastly, it must be pointed out, that the degi-ee of pelvic incli- nation in any individual may be greatly altered by a change in posture, and this circumstance can be made use of in the management of labour. The plane of the inlet is horizontal, when the woman lies with her body a little lower than half-way between sitting and lying. § 24. The inner surfaces of the pelvic canal are not parallel to each other ; such is at best only true of the surface of the two first sacral vertebrfc, which passes backwards and downwards, and of the posterior surface of the symphysis (considered as a straight line) and bodies of the pubic bones, which latter form with the C. V. an angle of about 100°. The lower portion of the sacrum, on the contrary, is directed downwards for a short distance, then curves a little forwards, to which direction the internal surfaces, and edges of the pillars of the pubic arch incline more or less. These ''oblique surfaces " have some influence over the movements which the head undergoes during its passage through the pelvis, though from this point of view the lateral surfaces, which especially in their posterior portions converge below, must be of far greater importance — plana inclinata ossium ischiorum (fig. 12). Their relations are to be found amongst the measure- ments given above of the transverse diameter at the various levels. The Axis of the Pelvis. § 25. It is difficult to define the direction which the pelvic cavity, so irregular in shape and bounded by parietes facing such different ways, has in regard to the horizon. A middle line is DEVELOPMENT OF THE SHAPE OF THE PELVIS. 19 obtained, by imagining the middle points of the antero-posterior diameters of the different regions of the pelvis connected with one another, although it is not an exact middle line in a mathe- matical sense, since lines drawn in an oblique direction through the centres of the planes of those diameters are not divided into equal halves by it. The middle line constructed in the way indicated, is called the pelvic axis. It is straight in the upper half of the pelvis, corresponding to the approximately straight course of the sacrum as far as the third vertebra, and is perpen- dicular to the plane of the inlet (fig. 11); from there to the point of the sacrum it curves slightly forwards, corresponding to the direction of the posterior pelvic wall ; below the point of Fig. V2. the sacrum its direction is no longer constant, owing to the mobility of the coccyx. If the position of this line is defined in relation to objects lying outside the pelvis, as for instance to the horizon, it gives us a good axis line of the pelvis, but it must never be confused with the line which the head, or a point representing its mass, traces in the pelvis during labour, and therefore from that point of view it does not deserve the name of " axis of propulsion." Development of the Shape of the Pelvis. § 26. The shape which has been described, and the relative dimensions which have been given, do not belong to the pelvis at the time of birth. In the pelvis of a new-born child sexual 20 DEVELOrMEXT OF THE SHAPE OF THE PELVIS. differences are indeed not ultogetber wanting ; the brim is already- wider transversely in the female than in the male, but the various distinctions are not so accentuated as in the adult pelvis. The infantile sacrum has smaller ala) in comparison to the width of the vertebrae ; its anterior surface is more concave transversely ; the curve in the direction of its length and that of the coccyx is distinct, though less decided than later ; the bone appears less pushed forward between the iliacs and is less inclined forwards. The bodies of the iliac hones rise up more at right angles to the horizon, and are almost straight from before backwards, the crests showing only a faint S-shaped curve ; Sp. II. and Cr. IL present but a slight difference, if any, to the advantage of the Cr. II. ; they frequently both measure exactly the same. The lateral tvaUs converge more rapidly below ; the Jiorizontal rami of the pubic bones are relatively short ; the angle formed by the pubic arch is acute. Owing to the sacrum being placed far back and having a less inclination, the C. v. is longer in comparison to the other diameters of the inlet, sometimes even equal to the transverse ; the same is true of the oblique diameters. In the pelvic cavity, the antero-posterior and trans- verse diameters are smaller in comparison to those of the inlet ; at the outlet, the smallness of the transverse diameter is particularly noticeable. § 27. The forces which convert this infantile into a sexually mature pelvis, are mainly the developmental forces inherent in the several parts of the pelvis, and the pressure of the body-weight. The various parts of the pelvis do not all grow in the same proportion after birth. The sacrum in the female increases especially in width, and indeed the alae do so more than the bodies of the vertebrae ; the limbs of the lower half of the pelvic ring (pubic bones) increase more rapidly in length than those of the upper half of the ring. Hence the pelvis soon becomes more roomy, and inasmuch as every part now grows more rapidly in the female than in the male, the increased capacity in the former is very obvious. On the other hand the depth of the lateral walls of the small pelvis, and the length of the sacrum do not increase in the female to the same degree as in the male ; the pelvis of the former is therefore less deep. That the female generative organs do not assist in bringing about the great increase in the width of the pelvis is self-evident. DEVELOPMENT OF TUE SHAPE OF THE PELVIS. 21 § 28. The pressure of the hody-ioeigkt is a very important factor, and begins to operate as soon as the growing child is able to stand upright. From a mechanical point of view, the pelvic ring may be divided into an upper (posterior) and a lower (anterior) half, separated from each other by the axis of rotation Avhich passes through the central points of the acetabula. The upper half- ring is completed in its middle by the sacrum, which has the shape of a double wedge ; it is wedge-shaped from above and in front, downwards and backwards, as well as from below and in front, upwards and backwards, and is inserted between the lateral limbs. In front these lateral limbs unite with the lower half- ring, which forms a kind of counter-arch. The weight of the body is transmitted by the vertebral column, and falls in the line of gravity on the upper surface of the sacrum ; since however the latter is inclined forwards, the force is resolved into two component forces, of which one (the normal) is directed perpen- dicularly to the upper surface of the sacrum, while the other (the tangent) acts parallel to it. The vertical pressure tends to drive the sacral wedge further down between the iliac bones, but no yielding in this direction is permitted, owing to the disposi- tion and the wedge-shape of the bones. As a result of this pressure however the substance of the wedge is compressed, causiug the sacrum to become wider, its vertebrae to be driven somewhat forwards between the ahe, and the transverse curvature of its anterior surface to be diminished. § 29. Owing to the fact that the line of gravity of the body falls in front of its points of support, the tangential force acting ])arallel to the upper border of the sacrum, would drive this bone forwards between the iliacs, and the shape of the sacrum would allow it to glide in this direction, were it not that the ligaments suspending it from the iliac bones become tense, and prevent any further descent. In consequence of this tension the posterior portion of the iliac bones are approximated, and the sacrum is jammed in between them at some point or other. This point forms a fulcrum, just as did the spot at which the above-mentioned widening of the sacrum fixed it more firmly against the lateral walls, round which the pressure from above tends to rotate the sacrum forwards, so as to make it more horizontal. The tense condition of the great and small sacro- 22 DIFFERENCES DUE TO SEX AND RACE. sciatic ligaments produceil by this movement, resists the dis- placement of the lower half of the sacrum backwards and upwards, which would otherwise take place, and increases the angle between it and the upper half. At the same time the weight of the trunk presses more heavily on the posterior portions of the bodies of the vertebra3 ; hence the depth of the upper ones diminishes gradually from before backwards. As regards the innominate bones, the traction on the posterior ilio-sacral ligaments (which become more and more tense with the displacement forwards of the sacrum) causes a rotation to take place round a vertical axis passing through the heads of the femoral bones, by means of which the posterior extremities of the innominates are approximated, their anterior rendered more divergent at the symphysis pubis, the whole pehis and especially the anterior lower half of the arch is stretched trans- versely, and the bodies of the iliac bones open more in front. The effect of the forces acting on the sacrum — to which must be added the action of the iliacus and psoas muscles which flex the vertebral column towards the extremities, and thereby force the sacrum towards the cavity of the pelvis — is such, that the sacrum approaches the anterior pelvic wall, the transverse diameters become wider, the anterior pelvic wall is flattened, and the anterior extremities of the innominate bones are everted. § 30. I have dealt somewhat fully with the influences which give the pelvis its final shape, since a knowledge of them assists us in understanding the mode of development of the pathological varieties. The fact that the alterations in shape thus brought about in the pelvis of the girl, exceed those occurring in the boy, is due to an inherited predisposition, and probably also to the slower progress of ossification in the former. Difercnces due to Sex and Race. The female pelvis, looked at as a whole, is distinguished from the male by the bones bemg more delicate, by its width being greater, its depth smaller. The iliac bones are flatter and diverge more in front. The promontory projects less; the sacrum is shorter, and, owing to the increased size of the alae, DIFFERENCES DUE TO SEX AND RACE. 23 broader ; its lower half forms a greater angle with the upper. The pubic arch is wider and more rounded, its pillars are somewhat excavated and their inner surface looks forwards ; the tuberosities as well as the acetabula are at a greater distance from each other. Various diameters are increased, but the transverse at the inlet is particularly so, in comparison to the C. V. The size of the cavity diminishes less on approaching the outlet, so that the lower aperture is both absolutely and relatively wider. § 31. Lastly, it must be pointed out that various individual divergences from the described typical form of pelvis are met with, although they scarcely deserve to be called pathological. They occur chiefly at the inlet, and affect the relation of the antero- posterior to the transverse diameter ; they must in large part be referred to differences in the primitive conformation, which may disappear or be increased according to the action of the forces coming into operation after birth. In addition to the already described normal form of brim (i.e. the outUne of an obtuse ace of hearts), there is also met with, first, a shape which is strongly ellijJtlcid ill a transverse direction, and in which the transverse diameter is considerably greater than the others ; secondly, a shape which is elliptical in the antero-posterior direction, and in which the sagittal diameter measures more than the others ; and thirdly, a rounded shape which is approximately circular, and is not uncommonly met with in very roomy pelves. All these varieties occur in every branch of the human family, and the differences found in various races depend, for the most part, merely on the varying relation of the antero-posterior to the transverse diameter. The latter however is the greater in the normal pelvis of every race. European women have the most roomy pelves, and the size of the transverse diameter of their great and of the brim of their small pelvis is especially notice- able. The American pelves are also very beautifully constructed, and the same is said to be true of the Chinese, whose pelves are almost indistinguishable from the European. The Negro pelvis on the other hand is small, rather inclined to be circular, and has a narrow pubic arch. That of the Caffres is graceful, with but sliffht differences between the two sexes. The smallest pelvis of all is found among the Hottentots and Bushwomen ; it is more or less dwarfed. The Australian pelvis is small and 24 THE PARTURIENT CANAL. light, with long conjugates, hut distinct sexual difierences. The pelvis of the Malays has a rounded inlet, a straightened sacrum, large iliac fossae and a wide pubic arch. The view that the further North a race of people lives, the wider does its pelvis become, and that a similar change is associated with the increasing civilisation of a race, is not proven. It is more likely to be true that favourable conditions as regards nutrition and occupation are the factors, which lead to a well constructed pelvis in a race. LITERATURE. Henlc, Ilandhucli der Anatomie, I. 1. Knocheulchrc, 3 ed., 1871, p. 264. H. Meyer, Die Statih und Mechanik, «tc. 1873. " Der Mechanismus der Symph. sacro-iliaca." Archiv, f. Anat. und Phyx., 1878, Anat. Div., p. 1. Litzmann, Die Formen des Deckens. Berlin, 1861. Fehling, " Die Form des Beckens beim Fcetus und Neugeborenen." Archiv, f. Gyn., X., 1876, p. 1. i^Cf. remarks by Litzmanu. ihid, p. 383.) Fasbender, " Das Becken des lebenden Neugeborenen." Zeitsclt. f. (i< b. u. Gyn., iii., 1878, p. 297. Ilegar, "Zur Geburtsmechanik. Die Beckenaxe." Archiv./. Gyn.,\., 1870, p. 193. Spiegelbcrg, '• Die niecliauisclie Bedeutung des Beckens." Mon. f. Geh., xii., 18.18, p.] 40. Duncan, "The l'elvis studied with a view to Obstetrics." Ilei^earches in Ob.itetncx, 1868, j). ."i.l. Hennig, "Tabellen von Racenbecken." Archiv./. Gyii., xii., 1877, p. 273. •' üeber Durchschnitte von Racenbecken." ibid., xiii., p. 157. If. Fritsch, "Das Rassenbecken und seine Messung." Abdnu-Ji au.i den Miff heil, de.« Vereins/ Erdhunde zu Halle. 1878. Part II. 3. The Vehh with its Soft Parts.— The Parturient Canal. § 32. In order to get a just conception of the pelvis as a parturient canal, as well as to understand many and especially pathological puerperal (ivents, it is necessary briefly to consider the soft parts which line the cavity of the pelvis, fill up the gaps, and cover and smooth over the often sharp projections, and to describe the connections of the genital canal with its neighbouring organs. In the great pelvis (cf. § 13) the iliacus internus muscle covers the internal surface of the iliac bone, and fills up its concavity. The space between the lumbar vertebrae and the ilium, as well as that above the lateral region of the pelvic inlet, are occupied THE PARTURIENT CANAL. 25 by the psoas major, and as these two muscles, in conjunction with the great vessels lying on their inner side (common and external iliacs), pass down on either side to the upper part of the thigh, they so alter the form of the inlet, that it comes to resemble a triangle with its blunted apex turned backwards, while the transverse diameter is somewhat shortened. In the i)dcic canal the symphysis and the middle of the sacrum and coccyx are free from muscles ; the remaining portion of the anterior and posterior wall, as well as the lateral walls are covered by the internal obturators and the origins of the pyriformes. These muscles with their covering of thin pelvic fascia, narrow the pelvic cavity at its sides by several millimetres, while acting in the same way in an antero-posterior direction, arc the walls of the bladder, the urethra, the vagina, the rectum and the cellular tissue connecting these organs. § 33. The principal alteration effected by soft parts takes place at the pelvic outlet. Strong muscles and fasciae— pierced only by the rectum, vagina and the neck of the bladder, closely connected with them and so holding them in situ — here form a floor, which bears the weight of the abdominal viscera, and acts powerfully in a direction opposed to the weight of these organs. The firmest portion of this floor is formed by the levatores ani muscles, which are lined on their upper surface by the pelvic fascia, on their lower by the perinital fascia, and which coiistitute the diapliragm of the pelvis. The flbres of these muscles arise for the most part from a line stretching on each side from the pubic arch to the ischial spine ; they con- verge behind, and unite in the middle line of the body, blending in part with those of the other side. The posterior fibres, closely connected with the sacro- sciatic ligament, diverge and run from the ischial spines to the lateral l)order of the coccyx (usually called M. coccygeus). Beneath this partition, between the anus and the external generative organs, lies the perinoium ; it rarely measures more than 3 cm. (I'i in.) from before backwards, while its greatest breadth corresponds with the distance between the ischial tuber- osities. In the perinaBum, especially in the space which lies between the ischial and pubic bones, the anus and the external genitals, are situated the muscles belonging to these organs. Seen from below (fig. 13), the sphincter ani extermis lies 2G THE PARTURIENT CANAL. furtlicst back and very superficially (6); between it and the lateral wall of the pelvis, bounded above and internally by the levator ani, which is descending? towards the middle line, covered below by skin and superficial fascia, is the tent-shaped ischio- rectal fossa, which becomes narrowed above and is filled by a considerable pad of fat. The superficial transversi perina}i muscles, running forwards and in an oblique direction, pass through the anterior portion of this fossa ; in front of them and near to the ascending ischial rami lie the ischio-cavernosi muscles (9) ; beside them, immediately next the middle line, is the constrictor vaginas (5) ; deeper down, between the ischio- cavernosi muscles and the constrictor vaginas, aj)pear the transversi pcriua?i deep muscles (4). § 34. These layers of muscles are separated from each other and strengthened by various fascia?. That lining the pelvic cavity (pelvic fascia) covers, as already mentioned, the upper surface of the muscular diaphragm of the pelvis, and becoming reflected upwards, blends with the connective tissue covering of the viscera which pass through it. The under surface of Ibis diaphragm is lined by the perineal fascia. In the region of the anus, this fascia is reflected downwards at an acute angle from' the origin of the levator ani to the inner surface of the ischium, and terminates at the tuberosity, thus lining the ischio-rectal fossa ; in the front half of the pelvic outlet, it splits into two layers, which embrace the muscles lying beneath the pelvic diaphragm. The deep layer is spread out in the space between the ischio-cavernosi and the constrictor vaginre muscles, i.e. between the crura of the clitoris, stretches above the vestibulum to the lower edge of the symphysis, lines the upper surface of the deep transversi perinaei muscles, encloses the urethra and passes into the middle pubo -vesical ligament. The superficial layer winds round the superficial transversi perinaei muscles, lines the ischio-cavernosi, the constrictor vaginae, and the under surface of the deep transversi perinaei muscles, and then merges into the fascia of the clitoris. The connective tissue between the external skin and the perinaeal fascia is well supplied with fat, and at the circumference of the sphincter ani externus becomes thickened, so as to form a fascialike membrane, blending with the proper perineal con- nective tissue — subcutaneous peri nee at fascia. THE PARTURIENT CANAL. 27 m ^j m ^ o C ^a a T3 <^.- o s o c <*H -c -4^ : _ Co U ?t O ^ 'r^ Si) a f2 a. th ?^ eo ■* ic -o 28 THE PARTURIENT CAXAL. THE SEXUAL APPARATUS. 29 The transverse perinseal septum is of great strength in woman, and on both sides of the posterior commissm-e of the labia, forms a hard ill defined body composed of connective tissue and elastic fibres and of interlacing bundles of unstriped muscle, and traversed bv large blood-vessels. The various voluntary muscles of the perinaeal region meet in this body, and become more or k-ss blended. § "So. The addition of the pelvic floor increases the length and the curvature of the pelvic canal ; it now appears closed below except for one opening, which is not at the central point of the pelvic outlet, but at its anterior portion. The axis of this opeziing cuts the middle line of the bony canal at an angle opening in front, and meets the sacrum in its upper half. During labour under the pressure of the advancing child, it is mainly the soft parts lying behind the opening that are stretched, and thus is produced a deep channel or furrow, opening into the enormously distended vulva, and finally forming a continuation of the middle line (x) of the bony pelvis (fig. 14). § 3G. The roof of the pelvic cavity is formed by the peritoneum (f/- §§ ^ and 10), which stretches between the symphysis and the middle of the first sacral vertebra, on a level with the ilio- pectineal crest and the ilio-sacral synchondrosis, and which I have named diaphragma mobile. It lines the organs lying in the brim of the pelvis, is pushed up by them, and is reflected from one to another in an antero-posterior direction, forming pouches and folds ; the most important of these is the middle one which lies transversely, and is destined for the reception of the internal generative organs. I will first describe these organs, and then their serous membrane. TJie Sexual Apparatus. § 37. The sexual apparatus forms a single canal, which divides internally into right and left branches, these branches passing oft' nearly at right angles (Henle) to the first-mentioned single canal. The latter (figs. 15 and 16) may be divided into three portions, lying one above the other. The loiuer corresponds to the uro-genital sinus, and includes the space known as the vestibulum and the external genital organs— lahia, majora, corpora 30 THE SEXUAL APPARATUS. cavernosa of the urethra and clitoris with the mucous folds of the latter, clitoris, nymphae, urethral orifice and Cowper's glands. The middle division is the vagina — a thick-walled tuhe, begin- ning at the posterior end of the vestibule, and having the same relation to the latter, as the leg of a boot has to the foot portion without the sole (Henle). The canal ascends obliquely at first, and then curves round so as to ascend vertically (the convexity being directed downwards), and at its anterior wall the boundary between the vagina and the vestibule is indicated by the urethral Figr. 15. — Vertical and Transverse Section of the Female Generative Organa. (After Henle.) Lj). Lab. pud. Ccu. transverse section through corp. cav. urethrse. H. hymen. Crp. column« vag. post. Va. vagina. Oue. os ut. ext. Oui. OS ut. int. Fv. fornix vag. Lu. lab. uter. Ut. uterus. Oo. oviduct. Lo. lig. ovar. 0. ovarium. Po. parovarium, ///j. hydat. of the parovar. Fo. follicle. CI. corpus luteum. orifice. From the opposite side of the vagina, and defining its posterior wall, springs a horizontal mucous fold — the hymen. The transverse fissure with a forward concavity, placed between the hymen and the urethral aperture is the vaginal orifice, which after the destruction of the hymen becomes funnel-shaped. § 38. The uterus is joined on to the vagina as an upper divi- sion, and forms a muscular reservoir, which is hour-glass in shape, narrowed below, flattened from before backwards, and has a comparatively small lumen. The latter communicates with i THE SEXUAL APPARATUS. 31 the cavity of the vagina by a transverse fissure (orificium uteri externum), which when intact is lined by a delicate fringe of mucous membrane. The orifice lies between two lips (labia oris uteri) which project in the form of tubercles into the vagina, and practically close it above. They lie however more in the line of its anterior than of its posterior wall, in consequence of which the anterior lip is lower than the posterior ; the axis of the uterine cavity forms an obtuse angle with the vaginal canal, and the anterior vaginal wall is separated from the anterior lip of the OS uteri merely by a shallow groove, while the mucous membrane from the posterior wall of the vagina is reflected downwards at an acute angle, in order to be continued on to the posterior lip of the cervix. The groove which is formed round the lips of the os by the reflection of the vaginal mucous membrane on to those lips is called the fornix vagince; the part of the uterine neck which bears the tubercles surrounding the os, which is enclosed by the fornix and which projects into the vagina, is the portio vaginalis. The constriction which gives the uterus its hour- glass shape, indicates the situation of the internal os or boundary between neck and body, which two regions moreover are distin- guishable by the surface of the mucous membrane, which is thrown into rugae over the former, smooth over the latter, § 39. The length of the vagina, i.e. of its posterior wall is about 7 cm. (2"75 in.), the anterior being 1'5 — 2 cm. ('6 — '8 in.) shorter. Its distensibility is well known ; in its closed condition the walls are in contact, and the lumen appears on transverse section as little more than a transverse fissure, showing however a different outline and various peculiarities according to the region of the vagina under observation. Its usual shape is that of an H, the transverse limb being slightly curved forwards or backwards, and about 2*5 cm. (1 in.) long; the lateral limbs of the H are somewhat convex towards the median line or else interrupted, with the middle of the curve reaching to the trans- verse limb. In this way the vagina accommodates itself to the condition of neighbouring organs ; very often indeed the fissure is unsymmetrically bent, projections of one wall corresponding to depressions of the other. The uterus, which has been described above as hourglass- shaped, is in the virgin condition constricted exactly at the middle of its length. Above this point the organ increases con- ;J2 THE SEXUAL APPARATUS. timuilly iu width {bodi/ of the uterus), while the cervical portion grows narrower towards its lower end. Hence the organ becomes pyriform, or similar to an inverted nine-pin, a resemblance which is even more distinct after repeated labours, owing to the fact that the weight of the upper portion becomes greater as compared with that of the lower, and that the constriction comes to lie below the middle point. The posterior surface is convex trans- versely, the anterior flattened ; the edges are rounded off, the lateral surfaces indistinctly marked off from those adjoining them ; the upper surface is slightly convex upwards and sharper. After pregnancy the surfaces retain a greater convexity and the edges become blunter ; the boundary between the upper and the lateral edges is then indicated by the insertion of the oviducts and round ligaments. The portion above these is termed the fundus uteri. In nullipara» the uterus is smaller than in women who have borne children. The length from the fundus to the anterior lip amounts to 7 — 8 cm. (275 — 3"15 in.), the width at the fundus to 3'5 — 5 cm. (1"25 — 2 in.), at the boundary between body and cervix to 2 — 2"5 cm. ('8 — 1 in.) ; the depth immediately below the fundus is 2 — 3 cm. ('8 — 1"2 in.). The cervix is 8 — 3*5 cm. (1"2 — 1-4 in.) long, 2-5 (1 in.) wide, and 1*5 — 2 cm. (-6— '8 in.) deep. The anterior lip as a rule projects 5 — 7 mm, ("2 — '3 in.) beyond the os, the posterior measures from the fornix to its free edge about 1-8 cm. ('7 in.). The walls are 1 — 1'5 cm. (--l — -6 in.) thick in virgins, but 2 cm. ('8 in.) in women who have had chil- dren (Henle). According to Krause, the weight in virgins averages 34— il grammes (M— lo oz.), in fruitful women 104—120 grm. (3-3—4 oz.). § 40. The iwsition of the uterus varies greatly with the condi- tion and degree of repletion of the neighbouring organs, and with the attitude of the body. Under ordinary circumstances it lies entirely in the pelvis, with its fundus directed forwards behind the upper portion of the anterior pelvic wall. In the erect posi- tion this forward inclination is increased, owing probably to the weight of the organ which compels the fundus to descend, the internal abdominal pressure contributing in a less degree. The uterus is not only inclined forwards, but almost always towards the right side also, while the left is rotated forwards, a posi- tion caused mainly by pressure of the rectum during develop- THE SEXUAL APPARATUS. 33 ment, and by the weight of the organ in the right lateral posture, which is the commoner. (Dohrn ascribes it to the pressure exerted by the rectum, which lies on the left side.) Moreover the organ is curved forwards, particularly in children and quite young persons ; the body forms with the cervix an obtuse angle open anteriorly, while the portio vaginalis on the other hand is displaced slightly in the opposite direction, giving the cavity a curve somewhat like that of a flattened S. The cavity itself is a fissure, lying between the anterior and posterior walls, which are in contact with each other, and above and at the sides unite along a line which is nearly parallel with the external outline of the uterus. The cavity is therefore linear in an antero-posterior and transverse section, but triangular in a bilateral section through the body, the triangle having sides that bulge inwards (they are concave only in multipara), and a blunt apex with the point directed downwards ; this cavity is continuous with the cervical canal, which has the shape of an elongated quadrangle, of which the sides are bulging with a concavity directed inwards ; the upper lateral corners of the uterine cavity open into the canals of the ovidacts. The internal surface of the body of the uterus is smooth ; that of the cervical portion has numerous transverse rugae. The opposed rugae however do not always fit accurately into one another, so that the section of the cervical canal has often the appearance of a clear lumen ; it is more frequently filled by secretion than is the body. § 41. The double portion of the sexual apparatus begins at the upper angle of the body of the uterus with the oviduct or Fallopian tube, an arched cylindrical canal 10 — 16 cm. (4 — 6"25 in.) long, which passes downwards, outwards and backwards by the side of the uterus. Near its external extremity which is turned towards the ovary, it widens and has a funnel- shaped opening into the abdominal cavity. The middle thin and narrow portion is called the isthmus, the external sinuous and wider portion the ampulla; the first has a transverse diameter of 2 — 3 mm. (ca. "1 in.), the latter of 6 — 8 mm. (*25 — '3 in.) and more. The funnel, or infundibulum, which surrounds the opening, is divided by clefts into numerous pro- cesses {fimhrice), of which one is specially long and jagged, and serves to fix the infundibulum to the outer end of the ovary (f. ovarica). The Fallopian tube is the efi'erent duct of the 3 34 THE PELVIC PERITONEUM. ovary, and is as a rule only periodically applied to it in order to take up its products. The ovary lies beneath the oviduct, between its abdominal aperture and the posterior margin of the side of the uterus, and is attached to the latter by a short ligament — lig. ovarii (fig. 15). In the horizontal posture, the tube lies behind and above the ovary, and thus forms a hiusa ovarica, •which is of importance for the reception of the ovum. The uterus and oviducts together raise the bottom of the pouch of peritoneum which projects into the pelvic cavity, to form the transverse fold (cf. § 36) which passes from one side of the pelvis to the other ; this fold lines the uterus in its middle portion, is reflected in front on to the bladder, behind on to the rectum, and on either side forms the broad ligament. This fold also encloses the vessels passing to the uterus and ovary, and the j'xi^'ovarium, which occupies the angle between the last bend of the oviduct, the fimbria ovarica and the outer end of the ovary, and consists of remains of the primordial kidneys ; the small canals of which it is composed, converge towards the lower edge of the ovary. The Pelvic Peritoneum. § 42. The peculiar arrangement of the pelvic serous membrane is important from a practical point of view, and will now be described : — The peritoneum leaves the uterus on four sides: on the anterior surface it reaches to the level of the internal os, some- times a little lower, and then (supposing the bladder to be moderately distended) is reflected at a somewhat acute angle (fig. 16) on to the posterior wall and base of the bladder, and from there on to the anterior abdominal wall. The anterior surface of the cervix is in immediate contact with the bladder, and connected with it by a thin layer of loose cellular tissue, by muscular fibres (derived from both organs) and venous plexus. The peritoneal pouch formed in this way between the uterus and the hladder—utero-vesical pouch— is bounded laterally by the slightly prominent and gently curved utero-vcsical folds, in which run a few strands of muscle fibres derived from the uterus. The peritoneum descends further on the posterior THE PELVIC PERITONEUM. 35 surface of the uterus than it does in front, but is closely con- nected with it only as far as the level of its reflection in front ; below that level a layer of loose cellular and numerous veins intervene between the cervix and the peritoneum. The latter next descends over the entire posterior surface of the cervix, Fig. 16. — Median Section through the Female Pelvis, left half. (After KohlrauEch.) covers in addition a portion of the vaginal fornix for a distance of 1 — 2 cm. ('4 — "8 in.), and is then reflected (at a more obtuse angle than on the anterior surface) backwards on to the rectum, at a point about 6 cm. (2'25 in.) above the anal orifice; thus is fovmed the deeip recto-uterine ov Douglas' pouch. 3G THH PELVIC PERITONEUM. This pouch also is bounded laterally by curved folds, the recto-uterine or semilunar folds of Douglas, which however are not always equally distinct ; behind they pass into the sides of the rectum, but on the posterior surface of the cervix they meet and form a transverse projection with a concavity looking back- wards (fig. 16, a). These folds of Douglas, especially at their free edge, contain bundles of smooth muscular fibres, which are mainly derived from the uterus and vagina, and run along the rectum to the neighbourhood of the second sacral vertebra (Muse, retractor uteri, Luschka). The peritoneum forming the floor of Douglas' pouch is thick, rich in elastic fibres, and con- nected by loose cellular tissue with the dense plexus of veins, which surrounds the uterus and makes its way in between the rectum and the vagina. The deepest portion of Douglas' pouch contains as a rule no coils of intestine. § 43. The anterior and the posterior layers of the fold in which the uterus is, as it were, taken up, do not come quite into contact at its sides ; there remains between them a sort of hilum for the entrance and exit of the uterine vessels, which are at this spot surrounded by strong bands of muscle. After uniting to form the ligamentum latum, these two layers pass on as peripheral folds to the sides of the pelvis, the posterior fold always extending deeper than the anterior. The line along which they separate in order to be reflected forwards and backwards on to the internal surface of the pelvic wall, is continued down along the hypogastric artery ; the lateral extremity of the free margin of the fold lies in the upper pelvis close to the iliac artery above its bifurcation. At the lower border of this free edge, the two lamellas gradually spread out into a single layer, which is continuous with the serous lining of the iliac fossa. The free edge of the fold encloses the Fallopian tube, and, corresponding with the course of the latter, runs directly transversely, and further outwards is sinuous and curved backwards. Since the opening of the Fallopian tube pierces the peritoneum on the proximal side of the lateral attachment of the ligamentum latum, a terminal lateral portion of the fold is left, which is empty and sharp, and measures about 2 cm. (-8 in.) in length between the infundibulum and the pelvis ; this is the infundibulo-pelvic ligament. The orifice of the oviduct lies in the posterior layer of the broad ligament imme- diately below its free edge, the abdominal orifice of the tube THE PELVIC PERITONEUM. 37 thus being directed towards the median line and at the same time backwards. From the posterior surface of the broad h'gament rises a secondary fold for the reception of the lower portion of the ovary ; it is placed obliquely and forms with the broad liga- ment a pouch, whose opening looks upwards. The portion which is thus spread out between the Fallopian tube and the ovary incl. its muscular ligament, is the ala vespertiUotiis. It contains the parovarium and numerous vessels, and is bounded laterally by u smooth curved edge to which the fimbria ovarica with its serous surface is attached — mfundibulo-ovarian ligament (Henle). § 44. The round ligament of the uterus is enclosed in a prominent longitudinal fold of the anterior layer of the broad ligament, and consists of a flattened cord 5 — 7 mm. ("2 — '3 in.) wide, composed of the superficial fibres from the anterior surface of the uterus, which have run together. It appears at the point at which the uterus passes into the oviduct, and forms an acute angle with the latter, as it leaves the uterus. It is covered throughout by peritoneum, runs downwards, forwards and out- wards towards the abdominal wall, and passes horizontally along the inner surface of the latter towards the middle line to the internal inguinal ring, its lower end becoming less intimately connected with the peritoneum. Like the spermatic cord in the male, it passes through the abdominal wall and out by the external inguinal ring, and ends in the pad of fat forming the mons Veneris and in the labium majus. As would be expected from its origin, the ligamentuni rotundum contains in its upper third smooth muscular fibres derived from the uterus, which usually run along its upper border, but only exceptionally extend as far as the middle third ; a number of thin strands from the deep abdominal muscles unite with its lower half and occasion- ally reach almost to the uterus. All these run along the upper edge of the ligament, and become more and more numerous in a downward and outward direction, and at the internal inguinal ring pass in an arched manner to the trausversus abdominis muscle. Occasionally some reach even into the inguinal ring, and then curve round upwards or downwards ; in the ligament itself they are accompanied by somewhat large tortuous veins. Now and then the round ligament is accompanied for some 38 URINARY PASSAGES, RECTUM, PELVIC CONNECTIVE TISSUE. distance from the internal inguinal ring between the abdominal muscles, by a narrow process of peritoneum — processus vaginalis peritonei or canal of Nuck. So long as the uterus lies in the small pelvis, the round ligaments must rise above the ilio- pectineal line and take a curved course up to the inguinal canal, while during pregnancy they will descend obliquely outwards to reach the ring ; but in any case before entering it, they cross the origin of the epigastric artery. The two layers of the broad ligament diverge more and more as they descend ; the posterior passes by the side of the rectum into the posterior wall of the peritoneal cavity, forming on its inner side the lateral wall of the fold of Douglas, and passing away over the hypogastric vessels and ureter ; the anterior ascends from its lower end by the side of the bladder to the anterior abdominal wall, its connection with the round ligament, as already stated, growing gradually looser. A layer of cellular tissue intervenes between the two layers of the broad ligament, becoming more and more abundant below and at the edge of the uterus ; in it run the blood- and lymph- vessels, as well as the nerves which supply the uterus and its appendages ; the lower portion also contains numerous plain muscular fibres derived from the superficial layer of the uterus, which radiate in a transverse direction and form a net-work enclosing the vessels. Hence the broad ligaments may be spoken of as the mesentery of the internal generative organs. Urinary Passages, Rectum, Pelvic Connective Tissue. § 45. In order to complete the topography of the pelvic cavity, a description of the eflerent urinary passages, of the rectum and of the so-called parametrium is necessary. The urethral orifice is usually vertical, oblong, 5 mm. ('2 in.) in length and situated between the nymphse above the entrance of the vagina ; in married women, and especially after frequent coitus with a narrow vagina, the opening often lies far back, even behind the symphysis, so that to bring it into view, it must be drawn forwards per vaginam ; it is surrounded by a frequently uneven wall of mucous membrane. The canal itself runs between the corpora cavernosa of the clitoris, beneath the hg. arcuatum inferius, in front of the median line of the lower division ÜEINABY PASSAGES, KECTUM, PELVIC CONNECTIVE TISSUE. 39 of the vagina with which its wall is very closely connected {urethro-vaginal septum), and has an almost straight direction from below and a little in front, upwards and backwards to the bladder ; only at the opening into the bladder is there a slight curve. The wall of the urethra is highly muscular ; the outer muscular layer may form a complete ring, but now and again leaves a gap anteriorly (superiorly) ; the internal layer runs parallel with the axis of the canal, and its fibres frequently interlace. The anterior convex surface of the bladder lies mainly behind the symphysis, but when the organ is distended, projects above it, and comes into contact w^ith the linea alba of the abdomen ; the lower portion is attached by connective tissue and ligaments {puho-res'ical ligaments) to the symphysis and pelvic fascia. The upper portion is so loosely connected with the abdominal wall by cellular tissue, that it can glide over it and raise the parietal peritoneum to a height of 3 — 4 cm. (1 — 1"5 in.) above the symphysis. The vertex of the bladder is covered by peri- toneum ; so also is the upper portion of the posterior surface, that namely which looks towards the uterus (vesico-uterine pouch). The portion of the posterior wall which remains uncovered by peritoneum, is loosely connected with the supra- vaginal portion of the cervix by cellular tissue and muscular fibres, but on the other hand is very closely attached to the anterior vaginal wall, by which the base of the bladder is sup- ported, and over the sides of which it occasionally slightly projects. When the bladder contracts during micturition, the peritoneum is drawn further down, so that it comes not only to line the whole supra-vaginal portion of the cer"\dx, but actually encroaches on the laquear vaginae, this being permitted by the looseness of the subperitoneal areolar tissue. A cordlike process of the superficial muscular layer of the anterior uterine wall becomes connected at the base of the bladder with the fibres of the detrusor urinse. The axis of the bladder forms with that of the urethra an angle opening in front, and both axes run nearly parallel to the middle line of the pelvis, though the bladder deviates slightly to the right. § 46. The ureters measure on an average 26 cm. (10 in.) in length and 5 mm. ('2 in.) in width. Their abdominal poi'tionx 40 URINARY PASSAGES, RECTUM, PELVIC CONNECTIVE TISSUE. are loosely covered by the posterior wall of the peritoneum, and descend from without inwards over the psoas muscle, crossing the internal spermatic vessels which run outwards over that muscle. The left ureter, on passing into the small pelvis, descends behind the rectal end of the sigmoid flexure, and traverses the common iliac artery l"o cm. ("5 in.) above its bifurcation. The ricjht ureter runs at a distance of 1 5 cm. ('5 in.) from the common iliac of its own side, and descends over the external iliac artery. Tae pelvic portion of the ureters averages 12 cm. (475 in.) in length, and takes an on the whole oblique course from behind forwards, and from without inwards, and passes through the pelvic cavity in a curve which is convex outwards and backwards, so that in the neighbourhood of the fourth sacral vertebra the two ureters are 11 '5 cm. (1'5 in.) apart ; the left is usually placed nearer to the middle line than the right, though owing to the frequent deviation of the uterus to the right, the right ureter is nearest to that organ, a relation which is only reversed when the rectum takes an abnormal course, viz. from the right side downwards to the left. As far as the base of the broad ligament, the ureters hug the lateral wall of the pelvis, the left one following the middle, the right the side of the hypogastric artery. They then cross the outer extremity of the base of the broad ligaments, traverse the parametric cellular tissue, cross the round ligaments, and pass through the plexus of veins lying close to the cervix and vagina, being at this point crossed by the hypogastric uterine artery ; they take a sinuous course (resembling a flattened S) by the side of the supra-vaginal cervix and vagina, in order finally to come into contact with the anterior wall of the latter for a distance of 15 cm. ('5 in.), and to cross its lateral surface at a very acute angle ; lastly they extend to the boundary of the upper and middle third of the anterior vaginal wall. As far as the level of the portio vaginalis therefore, they lie by the side of the cervix and vaginal fornix ; at the level of the internal os, they are on an average at a distance of 19 mm. (-7 in.), near the supra-vaginal portion of the cervix of 8 mm. (-3 in.), in the neighbourhood of the vaginal fornix at a distance of only 6 mm. (-2 in.) from the uterus ; about 15 mm. (-5 in.) below the vaginal fornix they lie against the antero-lateral wall of the vagina ; the higher up, the more are they placed laterally. ÜRINAEY PASSAGES, RECTUM, PELVIC CONNECTIVE TISSUE. 41 § 47. The rectum descends on the left side of the promontory, and forms two curves (which merge into one another like those of an S) in its course to the anus ; the upper curve is parallel with the sacrum, and has a forward concavity, the lower has an anterior convexity which sweeps round the point of the coccyx, and opens at the anus by an aperture, which in the erect posture is directed backwards, in the sitting posture downwards — sacral and peri- lueal curves. The concave surface of the latter measures 3 — 4 cm. (1*2 — 1"5 in.), and is supported by the portion of the levator which is in contact with its under surface. There is also a slight lateral sigmoid curve, caused by the intestine passing from the left side of the promontory towards the median line and even beyond it, and then running from the middle of the sacrum again to the left ; it then remains on this side as far as the second coccygeal vertebra, when it turns once more to the right towards the middle line. Contractions of the longitudinal muscular layer may obliterate this lateral curve and in part also the antero-posterior. The upper portion of the rectum is entirely surrounded by a duplicature of peritoneum, whose layers form the meso-rectum, reach to about the second sacral vertebra, and often allow this portion considerable mobihty. The middle portion reaches from the second to the last sacral vertebra, and is lined by peritoneum only in front and at the sides ; its posterior surface is embedded in a continuation of pelvic fascia, and connected by elastic con- nective tissue with the anterior surface of the sacrum ; the lateral surface is connected with the vessels passing tbrough the great sacro-sciatic foramen by connective tissue, which is loose and rich in fat. The lowest portion reaches from the point of the sacrum to the anus and is usually devoid of peritoneum ; the distance of the latter from the anus however varies greatly in individual cases, the distance of the lower edge of peritoneum measured in a vertical direction varj-ing from 5'5 — 8 cm. (2 — 3 in.). The posterior surface lies at first close to the coccyx, then advances beyond it by 2-5 — 3 cm. (1 — 1*2 in.), and below this and is enclosed and supported at its sides by the levator ani ; the anterior surface is in intimate though often loose connection with the vagina, forming the recto-vaginal septum, the thick end of which constitutes the main body of the perinaeum. § 48. Beneath the pelvic end of the peritoneal sac, i.e. 42 UKINAKY PASSAGES, RECTUM, PELVIC CONNECTIVE TISSUE. i V. LV. N^K "^ =^_, g c " g ^^- > -ä r M ^ O _Q ^ ^ C " ., ■" 5*§ p< c > ■15 Sg's-^^ -' -T-'o.bB-' URINARY PASSAGES, RECTUM, PELVIC CONNECTIVE TISSUE. 4S beneath the pelvic roof, extends a layer of connective tissue, more or less rich in fat, and which in unbroken continuity fills up all those interstices between the pelvic organs which lie between the boundaries of the peritoneum and the levator ani, and which connects these organs with each other. It repre- sents in the main the subserous connective tissue of the pelvis, and may be compared to the sub- or retro-peritoneal tissue in other portions of this serous membrane. Since the peritoneum sinks to different levels in different parts of the cavity of the pelvis, though never quite to the level of the levator ani, the whole pelvic cavity may be divided into a peritoneal, and into a sLibpentoneal pelvic cavity. There is however between the under surface of the diaphragm of the pelvis, and the lateral pelvic walls looking towards it, a further interspace which is deepest at the sides and filled by adipose tissue (cf. § 33), and which, since it is closed below by skin, may be called the sub- cutaneous pelvic cavity ((/. tig. 17). Of these three divisions, the subperitoneal cavity (whose contents surround the portions of the pelvic organs which are not lined by peritoneum) is of greatest interest from a patho- logical point of view. It not only contains loose adipose cellular tissue, which by its elasticity permits the distention of the hollow organs, and makes it possible for the loose serous mem- brane connected with it to adapt itself to the varying size of those viscera without tension, but in it lie numerous arteries and veins, absorbents and lymphatic glands ; the enormously developed venous plexus also form a very important constituent (fig. 18;. The connective tissue of the pelvic cavity is most abundant at the base of the broad ligaments, and at the sides of those portions of the uterus and vagina which appear to be let into them, viz. the cervix and the upper half of the vagina. It is this portion which Virchow (c/. his Archives, No. XXIII.) has called the parametrium ; but inasmuch as the loose cellular tissue encloses the portion of the bladder and of the rectum turned towards it in exactly the same way, it is impossible to assign definite boundaries to the division called parametrium. It is more accurate to speak of the contents of the sub- peritoneal pelvic cavity, as the subserous connective tissue of the pelvis, and of that portion which is in immediate proximity with 44 URINAHY PASSAGES, RECTUM, PELVIC CONNECTIVE TISSUE. THE MINUTE STRUCTURE OF THE GENERATIVE ORGANS. 45 utero-vaginal canal, as parametrium, or better as parametric connective tissue (since the word parametrium, like parovarium, involves the conception of a neighbouring organ, which is not appropriate here). LITERATURE. Luschka, JOle Anatomie des menscldlch. Bechens. Tübingen, 1864. Henle, Handbuch d. Anatomie, ii., Eingeweidelehre, 2nd ed., 1874, p. 443. Hasse, '• Beobachtungen über d. Lage d. Eingeweide im weiblichen Becken- eingange." Archiv./. Gyncekolorfic, viii., 1875, p. 402. Schultze, " Zur Kenntniss v. d. Lage d. Eingeweide im weibl. Becken." Ihid., ix., 1876, p. 262. " Die exacte Ermittelung d. Lage d. Uterus in d. lebenden Frau." Centralhlattf. Gi/n., 1878, No. 11. Ilach, Uthrr Lage vnd Form der Gchärmutter. Di»-7. Reinhardt, " Ueber d. Einfluss des Puerperiums auf Thoraxform n. Lungen- capacität." Bi-sxertntinn. Marburg, 1865. Winckel, Studien über den Stoffwechsel bei der Geburt, kc. Rostock, 1865, p. 27—38. Section II. THE EMBRYO, ITS MEMBRANES AND APPENDAGES. a. The Develoimient of the Ovum. § 82. The segmentation of the yolk, which is the first effect of conception, leads to the grouping of the largest number of the segmentation spheres at a point immediately beneath the zona pellucida, and thus to the formation of the blastodermic vesicle. At one part of the latter a large number of cells are heaped up and give rise to a thickening of oval or almost circular outline, which plays a direct share in the building up of the embryo, and is called the cmhrijoiiic area. The thickening soon splits into two lamellfe or hlastodcrmic layers, an upper and a lower, forming the epiblast and the hypoblast (ectoderm and entoderm, Kölliker), which continue to grow out from the embryonic area, till at last the whole wall of the blastodermic vesicle consists of two concentric layers, lying closely one above the other. The building up of the embryo now commences in the embryonic area of the blastodermic vesicle, by the lower layer splitting into the conjoined muscle-plate (mesoblast, mesoderm) and into the hypoblast (entoderm), and by the muscle-plate splitting into the somato-pleural or volunto-muscular, and into the splanchno-pleural or involunto-muscular plates (Remak, His, Waldeyer). The iijjjJer blastodermic or sensory layer (epiblast, ectoderm) gives rise to the central nervous system, with its offshoots, the higher sense organs, and to the epithelium of the skin with the glands connected with it ; the central nervous system is derived from the median (axial) portion which forms the so-called medullary plates ; the epithelium of THE e:\ibryo, its membranes and appendages. 91 the skin from the peripheral portion or corneal layer of the blastodermic vesicle. Moreover the origin of the urogenital organs, especially the sexual glands, is to be referred to the upper layer and to the axis-cord {i.e. the elongated mass due to cell proliferation which is formed in the axis of the transparent embryonic area), in which no division into separate layers can be made out. From the middle layer or inusclc-plates (mesoblast, mesoderm) are formed the connective tissues, the muscular and the vascular systems, i.e. the main bulk of the organism. The somato-pleural muscular layer forms the body wall ; the splanclino- pleural layer, the intestinal wall, with the exception of the epithelium, and the heart. The fissure remaining between the two layers becomes the pleuro-peritoneal cavity, but inasmuch as the fissure does not reach the middle line, there remains at that point a connection between the abdominal and intestinal walls, which leads to the formation of the mesentery. From the hypoblast, or lowest blastodermic layer, arise (through the epithelium forming diverticula which project into the splanchno- pleural muscular lamella) the small glands of the digestive canal, the large glands opening into it (liver, pancreas), the lungs and the kidneys ; but as the splanchno-pleural muscular lamella is itself involuted during the development of these glands, and made to encroach upon the pleuro-peritoneal cavity, all those organs that have been mentioned, come to lie in it. § 83. Soon after the walls of the embryo have begun to split into distinct layers, the embryo raises itself (by a process of con- striction) above the remaining or peripheral portion of the blasto- dermic vesicle, as an elongated tube which remains widely open on its lower aspect ; at the same time both ends of the embryo curve down- wards towards the cavity of the vesicle, so as to give it more or less the shape of a canoe. The portion of the blastodermic vesicle which is constricted off (fig. 22), is termed the umbilical vesicle (yolk-sac) ; and the opening by which it communicates with the cavity of the embryo (and which gradually Fig. 22. — Ovum, showing the yolk- sac and the amnion in process of development. (After Kölliker.) 92 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. narrows as constriction proceeds), remains as the vitello-intestinal or omphalo- enteric duet. At last there merely remains a ring- like constricting fold, the navel; and inasmuch as the walls of the blastodermic vesicle continue to form two layers, for some distance beyond the constriction, i.e. at their peripheral portion, the umbilical wall also consists of several layers. § 84. While the body-cavity is being formed and subsequently also, the embryo sinks into a depressed portion of the embryonic area, and thus becomes shut in on all sides by a kind of embank- ment. Along the margin of the embryonic area, the hypoblast and the splanchno-pleural muscular layer diverge from the epiblast and the somato-pleural muscular layer, with which they were in contact, first of all at the cephalic, then also at the j caudal extremity and at the sides. The epiblastic layer and the j Fig. 23. — Ovum, showing the amniotic folds about to coalesce, and the allantois at an early stage. ^~~i:^-orv Fig. 24. — Ovum, showing the subzona] membrane covered with villi, and the allantois which has undergone further development. somato-pleural muscular lamella become more and more pro- minent, and at the head, tail and sides form folds (the cephalic, caudal and lateral folds), which grow up all round and meet above the dorsum of the embryo, finally uniting over it to form a sac (figs. 22 and 23). As soon as the folds of the amnion have coalesced, the two layers of which they consist separate, the inner one giving rise to the amnion proper, the outer one forming with the remaining portion of the upper layer of the blastodermic vesicle a completely closed vesicle, which comes into contact with the zona pellucida. This constitutes the suhzonal membrane of the ovum, which therefore consists only of the epiblast (or rather its continuation over the peripheral portion of the THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 93 blastodermic vesicle), and eventually forms the chorion (figs. 23 and 24). At first the amnion lies close to the embryo, but soon a liquid, the liquor amnii, is thrown out between them, which distends the amniotic cavity, and surrounds the embryo on all sides. § 85. At the time that the amniotic folds coalesce, there appear at the posterior extremity of the embryo at the edge of the opening into the hind-gut, two solid aggregations of cells, which soon blend with each other ; into this pyriform outgrowth a diverticulum of the hind-gut projects, in consequence of which it becomes excavated, and forms a vesicle. This is the rudiment of the allantois. This vesicle grows rapidly between the somatic and the splanchnic muscle-plates, through the integumental portion of the navel out of the embryo, and thus comes to lie between the amnion and the blastodermic vesicle (fig. 24) ; it grows round the former, and becomes applied to the subzonal membrane of the ovum, i.e. to the chorion. The point of connection between the hind-gut and the allantois is called the cloaca, from which the urinary Madder is developed ; the narrower portion which passes through the integumental portion of the umbilicus, i.e. the peduncle of the allantois, goes to form the urachus. When the allantoic vesicle has reached the chorion, the largest branches of the aortas run in it ; these are called the umhilical arteries, and their terminal loops project into the chorionic villi ; the vessels that return from the latter unite to form the single umhilical vein, which runs to the navel with the arteries, passes through it back into the embryo, and communicates with the hepatic vessels and with the inferior vena cava. At the point where the allantoic vessels penetrate into the chorionic villi, the latter undergo great development, and become intimately con- nected with the mucous membrane of the uterus ; the capillaries of the latter also develop over a corresponding area, and thus is formed the placenta which constitutes the direct connection between mother and embryo. § 86. By the commencement of the fourth week, therefore in a very short period, the foundation, so to speak, of the main structure of the now 4*5 — 6 mm. ('2 — '3 in.) long embryo is com- pleted. The latter is shut off" by the amnion from the peripheral portions of the ovum, its body-cavity being closed, with the 94 THE EMBEYO, ITS MEMBRANES AND APPENDAGES. exception of the umbilical opening (fig. 25). The embryo is connected with the distal parts of the ovum merely by the umbilical cord, which at first contains also the pedicle of the umbilical vesicle or yolk-sac, the omphalo-cnteric duct with the omphalo-mesenteric vessels and the pedicle of the allantois with the umbilical vessels, but later on only the latter with the con- nective tissue supporting them, and is enclosed by a sheath of amnion. The umbilical vesicle, lying between the amnion and the chorion (fig. 25), soon atrophies together with the umbilical duct and its vessels ; it can however almost always be found even in the mature pla- centa as a small whitish vesicle, lying between the two embry- onic membranes. Moreover a small cord, the omphalo-enteric duct, runs in the umbilical cord to the little vesicle and occa- sionally an omphalo-mesenteric vessel is also preserved*. § 87. Between the amnion and chorion there is at first a considerable space ; but the former soon begins to grow rapidly and by the third month of pregnancy is in complete contact with the latter, though there remains between them a thin gelatinous layer, the inspissated remains of the albuminous liquid that previously separated Fig. 25. — Ovum, in which the vascular layer of the allantois has everywhere come into contact with the subzonal membrane. The yolk-sac (d) is atro- phied. The amniotic cavity (a) has increased in size. (KöUiker.) ' The small umbilical vesicle usually lies at the edge of the placenta, but frequently lower down, and sometimes at the opposite pole of the ovum. Its length is 3 — 10 mm. (r5 — "4 in.), its shape pyriform, round or oval ; it contains a whitish-yellow turbid | substance, consisting of fat and carbonates. The vitelline duct, i.e. the pedicle of the umbilical vesicle, is best preserved in the neighbourhood of the latter, but sometimes maybe followed as far as the umbilical cord. Not uncommonly it presents numerous local dilatations filled with yolk matter (?). In passing from the embryonic mem- branes into the umbilical cord, it sometimes raises the amnion into a fold (fold of Schulize). The vessels of the umlilical reside appear as white threads, running along the vitelline duct at a variable distance from it ; it is most frequently met with in monstrosities; the vein is usuall}' persistent. According to Ruge {Zeitschrift J". Geb. u. Gyn., i.) an absence of coils in the umbilical cord is associated with a persistence of the vessels. In the abdominal cavity the vitelline duct passes to the intestine, the blood-vessel to the mesentery, {cf. Ahlfeld, Arch.f, Gi/nuL, x'., pp. 184, 589.) THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 95 them. The ovum as a whole however is becoming surrounded by a membrane derived from the uterine mucous membrane, the decidua reflcxa (fig. 26, dr.), which at the point of attachment of the ovum is continuous with and attached to the inner surface of the uterus, i.e. to ihe decidua vera (dv.). Up to the third month the ovum and the uterine walls are still separated by a small interval, filled with mucus, which disappears with the further growth of the ovum, by the reflexa coming into contact with the vera. From this time onwards the membranes enclosing the embryo merely form separate layers of a single sac. plu' Pl" m. muscularis of the uterus, only partially shown, dv. decidua vera, phi. placenta uterina,external layer. })lu'. internal layer of the same with ]irolongations between the chorionic villi., chz. dr. decidua reflexa. chl. chorion Iseve. chf. chorion fron- dosum, which, together with the villi chv. constitutes the foetal placenta. «. amnion, ah. amniotic cavity, as. amniotic sheath round the umbilical cord. vd. vitelline duct. ys. yolk-sac. U. cavity of the uterus (drawn too large). Fig. 26. — Membranes of a human embryo in situ ; represented diagrammatically. (After KöUiker.) The mature ovum consists therefore of the embryo (called fcetus after the third month), and its appendaf/es — the amnion with the liquor amnii, the chorion and the decidua, together with the placenta and the umbilical cord. h. The Foetal Appendages. (1) Decidua. § 88. "We have already in § 64 mentioned the great develop- ment of the uterine mucous membrane, which begins with conception, and consists of a marked increase in the hypertrophy 9G THE EMBRYO, ITS MEMBKANES AND APPENDAGES. which accompanied the last ovulation. This increase in size depends on considerable enlargement of the test-tube uterine glands, on abundant new formation of connective tissue, on the appearance of numerous migrating cells and on great development of the vessels ; the epithelium is for the most part lost, as in menstruation. By the second week the mucous membrane has reached a thickness of 4 — 6 mm. ("15 — '2 in.), is more easily definable from the subjacent muscular coat, is soft, spongy and dark red, its surface being raised into small distinct folds and pierced sievelike by the dilated mouths of the uterine glands. This is the decidiia vera (decidua, W. Hunter). It ends abruptly at the / ^^^ \ Tig. 27. Fig. 28. Fig. 29. Ovum becoming embedded in the decidua, and reflexa in process of development (diagrammatic). internal os, and leaves the openings of the Fallopian tubes free. The ovum on entering the uterine cavity is detained in its upper portion, owing to that cavity being almost entirely filled up by the swollen mucous membrane. It finds a nidus and embeds itself in the folds of mucous membrane, which very soon (figs. 27 — 29) sprout up all round the ovum, and at last close in above it to form a complete sac ; they are called decidua reflexa (owing to the earlier view that the openings of the Fallopian tube were closed by the decidua vera, which was looked upon as an exudation which the ovum was obliged to push before it), the portion of the decidua vera to which the ovum remains attached. THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 97 3)eing called the decldua serotina. At first the decidua vera is separated by mucus (c/. supra) from the reflexa, but before long the latter is rapidly stretched by the ovum, and in the third month comes to lie in close contact with the vera ; thereupon both become blended into a single membrane, which as a rule can only with difficulty and in isolated places be separated into its original constituents, § 89. A healthy decidua vera has about the third month a thickness of 4 — 7 mm. ("2 — "3 in.), but soon afterwards begins to grow thinner. It consists of large spherical and elongated cells with a large nucleus and somewhat granular contents, y' c^A '''^''i ^ '^'1 '. '■ ■; ; '-. :/ ^>\\. /■■ - ^ n '■nA (^ \uc Fig. 30. — Diagrammatic Fection through an incap=\iled ovum (showiag the decidua Teü-ixa.) of 12 — 16 days. (After Kollmann.) c. Cavity in which the ovum lies. em. external membrane of the ovum. b. basilar membrane of the capsule of the ovum. Jh. free apex of the latter (cicatricula), devoid of glands, m. marginal zone of the embryonic capsule. ,«. nubmucosa. sp. seconne another, the movement of blood must be very irregular ; on the )ther hand the possibility of the blood escaping in any direction which is permitted by this arrangement) acts to some extent as 1 safeguard against stagnation in the vascular channels of the jlacenta, or indeed against the rupture of the ^¥alls which might )therwise easily take place, owing to the frequent alteration of ;he blood-pressure in the uterine vessels. The turgescent con- lition of the chorionic villi which is probably maintained for considerable periods, and the pressure which the liquor amnii ixerts on the inner laj-er of the placenta, doubtless also lead to :he slitlike spaces between the villi and the lacunse maintaining }heir shape. § 97. Amongst the numerous abnormalities in the shape of he placenta, as described by Hyrtl, most practical importance ittaches to the not uncommon formation of one or more acces- wry placenta, placentce succenturiatce. They do not arise :hrough constriction of one of the lobes of the main organ, but through a heaping up of the villi (which are originally spread )Ter the whole chorion) into two or more collections of diflerent dzes, of which the smaller forms the placenta succenturiata. The latter is connected with the main placental mass by a bridge .)f parenchyma or, what is less common, only by vessels ; when he two placental masses are close together, the bridge of paren- i;hyma is never absent, and vice versa. In certain rare cases the accessory mass is semilunar, its concave edge being turned i.owards the main placenta ; when both horns of the crescent have )ecome united to the convex edge of the latter, there remains petween the two a bare thin island of chorionic tissue which is I'ree from villi, and forms a windowlike aperture in the placenta — 'olacenta fenestrata. In this island may lie small lÄaccjitiiUe ''•uccenturiatce, and thus the number of apertures be increased, jvhile their size decreases. Sometimes wide branches of the iimbilical vessels run through the apertures. At the time of 112 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. labour, entiro accessory placentae, i.e. the separate cotyledons lying in the interval, may remain behind unnoticed, and lead to serious mischief. (6) Umhilical Cord. § 98. The mother is connected with the foetus by means of the umhilical cord, funiculus umbilicalis, which arises at the umbilicus of the child, and is inserted into the foetal surface of the placenta. In a j'oung embryo there pass out of the umbilical opening {cf. § 86) the vitello-intes- tinal duct with the umbilical vesicle and its vessels, the pedicle of the allantois in process of becoming ob- literated, with its vessels and a loop of intestine, all of them lined by that portion of the amnion which extends between the umbilical orifice and the part of the chorion lying opposite to it. Those structures at an early date almost entirely disappear ^ the loop of intestine is retracted into the closing abdominal cavity, and from the 3rd month onwards the cord consists merely of a covering derived from the amnion (umbilical sheath), of the umhilical vessels, and the soft connective tissue (Wharton^ s jelly) in which they are imbedded. At first it is short, but soon it grows rapidly and reaches an average length of 50— 55 cm. (19-5— 21-5 in.). The amniotic sheath cannot be stripped oß" from the jelly of AVharton ; it ends, especially in well developed foetuses, at a distance of "5 — 1*25 cm. (-2 — "5 in.), or even further from the abdomen, the skin of which is continued for that distance on to the cord (cutaneous or fleshy navel). Conversely, the amnion sometimes does not end at the abdominal wall, but expands like- a flattened funnel in the immediate neighbourhood of the navel i ' For further information as regards the persistent condition of the vitelline duct, cf. st'pra (§ bC, note . Figr. 33. — Wreath of capillaries at the margin of the skin and um- bilical cord. (After Virchow.) A. abdominal ■wall. B. persistent portion of the umbilical cord, c. marjjin of capillary wreath. THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 113 (amniotic navel) ; at its opposite extremity it is continuous with the layer covering the placenta. The amniotic sheath of the -cord has a stratified epithelium, but is non- vascular ; at a distance of 9 — 12 mm. ('4 — "5 in.) beyond the umbilical ring is situated a wreath of capillaries derived from the skin of the abdomen (fig. 33), whose upper border forms the line of demarcation, when later on the cord falls off". Between the epithelial cells are stomata (Köster), which may possibly be connected with the serous channels in Wharton's jelly. The jelly of Wharton (corresponding to the subcutaneous connective tissue of the abdominal wall, and in part derived from the allantois) consists of a gelatinous matrix, in which run strands of fibrillae, interlacing with each other in such manner that rounded or oval interspaces remain free from fibrill». The firmer portions form a thin superficial layer beneath the amnion, a sheath round every vessel and a sort of axial cord which sends processes towards the surface between the vessels. Within the three islandlike masses between the fibrillae, lies a net-work of mainly stellate cells, which form an anastomosing system of serous channels which can be injected, and in which contractile cells are found. True lymphatics are absent ; so also are nerves, except in the portion nearest to the foetus. The two umhilical arteries^ at a very early period are the direct continuations of the bifurcating aorta, but later on become con- tinuations of the hypogastric arteries ; they are smaller than the vein, and pass, crossing each other as they do so, through the umbilical ring into the cord, in which they run to the placenta without giving ofi" any branches ; between them lies the single vein. The course of these vessels is only straight in very short and thin cords ; as a rule it is that of a left-handed spiral (looking from the navel towards the placenta) ; hence arises the twisted appearance of the cord. These spiral tivists- are most probably due to the higher tension of the wider vein brought about by a greater blood-pressure, which tension stretches the vein more ' In some cases only one functional artery is present. - Kehrer {Ic.) gives the name of "spirals" to twists that cannot be undone, that are made permanent by their investment of amnion ; those on the contrary that disappear when the cord is untwisted, he calls " torsions." The latter are mainly due to changes in the foetal position, and he believes that rotations of the foetus may first of all produce "torsions," and that when these have become persistent by the growth of the amniotic sheath, they become " spirals." 8 114 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. than the arteries, obliges it to take a curved course and compel» the arteries to follow it (Neugebauer) ; inasmuch however as the right artery is usually rather larger than the left, the twist generally takes place towards the left side. It is also possible that the rotation is simply a consequence of the rebound which is brought to bear on the embryo by the stronger blood-flow through the right artery, and which is transmitted to its pelvis. In rare cases the blood-vessels take an altrrnating course, a left- handed spiral changing to a right-handed, and vice versa ; still more rarely their course is erratic, the vessels taking an equal share in forming a great glomerulus. These vessels not only have a spiral course round one another, but each of them is also rotated on its oxen axis. At those points where the vein shows- grooves and indentations on its outer surface, as a result of that rotation, it has in its interior semilunar or ring-shaped valves ,- the arteries only possess traces of these. The coats of both arteries and veins are very thick, especially (both in their intra-abdominal and free portions) as they approach the umbilicus ; they are moreover very rich in smooth muscular fibres ; hence their great contractility and liability to extreme narrowing. There is no elastic intima between the muscular fibres and the endothelium; only in the abdominal portion does it appear as a distinct layer, and gradually increase in a central (as opposed to a peripheral) direction. The difl'erence in. thickness between the walls of the arteries and veins is not sa marked as in the rest of the body, though the vein has somewhat thinner walls than the artery. Vasa vasorum are absent. § 99. The average length of the cord, as given above, is subject to considerable variations. It may fall to 15 (6 in.) and even 7 cm. (cases of absence of the cord, in which the foetus is imme- diately adherent to the placenta by means of its umbilicus, belong- to monstrosities). It is more often longer (Neugebauer and. Schneider), amounting to 160 (63 in.), 183 (72 in.) and even_ 194 cm. (76 in.) ; gi-eat length predisposes to the cord being; coiled round the body, neck and limbs of the foetus, as is so commonly seen (1 : 4"5 of all births). The thickness of the cord varies with the quantity of Wharton's jelly ; hence the difference between a thin and a fat cord. The so-called spurious knots are local collections of Wharton's jelly, or circumscribed collections of simple and twisted vascular THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 115 loops ; they have no importance. True knots, simple or double, or so-called weaver's knots, are rare. They are produced, when the cord is long, by the fcetus during its movements slipping through a loop and drawing it tight ; this may happen during pregnancy, although it occurs more frequently during labour. In the first case the knot is drawii tighter, and is therefore smaller than in the latter ; moreover it shows a diminution of the jelly at its concave borders. The cord is generally inserted obliquely into the placenta, and rarely exactly at its middle (iusertio centralis) ; as a rule it is placed at one side (insertio lateralis), and nearer to one edge. Sometimes the seat of insertion is displaced to the edge (ins marginalis), or beyond it, to the part of the chorion which is free from villi, in which case the vessels divide between the chorion and the amnion before they reach the placenta (ins. velamentosa). Only in exceptional cases does the cord divide before its insertion into two or more branches, which pass separately to the placenta (ins. furcata). c. The Foetus. (1) In the different months of Pregnancy. § 100. An acquaintance with the changes in form, size and weight, which take place in the ovum and in the foetus, as preg- nancy advances, is of importance for the accoucheur. Several ova of the Ist month are in existence, and some have been very accurately described by Thomson of Edinburgh. Figs. 34 and 35 (copied from Kolliker) show such in their natural size ; the estimated age of the first is 12 — 13 days, while the second belongs to the end of the 3rd, or the beginning of the 4th week. A well preserved exactly four weeks (28 — 30 days) old ovum has been described by Waldeyer. Together with the membranes, it has about the size of a pigeon's egg (fig. 36), is 19 mm. (75 in.) long, 16*5 mm. ('6 in.) wide, and weighs 2"3 grm. (355 grs.) ; the length of the embryo (fig. 37), measured from the summit of the posterior cephalic curve in a straight line to the caudal curve opposite the insertion of the hind limbs, amounts to 8 mm. ("3 in.), while the actual length of the dorsal line, from the summit of the anterior cephalic curve to the apex of the coccyx, amounts to 20 mm. ("75 in.). The embryo, both in form and in IIG THE EMBKYO, ITS MEMBRANES AND APPENDAGES. the disposition of its organs, resembles otlier mammalian em- bryos, the head and trunk forming one mass, from which the J^It- Fig. 34.— Human Ovum 12—13 days old. (After Thomson.) Fipr. 35. — Human Ovum at the end of the 3rd or the beginning of the 4th week. (After Thomson.) Fig. 36. — Human Embryo in sifu within its membranes, 4 weeks • old, natural size. (Waldeyer.) 1 Fig. 37. — The Embryo from fig. 36 magnified somewhat more than 4 diameters. a. rudiment of the umbilical cord. d. caudal fold of the amnion, i i. yolk-sac with yolk- duct. narrower caudal extremity projects ; visceral arches distinct ; Hmbs scarcely indicated ; umbilical cord very short and wide, 1 THE EMBEYO, ITS MEMBEANES AND APPENDAGES. 117 with its arteries and single vein ; yolk-sac and yolk-duct still large. The amnion lies moderately close to the embryo, and is separated from the villous chorion by a clear cavity. An embryo dating from the '2nd month, 6 — 7 weeks old, is very beautifully figured by "VValdeyer. It measures (fig. 38), from the summit of the posterior cephalic curve to the caudal curve, 13 mm. ('5 in.) in a straight line, the real length of the dorsal line, from the summit of the anterior cephalic curve, being 25*5 mm. (1 in.). An ovum of 8 weeks, which is figured in Ecker's Icon. Physiol. (Plate 27, fig. 7), has a length of 3*6 cm. (1'5 in.), the embryo measuring 2"1 cm. ("8 in.). By this time the amniotic cavity has increased, the fluid contained in it is more abundant, the amnion is in contact with the chorion, and the villi of the latter are es- pecially well developed at one spot. The umbilical vesicle is very small, its pedicle is fiHform ; the umbi- lical vessels, passingto the chorion, are the only remains of the allan- tois that are still visible, and they form the main constituent of the umbilical cord. The latter has pig. ss.— Human Embryo of the 6th increased in length ; tbe umbilical -^^h ^v^ek magnified 2 diametei-s. ° ' (After Waldeyer.) ring is narrower, although still containing coils of intestine. The head is more distinctly con- stricted off from the trunk, and the eyes can be made out as little dots ; the mouth and nose can also be distinguished, and in the lower jaw and clavicle, the first centres of ossification appear; the several segments of the limbs are differentiated. The primitive kidneys have almost disappeared, and have divided into urinary and generative organs. § 101. Towards the end of the Qrd month, the ovum is 9*5 — 11 cm. (3"75 — 4*25 in.) long. The chorion has lost a large part of its villi, and the placenta, though still very small, is perfectly distinct. The umbilical cord is much longer, and twisted, and is inserted far down into the lower end of the trunk ; the intestine is retracted from the umbilical opening. The embryo is 7 — 9 cm. (2-7o — 3*5 in.) long, and weighs about 30 grm. (460 grs.). The neck noAV separates the head from the trunk, the latter, owing to the development of the 118 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. ribs, being distinctly divisible into chest and abdomen. The oral and nasal cavities are separated by the palate, the former being closed by the lips. Teeth begin to form in the jaws ; in most of the bones, centres of ossification have appeared ; in the extremities, fingers and toes can be made out, as well as the rudiments of the nails. The scrotum and the labia pudendi originate as cutaneous folds ; the penis and clitoris are still of equal length. By the end of the 4th mnntk, the placenta has increased in thickness and size. The umbilical cord is more twisted and, owing to the formation of Wharton's jelly within its sheath, has become thicker. The foetus is 10 — 17 cm. (4 — 675 in.) long, and weighs on an average 55 grm. (850 grs.)^ ; its head amounts to a quarter of the whole length of the body, and the cranial bones are in part ossified, although they show very wide sutures and fontanelies. The face becomes more dis- tinct ; mouth, nose, ej'es and ears attain their proper shape. The sex can be distinguished ; the skin is firmer ; hairs begin to form. The foetus occasionally moves its limbs a little. A foetus at the 5th month, is 18 — 27 cm. (7 — 10*5 in.) long, and weighs 273 grm. (8|^ oz.) ; the liquor amnii however still weighs more than the foetus. The head continues relatively very large. The face has a senile look ; the eyelids begin to open. Distinct downy hairs {lanugo) show themselves, beginning along the lines of the eyebrows and on the forehead. The skin is richer in fat and therefore tenser, its surface being covered by Vernix caseosa (a white greasy substance consisting of epidermic scales, downy hairs and sebaceous matter derived from the skin), though this is still in small quantity. *' Foetal movements " are perceived by the mother. § 102. By the end of the ßth month, the length of the foetus amounts to 28 — 34 cm. (11 — 13*5 in.), the weight to 676 grm. (234 oz. avoir.). The head continues disproportionately large. The upper portion of the chest appears prominent, in consequence of the large size of the pectorals ; the gluteal muscles are better developed, and the whole body looks plumper than during the previous month. The umbilical cord is no longer inserted so low down, but in the middle third between the pubic symphysis and the xiphoid appendix. The eyelids are open, eyelashes and ' The measurements and average weights are borrowed from Hecker's data. THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 119 eyetrows more distinct ; the hairs of the scalp grow longer and gradually lose the characters of lanugo. The testes approach the inguinal rings. The small intestine has bile-stained contents ; so also may have the commencement of the large intestine ; indeed the contents of the latter may be the darkest (meconium). A fcetus born at this period moves, and makes feeble attempts at inspiration, but they soon cease. At the 7th month, the foetus reaches a length of 3-5 — 38 cm. (13*75 — 15 in.), and an average weight of 1,170 grm. (41| oz.). The head, still very large, is firmer, the extremities plumper, although the skin continues much wrinkled. A testicle may often be found lying close to the external inguinal ring. At the beginning of the 7th month, the whole body is covered with hairs, especially the forehead, cheeks, the neighbourhood of the mouth, and the neck ; on the trunk the hair is thick, but shorter; it is least abundant on the limbs, from the ends of which it is partly absent. The larger part of the great intestine contains meconium. The pupillary membrane has generally disappeared by this time, probably always by the end of the month. The foetuses which are born alive between the 24th and 28th week, generally perish very quickly, exceptions being extremely rare, and only to be credited with the greatest circumspection ^ In the 8th month, the length amounts to 39 — 41 cm. (15*25 — 16 in.), the weight to 1,571 grm. (3| lb.). The umbilical cord is inserted 1*5 — 3 cm. (*6 — 1*2 in.) below the point midway between xiphoid appendix and symphysis. The hairs of the scalp are more abundant, the down on the face is disappearing ; the nails have become harder, although they do not yet reach the finger tips. One of the testicles has generally descended into the scrotum. At the end of the 8th month, ossification begins in the lower epiphysis of the femur. With some care a foetus born about this period can be kept alive. In the Wi month, the length reaches 42 — 44 cm. (16*5 — 17-25 in.), the weight 1,942 grm. (4j lb.). The shape of the body becomes more rounded, owing to a greater development of fat ; the face larger and pleasanter ; the miliaria which were plentiful round the mouth and on the cheeks'^, are in process of ' Instances are given by Cullingworth in the Ohst, J. Great Britain, June, 1878, p. 163. Cf. also the remarks by Underhill in the Arner. J. Obstetrics, xii., 1879, p. 94. ■ Cf. Küstner, Arch. f. Gyn., xii., p. 102: and Epstein, Central -.titg.f. Kinderheilk., ii., No. 4. 120 THE EMBEYO, ITS MEMBRANES AND APPENDAGES. disappearing. The cranial bones are still flexible, and the nails not fully developed. The hair of the scalp is more abundant, but the lanugo elsewhere becomes less and less distinct. The vitality of children born at this period, approaches that of mature foetuses, although they still have much less energy than the latter ; they sleep a great deal, and unless well cared for, usually perish. In the first weeks of the lOtli month, the foetus measures 45—47 cm. (17-75— 18-5 in.), and weighs 2,323 grm. (5 lb.). By degrees it assumes all the characters of a mature foetus, and indeed possesses them during the last two weeks. The measurements and weights given above are, as already observed, borrowed from Hecker's data. For the 7th, 8th and 9th months, the measurements made in this maternity (^cf. Fesser) gave similar figures, while on the other hand those obtained by Ahlfeld are much larger. I will place the results for the months referred to side by side, to allow them to be compared : — Hkcker. Spiegelberg. Ahlfeld. 7th month .'iö— 38 cm., 1170 grm.. .,34-8 cm., 1069 grm,. ..38-3 cm., 1388 grm. 8th „ 39 — il cm., 1571 grm.. ..38-8 cm., 1511 grm.. ..42-2 cm., 1880 grm. 42 — 44 cm., 1942 grm.. ..45-7 cm., 2189 grm.. ..46-9 cm., 2517 grm. I- Not specially re- \ / JMot specially re- \ corded, because very 10th „ 45— 47 cm., 2323 grm./ similar to length \ 49-8 cm., 3096 grm. I and weight of the | Tnatnrp. frpbia. ) I auu weigm, oi iiie mature fcEtus. ; Toldt's observations, made on 200 foetuses, show that the general development as well as that of special parts must be taken into account, in estimating the age of a foetus. In the first place, the loeight, because influenced to a great extent by the state of nutrition, is of less value than the length. The latter at the commencement of the 5th week (measured from the vertex of the head along the middle line of the back to the apex of the coccyx) amounts to r5 cm. (-6 in.), and increases during each of the following weeks by about -5 cm. (•2 in.), so that at the end of the 8th week it reaches 3-5 cm. (1-3 in.). At the end of the 3rd month, the body-length (from the vertex of the head to the heel, when the body is extended) is 7 (2-75 in.), at the end of the 4th month 12 (4-75 in.), of the 5th 20 (7-75 in.), of the 6th 30 (11-75 in.), of the 7th 35 (13-75 in.), of the 8th 40(15-75 in.), of the 9th 45 (17-75 in.), of the 10th 50 cm. (19-5 in.) ; it therefore increases after the 6th month, at the rate of 5 cm. (2 in.) a month. The individual parts of the body which yield reliable data by which to estimate the age, are the degree of development of the hairs, the presence and size of certain centres of ossification, and the degree of development of some parts of the irain. In the os calcis at the beginning of the 7th month, there appeai-s a centre of ossification measuring 3 mm. (-1 in.) in diameter, which increases in length, and by the end of the 8th month amounts to 4 — 7 (ca. -2 in.), of the 9th 6—10 (ca. -3 in.), of the 10th 9—12 mm. (-35— -45 in.). In the astragalus, ossification sets in at the beginning of the 8th month ; the nucleus THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 121 has an ellipsoidal shape, and by the end of the month measures 2 — 3 (-1 in.). at the end of the 9th month 5—6 (-2 in.), of the 10th 7—9 mm. (-3 in.). In the \Q\KeT: femoral eii'ipliysh, the centre of ossification is usually only formed in the 9th month. Centres of ossification appear in the upper epiphysis of the tihia, and in rare cases in the upper epiphysis of the humerus towards the end of the 10th month ; if they are present, the maturity of the foetus may safely be inferred, although their absence without further evidence is not proof of imma- turity. Lastly, the superficial configuration of the brain serves to indicate the age ; the shape of the Sylvian fossa does so especially, since the several stages of its development are connected with definite periods of time. In the 7th month, it forms a wide more or less three-sided groove, which narrows and deepens in the 8th month, while in the 9th, the parts adjacent to it (frontal and temporal lobes) gradually approach each other, till by the end of the month the fissrire is completely formed. Again, during the 9th month, only the principal sulci and convolutions are present ; at the end of the 9th and the beginning of the 10th month, numerous branch or secondary sulci appear, and the whole brain is much more highly convoluted. (2) The mature Foetus. \ 103. A mature foetus, according to our own measurements (c/. Fesser), is on an average 51 cm. (20 in.) long, and weighs 3,128 grm. (nearly 7 lb.)* ; its width across the shoulders (the binacromial diameter) amounts to about 12 cm. (475 in.), and corresponds to a circumference at the shoulders of about 34 cm. (13'25 in.). The dorso-sternal diameter is 9 — 9*5 cm. (3"5 in.), the width at the hips (or biniliac diameter) 9"o — 10 cm. (4 in.). Every part of the body is well rounded oflf, and furnished with a thick layer of fat ; the skin has lost its deep rosy tint, and the Vernix is abundant only on the back of the child and on the flexor aspect of its limbs ; the lanugo has almost disappeared ; the hairs of the scalp are mostly dark and about 3 cm. (ca. 1 in.) long, the nails project clawlike beyond the tips of the fingers, and reach the tips of the toes. The head is still the most voluminous part of the organism ; especially is the cranium large in proportion to the face. The latter now shows a fresh plump appearance, and miliaria are confined to the point of the nose ; the bones of the head are hard, and their edges lie close together ; the sutures are narrow. The cartilages of the ears and nose feel hard ; eyebrows and eyelashes are well developed. The thorax presents a distinct convexity ; the breasts in both sexes are well formed, and contain some secretion. The umbilical cord is inserted immediately below the middle of the ' Hecker gives the length as 51-2 cm., and the weight as .8,275 grm. 122 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. longitudinal axis of the body (indeed after the 6tli — 7tli month, the relative position of its insertion remains unchanged ; its distance fi'om the symphysis compared to that from the ensiform process, being according to Hecker as 1 : 1'6). The scrotum is much corrugated and brownish ; the testes can be felt in it, but the tunica vaginalis is still open. In girls the labia majora are in contact, although they do not always completely conceal the minora. The meconium'^, a greasy substance consisting of intestinal mucus (inspissated) and epithelium, of small particles (derived from the liquor amnii, e.g. epidermic scales, lanugo and Vernix caseosa) that have been swallowed, and deeply bile- stained (crystals of Cholesterin and bilirubin), now only fills the large intestine. The centre of ossification in the lower femoral epiphysis, usually measures about "5 cm. ('2 in.) in diameter, but may be much smaller or absent. Mature children look about them in a lively manner, move their limbs vigorously and cry lustily. Soon after birth they evacuate urine and meconium ; they make suction movements, and the nipple, if proft'ered to them, is greedily seized and firmly held. § 104. The length and weight are subject to frequent devia- tions, both above and below the average which we have given. The heaviest foetus which I have hitherto met with in the hos- pital here, weighed 5,200 grm. (llg^ lb.), the longest measured 5H cm. (22'85 in.) ; but in private practice I have delivered a fffitus of 6,000 grm. (13 lb.), with a length of 57 cm. (22-5 in.)^. Generally speaking, length increases with weight, although not ' Cf. Zweifel, Arch, f. Gi/n., vii., p. 474. - We have numerous accounts of very large and heavy fcEtUfes, of so-called giant rhi/clren. Amongst well authenticated recent cases, i.e. where the fcetus was measured by a reliable physician, I may refer to that of Wolff in Eutin {Berliner Klin. Wochen- xchrift, 1878, p. 620) : boy weighing 8.250 grm. (18 lb.); 62-5 cm. (24-5 in.) in length ; the circumference of his liead was 41'5 cm. (16"25 in.) ; to that of Mayer in Eeinbach {ibid., p. 648) : boy of over 7,500 grm. (16^ lb.). The published cases of Hunter-Mair and Bradley in British Med. J., Jan. 4, 1879, of White in Netv York Med. Becord, March 23, 1878 (where one fcEtus is said to have weighed 20 lb. after loss of its brain), are not of much value, inasmuch as the weight is given in pounds, without its being stated whether Apothecaries or other weights are referred to. The foetus of 6,000 gi-m. (i;-ii lb.) weight observed by myself and Dr. Langer, was expelled in the third cranial position ; and the extraction of the head, and still more that of the shoulders, caused enormous dilSculty. The measurements were : length 57 cm. (225 in.), circumference of head 37 ( 14-5 in.), of shoulders 45 (17-75 in.), binacromial diameter 16 (6-25 in.), aircumference at hips 39 cm. (15-25 in.) ; the direct, diagonal, biparietal, and bitemporal diameters were 12, 14'5, 10, 95 cm, (ca. 4-75, 575, 4, 3-75 in.). THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 123 in the same proportion ; the children just referred to as weigh- ing 5,200 and 6,000 grm. measured only 56 and 57 cm. respectively, while the foetus which measured 58 cm. only weighed 4,470 grm. (9f lb.) ; length therefore varies less than weight. The circumstances which influence the size of the foetus, are first and chiefly the sex, boys being on an average longer and heavier than girls ; 51*5 cm. (20*25 in.) and 3,201 grm. (7 lb.) of the former correspond to 50*5 cm. (19*75 in.) and 3,056 grm. (6| lb.) of the latter. Secondly, the number of the pregnancy, children of primiparse weighing on an average 120 grm. (4]. oz. avoir.) less than those of multiparae ; the length does not show any important difi'erence. Thirdly, the age of the mother ; up to the 39th year as a rule the weight gradually increases, after that decreases, and the best developed foetuses are born when a certain pregnancy coincides with a certain time of life (" pre- dilection years " — Wernich). Fourthly, the constitution and physical development of the parents ; it is easy to see that the state of nutrition of the maternal organism must have an impor- tant influence on the formation of the foetus, and Fasbender's numerous measurements show that the tallest women bear both the heaviest and the longest children. In girls as a rule the trunk is larger in comparison with the head, and inasmuch as the length of their body is below that of boys, this greater development must afl'ect the transverse diameters ; it depends ■on a more abundant supply of the panniculus adiposus. More- over the contrast between the male and female figures, so familiar in adults, is already indicated at birth. As regards numbers, 100 girls are on an average born to 106 boys (according to Veit, the figures in Prussia are 100 to 105*88). § 105. The head is of most importance during parturition, on account of its size and unyielding character, and therefore claims special attention. It is of ovoid form, the smallest end pointing backwards, the largest forwards (fig. 39), and is divided into cranium and face, these consisting of the same bones as in the adult. The flat cranial bones are still incompletely ossified and thin, composed mainly of diploe, and therefore flexible and elastic ; at the same time they are to some extent displaceable in relation to one another, since they are still ununited, but merely connected 124 THE EMBRYO, ITS MEMBEANES AND APPENDAGES. by fibrous material, a continuation of periosteum and dura mater ; in this way are formed the sutures. Some of these sutures have the same names as those of an adult, but in addition to the latter, the prolongation of the sagittal suture between the two frontal bones (which is generally absent in adults) called the frontal suture, must be especially noticed ; sometimes also the sagittal suture is continued over the posterior part of the cranium. At the point where the rounded off angles of the frontal, sagittal and coronal sutures meet, is situated a large membranous gap — the anterior or great fontanelle (fig. 40). Its shape is quadrangular, similar to that of a kite, the short posterior sides being formed by the parietal bones, the longer anterior sides by the frontals ; its anterior angle is much more Fig. 3Ö.— Fcetal Head seen from the side. Fig. 40. — Fcetal Head seen from above. pointed and longer than the posterior. The posterior or small fontanelle lies at the point where the posterior end of the sagittal meets the lambdoidal suture ; only when ossification has been somewhat retarded, is a considerable membranous gap formed ; as a rule this gap has the shape of a triangle, the base being formed by the rounded top of the occipital bone, and its elongated sides by the rounded posterior superior angles of the parietal bones. In the rare cases in which the sagittal suture is pro-; longed on the upper portion of the posterior part of the skull, the small fontanelle will of course have a quadrangular shape. At the point where the lower angles of the parietals meet the squa- mous suture, there are also situated somewhat broad interspaces, called the lateral fontanelles (fonticuli Casserii), of which the anterior being covered by soft parts cannot be felt ; the posterior THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 125 however may be, and owing to its triangular shape, is apt to be confused with the occipital fontanelle. In some cases of delayed ossification, so-called anomalous fontanelies are found in other parts of the skull. A very small naso-frontal one occurs, bounded by the inner and lower angles of the frontal and of the nasal bones ; a triangular cerebellar fontanelle just above the posterior edge of the foramen magnum in the median line of the occiput ; a quadrangular meso-frontal in the lower portion of the frontal suture ; a sagittal fontanelle in the middle or posterior portion of the sagittal suture, sometimes formed only by one parietal bone, sometimes more or less symmetrically by both. Anomalous sutures are rarer (c/. Gruber, Virchow's Arch., vol. 50). § 106. The size of the foetal head, like that of the pelvis, is estimated by measurements taken in different directions. The diameters, which are important for practical purposes, and especially for understanding the mechanism of labour, are the following : — 1. Sagittal diameters (fig. 39) : a. The direct or fronto- occipital (F.O.) from the glabella to the most prominent point of the occiput (a, a) = 11*75 cm. (4*5 in.), according to my own measurements ; to this corresponds a periphery of about 33 — 34 cm. (13 — 13'5 in.), h. The great diagonal or mento-occipital (M.O.) from the point of the chin to the same part of the occiput {a, 6) = 13'5 cm. (5-25 in.), with a periphery of 36 cm. (14-25 in.). c. The small diagonal or suboccipito-bregmatic, from a point about midway between the occipital tubercles and the foramen magnum, to the posterior edge of the great fontanelle (c, c) = 9'5 cm. (3 '75 in)., the corresponding periphery being 28 — 29 cm. (11—11-5 in.). 2. Transverse diameters (fig. 40) : a. The great transverse d, {a, b), connecting the two parietal eminences, called therefore hi- parietal (B.P.) = 9-25 cm. (3-75 in.) ; b. the small or bitemporal d. (B.T.) the greatest distance between the two sides of the coronal suture (c, c?)=8 cm. (3 in.). 3. Vertical diameters : a. From the vertex to the base of the cranium, i.e. to the anterior edge of the foramen magnum (fig. 89, d, e) = 9-5 cm. (375 in.) ; b. From the most projecting part of the forehead to the chin, i.e. the length of the face = 8 cm. (3 in.). 126 THE EMBRYO, ITS MEMBRANES AND APPENDAGES, These measurements vary more or less in dififerent individuals, and generally speaking are somewhat smaller in girls than in boys ; the number of the pregnancy and the age of the mother influence especially the biparietal, the latter being also above the average in the children of multipara. Moreover individual peculiarities are met with, for instance well marked brachy- cephalic and dolichocephalic forms of skull, the former apparently- being commonest in boys. Further, Fasbender's researches tend to show that the head of the child is a model of its mother's on a smaller scale'. The sutures, the fontanelles and the flexibility of the cranial bones make it possible not only for the head to alter its shape, but also for its volume to diminish, partly by an overlapping of the edges, and a mutual displacement of the bones, partly by their becoming flattened. This mouldability however is confined to the cranial vault ; a line drawn from the supra-orbital ridge above the roots of the zygomatic arch, to the occipital pro- tuberance divides the compressible part of the head from the incompressible part lying below it. The lessening of the volume of the cranium due to the cerebro-spinal fluid being squeezed into the central canal of the spinal cord, and possibly to the blood passing into the cervical veins, is not altogether unimportant ; some diameters may be diminished to the extent of 1 cm. {*4 in.) or more. The trunk can to a far greater degree adapt itself to the shape of the parturient canal, for instance even the binacromial diameter can be diminished by 2 cm. (-75 in.). The mobility of the head upon and with the cervical vertebrae, and indeed on all three axes, is of importance, and results from the flexibility of the still in part unossified vertebral column, and from the yielding character of the ligaments. Rotation round the vertical axis can without injury take place through a quarter of a circle, and even more, provided it occurs gradually. The move- ments on the horizontal axis are the most extensive, and since the articular surfaces which connect the head with the vertebral column are not exactly in the middle of the base, but lie nearer to the occipital region, the sagittal axis forms a lever ' Grünbaum'« measurements confirm those of Fasbender, and show that almost all the diameters of the fcEtal head are to those of the maternal in about the proportion of -6 : 1. {Disisert. Berlin, 1879.) THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 127 with a long anterior and a shorter posterior arm, an arrangement I which explains the facility with which the head can be strongly ; flexed on the chest. (3) Attitude, Lie^, and Position of the Foetus in the Uterus, § 107. By attitude is understood the situation of the trunk, head, and limbs of the foetus relative to each other. Even the embryo and the young foetus present a well marked curve towards the abdominal aspect, and this primitive tendency to flexure is retained to the end of pregnancy. The longitudinal axis is invariably curved towards the ventral aspect, causing the latter to present a concavity of varying depth, in which the umbilical cord usually floats. The head is strongly flexed, the ; chin resting on, or at any rate very near to the chest ; the arms lie at the sides or in front of the thorax, the fore-arms being usually flexed and crossed in front of the chest ; the knees are I flexed, the legs, often crossed like the fore-arms, lie against the 'thighs, the latter being strongly adducted to the trunk; the .dorsum pedis is bent towards the shin, and the foot lies in contact with the inner and front surface of the leg ; the two ! soles are slightly turned towards each other. These various parts of the body, however, are not pressed against each other, , but float in the liquor amnii ; only when the latter is very deficient in quantity, are they to any extent squeezed one upon another ; under normal conditions the flexed attitude of the foetus must never be thought of as in any way enforced by the limited ' accommodation in the uterine cavity ; such a view would imply a constant pressure of the foetal spine on the uterine wall, which does not exist. , Nevertheless, while the limbs are conveniently disposed of, the ' whole body is reduced to the smallest compass. The whole foetus has the shape of an ovoid, whose small end is formed by the head, the wider end by the lower part of the trunk with the flexed thighs. During the course of pregnancy, this attitude is not uncommonly altered, although only very temporarily. ' This term is not in general use. Some authors speak of " presentation," but this word is inapplicable, for the presentation may vary, while the lie remains the same. I have therefore thought it best to use the word " lie," meaning by it, as Spiegelberg does by "Lage," the relation of the longitudinal axis of the foetus to the axis of the uterus or of the brim of the pelvis (Tr.). 128 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. The movements of the limbs, which bring about the alteration, are also the means of restoring the original attitude, partly by reflex action, and partly by contractions of the uterus. With the advance of pregnancy, the attitude becomes more and more stable, owing to the diminished size of the uterine cavity relative to that of the foetus. Persistent marked deviations from the normal attitude only occur in dead foetuses ; loith living ones they are 'practically restricted to the juried of partmition. § 108. By the lie of the foetus, is meant the relation of its longitudinal axis to that of the uterine cavity. The two axes may entirely or approximately coincide {longitudinal lie), or intersect each other at a more or less acute angle {transverse lie). During the first months, there is no definite lie, since the embryo is suspended by the umbilical cord, and is still very small in comparison to the cavity in which it is placed ; yet even in the first half of pregnancy, the region of the shoulders and the head are usually found to be directed downwards. When the uterus begins to grow, especially in length, the foetus which is likewise developing mainly in the direction of its length, will be embarrassed in every other except the longi- tudinal diameter of the uterine cavity, and the long axis of both will coincide more and more frequently, as pregnancy advances. The uterine wall, which is elastic, resisting and readily stimu- lated to contract, exerts an all round and equal pressure on its contents, the resultant of which must, from what we know of the shape of the uterus, coincide more or less with its longi- tudinal axis, and force the long axis of the foetus into correspon- dence with it. If the foetus abandons this lie, the walls of the uterus will be unequally stretched and mechanically irritated; contractions will follow, and these (when the proper shape is restored) as well as the reflex movements of the foetus, to which they give rise (consisting of extensions and flexions of its limbs), push its trunk back into the longitudinal axis of the uterus. In this simple way the great frequency (amounting to 99 per cent, of mature foetuses) of the longitudinal lie can be explained. But the foetus may have either its head or its breech lowest, while still in the longitudinal lie ; the former, called the cephalic lie, is the commonest both during pregnancy and at its termina- tion (in over 96 per cent, of all mature foetuses). THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 1'29 Numerous hypotheses have heen suggested to explain why the cephalic lie is so frequent. The one which has met with most support, although on the other hand it has provoked repeated opposition, is that which ascribes the cephalic lie to the force of gravity. This was in the earliest times assigned as the cause, but was given up, because various experiments appeared to show that the centre of gravity of the foetus was not situated in its head, that another portion of its body, usually the upper dorsal region, sank lowest, when the foetus was immersed in a vessel filled with fluid and of the shape of the uterus. It had however been forgotten, in making this experi- ment, that the point under discussion is why the cephalic end lies lowest in the uterus, not why that end presents (over the internal os). If the centre of gravity lies in the region of the shoulders, then the head must lie lowest when the uterus is vertical (which it approximately is, when the pregnant woman lies flat on her back), and still more when the woman is in the erect posture, since owing to the obliquity of the uterus in relation to the horizon (forming an angle of 35°), it is not the internal OS but some low part of the anterior uterine wall which is now placed deepest ; if the line of gravity of the foetus falls upon it, the head must occupy the lowest part of the uterine cavity. So far the force of gravity can be made to explain the situation of the cephalic end, especially during the first part of pregnancy, in which the quantity of liquor amnii is relatively large, and the force of gravity can act undisturbed on the foetus. There are however serious objections to the view that gravity is the principal cause of the head lying lowest : the fact that other observers have found the centre of gravity to be situated nearer to the pelvic end of the trunk ; that in the lateral position of a pregnant woman, the superior segment of the uterus may sink to a lower level than the inferior, without the cephalic lie being altered ; the fact that the cephalic lie becomes more and more frequent with advancing pregnancy, while the effect of the latter on gravity is to hinder its operation, owing to the relative amount of space in the uterus becoming more and more limited, and to the foetus therefore meeting with support at numerous portions of the uterine wall ; and finally the fact that the head is usually born first in other mammalia, especially in uniparae, in whom the uterus is placed horizontally. It appears therefore 9 -130 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. as if the cephalic lie, which is so favourable to the successful termination of labour, were the result of a general natural law. Although therefore the force of gravity cannot alone explain the frequency of the cephalic lie, it is certainly one of the causes. Amongst those that co-operate with it, the chief is to be found in the already mentioned similarity in form of the uterine cavity and foetal body (co- adaptation). In the normal attitude of the foetus in which all the limbs are flexed, the cephalic end is the smallest, the pelvic end with the lower limbs flexed upon it the largest ; the foetus therefore fills up the space at its disposal in the best and most convenient manner, when it lies with its head in the lower segment, and its breech in the fundus of the uterus*. If it abandons this situation, the higher specific gravity which the head attains after presenting for some time (in consequence of the increased pressure which the deeper layers of the liquor amnii and the column of blood have exerted upon it, — Labs), the pressure of the uterine wall, especially when contracting (form-restitution force), the reflex (sc. extension) foetal movements which are thus brought about, will restore the cephalic end to its former situation ; and this will be the more stable, the longer it has lasted, the more completely the form of the uterine cavity and of the foetus correspond, the more firmly the head is gi-asped by the lower segment of the uterus, and the greater the resistance and contractility of the uterine walls. Thus are to be explained the facts, that mis- shapen children are more often born in abnormal lies, that the latter are frequent where the uterine cavity is of irregular form, and are not uncommon where the quantity of liquor amnii is excessive, with premature births and with foetuses that have died in utero. In the case of premature births however, it must never be forgotten that we have no right to conclude that the lie which existed hcforc birth, was the same as that in which the foetus is expelled. § 109. Since various factors contribute in producing and rendering permanent the cephahc lie, the constancy of the ' In multiparous mammalia in which the foetuses lie in elliptical ampulls, cephalic : and pelvic presentations are nearly balanced ; and in such cases it matters not whether the head is directed forwards or backwards, {of. Franck. ThierärzÜ. GeburtshVfe, 1876.) THE EMBRYO, ITS MEMBRANES AND APPENDAGES. 131 latter must be exposed to numerous exceptions during the last trimestrium of pregnancy. • Change of He is as a matter of fact not uncommon. Long ago it was observed that the lie of the child was not always the same throughout the course of pregnancy, and the fact which has been mentioned, that premature foetuses come into the world relatively often in a pelvic lie gave rise to the opinion, which was enter- tained as early as the time of Hippocrates, that the foetus till about the 7th month always occupied the pelvic lie, and that this somewhat suddenly changed into the cephalic (" culbute "). When in the last century this doctrine was set aside, Scanzoni was the first to again declare in its favour (modifying it however in important points), and he showed that there was partial truth in it. Hecker and numerous disciples next showed that not only is the cephalic lie subject to frequent alteration right on to the end of pregnancy, indeed even during birth, but that any kind of lie may be changed at any period, so that such an event passed from the category of exceptional into that of ordinary occurrences. The commonest change is for a transverse to be transformed into a cephalic lie, the reverse occurring somewhat less often ; the change from the pelvic into the cephalic lie is also relatively common, the opposite movement being somewhat rarer; it is very rare for a transverse lie to pass into a pelvic, and vice versa. Amongst the causes favourable to or promoting the changes just mentioned, are alterations in the posture of the pregnant woman, i.e. alteration of the surface which supports the weight of the foetus, a relatively capacious uterine cavity, active and passive foetal movements, uterine contractions and variations in the intra- abdominal pressure. The further pregnancy has advanced, the better established is the lie of the fa3tus ; still even during birth a change sometimes occurs, either in a favourable or in an un- favourable direction ; indeed it is occasionally observed after rupture of the membranes. In multiparsB such an occurrence is more frequent than in primiparne, with girls than with boys ; contraction of the pelvis favours it (owing to the difficulty with which the presenting part becomes fixed in the brim before the commencement of labour) ; but unusual weight of the foetus acts in an opposite direction. § 110. By the position of the foetus, is meant the direction in which a definite foetal surface (the dorsal is the one usually referred ]3'2 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. i to) looks in reference to the sides of the uterus. In all the lonfTxtudinal lies, the back of the foetus is most frequently turned to the left (for that reason called the first position), more rarely to the right (second position) ; in most cases of the first position, the hack is also directed forwards ; in the second backwards. In the transverse lie, the back usually looks to the front (first trans- verse position). The cause of the back being generally directed to the left side lies in the force of gravity. For since the right side of the foetus has been found to sink lowest in the floating experiments that have been made, in the erect position of the pregnant woman the same right side must turn towards the anterior uterine wall (thus becoming the lowest), the back there- fore being turned towards the left. To this must be added the fact that the uterus is not infrequently rotated to the right on its longitudinal axis, so that the lower half of its left side lies deepest, and as it is this against which the dorsum of the foitus rests, the latter is also turned a little forwards. When on the other hand the woman lies flat on her back, gravitation directs the right side of the foetus backwards and downwards, the back towards the right, and owing to the rotation of the uterus on its , axis, frequently to the right and backwards. This also explains why, as is often observed, when the erect posture gives way to the dorsal, the first cranial position is frequently converted into i the second, and vice versa. Such an alteration in the posture of: the mother is the usual cause of the change in j^osition of' the foetus, which change occurs even in an advanced state of labour, more frequently than the change of lie, especially with the cranial positions. As aflecting the alterations of position ; during birth, must be mentioned the twisting or untwisting of any coils of the cord that encircle the trunk. When the back of the foetus changes its position, it generally moves along the posterior uterine wall, although of course it does not follow that the constant position with the dorsum directed posteriorly, is the ., commonest during pregnancy (Sutugin). \ (4) Nutrition and Circulation of the Foetus. ^111. The impregnated ovum derives its nutrition first of all from the cells of the tunica granulosa (which according to Lindgren pass through the pores of the zona pellucida into the THE EMBEYO, ITS MEMBEANES AND APPENDAGES. 133 interior of the ovum, and lead to an increase of the yolk-matter) ; next from the secretions of the mucous membrane of the oviducts and uterus, the ingredients of which by a process of osmosis pass through the external membrane of the ovum, and the primitive chorionic villi which before long spring up all over it, and mix with the yolk. When development has advanced further, the omphalo-mesenteric vessels take up the nutrient material con- tained in the yolk, and convey it to the embryo. When the allantois has brought the umbilical vessels to the chorion, and thus into intimate connection with the vascular spaces in the I uterine mucous membrane, and the formation of the placenta and of the so-called secondary circulation has begun (3rd to 4th week), the interchange between maternal and foetal blood proceeds in the manner described above, the latter taking up nutritive material from and giving back waste products to the former, while a mutual exchange of gaseous substances also takes place. This goes on till birth. The maternal blood therefore represents for the foetus the external world, from which its requirements of air and food-stuflfs are simultaneously satisfied ; there is abundant proof that nutri- ent material is not derived either from the liquor amnii, or from the secretion of the uterine glands. The existence of foetal Wespiralion and metaboUsni is demonstrated beyond doubt, by the proof of an independent production of heat (the temperature of ;the newly delivered fcEtus is as a rule '1° — "3° C. higher than the ;vaginal and uterine temperature of the mother) ; by the fact that |lime is produced by the intra-uterine foetus, while it is not found iready formed in the maternal blood ; by the foetal urine contain- ing urea and uric acid', which cannot have been taken up from the maternal blood, since they have not yet been detected in any , other portion of the foetus than in the urinary passages, and by ithe muscular work of the foetus {cardiac activity and movements '3f voluntary muscles). Further evidence is found in the fact ;liat obstructions to and interference with the placental circula- ;ion rapidly cause death, that the foetus generally first makes : nspiratory eftbrts, and that foetuses that have perished from this j!ause, present the signs of death by asphyxia or by drowning ; ■;onversely a child after birth ceases to breathe, when artificial lipnoea is produced by supplying it with oxygen; moreover j ' Uric acid deposits are occasionally formed in the kidneys of the fcEtus. 134 THE EMBRYO, ITS MEMBKANES AND APPENDAGES. Pfliif^er has shown (and hitely Zweifel has done so still more clearly) from the colour of the blood, that oxygen is consumed by the foetus, and Zuntz has proved that oxygen may pass back to the mother, when her supply runs very short. Further, the rapidity with which the embryo attains to the size of the mature foetus, is only intelligible on the assumption that active meta- bolism takes place, and especially that new material is supplied. The amount of oxygen consumed is of course not very larm., Bern, 1878. f/. also the papers mentioned below on foetal metabolism. Decidua and Placenta. Schröder v. d. Kolk, " Waarnemingen over het Maaksel v. d. menschelijke Placenta." J'erh. d. Ko7i. Kederl. Inst. Virchow, "Ueb. d. Bildung d. Placenta," ö'fÄ«/«»«. Abhandl., Frankfurt a. M., 1856, p. 779. Leopold, Arch./. Gyn., xi., p. 443. Langhans, Arch. f. Gyn., i., p. 317; ix., p. 341; Arch. f. Anat. u. Physiol, 1877. Winkler, Arch.f. Gyn., iv., p. 238. Hennig, Studien über d. Bau, der menschl. Placenta, Leipzig, 1872 ; also in (Schmidt's Jahrb., vol. 160, p. 188. Blacher, Arch.f. Gyn., xiv., p. 121. Turner, Lectures on the Comjxir. Anatomy of the Placenta, i. Edinburgh, 1876. 138 THE EMBRYO, ITS MEMBRANES AND APPENDAGES. Umbilical cord. Hvrtl, Die Blutgefässe d. vicnxchl. Xuchgehurt. Vienna, 1870. Neugebauer, Jforj/hologie d. menscld. Nabelsehnur. Breslau, IS.'jti. Köster, " Ueb. d. feinere Structur d. mensclil. Nabelschnur. Diss.. Wiirzburs, 1S68. Sabine, Arrh.f. O'yn.. ix., p. 311. Stutz, ibid.. xul, p. 315. Kehrer, Jieiträgc zurGüburtxli., ü., 1879, p. 49. Rüge. " Ueb. d. Gebilde im Nabelstrange," Z.f. Geb. u. Gyn., i., pp. 1 and 2.>3. b. Foetus. Waldeyer, Studien, d. PhysioJ. Inst it. zu Breslau, Part II f.. ISi;."». Kollmann, "Die menschlichen Eier von G mm. Grösse." Arch. f. Anat. u. PJiys. Anat. Abtheilung, 1879, p. 275. Toldt, " Ueb. d. Altersbestimmung menschlicher Embryonen." Prag. med. Wochenschrift, Nor. 13, 14, 1879. Hecker, Klinih d. Geburtsh., ii., 18G4. pp. 22 and 23 ; also Mon. f. Geburt.-erception of movements by the observer is therefore of quite secondary importance for the diagnosis of pregnancy, since it presupposes the existence of foetal parts, and this latter sign is sufficient ; if they cannot be felt, the remarks made in the previous section, in regard to a subjective perception of foetal movements, holds good, even when these have been perceived by the accoucheur. There are only two certain signs of pregnancy, the discovery of foetal parts, and hearing the foetal pulse. But they only decide the affirmative side of the question ; we cannot at once conclude that pregnancy does not exist, when they appear to be absent or cannot be discovered, § 128. In such cases, as well as during the first half of THE DIAGNOSIS OF PKEGNANCY. 155 pregnancy, in which the grounds for assurance can at best only be perceived towards its close, we are restricted to the second group of signs, those which make the existence of pregnancy probable. To them belong the cessation of the menses, and the changes in the sexual organs, including the uterine souffle (which have been described in §§ 66 — 75), in the abdominal walls and the breasts. It is true that these phenomena accompany with rare exceptions every pregnancy ; but any one of them may I be absent, or so indistinctly marked as to be valueless, and |) occasionally they also appear in diseased conditions of the sexual 1) organs; least of all is any one of the phenomena taken singly, t sufficient to justify the diagnosis of pregnancy, although when I they are all present, there can be very little doubt. The most valuable of these signs are the suppression of the menses, the characteristic enlargement of the uterus, the infiltra- tion and changes in the colour of the external genitals, vagina, and cervix ; the uterine souffle ; the hypertrophy of the abdominal walls and the flaccid state of the no longer depressed (possibly even prominent) navel ; the alterations in the areola, and the presence of mammary secretion. § 129. The suppression of the menses is a very valuable sign, when it occurs in a sexually mature person, who has not been exposed to any injurious conditions, and in whom no evidence of pelvic disease can be detected, that is, when it is unaccom- panied by any obvious or sufficient cause. It becomes still more important when the cessation has already lasted several mouths, and the uterus at the same time appears enlarged ; for the catamenia are rarely absent when the enlargement is due to disease, they tend rather to become irregular or profuse. Con- versely, we shall seldom be wrong in considering a person who menstruates fairly regularly, as not pregnant (cf. § 72). Although the uterus may increase in size from a variety of causes, the eidargement due to pregnancy differs so characteristi- i cally from that due to disease, in shape, mobility, and consistence 1 (§§ 65, 66), that a gravid uterus may almost always be recognised j by these peculiarities, and be confidently diagnosed from other kinds of enlargement, and this is especially true of the first half of pregnancy. In the second half, in which as a rule we have ** grounds for assurance " to help us, weight is only to be attached to the form of the uterus, when owing to its great distention by 156 THE DIAGNOSIS OF PREGNANCY. abunclaiice of liquor amnii, or o^\-ing to displacement, the signs showiug the presence of a foetus cannot be perceived. In such cases in addition to the characters already mentioned, we not infrequently have the presence of uterine contractions (a hardening with subsequent relaxation) arising either spon- taneously or after palpation, and settling the question. Even in the first months bimanual palpation may provoke contrac- tions ; but at that period I consider the shape, position, and consistence of the uterus as diagnostic. The peculiar anteversion associated with great mobility, the absence of sensitiveness to touch, the elasticity when compressed, the almost circular out- line of a transverse section of the body of the uterus (produced by hypertrophy and bulging of the anterior wall), with an absence of any noticeable irregularity of contour, are characters which almost certainly prove pregnancy. On referring back to the changes in the cervix, vagina, and vulva, described in §§ 68 — 71, the reader will see that they must yield very reliable signs ; scarcely any other than the pregnant condition brings vath it so persistent and widespread a softening and serous infiltration, such a characteristic formation of folds due to hypertrophy, such an altered position of the vaginal fornix in reference to the portio vaginalis. It is true that these signs are only fully developed in the later months of gestation, but the careful and somewhat practised observer as a rule discovers them very early. I attach great weight to the dark venous coloration of the mucous membrane of the genital canal, and to the small bluish varicose knots of the vulva ; they have rarely deceived me. Equal in value with these signs, is the uterine souffle. It depends, as we know, on the peculiar development of the vessels of the uterus during pregnancy, and there are but few patho- logical conditions (intra-mural myomata, large haematometra) in which a shnilar development of vessels occurs. These latter conditions are generally recognisable by their special symptoms, and if such symptoms are absent, the souffle settles the question of pregnancy. Especially is this true of the first months, for an enlarged diseased uterus of the size that belongs to early preg- nancy, scarcely ever yields the souffle, since when so moderate an enlargement is due to disease, it is not associated with a sufficient vascular hypertrophy to cause a souffle. ■'■ THE DIAGNOSIS OF PREGNANCY. 157 Among the remaining signs mentioned above, I regard the hypertrophy of the abdominal ivalls as decisive under certain circumstances, and also the possibility of raising those walls up in thick folds, in spite of the increased abdominal distention ; the same is true of the ease (resulting from the hypertrophy) with which the now smooth and flaccid umhilicus can be drawn in any direction. Amongst the changes in the mammce, the succulence and swelling of the areola, the great irritability and contractility (due to muscular hypertrophy) of the latter and of the nipple are of especial importance ; also the extension of the areolar pigmentation in a peripheral direction, shown by the appearance of the secondary areola ; and finally the facility with which a thin serous and even a milky fluid can be squeezed out of the nipple. I must not forget to mention that the raised temperature of the uterus, as compared to that of the vagina, may be a useful sign of pregnancy. § 130. These various considerations show that, although absolutely reliable signs are only present during the second half of pregnancy, the "grounds of probability" allow a tolerably safe opinion to be given in the first half, and often very early in it. Some signs of course are more to be depended on than others, and individually their value is less than when several co-exist ; but when all agree with each other and with the usual progress of gestation, the existence of the latter is placed beyond doubt ; as early as the second month it may be possible with their help to answer the questions which present themselves. Nevertheless, as has been pointed out in the introduction to this chapter, under some circumstances the diagnosis whether pregnancy is present or not may be extraordinarily difficult ; either on account of irregularities in its progress, or of unusual complications, or of pathological conditions simulating some of the symptoms of pregnancy. It is impossible here to describe in detail the differential diagnosis of abdominal tumours in reference to pregnancy ; the general rules to be followed in such cases are contained in the above description. The first question should always be whether any existing enlargement of the abdomen is due to that of the uterus, and evidence of this should first of all be sought. Should satisfactory evidence that it is, be forthcoming, the 158 THE DIAGNOSIS OF PREGNANCY. nature of the enlargement may be investigated. If a definite method is invariably followed, without relying on so-called medical instinct, mistakes will be rare, and in cases where no final decision can be arrived at, it is best to say so and to wait. The greatest and most ludicrous mistakes are less often due to want of knowledge, than to want of care and to a superficial examination. (2) The Diagnosis of the Period of Pregnancy, — the Calculation of the Date of Delivery. § 131. The diagnosis as to how far a woman is advanced in pregnancy, and when the proper time for her delivery will arrive, is even more difficult than the diagnosis whether she is pregnant or not. This difficulty in coming to an accurate conclusion depends partly, as already explained in § 62, on our ignorance of when pregnancy begins, partly on the fact that it appears not to have any definite duration, but to vary within certain limits. For calculating its duration in an individual case, we may have the following fixed points : — a. The day of tlie fruitful coitus. — This datum is but rarely available, since very few persons can accurately fix the time. It is only useful in those rare cases in which a single coitus took place ; and now and then when trustworthy women, especially such as have already borne children, know by peculiar sensations during or soon after coitus that they have conceived ; too much reliance however must not be placed on such sensations. It is under these circumstances that we obtain the most accurate information as to the period that pregnancy has reached, and the date of the labour may be fixed at the 272nd to 275th day after coitus. b. The last menstruatioyi. — Since most women conceive on an average within 11 days from the first day of menstruation (there- fore within the first week after the termination of menstruation), and the period of gestation includes 10 distinct menstrual periods, this gives a very valuable basis for our calculation. If the starting point is placed at the first day of the last menstruation (which is better than counting from the last day, since most persons are more certain of the beginning than of the end of menstruation), gestation will, as is well known, last 282 days {cf. § 62), and the THE DIAGNOSIS OF PKEGNANCY. 159 old view (which took 280 days as the normal duration), and NsBgele's ruethod of calculation (that from the first day of the last menstruation 9 months and 7 days should be counted, in order to find the date of delivery) are found correct. It is how- ever only the average duration which is thus fixed, and in practice it proves true in but few cases ; errors to the extent of a fortnight are met with on both sides, indeed yet greater ones may, for the reasons given above (§ 62), occur in individual cases. It is pro- bably safer when the information can be obtained, to base the calculation on the interval between the onset of the last menstrua- tion but one to the onset of the last of all, and to estimate the duration of gestation in that individual at 10 times that interval. c. The period iclien ßetal movements are first perceived. — This as a rule occurs between the 18th and 19tli week, i.e. a little before the middle of pregnancy ; primiparse perceive the movements somewhat (on an average one week, Ahlfeld) later. It is very unsafe to calculate the date of labour from this as a fixed point, since the date of such movements varies greatly, and depends not only on the sensitiveness and attention of the pregnant woman, but also on the quantity of liquor amnii which is present. § 132. d. The degree to which the changes in the uterus have advanced. — Of course only those changes can be used for cal- culating the period of pregnancy, which progress regularly on to its end, viz. the increase in size, especially in a longitudinal direction ; for it will be clear from § 68 ct seq., that the changes in, especially the shortening of, the portio vaginalis, cannot serve as a basis for our estimation (the shortening of the cervix merely indicates that contractions are taking place). From the second month onwards, the uterus gradually ascends, and moves forwards. It reaches nearly to the navel at the middle of pregnancy, while by the 28th week its upper edge projects a hand-breadth above it, reaching its highest point in the 36th week ; during the last weeks it sinks a little as a result of the fixing pains, which force the presenting part into the pelvic inlet. In order accurately to determine the height of the fundus, its margin must first be ascertained by percussion, and the length of the line connecting its highest point with the upper edge of the symphysis measured. The 160 THE DIAGNOSIS OF PREGNANCY. navel cannot be used as a fixed point, since its distance from the' symphysis varies greatly in pregnant, and indeed in all women ;■ Hecker found a variation of 13 — 31 cm. (5 — 12 in.), I myself of 13 — 28 (5 — 11 in.). The average elevation of the fundus, according to my measurements, amounts in the 22nd — 26th week to 24—24-5 cm. (9*4— 9-6 in. ; in the 28th to 26-7 cm. (10-5 in.) ; in the 30th to 28*4 cm. (11 in.) ; in the 32nd— 33rd to 29-5—30 cm. (11-5-11-75 in.); in the 34th to 31 cm. (12-25 in.); in the 35th to 31*8 cm. (12-5 in.) ; in the 36th to 32 cm. (12-6 in.) ; in the 37th to 32-8 cm. (12-8 in.) ; in the 38th to 33-1 cm. (12-9 in.) ; in the 39tli— 40th to 33-7 cm. (13*25 in.). Thus a gradual increase takes place, which is shown even by the series of minimum figures for each week. These measure- ments however cannot be utilised for an exact calculation in any individual case, since the variations for each period are too considerable; they can at best only justify an approximate conclusion. ' In addition to the height to which the uterus has risen in the abdominal cavity, the greatest circumference of the abdomen may be employed for calculating the period of pregnancy, since it is mainly dependent upon the extent of the uterine enlargement. It is however only a rough method, for although the average, as well as the maximum and minimum, increase with the several weeks, this increase after the 28th week is but trifling, and the maximum and minimum figures for the different epochs do not differ to any great extent. Thus in the measurements that I made, the circumference varied :■ — In 21 persons at the 28th week from 78 — 101 cm., averaging 90-8 cm. ., 43 „ 32nd ., 81—110 cm., ,, Ol'S cm. ,, 50 „ 35th ,, 84—109 cm., „ 90-4 cm. „ 01 „ 38th „ 85—108 cm., ,, 94-7 cm. „ 73 „ 39th— 40th „ 85—107 cm., ,, 947 cm. The errors which arise when the period of pregnancy is cal- culated from the height of the uterus, or the circumference of the abdomen, depend on the fact that each of those factors varies at the some period of pregnancy : the elevation depending on a full or empty state of the rectum and bladder, on the posture of the woman (whether erect or horizontal), on the more or less marked protrusion of the lower segment of the uterus into the pelvis, and on the variable quantity of liquor amnii ; the circum- THE DIAGNOSIS OF PREGNANCY. 161 ; ftii-ence of the abdomen depends on the same causes, and further ! on the varyhig thickness of the abdominal walls and on the ' repletion of the intestines. *^ 133. e. The best basis for our computation is the size of the foetus ; for this increases with each month, and the variations in different individuals cannot from the nature of the case be very great at corresponding periods. The practised observer can by palpation form an approximately correct opinion of the size of the foetus, and from it determine the period of pregnancy with a fair amount of accuracy. But it is still better to measure the length of the foetus, and to determine its age from a comparison of the result with the size at the different months, as given in §§ 101 and 102. By applying the arms of a pair of callipers to the lowest portion of the head, and to the highest portion of the breech (the two poles of the ovoid foetal mass), or vice versa, ; the length of the foetal axis is obtained, and this appears to I amount to about half the length of the whole child. In taking , this measurement, it will of course often be necessary to introduce ' one arm of the callipers into the vagina, in order to reach the end of the lowest pole. Every one of these methods however only yields approximately correct results, so that errors of 1 to 3 weeks are by no means uncommon. Especially during the first half of pregnancy, is the \ result obtained by the examination very unreliable, and the ' calculation based on the statements of the woman is the more trustworthy ; during the second half, the physical signs, if duly '' weighed, form a fairly good guide for the skilled practitioner, ' but here also the tyro should rely most on the time-honoured calculation of Naegele. The actual onset of labour must never ; be fixed for a certain day ; a margin of at least 7 to 14 days ' should be allowed ; otherwise the practitioner will incur ridicule, • and do harua. § 134. I may take this opportunity of mentioning that the best calculation may be falsified, by the duration of pregnancy I being protracted considerably beyond its normal duration (as ! already stated in § 62), and labour come on much later, — deferred 1 labour. j The extreme protraction in such cases amounts to 4 weeks or j a little more, beyond the usual 280 days, these being cases in j which the calculation was founded on the date of the last 11 162 THE DIAGNOSIS OF PREGNANCY. menstruation^ That such observations on the degree of the protraction, cannot allow of any final ox^inion being arrived at, is obvious from the varying relation of menstruation to the day of fruitful insemination. It is therefore interesting to note that in the cases of deferred parturition, in which the day of the fruitful coitus was accurately known, the postponement Avas a relatively short one ; the latest authentic date of birth in such a case being the 293rd day (Skey). In the observations bearing on this point, the children were always unusually well developed, and this must be looked upon as a criterion of the protracted preg- nancy. The cause of the protraction is unknown, but is probably to be ascribed to the menstrual interval in the individual con- cerned (cf. § 62) being a long one ; accordingly the protraction sometimes recurs in the same woman, is therefore habitual'^. (3) The Diagnosis between a First and a Subsequent Pregnancy. § 135. It may under some circumstances, and especially from a forensic point of view, be of great importance to decide by means of physical signs, whether a pregnant woman has already borne children or not. Usually it is possible to arrive at a decision, inasmuch as pregnancy and labour generally leave indelible traces behind, which form characteristic marks of distinction. In the case oi primij^ane, the physical signs are mainly those described above. The breasts are full and tense, distinctly pro- minent and sensitive to pressure. The abdominal walls appear smooth and stretched, especially at the sides of the hypogas- trium, and palpation is for that reason more difficult ; the same is true of the uterus, while in addition it may readily be induced to contract. Strife occur only in the later months, since the necessary stretching of the deeper layers of the skin does not take place till then ; they are reddish, reddish-white or slate- coloured, and have a "fresh" look. The labia are in contact, the fraenulum is uninjured, either at its cutaneous or mucous ' W. Duncan {Med. Times, 1877, ii., p. 712) records a case in which the duration, reckoned from the cessation of menstruation, amounted to 325 days. - Cf. the interestiiiK observations on the different factors which influence the dura- tion of pregnancy in our domestic animals, by Franck, T/neraiztUcke GeburisMlJe, pp. 141— 14Ü. THE DIAGNOSIS OF PREGNANCY. 163 surface ; the vaginal orifice is relatively narrow and contractile, and each portion of the torn hymen remains as a continuous fringe. The vaginal rugae are crowded together, the walls and especially the fornix, are not loose and flabby as in multiparge, at most does the distinctly hypertrophied urethral thickening pro- ject into the vaginal entrance. The portio vaginalis is slender, smooth and very soft; the external os forms a round small open- ing with smooth borders and a sharp inner edge, where the cervical mucous membrane begins ; at the end of pregnancy, when the presenting part is forcing down the anterior portion of the vaginal fornix, the anterior wall of the portio vaginalis appears very short. § 136. In women on the other hand iclio have home children, traces are found of the former enlargement of the breasts and abdominal integuments, and of the passage of the child through the parturient canal. Moreover the breasts are flaccid and pen- dulous, the nipple enlarged and withered. The abdominal walls are flabby, often look withered and discoloured, can easily be raised into folds, and sometimes the skin hangs down pouchlike, especially over the pubis. In addition to those recently formed, old faded wrinkled and puckered stride are seen, as early as the first months, not difi"ering in colour from the neighbouring skin. The uterus is more easily palpated, and often hangs over in front. The flaccid labia gape. The frenulum is often absent, although not invariably so ; in the former case it is replaced by cicatricial tissue, in the latter, i.e. when it is more or less pre- served, some cicatricial tissue is found on its mucous aspect ; not uncommonly also a cicatrised perinaeal tear may be found. Of the hymen large or small taglike remnants are found with clubbed ends (carunculse myrtiformes), the continuity of the fringe having been destroyed. The vaginal introitus and canal are wide, the mucous membrane smooth, without columnae rugarum, the vaginal walls project as great folds into the lumen of the canal ; the anterior vaginal fornix is especially apt to appear as a deep loose pouch. The cervix, i.e. the portio vaginalis, is plump and irregular ; at the sides of the external os, especially on the left, are deep grooves and even fissures, as if portions of the lips were missing. This sign is only met with after parturition, and must be distinguished from rents and gaps produced by operative measures unconnected with labour, and 164 THE DIAGNOSIS OF PREGNANCY. from cicatrised ulcers ; it may therefore be regarded as a certain sign of a previous confinement. ("Quae quidem cicatrices Sig- num indubitatum praebent partus jam editi," — Koederer.) Owing to these so-called " cicatrices " and gaps, the os is patulous, i.e. it allows the finger to penetrate more or less deeply into the cervical canal, which latter resembles a funnel con- tracted above. The internal os also is often freely patulous for weeks before parturition, but as the rule the cervix only begins to shorten with the onset of labour pains. These signs (and amongst them the absence or cicatricial condition of the fraenulum, the destruction of the line of attach- ment of the hymen, above all an old perinaeal rent and the cicatrices of the os are almost pathognomonic), when present, point clearly to a previous labour having taken place ; but their absence does not disprove such an event. For the flaccidity of the breasts and abdominal walls, as well as old stri£e may be absent, even after a labour at the full time ; the fraenulum and the line of hj'meneal attachment, indeed even the entire hymen (with the exception of small fissures, which are met ^\'ith even in multiparae) may be preserved, the os uteri may seem to have a smooth edge, and the deeper fissures at the points where the lips are connected with each other, may be missing. All the more so after an abortion or premature labour. And in cases where a number of years have elapsed since a single confine- ment occurred, traces which were distinct at the time may some of them have disappeared, others have become so indistinct, as to be no lon<]:er of value. (4) The Diagnosis between a Living and a Dead Fwtus. § 137. AVe obtain proof that the foetus is alive by recognising phenomena which only a living organism can present, e.g., by discovering movements of foetal parts, and hearing the foetal heart-beat. Conversely, an absence of these phenomena, when established by a repeated careful examination, is evidence of the death of the foetus. The latter conclusion however is not reliable in those rare pathological cases in which a super-abun- dant quantity of liquor amnii makes it impossible to feel the parts, and to hear the heart of the foetus, nor does it hold good THE DIAGNOSIS OF PBEGNANCY. 165 during the first 18 weeks, since during that period those mani- festations of life lie beyond our power of detection. In such cases we are justified in assuming that the foetus is alive, when no special injurious influences have been at work that might lead to its death, when the signs and symptoms of pregnancy have followed their regular course, and when the pregnant woman is in good health. The following conditions and appearances on the other hand indicate with more or less probability that the foetus has perished : diseases in the mother which, as a matter of experience, are often followed by intra- uterine death (syphilis) ; the operation of influences which are known to have the same effect (external violence, drugs, e.;/. preparations of lead, strong emotional excitement) ; the cessa- tion of the foetal movements, which had previously been distinctly felt by the mother ; the appearance in her of morbid sensations and symptoms, viz. shivering, lassitude, dyspepsia, a sallow pale look, a sense of chilliness and weight in the abdomen, as if it contained a foreign body ; the arrest of the objective signs of pregnancy which till then had progressed regularly, and in consequence of which arrest the uterus sinks before its usual time, diminishes in size (by absorption of liquor amnii) and becomes soft, while an abundant serous or sanguineous discharge takes place, and the breasts, after a sudden but temporary increase of fullness, collapse, become flaccid, and allow milk to exude. Moreover if the temperature of the uterus, which owing to the proper heat of the living foetus, should be somewhat higher than that of the vagina and axilla, falls to or below the latter, such fall is an indication of the death of the foetus ; but this sign is difficult to use in practice. When the internal os uteri is patulous, it is sometimes possible to feel the cranial bones to be loose and movable, a sure sign that the foetus is dead. To the qucstiuns which have beeu answered in the previous sections, there is frequently added in practice, one relating to the sex of the expected child, but inasmuch as the causes influencing the development of sex have as yet been but little elucidated, it cannot be answered with any degree of assurance. An opinion founded upon the greater frequency of the foetal pulse usually met with in girls (§ 119), is of no value, since the average numbers are so nearly alike, and the limits in one sex so greatly overlap those of the other. Nor can any more reliance be placed iE the other methods of diagnosis, such as the lel- 166 THE DIAGNOSIS OF PREGNANCY. increased extent and intensity of the cutaneous pigmentary deposits (so much insisted on by some authors), which are said to occur \shen the foetus is of the female sex (Hohl). Of more value would be the size, hardness and firmness of the cranium, characters which are more marked in boys than in girls, could we determine those characters before birth, and did we not here also meet with such numerous exceptions. The serious accoucheur will not attempt to answer the above question. LITERATURE. Rotter, "Uebcr fühlbares Uteringeräusch." ArcJi. f. Gyn., v. 1873, p. 539. Rapin, " De la localisation du souffle ut6rin." Soe. Vaud. de Med. Lausanne, IST.'i. Also Congres med. intcrnat. Geneve, 1877. Glenard, " Souffle maternel." Arch, de TocoL, Feb. — Aug., 187G. Frankenhäuser, " Ueb. d. Herztöne d. Frucht u. ihre Benutzung zur Diagnose," ice. 3/on. /. Geh., xiv., 1859, p. 161. " Ueber Nabelschnurgeräusch, Nabel; schnurdruck und Hirndruck,"' ibid., xv., 1860, p. 354. Hüter, "Ueb. d. Foetalpuls." Mon.f. Geb., xviii., Supplem., 1862, p. 23 Engelhorn, " Ueb. die foctale Pulsfrequenz." Arch. f. Gyn., ix. p., 360. Dauzats, " Recherches sur la frequence des battements du coeur du foctu! Arch. Tocol., 1879. Kehrer, " Die Yerlangsamung des Foetalpulscs während der Uteruscontrac- tionen." Bcitr. z. Gcburtah., ii., 1879, p. 19. Hecker, " Xabelschnurgeräusch." Klinik, d. Geburt. sh., i., 1861. p. 27. Winckel, " Zur Entstehung und Bedeutung des Xabelschnurgeräusches."' Klin. Beobacht. zur Pathologie d. Geburt. Rostock, 1869, p. 233. Bericht tnul Stiidien au.t dem Entbind. — Institut zu Dresden. Leipzig, 1874, p. 231. Pinard, " Du Souffle foetal." Arch. Tocol., 1876, p. 310. Verardini, lieber den Nutzen der Intraxaginalau.^cultation zur Diagnose der Schwangerschaft. I"or original cf. Gaz. Med. Ital.. Ko. 17, 1873, translated in Allg. Med. Central -Zeitiing, No. 47, 1873. Giornal. Vcnet. di Sc. vied., Jul}- — Aug., 1878. Schnitze, " Ueber Palpation der Beckenorgane," &c. Jena'sche Zeitu-hrift f. Med., V., Part 1, p. 113. Ahlfeld, " Beobachtungen ül)cr die Dauer der Schwangerschaft." Mon.f. Geb., XKxiv., 1869, p. 180. Loewenhardt, " Die Berechnung u. d. Dauer d. Schwangerschaft." Arch. f. Gyn., iii., 1872, p. 4.j7. Hecker, " Ueber d. Bestimmung d. Höhe d. schwangeren GeVjärmutter nach der des Nabels." Klinik, d. Geburt.sk., ii., 1864, p. 5. " Veränder. in d. Umfange d. Leibes Schwangerer," ibid., L, 1861, p. 11. Spiegelberg, " De cervicis uteri in graviditate mutationibus earumquc quoad diagnosin festimationc." Programm, Regimonti, 186.5. "Entfernung des Nabels von der Symphyse." " Entfernung d. Uterusgrundes von der Schamfuge." •• Der grösste Bauchumfang." 3Ion.f. Geh., xxxii., 1868, pp. 270 — 72. Ahlfeld, " Bestimmungen der Grösse und des Alters der Frucht vor der Geburt." Arch. f. Gyn., ii., 1871, p. 353. Runge, " Die Bestimmung d. Grösse d. Kindes vor d. Geburt." Diss., Strass- burg, 1875. Sutugin, '"On the means of ascertaining the length of gestation." Obst, .hmrn. Great Britain, No. xxx., Sept., 1875, p. 397. THE HYGIENE OF PREGNANCY. 167 Duncan, "Protraction of the period of pregnancy," In Fecundity, Fertility^ &c. Edinburgh, 1871, p. 457. Schroder, " Die Beschaffenheit des Hymen oder seiner Eestc als characterist Unterscheidungszeichen zv^ischen Erst. u. Mehrgebärenden." Schwangi'i'- schaft, Geburt n. Woclioihetf. Bonn, 18()7, p. 6. Roederer, Virginitas in Elem. art. oh.stctr. Gotting, 1753, p. 53. Cohnstein, " Vom Leben und Tode der Frucht." Arcli. f. Gyn., iv., 1872, p. 5i7. " Die Thermometrie des Uterus." Virchow's Archiv., 62, 1874, p. 141. (c/. Schröder, Scliioancicr. Schaft, «See, p. 15, Notes). Fehling, " üeber den Einfluss der todten Frucht auf die Mutter."' Arch. f. Gyn., vii., 1874, p. 143. Section IV. THE HYGIENE OF PREGNANCY. § 138, Since pregnancy is a pliysiological condition, it might appear unnecessary to speak of its hygiene. But this period of nine months is distinguished by such active and far-reaching changes in the organism, changes which are of the most radical nature and may rapidly transgress the normal limits, that new problems have to be dealt with. Moreover these changes may be accompanied by numerous disorders, and external influences may easily interfere with their natural progress and indirectly affect other organs ; again the various disorders not only have immediate consequences, but reach into the future and involve the foetus also, so that every ailment causes a double anxiety. It is the province of the physician to enlighten the pregnant woman in regard to her condition, to encourage her patiently to bear trifling and unavoidable discomforts, which are unaccom- panied by risk, at the same time to recommend such regime as is suited to her condition, and to advise her to avoid anything likely to do harm. It is true that in most cases a pregnant woman fares best, when in her new condition she adheres to the same mode of life as suited her well before. Sometimes however her habits are not very appropriate in view of her altered state, and many ladies would suffer, if these were not modified. While the above statement therefore is perfectly true, yet the physician must often step in to suggest improvements, and it is by no means the least of his duties to oppose any foolish prejudices. I shall 168 THE HYGIENE OF PREGNANCY. take it for granted that the principles of a rational general hygiene are known, and merely make a few special remarks. § 139. Since a pregnant woman is very impressionable, and liable to be prejudicially afiected by excitement, she should avoid everything that might make a deep and lasting impression upon her mind; affecting scenes, exciting shows and books are decidedly injurious. Depressing thoughts must be carefully kept away, and she must be forbidden to frequent the sick chamber ; especially should she not be present at a labour, still less at a difficult one. On the other hand, the necessity for regular exercise in thr open air is to be firmly insisted on. It is undoubtedly injurious to lie on a sofa all day, after being in bed till near midday ; such habits induce sluggish digestion, sleeplessness, and a host of psychical disorders. In such cases the physician must interfere with decision, and remind his patient of the wife of the labourer or the farmer, who continues at hard work up to the time of parturition, and as a rule does exceedingly well under it ; if all this is not sufficient, it is often of use to remind the woman of her duty towards her offspring. The carrying of weights, driving over rough roads, prolonged railway journeys are to be forbidden, also dancing after the fourth month and attendance at any parties which interfere with sleep ; in these cases how- ever habit is of much importance, and allows many an exception. The mode of dress depends on habit and constitution ; it must not be tight, but keep the body at a uniform warm temperature, especially the lower portion. Corsets are to be entirely discarded, also garters (especially such as are worn below the knees), since they encourage or directly provoke the development of oedema and varices of the legs. Women with flaccid abdominal walls or with a movable or a pendulous uterus, must wear an abdominal bandage for support, and they can best cut it out themselves to fit their figure ; it matters little of what material it is made. Such women also during the last weeks of pregnancy should allow themselves to be examined in reference to the lie of the foetus. The medical man is often questioned as to the advisability and permissibility of hot or cold baths, and his advice should be guided by the previous habits of the pregnant woman, while of course any excess is to be discountenanced, especially during the THE HYGIENE OF PREGNANCY. 169 1 first months. Women who are not in the habit of taking a bath regularly, should only be allowed tepid baths at 25° — 34° C. (77° — 93° F.) once a week, and only in the last 6 weeks somewhat more frequently. It is absolutely necessary that the external ;genitals be kept perfectly clean by the use of tepid water, bearing in mind the increased secretion and the frequent development of erythemas ; vaginal irrigations on the other hand are only to be allowed where there is much vaginal discharge, and even then they must be cautiously carried out and with lukewarm water. In regard to food and drink, the pregnant woman may be allowed to do as she likes, so long as excess is avoided especially iat supper time and during the last weeks. The so-called longings, when directed to things that are not absolutely in- jurious, should not be too rigidly opposed. Care must be taken that the bowels are daily evacuated ; negligence in this respect is well known to be common amongst women, and is always ^followed by more and more obstinate constipation with its con- 'Sequent disorders and sequelae during the lying-in period. ' When dietetic measures are not sufficient, mild laxatives may be administered every day, such as preparations of rhubarb, isenna, magnesia, &c. ; but strong saline purgatives are for- bidden, since their frequent use appears to have a decidedly injurious effect on the development, and especially on the forma- ;tion of the bones of the foetus. Much harm is done by clysters ; their habitual use leads to stretching, relaxation and elongation of the rectum without the desired object being attained, viz. an 'easy daily emptying of the large intestine ; where they are liked and do their work, the large intestines should be filled according to Simon's plan of irrigation as a substitute. A perfectly in- ; nocuous remedy for habitual constipation, and one rarely failing to accomplish its end, is afforded by combinations of iron with aloes in small doses (ferri sulph. gr. xlv, ext. aloes gr. xxx ; f. pilulae 30, sum. 1 — 2 o.m., or one may be taken after each of tbe three principal meals). The breasts, particularly the nipples, demand special attention ; they should be kept warm, supported below by a napkin and protected from any prolonged pressure ; excessive sensitiveness of the nipple and its areola may best be blunted, by bathing them with cold water containing some alcohol. Depressed nipples !may sometimes be rendered more prominent by pressing back I 170 THE HYGIENE OF PREGNANCY. S the areola with a wooden or elastic ring or a nipple-shield, such contrivances are generally useless ; the same is true of attempts to drag forward the nipple ; this and similar procedures are quackery, and give pain without doing any good. As regards the permissibility of coitus, man well might follow the example of the lower animals ; but with our mode of life, giving such advice is like preaching to stones. I am convinced however that many an early abortion in young women is brought on through sexual excesses, and therefore recommend the greatest possible abstinence for the first 3 or 4 months. Lastly, it must be mentioned that when the disorders accom- panying pregnancy are unusually severe and injurious, something may be done to alleviate the symptoms ; care in the use of remedies however is requisite, nor should too great expectations be based upon them. Therapeutics as a rule can do little for such disorders, and the practitioner will do least injury and therefore do most good to his patient, if he cautiously explains this, and cheers the preg- nant woman by holding out the prospect of spontaneous cure by labour. PARTURITION. 171 2. Parturition. § 140. As soon as pregnancy has reached its natural termina- Aon and the foetus is mature, the latter is expelled together with its appendages from the bod}- of the mother; in other words oarturition takes place, and the various organs which had under- gone alteration gradually return to their non-puerperal condition. Three factors have to be considered in reference to this process 3f expulsion : the expelling force, the body which is expelled, ind the canal through which it passes. The expelling force s derived from the contractions of the uterus and of the ab- dominal muscles, the other two factors forming the obstruction ;svhich the force has to overcome. The fcetus influences the [iprocess in virtue of its volume, shape, lie and attitude, as well t^s of its connection with the mother; the parturient canal in Ivirtue of the closure of the uterus, its own narrow calibre [(especially in the lower section) and the dimensions of the Jpelvis. ' In a normal labour these obstacles are overcome by the I expelling forces, without any injury being done either to mother lor foetus. It is this normal course of events^ the modifications which occur in special cases, and the phenomena that show i themselves in the uterus and foetus, that are to form the subject [of the following pages. [ But two preliminary questions must first of all be discussed : ' what is it that determines the onset of the contractions ? and iwhat are the relations of the uterus to the central nervous [System ? j § 141. The fii-st question, viz. what is the determining cause iOf labour, has been a qucestio rexata amongst obstetricians, but I every explanation that has been given {e.g. that based upon the I great irritability of the uterus and of its nerve endings at the termination of pregnancy, that based on the stimulation of the (cervix by the growing ovum, or on the loosening of the foetal ; connections, or on the return of the menstrual nisus and conges- jtion after 10 months), falls short of the mark, and simply brings ' us back to the point from which we started. The same must be ! said of the view that the onset of pains is due to the venous I engorgement of the placenta (leading to excess of carbonic acid 172 PARTURITION. and deficiency of oxygen, the latter being supposed to give rise to the contractions'), brought on by the spontaneous thrombosis in the veins at the placental site, which occurs during the last months of pregnancy. In all such explanations the question constantly arises, why does all this take place at a particular time ? On the other hand, the phenomena accompanying the birth of twins (which are often born at a considerable interval from each other), the continued growth of one after the expulsion of the other ; the onset of contractions of the uterus (or fcetal sac) at the right time {i.e. at the time that the foetus has become mature), in normal as well as in extra-uterine cases ; the fact that the extra-uterine foetus dies when it has become mature (in cases where it has not perished earlier as a result of the mechanical relations of the sac in v>hich it lies), all go to show that the reason why labour occurs at a definite time (which however varies in the case of different species) , must be sought for, not in the uterus and its changes, but in the fcetus. It is the maturity of the latter which gives the signal for contractions, and this can only be explained by some substances gradually accumulating in the maternal blood, as maturity approaches and arrives ; which substances had till then been used up by the foetus, but are so less and less, till at a certain point the foetus can no longer make use of them, since it now requires other sub- stances for its further development-. These substances (and we may assume them to be chemical irritants) by means of the blood call the motor centres of the uterus into activity, just as the other automatic movements in the body are called forth as a result of similar chemical irritation of their centres. By the time that these substances have collected in the blood, the anatomical changes in the foetal appendages have progressed so far, that the separation, so to speak, of the fruit from the tree is easily accomplished. A motor centre for the uterus exists in the medulla oblongata, and indeed very near to that portion of it which is occupied by the vaso-motor centre. From this point it extends some distance down the fourth ventricle. The motor nerves run partly in the spinal cord and reach the uterus through the sacral nerves, but the principal portion are spinal fibres, which ' Cf. Leopold, Arch./. Gyn., xi., p. 499 ; Runge, Z.f. Geb. v. Gyn., iv., p. Ih. ' It is for this reason that the mature extra-uterine fcetus perishes. PARTURITION. 173 ruu in the course of the aortic plexus. This is a plexus derived from the superior mesenteric plexus, and running down along the aorta, whose main fibres (aortic nerves) with the assistance of the branches of the spermatic ganglia which have joined them, and of the lumbar ganglia of the sympathetic cord, form a wide plexus at the bifurcation of the aorta — the great uterine plexus. About 4 cm. (1'5 in.) below the bifurcation, this mass of nerves divides into the two hypogastric plexuses, which after being joined by numerous branches from the lowest lumbar and the upper sacral ganglia of the sympathetic, encircle the rectum, and pass to the upper portion of the vagina and to the uterus. Each hypogastric plexus then divides into a smaller division passing to the posterior and lateral regions of the uterus, and into a larger one, which with the second, third, and fourth sacral nerves forms the great cervical ganglion. This in j)regnant women is a very broad plexus, which lies on the posterior vaginal fornix, and supplies the whole uterus, especially the cervix. It is however very doubtful whether the centre placed in the medulla oblongata, is the only one which controls the activity of the uterus. At most it is merely a reflex centre, in which stimuli coming from the surface and deep regions of the body are modified, and by which the changes in the uterus are brought into harmony with those of other parts of the body, more or less closely connected with it either in virtue of their function or their position. Whether the influence of that centre over the uterus is merely exerted by means of vaso-motor nerves, in other words whether the reflex movements are brought about through changes in the circulation in the generative organs as a result of the stimulation of vaso-motor nerves, or whether that influence passes by special motor tracts, is not settled, and matters little as far as the result is concerned. On the other hand, both clinical observation and experiment show that the lumbar sjnnal cord contains independent centres for uterine contractions, indeed that it is in this region of the spinal cord that the immediate centres (both reflex and auto- matic) must lie, and there are also other facts which show that the uterus is to a certain extent independent of tlte spinal centres ; it almost seems as if the uterus could not only be thrown into action in response to stimuli actually afi'ecting the 174 CLINICAL PROGRESS OF PARTURITION. nerves in its walls and the ganglia situated there, but as if the activity which has once been set going, were maintained by them. We may take it as settled that the normal sequence of movements is due to the anatomical arrangement of the fibres of the uterus, and not to special nervous co-ordination. LITEKATURE. Frankciihäuscr, Die Xevven der Gch'drmvtter. With 8 Plates. Jena. 1867. Spiegelberg, "Die Nerven und die Bewegung der Gebärmutter." Monats- schrift/. Geh., xxiv., 1864, p. 11. Oser u. Schlesinger, '-Experiment. Untei-s. üb. Uterusbewegungen." Strieker's Med. Jahrbücher, 1872, p. 57. Schlesinger, " Ueber Reflexbewegungen d. Uterus," ibid., 1873, p. 1. '• Ueber die Centren d. Gefäss- u. üterusnerven," ibid., 1874, p. 1. Goltz, " Ueber den Einfluss des Nervensystems auf die Vorgänge während der Schwangerschaft und des Gebäracts." Pflüger's Archiv., ix., 1874, p. 552. Basch u. Hofmann, " Untersuch, über die Innervation des Uterus und seiner Gefässe." Wiener Med. Jahrb., 1877. Röhrig, " Experimentelle Unters, üb. d. Physiologie d. Uterusbewegung." Virchow's Arch., vol. 76, p. 1, (1) The Clinical Progress of Parturition. § 142. For a variable period before the onset of actual labour pains, a series of phenomena show themselves (in rare cases they appear to be entirely absent), which may be called the pre- monitory .signs of labour : changes in the shape of the abdomen, increased secretion from the genital canal, and distinctly per- ceptible uterine contractions. The uterus sinks a Httle in the abdomen, grows wider, and projects further forwards ; the head expands the lower segment of the uterus (especially its ante- rior half) more than it did before, and enters the pelvic brim; the cervix is pushed further backwards and upwards, and is dis- tinctly shortened. As a result of the oedema (caused by the obstruction to the circulation) of the parturient passages, and probably also of an unusually watery condition and increased quan- tity of blood, these passages, and especially the cervical mucous membrane, secrete more freely, their surface feels smoother and softer, their wall can be more easily stretched, and the parts about the vulva appear fuller and tenser. The sinking of the uterus causes a feehng of looseness and freedom about the epigastric region, and often a remission of many of the dis- CLINICAL PROGRESS OF PARTURITION. 175 comforts caused by the pressure at this part of the body ; jothers however soon take their place, for instance pains about •the sacrum, difficulty in walking and standing, a more frequent desire to make water, and tenesmus. From time to time con- itractions of the uterus come on, which the pregnant woman per- jceives as unpleasant sensations passing from the sacrum to the 'pubes, as a feeling of tension in the abdomen, and during which .a hand laid on the abdomen feels the uterus harden and rise up [against the abdominal wall. This premonitory stage may last 'for a considerable time ; now and again it entirely disappears, land in such cases it has been brought on prematurely by external ; influences ; at other times it excites so little attention, that labour seems to begin all at once. But the actual commencement is always to be referred to the time during which the uterine contractions have been bringing about a perfectly evident, and never entirely obliterated, dilatation of the os uteri, — of the external os in almost all primiparae and in some multiparte, of the internal os in the majority of the latter. § 143. The uterine contractions, whose mechanism will form the subject of the following section, may be thus described : The uterus is a muscle composed of unstriped fibres, and is subject to the laws which regulate the movements of such fibres. Its contractions are therefore inroluntari/, they can neither be called forth by the will, nor when once in progress can they be inhibited. As with all unstriped muscles, the contraction is a peristaltic one, beginning at the fundus and from there passing to the cervix. But the separate contraction waves follow so rapidly upon each other that soon after the movement begins, the whole organ is in a state of contraction ; it hardens and rises up from the subjacent parts, the abdominal wall is pushed forwards, and pain is felt in proportion to the increased hard- ness. After a short time the tension gradually diminishes and relaxation sets in, beginning at the lower portion ; then follows an interval for restoration, a period of diastole, after which the same sequence recommences. Even when the relaxation is not very obvious (as not uncommonly happens in an advanced stage of parturition), if it seems as if some degree of contraction persisted throughout the diastole, this deceptive appearance is almost always due to the thickening of the uterine wall which accompanies. the progressive emptying of the uterus. 176 CLINICAL PROGRESS OF PARTURITION. Uterine contractions are essentially rhythmical. This rhythm can be demonstrated to a certain degree in each contraction, inasmuch as the latter does not at once attain its maximum strength ; it is feeble at first, increases steadily in strength, remains for a certain time at the climax of intensity, and then gradually subsides and passes into quiescence (phases of incre- mentum, acme and decrementum). The various phases of this rhythm are however not the same during the whole course of labour. On the contrary, at its commencement the intervals between and the duration of the several pains are approximately equal ; but as labour advances and the uterine walls increase in thickness, the intervals grow shorter and shorter, while the force of the individual contractions becomes stronger ; the maximum intensity is quickly reached, is maintained for a long time, and then rapidly passes into the period of repose. The duration of the contraction and that of the intermission are therefore usually in inverse proportion, and both the strength and frequency of the former are, when the muscular tissue of the uterus is healthy, as a rule in proportion to the amount of resistance ; the physical development of the lying-in woman in other respects has no influence over the pains. The contractions of the uterus during labour are invariably accompanied by j)rt?/f, and they are therefore in almost all languages spoken of as *' pains." This pain has its seat in the pelvis, in the sacral and lumbar regions, and from there radiates over the abdomen towards the pubes (following the course of the hypogastric nerves) and the thighs. At the commencement of labour, it is an indefinite dull forcing sensation in the pelvis, which becomes more painful as contractions increase in in- tensity ; indeed it often becomes unbearable, and causes the woman to be greatly agitated. The pain is mainly due to the tension and expansion of the lower segment of the uterus (including the cervix), and especially of the edges of the os. Later on, the nerves lying in the uterine muscular tissue are stimulated by the fibres in the several muscular layers gliding over one another, then follows the stretching of the vagina, and finally that of the vulva and perinseum, regions which from above downwards are more and more abundantly supplied by spinal sensory fibres. The pain in the thighs and sacral region is due in part to the alteration in the shape of the uterus during CLINICAL PKOGEESS OF PAKTÜKITION. 177 a contraction, in part to the pressure of the foetus (as it passes through the pelvis) on the nerve trunks and plexuses in the pelvic cavity, in part to the venous engorgement of the sacral portion of the spinal cord and its membranes, and of the sur- ' roundings of the sacral nerves at their points of exit ; in part also they are of the nature of " sympathetic pains." A perfectly ixiinless labour does not occur under normal conditions ; the suffering however may be extremely slight, and may therefore scarcely be noticed. This is especially the case \\ lien the preparatory stage has advanced very gradually, and the ol)struction to delivery is so very weak that the foetus can over- come it almost entirely by its own weight, the expelling force rendering it a slight assistance. § 144. In addition to the "pains" already described, the \ ahdominal muscles form an auxiliary expelling force, w^hich ' compared with the first however is only of secondary importance. j Indeed it may be entirely absent, as is shown by those rare cases in which parturition has occurred in paralysed or deeply nar- cotised persons, and by cases in which complete procidentia of '. the uterus &c., was present. This action of the abdominal walls depends upon a combination of respiratory movements. The [ parturient woman fixes her body by applying her limbs (especially [ the lower) to some convenient surface, takes a deep inspiration (thus forcing down the diaphragm), and closes her glottis. The ■ abdominal muscles now contract and diminish the size of the , abdominal cavity ; the expiratory muscles next come into action, , and push the already contracted diaphragm yet further down upon ■ the abdominal cavity, with the result that a uniformly distributed I pressure is brought to bear on the whole contents of the abdomen, ; therefore also on the uterus, and forces the latter downwards. I The simultaneous compression of the thoracic cavity makes it . impossible for the diaphragm to be forced upwards, and so pre- '' vents the uterus from being forced back against the vertebral ' column. I The action of the abdominal muscles, the so-called bearing ; down, is usually a voluntary act, but at the height of a pain, and i especially during the last stages of labour, it is withdrawn from the control of the will, and then becomes purely reflex. Its ! action as an expulsive force is entirely indirect, inasmuch as it is I the uterus which is directly affected, and the foetus is so only I 12 178 CLINICAL PROGRESS OF PARTURITION. secondarily. Since however the extent to which the uterus can descend on to the pelvic brim is limited, the pressure exerted on the part of the uterus lying above the brim, is transmitted through its wall, and thus comes to act on its contents. This force can of course only act as a propelling agent, when the os uteri no longer offers any obstacle, and it is of most importance in cases of great resistance ; it is most useful when its action coincides with the climax of a pain. I must not omit to mention that it is mainly by the action of the abdominal muscles that the detached placenta is expelled. A certain, and perhaps not unimportant, degree of expeUing force is contributed by the round ligaments of the uterus. These are direct continuations of the uterine fibres, and contract with the pains. In virtue of their direction (§§ 44 and 72), they must, when they contract, draw the uterus firmly down upon the pelvic brim, and its fundus forwards ; and since their fibres are spread out on the uterus, the Hgaments must, when contracted, exert a pressure on the surface of the latter which will increase the intra-uterine pressure (Labs). No proper expelling action can be ascribed to the vagina, it is too greatly stretched by the advancing foetus ; but by its elasticity, and by the contraction of the voluntary muscular fibres sur- rounding its lowest portion, it may help in expelling small masses, such as the last parts of the child or the placenta. § 145. Inasmuch as the blood-vessels in the abdomen are aflfected by the rise of intra-abdominal pressure accompanying labour, the blood endeavours to escape into channels exposed to less pressure ; consequently it flows into the lower portion of the cervix, into the vagina and its neighbourhood. This leads to an increase of the oedema (already mentioned amongst the premoni- tory signs), to increased infiltration and softening of the parturient canal, and to more abundant secretion from its mucous membrane, all of them physical signs of labour, which are especially marked in the cervix, and which have an important influence in enabhng the foetus to traverse the canal without injuring it. The pressure in the arterial system increases with each pain ; the frequency of the pulse rises from its commencement up to the acme, and then, as the pain diminishes, slowly regains its former rate ; exceptional cases however are met with in which the pulse appears not to alter. The body temperature also increases a little CLINICAL PROGRESS OF PARTURITION. 179 with eacli pain, and indeed rises gradually as labour progresses, though as a rule only to an unimportant extent ; its variations are greater than under normal conditions. The temperature of the uterus is slightly raised during a pain, a fact which is easily intelligible from a consideration of the severe work done by this muscle. The frequency of respiration is diminished during the pains, owing to the suffering associated with them and to the use of the abdominal muscles, but during the intermissions and during labour as a Avhole it is increased, in consequence of the muscular exertion and the increased production of heat. The secretion of urine is increased, owing to the raised arterial pressure and to nervous excitement, the urine being at first less, afterwards more concentrated than normal ; especially is the amount of sodium chloride increased. The nervous excitement is often extraordinary, and due mainly to the suffering which has been endured, and the prospect of that which is yet to come. The great muscular activity calls forth general perspiration. Vomiting during the course of labour is by no means uncommon. We have already spoken in § 119 of the behaviour of the foetal pulse during the pains ; the other changes which show them- selves in the child during labour, will be described further on. § 146. The progress of labour may be divided into two sharply defined stages, corresponding to the work which the forces of labour have to do, these stages being called the j^er-iods of labour. During the first, the cervix undergoes dilatation, and the parturi- ent canal lying below it is brought into a condition to allow the child to pass through it (period of dilatation) ; during the second (period of expulsion), the child, and afterwards the placenta with the foetal membranes, are expelled. 1. The period of dilatation follows immediately on the pre- paratory period described in § 142 ; it begins as soon as the os and the cervix dilate under the influence of the pains, and ter- minates with the complete transformation of the cervix into a wide cylindrical canal. If the cervix (at the commencement of this period) is not yet entirely obliterated, as is so common in multiparas, it soon becomes so by the advancing ovum, its canal being no longer marked off from the uterine cavity, but forming part of it ; in these cases however it is often possible for a long time to feel the anatomical internal os grow tense during the 180 CLINICAL PROGRESS OF PARTURITION. pains. The head is usually by this time entirely and firmly fixed in the pelvic brim, or is so at any rate during the pains. The latter gradually increase in force and frequency, cause more and more suftering, affect the whole system of the parturient woman, and compel her to seek for support. During these pains, the edge of the external os can be felt to be tense, and the foetal membranes are pushed through it by the liquor amnii in the form of a smooth, convex, tense bladder, " the bag of membranes presents " ; when the pain ceases, the edges of the os and the bag of membranes again relax, the latter recedes somewhat, and tlio presenting foetal part which, while the pain lasted, could probably not be felt owing to the tense condition of the bag of membranes, can now again be reached. Each pain dilates the OS uteri a little more, the bag of membranes can be felt over a larger area, and is driven further through the os ; when there is much liquor amnii between the lower segment of the membranes and the presenting part of the foetus, and when the membranes are very extensible, they may project into the vagina in the foraaj of a cylindrical or sausage-shaped pouch. Meanwhile the par- turient canal becomes more and more infiltrated, the secretions from it increase, much mucus is discharged, and there is often some blood mixed with it. This discharge constitutes the so- called " show," and is caused by minute tears in the sharp edge of the OS, and by a separation of the decidual layers in the vicinity of the lower pole of the ovum resulting from the protrusion of the membranes. More abundant losses of blood are due to the detachment of the lower end^ of the placenta (serotina). Whenj the OS has attained a certain width (about 8 cm. = 3 in.), the protruding part of the bag of membranes remains tense, even ii the intermissions between the pains ; it is now on the point oi bursting. One of the next pains, a strong effort at bearing down,j or any sudden exertion may actually cause the rupture; the liquor amnii in it {fore -waters) is discharged, the remaindei being held back by the close contact of the presenting part of thej foetus with the walls of the cervix. If however there is not this all round close contact, the whole of the liquor amnii, or at anj rate the greatest part of it, may be discharged when the memi branes burst ; but as a rule some of the liquor which was lef^ behind in cases in which the membranes burst as first described^ ' Cf. KUstner in Arch./. Gyn., siii., p. 433. CLINICAL PROGRESS OF PARTURITION. 181 is expelled with each subsequent pain. When the liquor amnii has been discharged, the cervix uteri is more and more stretched by the large foetal part which is advancing ; at last it becomes so wide, that its wall is in close contact with the sides of the pelvis, and appears to be a direct continuation of the vaginal wall, the latter being merely indicated by the margin of the os uteri which projects a very little beyond it. During the whole of this period the foetal movements may be distinctly perceived, both objectively and subjectively. § 147. Various Modes of Rupture of the Membranes. — The membranes not infrequently rupture at a much earlier period than that mentioned above, especially in primiparae ; but so long as it does not happen at the beginning of labour, and is unaccompanied by other anomalies, no evil results as a rule follow. In such cases the membranes usually give way unnoticed, and the discharge of the liquor amnii occurs almost imperceptibly. At other times the membranes do not burst, although the os is fully dilated ; they reach down to and even beyond the vulva {prolapse of the hag of memhranes), and only give way, when or even after the presenting part of the child has passed through the latter. If the bag of membranes gives way not at its lowest portion, but further up near the neck of the child, the presenting head is born covered with the detached piece of membrane (caul). In rare cases the whole foetus has been expelled without the membranes being ruptured, but only when it is small, and the quantity of liquor amnii less than usual. The rupture as a rule occurs at that part of the bag of mem- branes which lies lowest in the os, but when the latter is fully dilated, and the presenting part of the child is fixed in the brim, the rupture is apt to occur at the anterior border between the head and the symphysis. Occasionally moreover a part of the membranes lying above the cervix gives way first ; only a portion of the liquor amnii is then discharged, and the bag of membranes persists, although it is less tense than before ; the torn portion may be again closed up by the body of the foetus pressing on the wall of the uterus, the bag of membranes may once more become tense, and a fresh rupture take place within the os. A discharge (f " waters" is j^ossible without destruction of the hag of mem- hranes, in cases where two concentric membranous bags are 182 CLINICAL PEOGKESS OF PARTURITION, formed by an accumulation of amuio-clioriouic fluid (§ 91), and the tear merely involves the chorion^ ; and lastly, by some fluid, which has been secreted by the decidua, collecting between the ovum and the uterus (spurious liquor amnii), and being dis- charged during a pain. ■i^ 148. 2. The period of crpulsioii begins when the external OS is fully dilated, or at any rate has lost all power of resistance, and ends with the complete birth of the ovum. After the rupture of the membranes, a short interval of repose usually sets in, during which the wall of the uterus adapts itself to the altered relations. But before long fresh pains come on, stronger and more frequent than those of the first period, and propulsive in their action. These force the presenting part further into the dilated and unresisting os, in consequence of which its edges are pushed or drawn apart and upwards, " become retracted," and before long these edges encircle the head along its greatest circumference (period of crowning). Owing to the pressure of the sides of the lower segment of the uterus, and later on of the pelvis, the skin of the scalp is thrown into folds, and becomes highly oedematous ; sometimes even blood is efiused above and beneath the periosteum ; the swelling thus formed is called the " caput succcdancum.'" The advance of the foetus now becomes unmistakable, especially during the pains, although during the intermission the head may still recede a little. The deeper it advances, the stronger grow the pains, until at last they compel the woman constantly to bear down ; the surface of the abdomen grows very sensitive ; the woman is intensely excited, and perspiration everywhere covers her body. The fcetal move- ments are scarcely ever felt during this period. When the presenting part reaches the pelvic outlet, it stretches and pushes down the floor of the pelvis, giving rise to a sensa- tion of tenesmus, and expressing the contents of the rectum. The levator ani and the muscles beneath it are elongated ; the coccyx is pushed back {cj\ § 18), the anal aperture forwards ; the periniBum, especially its posterior portion, bulges like the segment of a sphere ; the labia majora are slightly separated, 'In a case of labour with a contracted pelvis, I ruptured a thin-walled sac which projected far into the vagina; fully 150 grm. (ca. 5-5 oz.) of thin sticky fluid flowed Ott; bat at the pelvic inlet there still lay the true bag of membranes, with a very thick resisting layer of amnion. CLINICAL PROGRESS OF PARTURITION. 183 and the presenting part becomes visible between them ; it has reached the genital fissure. Meanwhile the pains are increasing in frequency and force (Schiittelwehen, dolores conquassantes) , and cause more and more suffering ; the foetus presses strongly on the perinaeum, the labia diverge further and further during the pains, while a continually increasing fcetal surface occupies the pubic fissure ; and even though the head recedes somewhat during the intervals, it is not long before a portion remains constantly visible, till finally the greatest or almost the greatest circum- ference of the presenting part occupies the fissure, eveu during the intervals ; the foetal jiart is now at the point of exit. The perinaeum bulges more than ever, and is so thinned, even in its anterior half, that the cranial bones may often be felt through it ; the pubic fissure looks forwards and upwards ; the anus is patulous and oval in shape, the mucous membrane of the anterior rectal wall being visible ; the urethral thickening of the anterior vaginal wall is pushed forwards beneath the symphysis as a thick oedematous swelling, the nymphae and labia majora are pushed on each side, but the former are not entirely smoothed away. Slowly or suddenly under the influence of the abdominal pressure, the anterior and thinnest portion of the perinteum begins to retract over the head (as soon as the parietal eminences have got through), and the latter is completely delivered, the fra?nulum, as well as a small portion of the skin of the perinaeum, or at least its mucous layer, being at the same time destroyed. At this last moment, the woman testifies to the most acute suffering. If the period during which the head is passing through the pubic fissure is prolonged, a second caput succe- daneum may form on the surface which presents at the fissure. A short period of comparative repose follows the birth of the head. But it is not long before fresh pains set in, and these, materially assisted by the abdominal muscles, expel the body of the child. At the same time any liquor amnii which remained in the uterus {retained liquor amnii), is discharged, mixed with the blood which had been effused during the detachment of the placenta ; a good deal of blood moreover is often lost during the delivery of the head. § 149. The interval between the birth of the child and the expulsion of the placenta with the umbilical cord and foetal 184 CLINICAL PROGRESS OF PARTURITION. membranes (the after-birth), is generally spoken of as a separate third stoge {period of the after-hirth) ; this is not logical, but the expression may be used, provided it is borne in mind that there is no essential difference between the expulsive and after- birth stages. After the expulsion of the child, the parturient woman is exhausted, frequently on the verge of fainting ; in most cases an attack of shivering sets in, often indeed an actual rigor (1 : 3), caused by the rapid emptying of the uterus and abdominal cavity, and the consequent stimulation of the vaso- motor centre (the same occasionally happens after tapping in ascites, or after a sudden diarrhcßic evacu- ation), by the cooling of the body, and especially by the sudden loss of a source of heat which the parturient woman experi- ences, when the child is expelled. In order to make good this sudden disturbance of the equili- brium between heat pro- duction and expenditure, the regulating centre makes use, as we know, of rigors. Most women however soon experience the pleasant sense of repose, which follows on the performance of hard work. This repose lasts from a few minutes to a quarter of an hour, when fresh pains come on, which entirely detach the placenta and drive it into the vagina— " after-birth pains." The uterus may still be felt to reach high up into the abdomen, and during the "pain" has often an irregular nodular shape. The genital fissure is patulous; its sides are bruised Fig. 42. — Expulsion of the placenta. (According to Schul tze.) CLINICAL PROGRESS OF PARTURITION, 185 and very sensitive to contact ; fluid and clotted blood is expelled at intervals. The vagina is wide ; the cervix uteri and the lower uterine segment are flaccid, their walls having collapsed and consisting apparently of loose flaps covered with blood. Higher up lies the contracted body of the uterus, and in its (by this time comparatively narrow) obstetrical internal os may be felt the edge of the partly or wholly detached placenta. The detach- ment of the latter began about the end of the ex- pulsive period, and is mow completed by a con- traction of the area of placental insertion (in ' which contraction the pla- centa itself cannot share), and by a displacement of the placenta by the pains. The line of separation runs through the decidual ampullary layer, of which a portion remains attached to the separated placenta. By this process the ma- ternal blood-vessels pass- ing to the placenta, must necessarily be opened, and the detachment is therefore accompanied by loss of blood. Very soon however the vessels be- come contracted, and this contraction, assisted by Fig. 43.— Expulsion of the placenta. thrombosis taking place (According to Matthews Duncan.) in them^ checks further hemorrhage. Fresh pains (during ' This thrombosis of the uterine vessels at the " placental area " begins in a great many places towards the end of pregnancy (Friedlilnder, Leopold). At the time of parturition, the thrombi are far advanced towards organisation, and consist of large cells (similar to the decidual cells) derived from the vascular endothelium ; just as the latter, by the inequality of the walls of the blood-vessel caused by its proliferation, leads to thrombosis, so do those large cells finally bring about the organisation of the thrombus {cf, inter alios Patenko in Arch. /'. ('n/n., xlv., p. 422). 186 CLINICAL PROGRESS OF PARTURITION. which the attached umbilical cord, when ligatured or not yet severed from the child, again becomes tense owing to the placenta being squeezed) now force the placenta into the vagina, or at least into the cervix, not with the foetal surface first, as is usually represented (fig. 4'2), but edgewise, the mass being folded towards the uterine or foetal surface, and rolled together, and the lower edge emerging first (fig. 43). When the placenta makes its exit with the smooth surface first, that is with the membranes turned inside out, premature traction has been made on the cord, or very strong expression used. The placenta is expelled from the vagina and the vulva by the abdominal muscles, assisted by those in the floor of the pelvis, i.e. when it is not, as usually happens, expressed or extracted by the attendant. Its removal is generally followed by a further loss of blood. The uterus now forms a much smaller hard spherical or flattened (from before backwards) mass, lying above the pubes ; the vaginal walls are thrown into thick irregular folds, which fill up the pelvic cavity. The post-partum period commences. The iveiijht whidi a prcfincnit woman loses by delivery, amounts to nearly the ninth part of her body- weight at the end of the 10th month. This loss is mainly due to the expelled ovum (fa'tus, liquor amnii, after-birth), in a less degree to the blood which has been lost, to the fluid which has been evaporated from her luugs and skin, and to the excreta discharged during labour. Primipar«3 usually lose somewhat less in weight than do multipara'. •^ 150. The dtiratioii of hihoiir is subject to many variations, oven when its progress is perfectly natural. They depend on a number of circumstances, and not merely upon the relation of the expelHng forces to the obstruction that has to be overcome, as indeed is evident from the fact that it is especially during the first period of labour that the greatest variations occur. Generally speaking, labour lasts longer in primi- than in multipane, for reasons which are sufficiently obvious; in the former it averages ca. 20, in the latter ca. 12 hours (in 506 labours I found the figures to be 17 and 10| hours) ; the statistics that are not uncommonly quoted, as showing a shorter average duration, are due to the difficulty of exactly fixing the commencement of labour. CLINICAL PROGRESS OF PARTURITIOX. 187 Elderly primiparce {I.e. those a^ed thirty years and over) show a somewhat longer duration than the average which has been given. Hecker however, and his results are fairly similar to those of Winekel (Reports, Vol. II. 229—242, III. 185—188), found an average duration of only 21*1 hours ; Ahlfeld on the contrary, in 87 persons aged 32 years and over, found the duration to be 27'6 hours. The protraction is mainly caused by the length of the second stage, and is especially to be ascribed to the unyielding character of the lower half of the parturient canal (i.e. of its soft parts), and to the consequent diminishing force, or to some other anomaly in the action of the pains. The difference in the development of the fa'tus as affected by its sex, has a slight influence on the total duration, but it is not noticed till the period of expulsion, and then operates some- what unfavourably in the case of boys. In regard to the duration of the separate stages, the period of dilatation is on an average 7 to 8 times as long as that of expulsion ; the latter occupies in primiparae about two, in multipara one hour; it may terminate very rapidly with a couple of pains, or be prolonged beyond the time mentioned. The natural duration of the after-birth stage is almost always shortened by artificial interference. As a rule the seeond stage passes off the more quickly, supposing the conditions to be otherwise normal, the looger the premonitory and dilatation stages have lasted. Its duration is of importance as regards the prognosis for the foetus; the longer it lasts, the higher as a rule is the percentage both of apparently dead and of dead foetuses, as well as of those dying after birth. It has been already stated that the duration of labour in the case of males is generali}' greater than with females ; but even when the duration is the same, the male sex runs more risk throughout, than does the female. Labour usuall}* begins in the evening hours, and most fre- quently between 9 and 12 p.m. ; in the majority of cases it terminates during the night (1'19 labours take place between 9 P.M. and 9 a.m. to every 1 occurring during the other half of the day), the maximum frequency occurring in the morning hours from 12 — 3 a.m. Easy labours terminate more rapidly, the nearer their time of commencement is to the hours of 3 — G a.m., and 3 — 6 p.m. 188 THE MECHANISM OF LABOUR. Lastly, a greater number of labours terminate rapidly during the summer than during the winter (100 : 107 ; in primipara3 100 : 119, in multiparfe 100 : 103). LITEKATURE. j Kehrcr, Jicitriu/c :. rrrglclchrndoi it. experimentellen GeJjurtshunde. Part Il.i Giesscn. 1868. Venjlcirhende Physinlogie d. (ieburt, kc. Kiini'ke, Die vier Faetoren der Geburt. Berlin, 186'J. Lahs, Die Theorie der Gehurt. Bonn, 1877, Winckel. " Untersuchungen über d. Urinsecretion bei d. Geburt." Studien üb. d. Stoffweehwl hei d. Geburt, kc. Rostock, 1865, pp. 41 — 56. " Das Ver- lualtcn d. Temperatur bei normalen Geburten." Klinische Beobachtungen :. Pathologie d. Gehurt. Rostock, 1869, pp. 1 — 35. "Untersuchungen über d. Veränderungen d. Respiration bei der Geburt," ibid., pp. 35 — 44. Massmann, " Beobacht. über d. Verhalten der Eigenwärme während der Geburt." Petcr.-rm-restituti()n foree of the uterus. ! The general intra-uterine pressure and the pressure exerted on the foetal axis, constitute the sum total of the pressure exerted by the uterus during labour. The intra-uterine pressure, which rises with increasing contraction and with the emptying of the uterus consequent upon it, is the most important expelling force ; as long as the ovum is intact and no considerable portion of it has left the uterus, it is alone operative, and all the more so the nearer the shape of the uterus has approached to that of a sphere (as when the quantity of liquor amnii is excessive) ; indeed it may under some circumstances alone complete the expulsion of '\ the ovum. In no period of labour is this force entirely absent, when the whole uterus is contracting. The pressure on the foetal axis only begins to be exerted at the end of the first, and during the course of the second period of labour, when the lower pole of the ovum, or the presenting end of the foetus, meets with con- siderable resistance to its advance. Its operation however may begin earlier, when very little or no liquor amnii is present ; it acts the more energetically, the further the uterus deviates from the spherical shape. Owing to the additional jjrcss(ür which the abdominal u-alls exert on the walls of the uterus {cf. § 144), the force of the uterus, the THE MECHANISM OF LABOUR. 191 general intra-uterine pressure on its contents, increases con- tinually, till the child is completely expelled. The abdominal walls press the uterus down upon the pelvic inlet, and increase tlie frictional resistance between the latter and the lower portions of the uterus ; in this way they prevent the uterus from gliding away over the inlet, which thereby has another opportunity of exLTting its moulding influence on the foetus. Moreover thev assist {cf. § 145) in the opening up of the lower segment of the uterus, and lastly bring the direction of the uterine pressure, which is that of the uterine axis, into a direction which is per- pendicular to the plane of the pelvic inlet. (According to Schatz, the resultant of the total force lies at an angle of 10^ behind the axis of the brim.) § 154. Attempts have been made to determine the amount of force which the uterus develops during labour, partly by means of manometric observations, partly by experiments on the power of resistance of the foetal membranes. Schatz found that the pressure in a quiescent uterus during pregnancy, as also during the intervals between the *' pains " (so long as the muscular wall of the uterus had not become thickened), amounted to 5 mm. ("2 in.) of mercury, that the maximum pressure employed in expelling the ovum (including the action of the abdominal muscles) varied from 80 to 250 mm. (3 — 10 in.), that the force necessary for the expulsion of the head amounted from 19 — 60 lb. (17 — 55 Pfund). Poppel, basing his calculation on the force required to rupture a piece of foetal membranes, whose surface measured 5 cm. (2 in.) in diameter, found that in easy labours the head passes through the pelvis with a force of 4'5 — 21 lb. (4 — 19 Pfund). Duncan found that when the diameter of the piece of membranes experimented with was 4h inches, the force necessary to rupture them varied from 4 — 37| lb., averaging 16| lb. ; he concludes from this that in very easy labours the foetus may slip out by its own weight, since in many instances the force used to rupture the membranes is suflicient to expel the child also ; in difficult labours, on the other hand, the force may be considerably increased. All these calculations however are open to great sources of error ; the method that is based upon the resistance of the foetal membranes, to the fallacy that the liquor amnii lying in front of (below) the head, is not necessarily under the same pressure as the rest of the uterine 192 THE MECHANISM OF LABOUR. contents ; the manometric method to the sources of error which inevitably accompany this mode of estimation. As the uterus becomes more and more contracted, and conse- quently emptied, its volume and capacity diminish, so that when the organ is completely emptied, the anterior and posterior walls lie in contact ; at the same time the Avails are increased 2 — 4- fold in thickness. This alteration is partly effected by a shorten- ing and thickening of the muscular bundles, and by a change in their relative position ; bundles that before lay side by side now lie one beneath the other. But the chief cause is the shortening and the thickening of the muscular fibres themselves, which change results in part from a cessation of the elastic tension, in part from actual contraction. The muscular fibres continue in this state of contraction, or rather of retraction (tonus), after labour, as is best proved by the pathological conditions of relaxation and enlargement of the uterus, which are met vf ith j^ost jKirt urn. § 155. The dilatation and canalisation of the cervix are brought about by the general intra-uterine pressure, owing to the less power of resistance which the cervix possesses, and which is dependent on the slighter formation of the whole lower segment of the uterus, on its physiological softening, the absence of pressure exerted by the abdominal muscles at this spot, and finally on the attachment of the uterus to the pelvis. The weak lower segment of the body of the uterus {i.e. the small lower end of the uterine ovoid, or area of expansion — Duncan, cf. § 69), whose upper margin forms approximately the boundary of the firm attachment of the peritoneum to the anterior and posterior uterine walls, cannot long resist the pressure which the com- pressed ovum exerts on the uterine parietes during the " pains," which pressure increases as the pains grow stronger. This segment therefore gives way, becomes stretched, and its wall would tear, did it not open up more and more during the pains, and especially did not the os form a vent, which, through a radial recession of its edges, compensates for the expansion. As long as the pregnant uterus is quiescent, there are only the weight of the fa3tus and the intra-abdominal pressure to act on the internal os ; but as soon as contractions commence, the edges of the os are drawn apart ; and since the os is the only point which ofi'ers no resistance to the pressure of the uterus on its contents, the latter will pass into the gap, and dilate it more THE MECHANISM OF LABOUR. 193 and more. The cervix thus dilated forms a highly elastic canal, for its muscular fibres, though only weak, are nevertheless con- tractile. But it becomes to some extent elongated as well as dilated, and this elongation is all the greater, since the external 03 at first resists the dilatation, and the uterine muscularis in contracting retracts itself upwards along the ovum ; further, the ! contractions near the cervix run mainly in a longitudinal direc- tion. The dilatation and elongation of the cervix are consider- ably assisted by the action of the abdominal muscles, and by the attachment of the uterus to the pelvis. For while the action of the abdominal muscles, wherever these are in operation, is added to the resistance, which the wall of the uterus opposes to the ^pressure exerted upon it by its contents, the portion of the 1 uterus projecting into the pelvis is deprived of this assistance. At the same time the action of the abdominal muscles is to force 'the whole organ into the pelvis, in consequence of which its ; pelvic attachments are put on the stretch, and hence a force is ' exerted on the lower segment of the uterus tending to pull it in idifi'erent directions. Through this traction on the cervix, the edges of the external os become so much stretched, that they ' also give way, and are retracted over the ovum. , The cervix uteri and the lower segment of the uterus are thus I drawn out to a greater length than they had before labour, and inasmuch as the distance from the external os to the fundus remains approximately the same, the contracting part of the ' body of the uterus is shortened to the extent of the above- mentioned elongation ; moreover the internal os comes to lie at a greater distance from the external. Thus in Braune's section of a parturient woman at the end of the first period of labour (fig. 45), the length of the cervix amounts to : 10 cm. (nearly 4 in.), the length of the cavity of the uterine body \ to 18 cm. (7 in.), as compared with 26 cm. (10 in.), before labour^. ' That which Braune represents as cervix in figs. 44 and 45, appears to me to be ! both cervix and lower uterine segment, so that the ring which he describes as the internal os uteri, is really the lower border of that part of the body of the uterus which contracts during labour, the obstetrical internal os. This view is supported by the high position of Braune's internal os, and by the transverse furrow seen in the figure I lying immediately above the upper edge of the symphysis in Braune's cervix, and ' which appears to me to be the upper border of the true anatomical cervix. The only I way in which Braune could have proved that the portion lying between this furrow I and the orificium internum, was really cervix, would have been by demonstrating that it was lined with cervical mucous membrane, which was not done. Moreover the pelvis of this preparation appears to be somewhat contracted. 13 194 THE MECHANISM OF LABOUR. As a result of this shortcninj^, the body of the uterus has retracted itself from the ovum, and since the latter does not lie free, a separation of the foetal membranes from the uterine wall must necessarily take place ; this does not happen merely when the membranes project through the external os (when the meiii- branes " present "), but to a certain extent during the dilatation and elongation of the cervix, since there was no connection between it and the ovum. How far this separation extends, depends — iiccruM. rig. 44.— Section through the frozen body of a woman, dying during the period of expulsion. (After Braune.) mainly on the elasticity of the membranes ; the less the elasticity, the greater the separation. The shortening of the body of the uterus terminates at the pelvic attachments of the cervix ; and if the external os is fully dilated, the increasing contractions will, with the assistance of the abdominal muscles, force the ovum through it into the vagina. Cervix and vagina now form a wide cylindrical canal, which is continuous without any sharp projection with the THE MECHANISM OF LABOUR. 195 uterine cavity ; the presenting part of the foetus, ahnost always the head, lies entirely within the cervix, the obstetrical internal OS lying on a level with or even above the shoulders of the foetus (cf. fig. 44). These various changes are not infrequently somewhat different in multipara, since in them the head does not as a rule lie so deep at the commencement of labour, and is not so firmly pressed down upon and into the internal os, as in primiparge ; moreover />> .COCLiAC. V£N. PORT/E V. RLN.tM. Fig. 45. — The Uterus and Paxturient Cana of fig. 44 without foetus. the action of the abdominal muscles is feebler, the attachments of the uterus looser, and the lower portion of the cervix and especially the external os generally offer less resistance. Hence it follows that when the internal os opens up, the external often follows suit, and the canal of the cervix continues for a while to retain its cylindrical form {cf. § 69). But with a given width, the relations are such as are described above, except that owing to the very yielding character of its lower portion, the expansion 190 THE MECHANISM OF LABOUR. find elongation of the cervix are often less marked than in primipariTB. § 156. The hap of memhranes plays a very important share in dilating the cervix. The compressed liquor amnii receives the whole of the pressure of the uterine parietes, and therefore seeks to escape, as mentioned above {cf. § 155), in the direction of the OS, and at this point causes the membranes to bulge. The greater the elasticity of the latter, the further Tvill they protrude, and the greater is their wedgehke action on the edges of the os ; the less their elasticity, the more force is expended in separating the membranes from the decidua, and the less remains for dilating the OS. That the bag of membranes really contributes to the dilatation, is evidenced by the fact that the cervix again contracts ^ or collapses, when the membranes rupture before complete dila-H tation has occurred. "With the widening of the os, the pressure exerted on the portion of the membranes lying in it increases, and indeed in proportion to the superficial area of its orifice ; but the power of resistance which the membranes possess, can only increase in proportion to the radius, since the pressure must evidently be distributed on the fixed points of the periphery. Thus with increasing dilatation the disproportion between pressure and power of resistance constantly rises, while at the same time the counter-pressure which the lower uterine segment and its elastic reaction can exert, diminishes more and more. The foetal membranes therefore give way and burst. (The ■chorion is the least resisting of the two membranes, and not infrequently ruptures before the amnion.) The pressure of the liquor amnii lying in front of the head {fore-icaters), the tension of the part of the bag of membranes which presents, is not always the same as the pressure in the other portion of the liquor amnii, since the two masses are separated from each other by the cranium, which is in all round contact with the lower segment of the uterus. The head here acts like a ball-valve, and as such transmits pressure from within outwards. It is however not only in contact with the uterine wall, but also stretches it (in virtue of its w^eight). The pressure in the fore-waters compared with the general intra- uterine pressure, is therefore modified with the degree of this stretching. The two will be equal, when the segment of the uterus bounding the fore-waters and the head, is uniformly and THE MECHANISM OF LABOUR. 197 easily stretched ; but when during a pain the head is forced downwards owing to the I.U.P.^ (the head being closely adapted to the uterus), the presenting part of the bag of membranes is more and more protruded, and ruptures. But if the lower segment of the uterus is unusually strong, and resists the pressure, so that the head cannot move downwards, then the pressure in the fore-waters will remain less than that in the remainder of the liquor amnii, and under such circumstances a " caput succedaneum " may form on the head, while it is still within the bag of membranes. If a portion of the cervix lying considerably below the head, especially one situated near to the external os, is very resisting, then as the compression of the fore-waters increases with the pains, the former will push the uterine wall before them at the point where it is in close contact with the head, and will recede into the cavity of the uterus, and the head under these circumstances will only descend in con- sequence of the I.Ü.P. and its weight, and only simultaneously with the whole lower segment of the uterus ; this may indeed lead to an entire disappearance of the fore- waters. The same may also occur when the membranes are very resistant ; the fore- waters may be completely pushed aside, and the membranes thus become an obstacle to the advance of the head. § 157. After the bursting of the membranes, the I.U.P. con- tinues to operate, forcing the head, i.e. the lower end of the ovum, down through the os, and causing this to be obliterated, if not already so. The more the foetus passes out of the uterine cavity, the smaller does the latter become, and the more also is the transverse section of the foetal cylindrical mass diminished, and since its volume remains the same, the length of the cylinder must be increased. The uterus however in its vigorous efforts to shorten itself in the direction of its length, acts more forcibly than ever on the body of the foetus, in a direction parallel to its own longitudinal axis. At this stage also the F.A.P. comes into full play, and, assisted by the abdominal muscles, is the main agent in driving the foetus through the small pelvis. The soft parts lining the latter have no influence over this move- ment, but those lying at the outlet, i.e. in the pelvic floor, are very important. As the head is forced down vertically upon this floor, the latter is stretched (as described in § 148), the lowest ' Cf. § 163 (Tr.). 198 THE MECHANISM OF LABOUR. portion of the vafijinais elongated, its orifice is displaced forwards, and comes to be almost vertical. The pelvic floor thus forms a «utter-shaped pouch running forwards from the bony outlet of the pelvis, and in the formation of this " "perlnaal canal," that part of the perinsBum which lies between the anus and the point of the coccyx (posterior perinreum), also takes a share. The periniBum in virtue of its elasticity and high tension, exerts a great influence over the movement of the head. When the head is born, the anterior and posterior walls of the body of the uterus lie in contact with each other, and the delivery of the body is largely due to the abdominal muscles co-operating with the uterus. We have already, in § 149, spoken of the (expulsion of the placenta. § 158. The movements irhich the fo'tiis viahes during its paaxage throuf/li and its exit from the iielvis, are by no means merely progressive movements, for the foetus, and especially its head, are subjected to rotations due to the resistance offered by the parturient canal. The head enters the small pelvis in the position and attitude which it occupied Avhen above the brim, and inasmuch as the uterine axis is approximately at right angles to the plane of the brim, the circumference with which the head engajres, i.e. the transverse diameter of the head, lies parallel to the brim. It is only when the head is obstructed at the very outset, viz. at the inlet, and the vertebral column of the foetus is consequently ren- dered unusually convex in relation to the anterior uterine wall (owing to the fundus uteri as it endeavours to move forwards being forced further back by the abdominal muscles than are the deeper parts of the organ), that the head is inclined towards the posterior shoulder, that the base of the skull is pushed forwards, and the transverse diameter of the head forms an angle with the plane of the inlet, causing the sagittal suture to pass somewhat further back (Naegele's obliquity). The head is next driven directly downwards, in such a way that it retains the same relation to the imaginary planes running parallel to that of the inlet all through the small pelvis ; it is therefore forced onwards in the axis of the brim. This condition of things is maintained, till the head reaches the lowest part of the posterior pelvic wall (which looks forwards and do W7i wards), and the floor of the pelvis. The latter resists the force with which the head is pushed against THE MECHANISM OF LABOUK. 199 it at an angle which opens anteriorly, and hence the presenting part of the foetus is driven in a direction which is the resultant of these two forces, that is forwards and downwards towards the aperture of exit of the parturient canal {cf. fig. 14, § 35). § 159. The resistance which the pelvic canal opposes to this progress, causes the head, as already mentioned, to rotate, first on its transverse, then on its longitudinal, and lastly again on its transverse axis. The first rotation causes the liead to he increasingly flexed on the trunk, in consequence of which the occiput is depressed. The force exerted by the uterus is transmitted to the head through the vertebral column, and this, being articulated nearer to the occipital than to the anterior end of the base of the cranium, converts the head into a lever with unequal limbs, of which the occipital is the shorter ; hence the resistance, being equal at both ends of the head, must act most on the anterior limb of the lever, and retard its progress. The occiput must therefore descend yet further, and it will do this all the more, since its convexity is much greater than that of the frontal half of the head ; if therefore the parturient canal is distended by the propelled head, the occipital portion will be more likely to get room for its advance than the broad and less convex frontal region. Thus the force of the pains has most effect on the occiput, and results in so strong a flexion of the head that the chin is pressed against the chest, and the suboc- cipito-parietal plane comes to occupy that plane of this part of the pelvic cavity, which is parallel to the brim ; indeed in cases of great obstruction, the occipito-mental diameter almost cor- responds with the direction of the pelvic axis, and the point of the occiput lies in a nearly direct continuation with the vertebral column. The rotation on the longitudinal foetal axis occurs in the lower portion of the pelvic cavity, and is a gradual movement accompanying the progress of the foetus ; the latter therefore describes a spiral. By means of this rotation, the presenting part of the foetus comes to lie more and more in the sagittal median plane, i.e. under the pubic arch. The rotation of the head depends in part upon a similar movement of the trunk, the dorsal surface of which (as the uterus continues to diminish in size) avoids the sacro-lumbar promontory {i.e. the obtuse angle 200 THE MECHANISM OF LABOUR. which the posterior wall of the small pelvis forms with the larfre). and moves forwards where there is more room. But the chief causes of this rotation of the head are on the one hand the direction of the posterior division of the inclined planes of the ischial bones {cf. fig. 12), and especially the resistance of the projecting ischial spines, which compels the portion of the foetus which lies anterior to them to move forwards, the part lying behind them to move backwards towards the sacral concavity ; on the other hand the resistance of the pelvic floor, which inas- much as it directs the head forwards, must of course begin by forcing the lowest part of it in that direction. Meanwhile as the head alternately advances and comes to a standstill, its smooth surfaces adapt themselves to the shape and cavity of the canal in which it lies, and finally when its lowest portion has reached the aperture of exit of the parturient canal, it is retained in this position by the stretched pelvic floor, and especially by the muscles of the latter (levator aui) , which are thrust apart. When the lower part of the foetus reaches the vulva, the neck locates itself against the symphysis, the great mass of the head is placed on the pelvic floor, and the forehead occupies the sacral concavity. At this point the head again rotates on its transverse axis, but this time it is a movement of extension, end- ing in delivery. The expelling forces, continuing to act as before in the direction of the axis of the brim, drive the head against the posterior portion of the pelvic floor ; this latter however forces it forwards, and since the neck is squeezed against the anterior wall of the pelvis and flxed, the head turns upon this point as a 'point cVappid. The occiput being the lowest part, ascends in front of the symphysis, the pelvic floor presses on the forehead and forces it forwards, the occiput rises more and more, and the elasticity of the perinaeum, as it undergoes retraction, at last forces the face out of the body. But not only does the presenting part of the foetus rotate round the longitudinal axis, its whole body does so too ; for the amount of resistance profiered by the anterior and posterior foetal sur- faces to the extension of the body by the pains is unequal, and this circumstance, as well as the previously described influence of the sacro-lumbar promontory, must cause a rotatory to be^ associated with the progressive movement. The whole body of the foetus however does not rotate to an equal extent, for that THE MECHANISM OF LABOUR. 201 portion of it which remains high up in the body of the uterus, lags about 30° behind the deepest portion (Schatz). Thus the fcetal cylinder becomes twisted, and causes the body of the uterus to be so also to some extent ; indeed the whole parturient canal shares in a varying degree in all the rotatory movements of the foetal cylinder. Meanwhile the advancing foetal cylinder becomes more and more elongated, as it leaves the cavity of the body of the uterus, for the latter contracts more and more towards its centre, and grows narrower transversely. Hence result displacements and changes in the distance between par- ticular uterine zones and the foetal zones corresponding to them ; those that take place in a transverse direction are more important than those in a perpendicular direction, since of course the fundus always remains in close contact with the breech. After the birth of the head, the presenting portion which looked forwards as it made its exit, again turns to the side, a proof that the previous rotation to the front had only been partly followed by the trunk, and that the neck had been somewhat twisted. The delivery of the trunk takes place by means of a fresh rotation round the longitudinal fcetal axis, through which the binacromial diameter (as previously the head was) is brought into the median sagittal plane ; but this rotation takes place in a direction the reverse of that which the head previously under- went, and the occiput turns directly to the side. The trunk is now (corresponding to the pelvic curve) bent towards the side which is directed forwards, and this curve increases, the further the shoulders are forced downwards. The latter therefore do not pass down symmetrically ; the anterior is somewhat detained at the pubes, while the posterior rapidly advances from the coccyx over the perinasum to the posterior vulvar commissure. If now the point of the posterior shoulder has traversed the posterior commissure, the binacromial diameter lies in the antero-posterior diameter of the vaginal orifice, and both shoulders are delivered simultaneously ; in rare cases, when the pelvic floor is narrow and offers little resistance, the posterior emerges somewhat before the anterior. The remainder of the trunk as a rule follows obliquely in the direction of one of the thighs of the mother, or occasionally, when the expulsion is rapid, in a straight direction between the two thighs. § 160. The changes in the shape of the head which take place 202 THE MECHANISM OF LABOUR. during parturition (moulding of the head), and those which are caused by the mobihty of the bones in relation to each other and by their flexibility {cf. § 106), will be dealt with, when the special mechanisms are described. But here we may say a few words more about the local swellings caused by labour, especially the " caput snccedaneam." This is a serous or even sanguineous infiltration of the skin, and especially of the subcutaneous con- nective tissue, causing them to swell, and thus giving them a sero-sanguineous appearance ; in addition there is very frequently an extravasation beneath the periosteum. The swelling is due to the fact that the area on which it forms, is exposed to a less pressure than that lying about it ; this leads to venous hyper- a}mia, to oedema and extravasation at that spot. The swelling generally begins by the skin being thrown into folds, owing to the greater pressure on the parts above it, and to the com- pression and distortion of the cranium. The swelling may form within the os, when the lower uterine segment is very much stretched and firmly applied to the presenting part, indeed under some circumstances it may appear before the rupture of the membranes {cf. § 156). As a general rule however it is first formed in the narrowest part of the pelvis or at the pelvic floor. Its situation will vary accordingly, and may be used after birth for a retrospective diagnosis of the position, provided that the stage of labour at which the swelling was formed, is accurately known, since the part exposed to the least pressure may vary with the various stages. The size of the swelling depends on the length of time which it has taken to form, and on the amount of pressure. § 161. Influence of the jya'uis on the distribution of blood in the uterus and lüaccnta. — So long as the general intra-uterine pres- sure acts alone, the placenta of course is neither compressed nor expressed, nor can the umbilical cord be exposed to any injurious pressure. The maternal placenta continues to discharge its blood into the maternal channels. But during a pain the tissues of the uterus become pale, its efferent channels are over-filled, and a considerable portion of the uterine blood must therefore be expressed. Moreover since the blood-pressure in the arterial system is higher than that in the venous, the latter is most rapidly and easily emptied, the arterial channels being so only at a later period, when the pains have increased in force. But' the THE MECHANISM OF LABOUR. 203 blood squeezed out of the uterine walls cannot flow into the placenta, since the vessels passing through the uterine tissues to the placenta are exposed to the same pressure as the contents of the uterus, inasmuch as the tension of the uterine wall is equal to the degree of contraction of the muscular fibres (these of course form also the walls of the blood-vessels), and therefore to the degi'ee of compression of the contents ; the result is that as the pains grow stronger, a larger quantity of blood flows out of the veins, while less blood enters the arteries, and the maternal placenta is emptied by means of the maternal channels. Pro- bably as a general rule this momentary emptying has no influence over the foetal circulation, though in some cases slight symptoms of dyspnoea might be caused. At all events the efi"ect is of no importance, and therefore so long as only the general intra- uterine pressure is acting, it is but very rarely that any alteration in the foetal pulse is noticed during a pain. The trifling retar- dation which is occasionally observed must be looked upon as due to an increased general intra-uterine pressure, or to a stimu- lation of the origins of the vagi by compression of the cranium icf. § 119). The conditions of the placento-footal circulation alter when the body of the uterus has undergone considerable diminution in size, and when the general intra-uterine pressure is lessened as compared with other pressure relations. Owing to the contrac- tion of the uterine walls towards the end of labour, the placental area is diminished, and the placenta itself is gradually detached. Consequently the interchange of gases is interfered with, and the foetus, which hitherto had continued in a condition of apnoea, experiences a want of oxygen, which after delivery causes respira- tion to be a physiological necessity. The exciting cause however for the commencement of respiration depends not uncommonly on yet other causes, e.(i. cooling of the foetus, mechanical contact, and on the placental blood channels being squeezed in the direction of the foetal heart by the expelling forces (associated with a contraction of the placental area), in con- sequence of which the smaller or pulmonary vascular circle becomes for the first time injected and filled. These accidental causes are however of secondary importance compared to the want of oxj'gen, and merely serve to start the respiratory rhythm at tJie proper time. 204 THE MECHANIK M OF LABOUR. h. Special Mechanisms.— The Various Kinds of Presentation. § 162. In the preceding description of the progress of the foetus through the parturient canal, its vertex was supposed to present in the usual yray. In -what follows, this description is to he more minutely detailed, and the variations in the mechanism, as met with in the different kinds of foetal lie and position, together with their etiology and diagnosis, are to he discussed. As already mentioned in § 108, the foetus is found at the commencement of labour either in the longitudinal or in the oblique, commonly called transverse, lie; and though the lie changes so often before labour, yet at the proper period for the pregnancy to terminate, the child is in the great majority of cases found in the longitudinal lie, and with its head turned towards the pelvis — cephalic lie; it is rare for the pelvic end to be directed downwards — pelvic lie. When the foetus is in the cephalic lie and its attitude is normal, the vertex lies in the pelvic brim — vertex presentation ; if the chin is separated from the chest, and the occiput forced down upon the neck, the face presents in greater or less extent — -face presentation; in rare cases a condition intermediate between the vertex and the face presentation is met with, and the forehead lies over the middle of the pelvis — brow presentation. The attitude may also vary in the different forms of pelvic lie. The thighs and feet may be applied to the abdomen, and the pelvis be placed lowest — breech presentation ; or the thighs may be separated from the abdomen, and stretched downwards, and the feet be lower than the pelvis — footling presentation. If the legs remain strongly flexed on the thighs, the knees may present — knee presentation, or one or both extremities may be stretched down {incomjüctc (tnd complete footling or knee presentation). Amongst the various kinds of pelvic presentation, the breech alone is primary, footling and knee presentations being derived from it; the mechanism of all the pelvic presentations is the same as that of the breech. The mechanism of a face presenta- tion, on the other hand, is very different from that of the vertex, and therefore, although the face presentation is merely an unusual attitude of the head, will require a separate description. THE MECHANISM OF LABOUR. 205 So also will the brow presentation. Thus we obtain the follow- ing presentations : — ■ 11. Vertex presentation. {a. Ceplialic lie... < 2. Face presentation. ( 3. Brow presentation. h. Pelvic lie Pelvic presentation. .,„,,. , ,. «4.1, f i I Oblique or Transverse II. Oblique or transverse he of the foetus J presentation. If the relative frequency of these presentations is calculated from the records of lying-in institutions, it is feund that |ca. 95 vertex, and 3 pelvic presentations occur in every 100 labours ; somewhat over "5 (1 : 180) per cent, of transverse, and ca. '6 (according to Winckel's statistics 1 — 158) of face presen- tations. If the calculation is based upon a larger number of births and a larger area of population, the proportion especially of face and pelvic presentations diminishes, and that of vertex presentations increases. Thus out of 93'871 births in the Upper Ehine District of Baden, which I have added together from the records of Schwörer (Schneider's &c. Annalen der Staatsarzneikunde, 1846, Part 3; also Programm, Freiburg, 1857), of Hegar {Verhandlungen der Naturf. Gesellschaft .zu Freiburg, 1864) and from those collected by myself (unpublished) during 1860 — 62, there occurred : — 97-3 per cent, vertex presentations. 289=1 : 324= -3 „ face presentations. 1491=1 : 63 = 1*59 „ pelvic presentations. 732=1 : 128^ '78 „ transverse presentations. The greater frequency of face and pelvic presentations in lying-in hospitals is explained by the greater number of abnor- malities that occur in them, since such cases are often taken to hospitals, just because they are abnormal. Further it seems that if the calculation is based on labours coming on at the full time and in well formed women, especially if plural births are excluded, vertex presentations are much more frequent, and pelvic presentations much rarer (1*5 per cent.). The brow pre- sentation is the rarest of all. Each presentation is subdivided into various j^ositions (cf. § 110), according to the direction of the back of the foetus. In the longitudinal lie, the dorsum is most frequently turned towards the left side of the mother — first position, more rarely towards the 206 THE MECHANISM OF LABOUR. right — second position ; as a rule the dorsum is at the same time directed towards the anterior surface of the mother, whence further subdivisions result (dorsum to the front = the first, dorsum to the rear=the second subdivision). With a transverse lie ot the foetus, the commonest position is that with the head to the left — first, the rarer one that with the head to the right — second transverse position ; the direction of the back forwards or back- wards here decides the subdivision (dorsum to the front = the first, dorsum to the rear=the second subdivision). § 163. The diagnosis between the different kinds of presenta- tion can easily be made by the vaginal examination, provided the presenting part is within easy reach, the os sufficiently dilated, and the membranes are ruptured, or, if still entire, are at least relaxed, and contain little liquor amnii. But when the foetus is high up, when the bag of membranes is tense and very full, when the presenting part of the foetus is swollen and cedematous, the recognition of the latter per vaginain is often very difficult. The diagnosis must then rest entirely on tlie external examina- tion. This, provided the tension and sensitiveness of the abdominal and uterine walls are not excessive and insuperable, — which rarely happens — always yields sufficient and often much ^ more satisfactory information than the internal examination, and leads to far fewer errors. At the same time it throws light on the position, explains the characters discovered ^^e/* raginam, and enables us to recognise the latter with the least possible delay and discomfort for the parturient woman. The physical signs of each presentation and position will be described in detail under the appropriate headings ; here I will only mention the characters by which the separate parts of the foetus may be recognised. As regards the modus operandi, I must refer to what has been said in §§ 114 and 116. In palpating the abdomen, the two ends of the fcetal cylinder, head and breech, must first be sought for. The head is felt as a round, hard, fairly even, convex mass without marked projections ; it is more movable than the breech, and can more easily than the latter be distinguished from its adjacent parts, owing to the pre- sence of the neck. Further it can be made to ballote, like a ball immersed in a fluid, much more distinctly than can the pelvis, whose movements are hindered by its broad connection with the trunk. The ballotement is more obvious in the earlier months, THE MECHANISM OF LABOUR. 207 when the head is comparatively large, than in the later ; in these on the other hand the head is distinguishable by its greater hardness. Occasionally the cranial bones may be felt through the walls to crackle, as parchment (parchment crackling) does when pressed upon, and this sign is of a special importance in doubtful cases. Sometimes also the head is recognised by the I tapering occiput being distinctly felt through the abdominal walls. 1 The breech may be recognised by its uninterrupted broad con- I nection with the trunk, by its irregular shape, its inferior degree of hardness, and less distinct ballotement, and by the extremities which lie in close contact with it. The hack of the foetus is known by the long and broad even surface which it presents to the palpating hand ; sometimes also its deep bony elements can be felt. The limbs are recognised as small irregular bodies ■ which can easily be displaced, and which also change their position and attitude of their own accord. In making the examination, the first question to be solved is, I whether we are dealing with a longitudinal or a transverse lie, ' and if with the former, whether the head or the pelvic end is presenting. For this purpose the head is to be sought for first. As a rule it will be found just above the anterior pelvic wall, rarely in the fundus uteri ; the breech will of course occupy the - opposite division of the uterus. The presenting part of the I ovum may either be freely movable above the pelvis and therefore easily reached, or it may have already engaged and become fixed in the pelvic inlet ; in the latter case it can only be felt from the outside when the parietes are very relaxed ; occasionally also the broad shoulders may be recognised lying above the pelvis and a diagnosis arrived at. But an internal examination will under these circumstances enable us to decide the question, since the presenting part can be very accurately explored ^j^r vaginam. If no large foetal mass is found either in or above the brim of the pelvis, if too the fundus uteri is empty, the presentation (unless an excessive quantity of liquor amnii be the cause of the negative result) is probably transverse, a condition which will be confirmed by an unusually great transverse width of the uterus. A careful palpation will then reveal that the head and the breech are placed one at each side of the abdomen ; the one being at a higher level than the other. When the lie has been ascertained, there is usually no difficulty 208 THE MECHANISM OF LABOUR. iu making out the position, at least whether it is a first or a second. The dorsum throws light on this i)oint, since, apart from the broad surface which it presents, the side with which it is in contact, always offers the greatest resistance to palpation ; if the dorsum cannot readily he felt through the walls, an attempt may be made by pressing down deeply in the middle portion of the uterus to force the dorsum to one side, and thus to make it more accessible to palpation. The lower extremities will be found on the opposite side to the back, but their situation can only settle the position of the latter, when it is an exactly lateral one, which is not always the case. Auscultation gives us the area at which the foetal heart-sounds can be most distinctly heard, and thus materially fortifies or corrects the results obtained by palpation. Owing to the curva- ture of the foetal cylinder, the dorsum as a rule lies in close contact with the uterine wall, and there is much less fluid between them than there is on the ventral side of the foetus ; the conduction of sound is therefore least interfered with on the dorsal side, and the foetal heart-sounds will as a rule be loudest on the side which corresponds to the dorsum. Auscultation has thus a special value for diagnosing the position, more so than for determining the lie, although it is true that if the fcotal heart is very distinctly audible on one side, it is an argu- ment in favour of the lie being longitudinal, and that owing to the relation of the thorax the foetal heart- sounds are usually heard below the navel in head presentations, and above it in such of the breech. Nevertheless it is not uncommon even with a cephalic lie to hear the sounds most distinctly above the navel in the neighbourhood of the breech of the foetus, especially when the dorsum is directed posteriorly, and the breech is in close contact with the anterior uterine wall. Indeed all these state- ments are liable to many exceptions, when there is good con- duction of sound, and the foetus is unusually extended. Even for the diagnosis of the position, auscultation can only be relied upon, when it accords with the results of palpation, for where the quantity of liquor amnii is small, the heart-sounds can often be perceived distinctly on both sides of the uterus. A special exception to the above rule occurs in face presentations, where, as a result of the great extension of the trunk, the latter is pushed towards the side away from the dorsum, and the foetal THE MECHANISM OF LABOUR. 209 ! heart-sounds can therefore be heard on the side that corresponds : to its ventral surface. I need scarcely mention that in deciding on which side the t foetal heart-sounds are heard most loudly, it is not so much the side of the abdomen, as that of the uterus which is to be considered. § 164. From the point of view of frequency, the vertex pre- sentations are the only normal ones ; all others are abnormal, and must therefore be numbered amongst the pathological occurrences, all the more as they on the one hand depend chiefly upon an abnormal foetal attitude, on the other hand (and this is true even of the simple breech presentation, in which the attitude is normal) are associated with numerous perils for the mother or the foetus. If therefore I describe some abnormal presentations immediately after those of the vertex, this is done as much for the sake of a connected account, as for the reason that when they are properly managed, the great majority of the cases terminate spontaneously and successfully for the woman concerned. The transverse presentations however will be dealt with under the abnormalities of labour, since it is only in very exceptional cases that they terminate without artificial interference, and without injury to mother and foetus. A. Vertex Presentations. § 1G5. The {etiology and diagnosis of vertex presentations need not be further referred to here, after what has been said in §§ 108 — 110, and in the preceding one. It may always be expected on a 'priori grounds, that, if the lie is longitudinal and if palpation has found the head to be placed just above the pelvis, the case is one of vertex presentation. This becomes a certainty when through the vaginal fundus (which is often pushed far down by the head) we are able to feel a large hard rounded mass with a smooth surface, and when, either through the relaxed membranes if the os is dilated, or directly if they have ruptured, the characteristic cranial bones with their sutures and fontanelles can be made out, while no part of the face is within reach. The first position— dorsum to the left, the right side of the foetus turned to the anterior surface of the mother, occurs in ca. 70 per cent, of all vertex presentations (I like Nsrgele only find 14 210 THE MECHANISM OF L.U50UR. ca. 65 per cent.) ; the second — dorsum to the right, left side of the foetus turned to the front, in 30 per cent. In the former case the dorsum is as a rule also directed somewhat forwards, in the latter often backwards, although probably in the majority of cases sideways. The reason for this direction and for the great fre- quency of the first position, has been already given in § 110. § 166. The mechanism of the vertex presentations has been sketched in outline in §§ 158 and 159. The attitude, position (relative to the pelvis), and the direction in which progress is made in the different portions of the pelvis, are as follows : In most cases a portion of the vertex lies within the brim at the beginning of labour, and this portion is usually in the biparietal plane (fig. 46, A, B) ; in rare cases, where the resistance is very slight, in the occipito- frontal (C, D). When the head is still above the brim at the com- mencement of labour, it nevertheless enters in the biparietal plane ; the forehead and occiput are nearly on a level, though the occiput lies as a rule a little deeper. The sagittal suture runs ap- proximately in the trans- verse diameter or in the first oblique ; this, as I have shown, depends principally on the relation of the uterus to the pelvis, and on the uterus being twisted to the right on its axis ; the oblique entrance (Solayres', or lateral obliquity) occurs in about 20 per cent, of all vertex presentations. With very favourable conditions as regards space, the sagittal suture, or at least its middle point, lies midway between the anterior and posterior walls of the pelvis, therefore in the transverse median plane ; it is only when obstruc- tion is met with early, i.e. at the brim, that the head inclines towards the posterior shoulder {cf. § 158), and the sagittal suture runs behind the transverse median line (Ngegele's or biparietal obliquity) . When the head is driven down, it becomes strongly flexed and the occiput is depressed ; the degree of flexion depends on the I- - Fig. 4«. THE MECHANISM OF LABOUR. 211 amount of resistance met with, and as a rule increases, the further the head advances. At the same time the chin approaches the chest, the great fontanelle moves higher, to above the ilio- sacral synchondrosis, the small fontanelle approaches the middle of the pelvic cavity, and the occipito-mental diameter comes almost to correspond with the axis of the inlet, at any rate becomes perpendicular to the horizon (Rcederer's obliquity). The examining finger impinges upon the posterior portion of the parietal bone which is directed forwards, and since the head is not driven onwards in the middle line of the pelvic canal, but in the direction of the axis of the brim, the anterior parietal bone must in the lower part of the pelvic cavity present to a greater extent than the posterior ; the sagittal suture here always lies behind the transverse median line. Meanwhile the occiput becomes rotated forwards, owing to the rotation of the trunk, and to the resistance of the lower part of the posterior pelvic wall and of the floor of the pelvis (§ 159) ; the small fontanelle approaches nearer and finally glides out beneath and a little on one side of the symphysis ; at this period it may be felt at the outlet of the parturient canal, while one side of the occipital region appears in it. Through the action of the pelvic floor, the occiput is driven more and more forwards, the neck comes to lie in contact with the posterior surface of the symphysis, and the forehead and the face pass down rapidly along the posterior wall of the pelvis on to the perinasum. Then follows the movement of extension of the head, as described above ; the occiput moves up in front of the symphysis, and the vertex, forehead and face are delivered. The direction of the movement is that of the lower segment of the vagina, and runs almost at right angles to the axis of the inlet, that is to the direction of movement within the pelvic cavity. When the head is completely expelled, the occiput, which has hitherto been directed forwards, again turns to one side, since the shoulders have not rotated to an equal extent round the perpen- dicular diameter. They lie rather between the transverse and the oblique diameters of the pelvic cavity, the opposite to that in which the sagittal suture was previously placed. The deeper the shoulders descend, the more do they approach, as did previously the sagittal suture, the antero-posterior diameter of the outlet, and the occiput now turns again directly to one side, so that the 212 THE MECHANISM OF LABOUR. face looks straight at the opposite thigh. The further move- ments associated with the exit of the trunk are described in § 159. § 167. The course of events and the physical signs found in a first vertex position, are the following : The hack of the foetus looks to the left, the feet l}ing in the right side of the fundus ; the cardiac sounds are audible on the left side of the mother, and below the level of the umbilicus. The sagittal suture runs in the transverse or in the first oblique diameter of the brim, the small fontauelle is opposite the middle of the left ilio-pectineal line or above the left foramen ovale, the right parietal bone is directed forwards. The small fontanelle soon descends, and turns to the left side of the body of the os pubis ; the gi-eat fontanelle moves higher up, and is as a rule quite beyond reach ; the sagittal suture has crossed the first oblique diameter. At the outlet of the pelvis, the postero-superior quarter of the right and lowest parietal bone appears beneath the pubic arch, and is soon fol- lowed by the right side of the occiput, the occipito-frontal diameter lying in the direction of the conjugata diagonalis. The point of the occiput which is now in the vulva, passes up in front of the symphysis, while the vertex, forehead and face sweep forwards over the perinneum. The face when born, turns to the postero-internal side of the right thigh of the mother. The shoulders pass into and through the upper division of the pelvis, lying between the transverse and the second oblique diameter, the right one being placed against the right pubic bone, the left opposite the left ischiadic notch. The right then moves towards the symphysis, the left into the sacral concavity ; in this position they pass out, and, as they do so, the face turns completely towards the inner side of the right thigh of the mother. In a second vertex position the dorsum is turned to the right side of the uterus, and frequently somewhat backwards, the feet Ipng high up on the left ; the foetal heart-sounds are audible on the right side of the mother ; the left side of the foetus is turned towards the anterior wall of the uterus and pelvis. The sagittal suture in the upper portion of the pelvis lies in this case also in the transverse or first oblique diameter, and indeed for the reasons given above the oblique entrance occurs somewhat more frequently in this than in the first vertex position. The small fontanelle is in contact with (or below) the right ilio-pectineal THE MECHANISM OF LABOUR. 213 line, or with (or below) the right ilio-sacral synchondrosis, and usually even at the start is somewhat deeper than the great fontanelle, which is turned to the left, or forwards and to the left. As the head descends, the occiput turns towards the right pubic bone, so that the sagittal suture comes to lie in the second oblique diameter. The further progress is similar to that in the first position ; the postero-superior quarter of the left parietal bone moves from the right forwards to the pubic arch, and is soon followed by the left side of the occiput and the small fontanelle, the head passing out as in the first position ; the face when born, looks towards the postero-internal side of the left thigh of the mother. The shoulders pass through the pelvis, lying between the transverse and the first oblique diameter, the left lies against the left pubic bone, but soon turns towards the symphysis and passes out beneath it, while the right sweeps over the perinamm ; the face then turns directly to the inner side of the left thigh. § 168. The cajyut succedancum in vertex presentations is usually situated on the postero-superior quarter of the parietal bone which is directed forwards, since it is this portion which, when in the lower part and on the floor of the pelvis, pro- jects into the lumen of the vagina, and afterwards beneath the pubic arch, and therefore is subjected to the least pres- sure. This statement however does not exclude the possibility of the swelling being formed at an earlier stage of labour, and therefore on a difi"erent part of the cranium than that mentioned (cf. § 160). head passes very slowly through the genital fissure, and the occiput remains for a long time in the vulva, the swelling may extend on to the occiput (secondary caput succedaneum) ; indeed if the previous progress has been very rapid, it may form on it alone. The alterations in the simile of the head itself consist in a compression of the suboccipito-frontal diameter (to which the greatest pressure is applied in the narrowest part of the partu- rient canal), and in an increase in length of the occipito-mental Fig. 47.— Shape of the head in vertex presenta- tions (occipito-anterior position), with a well marked caput succeda- neum. Similarly, when the 214 THE MECHANISM OF LABOUR. diameter (fig. 47). Heuce the occipital and the frontal bones come to lie somewhat deeper than the parietals, and are pushed beneath the latter. This is the commonest alteration, although not invariably present, and it is greatly favoured by the anatomi- cal connections of the bones^ Moreover in many cases (in more than two out of three) the two halves of the cranium come to lie at a different level, though only the parietals are as a rule affected, more rarely the frontal bones ; the posterior parietal bone is generally pushed in beneath the anterior, since it is more pressed upon by the parturient canal than is the latter. Another effect of the pressure exerted on the transverse diameter of the skull is seen in the flattening of one parietal bone, almost always of the posterior, while the anterior becomes more convex ; consequently the outline of the skull, when looked at from behind and above, is seen to be uusymmetrical (fig. 48). A lateral displacement of the two cranial halves in relation to each other in the occipito- frontal direction also occurs, the parietal eminence and the whole of one side lying further forwards than the other; in the vertex presentations this occurs on the side which is directed backwards, and the pressure exerted upon it by the promontory, is in many cases the cause. Still more obvious is the difference in the form of the temporal fossie, the anterior being the deeper. These alterations in the shape of the skull soon disappear after birth ; it is very rare for one or other to last for a week or more. On the other hand there is a true congenital and per- manent obliquity of the cranium, in virtue of which the left side is displaced backwards and upwards, and especially the left half of the occiput becomes more prominent and convex ; the distance of the occipital protuberance from the parietal eminence is then less on the left side than on the right. Stadfeldt, who first de- scribed this asymmetry, ascribes it to the physiological and congenital sinuous formation of the axis of the cranium. The above-mentioned changes effected by the pressure of labour, usually obliterate this asymmetry (in the first vertex position, the left parietal bone is often pushed forwards), although it reappears shortly after birth. § 169. The following modifications of the ordinary vertex presentations as described above, may occur. ' Even the connections of the tabular with the basilar portion of the occipital bone admit of considerable movement. THE MECHANISM OF LABOUR. 215 a. The head may enter the brim in the second oblique diameter, with its occiput directed forwards or backwards. The first of these varieties — originally called the second position, is not frequent ; still rarer is it for the occiput to be directed back- wards and to the left — the so-called fourth j^osition. This latter position may also arise within the pelvic cavity at a later stage of labour, in cases where the head has engaged in the brim in the usual first position, but where the occiput rotates backwards Fig. 48. — Foetal head bom in the second vertex position (moderate pelvic contraction). (After Braune.) (From fig. 44.) instead of forwards. Similarly, when thp head has entered obliquely in the second position, occiput backwards and to the right, the usual rotation forwards may fail to take place ; the occiput continues directed backwards, and gives rise to the so- called third position. In these positions the occiput is turned to the ilio-sacral synchondrosis, the forehead to the opposite ilio-pectineal emi- 216 THB MECHANISM OF LABOUR. nence, and the anterior fontanelle lies at a somewhat lower level than the posterior; the examining finger impinges upon the parietal eminence, and the part in front of this lies in the axis of propulsion. The head may be born in this position, or the occiput may turn forwards even in the pelvic cavity, the third being converted into the second, the fourth into the first position. Such conversion is the ride, and always takes place when the head during its progress is subjected to a uniform pressure from all sides of the j^clvis, and the occiput is nowhere detained by any special individual anomaly. When it does, strong flexion of the head takes place under the influences of the expelling forces, the small fontanelle moves forwards and downwards, and approaches the middle of the pelvic canal, the great one ascends ; the forces of labour now become concentrated on the occiput, and the resist- ance of the posterior wall of the pelvis and of the pelvic floor drive it forwards, and expel it in the usual way. This rotation may take place in any plane of the pelvic cavity, either above or at the pelvic outlet, and the time of its occurrence depends on the period at which flexion of the head occurs. Sometimes it happens quite unexpectedly and rapidly, another time very slowly, especially when it only takes place in the lower portions of the pelvis, since the form of the skull has in such cases sometimes already become moulded so as to correspond with its unusual position. When however the rotation in the lower part of the pelvis is delayed, the case is more serious on account of the diminution in the size of the uterus which will by that time have been produced, and of the consequent threatened asphyxia of the foetus ; under such circumstances artificial assistance will be by no means infrequently called for. § 170. llie head passes out with the occiput rotated hack- wards, when there is not sufficient resistance to cause it to be strongly flexed ; birth in the third and fourth positions there- fore occurs chiefly with small heads and wide pelves. It is noticed in 1 — 2 per cent, of vertex presentations, the exit in the third position being about t^-ice as frequent as that in the fourth ; moreover the head enters the brim with the occiput turned backwards and to the right, much more frequently than with it turned backwards and to the left. The great fontanelle is then lower than the small one, frequently in the axis of propulsion; the forehead, directed laterally at first, turns THE MECHANISM OF LABOUR. 217 gradually forwards, so that the great fontanelle at last lies over the ostium vagina and one frontal bone — in the third position the left, in the fourth the right — becomes visible in the genital fissure ; the edges of the orbits and the nose can be felt behind the pubis. But the pains at last drive the occiput downwards and on to the perinteum, which it must traverse, and which it often imperils in a very high degree. Inasmuch as the broad forehead cannot easily emerge from beneath the pubic arch, it is strongly compressed and flattened against the pubis, or else it passes somewhat upwards behind the pubic bones, and thus makes room for the occiput to glide out over the perineum. When this has happened, the head makes another movement of extension, of which the neck firmly lodged against the anterior perinaeal commissure, forms the centre of rotation, and thus forehead, nose, mouth and chin pass under and out through the pubic arch. The shoulders pass through the pelvis in the / opposite diameter to the one in which the j sagittal suture was previously placed. I Since in delivery in the third and fourth \ positions, the occiput passes over the peri- ^ ^ naeum, the anterior segment of the vertex is the presenting portion ; these positions have therefore also been called (Wigand, Hecker) anterior parietal presentations. Pig. 49.— Shape of head Occasionally through depression of the an- Tai'present'atTon!' ^"'^' terior part of the head, they are trans- formed within the pelvis into face or brow presentations, and vice versa. The shape of the head born in an anterior parietal presenta- tion, differs materially from the cylindrical form which is met with in the usual vertex presentations, and is very similar to the original shape of the head. Since the pressure at the outlet is exerted in the fronto-occipital diameter, the skull is shortened in this and is elongated to make up for it in the vertical direction, i.e. in the direction of the anterior parietal region lying in the lumen of the pelvic outlet ; the skull is therefore brachy- cephalic; the head is high, the forehead steep (fig. 49). But since the heads born in this position, have frequently but a small circumference, they do not very often show this shape. The 218 THE MECHANISM OF LABOUR. caput succedaneum is placed on the anterior angle of tlie parietal bone which looks forwards ; sometimes on the great fontanelle, or even a little in front of it. § 171. b. Occasionally the head passes transversely through the pelvic cavity, and the sagittal suture is at the outlet in the transverse diameter— decj) transverse position of the head. The delayed rotation round the long foetal axis, is due to an absence of resistance to the progress of the fcBtus. If the cause lies in the smalluess of the head, or in the width of the whole pelvis being considerably above the normal, the head may also emerge in the same direction. But if, as happens in the so-called broad funnel-shaped pelves (increased width at the brim and in the cavity, with a normal width at the outlet), the head meets with the normal resistance at the outlet, it is detained there, and before passing out must rotate on its long axis. As a rule the occiput at this point rotates forwards, but if the great fontanelle lies relatively deep, the exit may take place in the third or fourth position. Since the accomplishment of rotation sometimes occupies a considerable length of time, the deep transverse position may cause a delay in delivery which is not without danger, and may require artificial interference. More- over the skull in this deep position is afiected by a marked biparietal obliquity, the anterior parietal bone presents, its eminence appears beneath the pubic arch, the great and small fontanelles lie far back, and are directed straight to the sides. § 172. c. In rare cases the head enofages in the antero- posterior diameter of the brim, and retains this relation during its whole course through the cavity. Similarly there occasion- ally occur retrogresfiive movements of the occiput, indeed complete changes in the relations of the head to the pelvis, changes whose causes are difficult to explain not only from a general point of view, but often also in any individual case. Another abnor- mality consists in the head engaging in the brim of the pelvis with a very marked inclination towards one shoulder. It may incline towards the posterior shoulder, i.e. with a well marked NiBgele's obliquity, so that the sagittal suture is found close to the promontory, and the anterior parietal bone covers the brim ; this is scarcely ever seen except in a contracted pelvis, although it may also in an exceptional case occur with a normal pelvis owing to excessive anteversion of the uterus and THE MECHANISM OF LABOUR. 219 to pendulous abdomen. Again, and this also is extremely rare with a normal pelvis, the head may be inclined towards the anterior shoulder, the sagittal suture lying near or in contact with and even over the anterior pelvic wall, and the posterior parietal bone covering the brim. These positions — called anterior and posterior parietal ptositions, or, since the ear of the presenting side can be distinctly reached, anterior and posterior aural presentations — therefore constitute a true caput ohstipum. Their aetiology, when the pelvis is normal, is difficult to explain, but their termination at any rate is usually favour- able ; the abnormal cephalic attitude in the majority of cases is i spontaneously rectified with the help of good contractions, or is set right by manual interference. If however the head remains in this position after the discharge of the liquor amnii, version must be resorted to, i.e. the head must be converted into a footling presentation ; if this is impossible or cannot be executed without danger, the size of the head must be diminished, since it cannot be delivered in this unfavourable position, and the maternal passages when labour is prolonged, are exposed to an injurious amount of pressure. § 173. d. During the exit of the shoulders, rotation is not uncommonly absent, and the binacromial diameter passes through the pelvic outlet and vulva in the transverse position. In such cases the external rotation of the head is also absent. This is especially noticed when the head has made rapid progress, and there is a want of resistance at the pelvic floor, therefore most often in multiparas and where the pelvic outlet is wide. Under these circumstances the shoulders sometimes pass out in the oblique diameter. At other times the shoulders, as they pass out, rotate in such a way that they do not pass through the opposite oblique diameter to that through which the sagittal suture passed, but through the same ; thus in the first position through the first oblique with the left shoulder forwards, in the second position through the second oblique with the right shoulder forwards. In such cases the occiput, when born, makes no retrogressive movement towards the side from which it rotated forwards, but a further rotation in the opposite direction, turning for instance in the first position towards the right thigh of the mother. In rare cases so extensive a super-rotation takes place, that the 220 THE MECHANISM OF LABOUR. slioulders reach the oblique through which they ought to pass in the normal course of events, but with the dorsal and ventral foetal surfaces reversed. The trunk has then rotated through a semi-circle, and the shoulders pass out e.g. after the birth of the head in the first position, as if it had been the third position. The cause of these abnormal rotations appears to lie mainly in the conformation and position of the uterus, to a less extent in the shape of the pelvis ; it is no doubt sometimes due to the prolapse of the extremities by the side of the head, or to the umbilical cord being coiled round the child. These rotations are most frequently noticed : when the occiput is primarily directed backwards, therefore more often in the second than in the first vertex position ; in primipara?, owing to the greater tension of their uterine walls ; and more often in forceps than in spontaneous deliveries. Where forceps have been used, the operation may have prevented the regular mechanism of rotation, or an already existing faulty direction of the shoulders in relation to the neck may have made the operation necessary. B. Face Presentations. § 174. Presentations of the face are a variety of those of the head, in which owing to the great extension of the latter and to the occiput being approximated to the neck, it is not the vertex but the face which presents at the pelvic inlet ; the forehead is here looked upon as a part of the face, although not anatomically belonging to it. In order to bring about such an attitude of the head, there must be a force opposing the flexion of the head, and such a force can only be found in the conformation of the foetus, or in some resistance on the part of the parturient canal. The foetal head may no doubt remain extended for short periods as a result of reflex movements, but it will not retain that position except under compulsion. Face presentations therefore only occur, when contractions are present which drive the head downwards and compel it to assume a definite attitude, although this state- ment obviously does not exclude the possibility of the face persistently presenting for some time before the onset of true labour pains. I myself have noticed this, on one occasion five, on another eight days before the onset of labour ; in the winter THE MECHANISM OF LABOUR. 221 of 1877 — 78 we were able more than once for several weeks previ- ous to delivery (which occurred at the proper time), distinctly to make out a face presentation through the vaginal fundus ; parturition took place as a vertex presentation, the child being alive. The extension of the head may be due to the shape of the foetus, e.g. to a considerable enlargement of the upper thoracic region (I once met with a face presentation with a large hydro- thorax), or of the anterior cervical region owing to a tumour (congenital goitre). But in most cases the determining force is exerted by the jjdvic brim, and a marked lateral deviation of the uterus and an oblique position of the foetus are then of special importance. As the foetal position is being rectified by the uterine contractions, the occiput may easily be caught and de- tained at the edge of the pelvic brim, especially when the dorsum is turned upwards. The uterus usually deviates to the right ; by its contractions its action is exerted on the left side, and if the forehead, for instance, is directed to this side, it will be forced down. Hence also is to be explained the relatively great fre- quency of the second face position, as compared with the second vertex position. The development of a face presentation is of course favoured by any obstacles which in themselves are likely to lead to a depression of the forehead, or to a very transverse position of the head at the brim, therefore especially by a flattened pelvis (cf. infra) ; thus one contracted pelvis is met with in about every four face presentations. Moreover the head will be all the more easily extended, the greater the development of the occiput, since the longer the occipital arm of the cephalic lever, the less the resistance which will suffice to delay the occiput. Hecker attaches most importance to this dolicho-cephalic shape, to the elongation of the posterior arm of the lever (from the foramen magnum to the point of the occiput) as compared with the anterior (from the foramen magnum to the chin), which characterises skulls born with the face presenting ; they are moreover distinguished by a smaller perpendicular, by a large transverse diameter and by a generally increased circumference. It is undoubtedly true that the skull in which the difference between the anterior and posterior arms of the lever has become smaller, in which therefore the point of the insertion of the vertebral column, i.e. the point on which the expelling force acts, 222 THE MECHANISM OF LABOUR. is nearer to the middle, i.e. nearer to the front of the head, can readily be induced to enter with the anterior surface of the head (instead of engaging like the ordinary skull with the posterior surface first), i.e. to engage as a face presentation, all the more so, when a relatively large transverse diameter favours such a position. Not only however is it a fact that the heads born in face presentations do not always present the dolicho-cephalic form, at any rate not in a marked degree, but this shape, where present in a characteristic manner, is not always primary, but has been produced by the pressure of labour, as subsequent measurements show ; and the same shape of head is also met with in exactly opposite cephalic attitudes (entrance with the occiput lowest). Moreover in the skulls concerned, the posterior arm of the lever is always somewhat shorter than the anterior, so that, although we are willing to admit the truth of Hecker's statements as regards the original form of the skull in face presentations, that form is insufficient in many cases alone to explain the development of a face presentation. Ahlfeld seeks for the explanation of this attitude in a diminu- tion of the foetal reflex activity, such as exists in premature, asphyxiated and dead foetuses. But the view that face presenta- tions are frequent in premature labours or with dead foetuses, is contradicted by all our experience, although we have now satis- factory evidence of its occasional occurrence. In order to prove Ahlfeld's hypothesis, it should be shown that the percentage of face presentations is higher in premature, immature and dead foetuses than in those that have reached the full time and are living. Amongst other points in the aetiology, we must mention that short and fat foetuses, i.e. those that are heavy in proportion to their length, very frequently present with the face. I myself amongst this class of new-born children, have found relatively many girls, perhaps for the reason that the male skull is on an average more frequently brachy-cephalic. Coiling of the cord round the foetus is common. In my experience face presenta- tions are more frequent in multiparcB than in primiparse. It must further be noticed that the obstruction which leads to the presentation of the face may be caused not only by the pelvis, but also under some circumstances by the soft parts, e.g. by uterine tumours (Lüdicke, Centralbl. f. Gyn., 1879, p. 212), or by the distended urinary bladder (Ahlfeld). THE MECHANISM OF LABOUR. 223 The frequency of face presentations is, as already mentioned in § 162, much too highly estimated in the records of lying-in institutions. A more general census shows that a face pre- sentation occurs only once in 32-1 births, a proportion which is very similar to that recorded in the great Eotunda at Dublin (Collins 1 — 497). The most common position, as with all longitudinal " lies," is that with the dorsum to the left. On the other hand the second is more frequent than it is with vertex presentations, doubtless owing to the fact that the uterus usually deviates to the right side. (According to Hecker, with whose results those of my Maternity correspond, 21 second occur to 28 first face positions = 1 — 1^, while the relation in vertex presentations is 1 — 2"26.) § 175. A face presentation may sometimes, when a part of the head can be felt above the brim, be diagnosed by the external examination alone, the occiput being found pressed back against the neck. On one side is the resisting and tapering convex surface, which corresponds to the occiput and in the region of the neck makes a distinct angle with the trunk, while on the other side no part of the cranial vault is found. Even when these points cannot be satisfactorily made out, the presence of a face presentation is rendered very probable, when (as already mentioned in § 163) the cardiac sounds are heard most distinctly on the side opposed to that on which the dorsum is placed, but corresponding to the lower extremities. A vaginal examination, made when the head is still high, shows the vaginal fundus to be flattened, the presenting part to be less movable than usual. On the latter may be felt through the fundus, small rounded pro- jections on one side, on the opposite a broad bony surface, the forehead. When the os is patulous, the face presentation is identified by the nose, on one side of which the eyes can be felt with their prominent supra-orbital ridges and the forehead, on the other the mouth with the lips and alveolar edges, and (when the head has moved further down) the chin. Sometimes too the tongue is detected within the mouth, and when the child is alive, sucking movements may be perceived. The direction of the nose is the best guide as to the position. When the face is much swollen, it may be very difficult to recognise, and is most liable to be confused with the breech. I have seen the swelled lids with the prominent eye-ball mistaken for the scrotum; 224 THE MECHANISM OF LABOUR. indeed in one melancholy instance the edge of the orbit was con- fused w-ith the iliac crest, and a blunt hook was introduced into the orbit. In doubtful cases, the cavity of the mouth with the highly characteristic alveolar ridges forms the safest guide. ,j § 17G. The mechanism in face presentations may be deduced from that of vertex presentations, if the mento-frontal and bimalar diameters are substituted for the fronto-occipital and biparietal diameters of the vertex, and if it is borne in mind that the long axis of the face, owing to the direction in which the pressure of the propelled vertebral column acts upon it, is divided into two arms of a lever, the shorter one lying towards the chin, much as in vertex presentations the shorter is directed the opposite way towards the occiput. The head lies above and enters the brim, with the axis of the face (drawn from the middle of the forehead between two frontal eminences to the point of the chin) running transversely or in the first oblique diameter, and owing to the greater frequency with which the uterus is rotated to the right, it lies more com- monly in the oblique diameter than in vertex presentations. Moreover N^gele's obliquity is, for reasons already stated, more frequent than in the latter. The forehead lies at first at a some- what lower level than the chin. But as the pains gi-ow stronger, the resistance to the progress of the head acts on the longer arm of the facial lever, i.e. on the frontal region, and detains it, while the shorter arm, viz. the chin end, descends more and more ; the head becomes more extended, the chin advances first. The latter must now however rotate towards the anterior pelvic wall (even though it may at the beginning have been directed backwards) , owing to the same causes as in vertex presentations, when flexion has occurred, force the advancing occiput in that direction. But it may happen that a chin which is directed backwards is unable, with the ordinary relations of pelvis to fcetal head, to reach the floor of the pelvis, without also drawing the shoulders into the inlet, i.e. in addition to the head which is lying against the anterior wall and in the inlet (since the neck is too short, even with the greatest possible extension). Under such circumstances the labour comes to a stand-still, or, what usually happens, the chin passes out in front. The extension increases yet more, and the chin passes into the vulva and beneath the symphysis, while the shoulders remain above the anterior wall of THE MECHANISM OF LABOUR. 225 the pelvis (fig. 50) ; the neck is squeezed against the symphysis, the head hecomes flexed, and the forehead, vertex, and at last the occiput sweep over the pelvic floor, against whose anterior edge the neck rests, when the head has made its exit. In the ßrst face position, the forehead is found at the brim on the left side of the pelvis, as a rule directed somewhat forwards and lying a little deeper than the chin. As the head descends, the chin comes down and rotates from the right side or from its dextro-posterior position towards the front, so that the right cheek can be felt in the middle of the pelvis, and the line of the face in the second oblique diameter. The foi-ehead approaches the sacral concavity, the chin advances from the right pillar of the ixrethra. pubic arch into the vulva, till at last the chin, though still in- clined to the right, moves up in front of the symphysis and makes room for the skull to glide out over the perinaeum. When the head is born, the face looks towards the upper side of the right thigh of the mother, and the delivery of the shoulders and trunk follows in the same way as in vertex presentations, being as in them occasionally subjected to irregular rotations. The second face position runs a similar course, right and left being of course reversed. In this position however the chin is ivery often directed forwards from the very start, since the head so frequently enters in the first oblique diameter ; the rotation of the head round the longitudinal foetal axis is therefore as a Irule less extensive. . If the chin contmnes directed hackicards, the head can only bo lexpelled when it is very small and yielding {cej. with dead foetuses), 15 frseniüum. anus. 2nd sacral vertebra. Fie 50. — Face passing through the pelvic outlet and vulva. (After Schröder.) 226 THE MECHANISM OF LAEOUE. when the pelvis is wide and the perinaeum very unresisting. To allow of delivery in this position, the neck must be very gi'eatly stretched, as mentioned above, and the occiput and shoulders must enter the pelvis simultaneously with it ; this can only occur, if the foetus is compressed to a degree which is not possible under normal conditions. If occiput and shoulders have simultaneously entered the brim (fig. 51), the skull is squeezed against the anterior pelvic wall, the neck and thorax against the posterior, and all these parts are so pressed against each other, that any further stretching of the neck is rendered impossible and labour comes to a complete dead-lock. The Fig. 51. — Face presentation, with chin directed posteriorly. (After Hodge.) case is of course different when there is no resistance, and to such a class belong the deliveries in the mento-posterior position which have been observed. In such the chin appears at the anterior edge of the perineum, against which it is firmly j)ressed, while the head is released from its jammed position by a process of flexion, and the forehead, vertex and occiput successively pass ' down beneath the pubic arch and from before backwards. § 177. The sero-sanguineous sivelling of labour is very rarely absent in face presentations, inasmuch as they rarely terminate rapidly. The swelling is either placed chiefly on the oculo- , THE MECHANISM OF LABOUR. 227 frontal region or over the clieek, ala nasi, angle of tlie mouth and lips, according to the part of the parturient canal in ^vhich the delay was longest. Since the delay generally occurs at, or just above, the outlet, the last-named positions form its usual site. The swelling is always on the side directed to the anterior pelvic wall ; and only when labour has been very protracted, does it extend to the other side of the face. Occasionally the whole face seems to be compressed in the transverse diameter, and its soft parts are pushed together towards the median line, so that the nose is flattened, the angles of the mouth are approximated, and the oval fissure appears to run vertically. The pressure in the transverse direction is sometimes followed by unilateral facial paralysis. The skull, through the great pressure against the lateral and posterior pelvic walls, is compressed and flattened from above downwards ; the occiput especially becomes prominent, its under surface running in an almost horizontal direction ; the forehead also is more projecting than usual (fig. 52). The vertical diameter of the head is shortened, slightly also the transverse ; the occipito-frontal and occipito-mental are elongated, but the difi-erence between them is ^'S- ^"f-e p'esentaSns!''''^ '" less than normal. The skull in a face presentation is very similar to that met with in a well marked example of occipito-anterior presentation {cf. supra, and suh "Contracted Pelvis"). The pressure exerted in the direction of the vertical diameter, sometimes causes one parietal bone (and in such cases it is almost always the anterior) to be pushed under its neighbour ; with a uniform strong pressure from the sides of the pelvis, both parietals may be pushed beneath the occipital and the two frontal bones. The neck too is fre- quently swelled, in consequence of the pressure and stretching to which it has been subjected, and the thyroid gland, owing to its [temporary engorgement, is unusually prominent, sometimes as jmuch so as in intra-uterine goitre. New-born children often jhold their head in an extended position for some days after birth. I § 178. Face presentations as a rule terminate spontaneously 228 THE MECHANISM OF LABOUR. ' and successfully, provided that the medical attendant watches patientl}^ and does not meddle. Nevertheless the prognosis , is not quite so favourable either for child or mother as with vertex ! presentations, even when the mechanism is perfectly normal, i In the first place the labour not uncommonly lasts longer than in vertex presentations, since it is the broad surface of the face and the still broader adjacent portions that pass through the parallel pelvic planes, and since a portion of the expelling force is expended on the neck and not directly on the head, owing j to the cervical and thoracic regions of the vertebral column being bent back, and is consequently lost. The stronger pressure to which the foetal head and parturient passages are exposed, increases the duration of labour, and in the case of the former the compression of the blood-vessels of the neck against the anterior pelvic wall is also of especial importance. Slight abnormalities such as in vertex presentations usually do no harm, e.g. a certain degree of uterine inertia, a moderate amount of pelvic contraction, or a somewhat rigid parturient canal, are enough, when the face presents, to endanger the life of the child, and often call for artificial interference, and this does not improve the prognosis even for the mother. Speaking generally, the mortality of both children and mothers is twice as great in the case of face as with ordinary vertex presentations, and of those that survive man}' have been injured. § 179. In managing a case of face presentation, a purely ex- pectant attitude must be maintained as long as possible. In reference to this point I must refer the reader to the section dealing with the management of an ordinary case of labour, merely adding here, that every endeavour should be made to preserve the bag of membranes intact. For this reason vaginal examinations should be few and cautious, premature bearing down efi"orts should be forbidden, and the lateral posture enjoined, that side being selected on which the chin is placed, since its rotation forwards is thus favoured. After the rupture of the membranes, still greater care in examining is necessary, lest the face and especially the eyes be injured, and lest air be prematurely admitted into the mouth. If the forehead remains for an unusually long time directed forwards or to one side, and the chin does not descend, counter-pressure is allowable in the lower portion of the pelvis, and is made by pressing with two fingers THE MECHANISM OF LABOUR. 229 backwards and upwards against the forehead during the pains. Violent attempts to alter the presentation or attitude of the head are not permissible, when once the latter is fixed in the pelvic cavity. Special patience and care are necessary in supportin«-- the periuaeum, and above all things undue pressure forwards must bo avoided, so as not to bruise the neck against the anterior pelvic wall. It is also advisable in these cases to support the perinsEum and to allow the head to emerge, while the woman is lyinf^ on her side. The face of the new-born child is often greatly dis- figured, and should not at once be shown to the mother ; she may be reminded that the disfigurement will rapidly disappear in 1 — 2 days. It is necessary during the second period, and especially when the progress of the head through the lower half of the pelvis is delayed, frequently to examine the foetal pulse, in order not to miss the right moment for interfering, should neces- sity arise. Interference however without definite indications is to be deprecated, as for instance simply on account of the delay in delivery ; it is in such cases as these that interference is often punished in a most disagreeable manner. Although a mainly expectant and observant behaviour was previously enjoined as the fundamental rule for our guidance in face presentations, this must not prevent an attempt being made at the right time to convert a presentation whicli is followed hy such unfavonrahle results, into the more favourable one of the vertex. This remark of course does not apply to cases where the face is fixed ; indeed even when the head is movable the greatest care is necessary. The attempt is made by bringing pressure to bear on the forehead or occiput -per vaginam, with the object of pushing the face upwards, or drawing the occiput down, or of accomplishing both ends one after the other, or simultaneously by combined manipulation. These attempts are occasionally successful, and many instances of such success have been pub- Hshed ; yet as a general rule the manoeuvre is not to be recom- mended, since it cannot be carried out while the bag of membranes is intact, nor when the width of the cervical canal is small ; the fingers have no fixed j^oi'it iVamm'i, the manipula- tions involve the use of considerable force, and further, being made within the genital canal, cannot be harmless to the mother ; finally, success is in a high degree uncertain. The best proceeding for rectifying the attitude of the head, consists in purely 230 THE MECHANISM OF LABOUR. external manipulations, and if carried out in the way recom- mended by Schatz, these are well worthy of notice. In order to convert a face presentation into one of the vertex, the trunk of the foetus must he pushed upwards in the long axis of the uterus, and for some moments the total length of that axis must be increased. If force is applied merely to the head, the opposite effect to what is desired, will follow ; for when the head alone is pushed up, the long axis of the ovum is apt to be shortened, while by bearing down efforts and the excitement of contractions the injurious result is made even worse. All this is avoided, and the desired end is attained, if the shoulder and chest of the child are seized through the abdominal walls, and are pushed at first upwards and towards the dorsal side of the foetus, and as soon as the chest and shoulders have been brought into the long axis of the ovum, only towards the dorsal surface. But in order that the whole body of the foetus and the whole uterus may not be pushed towards the same side, the upper part of the uterus and the breech must be held in their previous position with the other hand, or still better be pushed towards the thoracic side of the foetus, although this last movement must not in any way counter- act or neutralise the action of the first hand. If, when the pressure is exerted on the chest and shoulders in the direction of the dorsal surface, the head tends likewise to travel in that direction, a third hand will be able to prolong upwards, so to speak, the side wall of the pelvis which corresponds to the dorsal foetal surface, and thus easily prevent the head from shifting its position. This procedure may be adopted towards the end of pregnancy, or during any part of the period of dilatation, provided the membranes are still intact, but not later. It postulates a great familiarity with the mode of making external examinations, manual skill, and a non-irritable state of the abdominal and uterine walls. Anaesthesia induced by chloroform, and some- times also cautious co-operation j)cr vaginam, facilitate its execution. It not uncommonly fails, but in such cases has at any rate done no injury. When successful, a relapse at least in the period of dilatation need not be feared, since the cervix uteri at this stage firmly embraces the head, and the shortening of the body of the uterus, already by no means inconsiderable, prevents a recurrence. At any rate rupture of the membranes would make it difficult for the head to become re-extended. THE MECHANISM OF LABOUR. 231 C. Broir Presentations. § 180. A presentation of the brow is one in which the extension of the head is not sufficient to cause a face presenta- tion, so that a point near the middle of the frontal suture is in the line of projection, the forehead being the part which descends Urst (fig. 53). Such an attitude of the head is doubtless common above the pelvis, especially when the head is very movable, but it is very rare at the pelvic inlet or in the pelvic cavity, i.e. when the head is more or less fixed, since as the head enters the brim and descends, the propelling force is soon diverted to one Fig. 53.— Head entering the brim as a brow presentation. or other side of the brow, and converts the brow into a vertex or a face presentation. The causes of a persistent brow are much the same as those of a face presentation : lateral deviation of the uterus or of the advancing head, pelvic contraction (especially ni a moderate degree), an extra-median position of the head at the brim where the pelvis is greatly flattened (as in 2 cases under my care), and finally any obstruction which, when the brow has once entered the brim, makes this presentation permanent, and prevents its conversion into a vertex or face presentation. 232 THE MECHANISM OF LABOUR. That great mobility above the obstruction which produces the brow presentation, predisposes to the latter, is shown by the relative frequency in which these presentations are associated with small foetuses ; thus out of 18 cases, I have met with it twice in premature labours (at the 28th and 30th weeks), once in both of twin foetuses, and once with the first twin. Brow presentations are diagnosed by the point of the forehead being felt to be the presenting portion, while the great fontanelle with the anterior parts of the parietal bones are discovered on one side of the pelvis, the root of the nose and the edges of the orbits, sometimes also additional parts of the face, on the other ; the frontal suture lies in the transverse or in an oblique diameter. If the brow presentation is not converted into another under the influence of the pains, it is possible when the head is not large and the passages are wide, for it to be born without injury to mother or child. The brow then turns forwards and appears in the vulva, the eyes are placed beneath the pubic arch, while the superior maxillary region lies behind the symphysis, and the vertex on the periuseum and in the sacral concavity. The head now sweeps out from the latter, while last of all the upper jaw, the mouth and chin appear from behind the symphy- sis. The frontal suture during this process does not always correspond exactly with the antero-posterior diameter of the pelvis ; it may make its exit in the oblique. Delivery becomes more difficult when the dtin is directed backwards, and spontaneous expulsion is under such circum- stances scarcely possible. Indeed even when the position of the brow is favourable, if the space relations are at all unfavourable, either owing to the parturient passages or to the head, spon- taneous delivery is only accomplished under the most extreme pressure on the head and contusion of the genital canal. With such conditions a labour in which the brow presents, is as a rule terminated by artificial means, and must be so. § 181. It will therefore be advisable if the brow presentation has been early recognised, and if the practitioner is satisfied both from the dimensions of the pelvis and the size of the head, that the labour will be difiicult, to get rid of the brow presentation by podalic version of the foetus. A conversion into a vertex or face presentation by manipulations is useless when the head is high and freely movable, since after removal of the hand the same causes THE MECHANISM OF LABOUR. 233 wliich led to the brow presentation continue to act. Eectificatiou may be attempted with better prospects of success, when the brow is ah-eady somewhat fixed in the pelvic brim ; the best plan for attaining the desired end is to introduce the whole hand into the vagina and external os, and to grasp the occiput or the lower jaw, drawing it down towards the middle of the pelvis and holding it there during the next few pains. But the attempt will rarely succeed permanently ; I have invariably failed, probably because at the time of the procedure the shape of the head had been already so much altered as a result of the brow presentation, that the skull could not easily and rapidly adapt itself to another position or presentation, and I doubt whether, when rectification was rapidly successful in the hands of others, complete brow presentation did actually exist. No such conversion is to be dreamt of when the head is fully fixed in the pelvis. Under these circumstances progress must be waited for and carefully watched, while the lying-in woman is laid on the side corresponding to the dorsum of the foetus. Sometimes it is possible when the head has descended to or near to the pelvic outlet, to extract it with the forceps and to save the child. When however there is consider- able delay in the middle and upper portions of the pelvis, when the brow is unfavourably placed with the chin backwards, the period for maintaining an expectant attitude soon finds its limits; in view of the dangers which threaten the mother owing to the mechanical disproportions, and considering how faint is the chance in such cases of preserving the child, it is good practice relatively early to proceed to its diminution and extraction. The prognosis in brow presentations is therefore not favourable to the child. For the mother on the other hand under proper management, it is not so bad as is generally stated. Out of the 17 women in whom I have till now met with this presentation, only one died, and she had been exposed to a very difficult extraction after perforation ; almost half the foetuses died ^ ' Since persistent brow presentations are rare, I add the following details in reference to my 17 cases. Eleven of the mothers were I. -parte, three II.-p., one III. -p., one IV.-p., and one X.-p. Six of the seventeen had a contracted pelvis, either simply flattened, or flattened and generally contracted; the contraction was never extreme. In one case both small tivins entered the pelvis in the first brow position ; in both this spontaneously changed into the first and fourth vertes positions, and both children were born without assistance and alive. In another case only the first twin showed a brow presentation j the head was large and perforation was required. On two 234 THE SIECHANISM OF LABOUR. f The sJiaj^e of the head and sknll iu brow presentations is amongst the most striking, and may almost resemble that of a monster, especially when the head has been long in the pelvis, and the caput succedaneum is very distinct (fig. 54). The caput succedaneum is placed on the forehead, which becomes extremely prominent and is very steep in relation to the face, while the vertex and occiput are flattened. The vault of I 54. — (After Sv\-ayne.) the skull slopes down gradually behind like a roof, and sometimes actually shows a depression in the neighbourhood of the great fontanelle ; the occiput looks pointed without being really occasions labour was premature, coraiug on at the 28th and 30th weeks, the latter occurring in a moderately contracted pelvis; both children were born alive, the one whose mother's pelvis was contracted, being delivered with forceps. Out of the 18 children, 4 were extremely small. In the remaining 14 labours occurring at the full time, I found that 5 times the pelvis was contracted ; in two cases very distinct extra-median brow presentations occurred. Six of the children were born spontaneously, amongst them two still-born (one child was born alive although the pelvis was contracted) ; two were born alive with the help of the forceps, one dead after version and extraction (pelvis contracted) ; 5 were extracted after perforation (3 of the pelves were contracted) ; 8 therefore perished. One mother died, the child having been perforated. Thus including the premature and the twin foetuses, out of the 18 children which were alive at the beginning of labour 9 were bora spontaneously and 10 living. The numbers of tirst and second brow positions were equal. THE MECHANISM OF LABOUR. 235 elongated. The skull is therefore compressed in the " face- occiput " (mento-occipital) direction, elongated in the sub- occipito-frontal and mento-frontal (forming a triangle with one •point at the forehead, fig. 55). This conformation is due to the fact that when the head is hut partially extended, the occiput is comjiressed between the pelvis and the regions of the neck and shoulder, and a compensatory sagittal elongation of the skull can only take place in one direction, towards the forehead. D. Presentations of the Pelvic Extremity. § 182. The attitude of the foetus is the same in presentations of the pelvic extremity as in those of the vertex, except that in the former the thighs are more apt to abandon their flexed position upon the lower end of the trunk and to descend below it, leading, as already mentioned in § 162, to footling and knee presentations. These abnormal attitudes are easily accounted for by the readiness with which a living child alters the posi- tion of its limbs, by the frequency Avith which the lower segment of the uterus fails to adapt itself all round symmetri- cally to the presenting lower end of the foetus, and by the action of gravity on the extremities, especially after the discharge of the amniotic fluid. So too may be ex- plained the occasional detention of one Fiositioii, the right buttock is placed in front, the dorsum looks to the right, the hips lie in the first oblique diameter. The further mechanism may be deduced from that of the first breech position, if " right " is always substituted for " left." § 185. The sero-sanguineous swelling of labour is situated on the presenting, i.e. the anterior, buttock. It varies in extent according to the length of time occupied by the breech in passing through and out of the pelvis, and may amount to a simple sometimes scarcely noticeable oedema, or to a large bluish-black swelling due to extravasated blood. The generative parts are as a rule affected, especially the scrotum, which may come to resemble a tense, large, deeply coloured bladder. The head has a characteristic round brachy-cephalic shape, a shape which is all the more striking from the absence of a caput succedaneum. The formation of this " round head " depends on the fact that while the remaining periphery of the skull is subjected to the pressure of the parturient canal, the region of the vertex escapes this pressure ; and inasmuch as the occipital, parietal and frontal bones are forced upon the cranial cavity to an equal degree (the parietal bones owing to their greater mobility may glide over the other bones), the compressed cranial contents react upon the vertex in such a way that the vertical diameter of the originallj^ oval skull is increased, while the direct and the transverse are diminished. Equitations at the sutures are almost never seen where the pelvis is normal ; when present, they usually last so short a time that they disappear immediately on delivery. § 186. Deviations from tlic usual mechanism: a. If the dorsum is directed backwards, it is not rare for the breech to pass through the pelvis with the sacrum looking towards one of the ilio-sacral synchondroses, and with the abdominal surface looking forwards (so-called 3rd and 4th hreech positions). But THE MECHANISM OF LABOUR. 243 at the outlet the hips rotate into the direct diameter, and after the birth of the breech, the trunk continues to rotate in the same direction, so that the dorsum moves forwards and the child is born in the way described above. Sometimes however after the exit of the hips in the direct diameter, the dorsum ao'ain turns to the rear, and its forward rotation is deferred till the birth of the arms, or even till that of the shoulders, whose bin- acromial diameter also emerges from the pelvis in the direct diameter. But if the change of position does not take place even at that stage, if the dorsum remains obstinately directed backwards, the head advances into the pelvis, with the face looking forwards and lying in one of the oblique diameters. When the attitude is normal, the chin is pressed against the chest and near to the middle line of the pelvis, the forehead lies against the floor of one or other acetabulum, the neck is directed towards the opposite sacro-iliac joint, and the occiput looks uj^wards. 1. Under the influence of the oblique lateral pelvic surfaces, and especially of the ischial spines, the occiput (as the head descends) even now very frequently rotates forwards, and the head makes its exit in the usual way. 2. The occiput however may remain directed backwards. It then moves into the hollow of the sacrum, the head is still more flexed, the face descends below the anterior pelvic wall, the forehead becomes fixed under the pubic arch, the neck lies against the posterior commissure. If now the pelvic floor and the coccyx do not off'er too great a resistance, the forehead descends more and more in front, and finally the occiput sweeps out over the perinseum, while this is forced backwards. But when the pelvic floor and coccyx present great obstruction, the strong flexion of the head which is neces- sary for this mode of exit becomes impossible, and the head does not progress. 3. If for any reason the chin has become separated from the chest during the passage of the head into and through the pelvis, it may easily remain caught against or even above tbe anterior or lateral pelvic wall, the occiput being forced against the nape. The chin meanwhile ascends, and the head assumes the same attitude as in a face presentation ; its base corresponds with the pelvic planes, the mento-occipital diameter passing through one of the oblique diameters. In this position spon- taneous delivery is impossible, except with a very small and yielding head. 244 THE MECHANISM OF LABOUR. h. The hijJS enter the j^clvis transversely, the dorsum looking directly forwards or backwards (the former is more frequent). The sagittal diameter of the trunk then corresponds to that of the pelvis, the biniliac to the transverse of the latter. "When the sacrum has descended low, the breech moves down to the outlet, and at this point, if there is sufficient resistance, rotates round the longitudinal axis, so as to bring the hips into the antero-posterior diameter in which they emerge, as above de- scribed. Since during this movement the trunk must rotate through the quarter of a circle, and the lumbar part of the vertebral column oifers great opposition to such torsion, the shoulders also rotate and enter the pelvic canal in the oblique diameter ; their delivery and that of the head then take place in the usual way. It is very rare for the head to enter in the sagittal direction ; the forehead, nape and occiput are hindered from taking up the position by the projecting lower lumbar vertebrae and by the promontory, which compel the head to enter obliquely. c. Suycr-rotations are not uncommon in presentations of th< pelvic extremity, both when the dorsum looks forwards, in whicl case it rotates from the first into the second position and vice versa, and when it looks backwards ; indeed the trunk and the head may under such circumstances rotate through a semi-circle, so that the abdominal surface or the face, which were at first directed forwards, may reach the posterior terminal end of the oblique diameter at whose anterior end they were previously d. Footling presentations, as already observed, do not alter the mechanism, except that rotation round the longitudinal axis is not uncommonly delayed until after the exit of the breech, since the latter, diminished in size by the extremities being stretched down, does not always meet at the pelvic outlet and floor with the resistance which is necessary to bring about the rotation. Super-rotations occur here also, especially in incomplete footling presentations when the prolapsed limb is the posterior one ; for since the l)uttock belonging to the thigh which is thrown upwards, is apt to be caught above the anterior pelvic wall, it is the side on which the limb is prolapsed, that rotates forwards. § 187. The profjnosis of presentations of the pelvic extremity is not less favourable than that of vertex presentations as regards THE MECHANISM OF LABOUR. 245 the mother, so long as no complications arise ^\hich call for operative interference ; it is only primiparae that run somewhat more risk, owing to the greater resistance of their pelvic floor, and to its not being satisfactorily stretched by the yielding first- going trunk, and owing therefore to the frequent manual assist- ance that is required, and to the bruising of the lower part of the parturient canal caused by the latter. But as regards the child, presentations of the pelvic extremity are decidedly more dangerous than those of the vertex. The danger arises through the umbilical cord being compressed between the body of the child and the parturient canal, when the breech is born, and through the uterine cavity diminishing in size behind the gradually advancing child, which diminution leads to detachment of the placenta, and thus to a disturbance and interruption of the fffital interchange of gases, and therefore to asphyxia. The same occurrence may of course accompany head presentations ; but in these the expulsion of the trunk rapidly follows that of the head, and the want of breath which has set in, can therefore be rapidly satisfied. This is not so with an after-coming head, since the difficulties of labour are often only beginning when the child experiences a besoin de respirer, and since it is just the last stages that are so easily delayed. Hence it is important that the breech be born as slowly as possible, in order that the parturient canal may be adequately dilated and prepared so as to allow the after-coming trunk and especially the head to traverse it rapidly. In addition to the danger caused by the delay in the exit of the upper half of the body, there are others associated with premature rupture of the membranes, prolapse of the umbilical cord and coiling of the same round foetal parts, dangers whose advent cannot, for obvious reasons, always be prevented. Speaking generally therefore, the condition of the parturient canal as regards laxity and roominess, the size and attitude of the child and the power of the expelling forces determine the prognosis. If these conditions are at all unfavourable, inter- ference Avill be necessary, and dangers associated with the extraction are not infrequently added to those arising directly out of the presentation. Of the separate positions, that in which the dorsum looks backwards is the least favourable, since it is connected with disturbances in the mechanism, and especially with displace- 246 THE MECHANISM OF LABOUR. ment of the upper extremities, and then, as also where the head enters the pelvis with the face looking forwards, artificial assist- ance is frequently required. Footling presentations too as a general rule make the prognosis less favourable for the child, since the membranes are apt to rupture prematurely in such cases, and the umbilical cord to prolapse, and since the breech, diminished in size by the extension of the thighs, can traverse the parturient passages (especially the cervix) before complete dilatation has occurred ; during the additional dilatation of the latter which is necessary for the passage of the shoulders and of the head, so much time is often consumed that the child suc- cumbs to asphyxia. For the same reason an incomplete footling presentation is more favourable than the complete ; the breech being larger when one thigh is flexed on the abdomen, advances more slowly than when both feet present. On the other hand a prolapsed foot gives us a "handle", so to speak, for any ex- traction that may be necessary. § 188. From the previous description it will be evident that the management of a labour in which the pelvic extremity presents, requires closer attention than do the ordinary vertex presentations. In the first place, remembering the great risk to the child (over 20 per cent, are still-born), it is desirable when the practitioner is summoned sufficiently early, i.e. at the end of pregnancy or at the beginning of labour, to make an attempt by means of external manipulations (as described in the chapte] on ** External Version ") to convert the breech into a verte: presentation, and to render the latter permanent. The con- version will often be successful, owing to the instability ol presentations of the pelvic extremity, but is rarely persistent.] When the breech presentation cannot be so converted, the con- duct of the accoucheur must be regulated by the fact that thes< labours as a rule pass off most favourably, where there is leasl interference. His first care must be to preserve the integrity ol the ovum as long as possible, since a delay in the period oi dilatation, while the membranes are intact, does no harm, an( considerably expedites the rapid and uninterrupted progress oi the period of expulsion. The parturient woman must therefon occupy the recumbent posture even at the beginning of labour, and should lie on the side which corresponds to the dorsum ol the foetus; this favours the normal rotation round the longi« 1 THE MECHANISM OF LABOUR. 247 tudinal axis, and bearing down efforts are not so effectual in the lateral as in the dorsal posture. Nothing must now be done to encourage pains ; every unnecessary examination is to be avoided, neither rectum or bladder must be evacuated in the squatting posture, nor must any violent straining efforts be made, for fear of imperilling the safety of the bag of membranes. Even when the membranes have burst, and when an examina- tion must at once be made in order to obtain an accurate know- ledge of the position and attitude of the fcetus, and especially of the limbs and umbilical cord, the conduct of the accoucheur must mainly be a negative one, till the hips pass through the vulva. At this stage however the woman may bear down vigorously during the pains, although the presenting part must on no account be pulled or rotated. I cannot caution too distinctly against such interference ; during the whole progress of labour it is prohibited, for nothing is more likely than such manipulations to disturb the normal rotation of the body, to cause the arms to be separated from the thorax and to be thrown up by the side of the head, to lead to premature descent of the occiput, and thus to prevent the necessary flexion of the latter. However great the temptation to hasten matters may be, when labour progresses slowly, all interference is strictly forbidden, except where there are special indications. Nor is it any more permissible to bring down the thighs prematurely in the case of breech presentations, since by so doing the principal safeguard of the pelvic presentation is thrown away. It is only in the case of Primiparae, when the pelvic floor is very broad and resist- ing and the vulvar opening small, that it may occasionally be advisable (especially when the breech appears to be large and in view of the extraction which under such circumstances will often become necessary), at an early period, i.e. while the breech is still high (when the latter is low, it can no longer be done through want of room), to bring down the anterior thigh and thus to produce an incomplete footling presentation. This foot in case of necessity affords a convenient handle with which to extract the breech through the vulva, a matter which under the given conditions may be very difficult. When the hips are about to pass out, the lying-in woman should be so placed that assistance can be rendered at any moment that it should be called for. Her pelvis should be 248 THE MECHANISM OF LABOUR. raised by means of pillows, unless the practitioner prefers to deliver her in the lateral position. The foetal pulse must be very closely watched by means of auscultation during the whole of this period, since the fatal interchange of gases might at any time be interrupted by compression of the umbilical cord between the thighs, or between the thorax and the parturient canal, and such an interruption makes it necessary for delivery to be accelerated. It is always important to support the perinaeum during the exit of the hips, not only for the sake of its safety, but because pressure exerted on the posterior portion of the perinaeum in a forward direction, considerably assists the exit of the hips, by favouring the lateral curvature of the lower end of the trunk. When this exit has taken place, it is well (to avoid endangering the perinseum) not to permit the extremities to slip out too suddenly, although at the same time the rotation of the dorsum must not be hindered by too vigorous a pressure. The portion of the child that has been born, should be wrapped in a warm cloth, and the trunk be raised a little in front of the mother, since this is its natural relation ; the broad hepatic region how- ever must not be much pressed upon. The umbilical cord may now be felt for ; if very tense, it should be relaxed by gentle pulling at the placental end. If it runs from the navel between the thighs over the back to the placenta (if the child rides on its cord), the part which crosses the back may be drawn down ; the hindmost thigh should be flexed at the knee, and the cord slipped over it. It can scarcely ever be necessary to ligature and cut it owing to excessive tension. From this time onwards the pulsa- tion of the cord keeps us informed of the condition of the child, and it must be closely watched. Should it show important interference with the placental interchange of gases, the delivery must be immediately completed. While the trunk and still more while the head is passing out, the lying-in woman must bear down energetically during the pains ; one hand of the accoucheur should support the body of the : child, the other exerts a gradually increasing downward pressure on the fundus uteri, and as far as possible from the foetal dorsal side. In this way not only is the progress of the child favoured, but the flexion necessary for the natural exit of shoulders and head is assisted and insured. During the expulsion of the shoulders, the trunk must be raised and strongly bent to one THE MECHANISM OF LABOUR. 249 side in the same way as was done in the case of the breech, and a forward pressure should be exerted on the posterior shoulder through the perinaeum. When the shoulders are delivered, the head must rapidly follow. This is favoured by an assistant pi'essing forcibly on the fundus, and as soon as the face lies in front of the coccyx, by raising the trunk well up in front of the symphysis ; by this means the occiput rises up behind the pubes and moves towards the middle of the pelvic cavity, the chin approaching the middle of the pelvic outlet. Meanwhile two fingers should be laid on the perinaeum in front of the coccyx, not only to protect it, but at the same time to push the forehead forwards and the chin into the vulva. A forward pressure exerted by one or two fingers on the forehead or vertex per rectum is occasionally a useful procedure, a true imitation of the normal mechanism of rapidly accomplishing the delivery of the head from the vulva, and at the same time of preserving the perinseum. Tn footling and knee presentations the desirability of preserv- ing the bag of membranes intact as long as possible, is even greater than in ordinary breech presentations ; the longer the period of dilatation lasts in these cases, the more slowly the limbs and breech pass through the pelvis, the better ; they must never be brought down without imperative reasons. Now and again however an unfavourable, and especially a transverse posi- tion of the leg within the parturient canal, may call for a manual rectification. LITERATURE. Schatz, Der Geburt. mechanismus der Koirfencllagcn. Leipzig, 18(38. " Bcitragu zur physiolog. Geburtskunde." Arch. f. Gyii., iii., 1872. Lahs, Zur Mechanik der Gehurt. Berlin, 1872. Also Ärch. f. Gi/n., iii., 1872, p. 195, and iv., 1872, p. 311. Die Theorie der Geburt. Bonn, 1877. Küneke, Die vier Facturen der Geburt. Berlin, 18G9. Poppel, " Ueber d. Resistenz der Eihäute." Man. f. Geburt-ihnidc, xxii., 1863, p. 1. Lahs, " Ueb. d. Werth d. Poppel'schen Untersuchungen." 7« den Sdzunrj^- bericht. d. Gesellsch. zur Beförd. d. Naturwiss. zu Marburg, 1870. Ribemout, " Recherches expör. sur la resistance &c. des membranes de 1 eeuf humain." Arch. TocoL, Novemb., 1879, et seq. Duncan, "Contribut. to the Dynamics of Labour." Re.warches ui Obutetr., 1868, p. 299. f u I "On the efficient powers of parturition." Dublin Quartcrhj J. of .Un . Science, May, 1871. 250 THE MANAGEMENT OF LABOUR. Litzmann, "Das Verhalten des cervix uteri iinter der Geburt." Arch. f. Gyn., X., 1876, p. 409. Thiede, " Ueber d. Verhältniss des cervix uteri zum unteren Uterussegmcntc." ZfitKchrift f. Geh. v. Gyn., iv., p. 210. Bidder, " Ein Beitra^: zur Mechanik der ersten Geburtsperiode." rctcmh. Med. Zt'itschrifi, xv., 1868. Schatz, •' Naegele'sche Obliquität." TacjclAatt der Leipzujer Xafurf.-Ver- xammlung, 1873, p. 183. " Die Verschiebungen, welche die Oberfläche der Frucht u.d. Innenfläche d. Uterus während der Geburt gegen einander ausführen." Arch. f. Gyn., vi., 1874, p. 392. Stephan, "Ueber d. Mechanismus der Geburt bei Kopflagen." Arrkir. f. Gyn., xii., p. 464. Fasbender, "Sicheres diagnost. Zeichen f. d. Erkenntniss d. Kopfes" &c. Mim. f. Geb., xxxiii., 1869, p. 435. Ebell, " Ueber die Erkenntniss des Kindskopfes durch die Bauchdecken mittels des Fasbender'schen Zeichens." HerJ. Beitr. :. Geh., iii., 1874. Sitz- ungsbericht, p. 27. Spiegelberg, "Zur Lehre vom Mechanismus der Geburt." Man. f. Geh., xxix., 1867, p. 89. Stadfeldt, " On the asymmetry of the body (Axedeel) of the human skeleton." From Bibli. f. Laeger in Buhl. Quarterly J. of Medical Science, Aug., 1864. Cf. also Ohstetr. J. of Gr. Britain, May, 1879, p. 92. Dohrn, " Eine durch d. Geburt be%virkte Formbesonderheit d. Kindskopfes." 2[07i.f. Geh., xxiv., 1864, p. 418. Olshausen, " Ueber die nachträgliche Diagnose des Geburtsverlaufes aus den Veränderungen am Schädel des neugeb. Kindes." Volkmann's Sammlung lilin. Vortr., No. 8, 1870. Litzmann, " Ueber d. hintere Scheitelbeinstellung." Arcli.f. Gyn., ii., 1871, p. 433. Dohrn, " Ueber die Ursachen fehlerhafter Drehung der Schultern nach Austritt des Kopfes bei Schädelgeburten." Arch. f. Gyn., iv., 1872, p. 362. Hecker, Ueher d. Schädelform hei Gesichtslagen. Berlin, 1869. "Zwei weitere Beobacht. über d. Schädelform bei Gesichts- und Stirnlagen." Arch. f. Gyn., ii., 1871, p. 429. Mayr, " Beitr. zur Lehre von den Gesichtslagen." Arch. f. Gyn., xii., p. 211. Kamm, " Beitr. zur Lehi-e von d. Gesichtslagen." Bissertation, Breslau, 1879. Ahlfeld, Bie Entstehung d. Stirn- inid Gesichtslagen. Leipzig, 1873. Cf. also Arch. f. Gyn., xvi., p. 45. Schatz, " Die Umwandlung von Gesichtslage zu Hinterhauptslage durch alleinigen äusseren Handgriff." Arch. f. Gyn., v., 1873, p. 306. Duncan, Contrihut. to the Mechanism of natural and morhid Parturition. Edinburgh, 1875. (A collection of all this author's writings on the mechanism of parturition.) 3. The Management of Labour. § 189. Thousands of women are successfully confined without any skilled assistance whatever, and it is questionable whether the help which many of our midwives are able to render, always THE MANAGEMENT OF LABOUR. 251 deserves the name. It might seem therefore as if assistance were superfluous during so physiological an event as a labour is, when it runs its usual course, but it must not be forgotten on the other hand that the process which has been normal up to a certain point, may at any moment become pathological, that important irregularities may come on unnoticed, whose effect is revealed either at once or at a later time ; moreover that an indiscreet conduct of the parturient woman is frequently a cause of danger, and that with our highly civilised conditions of life she herself almost always demands an alleviation of her troubles, and her new-born child the care suitable to it. The " management of labour " therefore denotes the use of !the various means we possess of alleviating the troubles and difficulties of labour, and deals with the importance of watching over its progress, of guarding against abnormalities, at all events of recognising them early, and of preventing infection. It will, I suppose, be generally admitted that in order to fulfil 'these requirements, a thorough knowledge of midwifery is neces- sary, certainly more than an average midwife learns and under- stands, and it is therefore becoming more and more the custom, at any rate in large towns, to call medical men into the lying-in chamber; for obvious reasons however this will never be universal. The accoucheur must be familiar with all matters and arrange- ments required for a normal labour, and when once he has taken charge, the nurse or midwife must act entirely under his directions. § 190. The accoucheur, when summoned to a woman in [labour, should not delay to obey the call, even when he is informed that all is right ; otherwise he might miss the best : opportunity for rendering any necessary assistance. He must ; take with him the requisite armamentarium, and never trust to I the instruments of the midwife who may be present, since he \ cannot be sure that they are clean and therefore safe. Unless he ' knows that the lying-in woman has an irrigator, he should take with him a compact well acting syringe (preferably an ordinary I surgical syringe), to which a metal flexible tube can be affixed, a i male silver and an elastic catheter, a good pair of scissors, a stetho- I scope, a dressing case and a hypodermic syringe with a suitable solution of morphia. If the dwelling of the lying-in woman is at ! a great distance from his own, or if he is summoned during the 252 THE MANAGEMENT OF LABOUR. Dight, he will do well to take with him forceps and a noose. A more complete armamentarium is only wanted when he is sum- moned miles away, in which case he should also provide himself with ergot in powder or solution, with tincture of opium and chloroform. All ]ns instruments must he perfectly clean, and if they have already been used for other individuals, must be thoroughly disinfected. This is especially true of elastic tubes and such other instruments as are more difficult to rid of matters liable to cause infection, than are metallic ones. If the accoucheur shortly before being summoned, has been in contact with infec- tious disease or septic matters, it is his duty either to decline to conduct the labour, stating the reason, or at least previously to disinfect himself and his clothes in the most thorough and con- scientious manner possible. With our present knowledge of the mode of origin of puerperal fever, it is an inexcusable want of conscientiousness to take charge of a labour without such precautions. On reaching the lying-in woman, he should not introduce himself abruptly, but begin by obtaining all necessary informa- tion from the surroundings. He may then question the woman herself, especially in reference to her present pregnancy, and to any earlier confinements &c. ; when this has been done a vaginal examination should be made. First of all however the genital canal of the lying-in woman, as tvell as the arm that is about to examine it, must be thoroughly disinfected. Puerperal infection is almost invariably conveyed during labour, and not only by the introduction by the attendant of septic matters from without, but frequently by the natural contents of the tract itself. In the neighbourhood of and within the generative organs there are almost always matters in a state of decomposition, w^hich the examining fingers are liable to convey to the cervix uteri, or inoculate into any superficial abrasions, however slight, which are already present or produced by the exploration. Just as in operations carried out antiseptically on the surface of the body, the area of operation must be disinfected, so, if the labour is really to be conducted antiseptically, must the generative canal also be, as far as possible. The necessity for continuing this prophylactic disinfection of the genitals through- out the entire labour and especially during the period of dilatation, cannot be too strongly insisted upon, especially as the directions THE MANAGEMENT OF LABOUR. 253 for our midwives say nothing about it, and these women there- fore, together with so many practitioners, think that the antiseptic requirements have been sufficiently carried out by the disinfection of their hands and instruments. If the lying-in woman in spite of this falls ill after her confinement, all confidence in the importance of personal disinfection is lost. Before the examination therefore the external generative organs of the lying-in woman and their neighbouring parts over a considerable area, must be thoroughly washed with soap and itheu with carbolised water, clean linen being used, not sponges ; Ithe vagina must then be thoroughly irrigated with tepid 2 per cent, carbolic acid water. The accoucheur should throw off his 3oat, slipping any further coverings of his arms up to the shoulder, and then wash and scrub his arm with soap and after- wards with carbolic water, brushing especially the fingers and Qails as carefully as possible with a strong solution of carbolic. Septic matter is specially apt to cling to the nails, and the mere anointing of the finger with carbolic oil, whether 2 or 10 per cent., is therefore not sufficient. The fats used for anointing the finger, must also be carbolised, since such substances may contain septic material. , When the examination is completed, the vagina must again he washed out with tepid carbolic water. Inasmuch as air is neces- sarily conducted into the vagina during the examination, and Icannot be disinfected as is done in surgical operations and may excite decomposition in the genital canal, that air must he removed by irrigation, which ivill at the same time disinfect any that 'remains behind. Previous to each subsequent examination, the 1 hands must be again disinfected, even though they have not been ;again soiled, and after each future examination the vagina also .must for the above-mentioned reason be again irrigated with about ,2 per cent, carbolic water. This proceeding takes time, and may .often be annoying to the lying-in woman, but it is unavoidable, and the health of the woman will be our reward. The chief iuty of the accoucheur is to shield the lying-iu woman from ; dangers, and what greater danger can threaten her than that of ; septic infection ! j § 191. The examination should be made as complete and accurate as it can be, so as not to need early repetition, and so ;as to aß'ord the least opportunity possible for the admission of air 254 THE MANAGEMENT OF LABOUR. 1 into the genital canal, and for infection. The first examination should enable us to decide between the apparent and the actual commencement of labour ; ^Yhether the latter is at the full term or premature ; upon the stage to which it has advanced, upon the condition and especially the degree of canalisation of the parturient passages ; upon the condition of the liquor amnii ; upon the lie, position, life and condition of the foetus ; finally, upon the shape of the pelvis, and the exact relation of the foetal parts to it — questions which cannot be answered by a superficial examination, but which must be answered, if we wish to have a clear insight into the progress of labour, and to remain master of the situation. The first exploration should always be undertaken in an interval between two pains, since during a pain the woman is too sensitive and restless. It is well however to prolong it during a pain, in order to obtain as clear an idea as possible of the strength and efficiency of the expelling forces ; care must be taken not to burst a still intact bag of membranes prematurely. A prognosis may be made in regard to the progress and duration of the labour, according to the results of the examina- tion. It is usually possible to speak definitely in reference to the first point, but impossible as regards the latter. The prac- titioner should therefore be very reticent in offering an opinion ' as to the probable duration, and place the termination somewhat further off than seems likely, so as not to destroy the confidence which it is very desirable that he should possess, by a prophecy which does not prove true, and not afterwards to be bothered by I numerous questions and complaints. He may comfort his i patient during severe pains by reminding her of the great pro- gress that is being made. § 192. The rectum should be emptied by a simple enema, : unless this has been already done. The bladder during the : whole course of labour demands especial attention, and must never be allowed to remain very full for any length of time, although it is well if possible to avoid introducing the catheter, ' since it always irritates the urinary passages and may carry infection. It should only be used with the view of preserving the bag of membranes, or when the woman cannot micturate spontaneously. j The room, the bed and the clothing of the lying-in woman ' should next be noticed. In reference to the first we must con- I THE MANAGEMENT OF LABOUR. 255 tent ourselves with what we find, although light and fresh air can always be insisted on, as well as the departure, as far as possible, of persons who have no direct business in the room. The bed should be easy of approach on both sides, and not too wide ; a strong and smooth mattress is the best. To prevent the latter from being soaked through, a piece of macintosh cloth large enough to protect the sides of the bed, may be spread out < over its middle ; the sheet covers everything. Feather beds ■ should be avoided; woollen things and quilts are better. There ! is no need of any special contrivauce for fixing the extremities, 1 but where it is desired, a pillow for the feet or for supporting the I knees and the sacrum may be allowed. The clothing should consist of the ordinary night costume, without any tight portions ; stockings should not be taken oif. During the last stage of the labour when the lying-in woman remains permanently on her bed, the night-dress and jacket should be tucked up above the waist, so that they may remain clean to the end of labour, and not need changing immediately after it. Food and drink may be allowed ad libitum, provided that not too much at a time is taken, nor anything stimulating. There are no special directions for the lying-in woman to follow during the j^eriod of dilatation. So long as her condition, [ especially the pains and forcing sensations permit, she may be I' out of bed and walk about ; indeed this is prefei-able to lying j down too soon, since the weight of the foetus itself is better utilised for dilating the cervix ; she must however as far as possible avoid bearing down. The presence of an attendant, and especially of a medical man, is unnecessary during this period; but the results of the examination together with a skilful calculation must decide whether, how far, and for how long he may go away. When the lying-in woman is very excitable and sensitive to pain, it is a good plan to give her a subcutaneous injection of -015 grm. (i gr.) of morphia, this will give her friends and her attendant some rest. The continued presence of the latter during this period is further undesirable, for the reason that it leads to a repeated internal examination, and this is now to be avoided as superfluous and prejudicial. When the time for the rupture of the membranes is near at hand, the lying-in woman should take to her bed, in order on it to await the discharj^e of the amniotic fluid. When this has 256 THE MANAGEMENT OF LABOUR. occurred, an immediate exploration is always necessary, since at this moment abnormalities in the position and attitude of the foetus may arise, and since it is often not till now that the relation of the presenting part to the pelvis can be accurately determined, and such information is indispensable. If the liquor amnii has been discharged before the complete dilatation of the cervix uteri, the woman must in any case get into bed when that dilatation is complete. § 193, The posture of the woman is not a matter of much importance, unless the resistance of the parturient canal is unusually great and a cause of delay ; she may be allowed to lie as she likes. Practically however the choice rests between the lateral and dorsal postures, other positions only calling for consideration in special cases. As a general rule she should lie on her side, from the time when the presenting part is fixed in the pelvis till it reaches the floor of the pelvis, since in that posture the expelling forces act most nearly in a line with the axis of the inlet, and are thus perpendicular to the various parallel planes of the pelvic cavity. But for this purpose the pelvis must be sufficiently fixed, and this is best accomplished by well bending the upper part of the body and the lower extremities. The lying-in woman therefore during the pains lies with her face inclined towards the chest, the trunk bent towards the knees, the latter adducted towards the abdomen ; and since the feet need a imint cVappni and find one against the foot of the bed, the woman is most conveniently placed close to it. It is not necessary to separate the knees by laying a pillow between them, till the head is about to make its exit ; her hands may cling to a pillow or to those of the attendant. During the interval between the pains, the woman may modify this constrained attitude at will. Since the uterus so frequently deviates to the right, the left lateral posture is generally most appropriate. For the exit of the child however the lateral posture is not altogether appropriate, since in it the expelling forces act too much on the posterior portion of the pelvic floor, and cannot be brought to act even approximately at right angles to the plane of the outlet and of the vulva. At this stage therefore the dorsal posture is better. Indeed amongst us it is generally used throughout the whole course of labour, and it can more or less be modified at the different stages, so as to comply with the end in view, namely that of bringing the THE MANAGEMENT OF LABOUR. 257 axis of the uterus to correspond as far as possible with the axis of each part of the pelvis. As already observed, this is not usually necessary during the passage through the brim and the I cavity, but if it were desired in a special case to bring the brim of the pelvis to lie horizontally, the lying-in woman should be placed with her back well raised, while she herself is half-way between sitting and lying. During the exit of the child, the opposite is necessary, the lumbar vertebral column should form - as obtuse an angle as possible with the pelvic brim ; it should : therefore be greatly extended, so that the uterus may lie close upon it, and its axis fall on the anterior margin of the outlet. ' This is approximately effected by well raising the lumbar and ; sacral regions (either by pillows or by a third person lifting the woman), while at the same time the uterus is pressed against the vertebral column, and is prevented from lying too far forward (the abdominal belt recommended in England is very useful from this point of view). The expelling force may be brought to act perpendicularly to the plane of the outlet and of the vulva, by placing the lying-in woman in such a position I that she bends over forwards, by allowing her to raise herself : and to support the upper part of the body with her hands against ' the foot of the bed ; in this posture also the action of gravity comes into full play during the exit. Such a constrained and I unpleasant posture however is only resorted to, when there is I special difficulty and delay ; in ordinary cases it is unnecessary. ; Still less so is the kneeling, cowering position out of bed. I During the period of expulsion, the woman may assist the I pains by bearing down, but she must only do so while they last ; indeed at this period of labour, she will bear down of her own accord, and it is better not to say too much about it, lest she do I so at the wrong moment. She should not be allowed to throw back her head or grind her teeth ; a napkin may, if necessary, be laid between the latter. Unseemly screaming is mischievous, and may often be at once checked by a few decided words. If the abdominal walls are flaccid, the muscular system sluggish and the uterus very movable, a firm bandage may be useful in giving support. There is nothing further to be done at present, except to watch and to encourage. Vaginal examinations may be made more frequently and with less hesitation than during the first period, since the cervix, which is so liable to be inoculated, is 17 258 THE MANAGEMENT OF LABOUR. now beyond reach of the finger. When the foetus advances slowly, its heart-beat must be closely watched. Pressure may be made from above, by placing two hands flat upon the fundus, and often contributes materially to the acceleration of labour by bringing on pains and assisting the abdominal pressure, when, as frequently happens during the last moments, progress is slow. § 194. When the head reaches the vulvar aperture, and pushes the pelvic floor before it during the pains, the pcrincBum must be protected from laceration. The so-called ''support" of the perincsum, as still generally practised, and consisting mainly in pressing it against the advancing part, does not aff'ord such pro- tection ; the only eflectual way is to watch for, and obviate the causes of laceration. In rare cases the size of the advancing part of the foetus is out of proportion to the width of the vTilvar ring and to the extensibility of the perinieum ; but as a rule the causes lie on the one hand in the head pressing too much against the posterior part of the perinaeum, i.e. its extension is deficient and delayed, on the other hand in the head descending upon it with too much violence, and leading to more rapid a distention of the pelvic floor than its elasticity can bear. The jyerinteum is therefore to be protected by facilitatinfi the extension of the head round the symphysis {sc. neck), as a centre of rotation, and at the same time by allowing the head to emerge so slowly, that the elasticity of the perimeum may he fully developed and that its anterior portion can retract over tlie head. It will depend on the conditions of the individual case, which of the two indications is the chief one to be attended to — whether to promote the exten- sion of, or to delay the head. For carrying them out both hands are generally required ; one of them lies on the perinaeum so as to exert the desired counter-pressure, the other acts on the head itself. Each hand however may fulfil both indications ; that on the perinaeum may detain the part which is passing out and push it forwards, the other hand can also do so while controlling the head. It is better however when the two hands co-operate with each other ; and it is a good plan to bring the force leading to the extension and to retardation, to bear mainly on the head itself (since strong pressure on the perinaeum is prejudicial), and to allow the hand which is lying on the perinaeum in the main to simply watch its behaviour, and if necessary to strip it off from the advancing head. Sometimes the extension and I THE MANAGEMENT OF LABOUR. 259 elevation of the bead out of the vulva are best managed per rectum, by inserting two fingers into the latter, and pressing on the forehead and afterwards on the edges of the orbits ; the desired end is thus reached more directly than through the thick perinteum. But in the majority of cases this old mode of procedure (recently again recommended under a new name) is unnecessary, and, owing to the constant risk of abrading the mucous membrane of the rectum, should not be resorted to, except under special circumstances. These manoeuvres for pro- tecting the perineum are as a rule only to be used during the pains ; only under certain conditions, as when the perinaeum is very thin and fragile, is the head to be raised out of the vulvar fissure during the interval between the pains, while the other hand pulls back the perinaeum over it. The behaviour of the latter during the pains will indicate whether the woman should be forbidden or encouraged to bear down during the passage of the head. It is possible to supervise the perinaeum both in the lateral and in the dorsal posture ; hut the former is to be j^ref erred from the possibility of directly observing it, and at the same time of fixing the pelvis more satisfactorily. The accoucheur sits behind the strongly flexed woman, who should lie with her hips close to the edge of the bed, and lays one hand (which should be bare, so as to keep him informed by direct tactile sensations of the state of the head and pelvic floor during the whole period of exit) flat on the perinffium, the thumb on the upper, the fingers on the lower labium ; the other hand is carried above the upper thigh to between the two thighs, and placed on the advancing occiput ■while the arm steadies the woman. In the dorsal posture the pelvis must be somewhat raised; the accoucheur sits by the side of the woman, and holds one fore-arm parallel with the axis of her body between her slightly abducted and flexed thighs, while his hand rests on the perinaeum in such a way that the palm lies on the posterior commissure of the vulva, and the fingers next to the anus ; the other hand seizes the head from above. The emerging part is now delivered according to the principles that have been already stated ; the fingers lying on the head may, as necessity arises, raise it up or hold it back during a pain, or strip off the tense edges of the labia and the posterior commissure of the vulva. The hand lying on the perinaeum must 260 THE MANAGEMENT OF LABOUR. closely follow the head ; especially while the anterior portion of the periniTBum is heing retracted over the vertex, forehead and face, must the perinaeum be carefully watched and held evenly against the head, so that retraction shall take place slowly, for it is now that laceration is most apt to occur. It must however not be forgotten that under certain conditions the attempt to preserve the perinaeum entire is a hopeless task, e.g. as already observed, with a vulvar fissure which is very small, or out of all proportion to the size of the head and its advancing diameters (face or occipito-posterior presentations) ; so also sometimes with a non-elastic, fragile, very thin perinaeum. In such cases it is better to anticipate the tear hy making an incision with scissors or a blunt-pointed bistoury into the vagina, passing on one side of the raphe (or fraenulum) ca. 1*5 cm. ('5 in.) from it in the direction of the tuber ischii, and through the tense edge of skin and the muscular ring of the constrictor vaginae. It is not, necessary entirely to avoid the skin in doing so, since it will inj any case give way during the exit of the head, and since the requisite stitch can be more easily inserted from the cutaneous' surface than from the vaginal mucous membrane. As a rule an incision 2 cm. ('75 in.) long suffices ; after making it, the prac- titioner must be immediately prepared to hold back the head,] which has been released and which can now rapidly advance, lest a tear be superadded to the incision ; the incision should there- fore not be made at the acme of a pain. On the completion of the labour, the edges of the tear should be united with carbolisec silk or clean catgut. If however the necessary precautions foi preserving the perinaeum are attended to, an incision will be but rarely called for, and in view of the fact that it may become centre of infection, should only be made when absolutely neces- sary ; the wound must be kept as aseptic as possible, the edges being accurately brought together. Occasionally the perin^eui gives way, even when an incision has been made. § 195. As soon as the head is born, it is well to feel with th^ fingers of the free hand whether the anterior portion of the perinaeum is clinging to the mouth and chin, and, if it is, to pusH' it back. The umbilical cord should next be looked to, and if twisted round the neck, the loop should be loosened so that the trunk can slip through it ; if very wide, it may be slipped over the head. It is unnecessary to do more, except when the cord is THE MANAGEMENT OF LABOUR. 261 very tense and the tension is increased by gentle traction on the head, and when it appears to be a hindrance to the dehvery of the trunk, in which case the latter is to be extracted. For this purpose, after the retrograde movement of the occiput to one side has occurred, the head is grasped in the hollows of the two hands, allowing the face to remain free. The head is now pressed somewhat back, the pelvis of the lying-in woman being at the same time slightly raised, till the anterior shoulder descends behind the symphysis, when the thorax is lifted out of the vulva by placing the index finger in the axilla of the posterior shoulder, in true imitation of the natural mechanism and of the lateral curvature of the trunk forwards. But if the extraction of the shoulders is not necessary — and it rarely is so, — the hand which during the exit of the head was on the perinaeum, remains quietly in situ, and closely watches the anterior edge of the latter ; meanwhile the free hand must immediately be laid on the fundus uteri in order to follow it as it rapidly diminishes in size with the birth of the trunk, and to exert expression in case the exit of the latter is delayed. The delivery of the shoulders deserves special attention in regard to the safety of the perinteum, since they might enlarge a small tear, even one involving merely the frajnulum, and convert a vaginal into a perinseal laceration, and since it is not always possible immediately after the delivery of the head to exclude the existence of such a slight laceration. The fingers must therefore prevent the posterior shoulder from passing out rapidly, and at the same time be ready to receive it as it does so. If the perineum is in great danger, it may sometimes be saved by allowing the binacromial diameter to pass out in the oblique, or in some cases even in the transverse diameter instead of the sagittal, by rotating the posterior shoulder. If the birth of the trunk is delayed through feeble action of the expelling forces, these may be stimulated by placing the hand flat upon the body of the uterus and rubbing it, and by urging the woman to bear down vigorously ; by exerting a steady force on the uterus in the direction of the inlet, we can often make up for sluggishness of the abdominal muscles. But if delay is very great, and there is danger of the child being asphyxiated, the latter must be extracted. § 196. As the trunk comes into view, it is seized from below by the hand which has hitherto been lying on the perinaeum, 262 THE MANAGEMENT OF LABOUR. _ and which is now spread out so as to lift the trunk out of the parturient canal. The delivered child is laid on its side, with its anterior surface directed to the maternal generative organs ; it is placed close to the latter, transversely or obliquely between the thighs of the mother, and any loops of the cord that are still coiled round it, are to be unwound. If there is much fluid in its mouth and pharynx, as shown by a rattling, the little finger may be used for its careful removal. If the lying-in woman has been delivered in the lateral position, she must now assume the dorsal. Meanwhile the other hand, which has closely followed the uterus during the process of its complete evacuation, lies quietly upon it, and holds it firmly in the median line of the body with- out however pressing too heavily. If both hands were needed for delivering the child, the midwife or nurse should take charge of the uterus in the way described, and act under the directions of the accoucheur. If the new-born child is breathing well, the after-birth period may be first attended to, and after its termination the child separated from the mother ; but if a reliable nurse is at hand, she may undertake the supervision of the uterus. The umbilical cord should never he divided until the umbilical vein Jtas completely collapsed, by which time respiration also will be in full swing ; not earlier, unless we have to do with a deeply asphyxiated child. It is however unnecessary and a waste of time to wait till the umbilical pulse ceases*. ' The observations of Budin, Schiicking and others (?. c), which have been fully confirmed by those recently undertaken in my Maternity by Drs. Kroner and Bruntzel, show that when the cord is not ligatured immediately, an increase in the body- weight of the new-born child invariably occurs, which increase is entirely due to the passage into it of the blood from the umbilical vein and its ramifications within the placenta. If the umbihcal cord is immediately ligatured, this '' reserve blood " is wholly lost to- the child; by premature ligation a portion is lost, by postponed ligation {I.e. after collapse of the umbilical vein), the whole is retained for the foetus. Theincrefse may amount to over 100 grm. (3^ oz.), and is usually though not always in direct proportion to the original weight of the new-born child ; in our observations the increase averaged GO — 70 grm. (ca. 2 oz.). Its causes lie in the aspiration of the blood by the new-born child, in the weight of the blood itself, and in the pressure which the uterus exerts on a placenta that is still in utero (according to Schiicking the pressure in the veins rises during the pain from 40 — GO mm. to 100 mm.=from ca. 2 to 4 in.). The quantity is increased by the force of the expression which is exerted on the uterus with the object of expelling the placenta ; it may be still further increased, by elevating the delivered placenta, and by squeezing the vein in the direction of the child. (We do not yet know what share in the increase is due to foetal aspiration ; this has yet to be decided by observations in asphyxiated new-born children, whose cords have been cut at different intervals of time before the first inspiration. Two THE MANAGEMENT OF LABOUK. 263 In order to divide the cord, it is first tied at a point G— 8 cm. (2 — 3 in.) from the navel (where there is a tendency to um- bilical hernia at a yet greater distance), with a broad ligature and a surgical knot. If the cord is thin, the ligature should not be too tight and firm ; if the jelly of Wharton is abundant, not too loose ; the ligaturing thread should be pulled towards the child. The cord is then divided with scissors 2 cm. (J in.) from the ligature, care being taken not to injure the baby's limbs. The placental end need not be tied, since the cord is not cut till the umbilical vein has collapsed. As soon as the cord is severed, the child is wrapped in a cloth, handed to the nurse and put into a bath. § 197. It is evident from what has been said in the preceding paragraph, that the best plan is not to separate the child from the mother, until after the expulsion of the placenta, or at least not till the latter is beyond reach of the uterine pressure, i.e. has reached the cervix and vagina. In order to bring this about, the uterus is to be brought (the necessary manipulations being carried out beneath the sheet and above the night-dress, both to avoid wounding the woman's feelings and to guard against chills) exactly into the middle line and perpendicularly to the axis of the brim, so that the organ is not bent in any way ; if the bladder is full, it must be emptied by means of external pressure, or in case of difficulty with a catheter. The hand now grasps the uterus in such observations have been made in my Maternity ; the cord was ligatured im- mediately, 70 (2-5 oz.) and 43 grm. (1-5 oz.) of venous blood being obtained from the cord.) The largest part of the reserve blood passes during the first 3—5 minutes after delivery, and it does so owing to spontaneously acting causes ; doubtless this is the portion which is important to the child. Observations on the weight of the child during the first few days of its life appear to prove that this increase is necessary for the thriving of the new-born infant, although on this point we have not as yet sufficiently numerous observations, and those which are pubhshed (c/. Hofmejer and Meyer /. c.) are in part contradictory. On the other hand, the additional quantity of blood transferred by artificial means (e.r/. raising the delivered placenta, and com- pressing the umbilical cord) is superfluous, perhaps also injurious; apart from the possibüity of conveying thrombi into the foetal blood-channels, severe icterus is said to be due to it. . , It is unnecessary therefore to wait for the cessation of the umbilical pulse, provided the umbUical cord is divided at the time indicated by the observations referred to above ; the pulse in the umbilical arteries may continue for a ™^<=^ ^^°"f"' Pf"""^ than it is necessary to wait according to those observations {cj. inter alios Ahlfeld, m Arch./. Gyn., xil, p. 489, to whose observations I can add similar ones), when no important local mechanical stimulus affects the arteries, and it may cease much earlier when the latter are by such a stimulus thrown into a state of spasmodic contraction. 264 THE MANAGEMENT OF LABOL'R. such a way that its ulnar side sinks deeply down behind it, the entire hollow of the hand lyinf^ on the fundus and the thumb on the anterior wall. If a pain now sets in, the anterior uterine wall is to be pressed against the posterior, and the whole organ pushed somewhat down towards the pelvic inlet, the force only being applied as long as the pain lasts. Should the pains be too few and feeble, the fundus must be rubbed and kneaded with the flat hand, till a contraction comes on, when the pressure is applied in the way mentioned. When this has been done several times, the body of the uterus is observed to become flatter, showing that the placenta has passed out of it. If now the whole organ is strongly pressed down in the direction of the axis of the brim, the placenta may generally be driven first down into and then out of the vagina (expression of the placenta), during w^hich pro- cess the woman may materially assist by bearing down and by raising her sacrum. This expression of the placenta out of the vagina is however unnecessary ; indeed it often causes great pain, and cannot therefore always be accomplished. The best procedure is, when once the placenta has left the uterus, to draw it out by the umbilical cord, the traction being at the same time aided by pressure on the uterus ; the line of traction must at first run back- wards and downwards, upwards only as the placenta passes out. If the exit does not take place easily, two fingers should be guided along the cord to or near to its insertion, and the placenta pressed into the concavity of the sacrum, while the fingers of the other hand pull the cord in the direction mentioned. It is not advisable to seize and drag upon the actual lobe of the placenta which is lying in the vagina, owing to its liability to tear. The extrusion of the placenta from the vulva must always take place slowly, so that the foetal membranes which lie behind it and are often still at various points attached to the uterus, may not tear ofi". This will be avoided if the emerging placenta is twisted several times round its axis ; the membranes are thus twisted into a cord by which any portions that remain are drawn out. The placenta, when delivered, must be carefully examined, so as to make sure that everything belonging to it has actually come away. § 198. The management of the after-birth period recom- mended above, is not quite identical with what is known as Crede's method. In the latter, the hand is not placed on the uterus till after the complete expulsion of the child, and then THE MANAGEMENT OF LABOUR. 265 brings on pains by friction &c., i.e. by stimulation, the placenta being afterwards expressed from the uterine cavity in the way described ; Crede's method therefore amounts practically to the expression of the after-birth. I, on the contrary, lay most stress (following in this respect the plan of the Dublin Rotunda) on early and regular, i.e. generally distributed, contraction of the uterus, since this is the cause of detachment of the placenta, and such detachment, not the expression, is the important matter. And not only do I closely watch the uterus all the time that its evacuation is comparatively rapidly taking place {i.e. from the moment that the head passes out), but I follow and mechanically stimulate it, and thus insure that the contraction which takes place when the cavity is suddenly emptied, shall not only be vigorous but also general ; in this way I insure early detach- ment, and by a constant supervision prevent any irregularities in the contraction. According to Crede's method, anomalous contraction may come on unnoticed between the birth of the child and the beginning of the " expression," which is not possible with the method which I have described. I repeat therefore : a constant supervision of the uterus from the moment the head is delivered, by which general contraction of the uterus and detachment of the placenta are insured, istltc main point; the expression of the placenta from the vagina may then follow, hut is not essential, and, as it is often very painful, may he impracti- cable, which cannot he said of my method. Mine also is the only safe prophylactic against anomalies of the after-birth period, as far at least as they are preventihle. At any rate if my recom- mendation is follow^ed in every case, an anomaly will be recognised as soon as it arises, and this is no slight advantage ! § 199. After removal of the placenta, the vagina must be irrigated with cool 2 per cent, carbolic water, and the hand which is supervising the uterus must continue to do so for some time yet, until the accoucheur is confident of its permanent retraction. It is then a good plan to bind the abdomen mode- rately firmly with a wide bandage, preferably with a hand towel, which is passed tightly round the hips. In this way the intra- abdominal pressure which has been so suddenly lessened by the delivery is to some extent restored, the lax abdominal walls, and indirectly the uterus also obtain support, and the woman experiences great relief. Before the accoucheur takes bis 266 THE MANAGEMENT OF LABOUR. departure, be should examine the external genitals, and cleanse them from blood &c. with a soft linen napkin dipped in 2 per cent, carbolic water (a sponge should not be used, unless it is quite new and has been thoroughly boiled). Any perinseal tear that may be present should be immediately sewn up, but slight injuries and abrasions may be left to themselves. Another bed near at hand is now to be prepared, and as soon as it has been thoroughly warmed and provided with a fresh clean waterproof layer, the Avoman should be carried into it ; or if the same bed in which she was confined is retained, this should be cleansed by the removal of all soiled articles, and fresh, thoroughly warmed, clean sheets should be pushed under her. During the necessary changes of position, the woman herself should co-operate as little as possible, and lie quite passive. It is unnecessary to change her body linen, if the night-dress and jacket were turned up during the period of expulsion, as was recommended above ; but if a change is requisite, only warm and thoroughly well aired linen must be given. Tlie Use of Chloroform in Labour. § 200. I need scarcely lay down the axiom that chloroform narcosis is as justifiable in all obstetrical as it is in surgical operations, and that it is indispensable in the severer operations. Indeed it is of more value here than in most surgical operations, since it not only serves to allay pain and give rest, but directly facilitates obstetrical operations, by checking all bearing down and diminishing the tension of the abdominal and pelvic muscles, even of the uterine muscle; it is therefore specially advantageous for the lying-in woman. Chloroform may also be used with benefit for certain forms of general and local cramp or neuralgia during labour, just as it can in the non-puerperal condition ; more will be said of this use, when the several affections are described. When however we speak of administering chloroform during labour, we do not refer to such cases, but rather to its value in simply relieving pain during labours which belong to the category of normal ones. If a woman in labour, who is otherwise healthy, inhales chloroform, she very soon falls into a quiet sleep, in which perception is somewhat diminished, and general sensibility THE MANAGEMENT OF LABOUR. 26? dulled, while consciousness remains unaffected. Above all slic seems scarcely to notice the uterine contractions, or the pain accompanying them. The contractions themselves are scarcely, if at all, altered. Their frequency occasionally diminishes a little, but this soon regulates itself, and the somewhat prolonf^ed intervals between the pains seem to depend entirely on the generally quieter condition of the woman. Each individual contraction is more energetic than before, and often more effectual, since the woman no longer throws herself wildly about or contracts her abdominal muscles ; although the assist- ance which the abdominal contractions give, is not entirely absent at the height of the pains. During the intervals the parturient woman lies quietly asleep ; when a pain begins, she grows restless, groans, bears down and sometimes also tosses herself about. When the pain ceases, the previous quiescent state returns, the woman answers questions as if half asleep ; she seems to be aware of the pains, but certainly does not suffer from them. This ancesthetic effect of chloroform is scarcely ever so well marked as it is during parturition ; the effect being the more striking, the more agonised and exhausted the lying-in Avoman was before ; for inducing this anaesthesia only very small quantities of chloroform are necessary. If however the chloro- form is administered continuously, a deep narcosis soon comes on in these as in other cases. The pains grow more sluggish, the intervals between them longer ; the former however do not disappear altogether, for when once the parturient activity of the uterus is set going, it continues without interruption, although the rhythm may be retarded, till evacuation results, or till the nervous irritability is entirely exhausted. On the other hand in a state of deep narcosis the activity of the abdominal muscles diminishes and finally disappears. Vomiting also is very apt to supervene. In simple anaesthesia I have scarcely ever noticed it, a fact which may be due in part to the stomach of a woman who has already been in labour for a considerable period, being usually empty. Although the induction of prolonged narcosis therefore may exert an injurious influence on the action of the pains as well as on the general organism, this is certainly not true of mere anaesthesia, even if it should be prolonged for hours. Experience proves this, and it is highly probable that the increased cardiac 268 THE MANAGEMENT OF LABOUR. and respiratory activit}' which accompanies each pain, and is seen even when the woman is under chloroform, is mainly the cause of the safety with which chloroform is given in ohstetrical practice. Experience moreover has shown that the atony of the uterus which it was feared would supervene after labour, does not occur, so long as the uterus is kept under supervision, as described above, from the moment the child is expelled. As far as the fcmtus is concerned, no unimpeachable clinical observation has yet been published in which a foetus was injured by chloroform administered to its mother ^ Chloroform is indeed found in the expelled placenta, where it might of course be derived from the maternal blood that is still adherent ; moreover experiment has shown that the reducing substance which is found in the urine of persons who have inhaled chloroform, is also present in the urine of children whose mothers inhaled it, and further that such reducing substance is formed in the foetal organism (Zweifel) ; and that the chloroform therefore passes as such into the foetal circulation. But to what extent this is injurious to the child is still uncertain ; probably it is not so at all. § 201. It follows from all this that it is always justifiable to induce chloroform anaesthesia, even in labours which otherwise run a normal course, as soon as the pains become very severe, and cause great excitement and exhaustion by their long dura- tion. Of course any individual susceptibilities as well as ordinary counter-indications (diseases of the lungs, heart and great vessels, goitre) must be borne in mind. Where the above-mentioned conditions (severity of pains &c.) do not exist, chloroform should not be given ; e.g. never simply to get rid of the suffering of labour. The inhalation moreover should be interrupted at intervals, when it is necessary to continue it for a long time ; otherwise a very prejudicial accumulation might take place. The time for commencing the administration must depend on the condition of the patient, and may arrive as early as the period of dilatation. It is well to desist during the exit of the child, since the assistance of the fully conscious woman is often neces- sary for the preservation of the perinseum. Chloroform should ' According to Runge [Arch, f. £j-per intent. Pathologie), chloroform so lowers the blood-pressure of the mother, that the foetus may perish in consequence without the mother dying. But clinical experience of prolonged chloroform narcosis in lying-in women does not confirm this observation. THE MANAGEMENT OF LABOUK. 2G9 only be inhaled during the pains ; it is in this way that the desired object will be most easily and quickly attained, since respiration is accelerated during the pains, and any struggling against the odour of chloroform is most rapidly overcome ; when the pain ceases, the chloroform should be removed. The lying- in woman should not be compelled to assume any special posi- tion ; her bladder must be carefully supervised during the anaesthesia. Quiet must be enjoined to those present, and much talking is to be forbidden ; fresh air should be frequently admitted into the room. When the inhalation is finished, the woman should not be waked, but be allowed to recover spontaneously ; after the birth of the child, the uterus must be supervised with special care. No particular form of inhaler is necessary ; a towel or a handkerchief folded in the form of a cone, answers every purpose. It is very doubtful whether chloral is able quite to take the place of chloroform as an anaesthetic, for it is mainly a hypnotic. But like subcutaneous injections of morphia, it is everywhere in use where rest, sleep and the arrest of irregular pains and bear- ing down are desired. In regard to morphia, I will only add that parturient women as a general rule require large doses, and bear them well. LITERATURE. Schultze, "Erleichterung der- Geburt durch Verminderung d. im Becken gegebenen Widerstände." Jenahclie Zeitschrift f. Medicin &c., iii., 1867, p. 272. V. Ludwig, Warum lässt man die Frauen in der michenlarie gehären? 2nd ed., Breslau, 1870. Fräukel, "Versuche zur Kritik der knicend-kaucrndcn Stellung der Kreisscn- I den." Berl. Jdin. Wochenschrift, No. 28, 1871. Bloss, Ueher Lage u. Stellung d. Frau lüährend d. Gehurt. Leipzig, 1872. Lahs, " Einfluss der Lageänderungen und der verschiedenen Lagen d. Kreis- senden auf die Geburt." Arch. f. Gyn., xi., p. 22. Cf also Die TJieorie der •I Gehurt. I Van Bambecke, " De lextension de la tete par les doigts introduits dans le I Rectum." Bull. Soc. Med. de Gand, Feb. 3, 1863. I Olshausen, " Ueber Dammverletzung und Dammschutz." Sammlung hhn. I Vortrage, No. 44, 1872. Kehrer, " Ueber Dammrisse." Der Praht. Ar:t,^o.->—l,\^l^. Fasbender, "Ueber Verletzung und Schutz des Dammes." Zeitschrift f Geh. u. Gyn., ii., p. 43. i, u f ■■ Cred(i, "Ueb. d. zweckmässigste Methode d. Entfernung d. Nachgeburt. Mo7i.f. Geh., xvii., 1861, p. 274. 270 MULTIPLE PREGNANCIES AND BIRTHS. Spiegelbergr. " Erfalirungen unci Bemerk, über d. Störungen d. ISTachgeburtN- gescliäftes." Würzhurg Med. Ziittehrlft, ii., 186L p. 39. Cf. also Canstatts Jahreslericht, 1861—63. Schule, "Bemerk, zur Behandlung d. Xachgeburtsperiode.' Mon. f. Grh.. xxii., 1863, p. 15. On the best time for tying the cord : Budin, Bull. Therap., 1.5 Fel).. 1876. Schücking, Berl. Min. WocJiemeh., 1877, No. 1—2 ; 1879, No. 39 : Centralbl. f. Crijnäli., 1879, p. 97. The publications of Zweifel, Hofmeyer, Haumeder, Fritsch, L. Meyer, "Wiener, Luge, Hayem, Ribemont, Porak &;c. are to be found in the Ccntralhl. f. Gyn., 1877—79, and collected in the Disst-r- tatioii by Mayring, '• Ueb. den Einfluss der Zeit des Abnabeins der Neugeb. auf den Blutgehalt der Placenten." Erlangen, 1879. The use of chloroform during labour: Spiegelberg, Z><'^/^?<•7(c -STZ/zi/Z'- 1856, No. 11, et seq. ; Mon. f. GeburtsJ/., xi., 1858, p. 29. Winckel, 3Io?i. f. Geburtsk.,xxY., p. 241. Zweifel, Berl. Min. Wochenseh., 1874, No. 21 ; Arch, f. Gyn., X., p. 400 ; xii., p. 235. Fehling, Arch.f. Gyn., ix., p. 313. Piechaud, Emploi des anesthisiques pendant VaecoHclievient natvrel. Geneve, 1878. Multiple Pregnancies and Births. § 202. A multiple pregnancy is one in which several foetuses are developed simultaneously. These are usually two in number (twins), in rare cases three, four, or even five. There are undoubted examples of five ; one case is accurately related in the Journal des Connaiss. med. chirury., No. 12, 1867, by Galopin in Illiers ; others have been communicated by Szauer {Wien. Med. Presse, 1877, No. 50), by Pearce and Tolkmann {Central- hlattf. Gyn., 1877, p. 24; and 1879, p. 461), and I myself have seen a preparation of five fojtuses in Ireland. More than five have not been observed. Practically we are only interested in twin births. Multiple pregnancy is an anomaly both in itself, and indirectly by much oftener leading to difficulties than does single pregnancy. Nevertheless it is dealt with in this Part, just as presentations of the face, brow, and pelvic extremity have been, since as a rule twin births pass off spontaneously and successfully, and like the above presentations, are not far removed from normal ones. The frequency of multiple pregnancies varies in different countries and years, and runs parallel with fertilit3^ Bavaria, Ireland, and Eussia show the highest ratio, France the smallest ; Germany taken as a whole approaches the average. This in the case of twins amounts approximately to 1 : 80, in the case of MULTIPLE PREGNANCIES AND BIRTHS. 271 triplets to 1 : 6 — 7,000 of all births ; lying-in institutions for obvious reasons show a greater proportion. The frequency in- creases with the number of the pregnancy, and the age of the mother. Heredity appears to exert an influence (Goehlert), and one twin pregnancy undoubtedly predisposes the woman to its recurrence \ Twins may be of the same or of different sex ,- the latter is most common ; male twins come next in frequency, two females are rarest. The male sex predominates here also, though less so than in births generally {cf. Veit inter alios). The excess in the number of boys over girls increases with the advancing age of the parents, and especially with the relative age of the father, and since from what is said above, advanced age as a whole dis- poses to multiple pregnancy, the excess of boys in the latter is explained. § 203. Twin foetuses are either developed from two ova, origi- nating in the same follicle or in different ones (if the latter, there must also be two corpora lutea, either in the same ovary or one in each), or from a single ovum containing a double germ. The relations of the foetal membranes show whether development took place from two or from one ovum, although it may under some circumstances be very difficult or even impossible to decide the matter. The dccidua is of course always single (except where the uterine cavity is double), but the foetal membranes and the placenta may be single or double. If there are tiro chorions, the foetuses have developed from different ova ; there are then two amnions and two placentae, the latter being either quite distinct, or blended with each other at their contiguous edges into an apparently common placenta. When the placentae are quite distinct, there is always a layer of deoidua between the chorions of the two ova, the latter having become imbedded in portions of the uterine mucous membrane which were far apart. Even when the placentae form one mass, the decidua as a rule extends for the whole distance between the two chorions, proof that in the case of these ova also the reflexa grew up round each ovum, and that the placentae only came into contact later on ; if however the dividing layer of decidua does not exist between the chorions, the two ova became imbedded in the uterus so close to each other, that a common reflexa grew round them both. But 1 Puech, Annales Gynecol, April, 1877. Ik 272 MI'LTirLE PREGNANCIES AND BIRTHS. in all cases where two chorions are present in the after-hirth, the placental vessels of the two foetuses are entirely distinct, or only present unimportant anastomoses. If only one chorion, is present, the foetuses have developed from a single ovum with two germs, for we have no evidence that two chorions which were originally distinct can afterwards blend so to form a common chorionic cavity ; where there is a single chorionic cavitj^ we never find traces of the chorion having been primarily double. The placentae, though originally of double formation, always become fused in the case of a single ovum into one mass, and every vestige of a septum disappears. It is not rare in such cases for considerable anastomoses to exist between the ramifications of the umbilical vessels of the two foetuses ; and not only between the veins and arteries of the two sides, but sometimes also between a vein and an artery, the connection being efi"ected both in the deeper portions of the placenta, and by thick vessels lying on the surface. The more one umbilical cord owing to a marginal or velamentous insertion is at a disad- vantage compared to the second, the more does its collateral anastomosis with the latter develop, so that each controls an equal part of the placenta. The cords may be inserted near to each other into the margin, or at diametrically opposite points, nor is the velamentous insertion rare. The umhilical vesicle is as a rule double, even when there is a single chorionic cavity, the two vesicles often lying close together, usually between the portions of the two amnions which are in contacts Twins lying in the same cavity are always of the same sex, and much more alike than those developed from difi"erent ova. The latter show such resemblances as children do which have been born from the same parents at difi"erent times, but those occupying a common cavity are strikingly similar, their difference in weight is less, and they attain to a greater similarity in bodily structure than do the former. A single chorionic cavity occurs once in 8 twin pregnancies ; ' According to Ahlfeld {Arch./. Gyn., xi.), when the umbilical vesicles are indepen- dent of each other, the twins have developed from two different blastodermic vesicles ; when the umbilical vesicles lie close to each other in the neighbourhood of the amniotic partition wall, the foetuses have developed from two different blastodermic vesicles, or from one whose vitellus divided ; if there is only one vesicle placed between the insertions of the umbilical cords or in one of them, the twins have developed from a single vitellus. MULTIPLE PREGNANCIES AND BIRTHS. 273 the amnion on the other hand is double ahnost without excep- tion, one amnion being only found about once in 132 twin pregnancies (Ahlfeld). It may then have been originally single, since a common amniotic fold may grow up round two embryos originating in the same blastoderm. The common amniotic cavity however may also have been derived from an originally double cavity by a disappearance of the party- wall. For the amnion can be re-absorbed in consequence of inflammation, and traces of such are sometimes found between the insertions of the cords where there is but a single amniotic cavity, in the form of lines of fat and adhesions of the amnion (between these points of insertion) with the tissues lying beneath it, which have under- gone fatty degeneration. Where the amnion is single, the insertions of the cords are frequently close together, and por- tions of each amnion must therefore have been pushed into the angle which the vessels inserted into the chorion close together, form with one another; and this may in consequence of foetal movements easily lead to inflammation and atrophy from pres- sure. In some observations moreover distinct remnants of a former partition wall have been found. When there is a single amnion and the cords are inserted close together, the latter may interlace with one another, or there may be a fork-shaped cord, i.e. a cord which, while containing dupli- cate vessels, is single for some distance from the placenta, and then divides. In pregnancies with triplets or four foetuses, the foetal append- ages (corresponding wdth the mode of development of the ova) are arranged much as in the case of twins, although the relations are naturally more complex. In the case of triplets, there is as a rule one independent ovum, and another containing two germs ; here however as also in the case of four foetuses, there may be one chorion common to all the foetuses. The relative frequency of a common amniotic cavity appears to rise with the number of the foetuses. § 204. As a general rule twin foetuses are smaller, and rceu/h less than other new-born children. This is due in many cases to the twin pregnancy terminating more often than the smgle ones before the full term of 39—40 weeks, since the uterus owing to its unusual distention is earlier stimulated to contract. But even when the duration of pregnancy is normal, twms are 18 274 MULTIPLE PREGNANCIES AND BIRTHS. more frequently below the average measurement than are single children, though the weight of both taken together exceeds that of the single one. The reason is no doubt that the maternal organism cannot so easily provide material for nourishing two foetuses as it can for one ; their growth too may be mechanically hindered. Ttvins are almost invariably unequally developed, and great differences in this respect are met with, even when the shape is natural. The cause is probably local, one foetus pre- venting the other from developing ; possibly owing to one ovum being attached to a part of the uterus which offers more favour- able conditions for its growth, and shields it from the pressure of the second, while the latter matures under less advantageous circumstances. Thus in animals which bring forth several young at the same time, it is observed that those foetuses which lie towards the point of the uterine horns are frequently smaller than those situated deeper down. This difference in develop- ment is especially and not infrequently noticeable in uterus duplex, where each half contained a foetus. Corresponding to the disparity in the size of the foetuses, the placentae or the placental halves belonging to them, are also unequal in size, while the length and thickness of the umbilical cords are often in direct proportion to the development of the chil- dren. It is not true that the foetus born first is always the best developed, as has been assumed in disputed cases as to which was born first. Even in my own short series of observations, it has happened that the smaller foetus was expelled first. It is interesting to note the different fate which sometimes overtakes twins, while still in the uterus. Thus one foetus may perish or be discharged by abortion, while the other continues its natural development S and in rare cases the ovum which had perished prematurely is found to have degenerated into a mole. It is commoner however for the dead foetus to remain for months in the uterus side by side with the one which is advancing towards maturity, and to shrivel up without undergoing further change ; in such a case when the mature child is born, the com- pressed second ovum with its similarly flattened embryo is found ' Cf. inter alios the case recorded by Linton {Centralhl. f. Gyn., 1878, p. 512), in which abortion of one foetus took place at the 4th month owing to placenta praevia, the other being expelled in a mature condition 5 months and C days later. MULTIPLE PREGNANCIES AND BIRTHS. 275 lying outside the foDtal membranes of the first {foetus 'papy- raceus, f. comprcssiis^). Occasionally it happens that after the birth of the most developed child, the second less developed foetus is not imme- diately expelled; the latter remains behind in ntcro, and is only born after an interval, which may amount to several weeks, and during which it has undergone further development. The most striking instances of this kind have been noticed with uterus duplex. § 205. Upon these facts and upon the frequent disparity in the development of twins, the hypothesis has been founded that the two fcetuses originated at different times, that the ova were impregnated at different dates, that superfecundation occurred. According to this hypothesis, an already pregnant woman may through a later coitus become pregnant a second time. As far as this question relates to early superfecundation, i.e. to the separate impregnation of two ova discharged during the same ' The formation of fcctus papj-raceus is explained by the fact that the surviving fcEtu3 maintains a vascular connection with the dead one, which thus carries on a vegetative existence, which prevents the usual maceration from setting in. This mainly occurs when the twins are derived from a single ovum, and a number of cotyledons are therefore present in the conjoint placenta, which are common to Voth, so that the circulation is in part at any rate a common one. If such cotyledons derive their arteries from one foetus and their veins from the other, the two hearts work in the same direction in the more or less common vascular circle. If then (as is so frequently the case) the two twins are not equally well developed, the stronger heart takes over a portion of the work of the weaker, and the latter may become so much enfeebled, that the foetus to which it belongs perishes. Again, the more vigorous heart produces a larger quantity of liquor amnii than the other, and the weaker foetus (the liquor amnii of which diminishes more and more) comes to be straitened for room, and after its death will be compressed and flattened. The heart of the surviving foetus continues however for some time to maintain a slight amount of metabolism in the other foetus. Foetus papyraceua has also been met with when the chorion was double, and must then be due to an interruption of the circulation owing to anomalies in the umbilical cord. It is evident that the same cause may be effectual where the chorion is single, but when it is double there are sure to be vascular anastomoses between the placentae. I may take this opportunity of mentioning that when considerable arterial trunia of the two embryos anastomose with each other in the earlier stages of development (due, according to Ahlfeld, to the union of two allantoides that developed at different times), and when the heart of one foetus contracts more forcibly than that of the other, and sends its stronger arterial current in direct opposition to the feebler arterial current of the weaker heart, the onward flow of blood on one side of the anastomoses will be checked, and the blood will flow back towards the le?s powerful heart ; the latter then becomes paralysed and atrophied. The foetus with the weaker heart degenerates into an " acardia." L 276 MULTIPLE PREGNANCIES AND BIKTBS. ovulation period, we have no reason for doubting the possibiHty of such an event, since there is nothing to prevent newly introduced spermatozoa from penetrating to the ovum, and since superfecundation certainly occurs in animals, in whom polyandria is very common. But in the case of man, its occurrence cannot be proved where there is but one father, or where the fathers belong to the same race. Even those cases in which women have given birth to children of two races after having admittedly had intercourse with men of different races prove nothing, since in cross breeds the children do not always equally share the paternal and maternal peculiarities ; and, just as a child may sometimes resemble the father most, sometimes the mother, so also in the case of twins resulting from such a cross, one may only resemble the father, the other only the mother. Super- fecundation moreover does not explain the frequently great dis- parity in the development of the foetuses, nor why the dates of birth are often so widely separated, since the second conception must take place within a short interval after the first. This is what late superfecundation (superfoetation) is sup- posed to do, i.e. the impregnation in a person already pregnant (by a coitus occurring months after the first pregnancy began) of an ovum, which has been recently discharged and therefore belongs to a subsequent ovulation. This superfoetation however is a physiological impossibility, since physiological ovulation ceases as soon as pregnancy has commenced, and since its con- tinuance during the latter has never yet been observed. Less weight can be placed on the obliteration of the uterine cavity by the decidua reflexa blending with the vera as disproving the pos- sibility of superfoetation, since this blending is only completed towards the end of the third month, and is liable to exceptions in diseased conditions of the uterine mucous membrane ; nor does the argument hold good where the uterine cavity is double. Further, the assumption that foetuses which have reached a different degree of development originated at different times, is not (even if it were otherwise possible) admissible, where the differences in development are noticed in foetuses developed in a single ovum, which is not rarely the case ; for probably no one would assert that an ovum with a two or even more months foetus in it could be again impregnated. And since the unequal development of the foetuses originating in one ovum, can be MULTIPLE PEEGNANCIES AND BIRTHS. 277 quite simply explained by an unequal distribution of the nutrient material and by want of room, this explanation will also suSice in other cases to explain the difference in the development of twins ; all the more as the same phenomenon is quite as fre- quently met with in the so much rarer cases of triplets. The instances in which twins of similar or nearly similar development have been born at a considerable interval, cannot be explained by the h;y'pothesis of superfoetation. The noticeable point in such is that the uterus in which labour has begun, may after partially expelling its contents, again become quiescent : and only later resume its work ; it is also remarkable that the further development of the remaining ovum is not interfered with by the diminished size of the uterus, while the arrest of haemorrhage from the area of attachment of the placenta belonging to the first ovum, is somewhat more easily uuder- i stood without a complete retraction of the uterus. Never- j theless these events, though so greatly at variance with what I usually occurs, are not altogether inexplicable when compared ' with other pathological phenomena in the uterus, but the sup- j position of a superfoetation throws no light on the question. And if twins, in cases where the pregnancy has lasted an equal ; length of time, may yet be unequally developed, and are not ' born at the same time, the one remaining behind and making up I for what it has lost, this only shows that in multiple pregnancy i also the degree of development of the foetus influences the date of labour, Superfoetation then is physiologically untenable, explains nothing at all, and may be set aside as an exploded hypothesis. § 206. Twin pregnancy can rarely be diagnosed with perfect confidence. Various indications however of it are mentioned : ' thus early and great enlargement of the uterus ; an unusual degree of discomfort consequent upon this enlargement ; very widely distributed and strong foetal movements ; division of the uterus into two elevations along the liuea alba or in an oblique ! direction by means of a furrow, or at any rate a distinct trace of two horns at the fundus ; great expansion of the lower segment of the uterus with no or a very unstable presenting foetal part. ' All these indications however are relative, and therefore unreliable phenomena, and may be caused by an excessive amount of liquor amnii or of the so-called spurious liquor amnii {cf. § 91), or by a 278 MULTIPLE PREGNANCIES AND BIRTHS. voluminous child. They lead, it is true, to a suspicion of twins, hut it is an old experience that when t^ins have been prophesied on such grounds, labour generally undeceives and vice versa. The diagnosis becomes more probable, when we are able to exclude the presence of an excessive quantity of liquor amnii, and can distinctly feel numerous foetal parts, especially if these are both unusually numerous and small ; it becomes certain when, as sometimes happens, two heads are definitely recog- nised at opposite points of the uterus. Auscultation also may make us certain ; not merely if we distinctly hear the foetal heart sounds at opposite portions of the uterus, but only if their intensity diminishes from these portions in a peripheral direction, and if they are very feebly or not at all audible in the intervening median portion. A difi"erent rate of beat heard at different spots is only of importance, when made out at the same time, i.e. by two observers, or when in the case of a single examiner a very short interval elapses between his examination of the different spots ; for it is well known how variable the rate of the foetal pulse is, and how rapidly it is altered by such active or passive movements of the foetus as are provoked by the examination. It is moreover possible for one person simultaneously to auscultate different spots, if he will take the trouble ; and should he find that the pulsations are not synchronous, the diagnosis becomes certain (Küneke). During labour the diagnosis may be facilitated by the pre- senting part being more easily recognisable than it was before ; here however we must guard against deceptions, just as during pregnancy. The diagnosis is sometimes rendered certain by the foetal heart sounds being heard, while the presenting child is found to be dead (this I have seen in one case), or while a pulse- less umbilical cord is presenting (seen three times) ; so also when through the bag of membranes, or even after its rupture, many similar foetal parts can be felt, or such as could not possibly lie together where there is only one foetus (a foot near the shoulder, two right hands or feet) ; when two bags of membranes are dis- covered, or at any rate the indication of the pai'tition wall dividing them (Depaul) ; and finally when the presenting foetal portion is so small that it cannot possibly belong to the same foetus as do the other parts that can be felt in the still elevated uterine fundus. MULTIPLE PREGNANCIES AND BIRTHS. 279 After the birth of the first child, it is easy to make out that a second still remains in the uterus. The matter is at once settled, if when the head or trunk, as the case may he, is horn, the hand is laid on the fundus uteri, and grasps the organ according to the rules laid down under the " Management of Labour." The size and consistence of the uterus, its tense condition during the pains show at once that it contains another frotus. The recognition of foetal parts, and in some cases the foetal pulse and the vaginal exploration then furnish more exact conclusions. A pregnancy with three or four foetuses can only in very rare cases and under exceptional conditions, be diagnosed before the actual expulsion of the foetuses. § 207. As already mentioned, twin pregnancy often terminates prematurely as a result of the early great distention of the uterus and of the not uncommon premature death of one foetus ; out of 98 cases I find 27 premature hirt]is = 27'5 per cent., Eeuss esti- mated the ratio at 26"5 per cent, in the Maternity at Würzburg. Labour however usually passes off spontaneously and successfully. It may be compared to two single labours following rapidly upon each other, the second lasting a much shorter time than the first, since the period of dilatation is common to both. In the second moreover the pains are often sluggish and more or less ineffectual, at least as long as the bag of membranes continues intact, indeed this variety of uterine inertia may be of diagnostic importance ; but as soon as the liquor amnii has been discharged, and the size of the uterus is diminished, this changes. Progress then usually becomes very rapid, owing to the small size of the foetuses, and twin labours do not on an average last longer than a single one. The birth of the second child generally follows that of the first within a quarter of an hour, most rapidly when both were enclosed by one bag of membranes, or when the membranes of the second burst before the birth of the first; in over 80 per cent, the interval does not exceed one hour. Longer intervals are as a rule cut short by interference on the part of the accoucheur, and such a shortening is often rendered necessary, not by the length of the interval, but by other anomalies (abnormal presentations of the second foetus, haemorrhage). The expulsion of the p)lacenta, whether separate or blended, does not generally take place till after the birth of the second child; when separate, they rarely pass out at the same time. 280 MULTIPLE PREGNANCIES AND BIRTHS. that of the first fcetus usually emerges first, the opposite being exceptional. Occasionally the first child is immediately followed by its placenta, which therefore precedes the second child, and it may happen that the second placenta precedes the second child. "WTien the two placentae form one connected mass, a portion of it may separate after the birth of the first child and be expelled, the remainder only following the second child ^ The after-birth period owing to the size of the placenta, and to the lax condition of the uterine walls, lasts as a rule longer than with a single labour; still when the uterus is properly attended to, it may generally be terminated quite as soon. § 208. The position of the tico foetuses relative to each other, varies greatly. During labour two head presentations are commonest, or one head and one pelvic presentation ; two pelvic presentations come next in frequency, then one head and one transverse, one breech and one transverse, lastly two transverse presentations. Out of 1,144 pairs (899 collected by Kleinwächter, 203 by Reuss from the Maternity at Würzburg, 42 of my own) the foetuses showed : two head presentations 562 times = 49-1 per cent. one head and one breech presentation 362 „ := ST? two breech presentations 99 „ = 8"6 one head and one transverse presentation ... 71 „ = 6-18 one breech and one transverse presentation 46 ,, = 4-04 two transverse presentations 4 „ = "35 1,144 times = 99-97 per cent. Out of 2,288 foetuses, there were therefore of : head presentations 1,557 = 68 per cent. breech „ 606 = 26-48 „ transverse „ 125 = 5-46 „ 2,288 = 99-94 per cent. The excessive frequency of breech and transverse presentations, when compared to those of ordinary labours, is evident from these tables. Most of the transverse presentations are secondary, and occur mainly with the second foetus ; as a rule they result from ' When there is a common placenta and a true marginal or velamentoua insertion of the cord of the first foetus, this cord may be torn from the placenta as the foetus is expelled. The placenta therefore which is discharged after the completion of the labour may seem to possess only one cord, and the practitioner is apt to be misled through inattention, and unnecessarily to introduce his hand into the uterus in search of a seccmd placenta. MULTIPLE PREGNANCIES AND BIRTHS. 281 the sudden discharge of the liquor amnii, and from the very roomy condition of the uterine cavity after the first hirth. Change of lie and position are by no means rare with the second child, so that the presentation and position at labour do not necessarily show what they were before it. § 209. The numerous anomalies of presentation, position and attitude which are noticed in twin labours, owing to the small size of the foetuses and to the large size of the uterine cavity, possess no unusual features, and for details I must refer to the appropriate sections. Special interest however attaches to the simultaneous entrance of both foetuses into the pelvis, and I must therefore describe it here, although a purely pathological occur- rence ; indeed twin pregnancy is an anomaly from beginning to end. Both foetuses may, while their membranes are still intact, present simultaneously at the pelvic inlet ; but as soon as one bag of membranes ruptures, its foetus descends and pushes the neiffhbourina: bag: of membranes to one side. The same thing usually occurs, when the foetuses occupy a common amniotic cavity and lie side by side above the pelvis ; when the liquor amnii is discharged, one moves aside. In either case should it be necessary, i.e. should the selection be long delayed, the bag of membranes, or one of them, if there are two, may be opened, and the nearest presenting part (preferably the head) brought down till it blocks up the pelvic inlet, while the other presenting part (either with intact membranes or after then- rupture) may at the same time be pushed back ; the appropriate lateral posture should be enjoined. The same principles must be followed, where both twins present alternately. But when the amniotic fluid has been discharged, both foetuses may simultaneously or soon after one another descend into the pelvis, before the first one has blocked up the way ; under such circumstances they mutually interfere with each other's progress. This occurs when both bags rupture simul- taneously, or when that of the foetus which is placed highest gives way first, or (and this is commonest) when both t^ms lie in a single sac. The condition is met with once in 9Ü,UUU labours (Braun), and is therefore very rare. a. When both the heads present and occupy the pelvis, tue head of the second child lies in the cervical excavation ot tue 282 MÜLTirLE PREGNAXCIES AND BIRTHS. first ; or else the first head is born, but the second one pressed against its neck stops its further progress. In the former case the diagnosis can scarcely be made before the birth of the first head. Neither event is possible, except where the twins are small. If there is no urgenc}', the course of events should be waited for, especially where the pelvis is wide and the expulsive forces are strong. Under other circumstances, the two heads should be extracted one after the other with the forceps ; except where one foetus is dead (a difficult point to determine, if only one is dead and has not yet undergone maceration), when its skull should be perforated. b. Both children may present with the pelvic extremity, either with the breech or the feet, but this is one of the rarest compli- cations. It is the exception for serious dystocia to ensue from one foetus preventing the progress of the other, since the lower end of the body has a simpler shape than the upper, and the two breeches cannot interlock owing to their rounded form. It is sufficient to draw down the lowest breech or pair of feet, while the other is pushed up and to one side. If necessary, the whole hand should be introduced so as to gra«p the two feet which belong to each other. Again, the second child may ride on the transversely placed first one, an anomaly which can always be recognised, if the rule is followed in any case of " confusion des mcmhres,'" of introducing the whole hand into the lower segment of the uterus, after inducing chloroform narcosis, and of accurately examining the presentation and other relations of the foetuses or the foetus, before any rectification is attempted. c. One child may present luith its 2^<^li'ic extremity, the other with the head. In such a case the former, being the less bulky, especially when the feet present, descends first, and is delivered as far as the umbilicus or even the neck, but from this point the heads are so interlocked as to form a serious obstruction to delivery — interlocking tivins. Either the heads lie face to face with the two lower jaws hooked under each other (fig. 57), or the face of the one is turned towards the occiput of the other or lies against its nape, or both occipital regions are interlocked. The diagnosis is usually easy, inasmuch as the delay in the delivery of the first child leads to an accurate exploration of the pelvic cavity, if necessary with half the hand, and this reveals the condition of things. MULTIPLE PREGNANCIES AND BIRTHS. 283 Since the first child is more severely squeezed than the second, and is delayed owing to its pelvic end presenting, it runs much more risk than the other. If the parturient canal is very roomy, the foetuses small and the pains very powerful, both children may be simultaneously and spontaneously expelled. But as a rule when spontaneous delivery occurs, the head of the Pig. 57.— After Barnes. (" Obstetric Operations.") second child is expelled side by side with the expelled trunk of the first; then comes the head of the first and lastly tlic trunk of the second, or else the second child is entirely delivered before the head of the first. In the majority of cases of interlocking however, labour must 284 MULTIPLE PREGNANCIES AND BIRTHS. be terminated artificially. It may occasionally be possible to push the head of the second foetus back, and thus to get rid of the difiiculty, but as a rule the best plan will be to deliver the head of the second child with the forceps, and (considering how bad the prognosis always is for the first child) immediately afterwards to completely deliver the second child. Yet under some circumstances it may be advisable, indeed even necessary, after the extraction of the second head, immediately to deliver the first with the forceps. The natural course of events is imitated in both proceedings. On the other hand it sometimes happens that the second head cannot be delivered with forceps, and must be perforated before extraction ; and there will also be cases in which, in view of the living condition of the child whose head presents and the death of that whose trunk is delivered, it will be the best plan first of all to crush the higher placed head of the latter, and thus to make room for the forceps delivery of the presenting living head of the second child. The amputation of the trunk of the first child is inadmissible, since the disproportion is not remedied by such a proceeding. § 210. The prognosis in regard to the children, is much less favourable in a twin than in a single labour, owing to their small size, the frequent anomalies of presentation and attitude and to the much more frequent artificial delivery that is required (it is especially bad for the second child, owing to the number of transverse presentations) ; the death rate also during the first few days is much higher. The increased distention of the uterine cavity, the commoner irregularities in the course of labour, and the operations necessitated in consequence increase the morbidity and the mortality of the mothers also, although not to an important extent, when the management is good. This management during the period of dilatation does not difier from that of single births, so long as there are no anomalies to demand special treatment. After the delivery of the first child, the placental end of its umbilical cord must alwaj^s be ligatured, since there is a possibility of both children originating from a single ovum, and in such a case the two vascular systems frequently anastomose. Twins are rarely welcomed with pleasure, the mother should therefore not be distressed by the information of their advent being conveyed too abruptly. If the relation of the second child to the uterus is normal, the return of the pains MULTIPLE PREGNANCIES AND BIRTHS. 285 may be patiently awaited, so as to allow the uterus gradually to adapt itself to the changed conditions. The delivery of the second child is to be conducted according to the same rules as any other labour ; but here especially we can assist by external pressure. The rules for managing the after-birth period must be adhered to even more minutely, if possible, after the birth of the second child than after an ordinary labour, since the uterus in consequence of its previous distention shows a great inclina- tion to relax, since the placental mass as well as its area of attachment are larger, and the danger of haemorrhage is thereby increased. The hand which is supervising the uterus must not leave it for a moment. The placentae should not be extracted (unless there are special grounds for doing so) till they lie entirely and low down in the vagina. In removing them, traction should be made on both umbilical cords simultaneously ; if this is ineffectual, then either on one or other, the after-birth often following more readily when this is done. But if the placenta of the first child is found immediately behind it, it should be left to lie quietly where it is, unless it has quite come down and can be removed without the use of any force. The supervision of the uterus, when labour is completely over, is to be continued for a longer time than after a single birth ; some doses of ergot should also be given. The question how long it is well to wait before interfering, in cases where the interval between the two births is delayed, can only be answered when the second fcetus still lies in its own bag of membranes ; if there is no second sac or if it has burst prematurely, delay in the advance of the foetus must be dealt with in reference to its causes, and to the conditions found in the individual case. But when the membranes are intact and circumstances are otherwise favourable, the limit for waiting may be set at somewhat under an hour ; this is the hmit of spontaneous termination in more than 80 per cent, of all twm births, and there is all the less reason to wait longer, since the after-birth of the first child is generally still retained and does not permit further delay, since the lying-in woman has had abundance of time to recover by the time mentioned, and snice if the pregnancy is terminating at or nearly at the full term, we cannot look for any very long natural interval. In such a case it will be well therefore to attempt to bring on stronger pams, 286 MULTIPLE PREGNANCIES AND BIRTHS. by applying external pressure, by friction and ergot, and if this does not succeed, the liquor amnii may be let out. Should it however happen that one placenta immediately follows its own foetus, especially if the latter is immature, while the other ovum lies intact in the uterus, and if the latter again becomes quiescent, it is advisable, bearing in mind the recorded cases in which the second has continued to develop after the birth of the first, and has been born after a considerable interval, to desist from accelerating delivery, so long as the condition of the mother does not imperatively demand it. The description given of the course and management of twin labours in the main holds good for labour ivith triplets or quad- ruplets. On easily intelligible grounds, anomalies are here still commoner, and insufficient contraction of the uterus and haemor- rhage are especially to be feared. There is but a faint chance of maintaining the foetuses alive, particularly as they are almost always born a very long time before attaining maturity ; four foetuses have however been kept alive. LITERATURE. Duncan, " On some laws of the production of twins." Fecundity, Fertility, Sterility, 2nd edit., Edinburgh, 1871, p. 67—102. Neefe, '■ Zur Statistik der Melirgeburten." Jahrbuch f. Xationalöhonomie u. Statistik, von Hildebrand u. Conrad, vol. 28. Gochlert, " Die Zwillinge. Ein Beitrag zur Physiologie des Menschen." N'irchow's Archiv., vol. 76, p. 457. Hyrtl, Die Blutgefässe d. menschlichen JVachf/eburt. Vienna, 1870. Schultze,"Ueber Zwillingsschwangerschaft." Volkmann's Sammlung hlinischer Vorträge, No. 34, 1872. Kleinwächter, Bie Lehre von d. Zwillingen. Prague, 1871. Reuss, '• Zur Lehre von d. Zwillingen." Arch. f. Gyn., iv., 1872, p. 120. Puech, Bes Naissances multiples. Paris, 1873. Ahlfeld, "Ein Amnion bei getrennten Zwillingen." Arch. f. Gyn., vii., 1875, p. 2G6. •' Beitrag zur Lehre von d. Zwillingen," ihid., ix., p. 196, 231 ; xi., p. 160 : xiv., p. 321. Schatz, " Zur Frage über d. Quelle d. Fruchtwassers und üb. Foetus papyracei." Tagehlatt d. 47. Xaturf.- Versammlung zu Breslau, 1874, p. 240. Schuster, " Die Entstehung des Foetus papyraceus und sein Vorkommen bei einfachem und doppeltem Chorion." Bis.s'crtation, Strasbiu'g, 1876. Fricker, " Ueb. Verschlingung u. Knotenbildung d. Xabelschnürc bei Zwillin- gen." Bisscrtatio7i, Tübingen, 1870. Klingelhoeffer, " Eine Zwillingsgeburt mit beiden Köpfen im Becken." Berlin. Klin. Wochenschrift, No. 2, 3, 1873. Reimann, " On the simultaneous entrance of both heads of twins into the pelvis." J\.mer. Journ. of Obstttr., x., p. 47. THE PUERPERAL STATE. 287 III. The Puerperal State. § 211, The changes brought about in the maternal system by pregnancy, begin to undergo retrogression at the time of parturi- tion and continue to do so after dehvery. The period of time which is necessary for the completion of this "involution " ex- tends over several weeks, and is called the puerperal lieriod ; the person concerned being spoken of as a lying-in woman. Six weeks elapse before involution is complete, indeed sometimes even more, before the uterine mucous membrane is fully reformed. During the puerperal state, the organs affected by pregnancy return to their pre-gravid condition, although they perhaps never entirely regain their former structure, at any rate that which they had previous to the first pregnancy. At the same time the changes produced in the organism as a whole by jjreguancy and labour, also disappear. But while the activity of the pelvic generative organs falls into the background, the breasts develop into functional organs, so as to provide nourishment for the new-born child. To a description of these processes we must add that of the early changes in the body of the new-born child. Probably nowhere else do physiological and pathological pheno- mena verge so closely upon one another, as during the puerperal state. The rapid and important change in the circulation, indeed in the whole system, the entire transformation of a whole set of organs, the wounds caused by the act of parturition — in a word the radically different conditions of life, make it necessary to considerably extend the limits of health ; the new state of things brings with it a condition which eminently predisposes to disease. This in itself is sufficient reason for carefully watching every puerperal woman, and for studying the characters of the normal puerperal state. We must regard it as normal, so long as we only find phenomena which are necessarily connected with and 288 THE CHANGES IN THE MATERNAL SYSTEM. consequent upon involution, and when the puerperal woman both subjectively and objectively appears to be doing well. 1. The Changes in the Maternal System. a. Involution. § 212. The severe exertion of labour is immediately followed by an agreeable repose ; the sensation of chill which so often accompanies the emptying of the uterus {ef. § 149) by a sense of warmth, by perspiration and a feeling of great relief, and as a result of the fatigue sleep comes on from which the woman wakes up refreshed. The temperature of the body is on an average somewhat higher than is usual in healthy persons. During the first 2 — 3 hours after the labour, it remains at the same level that it had imme- diately after it ; only when the rise was unusually great, does a fall take place. Within the first 12 hours it then usually rises a little, and may reach as high a level as at any time during the course of childbed ; this elevation is partly to be attributed to the physical exertion of labour and to the psychical excitement. During the second 12 hours, the temperature again falls, and this fall is especially marked, when the temperature is taken during the morning remission. The fall, with very slight oscillations corresponding to the evening and morning variation, is maintained during the second 24 hours, giving way on the third day to another slight rise, which as a rule corresponds with the development of lactation. This rise lasts for a couple of days, and from the sixth day onwards makes way for the ordinary temperature. The subsequent temperature of lying-in women is somewhat higher than that of perfectly healthy persons, but the increase is inconsiderable (38° C. = 100'5° F. is the limit) ; indeed the variations are no greater than those commonly met with in the latter, and are liable to the usual diurnal oscillations. Owing however to the great sensitiveness of the body temperature of lying-in women, the maximum of ca. 38° C. (100"5° F.) is more often brought on in them by very trivial and frequently unaccount- able causes, than it is in non-puerperal women. The average higher temperature is certainly due to a disturbance produced by THE CHANGES IN THE MATERNAL SYSTEM. 289 the small wounds associated with labour, to the resorption of degeneration products formed in the generative organs, and to the irritation of the mammae which accompanies the development of their secretion. The pulse in lying-in women is generally slowed, and therefore is to some extent in contrast with the elevation in temperature. The pulse-rate, which had increased during labour, diminishes immediately after it, then rises again, and on the second, third or fourth day becomes remarkably slowed. The rate then varies between 44 and 70, indeed a frequency of less than 40, even of 30, has been noticed ; the usual figures are 44, 48 and 56. At the same time the beat is full and forcible, although according to the most recent observations (Fritsch, Löhlein, Meyburg) the arterial tension is not increased. This then cannot be the cause of the slowing ; it is rather the mental and physical rest of the puerperal woman as well as a certain impoverishment of the blood due to its abundant losses, while but a sparing amount of nourishment is taken, that are to be looked upon as explaining the phenomenon, perhaps also some temporary disturbances of the nervous mechanism caused by the impoverishment. The retardation is more frequently observed in multiparae than in Primiparae, and lasts also longest in the former ; it lasts longest when most marked. The duration varies from 1 — 12 days, but on an average the normal rate is regained on the 6th or 7th day. The retardation is not much affected either by the degree of the involution of the uterus, or by the onset of the lacteal secretion, and is always a favourable prognostic sign. The pulse- rate does not by any means always run parallel to variations of temperature ; for instance when the pulse in the individual is not readily affected, the changes in it always set in somewhat after those in the temperature, and this must be borne in mind in estimating their importance. Otherwise the variability of the pulse in lying-in women is very great, as a consequence of then- usually highly impressionable condition. I may mention here that the first cardiac sound is frequently changed to a soft blowing murmur, probably also a consequence of disordered nutrition and innervation. The respiratory rhythm is slowed, corresponding to the quiet condition of the lying-in woman, but presents no special charac- ters. The capacity of the lungs is practically unaltered, as would 290 THE CHANGES IN THE MATERNAL SYSTEM. be expected from the position of the diaphragm not being affected by pregnancy {cf. § 78) ; nevertheless owing to the greater range of movement of the latter after the emptying of the abdominal cavity, the capacity may appear to increase. The widening of the base of the thorax brought about by pregnancy diminishes, although it does not quite disappear, so that the previous narrow waist is generally lost. § 213. The s/ii/i increases in activity, and thus assists in elimi- nating the products formed by the retrogressive metamorphosis of the generative organs. Perspiration sets in very soon after the confinement ; the body, if kept warm, perspires copiously during the first eight days, but even when it is cool the skin is always moist ; this increased cutaneous activity, and with it a great susceptibility to changes of temperature, lasts for a long time, and is also found in suckling women. It is not uncommon for some of the hair of the head to be lost for a time, in consequence of the hyperaemia of the skin, and the accompanying exudation into the hair follicles. The deposits of pigment which were formed during j)regnanc3', disappear more and more, although as a rule never entirely. The secretion of urine is increased even more than during pregnancy. The urine is pale and clear, with a specific gravity of ca. 1015. Since the absolute quantity of urea and sodium chloride eliminated is practically unaltered, while the phosphates and sulphates are diminished, a greater quantity of water must be got rid of; and considering the copious perspirations and the sparing diet of childbed, the quiet condition of the woman, the insignificance or absence of any diminution in the urea elimi- nated shows that in lying-in women oxidation products are largely excreted by the kidneys. The increase in the secretion of urine does not extend beyond the first eight days ; the tem- porary diminution on the second to fourth day being associated with the commencement of lactation and profuse i^erspiratious. The urine is very frequently saccharine ; the sugar is in the form of lactose, and as a rule contemporaneous with the estab- lishment of lactation ; its quantity is generally in proportion to the abundance of the milk. It soon disappears, when the formation and consumption of the latter are balanced ; it re- appears when the supply of milk decreases or entirely ceases, and when the breasts are not emptied. When the lacteal THE CHANGES IN THE MATERNAL SYSTEM. 291 secretion is permanently arrested, the sugar also disappears from the urine. This lactosuria is, as I have for years been teaching, a resorption diabetes. Retention of urine is sometimes observed in the first two to three days. It is caused by the capacity of the bladder being increased through the loss of the pressure which the pregnant uterus was exerting on it, and of an efficient abdominal pressure; sometimes it is due to a swelling or bend in the urethra. Occasionally the urine is not voided, because micturition is made very painful by a bruised, sore condition of the urethra, in which (especially at its so-called vesical portion) fissures are often produced during labour (dysuria). The action of the boicels is sluggish, owing to the quiescent condition of the woman, the small amount of nourishment taken, the increased activity of the skin and the relaxation of the abdominal muscles. For the same reasons the appetite is poor during the first four or five days ; thirst on the other hand is increased, in consequence of the greater elimination of water. Inasmuch as the intra-abdominal pressure relations alter after labour, any a'dema and varices of the lower limbs and possibly of the region of the hips, which might have been present before it, rapidly diminish ; the oedema soon entirely disappears, but the varices are never completely lost. The abdominal walls appear greatly relaxed, and in the hypogastric region sometimes hang over sacciform ; the areas in which the cuticle is thinned (stria?) remain as faded streaks. But by degrees the abdominal skin regains its elasticity, and gradually retracts towards the navel in a centripetal direction. Only after rapidly repeated labours is the elasticity permanently lost. The retrograde changes in the generative organs, the copious discharges from them, the loss of material by the mamm«, the increased cutaneous and renal secretions, in conjunction with a sparing diet, lead to a decrease in the total wei(fht of the bodjj, which during the first eight days amounts on an average to 4,500 grm. (10 lb.), i.e. to about a twelfth part of the body-weight, and is in direct proportion to the size of the confined woman. This loss however is again made good in the course of a few weeks. Lastly, it must be mentioned that the great nervous irritability which so often accompanies the advance of pregnancy, is very slowly lost ; it is true that certain symptoms present during 292 THE CHANGES IN THE MATERNAL SYSTEM. gestation often become less marked, but fresh ones are apt to iippear, and the sensitiveness to impressions is, generally speak- ing, very great during childbed. § 214. The uterus ranks first in importance amongst the organs that undergo involution, much as it did when we described the alterations produced by pregnancy in the sexual system. Two processes affect it almost independently of each other, and run a symmetrical course — the diminution in its size and the reconstruction of its mucous membrane. The diminution in si^e commences at the time of labour, and when this is concluded progresses under the same influences i.e. contractions, which are now termed after-pains. These soon lead to a permanent shortening and alteration in the arrange- ment of the muscular fibres ; and since the muscle is now inactive as well as anaemic, the contents of the cells undergo fatty degeneration and absorption ; the fibres disappear. The anaemia of the puerperal uterus is a natural result partly of an inactivity which increases day by day, in part of the compres- sion of numerous (especially of the small) vessels by the Con- or retracted uterine musculature. Whether fibres are entirely or only partly disintegrated, and if the latter, which portion remains, is not settled. The fatty degeneration is macroscopically most distinct from the fifth to the eighth day, least so in the cervical portion ; during that period the uterus on section appears reddish-yellow or pale-yellow, and globules of fat visible to the naked eye may be removed from it ; the texture is extremely soft and friable, and tears readily. A new formation is not distinctly visible till the fourth week, and appears first in the external layer of the walls, where also numerous nucleated elon- gated cells can be seen, which are about to develop into short fibre cells. It is very doubtful whether they are the result of a true new formation ; these apparently newly formed cells are probably embryonic muscular elements which have been kept in reserve, which did not undergo h3rpertrophy during the previous pregnancy (c/. § 64), and therefore have not fallen a prey to the fatty degenerations of childbed. Thus disintegration and recon- struction take place hand in hand within the walls of the uterus, and the whole process is not usually completed till after eight weeks. Puerperal diseases have generally speaking no influence over it. THE CHANGES IN THE MATERNAL SYSTEM. 293 Other constituents of the uterine wall are destroyed beside the muscular fibres ; especially a large portion of the vessels. The larger arteries are obliterated by a connective tissue hypertrophy of the intima, or at any rate become greatly narrowed by it ; in the media also fatty degeneration takes place to some extent. Similar alterations affect the larger veins. The capillaries com- pressed by the muscular tissue, like it fall a prey to fatty degeneration; the sinuses and veins of the "placental site" are obliterated by thrombosis. The last result of the involution of the uterus is its diminu- tion in size. The organ which weighed about 1 kilo. (2*2 lb.) soon after delivery, two days later only weighs 750 grm. (26| oz.), is 19 — 21 cm. (7| — 8j in.) long and 11 cm. (4^ in.) wide ; its wall at the level of and below the fundus, especially below the ovi- ducts, has a thickness of 3 — 4 cm. (1 — 1^ in.). At the end of the first week it weighs about 500 grm. (ca. 1 lb.) and is 13 — 16 cm. (5 — 65- in.) long ; after fourteen days its weight is about 350 grm. {121 oz.), its length 13 cm. (5 in.), its thickness 1 cm. (ca. ^ in.). These of course are only average measurements, and are subject to considerable variations. After six weeks the uterus has nearly regained its previous size, although it always appears somewhat larger and more rounded than the nulliparous organ. The peritoneal lining of the uterus can in virtue of its elas- ticity follow the retracting subjacent muscular tissue; in so doing it becomes thinner ; its previously dilated lymph channels become narrower and less distinct. If in certain places the elasticity is wanting, the serous membrane is there found wrinkled and loose on the layer beneath it. § 215. The reconstruction of the uterine mucous membrane takes place in the following way. At parturition, the cellular layer of the decidua, with or without a portion of the areolar intermediate layer (c/. § 89), is thrown off with the placenta ; tke glandular layer remains behind, and with it sometimes also a thin lamella (varying in extent) of the cellular layer. The muscular tissue therefore is not laid bare, but on the contrary is covered by a layer of a yellowish-red or whitish substance, at least several mm", thick, which presents an irregular reticulated surface, and whose superficial elements are pushed apart by an abundant sanguineous infiltration. The same description holds good of the placental area, except that the yellowish-red layer 294 THE CHANGES IN THE MATERNAL SYSTEM. is thinner, and that the exposed and thrombosed vessels lying here give to the surface a nodulated uneven aspect. The whole tissue is copiously infiltrated with round cells, the gland spaces are in part filled with blood, and the most superficial layer of tissue is in a state of fatty metamorphosis. The wall of the uterus is covered and its cavity in part filled by a more or less thick layer, which consists at first mainly of blood, afterwards of blood-stained slime, and in which the mor- phological elements consist of blood, round cells, detached decidual cells undergoing fatty degeneration, and of the products of their disintegration. Any remains of tissue which are still adherent, and are not required for the formation of the new mucous membrane, dis- appear by a process of fatty degeneration, and together with a serous transudation form the principal portion of the discharges from the uterine cavity (lochia). By the second week the yellowish-red layer on the inner surface has become much thinner and looks like granulation tissue. The placental area is smoother than it was, some thrombi are detached, the remainder are smaller, firmer and somewhat discoloured ; the lochia are thinner and paler. Any remaining shreds of tissue are now cast off; only here and there can decidual cells still be found, and these have undergone fatty degeneration. The glands, especially their fundal portions, | lie quite exposed, since a portion of the glandular epithelium has also been shed ; the gland ducts no longer lie so obliquely, so nearly parallel to the uterine wall as before. The inner surface of the uterus is now therefore in part covered by epithelium. The intermediate areas which are infiltrated with round cells are more and more encroached upon, the whole internal surface gradually diminishes, and thus the islands of epithelium derived from the fundi of the glands, are by degrees approximated to one another, till by a continuance of these processes, and by a further proliferation of the epithelium belonging to the por- tions of the glands that are left, the islands at length come into contact, and thus form an unbroken coating over the pre- viously exposed surface. By the third week the muscular wall is lined by a delicate smooth pale membrane, which is still covered by a copious, pale, yellowish slime. This membrane is the new mucous membrane THE CHANGES IN THE MATERNAL SYSTEM. 295 consisting of a thin connective tissue layer, containing numerous lymphoid cells and some spindle cells (still in part undergoing fatty degeneration), and covered by a delicate epithelium. The epithelium is still absent from many parts of the placental area, especially from those where the thrombi were exposed. The epithelium gradually assumes the cylindrical form and becomes ciliated. By a proliferation of the interglandular tissue and by the mucous membrane becoming thicker, the shallow glandular recesses are elongated and stretched, and thus at last the mucous membrane regains its normal condition ; last of all over the placental area. This process is as a rule complete by the fourth week ; sometimes however the reconstruction takes place much more slowly, and occasionally for some months more, nothing but granulation tissue can be found on the uterine wall. Deposits of pigment usually lie free in the mucous membrane, and fur- nish an almost invariable sign of a previous labour ; they are not found after menstruation, since the haemorrhage accompanying it is superficial. We do not as yet know how the mucous membrane is recon- structed in those cases where the whole decidua is discharged at labour (as doubtless occasionally happens after very difficult instrumental labours) ; probably under such circumstances merely a layer of connective tissue is developed from the un- derlying layers, which then becomes covered by epithelium derived from the neighbouring parts, no new glands being formed, since they could only originate from the epitheHum of the surface. The thrombi of the placental area (including those of the uterine sinuses) become organised in the usual way with the assistance of the walls of the vessels ; indeed from and after the 8th month of pregnancy, a portion of the sinuses lying below the placental area is blocked by an accumulation of large multi- nucleated cells derived from the endothelium, and by coagulated blood. But the organised thrombi are very slow in shrinking, so that in sections of the uterus soft translucent spots corre- sponding to them may often be seen for some months. § 216. The cervix uteri soon regains its previous condition. Immediately after labour it is very soft and wide ; the internal OS uteri forms a broad swollen ring through which several fingers can be easily introduced. The canal is still long (averagmg 296 THE CHANGES IN THE MATERNAL SYSTEM. 7 cm. (2| in.) to the obstetrical internal os), and its mucous membrane is thrown into folds ; the external os is patulous, its lips are bruised and not infrequently torn, especially at the sides. By the following day, after about 12 hours, the internal os has become narrower and more resistant ; the whole cervix is smaller, its mucous membrane forms distinct prominent longitudinal folds. The cervix now rapidly grows smaller and narrower, and in 12 days after labour has almost regained the length of a fully involuted (4 cm. = li in.) cervix, while the body of the uterus still lags far behind. The internal os will as a rule no longer admit the finger after the tenth day ; the longitudinal folds of the mucous membrane have disappeared, or are quite insignificant. The portio vaginalis alone continues thick, and together with the external os remains patulous for a long time ; the anterior lip especially appears enlarged, and very often presents erosions and granulations. The portio vaginalis is not fully involuted for several weeks, and indeed after the first labour it scarcely ever completely regains its virgin shape. No decrease in the thickness of the cervical walls takes place, inasmuch as they had been greatly thinned during labour. The broad ligaments, Fallopian tubes, and especially the round ligaments, are affected by the involution processes to the extent to which they shared in the hypertrophic changes of pregnancy ; the hyperaemia and turgescence of the pelvic connective tissue are specially slow to disappear, \vhile the previous disposition and position of the ovaries and Fallopian tubes are not regained, till the diminishing uterus gradually sinks down into the pelvic brim. The vagina usually continues wide, smooth, and irregularly swelled for some days after labour (only very rarely does the con- traction and involution of its muscular wall cause it to be rapidly narrowed), and its lumen does not regain its non-puerperal con- dition till the 3rd or 4th week ; only then does the columna rugarum again become distinct. The great prominence of the anterior wall, which sets in during pregnancy, and still more immediately after labour, disappears, although the structure of that wall generally remains looser and more elastic. The inlet is the first portion to regain its narrow dimensions, by the con- traction of the muscles round it, although even it usually appears wider than in the nulliparous condition, in consequence of the THE CHANGES IN THE MATERNAL SYSTEM. 297 tears that have taken place. The width and relaxation of the vaginal walls increase with every labour. The epithelium is re- generated, and any hypertrophy of the papillae that was present, disappears, although perhaps not entirely. At the vaginal entrance some small superficial abrasions can generally be found, these being of course commonest in Primi- parae. In the latter the hymen is torn through in many places, especially along its posterior margin. These tears lead to the formation of small rounded flaps or of conical nipple- and tongue- shaped larger flaps, which vary in length, are placed on a broad base and are called carunculae myrtiformes ; the former variety are usually along the anterior, the latter along the posterior margin. The small thin flaps are merely due to tears passing through the edge of the hymen, the fleshy ones placed on a broader base to tears which have involved its attached border and the subjacent tissues. Occasionally parts of the hymen are missing, owing to the partial detachment of its attached border, and to the detached flaps having become gangrenous. The external genitals gape for the first days after the labour, and have a bruised appearance ; their inner surface is often excoriated, and the continuity, especially along their posterior margin, is often broken (fraenulum). The nymphae are the first to regain their previous shape ; the labia majora before long come into contact, although they remain enlarged, but they never conceal the vestibule as completely as before ; they gape longest near the perineum. The latter begins to retract in the first 24 hours, and rapidly regains its former dimensions ; this causes any existing wounds in it to become much smaller than they were directly after the passage of the child. § 217. The chief clinical features associated with the involu- tion processes above described, are the perceptible change in the size and condition of the uterus, the after-pains and the lochia. Immediately after labour, the uterus forms a firm mass which (owing to the laxity of the abdominal walls) can be easily grasped, is rounded, somewhat flattened antero-posteriorly, or irregular in shape, and lies between the navel and the symphysis. It is generally in the median line, but now and then inchnes to the right, more rarely to the left side, and as a rule it is slightly twisted round its axis. Moreover it is moderately anteflexed. and may cause a slight convex projection above the symphysis. 298 THE CHANGES IN THE MATERNAL SYSTEM. The average elevation of the fundus above the latter amounts to 11 cm. {4h in.), its greatest width is 10 cm. (4 in.), the length of the cavity from the edge of the anterior lip of the os uteri being 15 cm. (6 in.) ; in primiparse these measurements are as a rule somewhat smaller than in women who have been repeatedly con- fined. If the bladder is distended, it forces the uterus away from the anterior abdominal wall and straightens it ; at the same time it pushes it to one side, usually the right, and thereby increases its rotation round the longitudinal axis. It also pushes the fundus upwards, thus increasing its elevation above the anterior pelvic wall. The filling of the rectum has a similar, though less marked, effect in raising the uterus and displacing it to the right side ; this explains the (apparent) enlargement of the uterus which is so often noticed some hours after a confine- ment. If met with in conjunction with an empty bladder and rectum, the enlargement is real, and must depend upon abnormal relaxation of the parietes, or in some cases on an accumulation of blood. In perfectly normal cases, the size of the uterus existing at the time of delivery, begins steadily to diminish. The diminu- tion is perceptible after 24 hours, a change in the elevation being easier to discover, and more distinct than one affecting the width. Just as the decrease in weight was the most considerable during the first 14 days, so also does the volume diminish most rapidly during the same period ; these changes afterwards proceed much more slowly. By the third week the anteflexed uterine fundus lies behind the anterior pelvic wall, at any rate when no intestinal convolutions lie in front of it, as is very commonly the case when the body is erect ; when it is higher, this must depend on the distention of the neighbouring organs. The cavity about this time is on an average 10 cm. (4 in.) in length. § 218. The diminution of the uterus during the first few days is due mainly to the after-pains, afterwards to the retrogressive metamorphosis of its elements. The after-pains are a continua- tion of the labour pains, like them are rhythmical, and can be recognised as contractions both b}' a palpating hand and by the lying-in woman. These contractions are always followed by a tonic retraction, which maintains the uterus in a condition not far from the maximum of contraction, and which must be clearly distinsfuished from mere elastic reaction. THE CHANGES IN THE MATERNAL SYSTEM. 299 The after-pains generally last for the first 4 days ; in rare cases they last longer, but frequently only for 1 to 3 days. Their duration, frequency and severity are in inverse ratio to the dura- tion of labour, and to the force of the labour pains ; where labour lasted very long and the expulsive forces were very strong, they may be almost entirely absent ; conversely, after an unusually rapid labour they may be very severe and proportionately painful. For this reason after-jmins are as a rule much weaker in primi- than in multiparae, and indeed the former may escape them altogether. The old adage of midwives that all women sooner or later suffer alike, represents therefore what is actually the case. It is natural that the after-pains should be specially severe and prolonged when the uterus has been greatly distended {e.g. by twins or excess of liquor amnii). The sucking of the new-born child almost invariably calls them forth by a reflex action. As long as they do not recur too often, are unaccom- panied by fever, and the uterus is not sensitive to pressure during them (it must however not be forgotten that palpation may produce contraction, and thus be very painful), the after- pains must be regarded as a normal and very favourable phenomenon, by which the uterine vessels are firmly closed and the uterine contents expelled. But very severe and very painful after-pains always point to some irritation of the uterus, or to a pathological accumulation within its cavity. § 219. The lochia (cf. § 215) are derived from the blood con- tained in the uterine cavity, from the mucous membrane which is being superficially disintegrated and regenerated, from an exudation accompanying this process, from cervical secretions and from vaginal exfoliations. Accordingly, during the first few days they consist of almost pure blood, mixed with clots and shreds of decidual and sometimes foetal membranes or even of placenta. After the third day the amount of blood diminishes, the lochia become pale, serous, and contain blood-corpuscles, pavement epithelial cells, also cylindrical cells from the cervix, mucus corpuscles and granules, aggregations of granules, and often still some remnants of decidua. The reaction is alkaline, the chemical constituents being albumin, mucin, saponified fat, and compounds of chlorine and phosphorus. From the 6th to 8th day the discharge is still thin, the blood-corpuscles continue to diminish, while the pus cells, granular cells and fat globules 300 THE CHANGES IN THE MATERNAL SYSTEM. increase. During the second week the secretion is greyisli- ivhite, sometimes thick and viscid, sometimes creamy ; its main component is pus, the epithelial cells have greatly diminished, and instead of them are found young spindle-shaped connective tissue cells which contain fat, free fat and crystals of Choles- terin ; the reaction is neutral or acid. Occasionally an infuso- rium, the trichomonas vaginalis, is found in the discharge ; bacteria are present. The lochia steadily diminish in quantity, become paler and clearer, approach more and more to a non- puerperal secretion, and finally after lasting for a variable time disappear. The composition varies with the condition of the internal surface of the uterus, of the cervix and vagina ; there are numerous gradations between lochia serosa and 1. alba seu lactea. Blood not uncommonly reappears at the end of the first and in the course of the second week, especially when the lying-in woman leaves her bed too soon. When no disinfective measures are used, the odour after the fourth day becomes very penetrating, and is due to a volatile acid ; later on it rather resembles that of stagnant pus. It is only when the discharge from the uterus is not quite free and continuous, and when the secretion is retained in the lower portion of the vagina, that the odour is very foetid. The quantity of the lochia, as well as their duration, vary with the peculiarities of the individual, and with the condition of the generative system. In women who usually menstruate copiously, generally in multipara, in non-suckling women, after unusual distention of the uterus, and where its involution progresses but slowly, the discharge is copious, remains longer sanguineous, and extends over a longer period. The average quantity of the lochial secretion amounts (according to Gassner's investigations) in the case of the lochia cruenta from the 1st — 3rd day to 1 kilo. (85| oz.), of the 1. serosa from the 4th — 5th day to -28 k., of the 1. alba from the 6th— 8th day to -205 k. ; thus during the first eight days 1*485 k. are lost. In suckling women the total quantity amounted to 1*085 (38^- oz.), in non- suckling women to 1*88 kgr. (66| oz.). THE CHANGES IN THE MATERNAL SYSTEM. 301 h. The Secretion of Milk. § 220. The development of the mammary glands which began during pregnancy (cf. § 73), rapidly increases after delivery. On the second or third day of the post-partum state, a marked turgescence sets in, which is favoured by the stimulus of suckling and by the emptying of the glands, but occurs even where this stimulus is absent ; it often develops suddenly in the course of a day or a night. The breasts are full, enlarged and elastic, some- times hard and nodulated ; the skin is tense, the subcutaneous tissue of the areola slightly oedematous and very sensitive to touch ; the superficial veins are filled and shine through the skin. The axillary glands are swelled, and the lymphatics pass- ing to them from the mamma can be felt as cords ; pains run parallel with them to the shoulder and arm. This state of congestion is not always so strongly marked, but is rarely quite absent in the normal condition. Associated with it there is often a general, sometimes a very considerable, state of excite- ment, but there is no rise of temperature in lying-in women whose generative system and mammary glands are healthy, or at most the rise is very slight (amounting to '5° C). The swelling and excitement usually pass away with a free perspiration and an abundant flow of milk within 24 to 48 hours ; the mammae become softer and less tense, and the secretion is now fully established. A constant flow of milk is henceforth kept up by the breasts being regularly emptied by suckling ; this removes any possible obstruction to the efflux of the milk, arising from a motor stimulation of the contractile elements in the lactiferous ducts, from an increased fiUing of the blood-vessels of the gland, and from a relaxation of the musculature of the nipple and areola. The amount in 24 hours may reach 1,350 grm.= 47i oz. (Lamperriere, Compt. Rend., 1850, vol. 30) ; Gassner found that the average quantity of milk secreted by three lying-in women during the first eight days, amounted to 2*15 kgr. (76 oz.). The period during which milk is secreted (lactation) varies greatly ; constitution, mode of life and especially the state of digestion and assimilation aff'ect it. In a healthy condition with regular suckling, milk continues to be formed for 9—10 months ; it then becomes scantier, its quality alters, and finally 302 THE CHANGES IN THE MATERNAL SYSTEM. the supply dries up. By diligent continuous suckling however it can sometimes be prolonged for a much longer period, e.g. for 1 — 2 years. Menstruation is usually absent during lactation, although it is not rare for the menses to appear, indeed they sometimes recur at the proper time, after an interval of six weeks, and under otherwise healthy conditions no injury results either to mother or child. A fresh pregnancy may therefore set in during the period of suckling, and is not uncommon in very fertile women ; in such a case however the secretion of milk usually dries up very quickly, although occasionally not for some months. If a lying-in woman does not suckle, the milk flows out spon- taneously for a short time, and may be very copious ; but before long the gland returns to its quiescent condition through want of a stimulus to empty itself, and this is favoured by the free action of the bowels which generally take place. The paren- chyma of the gland undergoes involution, the lobules become atrophied and condensed, and the connective tissue septa between them again grow thicker and poorer in fat. § 221. The secretion of the mammary glands during the first days after parturition does not differ materially from that which can be expressed during the last part of pregnancy, except in being more copious. It is a turbid, whitish, somewhat slimy fluid, alkaline in reaction, in which some yellow streaks and spots are plainly visible ; it is called the colostrum. On the 2nd to 4tli day the fluid increases in quantity, becomes of a lighter bluish-white colour, thinner and better mixed than before, the j-ellow flakes having disappeared. This is the true milk. The colostrum contains morphological and chemical consti- tuents, which are absent or at any rate much less abundant in true milk, viz. colostrum corpuscles and albumin. The struc- tural bodies consist of small fat globules, free nuclei, and of cells of the size of a colostrum corpuscle, containing nuclei but with fewer fat globules. The corpuscles themselves are round mulberrylike bodies of variable size, consisting of a number of large and small fat globules which are held together by a hyaline connecting material, which swells up in acids or alkalies. They are undoubtedly cells ; for on the one hand acetic acid or carmine pigment brings out a nucleus in them, and on the other hand under suitable treatment they possess amoeboid movements THE CHANGES IN THE MATERNAL SYSTEM. 303 and by means of them can expel fat globules. Only a certain number of colostrum corpuscles however exhibit this latter character, and it is an indication that changes in their constitu- tion are in progress. As a matter of fact colostrum corpuscles are cells of the alveolar epithelium, which first become round, clear and faintly granular, then exhibit movements, and at last by means of them take up fat globules from the contents of the alveoli. We do not know why this change in the alveolar epithelium is practically confined to the early period of the glandular activity, and afterwards disappears or grows much less marked (Heidenhain). True milk contains few colostrum corpuscles; the milk globules form its predominating constituent. These are bright globules of fat of very variable size, the smallest being almost too small to measure, the largest having a diameter of '025 mm. ("001 in.); the common size is from -002— -005 mm. (-00008— "0002 in.). Tbese fat globules are a product of the secreting alveolar epithe- lium, i.e. of the gland cells (c/. § 57). Within the body of these cells, especially in their inner half, globules of fat are formed. The outer portion of the cell, together with the fat con- tained in it, is discharged during the secretion. The detached part of the cell dissolves in the milk, the fat globules being set free ; a portion of the body of the cell may often be seen still clinging to them, but this too is by degrees dissolved. If nuclei are contained in the detached portion, they also pass into the secretion. The remainder of the body of the cell is then reconstructed, beginning in the outer portion, when the process which has been described, begins afresh. The more copious the secretion, the less filled are the cells ; conversely, when the for- mer is scanty, the latter are full and swollen. The formation of the constituents of the milk has therefore no resemblance to that of the cutaneous sebum, as was at one time almost universally believed. It does not depend on fatty degeneration of the cells (as occurs in the latter), but on a production of fat within the cells, while the latter are maintained. The milk globules possess no external membrane, but are emulsified by the casein which is dissolved in the milk. The casein (like the gum used in the artificial emulsions of the chemist) produces the emulsion by forming a thin fluid pellicle round the fat drops ; any treatment of the milk which causes 304 THE CHANGES IN THE MATERNAL SYSTEM. the fat globules to run together or to be easily dissolved, acts by destroying these envelopes of soluble casein. § 222. In addition to fat, milk contains casein, traces of albumin, sugar, salts and gases. The amount of butter varies from 2*5 — 7'6 per cent., but rarely averages more than 3*5 per cent. It is derived from the albuminates of the food, and is for the most part formed in the glands, i.e. in the milk cells ; a certain portion of the fat however (Voit, Heidenhain) probably passes straight from the blood into the secretion. Casein is a potassium albuminate, which is not found in colostrum, but is derived from the serum-albumin in the mammary gland (it does not exist in the blood) ; whether the conversion takes place in the milk cells is still undecided, but it undoubtedly occurs in the fully formed secretion. The pro- portion of casein varies within small limits (about 1 per cent.), according to the state of nutrition, the maximum quantity being 4 per cent. Only traces of albumin are present ; according to Hoppe- Seyler about "4 per cent^. Milk-sugar is found exclusively in milk, and must therefore be formed in the mammary gland. The presence of sugar and starches in the diet appears to have no influence on its formation ; albuminates therefore constitute its immediate source, and Car- nivora fed on a purely meat diet have a very considerable proportion of sugar in their milk. The quantity of sugar exceeds that of the fat and albuminate, is much more constant than that of the former, and amounts to 3 '2 — 6 per cent. The salts in milk consist principally of patassium, lime, chlorides and phosphates ; they amount to about '14 per cent. The gases amount to about 3 volumes per cent, (nitrogen,, oxygen, carbonic acid). According to 89 analyses by Vernois and Becquerel, milk consists of: Water 889 Solid matters 11, viz. : Butter 2-6 Casein 39 Milk-sugar 4'3 Salts H 10-94 ' Puis (Pflliger'e Archiv., xiii., p. 176) found "95 per cent., in a lactation of lOJ months' duration. THE CHANGES IN THE MATEKNAL SYSTEM. 305 The variations from this average, as well as the total quantity, depend mainly on the nutrition of the mother, and on the duration of lactation. From this point of view the presence of albuminates in the diet is of the greatest importance ; the more abundant they are, the more copious is the quantity, and the better is the quality of the milk ; it will also be very rich in fats. During the progress of lactation, a gradual increase in the amount of albu- minate shows itself together with a simultaneous decrease in the amount of fat and even of sugar ; the amount of sugar and salts however is in most cases but little altered. Various substances taken with food, such as colouring agents and the scented matters of numerous plants, pass over into the milk ; amongst di*ugs, iodine, mercury^, the alkaloids of opium, and salicylic acid*^, have been found in it. The influence of emotional disturbances on its formation is well known. If diluted with water, woman's milk becomes faintly bluish ; the cause is unknown. c. The Diagnosis of the Puerperal State. § 223. The signs that delivery has taken place at some previous time, are mainly those mentioned in § 136, where the diagnosis of a subsequent pregnancy was discussed. Those which indicate that a confinement has recently taken place, and that the puerperal state is still present, are the following : The general condition is, as described above, that of a woman recovering from an illness. The breasts appear full, hard, nodular, and often tense, their pigmentation and secretion are very noticeable, the latter being so both in respect of quantity and quality. The abdomen is slightly tympanitic, its walls are relaxed, the skin moves freely over the underlying muscles. The uterus feels enlarged and like a ball lying beneath the abdominal walls ; the cervix uteri is soft and broad, wide below, but contracted above like a funnel ; its lips are bruised, and not infrequently present fresh and deep lacerations. Through the anterior vaginal fornix the body of the uterus is felt as a heavy super-incumbent mass, which can however readily be moved, and has a bulgmg ' Cf. Klink, Vierteljahrsschri/t für Dermatologie, iii., p. 207. * Pauli, Dissertation. Berlin, 1879. 20 306 THE CHANGES IN THE MATERNAL SYSTEM. anterior wall ; it contracts on firm pressure, especially on bi- manual examination. The lochia! discharge (c/. supra) flows from the os uteri. The vagina is wide, its walls lax, the columna rugarum is absent. The external genitals are still swollen and bruised, the hymen is torn, its fragments are congested ; erosions and small tears will usually be found granulating. The perinaeum is discoloured and very elastic, and lacerations are especially common in its vicinity. The perinseal portion of the vaginal entrance gapes most freely ; there too the mucous membrane is most injured and much smoother than before. § 224. If all or most of these signs are present, especially if they are evidently of recent origin, the diagnosis cannot be doubt- ful. Such will be the case during the first ten days, for there is no other condition which would produce even an approximate aggregate of those signs. In case of doubt, the changes in the breasts, perinaeum and vaginal orifice, and those in the uterus are the most reliable. Mammary secretion may indeed occur in the non-puerperal condition, but the quantity and composition of the fluid secreted in such a case, are entirely difi'erent, and on the other hand the breasts of a recently confined woman are scarcely ever quite empty and soft. The vaginal orifice, the vulva and the perinaeum may be stretched in surgical intra- vaginal operations, but, apart from the fact that in such circum- stances an opinion as to what has caused the signs, is scarcely ever required, such stretching is very difi'erent, and the tissues have an entirely difi'erent appearance to that seen in the puer- peral state. Enlargement of the uterus is of course a common occurrence, as well as dilatation of its cavity ; but the softness of the tissues characteristic of the puerperal state is absent in all pathological conditions, and so also is the gradual diminution in size. The latter feature is the most important diagnostic sign of j childbed, especially when it can be ascertained from day to day by bimanual examination and by the sound. It is of course true that involution and diminution of the uterus may follow upon the expulsion or extraction of pathological contents, but they then take place much more rapidly and vigorously ; the process is never so regular or prolonged as in childbed. The above brief description of the various phenomena will! make it evident that the signs of childbed only attain their full I value, when compared with one another, and when the morbid] THE CHANGES IN THE MATERNAL SYSTEM. 307 conditions whicli produce similar phenomena are eliminated. It will further be clear that they are only reliable during the first 14 days, and this period of time coincides with that during .which the progressive diminution of the uterus can still be made out. After that period the diagnosis becomes more uncertain, and it is especially difficult to determine the date of the labour that has taken place. During the first 14 days the date can be fixed with a moderate degree of accuracy by the progress in the retrograde changes of the external organs and of their injuries, land especially by the size of the uterus. When a later, and of course a mere anatomical, diagnosis of "parity" has to I be made, the changes (^cf. §§214 and 21")) in the larger vessels of the uterine iWalls, and especially those in the sinuses of the "placental area," are of im- portance ; so also is the deposit of pigment over that area of the uterine walls (cf. Williams, London Obstetrical Transact., xx., p. 172 ; and Balin, I.e.). LITERATURE. Winckel, Die Pathologic v. Therapie des Wochenbettes, 3rd ed. Berlin, 1878. Baumfelder, " Beiträge zu den Beobachtungen der Körperwärme," &c. Bis- ■wrtation, Leipzig, 1867. The pulse in childbed : M'Clintock, Clinical Memoirs on Di.'^eascs of Women. Dublin, 1863, p. 356. Blot, Arch, gener. de med., May, 1864. Fritsch, Arch.f. Gyn., viii., p. 383. Löhlein, Zeitschrift f. Geb. u. Frauenhrankheiten, i., p. 482. Mayburg, Arch.f. Gyn., xii., p. 114. Dumas, Arch. Toculogie, July, 1878, p. 410. The urine in lying-in women: Kleinwächter, ^/t/<./. ö'y«., ix., p. 370. iHempel, ibid., viii., p. 312. Johannovsky, ibid., xii., p. 448. Hofmeister, \Centralblatt f. Gyn., 1878, p. 88. Kaltenbach, Zeitschrift f. Geb. v. Gyn., iv., p. 161. I Gassner, "Ueb. d. Veränd. d. Körpergewichtes bei Schwang., Gebär, u. .Wöchnerinnen." Mon.f. Geb., xix., p. 46 et seq. Changes in the uterus during childbed : Heschl, Zeitsch. d. Gesellsch. der Wien. Aerzte, viii., 1862. Hecker, A'linik d. Geburtsk., i., 1861, p. 85. Duncan, Arch.f. Gyn., vi., p. 425. Crede, ibid., i., p. 84. Pfannkuch, \ibid., iii., p. 327. Ed. Martin, Zeitschrift f. Geb. it. Frauenkranhh., i., p. 405. |Börner, Ueber den puerperalen Uterus. Graz, 1875. Serdukoff, Obstctr. Journ. ' Gr. Britain, Octob., 1875, p. 477. Lott, Zur Anat. v. Phys. d. Cervix uteri. I Erlangen, 1872, p. 101. ! The internal surface of the puerperal uterus: Friedländcr,P/(y.v.- \Anat. Untersuch, über den Utems. Leipzig, 1870 ; also Arch.f. Gyn., ix., p. 22. j Kundrat u. Engelmann, Strieker's Med. Jahrb., 1873, pp. 135, 167. Langhans, [Arch, f Gyn., viii., p. 287. Leopold, ibid., xii., p. 169. Sincity, Arch. Tocol., Dec, 1876, p. 749. Küstner, Arch. f. Gyn., xv., p. 37. Patenko, ibid., xiv., p. 422. Balin, ibid., xv., p. 157. 308 THE NEW-BORN CHILD. The lochia : Wertheimer, Virchow's Archiv., xxL. p. 314. Rokitanskj' jun., Strieker's Med. Jahrb., 1874, p. 161. The changes in the vaginal orifice after delivery: Bellien, Arch.f. Gyn., vi., p. 132. Duncan, Obst. J. Gr, Britain, Jan. and May, 1877. Budin, Arch. Tocologie, March, 1880. The secretion of milk: cf. especially Heidenhain, Physiologie der Absondervngsvorgange. Part 7, 1880. From Hermann's Manual of Physiology. Partsch, " Ueber den feineren Bau der Milchdrüse." Dissertation, Breslau, 1880. Kühne, Lehrbuch d. physiol. Chemie. Leipzig, 1868, p. 558. Rauber, Ueber den Ursprung der Milch. Leipzig, 1879. cf.also for clinical features: Chantreuil, Arch, de Tocologie, May, 1874. Schramm, Scanzoni's Beiträge, v., p. 1. Kehrer, Beiträge r. rergl. u. exjjerim. Geburtskunde, iv., p. 39. L. Mayer, Berliner Beiträge z. Geb. u. Gyn., ii., p. 136. Jacobi, Amer. Journal Obstetr., x., p. 353. 2. The New-horn Child. § 225. As a rule the placental interchange of substances ceases, and the first sense of a want of breath sets in at about the time that the foetus is expelled from the parturient canal, the slight variations in the moment of the first inspiration depending (cf. § 161) on the special conditions of the labour, and on other secondary influences. When vigorous children are born soon after rupture of the membranes, and with the expen- diture of but little force on the part of the uterus, and when the detachment of the placenta and the squeezing out of the con- tents of its blood channels towards the child's heart do not follow immediately on its exit, the apnoea of intra-uterine life may persist for one or two minutes after birth ; this apnoea may also be unusually prolonged in those cases e.g. premature births, in which the irritability of the nervous centres is but slight, owing to imperfect development. The first respiratory movements lead to an enlargement of the thorax ; the lungs consequently expand and cause the pulmonary alveoli to open up and fill with air, their capillary system being extended and widened ^ The resistance which the pulmonary arteries previously presented has now disappeared, and as a result a great quantity of blood (probably mainly derived ' The first inspiratory movements cause the ribs to be so much raised, that they never return to their old position during expiration. When once inflation has taken place, the force of elasticity is no longer sufficient entirely to expel the air. The thoracic aspiration will of course depend on the extent to which the ribs continue raised. {Of. Bernstein, PflUger's Archiv., vol. 17, p. 617; Hermann, ibid., vol. 20.) ^3^ A. Placenta. B. Posterior vascular system. C. Intestine. D. Liver. EE. Lunga. F. Anterior vascular system. DA. Ductus venoBUfl Aranzi. vu. umbilical vein. /. superior hepatic veins. v. inferior hepatic veins. p. vena portse. C'i. Vena cava inferior. Cs. Vena cava superior. ad. right auricle. as. left auricle. vd. right ventricle. vs. left ventricle. ap, pulmonary artery, vp. pulmonary vein. ah. hepatic artery. au. umbilical artery. a. aorca. DB. Ductus Botalli. Fig. 58.— Foetal circulation. (From the description of Professor Hasse, drawn by H. Strasser.) Bed=arterial blood. Violet=mixed blood. Blue=venoHs blood. Placenta. Posterior vascular system, Inteatine. Liver. Lnngs. Anterior vascular system. Vena portse. Hepatic veins. Umbilical vein -j Umbilical artery [-Obliterated. Ductus Aranzi. J Ductus Botalli. Vena cava inferior. Right auricle. Right ventricle. Left auricle. Left ventricle. aorta. pulmonary vein. pulmonary artery. hepatic artery. Fig. 50. — Circulation in the new-bom child. The foetal channels are becoming obli- terated. The arterial blood is not yet quite pure. Red=arterial blood. Blue=venoua blood. B. Posterior vascular system. C. Intestine. D. Liver. E£. Liinga. F. Anterior vascular system. p. Vena portae. /. Hepatic veins. Ci. Vena cava inferior. Ad. Right auricle. Vd. Right ventricle. As. Left auricle. Vs. Left ventricle. a. aorta. vp. pulmonary vein. ap. pulmonary artery. ah. hepatic artery. Fig. 60. — Circulation in an aidult. The colours denote the same kinds of blood as in fig. 59. THE NEW-BORN CHILD. 309 from the " reserve blood ") rushes from the right ventricle past the orifice of the duct of Botallus into the pulmonary channels ; that duct being no longer filled, becomes contracted. The arterialised blood returns by the pulmonary veins to the left auricle and greatly distends it ; and since considerably less blood is meanwhile entering the right auricle (for the umbiUcal vein no longer conveys any blood), the blood-pressure sinks in that, while it rises in the left auricle. Both auricles therefore become equally filled ; the current through the foramen ovale ceases, and the orifice gradually closes. The reflux from the left into the right auricle which might result from the higher pressure in the former, is prevented by the disposition of the valve of the foramen ovale {cf. § 112). As the work done by the right ventricle ceases to affect the descending aorta, the force of the current in the latter naturally diminishes greatly, and is no longer able to maintain the circulation in the long umbilical arteries ; these therefore immediately after birth become greatly contracted, and the posterior portion only of their trunk remains patent, i.e. that which has an outflow through one or more collateral branches in the wall of the bladder (superior vesical artery). The umbilical vein and the ductus venosus Aranzi being no longer fed, likewise contract, and are emptied of the blood contained in them in the direction of the thorax by the force of aspiration {cf. figs. 58, 59, and 60). The obliteraiion of the foetal channels takes place in the following way. The ductus arteriosus Botalli collapses after being emptied, is pushed aside and bent, as a result of the expansion and displacement of the pulmonary branches to the right and the left, and of the heart changing from a horizontal to a more vertical position; these influences, assisted by a hypertrophy of connective tissue commencing in the iutima, lead to its obliteration. The duct is converted into a fibro-elastic cord (ligamentum arteriosum), which very frequently retains a small lumen. The umbilical arteries become contracted and thrombose from the umbilical ring to the commencement of the posterior portion of their trunk already mentioned, and are in- verted into a solid cord (ligamentum vesicale laterale). The vein and its continuation, the ductus venosus, are emptied by aspiration, and collapse ; and since no more blood is supplied to them, and the intra-abdominal portion together ^Nith the duct ot 310 THE NEW-BORN CHILD. Aranzi is flattened by a descent of the diaphragm and of the liver, their walls remain in contact, and the vessels are oblite- rated by an agglutination of the layers of endothelium. Throm- bosis is pathological ; a persistent patulous condition is extremely rare^ , Owing to the additional supply of blood brought by the pul- ^ monary veins, and to the arrested influence of the right side of the heart upon the current in the aortic system, an eccentric hypertrophy of the left side of the heart takes place, so that by degrees the normal difi"erence in size of the two halves of the heart is brought about. This hypertrophy extends even to the muscular bundles of the valve of the foramen ovale, and assists considerably in the obliteration ofthat foramen. § 226. The remnant of the umbilical cord dries up from the divided surface towards its origin at the navel ; it turns brown, becomes flattened by pressure, and falls ofi" as a rule on the fourth or fifth day, sometimes later. In rare cases detachment occurs before the fourth day ; sooner in strong healthy children than those that are weakly and premature. The line of demar- cation is formed by the edge of the circle of capillaries derived from the abdominal skin (c/. § 98) ; the dead remnant there gives rise to an irritative inflammation, by which it is entirely detached. At this spot the skin contracts in a somewhat circular manner, and after the detachment a small sore remains, resembling an ordinary flat superficial scar which is on the point of closing. It continues to discharge a day or two, then dries up and healing is complete. If the circle of capillaries is placed low down, the navel will be depressed ; if very high, the navel will project. The sero- sanguineous swelling of labour disappears very quickly, usually within 24 — 48 hours ; although in very severe cases the afi'ected area may continue red and sensitive for some- what longer. The moulding of the head during labour dis- appears as the original foetal shape returns, the rapidity with which it does so varying with the degree to which the bones were displaced and compressed. Such moulding usually dis- appears entirely wdthin two or three weeks, a true tocological shape persisting only in very rare instances. The shape of skull peculiar to the individual gradually becomes apparent, ' Cf. Baumgai-ten in Med. Centralblatt, 1877, p. 721. THE NEW-BORN CHILD. 311 although it was of course settled and prefigured in the orifnnal development of the foetus'. § 227. Soon after hirth the intestine hecomes functional, its first action being to expel a large portion of the meconium filling up the colon. In a couple of days the evacuations become more faecal, varying according to the kind of the food that has been taken. The mother's milk is the only natural food for new-born infants. It is especially rich in those sub- stances which are necessary for the first of those metabolic processes, which are about to develop step by step, and is there- fore best fitted to compel the tender growing organism to take up in the normal way all the various substances necessary for its tissues and fluids ; it alone requires in order to be digested neither a prolonged sojourn in the stomach, nor any special mechanical force beyond such as can be furnished by the stomach while its muscle is still weak. When active assimilation has once started, the secreting apparatus of the stomach and intestine become functional, both are filled with gases, and the stomach passes from its originally vertical into the transverse position. The entire abdominal cavity enlarges, its vessels become fuller, and convey more blood to the hver for the formation of bile. All the digestive ferments are, generally speaking, present in the new-born child. Pepsin is specially constant in the stomach, its formation beginning at the 3rd— 4th month of foetal life, and being connected with the development of the gastric glands, whose activity therefore is moderately great even in new-born children. The acid of the stomach however is absent during the later months of foetal life, although present in new-born children ; the formation of trypsin begins in the foetus at the 5th month. The parotid contains ptyalin, but in the submaxillary gland this ferment is not found till later ; as yet an infusion of the pancreas contains no sugar-producing ferment, although it is able to digest albumin and to decompose fats. The renal secretion is copious, and contains all the principal constituents of urine. The urine is pale, dilute, with an average specific gravity of 1006 and an acid reaction ; albumin is rarely present and only during the first days ; never in healthy children The urine even in the first days often soils the child's hnen with - Cf. Hecker, Arch./. Gyn., xi., p. 348; Rüdinger, Beitr. ... Anthropologie ^c. Bayerns, 1877, vol. i., p. 286. 312 THE NEW-BORN CHILD. a yellowish-red powdery deposit, consisting of urates which pre- viously filled the straight uriniferous tubules {uric acid infarct of the kidneys), and have been washed away by the urine. Their formation depends on the greatly increased, though not perfect, combustion of albuminates. § 228. At birth the skin of the foetus is exposed to very dif- ferent conditions from those in utero. It loses its vernix, turns very red, and usually on the third day its epidermis begins to desquamate (constituting a physiological pityriasis). The desquamation is in most cases branny, though the squamae may form shreds or lamellae ; both varieties occur in perfectly healthy children, but in my experience the exfoliation of very large lamellae is commonest in diseased children, and especially in children of diseased mothers. The desquamation begins on the anterior surface of the trunk, then spreads to the lower extremities, then to the face, and last of all (but not always) affects the upper limbs. Its duration varies greatly ; in most cases the process terminates in 5 — 7 days, but it is not rare for it to last a fortnight. It persists longest where it appeared latest, i.e. on the face. On cutaneous surfaces which look towards each other, the desquamation not uncommonly leads to intertrigo ; the scrotum sometimes loses the whole of its epidermis, since owing to the incessant moistening by urine, the regeneration takes place but slowly. As long as the desquama- tion lasts and especially during the first period, the skin is very hyperaemic and has a deep red colour ; this by degi-ees passes into a light yellowish-brown tint, and may be mistaken for a slight icterus. The skin only assumes the proper flesh colour when the desquamation has terminated. New-born children perspire readily and freely, especially after the first three days of life ; sudamina are very apt to form. The inflammatory swelling (so common in both sexes) of the small mammary glands, or rather of their rudiments (for at this early period there are only the main ducts with a few dilated offshoots), is to be looked upon as a consequence of the cutaneous hyperaemia. Those glands become red and sensitive to pressure, and a serous milky or colostrumlike secretion (called by the Germans witches' milk) can be squeezed out ; it is more abundant in vigorous than in weakly children, and may be absent in the latter. This turgescent and irritable state passes away in a couple of days without THE NEW-BORN CHILD. 313 further consequences, though injudicious manipulations may cause a suppuration of the rudimentary glands. The majority of new-born infants (about frds of the whole number, especially weakly and premature children, and those of Primiparae somewhat more often than those of multipane) show during the first week a true icterus of variable intensity, which as a rule begins on the second or third day, and in most cases has disappeared by the 6th — lOth day. Sometimes however it does not terminate till the 2nd or even the 3rd or 4th week; or else after lasting several days and entirely disappearing, a short relapse takes place. The children are as a rule perfectly well during the attack, drink and pass faces, which considering their nourishment are normal. Only in severer cases do they appear to suffer or to be somnolent ; at first they waste con- siderably, and afterwards make up for it very slowly, if at all. Simple icterus is therefore almost a physiological phenomenon and requires no special treatment, though it will be well to see that the bowels act freely and that the skin is well cleansed. The causes are obscure. The view (Frerichs) that a diminished fullness of the capillaries of the hepatic parenchyma consequent on the arrested afllux through the umbilical vein and on the developed pulmonary circulation, causes more bile to pass into the blood is as yet no more than a hypothesis ; nor is there much probability in the theory that a congenital narrowing of the terminal portion of the bile-duct, or possibly a sluggish peristalsis of the latter in view of the thick copiously secreted bile, prevents its complete escape and thus leads to its resoqjtion (Kehrer). It is much more likely that the ordinary ic^'^^^• neonatorum is usually caused by the blood. Zweifel believes that the icterus arises through the blood exuding from the vessels ot the skin, and through the colouring matters of the blood being set free ; Porak takes the view that the surplus red corpuscles in the blood are destroyed, while the colouring matters from them are set free. In favour of these views are the absence of bile-pigment m the urine of the jaundiced infants, and on the other hand the occurrence of crystals of bilirubin in their tissues (Orth), and of similar substances in the urine (Parrot and Piobin) ; bihrubiu and hffimatoidin being in all probability identical pigments. Porak's view seems to me to be better supported than that of Zweifel, inasmuch as the changes which favour the extra- 314 THE NEW-BORN CHILD. vasation of blood under the skin (ecchymoses) in the latter, have not been observed in the jaundiced new-born children, and since the sclerotic also is coloured yellow. The wholesale destruction of red blood-corpuscles is however undoubtedly due to the over-distention of the vessels of the child with the blood which should have been lost with the placenta and umbilical cord, a view which does not favour the practice recommended by so many, of forcibly squeezing the placental blood into the new- born child (c/. § 196). It is a curious fact that icterus often somewhat delays the onset of desquamation, the latter only becoming fully developed as the yellow coloration diminishes or disappears. The production of heat in the newly-born babe is scarcely sufficient entirely to make good the loss which, as the fcetus passes out of the maternal body into a medium which is nearly 20° C. (36° F.) colder, results by radiation and conduction through the air, and by means of the evaporation from the surface of the very moist skin. The temperature of the babe therefore, though rather higher than that of the mother immediately after birth, very soon becomes lowered. This fall may be very important in premature and weakly children, and indeed the temperature may sink far below that which is usually considered as the minimum under normal conditions. Happily new-born children bear such a fall better than older individuals, and an excessive fall is almost always guarded against by artiöcially preventing the loss of too much heat, and also by warming the child ; if a proper amount of nourishment is taken and respiration is free, it is not usually long before the young organism loses the dis- position to a fall of temperature and becomes able to produce sufficient heat for itself. § 229. All new-born children lose in iceiglit during the first three days. This is due to the altered conditions of life which have followed on delivery, to the small amount of nourishment taken during the first few days and especially to the abundant discharge of meconium and urine. This physiological atrophy can be greatly lessened, although not altogether prevented, if the cord is not ligatured too soon, and if the mother and indirectly therefore the child are suitably nourished, granting the conditions to be otherwise healthy. The total decrease averages 220 grm. (7| oz.) and lasts for about 3 days, when the new-born infant THE NEW-BORN CHILD. 315 begins to make good the loss by a gradual increase ; the original weight is often regained by the 5th day, but generally by the 7th or 8th day ; after this the gain in weight continues, slowly at first, more rapidly after three weeks. The children of primipane during the first two days show a greater loss in weight than those of multiparse, and the latter also develop more regularly and rapidly than the former ; the age of the mother has an influence similar to multiparitj'. Whether sex has any influence on the date of the commencement and the rate of growth is un- decided. It is easy to understand why hand-fed children lose weight for a much longer time, and afterwards grow much more slowly than those nursed at the breast. § 230. The mental activity of the new-born babe is still on a very low level ; the organism is governed by its spinal cord, as Virchow has well remarked. It feels and moves unconsciously, either in a reflex manner or spontaneously (Preyer), possibly also instinctively {i.e. guided by an inherited memory), when such a movement as that of suckling is executed with a definite purpose. Volition is still dormant ; the inhibitory centres are as yet unde- veloped, hence the freer scope for reflex activity, for hyperkinesia ; hence also the liability to convulsions (Soltmann). Reflex actions which are executed as a result of experience, i.e. through intervention of the brain, are absent, e.g. closure of the lids when the surface of the eye is touched. Tactile sensations and the sensitiveness to temperature are very feeble ; sensitiveness to pain also is little developed and the muscular sense is slight. The sense of taste appears to be the most acute (Kussmaul), for the baby can distinguish the various sensations connected with it, and its mouth is thrown into the usual contortions. The perception of odours can scarcely bo dis- tinguished from taste, so that that sense must also be present at an early date. Light is undoubtedly perceived after a few days of life, for new-born children soon turn their head towards luminous objects. They next begin to stare at things, an act which is often mistaken for vision, but it is not till the 8nl— 6th week, often still later, that the children begin to fix bright, shining objects. The sense of hearing remains longest dormant during the early period of life. 316 MANAGEMENT OF THE PUERPERAL STATE. LITERATURE. Schlicking, " Zur Phys. der Nachgeburtsperiode &c." Berl. Klin. Wochcnsch., mi, Nos. 1 and 2. Ribemont, " Rechcrch. sur la tension du sang dans les vaisseaux du foetus et du nouveau-nö", Arch. TocoL, 1879, p. 577. The obliteration of the foetal blood channels: Landau, *• Ueb. Melaena der Neugeborenen .Sec.'' Habilit.-Sclirift, Breslau, 1874. Strawinski in Wiener Acad. Sitzung.shericliten, vol. 70, Part 3, July, 1874. H. Meckel in Berliner Charite-Annalen, 1853, iv., p. 318. Stutz, Arch. f. Gyn., xiii., p. 315. Digestion in ne \v-b orn children: Zweifel, Untern, über d. Vcrdauu ngS' apparat d. Nengehoremm, Berlin, 1874. Wegscheider, " Ueber d. normale Ver- dauung bei Säuglingen," Strassb. JDi.^.scrt., Berlin, 1875. v. Puteren in Schcnk's Mittheil, aus dem Embnjol. Institute, i., 1877, p. 95. Langendorff, Arch. f. Anat. u. Phys., Phys. Abtheilvng, 1879, p. 95. Urine of new-born children : Dohrn, Mon.f. Geburtsk., xxix., p. 105. Martin und Rüge, Z.f. Geh. v. Frauenliranhh., i., 1875, p. 273. Parrot et Robin, Arch. Gener. d. Med., 187(;, i., p. 129, 309. Cruse, Jahrb. f. Kinderheilk., xi., 1877, Part 4. Breasts of new-born children: ^miij, Arch, dc Physiol.,\Blö,\y. 'I'd!. Genser, Jahrb. f. Kinderheilh., ix., 1875, p. IGO. Icterus of new-born children: Kelirer, StJidien üb. d. Ictcr. A'eonat. i^parat-abdruch. Schultze in Ilandh. der Kinderkrankheiten von Gerhardt, vol. ii., 1877. Violet, Virchow's Arch., 80, p. 353. Zweifel, ^Ij'cä. /. Gyn., xii., p. 251. Porak, Annal. Gyn6col.. x., 1878, p. 189. Changes in the weight and state of nutrition in new-born children : Kehrer, Arch. f. Gyn., i., p. 124. Gregory, ibid., ii., p. 48. Kez- märszky, ihid., v., p. 547. Krüger, ibid., vii., p. 59. Fleischmann, Wien. Klinik, June and July, 1877. Camerer, Zeitsch. f. Biologic, xx., p. 383. Ritter v. Rittershain, Statist. 3fittheilungen, Prague, 1878, p. 44. Ahlfeld, Ucb. Ernährung des Säuglings an der Mutterbrn.ci-ii. ISsO. 334 PART III. PATHOLOGY AND THERAPEUTICS OF PREGNAK'CY, PARTURITION AND THE PUERPERAL STATE. § 242. To enable my reader. to understaml the followiug descriptiori, I must begin by defining the various kinds of mechanical interference that are peculiar to midwifery, i.e. the ohstctrical operations. But I cannot here describe them fully, since a detailed account both of the indications for their use and of their mode of emplo}Tiient presupposes a full knowledge of the conditions under which they are practised, and the latter forms the subject of this part of my work. A superficial acquaintance with the objects of obstetrical operations will suffice for the present. Apart from a few operations intended only for special cases, obstetrical operations have the object either of causing or facili- tating the expulsion of the foetus from the parturient canal (preparatory operations), or of supplementing the expulsive forces where they are insuflicicnt (extraction operations). To the former class belong 1, the induction of premature labour, by which labour is brought on before pregnancy has reached its natural termination, but at a time at which the foetus is viable ; 2, the induction of abortion, by which labour is brought on before the foetus is viable ; 8, the artificial rupture of the bag of membranes ; 4, version, i.e. the conversion of one foetal " lie " into another, always into one of the forms of longitudinal lie. For assisting or supplementing the expulsive forces, we have the following means at our disposal : 1, expression of the foetus from u'ithout ; 2, extraction begin ning icitJi the pelvic extremity, whether this presented primarily, or was only brought down by version ; 3, the extraction of the head by means of the forceps, an instrument (comparable to prolonged hands) consisting of two blades which are introduced separately, and afterwards easily united. In some cases it is necessarv before the extraction to THE PATHOLOGY OF PREGNANCY. 335 «liininish the resistance and size of the skull by opening and empt3äng it (perforation), or to draw it out with crushing instru- ments (cephalothrypsij) , or with strong bone forceps (cmnioclaHin). It maj' also be necessary to open the cavities of the trunk, to break up the vertebral column, or to remove certain portions of the body {embryotomy). Again, where the obstacles to delivery are so great that the latter class of operations is inadmissible, or where they are not so consistent with the life of the child, an exit for the latter must be found through the uterine and abdominal parietes {C(es(irian section). Finally, where the life of the mother is in great peril, the spontaneous dilatation of the uterus cannot be waited for, but must be effected by force, and the organ is then immediately emptied ; this is forced delivery in the narrower sense of the word {Accouchement force^. 336 THE PATHOLOGY OF TKEGNANCY. I. — The Pathology of Phegnaxcy. § 243. The diseases of pregnant women are either exacerba- tions of the usual deviations from a perfectly healthy condition, which thus transgress the limits of health ; or incidental diseases not directly due to pregnancy, but whose progress is specially modified by it ; or affections of the sexual organs ; or finally anomalies in the development of the fcetus. The last chapter' deals with uterine haemorrhage in its various forms, and with the premature interruption of pregnancy. Some of these maladies persist during labour, and several of them will there- fore for the sake of completeness only be described in the subsequent part. 1. Disorders caused by a Morh'ul hticnsitij of Phißwloiiieal Phenomena. % 244. The changes which take place in the system of a i pregnant woman, have been described in § 70 et aeq., and we ! attempted to refer them to their causes. It is extremely difficult i to draw the line at which these phenomena become morbid, i especially as they generally only become so owing to individual j peculiarities. The practitioner will require all his acumen in | drawing the line, as well as tact in deciding how long he may j maintain a passive attitude, and when he should interfere. The ' management of such a case invariabh* requires great care, since the conditions we are about to discuss may severely injure the system, and may terminate the pregnancy prematurely ; and conversely such a premature termination is liable to be favoured > by his mode of procedure. Moreover when the question of active interference comes up for discussion, it is well to remember that our therapeutical resources as a rule cannot cure the mischief; an alleviating treatment is generally the only one left, and is at the same time of most value. Above THE PATHOLOGY OF PREGNANCY. 337 all the strength of the sick woman must be kept up as long as possible, and broadly speaking dietetic means will be of more service than medicinal. The most important diseases are the following : a. Changes in the Blood. § 245. The deterioration of blood which occurs in so many pregnant women, may become a true hydremia (serous plethora, § 76). This differs but little in its outward signs from other kinds of dropsy, and can only be looked upon as an affection siti generis, where there is no disease either of the organs of circulation or of the kidneys. An individual predisposition will almost always be found, but bad nourishment during pregnancy and a damaged condition of the walls of the vessels constitute one of the main causes. Hydrasmia leads to serous exudations into the subcutaneous areolar tissue, and into the great cavities of the body, especially that of the abdomen ; its onset is some- times slow, sometimes rapid, and occasionally the exudation disappears from one part in order suddenly to develop in another. Effusion into the thorax is specially dangerous when it forms unexpectedly and quickly. Amongst the subcutaneous exuda- tions, those affecting the lower limbs and the external genitals are most troublesome, and since the pressure exerted by the uterus &c. in the pelvis is at the same time interfering with the return of the blood, they may reach an enormous extent. The face as a rule remains unaffected. The urine secreted is generally very abundant and dilute ; when the kidneys are health}^ there is no albumin or only a temporary trace. The hydremia rarely disappears before the termination of pregnancy, but the conditions it gives rise to may lead to premature labour; the previous good health rapidly returns, when the labour is over. Treatment must aim at improving the composition of the blood, at inducing a copious excretion of water, and at alleviatmg the local discomfort.. In regard to the first point the indications are clear, and to bo regulated mainly according to individual conditions. There is nothing better than a prolonged course of iron ; and I can strongly recommend for these cases the com- bination of iron with phosphate of lime (aa '2 grm. = gr. n], ter 2iA 338 THE PATHOLOGY OF PREGNANCY. die), or with alkalies (especially Blaud's pills ^), which at the same time have a diuretic action. Irritating diuretics and the frequent use of saline purgatives are to be avoided. The oedema of the lower extremities is best combated by keeping them raised, by alcoholic liniments, by bandages and elastic stockings ; that of the labia by aromatic lotions, chamomile hip-baths and purgatives. Punctures should not be made rashly ; they often bring on " pains", and the punctured points are apt to become inflamed. § 246. In very rare cases the impoverishment of blood does not lead to hydraemia, but to ancemia of the severest type. This was long ago described by Addison and Lebert, and called pro- gressive pernicious ancemia by Biermer; but Gusserow was the first to show that it occurred in pregnant women. Its nature is that of a true oligemia or better oligocythosis, to which hydrae- mia is afterwards superadded. The aetiology is still obscure. We may however take it for granted that the blood-forming apparatus is diseased in such a way that too few red corpuscles are formed, and that too many atrophied ones, i.e. corpuscles whose form has not attained full development, are continually thrown out into the circulation ; with this disturbance in the formation of red corpuscles, an active disintegration of those already present gradually becomes associated. At any rate the hydraemia of pregnancy offers a favourable soil for the develop- ment of pernicious anaemia, although the latter does not origi- nate spontaneously from the former during pregnancy, unless specially favourable conditions are present in the organism, e.g. hypoplasia of the vascular system (essential chlorosis), and when in women who are subject to hj'poplasia pregnancies follow rapidly upon each other, and assisted by the periods of lacta- tion bring the income and expenditure of the body into great disproportion. Fatty degeneration of the cardiac muscle (especi- ally of the papillary muscles) is almost always present ; also of the intima of the arteries and of the capillaries in some places. These changes as well as the almost constant retinal haemor- rhages are certainly secondary. ' Their composition is ^ven in Johnson's " Medical Formnlary." Petri sulph. partes 30, Pot. Carb. 30, gum. acacife 5, aquae 30, syrupi simplicis 15. Dissolve the gum in the water, on a water bath ; add the syrup an^i iron, then the ' carbonate of potassium and evaporate to proper consistence ; divide into pills of ■ •4 grm. (gr. vj) each. Dose, 1 — 3 pills ter die (Tr.). THE PATHOLOGY OF PREGNANCY. 339 The disease generally begins insidiously (as is indicated by the term progressive anemia) during the earlier mouths of pregnancy, although the first threatening symptoms as a rule only show themselves during the second half, and is extremely dangerous. Out of 25 cases collected by Graefe (L c), almost all died, most of them very rapidly, soon after labour ; the majority had died before 10 months after the distinct appearance of the disease; only one is spoken of as cured, but two were discharged as improved. The pregnancy often terminates prematurely (out of those 25 cases it did so 12 times, once in the sixth, 5 times in the seventh, 4 times in the eighth and once in the ninth month ; of one case there is no record). The induction of premature labour or of abortion is urgently called for, and indeed before the disease attains its maximum severity, since when it has done so, the very act of parturition, even though the accompanying loss of blood be but very small, may suffice rapidly to cause death. The three cases mentioned above show that when pregnancy is terminated, i.e. when the chief cause is removed, the disease may be arrested and the dangerous symptoms checked ; but the probability of this hap- pening will be greater, the earlier the pregnancy ia brought to an end. Transfusion also must be looked upon as a rational proceeding, although the four cases in which it was carried out (c/. Graefe) ended fatally in spite of it ; perhaps the operation was done too late, perhaps also the want of success was due to the way in which it was performed. Further observations must decide upon its value. Dietetic and medicinal means are only of use at the beginning of the disease. A treatment similar (from an obstetrical point of view) to that of the disease which has just been described, is required l»y the h(emorrhagic diathesis which is occasionally met with, and in ' the development of which pregnancy seems sometimes to take an important share. {Cf. Kehrer, "Die Hamophihe beim weib- lichen Geschlechte," Arch. f. Gijn., x., p. 201.) § 247. I believe that my investigations {cf. § 70) have estab- i lished on theoretical grounds the occurrence of a true ph'thora I with pathological sequelae, the existence of which had for clinical i reasons seemed probable. A considerable increase in tlie total j quantity of blood will of course only show itself under very favourable conditions, and during the second half of pregnancy. 340 THE PATHOLOGY OF PREGNANCY. The symptoms are for the most part local : congestion of the chest and head, palpitations, tendency to vertigo, engorgement of the portal system, sluggish action of the howels ; the symptoms may be peculiarly troublesome during the exertion of labour. Plenty of muscular activity, a sparing diet, and an abundant consumption of water, now and again a saline purga- tive, are the remedies to be recommended. Moreover the experi- ence of many a country practitioner shows how beneficially small, and even repeated, venesections act on the disoi'ders that have been mentioned ; to forbid them altogether in pregnant women is an even more one-sided practice, than was the former routine of bleeding for every ailment that accompanied pregnancy, h. Disorders connected with the Circidation. § 248. (Edema and varices of the lower extremities and of the pelvis are the only circulatory disoi'ders, which, when the system is healthy, can assume grave characters during pregnancy and need to be mentioned {cf. § 74). This mechanical cedema may be distinguished from that due to hydrsemia, by being restricted to the regions just mentioned, by i as a rule only becoming marked during the last months, by never reaching such a degree of severity, and by diminishing with the horizontal position. The advice to be given under such circum- stances is ob\'ious. Varicose veins are most common in multiparjE, although by no means rare in primiparse. They may be capillary, in which case an arborescent net-work of bluish vessels is seen round the . ankles, and especially on the inner surface of the thighs. This variety has no importance, unless the great veins too are involved. The saphena seems to be the first to undergo dilata- tion, then its lateral branches, which form great swellings on the inner surface of the leg and thigh, especially above the knee. It is clear however from the great frequency with which the haemor- rhoidal and vulvar veins are affected, that the deep vessels lying below the point of bifurcation of the iliac veins are also involved. Both limbs usually sufier ; when only one is affected, the left is so most frequently. As a rule varices only become severe during the second half of pregnancy. Generally they merely form an unpleasant compH- THE PATHOLOGY OF PREGNANCY. 341 cation, but they may grow dangerous by inflammation and suppuration, by thrombosis and even by embolism, lastly and chiefly by rupture. I know oifoiir cases in which death resulted from hcemorrhage^ due to such a cause. The treatment of varices is that of oedema of the lower extremities, and in such cases a proper dietetic regime, attention to easy deftecation, and sym- metrical compression of the thighs are especially important ; injections of ergotine (grm. 'l^^gr. iss, to be repeated) into the aöected limb are always worthy of trial, nor is there any risk that the progress of pregnancy will be disturbed by them. Inflammation, suppuration, and rupture must be treated accord- ing to the usual principles ; rupture by a firm compress followed by a suture. c. Disorders of Digesilon. § 249. The severest of these is the so-called uncontrcllahlc vomiting. Retching and vomiting, when the stomach is empty or soon after food, are unimportant symptoms during the first months of pregnancy, and do not seriously alarm the pregnant woman or her friends ; but the persistent vomiting in which tbe ; stomach retains absolutely nothing is, if at all prolonged, a very 'grave symptom. The patient rapidly grows thin, the eff'orts at 'vomiting (which may set in without any food being taken) soon ! bring up nothing bvit thin clear or greenish coloured mucus, 'which is not infrequently streaked with blood. The mouth grows dry, the tongue fiery red and glistening, the breath [offensive, the skin dry and pale. The urine is very scanty and [concentrated; constipation is almost always present; thirst is I great and very distressing, owing to the refusal of the stomach I to take anything. Fever also is present. It is remarkable how long the onset of extreme marasmus may be delayed, even jwhen assimilation is arrested; but eventually it shows itself, and the woman dies from exhaustion, or falls a victim to some I intercurrent, under other circumstances perhaps shght, illness. i ' Once from a varix of the leg in a laundress (vü-p.) who was in the eighth inonU. 1 of pregnancy, and fell down dead at the entrance to the lying-iu establishment wbcre ; she sought assistance; once in a woman (vi-p.) in the ninth month from a van. c I the inner surface of the right labium ; twice in primiparre, in one ^ou.an at the .4 I week, the varix being on the posterior side of the right th.gh ; the other ..^ near h ! normal end of her pregnancy, the haemorrhage occurring from the mner side of ' left leg. 342 THE PATHOLOGY OF PREGNANCY. In a few cases pulmonary phthisis has been the means of death. It might be supposed that the efforts at vomiting and retching would generally lead to abortion, but this is not the case ; if the labour comes on spontaneously, it generally does so but a short time before death, and the accompanying loss of blood and the exertion of labour morel}- accelerate the end. In some cases however abortion takes place before the condition of the pregnant woman has become hopeless, and she then usually improves. Now and again the disease is suddenly arrested, especially about the time when the uterus increases in size more rapidly than usual, i.e. when pregnancy has considerably advanced ; occasionally also when the first foetal movements are felt. The important fact has occasionally been observed that on the death of the foetus, the vomiting has suddenly entirely ceased and convalescence set in. Thus also is to be explained the fact that in cases where abortion takes place spontaneously or arti- ficially a short time before the end, or at the time when the sickness is most severe, the fcetus is almost always quite fresh, while in those cases where abortion occurs at the time of, or after the subsidence of, the illness, it is not uncommonly found > already macerated. PrimiparaB are more often attacked by this serious disorder^ than women who have already borne children. It comes oi between the second and the sixth month, the first and the last ones appearing to enjoy an immunity ; it is commonest in the interval between the beginning of the second and the end of the| fourth month. Now and then some serious disease of the stomach (simple ulcers, or infiltrations of the gastric walls)! gives rise to the vomiting, but as a rule the causes are obscure ^ of course such a cause should always be looked for in the first instance, and its detection may be exceedingly difficult. When such a cause can be excluded, we must seek for an explanation| in the well known "sympathy" between the genital organs anc the stomach, in perverted innervation, and with reference to this point it is important to note that in quite a large number of cases some source of irritation has been found in the uterus, e.g}^ flexion with impaction in the pelvis, or some hindrance to its rising up out of the latter, or an inflammatory swelling at circumscribed portion of the body and especially of the cervix," THE PATHOLOGY OF PREGNANCY. 343 with or without ulceration. Nevertheless there are numerous cases in which no objective organic change can be detected. An accurate diagnosis is therefore of the greatest importance for the manafjement of these cases. If one of the conditions mentioned above is found, this is first of all to be treated ; and in such an instance abstraction of blood from, or cauterisation of, the cervix may be of the greatest value. If no such a cause is found, we can only treat the symptoms, to which indeed we are restricted in those cases also in which local treatment has failed. The remedies recommended are so numerous and so various, that we can from this fact alone conclude that they are almost invariably useless, as far as a permanent cure is concerned. First and foremost we find the most diverse sedatives and nar- cotics, administered by the stomach, by the rectum, by inhala- tions, or subcutaneously ; cutaneous irritants also are applied to the region of the stomach. Ice is given internally, or kept on the epigastrium several times a day from half to one hour at a time, and may be very beneficial ; the local application may be followed up by stimulating fomentations (mustard and camphor). The frequently repeated use of ether spray on the gastric region is also eulogised. Amongst internal remedies, the oxalate of cerium is highly spoken of; -2— '3 grm.= 3— 4i grs. being given several times daily (Peters, New Turk Medical Record, March 3, 1877 ; Conrad, Schweiz. Correspondenz Blatt, No. 23, 1878) ; also bromide of potassium in doses of 1 grm. (15 grs.) several times a day (Friedreich), or per rectum according to American authors; tarinin also in '2 grm. =3 grs. doses (Duboue, Arch. TocoL, Sept., 1877) ; the finct. uuc.vomic. is recommended by Eoth {Centr.-Bl. f. Gyn., 1877, No. 18) in doses of 15 to 20 drops four times a day. The horizontal dorsal decubitus is of high value here, as in the vomiting of sea sickness. The greatest attention must be paid to the regular action of the bowels, and as a rule they are very troublesome ; small doses of calomel, and Carlsbad salts are recommended for this purpose. If the patient can sleep fairly well, i.e. for some hours uninterruptedly, she should always have something to eat before going to sleep. • In a very severe case I kept my patient alive by allowing her to ' have every quarter of an hour for more than fourteen days just one table-spoonful of liquid easily digestible food : meat broths iced milk, tea with milk, water, given alternately. The stomach 344 THE PATHOLOGY OF PKEGNANCY. did not reject these small quantities ; and if regurgitation did occur, they were again swallowed, the patient being thus kept up till the vomiting gradually subsided. Before extreme measures are resorted to, nourishment is to be supplied by means of pan- creatised meat enemata (Leube). Copeman {Brit. Med. Journal, May 15, 1875, and Sept. 28, 1878) recommends as an excellent, i.e. unfailing, remedy the dilatation of the external os uteri and of a portion of the cervical canal ; further published observations support this recommendation (Murillo, Annal. Gynec, p. 233 ; Eosenthal, Berlin. Kl. Wochenschrift, 1879, p. 388). Our last resort is to empty the uterus, i.e. to induce abortion ; premature labour will but rarely have to be considered, owing to the period of pregnancy at which the disorder under discussion generally attains its maximum severity. Abortion is justified by the fact that the persistent vomiting may be fatal, that on the other hand it frequently ceases after a spontaneous evacuation of the uterus, and lastly that numerous instances have been pub- lished in which artificial abortion was the means of cure (this result occurred in 27 out of 36 carefully observed cases which were collected by M'Clintock). On the other hand it must not be forgotten that in some cases which were looked upon as utterly hopeless, the vomiting subsided spontaneously, both mother and foetus being preserved ; that in other cases even the operation did not succeed in saving the life of the former ; and that sometimes when the operation was not successful, the vomiting ceased after a while. Each individual case therefore must be judged on its own merits ; the only general rule that can be laid down is that no interference is justifiable till a sufiioient trial has been made of all those measures which are consistent with the progress of the pregnancy (and here I will once again call attention to Copeman's recommendation, and to the value of nutrient enemata for preventing extreme marasmus). Such interference however must not be postponed till it is too late, e.g. till a fatal ter- mination is obviously unavoidable ; and sometimes the disease advances suddenly and rapidly to this lamentable termination. The responsibility of the operation must never be undertaken by a practitioner, except after a consultation with a colleague experienced in the management of such maladies. § 250. The salivation which has been already mentioned may not only be troublesome, but when excessive may greatly weaken THE PATHOLOGY OF PREGNANCY. 345 I the pregnant woman. Astringent lotions for the mouth may be tried, but are generally useless. Iron and a good diet are of most value ; also iodide of potassium, as far as it can safely be given during pregnancy. Ebstein {Berliner Kl. Wochenschrift, No. 25, 1873) recommends atropine, a drug which is known to abolish the action of the chorda tympaui on the salivary secre- tion ; -0006— -0015 grm. (='01— '025 gr.) may be injected subcutaneously in the vicinity of the submaxillary gland. Constipation rarely becomes so obstinate as to cause anxiety, but diarrhoea may do so, and I would draw attention to this disorder, although it is not directly due to the pregnancy. Apart from its weakening action, it may, if at all prolonged, lead to premature labour, especially when dependent upon catarrh of the great intestine and accompanied by severe tenesmus. It should never be thought lightly of. (1. Disorders connected with the Urinary Si/stem. § 251. Severe disorders connected with the excretion of urine in either one or other direction, either depend upon anomalies of the uterus and its neighbouring organs, or are independent troubles ; as far as pregnancy is a factor in their causation, it will be sufficient to refer to what has been said in § 74. Amongst the changes in the composition of urine, albuminuria alone needs mention here. It is desirable in each case to elu- cidate its cause, owing to its important bearing on prognosis (r/. Eclampsia) ; and in reference to this point it must be noticed that it may not only be due to changes in the renal parenchyma, or to altered relations as regards the processes of diffusion in the kidneys, but may also be due to a formation of pus in any portion of the urinary passages. It is therefore found in cases »t irritable bladder or catarrh of that organ or of the urethra, which may have been in existence before pregnancy, or it may originate during the latter from (in addition to other causes) pressure on the neck of the bladder and the upper portion of the urethra, or from pyelitis. Treatment varies with the nature of the albu- minuria, and for this matter I must refer to text books ot pathology. If the albuminuria resists all rational modes of treatment, if its sequelse threaten life, it may be necessary to bring the 346 THE PATHOLOGY OF PREGNANCY. pregnancy to an end. But such an albuminuria is always a consequence of nephritis, which either sets in in the acute parenchymatous form, or was present as a chronic nephritis before the pregnancy began, and becomes intensified during the latter by the frequently associated engorgement of the kidneys. e. Diseases of the Skin. § 252. Diseases of the skin are exceedingly common in preg- nancy, and some ^Etiological connection must therefore exist (cf. § 80). This is also shown by the fact that the severe kinds often only disappear with the post-partum period ; latent diatheses seem sometimes not to be called into life, till preg- nancy sets in. All forms of cutaneous diseases are met with, but especially anomalous pigmentations, affections of the follicles, new vascular formations and neuroses (pruritus). The latter are rare, but may be very obstinate and severe, and cause great suf- fering. I have had under my care an elderly lady, a primipara, in whom the affection began as early as the second month, and lasted till her confinement, with only a slight remission accom- panying the use of Fowler's solution. Delivery and the free perspirations associated with the pains, at once led to its dis- appearance. No eruption was present except that caused by the frightful scratching. The woman became so reduced, that at the 5th month artificial abortion was seriously meditated ; but I did not induce it because the digestive organs were in good order, and the woman was most anxious for a child. The latter was born perhaps 2 — 3 weeks too early, but was healthy and together with its motlier (who has not become pregnant again) did well. Pruritus of the external genitals is commoner than the general afi"ection ; happily many of the cases that are so-called, are merely symptomatic, and due to a local inflammation and eczema. Treatment is not altered by the existence of pregnancy. I have found the most reliable to be the use of solutions of corrosive sublimate applied 1 — 3 times (1 : 100 — 200 parts of dilute alcohol), followed by the application of tar water (aqua picis liquidse), and by chamomile hip-baths. A very peculiar affection is described by Hebra as impttigo herpetiformis, which he has seen 5 times. In every case small pustules appeared on the inner side of the thighs, accompanied NEUROSES. 347 by high fever and great prostration ; these pustules rapidly spread up the body till they reached the hairy scalp ; the groups that appeared first dried up in the middle, and at the same time extended peripherally, like herpes iris. In four cases the disease ended fatally, but the post-mortem threw no light on its causa- tion ; in the fifth, convalescence took place after several relapses. Bulkley describes a similar, though different and much less dangerous, affection, as herpes gestationis ; this also begins with clusters of vesicles on the extremities, and from there passes to the trunk. At first it is accompanied by pruritus and urticaria ; it appears early in the course of pregnancy, only disappears in the post-partum period, and frequently recurs with a fresh conception. The treatment differs in no respect from that of similar affections in the non-gravid condition. f. Neuroses. ■§ 253. The highly impressionable condition of the nervous system may, as already mentioned in § 81, lead to disorder in any of its departments ; but as a rule serious illness only arises, when a special predisposition exists. Amongst the neuroses, eclampsia undoubtedly takes the chief place ; it will be dealt with in the part devoted to the " Pathology of Labour " ; the psychical disorders will be described under the " Pathology of the Puerperal State"; both these troubles may occur during any part of the pregnancy or the puerperal state, but it will be most convenient to complete the description in one place. Chorea on the other hand requires some mention here ; for although it is often merely a disease complicating pregnancy, yet cases are met with, m which we must consider that some direct {etiological connection exists, i.e. that the chorea is due to changes affecting the system in connection with pregnancy. Chorea is not common. I have only seen it three times in a by no means small range of practice ; Barnes could only find 56 published cases, which Fehling increased to G8». In a large number of them the chorea existed before pregnancy set in ; in the majority it appeared in the first half of the latter, ' In Schwechten-s (;. c.) dissertation, 80 cases are described ; there is one more by myself, one by Prince, and two by Richardson, making 8 1 cases ; the following aw are based on this series. 348 NEUROSES. and lasted to the beginning and even to the end of labour. It rarely terminated before parturition began ; still more rarely (in 3 out of 84 cases) did it persist beyond the lying-in state. It is almost always bilateral. Primiparte appear more susceptible than multiparae, a fact which depends on the predisposition to illness w^hich is so often already present, and on the greater frequency with which causative influences operate during a fii-st pregnancy. An attack during the latter however need not make us fear a recurrence in the following ones. It is extremely rare for the chorea to begin during the lying-in period. If we except the cases in Avhich serious lesions of the nervous centres can be demonstrated, or in which hereditary disposition exists, the causes of chorea are obscure, just as they are in the disease apart from pregnancy. The association with rheumatism and cardiac mischief has been sometimes observed, and it is possible that some of the cerebral changes that have been referred to, are connected with emboHc processes originating in the heart. In a few cases albumin and sugar were present in the urine, but only temporarily ; an increase in the urates and phosphates is more frequent, due possibly to the great nervous activity and to the muscular work. But in a great number of observations, no clearly defined cause could be found, and such cases must be regarded as reflex neuroses, which where there is a predisposition, develop under the influence of iusufiicieut nourishment of the centres (due to the impoverished state of the blood) and of the peripheral irritation in the generative organs ; for a badly nourished condition, a slight bodily development (imperfect development of the vascular system) and annemia are certainly not rare in choreic patients. The disease ended fatally in 23 out of 84 cases, almost always in consequence of pre-existing or secondary complications. When these are absent, the prognosis as regards life is good, much as in the chorea of puberty. On the other hand it is not rare for chorea to pass into other diseases of the brain. Its influence on the progi'ess of pregnancy is not favourable ; in scarcely half the cases referred to was the natural termination reached. In this respect chorea resembles eclampsia, but the intra-uterine death does not always precede the premature labour, for the foetus is often born alive. I must not forget to mention that new-born children are said to have been seen suffering from the NEUROSES. 349 same disease. Chorea is much less serious during the lying-in state. The remedies generally recommended for chorea arc hardly ever of use during pregnancy ; hroadly speaking therefore specifics may be left on one side. On the other hand a non- irritating regime is very desirable, together with the use of iron and quinine (the former especially in moderately large doses). Narcotics are of the greatest value for cutting short and diminish- ing the severity of the attacks^ as well as for quieting the great reflex irritability ; opium in large doses ; bromide of potassium given for a length of time ; chloral, chloroform and morphia (subcutaneously), when an immediate effect is required. Bearing in mind the possibility of severe central affections developing, when the chorea lasts till the expulsion of the foetus, and bearing in mind also that such expulsion so frequently comes on prema- turely, the induction of premature labour and even of abortion are indicated, when palliatives prove useless and the prognosis is bad ; but operative interference must not be postponed till too late. In view of the great irritability of the patient, the gentlest methods must be employed for the operation. § 254. That which has been said above about chorea, is still truer of epilepsy. Where this is present, the complication almost always existed before pregnancy ; its attacks are some- times unafl"ected by the latter, sometimes diminished both in frequency and intensity. In very rare cases however pregnancy appears to give rise to the first outbreak of convulsions, although only where the predisposition already existed. Under such circumstances, parturition is unafiected, indeed its onset usually counter-acts- the predisposition. When pregnancy recurs, the disorder is apt to return. Epileptic convulsions have but rarely a prejudicial influence on the foetus. Instances are on record in which the convulsions appeared to be determined by the sex of the foetus (by the male sex, according to La Motte, v. Swieten). § 255. Amongst the severe disorders of the organs of sense, I need only mention those connected with vision. Apart from the amaurosis which is at times associated with eclampsia and albuminuria due to Bright's disease, the more serious forms of amblyopia and night blindness (hemeralopia) are the commonest, although even they are very rare. Colour blindness is veiy exceptional ; no case of nyctalopia has as yet been recorded. 850 COMPLICATIONS DUE TO INTERCUREENT DISEASES. When these anomalies do not depend upon disordered nutrition of the retina, as is sometimes the case, they are due to a highly anaemic condition, or are mere associated anomalies of sensa- tion, much like the association that is seen during the develop- ment of menstruation and even in diseases of the genital system. They should therefore not cause alarm, for after lasting for a while, or at any rate during the post-partum period, they will certainly disappear : no relapse takes place. Nor are the dis- orders connected with a disturbed condition of nutrition of the retina, as dangerous as might be supposed. Proper diet with the use of iron and quinine (in large doses) are the remedies to be recommended. LITERATÜEE. On progressive pernicious ana;mia: Gusserow, Arch. f. Gyn., ii.- p. 218. Quincke, Volkmann's Sammlung Min. Vorträge, No. 100, 1876. Graefe. " Ueber den Zusammenhang der perniciösen progressiven Anämie mit d. Gravi- dität." Dis.tertatlon, Halle, 1880. Eiclihorst, D.jJi'ogrc-mve permciöse Anämie . Leipzig, 1878. On uncontrollable vomiting: M'Clintock, Oh.st. Journal of Great Britain, i. 1873, p. 128. Weber, Allgemeine med. Centralzeitung, 1877, No. 45—48. Disorders of the urinary organs: Kaltenbach, yl?r/i./. Gyn.,i\\.,\\. 1. Hofmeier, Zeitschrift f. Geh. v. Gyn., iii., p. 259. Möricke, ibid.. v., p. 1. Barker. Amer. J. Ob.s-t.. xi., p. 449. Richardson, Transact. Amer. Gyn. Soc, iii.. p. 178. Monod, Annal. Gynec., xiii., p. 255 (on cystitis). Cutaneous affections: Hebra, Wien. med. Wochenxchrift, 1^12. "So. i^. Duncan-Bulkley, Amer. J. Ohstetr., vi., p. 580. Treymann, Petersh. Med. Woch., 1876, No. 36. Chorea: Barnes, Transact. Ohat. Soc. London, x., p. 147. Fehling. ^1/t//. /. Gyn., vi., p. 137. Simpson, Ohstetr. Journal Gr. Brit., May, 1876. Prince, ihid., Oct., 1876. Richardson, Boston Med. Surg. Journal, July 12, 1877. Schwechten, "Ueber Chorea gravidarum." Dissertation, Halle, 1876. Baumeister, " Augenerkrank. bei Schwangeren, Gebärenden und Wöchnerin- nen." Berl. XI in. Wochenschrift, No. 49, 1876. 2. Complications due to Intercurrent Diseases. § 256. There is no disease which is prevented by pregnancy from attacking a woman, and any disease that existed before conception for the most part runs its course unaffected by it. In former times it was generally believed that the puerperal condition was a protection against many diseases, and had a i ACUTE INFECTIOUS DISEASES. 351 curative influence over others ; but this is not the case. On the contrary, there are a number of intercurrent diseases whose progress is modified by pregnancy, parturition, and the post- partum state, and generally speaking not in a favourable direc- tion ; conversely, such diseases may have a disturbing influence on the course of pregnancy. It is only of these, and indeed of the most important of them that we shall here si)eak, viz. the acute infectious diseases, intermittent fever, icterus, diseases of the heart and lungs, tuberculosis and sj-philis. The aff'ections of the sexual organs will be left for the following chapter. a. Acute Infections Diseases. § 257. The acute infectious diseases mainly influence the progress of pregnancy in two directions ; on the one hand by leading directly to the death of the foetus, and on the other hand by giving rise to a hsemorrhagic endometritis. In both cases labour comes ou prematurely, and the physical exertion connected with it, and especially the loss of blood, very often aggravate the existing disease, and not rarely lead to a fatal result. Intra-uterinc death is almost always due to a considerable rise in the maternal temperature ; only in rare cases can it be ascribed to the foetus becoming infected by the disease of the mother ; such infection can only be affirmed with confidence of variola^ Since the fcetus has a somewhat higher temperature than the mother, even when healthy, this must also be true in fever. The foetus shows it by more active movements, by a greater frequency of its heart-beat, which generally keeps pace with the temperature of the mother, rather than with her pulse. But sooner or later the movements and the cardiac activity are paralysed and the foetus dies, a result undoubtedly and entirely owing to the excessive retention of heat with all its accompanying changes in the most important organs. Thus we can under- stand how, as Kaminsky has shown, a maternal temperature of over 40° C. ( = 104° F.) may be very dangerous to the foetus. And if a high temperature is less injurious in the non-infectious ' Spitz in the hospital here has seen spirilla in the blood of the foetus of a woman with relapsing fever. The same observation has been made by Albrecht ; c/. / ttcis''. Med. Wochenschrift, No. 18, 1880, 352 ACUTE INFECTIOUS DISEASES. inflammatory diseases, this depends on the circumstance that it lasts a less time in the latter, or at any rate remains at a high level for a shorter period than in infectious diseases. Apart from the excessive retention of heat, the foetus may, as Eunge has shown, perish through want of oxygen, and indeed in all cases in which the disease greatly lowers the blood- pressure of the mother. And in the last place it must not be forgotten that the epithelium of the foetal placenta (so important for the life of the foetus) may degenerate in consequence of the influence of the diseased maternal blood on the ovum, and directly lead to the death of the foetus. Inflavnnation of the inner u-all of the uterus during infectious diseases is no rare occurrence ; owing to the diseased state of the blood, it is frequently associated with haemorrhage, and hence arises that uterine hasmorrhage which is so often spoken of as menstruation or pseudo-menstruation. The same thing doubtless often occurs in the pregnant uterus also ; in the casf of cholera it has been distinctly proved by Slavjansky. Thf continuance of pregnancy however is incompatible with the destruction by haemorrhage of the decidua, if at all extensive. Nor must it be forgotten that disease of the foetal membranes often follows on that of the decidua, and thus tends further to provoke the expulsion of the foetus. I was the first to show that diseased, and especially over- heated, blood might increase the irritability of the uterus, and directly stimulate the organ to contraction, and Eunge has brought forward experimental evidence in favour of this view ; in this way therefore the pregnancy may also be interrupted, and the foetus born alive. As regards particular diseases, the following points should be noted : § 258. The acute exanthemata attack pregnant women more often in the early than in the later months ; but the liability to the severer forms of illness as well as the mortality, increase with the duration of pregnancy. Variola is the disease most frequently observed, and is a source of extreme danger owing to the susceptibility of the pregnant woman to the haemorrhagic form. This is doubtless the chief reason why abortion and premature labour set in so frequently, and why the disposition to severe uterine hsemorrhag-e is so great. Nevertheless the ACUTE INFECTIOUS DISEASES. 353 foetus may also perish primarily, in the manner already men- tioned. It then comes into the world with or without the sißi'icarditis during pregnancy presents the same characters as in the non- gravid condition. Acute endocarditis on the other hand, and especially valvular endocarditis presents to some extent the same tendency to assume a destructive character, as does this disease during the lying-in period ; it is therefore more dangerous CARDIAC DISEASES. 359 than the more slowly progressive affection which occurs apart from pregnancy, and which is generally accompanied by plastic compensatory changes. ' Women suffering from chronic diseases of the heart howevcv may he greatly imperilled by pregnancy and the lying-in condition, since the changes compensatory of the cardiac lesion, which are sufficient for the ordinary state of things, no longer suffice for the pressure relations when altered by pregnancy, and often very suddenly so by parturition, and under which the heart has to carry on its work. By the intercalation of the placental vascular area between the uterine arteries and veins, the resist- ance opposed to the blood in the aorta increases, and with it the amount of work which the heart has to perform. This is rapidly altered when the placental circulation is arrested at birth ; first of all the pressure in the aorta falls, and the venous system becomes relatively over-filled by the closure of the great uterine and utero-placental vessels. Owing to this and also to the fact (tending in the same direction) that the diaphragm (through the emptying of the abdominal cavity) has now a greater range of movement, more blood enters the thorax and the lungs alter delivery, and the work for the right side of the heart is increased. This disturbance in equilibrium would soon be made good by a healthy organ, but may cause great confusion where the mechanism of the heart is disordered ; the period and manner in which it does so will depend chiefly on the seat of the lesion, on the degree of compensation which has already taken place, on the structure of the cardiac muscle itself, and on other changes in the vessels of the gi-eat and small circulatory systems and in the lungs, and on the composition of the blood. The varieties that may be met with here are endless, but, speaking generally, the following remarks hold good for the commonest anomalies. When the aortic valves are incompetent, serious disorders of the circulation usually show themselves even during pregnancy, especially during the second half, since frequently, and more par- ticularly where the disease is still of recent origin, the amoum of compensation is not sufficient for the increasing obstruction in the arterial area. The attacks of dyspnoea and irregular cardiac action may lead to premature labour; the symptoms attain their greatest severity during parturition, but when this 360 CABDIAC DISEASES. is over and the blood-pressure has sunk, the symptoms subside and apparent convalescence rapidly sets in. Incompetency and for the most part co-existing stenosis of the left auriculo-ventricular orifice need not cause any special trouble, when the disease is old and has been compensated by hypertrophy of the right ventricle, when the distention of the abdomen is slight, and when the increased arterial tension is immediately reduced to the normal level by the loss of blood during delivery. Where however the pulmonary channels are permanently engorged by the regurgitation, its consequences may show themselves gradually or suddenly during pregnancy (especi- ally during the last months) by alarming symptoms (dyspncea, extensive pulmonary catarrh, general oedema, albuminuria, ascites, pleuritic effusion), if any complications or additional difficulties still further interfere with free respiration and with the circulation through the lungs. But when the disease develops slowly, the compensatory changes in the right ventricle may take place to such an extent even during pregnancy that the ill effects are for the time being overcome without special accident, and the symptoms rapidly subside at birth. The symptoms of engorgement during pregnancy may indeed be entirely absent under favourable conditions, or only show them- selves in a slight degi'ee, and after labour prove all the moreJ threatening ; this is especially true of comparatively recent mitral lesions. Under such circumstances the right ventricle maj be unable to pour the blood which is being copiously supplied bj the veins of the body, into the pulmonary arteries in sufficient quantity, especially as a regurgitation from the left side of the heart into the pulmonary veins is taking place. A turbulent action of the heart, serous transudation into the lungs, insuffi- cient oxygenation of the blood become super-added to each other, and in this way or by embolism, death may rapidly super- vene. In cases that run a smoother course, catarrh, dyspnoea &c., yield to suitable treatment, and equilibrium is soon restored with the help of the discharges which take place during the lying-in period. As regards treatment, it will be gathered from the above state- ments that in pregnant women whose aortic valves are diseased, the cardiac activity must not be lowered nor must the pressure in the vessels be increased ; digitalis therefore must not be DISEASES OF THE EESPIEATORY PASSAGES. 301 administered. A quiet life, saline purgatives, venesection in severe disorders are indicated ; sometimes also the induction of prema- ture labour, since, as has been shown, the emptying of the uterus has often a beneficial efi'ect. This operation may also appear to be indicated in mitral disease, but never where mitral incom- petency has not yet been fully compensated for, nor where the increase of blood-pressure and pulmonary hyperaemia which accompany labour will be dangerous. In these cases digitalis in small doses may be used with advantage, for it increases the pressure in the aortic system, diminishes the frequency of the pulse, and is a true tonic ; if the lungs are abnormally engorged, an effectual venesection should be carried out -without delay. Fritsch explains in a difterent manner the influence of puer- peral processes on a diseased heart ; according to him the alarmiug symptoms which so readily set in after parturition, depend on an accumulatioil of blood in the great vessels of the lower abdomen, due to a fall of the intra-abdominal pressure, and to the con- sequently inadequate filling of the diseased heart. I admit that Fritsch's explanation suits certain cases, but it certainly does not all, for the lowering of the intra-abdominal pressure has not been shown to exist in all cases ; nor can his view explain why severe symptoms so often occur during pregnancy. d. Diseases of the Respiratory Passages. § 264. Chronic diseases of the air passages, especially of the lungs, in which the respiratory surface is diminished, may be afi'ected by pregnancy and labour, much in the same way as is a mitral incompetency that has not undergone compensation, and this is especially true of extensive emphysema of the lungs. Amongst acute diseases, true imeamonia is a highly dangerous complication. It is rarer in women generally than in men, but above all is rare during pregnancy ; women show a greater mor- tality from the disease than does the other sex, and this mortality is particularly high during pregnancy. In these cases the fre- quency and mortality at the difterent periods hold a similar but converse relation ; during the earlier months, pneumonia is more common but less dangerous, the opposite being true of the later months. Pregnancy is not infrequently interrupted, and will be so with all the more likelihood, the further it has advanced ; lüis 862 DISEASES OF THE RESPIRATORY PASSAGES. is due partly to the inadequate aeration of the maternal hlood and to the lessened supply of blood to the left side of the heart, partly to the death of the foetus, which was primarily caused by it and by the febrile temperature. Labour often has a prejudicial influence owing to the increased demands it makes on the already heavily taxed heart, to the increased pressure (explained above) in the venous system, and to the lowering of the aortic pressure which follows on delivery. The prejudicial influence which is associated with labour, is more frequent and marked, the further pregnancy has advanced. It will be obvious therefore that generally speaking the induction of premature labour is not to be thought of, either at the beginning or at the height of a severe illness^ Medicinal treatment does not diö'er materially from that used apart from the puerperal state ; but I must point out that digitalis is of special value in these cases, and that venesection should be practised when threatening symptoms are present, although it must of course be borne in mind that collapse may come on after it, and after the labour which not infrequently follows on venesection ; if such should occur, restoratives must be freely used. The above remarks relating to pneumonia, are in the main true of severe acute pleurisy ; it is accompanied by special risk at the time of labour, all the more so when there is a co-existing hypersemia of the lungs. § 265. As regards complications due to a chronic broncho- pneumonia or tuberculosis, the view was long held that pregnancy afforded an immunity against such complications, and that if it commenced while such a disease was present, the latter wouldj run a milder course, and in some measure become latent, whilej on the other hand parturition rapidly aggravated the disease.] The latter idea is as true as the former is false, although it can-j not be denied that occasionally disorders which existed previous] to pregnancy do appear to be alleviated, the latter reaching its end without any very great discomfort. How slight a protection] is afforded by pregnancy, is shown by the fact that acute tuber- culosis may develop during it, and run so rapid a course that! death occurs before the termination of pregnancy; extremely] ' Fischl has compared the 21 cases collected by Gusserow in which premature labourl was induced on account of pulmonary disease, with 21 others in which an espectantj treatment was pursued ; of the former 15 women died, of the latter only 3, DISEASES OF THE RESPIEATOKY PASSAGES. 363 dangerous pulmonary haemorrhages have also been observed in pregnant women. In the majority of cases of pulmonary tuberculosis occurric" during the gravid state, the disease appears to have developed but shortly before the commencement or during the pro<^res3 of gestation, for conception is an exceptional occurrence, where phthisis is already advanced. The influence of hereditary predisposition is especially well seen here, being particularly favourable to the outbreak of the disease during matrimonial life, during pregnancy and even after delivery. Such women sometimes continue in good health during the first or even the second gestation, and only fall a prey to the inherited diathesis in a subsequent pregnancy. The lying-in condition has a still more injurious influence where disease is already present, or a predisposition exists, and it much oftener accelerates the fatal end ; there are ho'wever exceptions to this statement also, and indeed the influence of the various puerperal stages on the development and progress of tuberculosis, is so variable that the conditions in each individual case must be very carefully estimated. Although pregnancy usually reaches the full term in spite of progressive tuberculosis, it is not rare for labour to come on some w^eeks too soon ; abortion may also take place, and be as injurious to the phthisical woman as is the lying-in period after a premature or a full term labour. The children of mothers whose tuberculosis has made progress during the pregnancy may be born healthy ; but they are often weakly and badly nourished, and many of them perish during tbe first months of life from catarrhs &c. Out of those which con- tinue to do well, many after a while become scrofulous, and doubtless not rarely tuberculous. Girls therefore who show distinct symptoms of pulmonary tuberculosis or inherit a dis- position to it should be forbidden to marry ; or at any rate the attention of parents should be drawn to the possibility of the germs of disease developing, or of a relapse taking place into a disease from which a girl had previously recovered. If a tuber- cular woman has safely passed through pregnancy and the lymg- in condition, she must never even for a short period suckle her infant ; happily the supply of milk is rarely suflicient to allow ut her doing so. 864 SYPHILIS. e. Syphilis. § 266. Syphilis is unhappily not a rare affection in pregnant women. When the disease has been contracted at the fruitful coitus or during the course of pregnancy, and is therefore recent, it is followed by a rapid and extensive development of the primary symptoms ; they are such as point mainly to a severe local irritation, e.g. oedema, abrasion of the epidermis, follicular; abscesses, eczema of the external genitals and their neighbour- hood, and even a destruction of deeper tissues. This feature is to be explained by the anatomical conditions of the genitals dur- ing pregnancy, and by their increased nutritive activity. The secondary and constitutional symptoms on the other hand are usually very mild ; the glands become but slowly infiltrated ; papules form on and about the sexual parts, and are seen in various stages of development, the portio vaginalis is diseased, squamae appear on hands and feet. The mildness of the symp- toms is probably due to the improved and more active processes of nutrition in pregnant women. Constitutional syi)hilis has a very injurious influence on the fcetiis, and in reference to this point the syphilis of the progenitor ranks first in importance. The child may perish early in the' uterus, and abortion or premature labour follow ; or it may remain alive, although then also it is generally born prematurely,] is puny, syphilitic, and succumbs soon after birth ; if the chilt looks healthy at birth, the disease may break out after some weeks or months, sometimes only at the age of puberty. § 267. Either parent may bequeath syphilis to the foetus, the! latter being infected at the time of impregnation by the ovum orl the semen ; infection is also possible in utero during the progress] of pregnancy, when the mother has but recently {i.e. since con- ception) contracted the disease. We have therefore the following^ varieties of infection : a. The mother is constitutionally diseased at the time of con- ception ; in such a case the foetus is usually expelled by abortion] or premature labour, and is often macerated. b. The mother is healthy, hut the father is constitutionaUif\ diseased ; in this case the syphilitic poison passes into the ovui with the semen. This mode of infection is usually the worst,] although sometimes the fluids of a mother that is still healthy SYPHILIS. 3(55 at tbe time of conception, appear able to some extent to "neutralise" tbe paternal poison, and the children are born apparently healthy, although as a rule somewhat puny ; sooner or later however they are attacked by syphihtic affections. Under these circumstances the mother usually remains untainted, although we cannot disprove the possibility of her being infected by the syphilitic foetus {choc en retour) ; when she is so, there are no primary symptoms. c. The mother is only infected at the time of impregnation. If the progenitor is then constitutionally diseased, that which has just been mentioned under h. is applicable ; but if the father is not yet saturated with the poison, the infection of the ovum of course does not take place at conception, but it is only the Syphilis winch is contracted during pregnane}/ that has to be considered. It is uncertain whether this can affect the foetus ; Kassowitz denies the possibility on the ground that the syphilitic poison does not pass through the placental partition walls. Others declare that it does (Sigmund) ; so that the point is still unsettled. d. Inoculation of the foetus as it passes through the parturient passages must be extremely rare, if it occurs at all. Weil (Deutsche Zeitschrift f Pract. Med., 1877, No. 42) records such an event. e. If the maternal and paternal syphilis is latent at the time of conception, the virulence of the disease in the foetus depends on the degree and on the duration of the latency. The children may be born in apparent health and sicken later on, or they may be born in a weak and premature condition, or iutra-uterine death may occur and be followed by abortion. Not a few of the cases of so-called habitual abortion are due to latent, especially paternal, syphilis. On the other hand it must not be forgotten that as time elapses sj^ohilis loses more and more the capacity of transmitting itself by heredity. In view of the great danger to which constitutional syphilis exposes the foetus, every pregnant woman that has contracted the disease must be subjected to a course of mrrcurii ; not only if diseased before the pregnancy set in, or if she becomes so at conception ; but in cases also where she has pre\nously borne children tainted bv the father, or when the diseased condition of children that have been born, points to the continued activity of 366 SURGICAL OPERATIONS. a poison that is more or less latent in her. In the latter case it is better before a woman af^ain becomes pregnant, to subject both her and the father to a thorough auti-syphilitic treatment ; but even in the opposite case a course of treatment that is under- taken early may be of great value. Mercury may be freely given during pregnancy, and if administered in time exerts the most salutary influence on its progress and on the preservation of the foetus. The long experience at the Lourcine in Paris, and the observations made at Selbo (Norway) by Faye inter alios are proofs of this. The use of suitable inunctions, or the prolonged administration of small doses of corrosive sublimate is the best. Where however the mother has only contracted sj-philis during the last months, it might be desirable, inasmuch as the child then runs no danger, for a time to adopt a palliative treatment, and only to undertake a thorough course of mercury during or after the lying-in period. Local secondary or primary affections of the genitals should, if possible, be cured so as to avoid any possibility of the child being inoculated during labour. But no very irritating or caustic remedies must be employed, since the former are apt to bring on premature labour. /. Surgical Operations. § 268. Lastly, we must make some observations on the per- missibility of the more formidable surgical operations during pregnancy. Such must be unhesitatingly performed in aflfections which directly compromise the life of the mother ; also in cases where postponement damages the prognosis of the disease which calls for the operation ; further in all cases where the pregnancy itself seems to be causing a greater and more rapid development of the malady. But when no such argument for an operation exists, the latter must be postponed until after labour ; for though in the majority of cases pregnancy is not interrupted after accidental injuries or after operations, still it is by no means rare for it to be so (according to Cohnstein's statistics, no interruption occurred in only 54*5 per cent, of all cases). The disposition to such interruption appears to be especially great in the first and last months ; moreover an operation undertaken during what would be the menstrual period of the woman, were she not pregnant, appears to favour it. The interruption is due DEATH DURING PREGNANCY. 367 to reflex irritation or to the loss of blood, or is a result of the traumatic fever or of the secondary septic mischief. Operations on the generative organs are particularly apt to shorten the duration of pregnancy, especially those on the external organs and the vagina, much in the same way as apart from pregnancy they frequently accelerate the onset of menstruation, or at any rate give rise to uterine haemorrhage. During pregnancy more- over it must be remembered that the haemorrhage is usually very profuse owing to the enlargement of the vessels in and about the generative organs, that it is difficult to arrest on account of its venous and capillary origin, and that the application of compresses and of styptics which is usually necessary disposes to suppura- tion and to the development of phlegmonous processes, while the wide blood- and lymph-vessels favour a general infection. It is moreover desirable not to operate too soon after parturition, owing to this tendency to septic mischief. g. Death during Pregnancy. § 269. A pregnant woman may die after a more or less pro- longed period of illness, or quite unexpectedly. This sudden death is most frequent during or soon after labour, but it also occurs during pregnancy in consequence of latent cerebral affections, and especially owing to cardiac disease and embolism. The question arises what treatment should be adopted in these cases. In olden times it was directed by law that before the corpse of a pregnant woman was buried, Caesarian section should be performed {lex regia of the Romans), and in most countries it is still at this day ordered that the burial shall not take place, till the necessary measures have been taken for saving the child which is still in utero. We may here pass by the considerations which in earlier days influenced canonical injunctions that every such infant should be baptized, and also those which required the delivery of a foetus which was not yet viable, so that we need only concern ourselves with the proper procedure, in cases Avhere the mother dies after the 28th week and the child is alive. Since Ave are merely concerned in saving the child, the latter must be delivered in the way which exposes it to least risk, that 368 DEATH DURING PREGNANCY. is — apart from the rare cases iu which sudden death occurs during the second stage of labour — by Ccesarian section^. The latter, if it is to attain its object, must be performed very soon after death ; for when the mother ceases to live, the child of course is rapidly asphyxiated. Generally speaking, not more than ten minutes must elapse between the death of the mother and the extraction of the foetus, although there are instances on record in which living children were delivered after a greater interval and recovered". Under these circumstances the diag- nosis of the death of the mother is of the highest importance, for the operation may not only be done too late, but too soon ; melancholy cases have been published, in which pregnant women who were merely in a state of deep syncope, or suffering from an attack of severe and hysterical asphyxia, were awaked by the commencing operation. But it appears to me that with the help of our present knowledge and appliances, a rapid and immediate diagnosis that death has occurred cannot be difficult, and that a cautious practitioner may in the course of at most a few minutes place it beyond doubt. By means of auscultation we may rapidly and with even more assurance satisfy ourselves as to the living condition of the child ; if it is obviously dead, the decision for or against an operation depends on the judgment of the medical man ; where there is doubt, he must operate at once. § 270. It is much more difficult to arrive at a decision, when we find ourselves at the bedside of a pregnant tvoman, who is at or near the jwint of death. Caesarian section usually only succeeds, where death has taken place suddenly, circulation and interchange between the foetal and maternal blood till then going on freely ; when the life of the mother ebbs away slowly, the fo3tus generally dies before her life becomes extinct, and when ' In Prussia the performance of Caesarian section on a woman who has died during pregnancy, is left to the judgment of the medical attendant in the particular case. - Amongst the more recent accounts of a Caesarian section which was longer deferred, but in which the child was saved, I will mention the following : Pingler, Moiuitsgchrift f. Geb., xxxiv., p. 244. Brotherston, Edinburgh Med. J., April, 1868, p. 930. Nierop, cf. van Hasselt, Die Lehre vom Tode u. Scheintode, i., 1862, pp. 12, 13. Buckeü, London Obstet. Transactions, xix., p. 179. Cleveland, Amer. J. Obst., xi., p. (i26. Blatner, Amer. J. Obst., viii., p. 160 (the child was extracted one hour after death in a state of asphyxia ; of course it was not kept alive). DEATH DURING PREGNANCY. 369 that has happened, there is no object in the extraction; excep- tions to this rule, e.g. the undoubted case told me by Hoscheck {Arch. /. Gyn., ii., 1871, p. 118), and the similar one of Pain^e (Yirchow's Archiv., Ixvi., p. 366) belong to the rarest phenomena. To wait for the death of the mother is therefore to sacrifice the child also ; on the other hand to save the latter by performinrr Caesarian section on the dying woman appears inhuman, and is repulsive for many reasons. Still in many cases the inhumanity IS m reality only apparent, and looking at the question from a broad point of view, I cannot but agree with Loewenhardt {Aphorismen zur Gehurtshulfi. Chirurgie. Berlin, 1871, p. 82), ! when he urges us in such cases to save what we can, i.c'. to save . one life at any rate, instead of carrying our wish to avoid injuring the second which is about to become extinct, so far as to allow the child also to perish. A conclusion should never be arrived at except after consultation with another accoucheur, nor should I the step decided on be carried out except with the consent of 1 the nearest relatives of the pregnant woman. I consider it a : bad practice to attempt to avoid Caesarian section by extracting I the child per vias naturales, after forcibly dilating the cervix uteri. In a pregnant woman this latter operation is quite as severe as the former, while it is accompanied by far more risk to the child, whose life after all is the only one we can save, and offers less prospect of preserving it alive. The Ca?sarian section must be carried out according to all the rules of our art, not only in the case which we have just discussed, but even when ; the death of the mother has been ascertained ; this would lie a I superfluous remark, if the grossest errors had not been committed •in this respect. \ When we consider what a slight prospect there is of preserving ja foetus by extraction, in cases where the death of the mother (has occurred slowly, and bearing in mind the difficulty already \ mentioned of performing the operation on a pregnant woman who is just dying, the suggestion presents itself of inducing j^remuturc \labour with the view of saving the child (of course only when it 'is viable) in such cases of disease which, as far as medical .knowledge goes, appear hopeless, and in which the death of [the mother is expected to take place before labour sets in i spontaneously. ^Ye are bound to admit that it is in but few instances that we have good grounds for pronouncing a i 24 370 DEATH DUKING PREGNANCY. judgment as to the entire hopelessness of a disease, or as to the period at which death will occur, and in not a few cases the condition of the mother will he aggravated hy the induction of labour, while further it may appear barbarous to embitter the last days of the life of a sick woman by such a procedure ; still I agree with Stehberger and Pfannkuch {Arch. f. Gyn., i., p. 465, and vii., p. 173 — 75), who are also supported by Runge and Leopold {ibid., xiv., p. 299) (the latter at the same time com- municating an observation bearing on the question) in consider- ing it more humane (since there is no longer any hope of the mother's recovery) to carry out any legitimate measures for tho sake of the child, so as at least to preserve what we can. LITERATURE. Winckel, •■ Der Foetelpuls bei Fieber der Mutter." KI in. Brobarlit. :. Pathol, d. Geburt. Rostock, 1869, p. 196. Infectious diseases: Goldschmidt, " Ueb. die Häufigkeit einiger acut. Infectionskrankheiten während d. »Schwangerschaft &c." Dinnertation, Kopen- hagen, 1879. Runge, " Die acuten Infectionskrankheiten in ätiolog. Beziehung z. Schwangerschaftsunterbrechung." Volkmann"s Sammlung Klin. Vortr., No. 174, 1879. Cf. also Runge, Arrlt.f. Gyn., xii., p. 16, and xiii., p. 14."]. Small-pox : Barnes, Ob.'^t. Tran-met. London, ix., p. 102. Loth. Mayor, Berlin. Bciträ{ir z. Geburt. tli., ii., p. 186. Virchow"s Archir.. vol. 79, p. 41!. AValch, Philadelphia Med. Time.'«, May 25, 1878. (Cenfralblatt f. Gyn., 1878, ]). .531.) Bollinger, " Ueb. Menschen- und Thierpockcn &c.. u. über intrauterine Vaccination." Volkmann's Ä7/w. T'cij-^/'o*/»;', No. 116, 1877. Burckhard, ä-«^S(7/. Arch. f. Min. Med., xxiv., Parts 4, Ö. Scarlet fever : Olshausen, An-h.f. Gyn., ix.. p. 169. Measles: Gautier. Annal. Gynecol., May. 1870. Cholera.- 'üenrng, Monat.i.^chrift f. Geh., xxxü.. ^.'21. Weher, Allyemeinc med. Centralzeit., 1871, Nos. 3, 4. Slavjansky, Arch. f. Gyn., iv., p. 285. Continued fevers : Kaminsky, Petersb. Med. Zeitsshrift, 1868, Part 2. Wallichs, Mon. f. Geb., xxx., p. 253. Zuelzer, ibid.. xxxi., p. 419. Gusserow, Berliner KU n. Wochenschrift, 1880, No. 17. Intermittent fever: Ritter, Virchow's -1/y7/«c., vol. 39, p. 14. Mendel. Monatsschrift f. Geb., vol. 32, pp. 1, 81; with discussion. Burdel, Annul. Gyneool., viii., p. 31. Icterus: Davidson. Monatsschrift f. Geb.. vol. 30, p. 4.52. Valcnta, Med. Jahrbuch, as a supplement to Wochenblatt d. Gesell, d. Aerztc :u Wien, xviii.. Part 6, 1869. Conrskl, Pester Med.- Chirurg. Presse, xii., Nos. 48 and 50. Weber, Petersb. med. Woch., 1878, No. 36. Duncan, Med. Times, i., 1879. p. 57. ANOMALIES OF THE SEXUAL ORGANS. 371 Diseases of the heart: Spiegelberg, .bv/t./. ffy«.. ii.. p. 230. Lebert. ihUL, iii.. p. 38. Fritsch, Hid., viii., p. 373. x., p. 270. Schmidt's Jahrburh, vol. 173, p. 193. Löhlein, Zeitsch.f. Geb.u. Frauenhranlih., I, p. 482. Macdonaltl. Obst. J. Great Britain, May— Nov., 1877. published separately by Churchill. London, 1878. Diseases of the lungs: Gusserow. .l/nwrtAv.sr /(/•//);/. (9/"&., vol. 32. p. 87. Wernich. Berlin. Beiträge z. Geb.. ii., p. 247. Fasbender. ibid., iii., p. 49. Lebert. Arch./. Gyn., iv., p. 457 ; Journal de Med. et de Chir., 1878, p. 178. Pleurisy : Fischl, Prag. Viertrljahrea.trhrift. 1875. p. 1. Leopold, Arch./. Gyn., xi., p. 284. Syphilis: Fränkel, Arch. f. Gyn.. \.. \). 1. Kassowitz in Strieker g .Ved. Jahrb., 1875, p. 359. Weil, '' Ueber den gegenwärtigen Stand der Lehre von der Vererbung der Syphilis." Volkmanu"s Älin. Vorträge, No. 130, 1878. Caspary, Yierteljahresschrift für Dermat. v. Syphili.t, 1877, p. 481. Mewns, Zeitschrift f. Geb. u. Gyn., iv., p. 10. Sigmund, Wiener med. Pres.ie, xiv., 1873, No. 1. Fürth, Wiener Klinik., 1879. Cf also references from the Scandinavian literature in Schmidt's Jahrbuch, vol. 172, p. 35. On local syphilis in pregnant women, cf. Moret, " Des manifestations syph. chez la femme enceinte &c." These, Paris, 1875. Cernatesco, " De la marche et de la duröe du chancre syphil. et des syphilides vulvaires pendant le coui-s do la gestation." These, Paris, 1875. Surgical operations: Cohnstein, " Ueb. chir. Operationen bei Schwan- geren." Volkmaun'sÄ'//«. T'^^r^/'ä^p, No. 59, 1873. '^ia.ssot. Arch, de Tocologie, Jan., 1877, p. 15. Verneuil. Annal. Gynecol., viii., 1877, p. 229. Death during pregnancy: Ih^vnuoi, Annal. Gynecol., \.,\9i'^,'p.2b~. Hecker, Arch. f. Gyn., x., p. 540. Duer, Amer. J. Obstetr., xii., p. 1. Dohrn. Deutsch. Med. Wochenschrift. 1S78, No. 27. Storch, Centralblatt f. Gyn., 1879, No. 25. Garezky, " Zur Frage über die Fortdauer d. Lebens d. Frucht im Uterus nach d. Tode d. Mutter." Petersb. russ. Di.tsertation, 1878 ; cf Centralblatt f. Gyn., 1879, p. 36. 3. Anomalies of the Sexual Orgam. § 271. The various anomalies of the generative apparatus, so long as tliey do not interfere with ovulation and insemination, or prevent the ovum from imbedding itself in the uterine mucous membrane, may complicate pregnancy, and give rise to a more or less troublesome and dangerous series of phenomena. So far as they interfere with labour, they will be described {cj. § 243) in the'next part, for the sake of completeness. Here we shall merely speak of those whose prejudicial influence makes itself felt during pregnancv, or at any rate is very marked dmnng that state ; they include tailures in development, deviations m position, new formations, inflammatory conditions, and injuries. 372 UTERUS UNICORNIS. a. Failures in Development. In this place we are only concerned with uterus unicornis, and the various forms of uterus duplex. (1) litems Unicornis. § 272. By uterus unicornis is meant a complete development of one foetal horn, while the other is more or less atrophied. The uterus which in such a case only represents half of the normal organ, forms an elongated, cylindrical or flask-shaped body, which is curved towards the side to which it belongs, and is continuous with its Fallopian tube. On the other side the uterine horn and the tube are completely absent, or there is a rudimentary horn with a tube ; the horn maybe solid, or contain a cavity which, in the slightest form of the malformation, opens into a cervical cavity which is common to that of the normal side. The ovary is usually present on both sides. Both the normally developed and the rudimentary (if it possesses a cavity) horns may become pregnant. In the case of the latter, owing to the weakness of the parietes, rupture takes place between the 2nd and 4th month as a result of the pressure exerted by the growing ovum (c/. Extra-uterine Preg- nancy). When the horn does not communicate with the cervical cavity of the well developed side (which is extremely rare), the pregnancy is brought about by means of the so-called external migration : either of the ovum, as when an ovum which originated in the ovary of the normal side is fertilised and taken up by the Fallopian tube of the abnormal side ; or of the semen, which in such a case must pass out of the normal horn, and reach the ovary of the rudimentary side by means of the peritoneal cavity and fertilise an ovum of that ovary — processes which are explicable by the close approximation of the two uterine appendages, by the locomotion of the spermatozoa, and to which similar and constant phenomena in lower animals are analogous. Pregnancy in the normal horn usually runs an undisturbed course, indeed such a horn may harbour twins. The course of labour is not interfered with, nor do any special dangers accom- pany the lying-in state ; exceptions to these rules are very rare. The upper division of the horn, which is always delicately UTERUS DUPLEX AND TAGINA DUPLEX. 373 constructed, and whose walls gradually thin towards the point at which the Fallopian tube is inserted, may, when the ovum (placenta) becomes attached to it, in spite of the hypertrophy • which accompanies gestation, by degrees become so attenuated that it gives way during labour, and rupture takes place (Molden- hauer). If the rudimentary horu has at the same time been greatly enlarged (and the non-gravid side always shares more or less in the hypertrophy of that which coutains an ovum), it may be an obstacle to the child entering the pelvic inlet, as in the case related by Müller and Borinski. But these are, as already mentioned, extraordinary cases. It is extremely difficult to diagnose a one-horned uterus during pregnancy and labour. Marked lateral deviation, the discovery of a somewhat enlarged horn on the other side, in some cases a delicate shortened and laterally inserted "vaginal portion " are aids to diagnosis, although they are not always present. The shape of the pregnant horn is not so exactly spindle-shaped, as to make it always distinguishable from an ordinary uterus containing little liquor amnii, nor does it become so during the pains. , (2) Uterus Duplex and Vagina Duplex. § 273. The double formation which depends on imperfect blending of the foetal rudiments, where both sides are equally developed, may lead to the two halves remaining perfectly distinct, so that like the two portions of vagina duplex they are not in anyway connected with each other {uterus duplex se])ariitux s. didelphys) ; this condition is very rare, and only found where a cloaca is present, in which case the two vaginte open separately into it. Again, the uterus may have two horns {uterua bicornis) ; here the dupHcate formation may aflTect the whole organ {uterus bicornis duplex), and be associated with two separate vaginie, each of which possesses a hymen, or with a single vagina and two "vaginal portions"; or the body of the uterus alone is double and the cervix single {uterushienrnis uuicollis s. simplex). The division and divergence of the cornua may be considerable, or only just indicated, the uterine cavity being divided in a corresponding manner. There may therefore be no fundus uteri at all (when the division is complete) ; but the more the 374 UTERUS DUPLEX AND VAGINA DUPLEX, two horns unite into one mass, the more does the uterine sub- stance which lies between the two cavities assume the function and shape of the fundus, till at last that portion merely forms a small wedge-shaped projection into the cavity, and externally only presents a depression which indicates the dinsiou {uterus arena t us). In another variety of duplication, no trace of a division is visible externally on the uterus, or at most only a faint longitudinal furrow can be made out along its middle line, the uterus being broader than usual ; but the cavity is divided to a varying extent by a septum {uterus sejjtus s. hilocularis) . Sometimes it is divided from the fundus to the external os into two equal halves {uterus sei^tus duplex), in which case the vagina also may be double ; at other times the partition wall only exists higher up, the cervical cavity being single ; sometimes the lower half of the uterine cavity, sometimes only a slight projection at the fundus indicates the division {uterus suhseptus). § 274. Pregnancy has been seen in all these different forms of duplication, with the solitary exception of uterus didelphys ; indeed with vagina simplex and uterus bicornis twins are not uncommon, although they must be extremely rare with vagina duplex. Pregnancy as a rule is not hindered in its progress, and the children are carried for the full time ; the belief that where there is a duplex condition, pregnancy is more often terminated prematurely than with a normal uterus, has still to be proven. When one half is not impregnated, it usually, although not quite invariably, shares in the hypertrophy of the pregnant half up to a certain point, and in the formation of a decidua. AVhen the vagina of one half is rudimentai-y and occluded, it may happen (as has been observed in two cases) that pregnancy of one side co-exists with haematometra of the other ; in such circumstances the former is usually brought to a premature termination. During labour irregularities are apt to occur especially in the form of delay ; they depend upon the malformation itself, and are caused by the pregnant half diverging from the axis of the pelvis, or by the unimpregnated horn becoming prolapsed (it may how- ever, as occurs where a myoma is embedded in the lower segment of the uterus, be drawn up high above the pelvic brim by the retraction of the internal os), or by the deficient development of UTEKL'S DUPLEX AND VAGINA DUPLEX. 375 the musculature at the apex of the horned uterus. Buriufr the placental stage, severe haemorrhage may set m, especially when the placenta was inserted into the septum between the two halves. The functional independence of the latter, when both become pregnant, is shown by the fact that in cases where the two labours take place simultaneously, the contractions are to a large extent independent of each other, as regards the mode and period of their occurrence, and still more by the fact which has been mentioned in the chapter relating to multiple births (§ 204), that the two labours may occur at different dates. On the other hand it must be pointed out that when only one side contains a foetus, the os of the empty half frequently dilates at labour and casts off its mucous membrane. Where only one side is pregnant, the cephalic " lie "' is the commonest (Schatz calculates the proportion of cephalic to pelvic presentations as = 21 : 2) ; where the division is but slight (the cavity resembling an ace of hearts), the cephalic lie appears less frequent than that of the pelvic extremity (5 : 8) where the cavity consists of two pouches formed by the uterine horns which converge and communicate freely, the transverse lie has been frequently observed (according to Schatz, in 10 out of 23 single labours). Where the lie is a longitudinal one, and the foetus- containing cavity is spindle-shaped (whether the right or left horn is pregnant), the first position is the most frequent ; where the cavity resembles an ace of hearts, and the he is longitudinal, the back of the fcetus looks towards the empty horn (Schatz). When the division is incomplete, one horn may contain the placenta, while a by no means unimportant portion of the fcetus occupies the other horn ; the latter has therefore first of all grown out of the placenta-containing horn into the common cavity, and on further development into the horn of the opposite side. § 275. The duplicate formation is not infrequently so ill- marked as to be overlooked, for it is doubtless much more common than would be supposed from the cases that have l.een published. Where the vagina is double, attention is directed to the malformation, and the diagnosis of the latter can almost always be made. In the first place a complete vagina duplex, if associated with a double external os uteri, is proof of the existence of uterus duplex; for although vagina duplex is found with uterus simplex, still in such a case the duplex condition is 376 UTEKUS DUPLEX AXD VAGINA DUPLEX. always imperfect, inasmuch as the partition wall does not divide the entire vagina equally into two lateral halves, hut is only developed at certain parts, and is provided with only one hymen. When the vagina is single and the portio vaginalis is double, there is good reason to suspect a double uterus, especially if both " vaginal portions " should show the characteristics of pregnancy in a different degree ; a mere division of the external os however by a thick sagittal band does not mean much, since it may only affect the lowest portions of the cervical cavity. It is not per- missible to pass a sound into the half of the uterus which is thought to be empty, for (apart from other reasons) even where the diagnosis is perfectly clear, such a procedure might by irritating one side, cause contractions of the pregnant half. External examination is of no great help, except in cases of uterus bicornis ; it is useless in the different varieties of uterus septus. Where the two horns are very distinct, the lateral situation of one or of both pregnant horns is noticeable, although not always very obvious. Where a unilateral preg- nancy is present, the empty horn may be easily overlooked, since it lies concealed behind the enlarged one, and since (as has been stated under " Uterus Unicornis"), the spindle shape of the latter is not very easy to detect. Where the pregnancy is bi- lateral, the furrow down the middle of the abdomen is charac- teristic ; it separates two laterally situated pregnant swellings to a greater or less depth ; both enlarged horns however may be pushed against each other by the abdominal walls, and come to lie almost parallel. The condition of things is made clearer when the uterus contracts, as it can be made to do during preg- nancy, if desired, by means of external friction. The primary shape of the uterus then reveals itself; if the pregnancy is bilateral, the two horns diverge more if unilateral ; the spindle shape of the pregnant horn usually forms a greater contrast with the ordinary triangular shape of the uterus, while the empty one is drawn up as the internal os rises, and can be more easily felt. These signs, confirmed by the way in which both sides share in the contractions, and by the course of the round uterine liga- ments which can easily be made out, establish the diagnosis. After delivery, when the abdominal walls become very lax and the vagina is patulous, there can no longer be any difficulty in recog- nising the anomalous shape of the uterus. PROLAPSE OF THE UTERUS AND VAGINA. 377 Treatment in all malformations of the genital canal is restricted to symptoms, and must be guided by the disorders to which the abnormality gives rise. Any septa or bands of the portio vaginalis or vagina, which delay the fcetus during parturition, should only be divided when it is absolutely necessary ; in many cases they are pushed to one side. It is however always better to cut them through at a selected spot than to allow them to be torn by the pressure of the presenting foetal parts. b. Displacements. (1) Prolapse of Uterus and Vagina. § 276. Prolapse of the generative organs is very rare, except where it existed previous to conception. For though the hyperemia and the hypertrophy of the vaginal walls associated with pregnancy, might tend to increase any descent that existed, the gradual ascent of the uterus which so soon follows will counter- act any such tendency ; the descent of the uterus at the beginning of pregnancy which has been so generally accepted, is, as we now know, not a fact ((/. § 66). Prolapse therefore, if not antecedent to pregnancy, can only take place suddenly during that state through a shock affecting the whole body, through violent action of the abdominal muscles and where a predis- position exists, and this mode of origin is as rare in the gravid as it is during the non-gravid condition. Indeed with advanced pregnancy, this displacement is no longer possible. The pelvis is not roomy enough to allow the bulky uterus (which moreover is supported during any shocks on the pelvic brim) to pass through it. It must moreover be remembered that the severest forms of prolapse (procidentia) are by no means favourable to conception, and that when the latter takes place it usually only does so when the organs have been replaced ; moreover ad- vancing pregnancy is an important means of retaining them in situ. It will thus be readily understood why compared to the frequency of prolapse in women generally, this displace- ment is rarely met with in pregnancy. Most of the cases winch are described as such, are doubtless due to prolapse of one or both vaginal walls, and to an elongation of the cervix either tn 378 PROLAPSE OF THE UTERUS AND VAGINA. ioto or iu its intra-vaginal portion. These displacements are for obvious reasons commoner in muiti- than in primipamp. § 277. In this form of displacement the course of events is usually as follows : (1) The prolapse, as already mentioned, dis- appears with the increase in size and the rising up of the uterus, some descent of the vagina at most persisting. But (2) it may also be that the organ lying with its cervix outside and in the vulva, wdth its body in the pelvic cavity, is prevented from rising up by injudicious practices, and attains such a size within the pelvic cavity that the passage through the pelvic brim which is rendered necessary by the continued grow^th becomes impossible. This will especially occur when, as is so often the case, a retro- version of the body of the uterus is associated with the prolapse ; indeed commencing pregnancy favours such backward displace- ment, for the elongated supra-vaginal portion of the cervix which is so often atrophied where there is prolapse, cannot support the body of the uterus as it increases in weight, and when the uterus is low, the intra-abdominal pressure is exerted on its upper and anterior edge and pushes it backwards. When this happens, the pregnant organ and its neighbouring parts become incarcerated, and abortion, peritonitis etc., and even the death of the mother may follow. (3) In rare cases the greater jiart of the prolapsed uterus passes entirely out of the pelvis ; and unless artificial or spontaneous reposition takes place, pregnancy well be prematurely terminated, since a uterus inside an inverted vagina and asso- ciated with a displaced bladder can hardly continue to develop, till the foetus reaches full maturity. With this view and the statement already made that prolapse cannot occur during the second half of pregnancy, the fact accords that no well authen- ticated instance of the latter occurrence is known ; for in the few cases in which it is stated that an uterus advanced in pregnancy or actually parturient lay outside the pelvic cavity, we are either not informed wehere the fundus lay, or else the latter was still in the pelvis ; and still more frequently the protrusion in these cases was formed by the cervix. This is confirmed by the fact that the presenting part of the foetus has never yet been felt during preg- nancy in the prolapsed portion, such only happening during labour. The future course of a prolapse occurring during pregnancy depends on its degree, on the width of the pelvis, and especially 1 PROLAPSE OF THE UTERUS AND VAGINA. 379 on the condition of the woman. As a general rule it causes but little discomfort, and what there is, is similar to that met with apart from pregnancy ; at most are the dragging sensations more marked. If we except the cases in which incarceration takes place, abortion and premature labour are not so common, as might a priori be expected; when they occur, it is usually owing to mechanical violence or to interference with the circulation in the uterus. § 278. The main object of treatment must be to favour spontaneous reposition by advising the woman to avoid all severe exertion, by keeping her bowels freely open, and by forbidding her to hold her urine too long. The prolapsed organs must always be returned to their position in the pelvis, and be retained there by a perinseal bandage and a tampon of cotton wool dipped in glycerine. A fresh tampon should be inserted every day and removed at night, but if such a procedure is too irksome, a simple gutta-percha ring may be substituted ; I prefer the tampon however, since the ring irritates the vagina and the portio vaginalis, and is usually pushed down by the bulky organs to such an extent that even when a ring is used, a perinaeal bandage is also required. After the fourth month, the latter alone will suffice. If the patient is not seen till symptoms of incarceration have appeared, the bladder must be emptied, chloroform anaes- thesia induced if necessary, and the uterus returned to its place in and above the pelvic brim, care being taken that the body of the uterus is not forced against the promontory so as to produce a retroflexion. If the prolapsed parts are greatly swelled, and reposition cannot at once be effected, the attempt should be renewed at intervals, superficial scarifications of the lips of the OS and warm fomentations being meanwhile tried for reducing the swelling. If even then reposition does not succeed, an expectant treatment must be adopted, till the incarceration compels us to resort to interference, which of course means diminishing the size of the uterus by emptying it, i.e. by artificial abortion. This is better than waiting for the latter to take place spontaneously. Prolapse mainly interferes with labour owing to the unyielding condition of the lips of the os, and to their impaction between the presenting fcetal parts and the anterior wall of the pelvis : of this we shall say more further on. As far as the prolapse itself 380 PROLAPSE OF THE UTERUS AND VAGINA. is concerned, our object must be first of all to replace what is prolapsed, if it is still (partially) so, and to retain it in situ b}' a perinaeal bandage ; if this is found impossible, warm fomentations should be applied to the parts. During the pains counter- pressure in an upward direction should be made and the action of the abdominal muscles restrained as much as possible, since their contractions tend to increase the prolapse and incarceration of the lower segment of the uterus ; indeed it is possible for the uterus when diminished by the discharge of the liquor amnii, to be to a great extent pushed out of the pelvis. When such is the case, as also when the mischief is less severe, delivery should be undertaken as soon as it appears at all necessary and permissible. It will of course be obvious that during the so-called third period of labour, no traction must be made on the cord, that when that stage is over, the prolapse must be immediately and completely- reduced, and that during the lying-in period the greatest watch- fulness is necessary to keep the organs in situ. § 279. Prolongation of the cervix, especially of its intra- vaginal portion, must not be confused with prolapse ; sometimes it becomes so considerable that the os uteri appears in the vulva. The condition is not a dangerous one, except where a false diagnosis is made ; in the latter case attempts at reposition and the introduction of pessaries might lead to injurious irritation, flexion, inflammation and premature labour. Otherwise the condition is unimportant, and causes no trouble even during labour, except perhaps b}' a delayed softening of the lips of the OS interfering with its dilatation. This softening however some- times takes place even during pregnancy, and is dependent on the oedema consequent upon venous engorgement ; it may be so marked that the portio vaginalis appears as a club-shaped doughy or even semi-fluctuating body, which keeps up a constant irrita- tion, and may lead to premature labour. Rest, purgatives, and gentle scarifications of the lips of the os are the indications for treatment. § 280. Prolapse of the vagina alone, though rare, is commoner in pregnant women than that of the uterus during the same con- dition ; this however only relates to the slighter forms, since the severer can scarcely occur without the uterus sharing in the displacement. Prolapse is almost always mainly confined to the anterior wall ; generally the latter is alone afi"ected, but in rare HERNIE OF THE UTERUS. 381 cases it is only the posterior. This displacement is especially troublesome, owing to the usually associated displacement of the bladder, and to the irritation of the vulva. The discomfort may be alleviated by attending to easy defaecation, cleanliness (tepid bidet baths), a perinaeal bandage with or without a tampon ot cotton wool. During labour the prolapsed anterior vaginal wall I sometimes forms a more or less large swelling which appears at or even outside the vulva, and is pushed down by the descending head ; owing to the pressure of the child it becomes very tumid, and, if it cannot be or is not replaced, may prove an obstacle to the progress of the head, or be torn off by the latter or contused and broken through, or be so squeezed as to become gangrenous during the lying-in period. The prolapsed wall therefore must, as long as possible, be pushed back over the head with the fingers, and held back during the pains, till the head has descended far enough to prevent a recurrence of the prolapse. Even when reposition cannot be efiected, it is always advisable to hold back the prolapsed wall, and to push it up with the fingers during the pains, since under such circumstances the head Avill sometimes all at once glide out over the swelling. Where incarceration is already present, and the dangers which have been mentioned are threatening, the forceps may be applied with the object of avoiding them ; and the traction must be so directed that the least possible pressure is brought to bear on the anterior vaginal wall, and the latter can sometimes be replaced during such traction. (2) Hernia of the Uterus. § 281. These displacements are rare at any time, but it is I much rarer still for the dislocated organ to be impregnated, or ' for the hernia to come down after conception has taken place. • Pregnancy is most frequently seen in an inguinal hysterocelo (Hall Davis, Obstetric Medicine, 1836, ii., p. 912 ; Cazeaux, i Traite des Accouchements, 7th ed., p. 728, Scanzoni, I.e.) ; next I in simple umbilical hernia (Kennedy, Obstet. Auscultation, 1833, I p. 40 ; Murray, London Obst. Transactions, 18(50, i., p. 77 ; ! Leotaud, Gaz. des Hopitaux, 1859, No. 105) ; in a few older I cases pregnancy is recorded in a hysterocele crurahs (Klob, I.e.) ; ; hernia uteri foraminis ovalis and hernia ischiadica have only 382 HERNIE OF THE UTERUS. been observed in the non-gravid state. The so-called hernia ventralis, in which the pregnant uterus is driven forwards between the abdominal recti muscles which have separated from each other, and causes the aponeuroses in the middle line with the general coverings and the peritoneum to bulge out into a sac, or does this at a median or laterally placed cicatrix of the abdominal wall, does not concern us here ; it belongs to the so-called even- tration of which we shall speak later on. § 282. An timhilical hernia, although existing before the commencement of pregoancy, can of course only contain the uterus when gestation has made considerable progress. In Kennedy's case the whole organ is said to have been situated outside the abdominal cavity, and to have hung down to the knees ; in others the protrusion was not so considerable, reposi- tion was effected and labour came on spontaneously. As soon as the displacement is detected, reposition must be made, relapse being prevented by an abdominal bandage, and a pad &c. Infiiiinal or femoral uterine hernice may be congenital anoma- lies, but are more often secondary and due to hernia of the ovary or to an entero-epiplocele in which these parts adhered to the uterus. Pregnancy terminates in abortion or premature labour, no instance being known in which a fcetus lying in such a hernial sac reached the full time ; even the case recorded by Cazeaux (Ladesme in Salamanca, 1840 — Caesarian section) was one of premature labour. The diagnosis will depend on the history of the patient ; on the shape of the body which is contained in the hernial sac and which grows narrower towards the ring and by the side of which the ovary can generally be felt ; on the auscul- tatory signs ; on the elongation and dragging of the vagina upwards and towards the side of the hernia, on the simultaneous displacement of the vaginal portion Avhich is lying in the pointed' fundus vaginre and is greatly shortened, and on the absence of the uterus from its proper situation. If the condition of things is recognised sufficiently early, an attempt should always be made to replace the pregnant organ, and when this cannot be done to induce abortion at an early date ; for the latter almost always eventually comes on spontaneously, and after the discharge of the liquor aranii, reposition may possibly succeed, or labour may pass off successfully. If however the foetus is already of considerable dimensions, there is but ANTEVERSION OF THE UTERUS. 383 little probability of reposition or of a successful termination, and hysterotomy may prove necessary. It is not a good plan to allow the pregnancy to go on with the object of performing such an operation later on when the foetus is viable, since as labour is always premature, there is but a slight prospect of saving the child. In cases however in which it appears necessary to perform Caesarian section, it might be advisable with the view of avoiding '. it, to perform the operation usually practised for strangulated : hernia and after enlarging the ring to return the uterus. The best way of inducing abortion is to puncture the membranes through the os ; the introduction of a flexible metallic sound into the (at the same time anteflexed) uterus cannot prove very difficult, if its direction is clearly recognised. I (3) Anteversion of the Uterus. ' § 283. The natural inclination of the uterus forwards always I appears to be greater during the first months of pregnancy than I when the uterus is empty, and the latter may or may not retain , its slightly curved shape. But pathological anteversion before I the uterus projects well over the pelvic brim is extremely rare, I and probably only occurs when the pelvis is very wide, especially I in a sagittal direction, when the sacro-uterine ligaments exert I strong retraction, when the anterior uterine wall is unusually ' thickened, and the intra-abdominal pressure exerted on the I posterior wall is increased ; it can therefore develop suddenly. ' The presence of anteflexion during pregnancy always presupposes such a displacement previous to conception. The symptoms ' resemble those in the non-gravid state, but the signs of pressure I in the pelvis and of vesical irritation (hindered repletion of the I bladder and consequent frequent micturition) are increased. ! The so-called incarceration is extremely rare; but when it occurs, , there may be retention of urine due to compression of the region I of the neck of the bladder, and the latter may ascend on one side ' of the uterus. Abortion does not follow unless there are simul- I taneous parenchymatous changes in the uterus, or unless the i displacement has led to vascular engorgement of that organ. When the displacements occur during the earlier mouths, they |.are rectified through the gradual and spontaneous ascent of the ' uterus ; the mechanical discomforts are usually slight and may 384 ANTEVERSION OF THE UTERUS. be alleviated by the dorsal position, by attending to easy and regular defecation and by the use of a hypogastric belt. If the pressure symptoms are severe, the anteverted or flexed organ may be raised per vaginam above the anterior pelvic wall, and in some cases an anteversiou pessary may be required. § 284. Anteversion during the later months gives rise to the so-called j^^ndulous abdojnen ; it is always associated with a certain degree of flexion, the latter being generally developed in proportion to the pendulous abdomen ; the lower portion of the anterior wall of the body of the uterus may form a great pouch hanging down in front of the anterior wall of the pelvis, while the cervix is still in the pelvic brim. The formation of pen- dulous abdomen is favoured and increased by great flaccidity and laxity of the abdominal wall ; hence its severer varieties are seen in multiparae ; primiparae however are sometimes afi"ecied by it, since their abdominal walls also may gradually give away under the intra-abdominal pressure. The principal cause is pelvic contraction, since this prevents the foetus from descend- ing into the pelvis, retains it wholly in the abdominal cavity, and prevents the lower portion of the uterus from becoming fixed in the pelvic brim. The pressure of the diaphragm and intestines now causes the uterus to move forwards (pendulous uterus), which it will do the more readily and extensively, the shorter the abdominal cavity and the greater the lordosis of the lumbar vertebrae. In the severest varieties the recti muscles are widely separated, giving rise to the above-mentioned eventration, in which almost the whole uterus lies in a sac formed merely of skin and fascia, and its fundus reaches down to the knees. Similar results may follow on any diminished resistance to the enlarging uterus, e.g. on cicatrices in the abdominal wall ; thus eventration has been occasionally seen in the cicatrix left by Caesarian section, by the incision in ovariotomy, and even in cicatrices l3'ing at the sides and due to abscesses. The troubles caused by pendulous abdomen or eventration are purely mechanical : pains due to the stretched abdominal skin, excoriation of the fold at which reflexion takes place, oedema of the lower portion of the abdominal walls, urinary troubles owing to pressure on the bladder, and difficult defaecation through want of a sufficient abdominal pressure. Progression is rendered very difficult, and the woman when erect is obliged ANTE VERSION OF THE UTERUS. 385 to throw the upper part of her hody far back in order to preserve her equilibrium. The only treatment which can be adopted, but which almost always suffices, is to raise and fix the uterus by a well adjusted, firm abdominal bandage, which holds the 0Y<^:m up and back, and offers it a firm support beneath the abdominal walls ; at the same time it is well that the woman should use the abdominal muscles in moderation. § 285. During labour slight degrees of pendulous abdomen are spontaneously set right by the dorsal position and the action of the muscular fibres in the uterine ligaments ; and if the pre- senting foetal part is fixed in the brim of the pelvis, the foetus compels the uterus to assume a direction more or less approach- ing the axis of the brim. In severer forms however the uterus is not infrequently driven far forwards by the abdominal pressure (diaphragm), which in these cases acts entirely on its posterior wall, all the more so as the anterior abdominal muscles which usually counter-act such a displacement, have now lost all such influence. The os uteri is turned towards the promontory, the presenting foetal part is likewise driven against it and, since the axis of the uterus forms an acute angle with the axis of the brim, does not enter the pelvis, or at any rate does not do so square with the plane of the brim. If in these cases the body of the uterus is raised till the two axes correspond, and is fixed in this position, especially during the pains, matters will generally be rectified, except where pelvic contraction prevents the head from engaging, and makes the use of other measures necessary. § 286. In order to complete the present subject, we may here mention that the anterior icall of the lower segment of the uterus may bulge down in a similar manner to the so-called incomplete retroflexion. The region in question is deeply pouched by the descending foetal part, while the os uteri remains directed back- wards, or even near to the sacral promontory. The diverticulum however is mainly derived from the stretched and elongated cervix, and causes it to be flexed ; the body of the uterus which is being retracted over the foetus remains unaffected. The development of this condition is favoured by the axis ot the uterus lying somewhat behind the axis of the brim, by the lower end of the foetus descending into the pelvic canty before the pains begin, by the anterior wall of the cervix being pre- 386 RETROVERSION OF THE UTERUS. vented from retracting through its being compressed between the foetus and the anterior pelvic wall, and by premature rupture of the bag of membranes. The anterior wall of the cervix being thus greatly stretched and jammed during the exit of the child, may be contused or even torn off. Indeed such cases as these have been so misunderstood that the uterus has been supposed to be completely occluded and its bulging wall incised ! Where this condition is present, the woman should lie on her side and avoid bearing down ; with patience and the use of morphia injec- tions, the anterior cervical wall will usuallyretract spontaneously ; the accoucheur may, if necessary, assist in its retraction over the head, by drawing it forwards with two fingers during the pains, sometimes also during the interval between the pains. When the anterior lip is jammed, it may be requisite to make a sagittal incision, or even to extract the presenting head. (4) Retroflexion and Retroversion of the Uterus. § 287. While the severest forms of anteversion or -flexion belong to the second half of pregnancy, displacement backwards is mainly a disorder of the first four months. It is usually a " retroflexion'', partly because this in itself is commoner than " retroversion'', and conception does not take place very readily in the latter, and partly because when it does occur, the flaccid state of the uterine walls (which accompanies the hypertrophy and the serous infiltration of pregnancy) in conjunction with the obstacles which prevent any great displacement of the cervix forwards and upwards, usually converts a version into a flexion ; the displacement is in most cases neither exactly the one or other, but the axis of the cervix forms a curve which is open below, and the whole organ has the shape of a retort (fig. Gl). This distinction however is unimportant except for diagnosis. We shall therefore speak of the condition under the name " retroflexion." Displacement of the gravid uterus backwards presupposes the existence of that abnormality before conception. In rare cases doubtless a violent shock may cause it to take place suddenly ; but if the position of the uterus has till then been normal, its size even by the 2nd to 4th month is opposed to such displace- ment ; so also will be the fact that any increased abdominal RETROVERSION OF THE UTERUS. 387 pressure acts mainly on the posterior wall. The excessive re- pletion of the urinary bladder which in former times was so frequently accused of causing the retroflexion, may easily increase a displacement backwards which already exists, but can never of itself bring it about ; in this matter cause and efTect have been confused. In cases however in which the uterus is slightly inclined backwards, as so commonly happens when it lies low, the distention of the bladder may increase this inclina- tion to such an extent, that a sudden rise in the intra-abdominal Fig. Gl.— Uterus displaced backwards, diagrammatic. (After Schultze.) pressure may act on the anterior uterine wall, and all at once tilt the uterus backwards. § 288. If the dislocated uterus is impregnated, the backward displacement is generally at first increased, in consequence of the swelling and increased size of its walls ; all the symptoms which accompany such a displacement in the non-gravid con- dition, e.g. a sense of fulness in the pelvis, pain in the sacrum and thighs, diificulty and pain in defsecation, frequent micturi- tion, as well as the so-called reflex symptoms, become intensified. The portio vaginalis is found behind or at the upper edge of the symphysis, the cervix is sometimes in a line with the body of 388 RETROA'ERSION OF THE UTERUS. the uterus, sometimes bent downwards ; on a level with it is a firm, elastic, round swelling which fills up the recto-Yai^inal excavation, causes the posterior va«i;inal and the anterior rectal walls to bulge, and is continuous with the cervical wall ; while the posterior part of the vaginal fornix is thus distended and pushed down, the anterior part appears as a narrow empty cleft which is drawn upwards. Abdominal palpation reveals the fact that the hypogastrium is empty, thus suggesting that the tumour which is filling up the pelvis may be the uterus ; and a catheter introduced into the bladder shows that the latter can be pushed unusually far backwards. The displacement usually rights itself spontaneously with the growth of the uterus, generally slowly, sometimes in the course of a few days, as I have repeatedly seen. It is difficult to say how it does so, since the intra-abdominal pressure is adverse to reposition ; but it must be remembered that the body of the uterus, as it enlarges in all directions, will grow in that in which there is least resist- ance, i.e. forwards and upwards ; probably the muscular structures in the uterine ligaments also assist. Spontaneous reposition is facilitated by keeping the woman quiet and on her side as long as possible, by attending to easy defiecation and regular micturition. In not a few cases however abortion takes place ; indeed retroflexion is one of the frequent causes of habitual abortion, and one which is not rarely overlooked. In bringing about such abortion, the hypememia accompanying the displacement and the engorgement of the decidua and placenta have a larger share than the mechanical obstruction to the actual growth of the organ ; for it is clear that the diseased uterine mucous membrane plays an important part in causing abortion from the fact that it may take place even with the most quiet and careful regime, although it does so much more rarely than under opposite conditions. In a few cases I have observed that during the expulsion of the ovum, the retroflexion diminished and was converted into a retroversion (reclination), and that the latter persisted for some time after the emptying of the uterus, — evidence of the above-mentioned co-operation of the muscular fibres in bringing about spontaneous rectification. •^ 289. In a certain number of cases the uterus does not rise up out of the pelvis, nor does abortion take place, but the uterus continues to develop in the pelvic cavity. "When this happens, RETKOVERSION OF THE UTERUS. 389 the pressure symptoms described in the previous paragraphs gradually grow severer, feces and urine are discharged with greater diificulty, the tenesmus increases, and forces the bulky uterus further and further downwards and backwards and the cervix against the bladder, till at last the uterus completely fills up the pelvic cavity, and seems to be immovably impacted in it {incarceration of the uterus). In rare cases this takes place more rapidly, when the intra-abdominal pressure has been suddenly raised, and with this difference in the mode of origin the sj'mptoms also vary. The patient complains of severe pains in the pelvis and especially the sacrum, radiating down the thighs ; the tenesmus is intolerable, and straining efforts only increase her agony. At first the pregnant woman may be able to pass some drops of urine, but soon this is found impos- sible, and the bladder rises to a high level in the abdominal cavity. The action of the bowels has been probably for some time already rendered difficult, by the extensive compression of the rectum and the hardness of the faeces to be evacuated ; at last not even flatus can pass. The abdomen grows distended and sensitive, vomiting sets in and the temperature rises. The tenesmus and bearing down may become so severe that the body of the uterus descends to the floor of the pelvis, and covered by the posterior vaginal wall appears in the vulva, or even bursts through the vagina and shows itself uncovered (Greuser, Monats- schrift f. Gehurtskundc, ix., p. 73 ; Mayer, Presse Medic, i., 1837, p. 153) ; again, the anterior wall of the rectum may be protruded, and the fffitus make its exit through the anus (Ilal- bertsma, Monatsschrift f. Gehurtskundc, xxxiv., p. 414). § 290. But it is the bladder which presents the most dangerous symptoms, and for that reason as well as on account of the errors in diagnosis to which it gives rise, its condition deserves special attention. Thus it frequently happens that the retention is not complete, but that urine continually dribbles, or is passed at intervals in larger quantities, either voluntarily or involuntarily, while the bladder continues distended and may attain to an enormous size through the distention having occurred gradually. This ischuria paradoxa has but too often led to a mistaken diag- nosis as regards the nature of the dilated bladder. Cystitis follows moderately quickly ; owing to it and to the air which is introduced during the attempts at catheterisation, the urine undergoes decom- 390 RETROVERSION OF THE UTERUS. position leading to the so-called diphtheritic inflammation, and even to gangrene of the mucous membrane and subjacent strata. The inner wall of the bladder, i.e. the mucous membrane, either Fig. C2. — Retroflexion of the gravid uterus, showing the distended bladder with the mucous membrane and a portion of the muacularia detached and in a state of gangrene. (.Schultze, Arch./. Gi/n., i.) alone or in combination with the innermost muscular layer, may be detached in more or less large pieces, or even in its entirety, KETKOYERSION OF THE UTERUS. 391 from its subjacent layer, and form a complete pouch lying in the bladder (fig. 62). The detachment begins at the vertex of the bladder, since the external pressure which opposes the distention is least at that point ; moreover the serous coat and the external muscular layer allow of more stretching than do the inner muscular layer and the mucous membrane, so that the latter will reach their limit of extensibility soonest, and separate from the former. The detachment proceeds in the direction of the cervix, and at that point the loose sac is connected with the mucous membrane that is still adherent ; here too when the former has been expelled, the regeneration of the inner wall will begin. Between the detached and the remaining layers, blood, pus and urine that has trickled through, accumulate. The gangrenous mass may lie over the neck of the bladder and prevent the urine escaping, even if the catheter gets into the bladder. Quite recently cases have been recorded in which several layers of the wall of the bladder and even portions of the peritoneum perished (Madurowicz, Hecker-Zantl), much as occurs in inversion of the bladder. Rupture of the bladder is extraordinarily rare\ even where the distention is extreme. On the other hand the decomposed urine and pus &c. may be absorbed by the bladder, while owing to the hindered emptying of the kidneys where distention is extreme, urine may accumulate in the renal pelves and in the renal parenchyma (the ureters do not undergo much dilatation), leading to se2-)tic or uremic iMisoninfj ; this is one of the com- monest causes of a fatal issue. The latter may also take place from iKritonitis, although this is rarer than is generally believed. The great distention of the abdomen, the pain when the bladder or the incarcerated uterus is touched, simulate such, or at any rate make it appear greater than it really is ; where peritonitis is found at the necrops}-, it usually accompanies septicajmia, or has started from an inflamed uterus. This uterine inflammation moreover with its sequelae, parametric phlegmon and abscess, frequently causes death. § 291. This termination however is fortunately on the whole rare, for the symptoms usually become so severe before the situation is quite hopeless, that assistance is called in, and this ' Quite lately Schwartz in Halle hag described such an occurrence ; cf. Centralblatt J. Gyn., No. 6, 1880, where the author also quotes the scanty records of this occurrence. 392 RETROVERSION OF THE UTERUS. can do very much towards obviating the worst. Even if the capital remedy, i.e. the liberation of the uterus from its incar- cerated position, does not succeed, still spontaneous reposition will sometimes follow, if only the symptoms that are most urgent at the time, i.e. those due to the bladder and to the complete rectal obstruction, can be alleviated. If however the impaction is very firm, abortion usually follows, and it is remarkable how the uterus, though turned almost completely upside down, manages to get rid of its contents. With its diminution in size, the main object is gained, and if the injury done to the bladder, to the uterine tissues, to the neighbouring parts, and to the abdominal cavity is not too severe, complete reparation and recovery are still possible. It must yet be mentioned that the symptoms of incarceration may not show themselves so early as the 3rd or 4th month (as is stated above to be the rule), but somewhat later, viz. at the end of the 4th or the beginning of the 5th month. This is seen where the pelvis is very wide, the uterus relatively small, and the patient not of a very sensitive temperament. Indeed the pregnancy may run more than half its course, before symptoms of incarceration appear, the anterior wall of the uterus rising up out of the pelvis and continuing for a while to develop above it. Lastly, there are cases in which these symptoms do not show themselves at all, or do so only temporarily ; this happens in the so-called incomplete retroflexion, of which we shall say more hereafter. § 292. It is usually easy to diagnose incarceration of the retro- verted uterus. The symptoms already described are characteristic in a woman that feels herself to be pregnant, and the distention of the bladder strengthens the suspicion. Nor can it be difficult to detect the incarceration, if only the practitioner does not allow himself to be deceived by co-existing tympanites. If the bladder can be catheterised and emptied, bimanual examination will clear up the case ; if the former cannot be done, the difficulty is greater. The physical signs are those mentioned in § 288, but are even more marked. The whole pelvic cavity is filled up by the body of the uterus, the perinaeum bulges, there is oedema of the vulva, jiossibly of one or both thighs and of the gluteal region ; the urethral orifice is drawn up behind the symphysis, the vagina is compressed against the upper border of the symphysis, the anterior vaginal wall ascends vertically towards RETROVERSION OF THE UTERUS. 393 it. The portio vaginalis is driven against the anterior pelvic wall, and can often only be reached with difficulty at its upper edge, sometimes not at all ; now and then it can be felt from without, but care must be taken not to confuse a little tumour occasionally felt, and reaching several finger-breadths above the symphysis, with the portio vaginalis ; this tumour is formed by the wall of the bladder, and persists after reposition. It is easy to mistake the distended bladder for the body of the uterus, the flexed organ for retro-uterine swellings impacted in Douglas' pouch, especially when these are associated with sudden pelvi- peritonitic disease, and the bladder cannot be emptied ; but the consistency of the pregnant uterus and its contents is different from that of other swellings, and it may not infrequently also be recognised by the contractions which set in when firm pressure is applied to the body, either |)^'r red am or j^cr vaginam. When necessary, a thorough examination under deep chloroform nar- cosis will clear up the condition ; indeed in urgent cases the tumour and even the bladder may be punctured with a fine trocar (and aspirated). § 293. Treatment. In view of the frequency of abortion and the great dangers of incarceration, the spontaneous replacement of the uterus is to be encouraged, Avhenever a woman with a retroverted or retroflexed uterus becomes pregnant, or whenever the displacement is discovered sufficiently early during pregnancy. This is done by prescribing a quiet mode of life, and the greatest attention to regular micturition and defiecation ; to facilitate the latter, mild purgatives are alone to be used ; not enemata, for the tenesmus which follows their use generally increases the displacement, while the injection usually does not pass beyond the fundus uteri. Rigid confinement to bed is only necessary, when signs of threatening abortion show themselves ; in most cases a moderate amount of exercise may be allowed, but all exertion which requires vigorous action of the abdominal muscles is forbidden, and the woman must rest on the sofa m the latoro- prone position for some hours at a time. It is a good plan, aMii o the woman is in such a position, occasionally and in'/- vaoimm lo push the fundus uteri up. I have never seen any harm done d> the use of pessaries in these cases, but no good either If there is reason to fear the onset of abortion, the uterus mmt invnediately he eompletehj replaeed. If impaction has not jct 394 BETKOVERSION OF THE UTERUS. ensued, i-ej)lacement per vaginam will generally succeed. It is effected by making the woman lie perfectly horizontal, with raised pelvis and flexed thighs, by introducing four fingers in supination, and applying steady pressure to the body of the uterus in the direction of the promontory, and when it has reached the latter, pushing the uterus past one side of it (whichever is easiest) into the great pelvis, while the other hand presses down the cervix from outside. The replaced organ must be brought into a position of anteversion, and may be retained there by a Schnitze or a lever pessary, till the danger of relapse has passed. This treatment is decidedly preferable to the introduction of small india-rubber bags into the vagina or rectum, as is sometimes recommended, and which when distended exert a steady pressure upwards ; the tenesmus which they provoke generally undoes whatever good they may have accomplished ; and where they do succeed, the plan I have mentioned would have been more eÖectual. I need scarcely add that during the whole of this period, the pregnant woman must keep perfectly quiet in bed, and lie as much as possible in the semi-prone position. § 294. If however we are dealing with a case of incarceration, the first thing to be done is to empty the bladder. This is usually not an easy matter, although it generally succeeds if the direction of the urethra is borne in mind ; the point where the neck of the bladder is compressed must be sought for, and a thick elastic catheter used, since it follows the occasionally tortuous course of the canal better than does a metallic instru- ment ; nor must it be forgotten that the seat of obstruction is often high up, that a dilatation may have formed below it, and that the instrument may have to be introduced very far. Some- times the genu-pectoral position facilitates a proceeding which appears impossible in the ordinary posture ; or else the cervix uteri may be forcibly pushed (by means of several fingers in the vagina) backwards and downwards from the pubes, when the urine will sometimes at once flow ofi" spontaneously ; if this proceeding is repeated and accompanied by external pressure on the bladder, the latter may sometimes be entirely emptied. But even if none of these plans for drawing the urine are successful, the attempt at immediate reposition need not be at once given up, although of course the result can only be perfectly satisfactory when the bladder is emptied. Under these circumstances how- RETROVERSION OF THE UTERUS. 395 ever {i.e. while the bladder is unrelieved) reposition will rarely succeed by the means mentioned above, so that in such cases of impaction it is better to make the attempt per reetum. The patient is to be put under chloroform, and two fingers, or half or, if necessary, even the whole hand introduced into the lower part of the rectum ; while now the fingers of the other hand try to draw the portio vaginalis downwards and backwards, the body of the uterus is pushed obliquely upwards along one side of the promontory ; occasionally reposition is greatly facilitated by the ventral posture with raised pelvis, or by the genu-pectoral. At any rate this mode of procedure will effect anything that can be eftected, and makes other methods (introduction of levers, bags) superfluous. Reposition may be rendered impossible by adhesions of the uterus in Douglas' pouch, by bands of adhesion above the uterus (Schatz, Moldenhauer Arch. f. Gyn., vi.), or by inflammatory swelling and consequent absolute immobility of the organ. Undue force might do great damage by tearing the adhesions and injuring the uterus ; no excessive violence therefore must be used in replacing the uterus. If the bladder cannot be emptied, it may be punctured between the umbilicus and the symphysis, ca. 8 cm. (3 in.) above the latter, so that the opening in it may remain in contact with the seat of puncture in the abdominal walls during the outflow of urine, and at the same time lie above the seat of compression. A fine trocar will suffice for the purpose. After the operation the uterus may sometimes be replaced, but if not, its size must be lessened by getting rid of its contents, i.e. abortion must be induced. When this is done, the symptoms are immediately greatly relieved ; reposition may at once be found possible, or if not, as the uterus becomes con- tracted and involuted, the most urgent symptoms caused by the impaction disappear. Interference however must not be delayed, till the bladder, peritoneum or uterus are irremediably damaged. The puncture of the ovum is not always, indeed is rarely, an eas^ matter ; it is all the more difficult the higher the portio vagina is, the more firmly it is pressed against the symphysis and the more the uterus is "verted", as opposed to ' üexed. i o i the operation it is best to use a uterine sound, which can be bent as required, or an elastic bougie through which a fine stiia can be pushed ; if the portio vaginalis is directed straight upwards, 396 RETROVERSION OF THE UTERUS. the posterior lip may be drawn down with a tenaculum, and a metal canula sharply re-curved at its point introduced into the OS, and through this an elastic bougie passed into the uterine cavity ; even if the membranes are not at once ruptured by it, " pains" soon set in (<;/'. P. Müller, Berliner Bciirai/e, iii., 1874. p. G7). If these methods do not soon attain their object, the most prominent part of //"• hudy of the uUrusmay he j^nnctured with a moderately thick trocar under all aseptic precautions ; it must therefore be done from the vagina, although the fundus can be most accurately hit from the rectum; care must be taken to pierce the wall perpendicularly and not obliquely ; the aspirator offers many advantages. The puncture of the uterus is not so dangerous as might appear, since the wound after discharge of the liquor amnii is soon closed by contractions ; the canula should therefore be left in at least long enough for sufficient liquor amnii to flow off. Displacement may be prevented from recurring after reposition, by suitable posture, by pessaries, by regular emptying of bladder and rectum ; the sequel.e of incarceration are to be treated according to the usual rules. Since such incarceration may be fatal, even after abortion has occurred, I must here once again caution against interference being delayed till it is too late. § '295. Incomplete Retroflexion. As already mentioned, the displacements backwards are spontaneously rectified in a great many cases. But sometimes this only happens very gradually and imperfectly by the anterior wall of the uterus, which is least affected by the pressure of the neighbouring organs, rising up into the great pelvis and growing into the abdominal cavity, thus forming a secondary pouch in which the great mass of the fa3tus comes to lie, while the posterior wall remains in the pelvis. These are the cases of incomplete retroflexion, of retroflexion during the second Imlfofpregnaiicy and labour, of sacciform dilatation of the posterior uterine wall, of which we read in medical literature. Although as a rule the larger abdominal part of the uterus at last draws up the pelvic part with it and thus completes reposition, this may not be the case. Symptoms of incarceration may show themselves, even at a late period, where this condition of incom- plete retroflexion is present ; they may last but a short time, or be followed by premature labour. Pregnancy in this variety of displacement also is not infrequently terminated prematurely (it RETROVERSION OF THE UTERUS. 397 was so in 5 out of 11 cases collected by Veit), although it may last its natural time (as in 5 out of those 11 cases). When parturition occurs in these cases, the pelvic cavity is found to be filled by a diverticulum of the posterior uterine wall, and this as a rule contains the head. The cervix is pressed firmly against the upper edge of the symphysis and does not Fig. 63. — Diagram of an incomplete retroflexion. (Oldham.) move into the pelvic axis, so that the parturient canal does not attain its natural development (fig. 63) ; the bulging wall is greatly sti-etched downwards, and is occasionally broken through. In a few cases when the pains have lasted for some time, reposi- tion has occurred spontaneously even at this stage, the os uteri 398 NEW FORMATIONS. receding from its forward position towards the pelvic axis. But serious troubles may also occur when the bulging wall is not drawn up, or when, as occurred to Crede (oral communication), the placenta lies in the diverticulum and has to be removed by hand. The diaffiiosis of this condition will not be difficult, if a careful bimanual examination is made; treatment during pregnancy must be mainly expectant, since apart from frequent dysuria and painful defsecation, there are no symptoms ; gentle attempts at reposition should however even then be made at intervals. It is well as early as possible during labour, and while the woman is in the genu-pectoral position, j^er rectum to push the pelvic por- tion of the uterus up, while the abdominal portion is firmly pushed forwards ; when difficult, the reposition will be facili- tated, if at the same time the cervix is pulled towards the middle of the pelvis by the accoucheur or an assistant intro- ducing his fingers into it. Digital dilation of the os favours the descent of the presenting part, and the disappearance of the irregularity. c. New Formations. § 29G. Pregnancy may occur where the most diverse new formations exist in the generative organs and their vicinity ; such growths may all exert a disturbing influence on the progress of labour, but a reciprocal influence between them and pregnancy occurs principally in the case of myoma or carcinoma of the uterus, and of ovarian tumours. The following description is true, mutatis mutandis, of all the other tumours that are met with. (1) Fihro-myomata of the uterus are not often seen during pregnancy, for it is a well known fact that they are commonest in virgins and elderly widows, particu- larly in nullipara}. Nor can there be any doubt that they may prove obstacles to conception ; nevertheless impregnation some- times takes place where from the size and position of the tumour it might be least expected, most frequently of course in the case of subserous and intra-parietal tumours, most rarely with sub- mucous, as is easily explicable from a consideration cf the relation of the latter to the inner surface of the uterus. NEW FORMATIONS. 399 It is not uncommon for the swelling to share in the hyper- trophy of the uterus caused by pregnancy, for it to grow softer, more juicy and bulky; thus I have watched a case {Arch.f. Gyn,, v., p. 110) in which a retro-cervical myoma which was scarcely noticeable previous to conception, had attained such a size, when labour came on at the full time, that in spite of the death of the foetus Caesarian section became necessary. The softenin«' depends on an (Edematous infiltration, but dilated lymphatics and lymphorrhagia are not rare, and may lead to the formation of cysts with or without haemorrhage. Instances however are by no means wanting in which the new formation undergoes no change whatever. The difference depends doubtless on the more or less intimate connection of the growth with the wall of the uterus, and on the varying abundance of muscular tissue and vessels. The myomata which become softened usually also undergo a change in shape, partly owing to the pressure of the abdominal or pelvic walls, partly and principally owing to the dragging exerted by the uterus, as it extends in different direc- tions. This change in shape is most marked in intra-parietal tumours situated in the lower portion of the uterus ; for these, as the latter is stretched at the end of pregnancy and during labour, seem sometimes almost to disappear, so flat do they become ; when the uterus is emptied and its wall retracted, they regain their original shape. Moreover an alteration in position may take place, the tumour rising up with the body of the uterus. The tumour may also be expelled during pregnancy (as haj)pened in a case of Cappie's). Pregnancy frequently terminates in abortion or premature labour ; especially when the myoma is attached to the lower half of the uterus, since it is very apt in this position to prevent the symmetrical development of the uterine wall, and only permits a certain amount of that development. Sometimes also abortion is brought on by the retroflexion due to a fibroid, still oftener by the haemorrhage caused by the growth. Not only is the placenta relatively often found in the lower segment of the uterus (placenta pnevia), but it may also be placed on the tumour itself, and in these cases hemorrhage seems to be par- ticularly dangerous. During the lying-in state (of the efiect on labour more here- after), the changes produced in the myomata by pregnancy 400 NEW FORMATIONS. usually retrograde ; those of the latter that bad become byper- tropbied undergo atrophy to a corresponding degree through fatty degeneration and contraction, indeed they may become absolutely smaller than before, possibly also nearly or entirely disappear. Gangrene, suppuration in the tumour or in its cap- sule, often due to the pressure accompanying labour, may cause death, although they sometimes also lead to expulsion and re- covery, after destroying the base or breaking through the capsule. Secondary hfemorrhages are not rare, and it is doubtless true that a myoma which is sessile at the fundus, predisposes to inyersion of the uterus. In the last place it may be pointed out that occasionally the lying-in period oilers the best chance for re- moving the fibroid by operation, either by enucleation or by excision, owing to the increased accessibility. § 297. The diagnosis of fibroids is sometimes easy ; in many cases indeed the origin, size and consistence can be accurately determined. As a rule however there is very great difficulty, especially in the case of intra-parietal growths, since at any rate during the first four or five months, they often conceal the existence of pregnancy, or conversely the latter may conceal the presence of the former, so that the fibroid can only be recognised during or after delivery. Myomata which have become succulent and semi-fluctuating, may be confused with cystic tumours, and operated on (punctured), a matter which is not unimportant in the case of myomata. Foetal parts (head), a second foetus, a uterus bicornis have been mistaken for such tumours. Nothing but the most careful and repeated examinations carried out with the utmost circumspection, will prevent error ; and although such examinations do not always entirely elucidate the case, they will at any rate prevent disastrous mistakes. The treatment during pregnancy rests between removing the tumour, and terminating the pregnancy prematurely; apart from these measures we can but treat the symptoms. The removal of a sessile tumour is most easily accomplished where it is situated on the cervix, and is intra-vaginal, but inasmuch as the operation is sure to bring on pains prematurely, and can be carried out just as well, indeed even better, during nataral labour, such interference is not advisable during pregnancy, except when urgent symptoms (haemorrhage, gangrene of the tumour) leave us no option. Pregnancy must only be terminated by abortion. NEW FORMATIONS. 401 since premature labour is, or may be, accompanied by the same serious complications as is labour at the full term. It is how- ever permissible, indeed imperative, to bring on artificial abortion, in cases where the pelvis is greatly encroached upon by myomata, •which both by their situation (retro-cervical and -vaginal) and size seem to be irreplaceable, since the Ciesarian section, which will probably have to be performed under these circumstances, offers a most unfavourable prognosis for the mother. Abortion of course may be required by other kinds of tumours also, when- ever they lead to great danger. When we are dealing with subserous myomata projecting into the pelvic cavity, it is a good plan not only where there are symptoms of incarceration but even without them, now and then during the last months to make careful attempts at reposition, in order both to guard against incarceration, to keep the tumour movable and possibly to elevate it permanently. "We must also mention extirpation by abdominal section much as in ovarian tumours ; it has been successfully performed by Schröder {Zeitschrift f. Geb. u. Gyn., v., p. 397). Extirpation of both prcrjnant uterus and fibroid has lately been successfully accomplished by Kaltenbach {Centralblatt f. Gyn., No. 15, 1880). § 298. The above remarks relating to submucous fibroids, hold good of pedunculated myomata (polypi), so long as they lie in the uterine cavity. These are especially dangerous owing to the haemorrhage to which they give rise, and on that account and owing to mechanical interference with the ovum they generally cause abortion ; inasmuch as they cannot be reached by the finger, they are only discovered at or after the expulsion of the ovum. Polypi lying in or projecting from the cervix, and which arise from the latter or higher up, cause even severer hemorrhage, and, when of large size, may lead to mechanical troubles. If they are readily accessible, it is best to remove them, not with the ligature but with scissors, or if there is a risk of hemorrhage with the ecraseur. The small cellular cervical polypi, and they also may give rise to copious purulo- sanguineous discharges, and thus cause great weakness, are to be removed as soon as discovered ; as caustics, I recommend fuming nitric acid, u solution of chloride of zinc or a red-hot iron. 26 402 CANCER OF THE CERVIX UTERI. (2) Cancer of the Ccnix Uteri. § 299. Unhappily cancer of the cervix does not always prevent conception ; it only does so, when the growth entirely occludes the canal. Cancer of the body of the uterus is never observed during pregnancy. The complication is a very grave one, for, if at all advanced, it seems materially to curtail the life of the patient, not directly through the pregnancy, but through the laceration of the diseased parts during labour. Now and again the progress of the disease, as well as its local and general symptoms, appear to be to a certain extent arrested by pregnancy^ but this is exceptional ; the rule is for the disease, much as in the non-gravid condition, gradually to involve contiguous parts, and in the case of the soft carcinomata even more rapidly, probably owing to the active changes in nutrition that are associated with pregnancy. The actual duration of gestation is not shortened in the majority of cases ; it is so more rarely, the more the disease is confined to the portio vaginalis or the roof of the vagina ; and conversely the more frequently, the higher the region of the supra-vaginal portion of the cervix it has attacked. The irritation caused by interference with the physiological changes in the latter portion owing to the cancerous degeneration may terminate the preg- nancy prematurely. On the other hand it is noticeable that pregnancy complicated with cancer now and again lasts beyond the usual period ; no explanation of this fact is known, unless it is that in a large proportion of these cases the pains which come on at the proper time were rendered ineftectual by the rigidity and hardness of the cervix uteri, and again became quiescent, the fcetus then dying and being retained for months as a whole or in part within the uterine cavity {cf. Depaul-Schmit, Arch, clr Tocologie, Feb. 1876, p. Ill ; cf. also infra). The diagnosis is not affected by the co-existence of pregnancy. In regard to tJu'rajn^xtics, the principles recommended apart from ' I have seen a small commencing epithelioma of both lips of the os remain un- changed from the 3rd month right on till labour at the full time, both as regards size and shape ; during labour it caused very little trouble, but afterwards grew all the more rapidly. 8 v^i^eVa post pai-tum I removed it with the red-hot wire. Qaite lately I have had under observation an entirelj- similar case, which I first saw in the sixth month of pregnancy ; here also labour came on at the full time and passed cff with but little trouble, the growth being removed six weeLs afterwarJs. OVAEIÄN TUMOURS. 403 [at condition hold good. I must strongly recommend the early moval of the growth, if it is still confined to the portio vaginalis his has lately heen successfully performed by Savory, Schröder, enicke. Bidder, Wiener (I.e.) inter alios) ; when however such proceeding is not possible, I must warn against undue local eddling, since this, unless radical for the time being at least lUd apart from removal no treatment is so), does not diminish le danger accompanying labour, and on the other hand is apt I interrupt the pregnancy. Such interruption is always to be raided, and artificial abortion or premature labour are therefore it out of the question ; on the contrary, considering the hope- ss prospects for the mother, all our efforts should be directed I preserving the child. Abortion destroys the latter, and in no ay prolongs the life of the mother ; indeed after abortion the sease usually spreads very rapidly. Premature labour has still ss to recommend it ; generally it has no object, since the injury 3ne to the diseased parts is much the same as in a full time ,bour, and the preservation of the premature child is highly foblematical owing to the difficulties of labour and to the inter- irence which is rendered necessary (in one case in spite of remature labour, I was only able to deliver after craniotomy). he end of pregnancy must therefore be patiently awaited, and le treatment adopted which is recommended farther on. If the ill term has arrived without labour taking place, or if now .or lortly before this the symptoms in the mother have become very jvere, pains may be encouraged so as to assist the mother and reserve the child. The further treatment should be that pur- led in a spontaneous labour at the full time (ef. also § 269). (3) Ovarian Tumours. § 300. This complication can hardly be called rare, as indeed 5 shown by those cases in which ovariotomy has been performed 1 ignorance of the co-existence of pregnancy. Moreover bilateral varian disease has been met with during pregnancy. The imour in most cases existed previous to conception, although ; was then usually of relatively small size. It may possibly egin to develop during pregnancy, but the question is still nsettled. Pregnancy and ovarian tumour may co-exist side by side 404 OVARIAN TUMOURS. without causing any serious symptoms, and the pregnancy mayj terminate successfully. The tumour may remain stationary, or| possibly even diminish in size (Milne, Kdinhurfjh Med. Journal,' 1874), an event which of course can only occur in the case of cysts, and is to be looked upon as a result of pressure exerted by the growing uterus. But often enough important changes in the new growth show themselves under the influence of preg- nancy, and vice versa. This depends mainly on the nature of the tumour, its position, connection with the uterus, and mobility. Pregnancy not infrequently favours the growth of the tumour by the increased afflux of blood to the generative organs, of which of course the ovaries receive a share ; this is not merely! true of cystomata, in which the rapid increase of the contents' may cause the gravest mechanical troubles, but also and still more of the solid tumours. Thus I have on two occasions beeni able to examine bilateral cancerous growtbs soon after labour] {Monatsschrift f. Geb., xxx., p. 380 ; and Hempel, Arch. f. Gyn.,\ vii., p. 556), in which not a trace of healthy tissue remained, and! in which therefore the disease must have made rapid progress during gestation. Moreover the danger of originally innocent! growths turning into malignant ones, as now and again seems to take place, is quite as great as is the increased rapidity of growth. Another series of dangers may depend on reciprocal inter- ference with each other of the uterus and tumour. If the latter is fixed in the pelvis and not easily displaceable, the former may be subjected to severe pressure, indeed become retroflexed audi thus lead to abortion ; but this is rare. It is much more common for both to rise up into the abdominal cavity ; and if so, it is the extreme abdominal distention which is the source of the trouble, all the more so if the cyst be rapidly filling at the same time ; if now owing to interference with respiration and to irritation of the peritoneum, ascites is superadded, the situation becomes extremely grave. Nutrition may suffer greatly, and the patient be brought to a condition of extreme exhaustion before her pregnancy reaches its full term. The mechanical irritation sometimes leads to the formation of extensive adhesions,, the pressure to rupture of the cyst and to a discharge of its. contents into the abdominal cavity. Moreover a retrogressive OVARIAN TUMOURS. 405 [ metamorphosis of the cyst wall consequent upon haemorrhage \ and suppuration (generally after puncture), may also lead to ; such a discharge. Kupture is not always fatal ; the fluid poured |i out may be absorbed and the pregnancy reach its normal dura- ; tion, but as a rule death takes place by collapse or else by 1 peritonitis. In other happily rare cases, the uterus rises up I beneath the tumour, twists both tumour and pedicle round their iaxis, and so strangulates them; death may then take place I through haimorrhage into the cyst and abdominal cavity, followed j by peritonitis, but usually is rapidly brought on by gangrenous [changes in the tumour, sometimes by shock. I The influence of this complication on the progress of pregnancy 'as such, depends on the changes that have been mentioned, as ■well as on the general deterioration in health which sets in; as , already mentioned, when the tumour does not grow or does so I but slowly, pregnancy often reaches its natural termination. The li development of the foetus itself is not directly affected. ' The lying-in state is rarely normal ; this is chiefly due to the ; labour being generally difficult, and to severe operative inter- iference being often called for. Special dangers follow on the contusion to which the tumour has been exposed during labour, jon the secondary inflammations and gangrenous processes in it, 1 which, as I have seen, may also be produced by thrombosis in !the tumour. A rapid increase of the new growth is likewise i often seen during the lying-in state. § 301. From a diagnostic point of view, we should always be I suspicious when a patient sufi'ering from an ovarian tumour, who I has hitherto been menstruating regularly, ceases to menstruate I for a considerable time, and when her abdomen grows somewhat \ rapidly. If, as is the rule, both tumours lie side by side, it is not > an easy matter to distinguish them. In obscure cases the re- I cognition of the pregnant uterus is generally easier than that of I the accompanying new growth ; but this is not always so. The i uterus, owing to adhesion of the tumour to the anterior abdominal I wall or to its enormous size, may be entirely forced to one side, so Us to be difficult to discover. Thus I examined and tapped a case ! in which the cyst filled almost the whole abdominal cavity, had i forced the uterus far into the right lumbar region and to some extent roofed it in, while in the pelvis the only part of the uterus that could be felt was the portio vaginalis, which was displaced to 406 OVARIAN TUMOURS. tlie right side and liigli up ; it was not till auscultation had been practised on four different occasions, that the condition of things was cleared up. The diagnosis may be especially difficult with a multilocular and very nodulated new growth, when the uterus is firmly applied to it, and seems to form part of the growth. Conversely, the uterus may so conceal the tumour that its exist- ence, and still more its nature, are utterly beyond recognition. But a very careful palpation, under anaesthesia if necessary, and a repeated auscultation, where there is any suspicion, will as a rule clear up the case, or at any rate prevent any disastrous mistake. § 302. Considering the great danger which this complication causes during pregnancy, and possibly still more during labour, it will at once be obvious that an expectant treatment is only admissible up to a certain point ; only when the tumour is small, of slow growth, and where pregnancy progresses without any serious symptoms. Under opposite conditions, i.e. when the tumour is large to begin with, multilocular, or solid, or rapidly gi'owing, something must be done, if possible of the nature of prophylaxis ; for the success of any treatment that comes up for consideration, depends in no small measure on its not being delayed till the woman has been too greatly reduced by the complication. A^Tiat can be done ? In the first place artificial abortion must be rejected, since while sacrificing the foetus it is but of little use to the mother ; it leaves her with the tumour and moreover under circumstances which favour its rapid and insidious development ; the post-partum period supervening on abortion has often the same injurious influence as that after an ordinary labour. Our choice therefore lies between the artificial induction of premature labour, tapping the cyst, and ovariotomy. When the contents of the tumour are mainly fluid, therefore with unilocular cysts, or with multilocular in which one cavity greatly predominates, trvpping has much to recommend it. It has been performed a good many times, and (esjiecially in the extensive experience of Sir Spencer Wells) appears not to be more dangerous than in the non-gravid condition ; in a large majority of cases it allows the pregnancy to reach its normal duration, and therefore saves the child. I myself have twice per- formed this operation under urgent circumstances, without inter- OVARIAN TUMOURS. 407 fering with the pregnancy. But with other tumours than those mentioned, the operation must not be thought of ; at any rate it can be of no use, and we are left to choose between artificial induction of premature labour and removal of the tumour. Since the former of these, considering the size of a viable child and its relation to the progress of labour, scarcely offers better prospects than does labour at the full time, while the mother is left with her tumour exposed to the injurious effect of the pressure which accompanies labour, and of the lying-in state, I cannot advise artificial induction as a general rule, although in auy exceptional case it might conceivably be the best treatment, indeed the only one admissible when ovariotomy is declined. The latter operation is on the whole not so dangerous as would a imori be expected ; it is least so for the mother, especially since the introduction of antiseptics ; nor is it much more so for the continuation of pregnancy. Ovariotomy has now been performed in a by no means small number of cases, sometimes unintentionally through error in diagnosis, but generally for definite indications. Sir Spencer Wells {London Obst. Transactions, vol. xix., p. 185) has operated 9 times, losing one patient; Schröder {Zeitschrift f. Geb. u. Gyn., v. p. 383) 7 times, always with success; I myself 3 times with a similar result ; others also have succeeded. In some cases it is true abortion took place after the operation, although without prejudicial influence on the woman. I must therefore strongly urge that the operation be performed under the circumstances above described ; not only where life is actually endangered, but here as elsewhere without much delay, if the physician is convinced that such danger will eventually arise. According to the evidence before us, the mother will have a better chance, when the difficult labour that might be caused by the complication, is from the first made impossible; nor is the prognosis worse for the fcctus, since without an operation quite as many foetuses perish during birth, as perish by abortion brought on by the operation. If however the latter is declined, we are compelled to resort to other treatment according to the cir- cumstances of the case. Ovariotomy is imperatively demanded, indeed it is our only resource, in those cases in which the cyst has burst, or in which the symptoms point to suppuration or to twisting of the pedicle. 408 METRITIS. d. Inflammatory Conditions. (1) Metritis. § 303. Acute metritis, that is parenchymatous metritis, is rare even in the non-gravid condition, and in my mind there is con- siderable doubt whether it ever occurs spontaneously during pregnancy ; apart from the diftuse or circumscribed swellings which not infrequently accompany retroflexion, I have not seen anything approaching to metritis. Of course I except those cases in which products of metritis are found in a woman who has died soon after delivery ; such belong to the puerperal dis- eases in the narrower sense of the word, and no longer to pregnancy. Cases however are on record in which the disease of the gravid organ led to abscesses, and even to perforation of the wall (rupture), and in which when the lowest portion of the uterus was involved, the abscess discharged into the vagina (Dezeimeris, "De la Rupture spent. &c., L' Experience, Journal de Med. et Chir., 1839, No. 94 ; Kennedy, Pathological Soc. of Dublin, 1839). I must also call attention to the fact that sometimes small fibroid nodules of the uterine wall swell up during pregnancy, grow soft and sensitive, and may be mistaken for inflammatory infiltration. Inflammation (due to irritation) of the uterine serosa is commoner, and leads to its thickening and to the formation of pseudo-membranes ; but even this is rare, if we except those cases in which it is associated with incarceration or tumours. Old adhesions often get stretched without much difficulty during pregnancy, owing to the alteration in size and position of the uterus, and are then broken down. They are by no means such a frequent cause of abortion, as was at one time believed (Boivin). Parametric inflammations and phlegmon in the lig. latum are somewhat commoner than similar conditions of the pelvic peri- toneum ; the causes are injury or effusion of blood into the cellular tissue. I have seen two cases, both terminating in abscess ; one burst into the rectum, the other I opened below the right Poupart's ligament. In neither case was the progress of pregnancy interrupted. Treatment in all these inflammatory- conditions must be guided by the usual rules. ENDOMETRITIS. 409 § 304. Sometimes the uterus, especially during the later months of gestation, is extremely sensitive to pressure and to the foetal movements ; indeed attacks of pain very similar to colic or to labour pains may set in spontaneously. This con- dition has been called rheumatism of the litems. The pain may either he simply neuralgic, or accompanied by fever or gastric disorder ; nor is it rare for the bladder and the lower part of the intestinal canal to be also affected. The severer forms of this affection, especially those associated with fever, are probably due to inflammation of the uterus, chiefly of its inner surface, and as a rule they soon bring on labour, which is often followed by severe disease during the puerperium. The slighter forms, which have more of a simple neuralgic character, are difficult to explain, but I see no reason why the word " rheumatism " should not be applied to them, since they are readily brought on by chills, and similar affections are met with elsewhere, e.g. in the bladder, and similarly described. The name indicates what we mean by the disease. These cases are to be treated with purgatives, e.g. ol. ricini (which do good even when there is no constipation), opiates, warm baths, warm fomentations on the lower abdomen, and diaphoretics. I have seen great good done by the applica- tion of flying mustard poultices to the lower abdomen, and by fomentations made by dipping flannel rags in hot water, and sprinkling them with some ol. terebinthinae, by enemata of ol. ricini and ol. terebinthinae (aa. one table-spoonful), and by sub- cutaneous injections of morphia in the abdomen. (2) Endometritis. § 305. The commonest and (anatomically) the most easily demonstrated inflammatory condition affecting the gravid uterus is endometritis. In the form of an acute disease associated with destruction of tissue, it often accompanies the acute infectious diseases, as was described in § 257. As a chronic disease, it ap- pears in two forms, endometritis hyperplastica and e. catarrhalis. a. Endometritis decidualis chronica, hyperplasia of the deciduo. The change is either uniformly distributed in every part, or is especially marked at certain spots, at which it leads to tbe formation of excrescences— endometritis decidualis tuberosa or polyposa. 410 ENDOMETRITIS. § 306. In the limformly distributed \a,viety, a, partly fibrous, partly embryonic connective tissue of the nature of granulatinf,' tissue is developed, and thus gives rise to thickening and induration of the decidua ; the subjacent muscular fibres may also share in the hyperplasia, and the formation of cysts has sometimes been seen. The disease may be confined to the placental portion of the decidua, but sometimes it chiefly affects the vera in its whole or in part of its extent ; the reflexa also may be involved. The first of these situations will of course be most injurious for the foetus, but even when the disease is extra- placental, early abortion is apt to take place owing to the inces- sant irritation and to the destruction of tissue by extravasated blood. On the other hand when the inflammation is moderate in extent and runs a slower course, or when the placental portion is not involved, the pregnancy may reach its natural duration ; indeed the disease may not develop till the last months. In these cases labour may be complicated by difficulty in the detachment of the decidua ; and if the placental portion also is diseased, the detachment of the placenta will be interfered with. The cause of this diff"use hyperplasia cannot always, indeed can only rai-ely, be made out with certainty. Syphilis may lie at the bottom, in other cases a chronic endometritis existed antecedent to conception and was carried over into pregnancy; sometimes, and especially when the malady sets in later, injury or over-exertion may be the cause (Kasche- warowa). In a few cases the hyperplasia is undoubtedly secondary, i.e. consequent on the death of the foetus, and this appears to be most common in those cases in which the ovum remains quiet in the uterine cavity for a considerable time after its death (Duncan, Researches in Obst., p. 293). § 307- The polypoid variety of endometritis decidualis, between which and the diffuse, transitional forms are found, is characterised in a well marked case by a two- to three-fold thickening of the whole decidua, on whose surface are situated bosses and ex- crescences of various shape and size, 1 — 2 cm. (^ — | in.) high, and with a smooth surface ; sometimes they are polypoid in shape, sometimes more knob -shaped, situated on a broad base, sometimes merely thickened nodules. They are as vascular as, or even more so than the rest of the decidua ; the glandular orifices are few, sometimes absent ; they are often of small diameter, ENDOMETRITIS. 411 especially at the apices of the excrescences. The hyperplasia is produced by decidual cells which are remarkable by their size and large nucleus ; they lie concentrically round the vessels, and cause the narrowing of the glands. This hyperplasia in a few- cases (Dohrn, Monatsschrift f. Geb., vol. xxxi.) in which the vera was absent, has also been seen in the reflexa ; but this has hitherto only been observed in the ova of early abortions. The chorionic villi are almost always thickened (secondarily) and hypertrophied, the embryo being usually shrivelled. Sometimes the cause is syphilis ; where there is no reason to suppose such an origin, the explanation is generally unknown ; the supposition that it is due to irritation preceding conception does not help us, both owing to its frequency and its vagueness, but it is possible that the mucous membrane' may have been similarly diseased previous to pregnancy. The hyperplasia may often have no importance, and be secondary. § 308. b. Endometritis dccidualis catarrhnlis (Hennig), liydrorrhcea uteri gravidi. In this disease the inflammation of the decidua is slight, and leads not to hyi^erplasia, but merely to increased transudation and migration of blood-corpuscles. Hence arises the thin serous albuminous discharge which is occasionally present during every stage of pregnancy, but espe- cially during the last three months. The secretion is derived from the decidua vera alone, or from it and the reflexa; and these may be the source, since (although they are generally blended) the division between them which exists during the first months, sometimes persists. If the fluid has a free exit into the cervical canal, the discharge may be more or less constant, although its quantity is siiiall within any limited period ; if however fluid cannot flow out continuously owing to the occlusion of the orifice leading into the cervical cavity, it accumulates between the decidua vera and ovum, gradually sinks and is then discharged at longer or shorter intervals all at once, in a gush ; as a rule slight contractions of the uterus are connected with this, and this organ becomes distinctly smaller after the evacua- tion, although by degrees it again increases somewhat. I have in a good many cases seen a single copious discharge, but then it was always only a few (three at most) weeks or days before labour, and in every respect resembled the ordinary discharge of the liquor amnii'; the uterus at the same time diminished 412 ENDOMETRITIS. considerably in size, the parturient canal became much softer and pains set in. Within a short time however (a few hours), and this feature clears up the diagnosis, the pains again subsided, and when labour came on subsequently, the foetal membranes were found intact. The discharge itself is thin, similar to liquor amnii both iu colour and smell, and if it lasts for a considerable time is by that character distinguishable from one of cervical origin. No changes show themselves in the generative organs, if we except, what has been sometimes observed, great softening of the cervix and vagina. The patients are generally, but not always, multiparas frequently of a pallid aspect ; if not already so previous to preg- nancy, they may, when the discharge is copious, suffer in health, and get thin. Now and again a sanguineous discharge is asso- ciated with the thin serous one, a fact which is easily explained, if we remember the origin of both. It is not rare for the preg- nancy to be interrupted before running its full time, on the one hand owing to the diseased condition of the inner surface of the uterus, on the other hand owing to the diminution of the preg- nant organ which accompanies a sudden and copious discharge. Treatment can only be symptomatic. I recommend that digestion be kept in order, that the diet be strengthening, non-irritating and combined with iron ; tepid baths once or twice weekly, a quiet mode of life, and morphia when there are contractions, will also be of use. I must caution against astringent vaginal injections or any other local treatment ; they are useless, and cause an irritation which will be apt to provoke premature labour. This hydrorrhcea must not be confused with the discbarge of the fluid mentioned in § 91, which sometimes collects between amnion and chorion (amnio-chorionic fluid), and which may be evacuated previous to labour ; but if so it is only once. The quantity of the chorionic fluid may be so great as to simulate hydramniou ; M'Clintock relates such a case in his Clinical Mem. on Diseases ofWoinen, 1863, p. 388. The discharge of the true liquor amnii is still less likely to cause confusion ; for it is always soon followed by labour, and the bag of membranes is then found to have already burst. The numerous cases that are recorded of the so-called discharge of liquor amnii weeks before labour, are to be looked upon as cases of hydrorrhoea, in which the discharge only occurred once. LEUCORRHCEA. 413 (3) Leiicorrhcea. § 309. Cervical leucoirhnea depending on simple catarrh or on deeper seated inflammation of the cervix, and accompanied by erosion or even ulceration with the other sequelae, is not rare in pregnant women ; but in most of them it existed from before pregnancy, and is increased by the cervical changes associated with the latter. So long as the discharge does not weaken unduly, and the other local symptoms do not cause great dis- comfort, nothing should be done in the way of treatment beyond advising the cautious use of copious irrigations of tepid carbolic or salicylic acid lotions ; if there is much irritation, merely of chamomile tea, and tepid hip-baths with a bath speculum. If however great weakness and discomfort are produced, I can after frequent trial recommend the single application of an active caustic (the red-hot iron is best), although I must strongly denounce repeated superficial cauterisations, especially by nitrate of silver ; these are not unlikely to induce pains. The super- ficial abrasions and erosions of the edges of the os which are so frequently seen in pregnant women (c/. Lieven, Wiirzh. Med. Zeitschrift,\., 1864), are unimportant, so long as the surrounding mucous membrane is healthy, and no deeper disease is present ; experiment has convinced me that they may be caused by digital examination, that a finger that is examining roughly may detach and scratch off the softened layer of epithelium. It is possible that coitus is also a cause. § 310. Vaginal leucorrhoea is commoner during, than apart from, pregnancy, owing to the predisposition caused by the physiological changes in the vagina {cf. § 71). The secretion may be very copious, sometimes thin and milky, sometimes like thick cream ; a purulent or purulo-sanguineous discharge points to gonorrhoeal infection. The hypertrophy of the papillae, which has also been mentioned in § 71, may at the same time be very marked. Occasionally there is an abundant development of fungi, forming whitish or yellowish grey patches on a rod ground, especially in the lower portion and at the entrance of the vagina. Owing to the copiousness of the secretion and to the accompany- ing irritation, which readily spreads to the vulva, and there often gives rise to an intolerable burning or itching (especially where fungi are developed), and owing to the urethra being also 414 LEUCORRH(EA. involved, the vaginal blenorrhoea may be very weakening antl troublesome. Treatment must nevertheless be restricted to gentle remedies : attention to regular defaecation, scrupulous cleanliness, bidet hip-baths of tepid chamomile tea ; cautiously performed irrigations with tepid lotio plumbi, dilute solutions of acetate of aluminium, carbolic or salicylic acid ; at most the introduction every night of a small pledget of cotton wool soaked in glycerine and covered with small quantities of the remedies just mentioned, will suffice for diminishing the secretion and the symptoms, and often also lead to recovery. The vaginal walls become greatly hardened by the leucorrhoea, and when stretched during labour may be very painful, while the diminished elasticity may cause them to be torn ; the skin of the perinaeum also owing to the prolonged moistening with the irritating secre- tion, may sometimes grow very tight and rigid, so as to yield but little during the exit of the foetus, and to tear easily. Sooner or later however recovery almost always takes place sponta- neously, during the lying-in state, if not before. The vaginal catarrh may lead to the formation of numerous little cysts lying closely together on the surface {colpo-hypcr- plasia cystica of Winckel), and which contain either fluid or merely air {colpitis vesiculosa emphysematosa of Ruge). They consist either of dilated lymphatics, or in rare instances of dilatations of the little glands which are now and again found scattered in some parts of the vagina ; their usually multiple appearance points to the frequency of the first-named explana- tion. The air-vesicles generally contain atmospheric air, but sometimes a product of the small cysts (trimethylamin, accord- ing to Zweifel). After birth this condition generally disappears, without leaving any traces. Pustular colpitis, although so rare even in the non-gravid condition, I have once seen during pregnancy. Dr. Matthews Duncan tells me of a similar case. All these various conditions practically require the same treat- ment, as that already recommended for simple catarrh. (4) Abnormal Softening and Mobility of the Pelvic Articulations. § 311. It was mentioned in § 72 that the swelling and abundant infiltration with intercellular fluid, which afi"ect all the INJUEY AND RUPTURE. 415 pelvic organs during pregnancy is also noticed in the fibrous capsules of the pelvic joints, and increases the synovial fluid. In rare cases however (in some mamrüalia, e.rj. the guinea-pig, it is a normal occurrence) this change takes place to an unusual degree, and is associated with a painful condition of the affected parts, which is especially severe during movements of the trunk, e.g. during progression ; indeed the latter is rendered impossible. In some cases it has been possible actually to demonstrate the great mobility in the pelvic articulations ; indeed even crepitation is said to have been detected under such conditions. The woman affected in this way must keep perfectly quiet, and wear a tight pelvic bandage which will hold the articular surfaces together, and allow the latter the least possible range of move- ment. The same must be done after labour, if permanent and serious mischief is to be prevented. Even inflammation of the pelvic joints has been seen during pregnancy ; the diagnosis and treatment are given in text books of surgery, and require no special description. e. Injur)/ and Rupture. § 312. The uterus may be ivounded in the most various ways. If the injury is slight, the gestation may go on, as has happened after intended or unintended tapping, without harm to the mother or even to the foetus^ Instances of recovery after mjury to the uterus by a gunshot icound which involved the fictus, are recorded by Staples in the Neic York Med. Record, Sept. 9, 1876; by Hays, New Orleans Med. Surg. Journ., Oct., 1879, and others. Very extensive injury, such as the slitting up of the uterus by the horn of a bull (Geissler in Mon. f. Geb., xx., Thatcher), is usually fatal ; such accidents must be treated according to the rules for gastro-hysterotomy. When a uterus advanced in pregnancy is ruptured, without the abdominal cavity being opened, the cause is often a crush ; thus I know of a case in which a farmer's wife at the nmth ' Bandl {I. c.) relates such an instance of tapping, which occurred under Brann's observation. In my Maternity during the spring of 1879 a bydrammouc u^ruB was tapped, of course by mistake, without injury to mother or fcctus, the latter be.ns born Hponta;eously a fe^ weeks later. A similar result happened m the c^e r corded by Grenser (LeLuch d. Gehurtsh.), in which a meat hook had Penefated thro gh tl abdominal wall of a woman advanced in pregnancy, and entered the fa^tal cav.ty. 416 INJURY AND RUPTURE. month of pregnancy rolled with a cart down a steep incline. I She at once showed signs of rupture, and was saved by gastro- r tomy. The symptoms of such an accident are those of the ! rupture of an extra-uterine foetal sac at an advanced stage {cf. j infra), and the only correct treatment is to remove the child by abdominal section. Sjyontaneous riq)ture of the pregnant uterus is one of the | rarest events ; the instances in which it is said to have taken ! place during the first half of pregnancy are extremely doubtful j in point of diagnosis ; nor are all of those belonging to the later j period quite clear, since they also may have been confused with j extra-uterine foetal sacs ; some however cannot be so explained | away. The rupture probably always depends on abnormal structure of the uterine wall (e.g. on a cicatrix left by previous | Caesarian section), on its destruction by some intra-parietal new j growth or on degenerative processes ; it then almost always I takes place when the body is exposed to external violence, or I when there is vigorous action of the abdominal muscles. These i ruptures are comparatively often situated in the upper portion of ! the uterus, while those occurring during labour always affect the ; lower. An incomplete rupture has also been observed, i.e. a j rupture of the uterine wall without its peritoneal lining being ' injured ; a portion of the foetus then lay in a closed cavity, which did not communicate with the peritoneal cavity (Hilde- brandt, Berliner Klin. Wochenschrift, 1872, No. 36). The signs of rupture are hnemorrhage, shock and alterations in the shape of the abdomen and uterus, i.e. in great measure those of the same accident in advanced extra-uterine pregnancy, or of rupture of the uterus during labour ; the prognosis also is the same, and treatment will only oflFer much prospect of success, when the foetus with its membranes is completely removed by j gastrotomy. It is only in very exceptional cases that labour follows so rapidly after the accident, that the child can be bom \ per vias naturales. (I heard of such a case at Freiburg in 1862 in the practice of the then assistant-physician Keppner in Horuberg [Baden] . In this case labour took place during the j summer of 1861 on the fourth day after spontaneous rupture, I and on the following [fifth] day was terminated by that prac- J titioner after perforation of the dead child ; the placenta was followed by a mass of coils of intestine, which were replaced and INJUBY AND RUPTURE. 417 held back by a tampon. Eecoveiy was rapid. In August 1862, Keppner after consultation with me induced premature labour at the 28th week in the same woman, who had soon again become pregnant ; the child was born spontaneously and alive, but died after two hours, the mother passing through a perfectly normal post-partum period.) Injuries of the vagina and of the external generative organs in pregnant women, apart from spontaneous rupture of a varix or a haematoma in those parts, must of course be due to external violence. The treatment to be adopted must depend on the principles of general surgery. LITEEATUKE. Failures in development: Kussmaul, Tim dem Mangel dev Verkiim' mening u. Vcrdojipehing der Gebärmutter. Würzburg, 1859. Fürst, Mun. f. Geh., XXX., 1867. Müller, Arch. f. Gyn., v., p. 132. Borinski, ibid., x., p. 14.'j. Moldenhauer, ibid., vii., p. 175. Schatz, ibid., iL, p. 289. Gontermann, Berl. Klin. Wuch., 1879, p. 61G. Stadfeldt, '• Howitz Gynecol., kc" Meddeleher, ii., 1878 ; Centralbl. f. Gynäh., 1879, p. 320. Leopold (Die Ueberwandcrung des Eies). Arch. f. Gyn., xvi.. p. 21. Prolapse : Hüter, Man. f. Geb., xvi., p. 186. Gusserow, ibid., xxi., p. 99. Elongation of the portio vaginalis: Gwemoi, Arch, gener. Med., 1872, i., ii. Kessler, Dorj^at. med. Zeitschrift, vi., 1875, p. 103. Herniaj : Klob, Path. Anatomie d. iceibl. Sexualorgane, 1864, p. 105. Scan- zoni, Beiträge z. Geburtshtuulc, vii., p. 167. Anteflexion : Ahlfeld, Arch. f. Gyn., xiii., p. 161. Retroflexion: Tyler Smith, London Obst. Transact., ii., p. 286. Schatz. Arch. f. Gyn., i., p. 469. Barnes, Obst. Oper., 3 edit. Franke, Mon. f. Geb., xxi., p. 161. Depaul, Arch. Tocol., 1876, Jan. Ed. Martin, Zeitsch. f. Geb.v^ Franenhranhh., i., 1875, p. 1. Maduro^vicz, Wiener Med. Wochenschrift, 1877, Nos. 51, 52. Zantl, Müncheyier Dissertation, 1878. G. Veit, " Ucbcr d. Retro- flexion d. Gebärmutter in d. späteren Schwangerschaftsmonaten." Yolkmann's Sammlung klin. Yortr., 1879, No. 170. Tumours: Gusserow, " Die Neubildungen d. Uterus." Billroth's II-'^''^ Franenhranhh., 1878. Demarquay et St.-Vel, Malad, de Vi'teru.i, 18.0, p. lo9. Myoma of the uterus: Gueniot, Bulletin gener. Therap., vol. 71 1S06. Horwitz, Petersb. med. Zeitsch., 1868, xiv., p. 249. Spiegclberg. Mon.fUeU., vol. 28, p. 426. Lambert, -Des pross. compliqucs des myomes utör. lhe»r Paris, 1870. Nauss, Haller Dissert., 1872. Löhlein, Z f Geb. v. Gyn., i., p. 1-0. Carcinoma of the cervix uteri: Cohnstein, Arch. f. Gyn v., p. S<\6. Chantreuil, Gaz. des Hop., 1873, Nos. 37, 45. Pfannkuch, ^J']' {; I'^^^'l;' p. 169. Ruttledgc, Berliner Dissertation, 1876. Benicke, Z f Geb. u_ Cr jn . 418 EXTRA-UTERIXE TREGNANCY. i., p. 337. Herman, London Ohnt. Tranmrt., xx., p. 191. Wiener, Birxlancr Acrztl. Ztitxch., 1880, No. 4. Savory, Ohst. J. Great Brit., iii., p. 47. Bidder, Deutsch. Med. Woch., 1879, p. 193. ' Ovarian tumours: Olshausen. A'/'fl/iA/u/'^r« r/. Ofa;vV«, 1877, p. 108. Sp. Wells, Diseases of the Orarie-f, 1872. p. 1G6. Br. Hicks, Loudon Ohst. Tran.iaet., xi., p. 203. Wernich, Berliner Beitr. :. GeUirtsh., ii., p. 143. Rugc, Z. f. Geh. u. Frauenkranhh., i., 1875, p. 8. Schröder, Z. Geb. Gyn., v., 383. Endometritis: Virchow, Die Krankhaften Geschwülste, ii., p. 478; Archiv., vol. 21, p. 118. Kaschewarowa, Virchow's Archie., vol. 44, p. 103. Heerar u. Maier, ibid., vol. 52. Vom Hofe, " Ueber Hyperplasie der Dccidua." Marburger Dissert., 18f)9. Kaltenbach, Zeitschrift f. Geh. u. Gyn., ii., p. 22."). Myschkin, "Endom. dccidualis," Petersh. Dis.fertation. 1878 ; cf. Centralhlatt f. Gyn., 1879, p. CA. Ahlfeld, Arch. f. Gyn., x., p. 168. Maslovsky, Centr. f. Gyn., 1880, p. 3.52. Hydrorrhoea uteri : Heorar. Mon.f. Geh.. xxii.. p. 429. Fabln-i. Bendic. delle Sess. delV Acad, dclle Scienzv delV Instit. di Bologna, 27 April, 1871. Colpitis: Engel, Orrosi hetilap, 1878. Cf. Centralhlatt f. Gyn., 1879, p. 88. Winckel, Arch. f. Gyn., ii., p. 383. Cheneviere, ibid., xi., p. 351. Zweifel, ibid., xii., p. 39. Ruge, Z. f. Geb. it. Gyn,, ii., p. 29. Klauser u. Welponer, Centralbl.f. Gyn., 1879, No. 14. Mobility of the pelvic articulations: Dohout, Bulletin gi-ncr. de Therap., 1863. Rupture of the uterus: Bandl, Veber Bujitur der Gebärmutter vnd ihre Mcchanili. Vienna, 1875, p. 9, 4. Diseases of the Ovum. This is not the place for a detailed description of the pathology of foetal development. Consistent with the object of this book, we can only note those abnormalities which may disturb the progress of pregnancy or of labour. a. Pregnancy outside the Uterine Cavity — Extra-uterine Pregnancy. § 313. The ovule is as a rule fecundated at the ovary itself or in the Fallopian tube near it, and passes from there to be imbedded in the uterine cavity. In rare cases however it imbeds itself in a portion of the genital canal on the proximal side of that cavity, namely in the Fallopian tube or ovary, or even in the serou?. membrane lying behind these organs ; it then continues to develop in that situation, much as it would do in EXTRA-UTERINE PREGNANCY. 419 the uterus, and under favourable conditions reaches full maturity. Of the three principal varieties of extra-uterine pregnancy tubal, ovarian and abdominal, the first is commonest, and the ovarian the rarest. Until recently, the occurrence of ovarian pregnancy was entirely denied ; but its presence has now been definitely proved in at least 13 autopsies, while on the other hand no a imori objection to such an event can be raised. Since the cumulus proligerus of the ovum does not always lie in the follicle immediately behind the point of rupture of the latter, the ovule need not be discharged with the liquor folliculi, but may be retained in the discus prohgerus ; if then it is fecundated in that position (and we know that the spermatozoa penetrate as far as the ovary), it will find a soil in the theca folliculi, which possesses all the elements of a mucous membrane, and in which therefore the ovule may comfortably imbed itself. Such an event is less easy to understand in the case of a serous mem- brane, if the peritoneal sac is looked upon as a lymph-sac ; but it will appear less strange if we remember that the ovum always imbeds itself in a part of the peritoneum in close proximity to the generative organs, and that this small portion of the peri- toneum, even in the higher vertebrata, has a share in the sexual functions^, that it is continuous with the germinal epithelium, and that an ovum lying on it will still be on congenial soil, and may there continue to live and develop for a time. Moreover islands of germinal epithelium sometimes occur at still more distant spots. § 314. The causes of tubal and abdominal pregnancy must lie in some obstruction which renders the passage of the ovum into and through the oviduct impossible or difiicult, or else they must be looked for in the so-called migration of the otnm. All the other explanations (mechanical) have not a shadow of evidence to support them, and at post-mortems it is only now and then that even the obstruction above referred to can be demonstrated, since the extra-uterine development causes the most fundamental changes in the internal genitals, and obliterates primary anomalies. The obstruction in the tube may be complete or merely due to a lessened calibre, which allows the spermatozoa to reach to the ovule, but does not permit ' In the frog the endothelium of the abdominal cavity at the time of sexual maturity takes on a structure similar to the epithelium of the oviducts, and becomes ciliated. 420 EXTRA-UTERINE PREGNANCY. the latter, when fecundated and consequently increasing in size, to reach the uterine cavity. Where there is complete occlusion of one tube, the spermatozoon may pass through the other, which is patulous, and across the abdominal cavity to the adjacent ovary of the abnormal side, and there effect impregna- tion, after which the ovule is grasped and retained by the tube belonging to its ovary. The obstruction is generally produced by peritoneal adhesions and bands, which fix and bend the tube more than is usual ; this view is in harmony with the fact that extra-uterine pregnancy in the majority of cases affects multi- parse, who have been more or less sterile for some years previously (for such anomalies are generally due to previous puerperal periods, and tend to make conception difficult), and also with the fact insisted upon by Hecker that left-sided tubal pregnancy is the most frequent (since pelvic inflammations are known to occur more often on the left than on the right side). In a few cases the obstruction to the passage of the ovum is said to have been caused by polypi blocking up the uterine end of the oviduct, as Breslau (Monatsschrift f. Geb., xxi., Siippl. 1859), Beck (Illustrirte Med. Zeitung, ii., 1852), and Leopold [Arch. f. Gyn, xiii., p. 354) observed^ ; or by intra-parietal fibroids of the uterus (Magrath, London Obst. Transact; Roth in "Gross, tubaire," These de Strasburg, 1844). Twins also have been somewhat often seen in tubal pregnancy, and it is not impossible that the two ova may have hindered each other during their transit. Nor must we forget the occasional presence in the Fallopian tubes of accessory orifices, as when the inter- stitial portion of the tube divides before entering the uterine wall {cf. Hennig, I.e.). The migration of the ovum, i.e. the extra-uterine m., is not a very rare event, and must be looked upon as one of the commonest causes of abdominal pregnancy. It may however also lead to the tubal variety, of course in the tube on the opposite side to that of the ovary which produced the ovum, as when an ovule fecundated in its ovary has during its journey attained to such a size that it can no longer pass through the tube of the opposite side as far as the uterine cavity. Moreover intra-uterine migrations, in which the ovum which had reached ' As regards the grounds for such an assumption, cf. Ahlfeld, Centralblatt f. Gyn 1879, Nos. 2 and 4. Leopold, ibid., No. 3, takes the opposite view. \ EXTRA-UTERINE PREGNANCY. 421 the Uterine cavity in the usual way passes from there into the opposite oviduct and remains in it, an event the possibihty of which was first suggested by Tyler Smith, have now been demonstrated by Schultze {cf. Hassfurther) . Amongst astiological varieties must be ranked the cases of Lecluysc and Koeberle. In the former (BuUcfi/i Acad. med. Bclg., 18G9, iii., No. 4, p 362) the abdominal pregnancy probably resulted from an opening'sevcra'l cm. in size, which remained in the uterine cicatrix of a previous Cajsarian section,' by means of which opening the uterus and abdominal cavity communicated \vith each other. The latter case (Keller) occurred in a woman in whom Kceberle extirpated the uterus and a part of the cervix about 2 years before, leaving the ovaries behind ; the woman conceived through a fistula remaining in" the cervix, and died in consequence of this pregnancy. § 315. The early development of the ovum, whatever be its extra-uterine point of attachment, is the same as in normal gestation; its appendages therefore, i.e. chorion and amnion, develop in the usual way. It is otherwise however with the membranes derived from the mother, i.e. decidua and sac ; the formation of these will vary with the situation of the ovum, so that we have now to consider the several varieties of the abnormality. But first of all I must mention that the formation of the extra-uterine jüacenta will not present any special characters, since the decidua of the uterus itself is nothing more than con- nective tissue, and the chorionic villi are not in any essential, at most only in fortuitous, relation with the uterine glands, and are only connected with a relatively thin connective tissue layer of the serotina ; indeed sometimes the villi are simply stretched out between the chorion and the decidua, the interspace between these amounting to no more than a cleft (Langhnns). The extra- uterine placenta mainly differs from one of uterine origin, by the foetal and maternal tissues being much more loosely con- nected with each other, although also by its situation, form and size ; each of these characters is equally variable. Sometimes the placenta is very large and thick ; sometimes large, but very thin and membranelike ; sometimes it is extremely small. Occa- sionally it has been found broken up into a considerable number of small lobes with very ramifying blood-vessels, the latter penc- tratinfj into the most various abdominal organs. 422 EXTRA-UTERINE PREGNANCY. Tubal Pregnane}]. § 316. The ovum is sometimes attached to the abdominal extremit}', sometimes to the uteriue portion of the tube, some- times to the portion that is perfectly free, i.e. more or less near its middle. Hence arises the division into tubo-abdominal, tubo- uterine and simple tubal pregnancy. At the seat of the attach- ment,, a decidua and even a reflexa (Hen- nig) develop by out- growths (in the form of villi and trabecule) from the vessels of the mucous mem- brane and of the subjacent connective tissue ; the chorionic villi advance towards this connective tissue and sink into it, al- though the attach- ment is but loose. The formation of the placenta takes place much upon the plan in which it is met with in rabbits, cats and dogs ; no reci- procal intergrowth of the chorionic villi and the maternal vessels seems to take place, nor does the maternal tissue penetrate into the foetal placenta. The villi are merely stretched out between decidua and chorion, without being actually immersed in the maternal blood. a. In simple tubal pregnancy, the foetal sac is entirely formed EXTRA-UTEKINE PREGNANCY. 423 by the walls of the Fallopian tube. These walls undergo hyper- trophy as the ovum grows, although not to a corresponding extent; the wall of the Fallopian tube is gradually thinned" the muscular bands are separated from each other, the sac at last gives way under the pressure of the ovum and bursts (fig. 64). The rupture generally takes place at the free surface, i.e. the thinnest part of the sac, although it occasionally does so at the placental site ; in the majority of cases rupture occurs within the first 8 weeks, but it is not infrequent in the third month ; it is rare later on. There may be no premonitory symptoms of any importance, or partial tears may more than once precede the final one, and be accompanied by symptoms of local peritonitis. The fcBtal membranes may give way, and the embryo escape into the abdominal cavity, or they may remain intact, and the ovum pass out entire ; occasionally the latter remains altogether in the tube. When the foetal sac is completely ruptured, fatal haemor- rhage generally ensues, but even in those cases in which the end is not so rapid, the secondary peritonitis as a rule causes death. It is possible even in these circumstances for recovery to take place, through the ruptured oviduct, or the embryo (which soon perishes), or the whole ovum being enclosed and shut off by masses of exudation ; indeed this is doubtless the way in which the origin of many retro-uterine hsematoceles is to be explained, viz. by previous rupture of a pregnant oviduct. The ovum, if young, perishes, shrinks up and is lost in the exudation ; but if it is more advanced at the time of rupture, a new foetal sac is sometimes produced by pseudo-membranes and adhesions, and the foetus may undergo the changes which are shortly to be described under "Abdominal Pregnancy". The haemorrhage is always least, when the ovum remains sticking in the tube, since it may then act like a tampon in arresting the haemorrhage at the point of rupture (Wiedersperg, Prar/er Vierteljahresschrift, 1865, iv.). These cases also are the most likely to recover, and Virchow was actually able to demon- strate such an event at a post-mortem {Gcsammte AhhamlhiiKjcn , p. 796). Sometimes the rupture is brought on by extravasation of blood into the placenta, and by the consequent stretching^ of the foetal sac (c/. Kreuzer's case recorded by Kussmaul,^ Von dem Mangel, der Verkümmerung und Verdoppelung der Gehar- mutter, von der Nachempfängniss und der Ueherwanderung des 424 EXTRA-ÜTEEINE PEEGNANCT. Eies, p. 362, Würzburg, 1859) ; this occurrence probably always ends fatally, and is also met with in the other varieties of extra- uterine pregnancy. The tube may rupture at its lower edge, which is not covered by peritoneum ; in such a case the blood is effused into the tissues of the broad ligament and separates its two layers, the ovum making its way into the space between them. This doubt- less very rare occurrence has been spoken of as cxtra-peritoncal pregnancy (Dezeimeris). It proves fatal through the effused blood breaking down the pelvic connective tissue &c. EXTRA-UTERINE PREGNANCY. 425 In exceptional cases, tubal pregnancy reaches the full term. This of course can only be explained by an unusual hypertrophy of the muscular tissue of the tube, which enables it to resist the stretching; still there are several examples of the tube being sufficiently stretched to harbour a five months, and even an older, foetus^ Saxtorpli has recorded (although it is not very accurately described) a case of tubal pregnancy in which the foetus was mature, and I have been able to add a similar observation, in which there could be no possible doubt {Areh. f. Gyn., i., p. 406) ; Fabbri also (Mem. clelV Acad. delV Instit. di Bologna, 1871, xii.) has seen a tubal pregnancy advance to the 9th month, and then after the death of the foetus run on to the twelfth ; two additional cases are related by Simpson and Tinker (ef. under Fränkel), and a sixth by Litzmann {Areh. f. Gyn., xvi., p. 323). But the most favourable termination of a tubal, as of every other extra-uterine, pregnancy is the very early death of the ovum, before rupture takes place ; for then nothing is left except the remains of a haematoma. Doubtless this event is not so rare as is generally supposed, and these cases probably constitute a by no means small proportion of those described as ha;'matomata of the pelvis, or hematoceles. § 317. Pregneincy in a rudimentary uterine horn (fig. 65) runs a course extremely like that of tubal pregnancy (ef. svpra § 272). Hitherto 20 such cases have been observed (ef. Jansch, Yirchow's Archiv., vol. 58) ; in almost every one (in 16 out of 18 of which there is a record) rapid death took place by rupture of the horn and by hemorrhage ; although somewhat later than happens on an average in simple tubal pregnancy, viz. between the 3rd and 6th months. The rupture invariably occurred at the apex of the horn, in the neighbourhood of and above the point of insertion of the oviduct ; indeed this is always the thinnest portion of the walls of the horn. In one case the foetus died in the horn at the 5th month, and was converted into a lithopedion ; in another the normal termination of pregnancy was reached (Turner), and the child, when the pains after lasting for several days had ceased, became changed into a lithopedion and was extracted from the mother, on her death six months afterwards from phthisis-. The ' They are recorded by E. Fränkel {Arch./. Gyn., siv., p. 205). _ , . -u.,- ^ A case in which a lithopa^dion was formed after bursting of the horn, 13 related b, Chiari. {Wiener Med, Wochenschrift, ISTfi, 2-i Nov.) 426 EXTRA-UTERnfE PREGNANCY. course and termination of pregnancy in a uterine horn are so similar to those of tubal pregnancy, that it will probably never be possible to diagnose one from the other during life; at best may we have reason for suspecting a pregnant horn, if, as just mentioned, the rupture takes place at a somewhat late date. Should the case Fig. G6.— Interstitial pregnancy. (Breschet.) ft. body of the uterus. b. its cavity opened from the front. c. fcEtal sac in the uterine wall. d. ovum with hypertrophied villi. e. point of attachment of the placenta, which still adheres to the uterine wall. ./". oviduct. ij. ovaries. h. peritoneal folds of the broad ligaments. i. cervix ) , L vagina j °P^°^^- EXTRA-UTERINE PREGNANCY. 427 be one in which a lithopaecTiou is formed, the thought of abdominal pregnancy will always be uppermost, as it will also be with a similar termination of a tubal pregnancy. Even post mortem, the diagnosis from a tubal pregnancy is not easy, and these cases used invariably to be mistaken for the latter ; the origin of the round ligament is the best guide, for, while in tubal pregnancy that origin is placed on the uterine side of the foetal sac between it and the uterus, in pregnancy in one horn the ligament starts from the outer side of the sac. § 318. h. Tuho-uterhw or interstitial prefjnaney arises, as already remarked, by the ovum becoming attached to, and Fig. G7.— cr. uterine cavity, b. round li^^araent.s. c. fcetal cavity. (/. placenta. {VoT^T^el, Monatsschrift f. Geb., xxs.!.) developing in, the portion of the tube which pierces the uterine wall (figs. 66 and 67). This portion first undergoes eccentric hypertrophy, and forms a small bulging sac at the upper corner of the uterus ; but before long the walls of the sac no longer grow 2>rt'"^ _2^r/.s.s» with the ovum, and the sac bursts at its outer side as in ordinary tubal pregnancy. This rupture usually occurs within the first three months ; only in rare cases do the adjacent uterine tissues hypertrophy to an enormous extent, and form a 428 EXTEA-UTEKINE PREGNANCY. firm capsule round the ovum (much as happens with an intra- parietal myoma) so that the latter can resist the pressure, and the foetus attain maturity. In a woman under the care of Rokitansky {Handbuch, iii., p. 608), pregnancy lasted 16 mouths, and the fcetus, which was over-mature and had been dead for a considerable time, was extracted by laparotomy. The foetal sac in interstitial pregnancy scarcely ever communicates with the cavity of the uterus or Fallopian tube, the openings originally leading to it being obliterated. Only in a few cases has a dilatation of the uterine orifice of the tube been observed, together with a communication of the epi-uterine sac Avith the free uterine cavity, into which the foetus projected partly or entirel}' (Monteils-Pons, Union Medicalc, 1856, No. 51 ; Braxton Hicks, London Ohstct. Transactions, ix., p. 57 ; possibly to this class belongs the case recorded by M'Burney in the New York Medical Journ., March, 1878, as well as that by Munde in the Amer. J. Obstetrics, xii., p. 330). Where such a condition exists, the foetus may be born j)^^' ^"^^'-^ naturales, the placenta remaining in the epi-uterine sac ; but rupture of the latter owing to its thin layer separating it from the peritoneum, is also possible. On the other hand the placenta may alone grow towards the uterine cavity and be born, the foetus re- maining in the tubal cavity, subject to all the sequelte of this condition. Interstitial pregnancy may at a post-mortem be confused with a pregnant uterine horn, since in both the round ligament bears a similar relation to the foetal sac. In the latter case however, a muscular band of varying length will be found connecting the two portions of the uterus ; this baud as a rule comes into con- nection with the pregnant horn not in its upper portion but lower down, just above the situation of the internal os. lu inter- stitial pregnancy, on the other hand, there is at most a more or less thick partition wall between foetal sac and uterus, the former being attached to the latter by a broad base. In interstitial pregnancy, as the growing foetus rises up, the whole uterus will be drawn up with it, as occurs with intra-parietal swellings placed at the fundus ; with a pregnant horn on the contrary, this does not occur, or at any rate does so in a less marked degree. Finall}', the decidua formed in the rudimentary horn will probably be better developed than it can be on the mucous EXTKA-UTERINE PREGNANCY. 429 membrane of the tube wliich lines the sac in interstitial pregnancy — evidence enough to decide a doubtful case. § 319. In tuho-ahdominal pregnmiqi (also called inho-ovarlan, inasmuch as the ovary may quite early be involved in the forma- tion of the foetal sac) , the ovum attaches itself to the abdominal orifice of the oviduct, and develops there. Since the tube in these cases only constitutes a portion of the sac, the remainder being furnished by the surrounding serosa, this form of extra- uterine gestation may be described with the abdominal variety. Ovarian Pregnancy. § 320. This variety, as mentioned at the beginning, only occurs, when an ovule is impregnated in its follicle and becomes imbedded in it ; when the latter process takes place after the ovum has passed out on to the surface of the organ (epi-ovariau pregnancy), the case is one of abdominal pregnancy. The fcEtal sac may be formed by the wall of the follicle and the neighbouring ovarian stroma, and by its rapid growth envelop the growing ovum on all sides, so that the latter comes to lie entirely beneath the albuginea, the sac resembling an ovarian cyst ; or else at the point where the follicle ruptured, there remains an aperture through which the ovum grows out, and thus comes to lie as in abdominal pregnancy, while the placenta remains in the ovary. Both conditions have been observed. The following characters however show that the gestation is of ovarian nature : 1. the absence of the ovary in question ; 2. the presence of well marked ovarian structures in the wall of the foetal sac ; 3. a connection of the latter with the uterus by means of the ovarian ligament ; and 4. the fact that the oviduct has no share in forming the foetal sac, while the topographical relation of the tube is the same as, or similar to, that met with in ovarian C3'stomata.^ But whichever be the mode of further development of the ' I have shown elsewhere {Arch. f. Gyn., xiii., p. 73) that only nine of the cases so far recorded in medical literature, satisfied these conditions. The example which I have published forms the tenth. Since then one has been described by Hildreck {Boston Med. Surg. Journ., Nov. 8, 1877), one by Patenko {.Irch.f. G;/n., xiv.. p. 156), and one by Benicke (Zeitschrift/. Geb. u. Gyn., iv., p. 276), making 13 reliable ca.-^e9. to which should probably be added as a 14th the preparation discovered by Bandl {Handbuch der Frauenkrankheiten by BiUroth, Part v., p. 49) in the Pathological Museum at Vienna. 430 EXTRA-UTERINE PREGNANCY. ovarian pregnancy, in both cases the sac usually ruptures by the 3rd or 4th month. If the sac is formed in the manner first described, the hypertrophy of the ovarian tissue will rarely keep pace with the degree to which it is stretched ; nor is the com- parison which has been drawn between it and a rapidly growing cystoma to the point, since the latter grows in consequence of some morbid new formation and not by mere increase in size, and since the ovarian tissue need not be stretched in any way. When on the other hand the foetal sac gains additional strength by involving neighbouring parts of the serosa and the organs lined by it, an ovarian, like an abdominal pregnancy, may approach to, or even attain, the full term ; the progress of the ovarian is then practically the same as that of an abdominal pregnancy. Peritoneal or Abdominal Pregnancy. § 321. We spoke in § 313 of the way in which this variety originates. The ovule, attached to the germinal epithelium, is nourished through a reciprocal approximation of the chorionic villi and of the new tissue which springs up from the serosa, and (as is seen in the case of other organised bodies which have passed into the peritoneal cavity under j'et more unfavourable circumstances) is at last enveloped by a capsule produced by the neoplastic structures. This capsule may grow jjari jx/ss^t with the ovum, during which time (through the serous membrane and through organs lined by the latter, and situated further and further from the primary seat of attachment, contributing to the formation of membranes) it grows stronger, becomes adherent to neighbouring organs, and thus forms a strong foetal sac which is closed on all sides. Or else the primary capsule atrophies or tears, as the ovum continues to grow, so that the latter at last lies free in the abdominal cavity, merely attached to the serosa by the placenta^ ; the former event is the commonest. It is worthy of notice that as a rule the newly formed foetal sac contains muscle cells, doubtless derived from the musculature of the sub- serosa of the pelvis, their presence being distinctly shown by the part they afterwards play in the efforts at expulsion. It is in this kind of pregnancy that the placenta presents the greatest ' Cf. the above-mentioned case of Leclnyse, that of Matecki {Monatsschrift f. Geh., sxxi.), and that of Jessop {London Obstet. Transactions, xviii., p. 261). EXTRA-UTERINE PREGNANCY. 431 divergencies from the uterine organ, both in form and size, and these characters moreover vary greatly in different cases '; on an average the placenta is much more bulky, when situated on the pelvic peritoneum than when higher up, the former (the ger- minal epithelium) too is the usual seat of insertion, although placentae have been met with on other viscera, and even on the anterior abdominal wall (Koeberle). § 322. By secondary abdominal pregnancy, are meant those cases where the foetus, after lying primarily in the tube, the ovary or even in the uterus, continues after the rupture of such organ to grow in the abdominal cavity, and in which, while the ovum remains connected with its first sac, the latter is enlar^^ed and strengthened by the adhesion of the abdominal viscera, and by the formation of pseudo-membranes. It is rare for an ovum which has passed entirely out of the primary sac, i.e. tofrether with its placenta, to survive the dangerous conditions which are then set up, and for it to create fresh connections and a fresh sac; such however does take place, and foetuses have been found years afterwards still connected with maternal organs, and fairly well preserved. It is however not proved as has been suj^posed (Braxton Hicks, London Obst. Transactions, vii., p. 101), indeed it is in itself improbable, that the ovum which has passed quite I early out of the ovary or the tube in an intact condition, can form new connections and a placenta with the help of the peri- toneum ; this would in the strict sense be a secondary peritoneal pregnancy. § 323. Abdominal pregnancy reaches the full term more often ' than any other abnormal variety, and as a rule is attended with : the minimum of discomfort, so that it is not uncommonly only discovered when the pains set in, or still later. There may however during the later months be severe attacks of pain of an extremely I agonising and exhausting character ; they seem especially to ^ occur in the case of ova lying free in the abdominal cavity, and to be caused by the foetal movements. In other cases pressure on the pelvic organs or attacks of peritonitis disturb the course 1 of pregnancy, and weaken the woman. Moreover rupture of the i foetal sac may take place before maturity is reached, and is I generally due to some external influence ; or blood may be effused into the placenta, leading to hicmorrhage into the sac, to death of the foetus and to secondary rupture of the former ; under 432 EXTRA-ÜTERINE PREGNANCY. such circumstances the haemorrhage or the secondary peritonitis is generally fatal, although it is commoner in these cases than ^vith tuhal pregnancy for the patient to survive the risks, and to be endangered by the changes that subsequently take place in the foetus. Sequehe and Complications. § 324. If everything goes on well till the foetus attains maturity, efforts of expulsion set in at the usual time ; the uterus, the foetal sac, and the voluntary muscles come into action. The former opens up and expels the superficial layer of the decidua, the detachment of which, as is shown in an accurate observation of Helie {Monit, des Höjntaux, 1860) begins at the internal os. These attempts at parturition, in which the breasts frequently participate, possess a certain amount of physiological interest, as showing that the stimulus to labour at the full time does not lie in the uterus, but rather in the foetus and the great nervous centres (cf. § 141). During the efforts at expulsion, the foetal sac may burst (Thormann, — Wiener Med. Wochenschrift, 1853 — saw a case in which the sac which had been pushed forwards into Douglas' space, made its way through a rent in the posterior vaginal wall, where an arm of the child appeared), or rupture may take place by detachment of the placenta, haemorrhage into the sac, and by consequent excessive distention of the latter ; the patient will rarely survive the consequences of such an event, but succumb to shock, internal haemorrhage or peritonitis. As a rule however the sac does not give way, and in this case, if the foetus has not been previously excised, a quiescent condition returns after a few days, possibly again to be interrupted by the onset of pains. The child usually dies, although in a few rare instances it has survived the normal time by some days and weeks {cf. Keller, Des grosscsses extra-uter. kc. Paris, 1872, p. 40. Most of the older cases of prolonged pregnancy belong to this class). The abdomen diminishes somewhat in size, probably owing to absorption of the foetal fluids and to collapse of the placenta ; the uterus becomes involuted, while the lochial discharges begin. The woman suffers more or less, for the foetus cannot remain in its sac without undergoing changes. § 325. In the majority of cases, the foetus soon decomposes and becomes macerated in the effused blood and in its own and EXTRA-UTERINE PREGNANCY. 433 the surrounding fluids. The irritation thus produced provokes inflammation and suppuration in the foetal sac, which proves fatal through septicaemia and through extension to the neigh- bouring peritoneum. If however the inflammation and suppm-a- tion are confined to the foetal sac, if the whole process takes place somewhat slowly, so that the patient has strength to resist the septic infection &c., the sac behaves like a large intra- abdominal purulent exudation, and may, as is not very rare, discharge its contents externally. Perforation aff'ects (in order of frequency) the intestine (colon and rectum), anterior abdomi- nal wall, vagina or bladder (strangely enough described as vaginal and vesical gestation), and sometimes takes place by several openings at once. The foetus is either expelled suddenly and en masse {e.g. through the anterior abdominal wall— Kiwisch ; through the rectum— Grenser, Schmidt's Encj/do- pedia, Supplement, iii., 1845, and Duncan, Edinburgh Med. Jourtial, July, 1863), or piecemeal. In the latter case the process may last for years, and may at any moment prove fatal to the woman through the prolonged suppuration, recurrent attacks of peritonitis, or a closure of existing fistula) and the development of fresh ones ; but not a few observations are on record, in which, especially wdth subsequent surgical assistance, the suppurating mass has been completely got rid of, being follow^ed by cicatrisation and recovery with or without persistent abnormal fistulous passages. The exit through the abdominal walls yields the best results ; that through the intestine the worst, probably because it is least easy to give any assistance. § 326. The most favourable change in the extra-uterine sac is the rare occurrence of the production of a so-called lithojucdion. Here the rapid disintegration of the foetus and the inflammation of its sac do not set in after its death, but the fluids in the sac are absorbed, its walls collapse on one another and on the fcrtus. The skin of the foetus, and afterwards the soft parts beneath the skin as well as those further from the surface, are converted into fat (adipocere) and into a greasy pulp (consisting of fluid and crystalline fat, Cholesterin crystals, and yellow pigments derived from the blood) ; in this way the bones are loosened from their connections and the whole mass is infiltrated with limo-salts, the foetal surface becoming incrustated with them. Sometimes the whole of the fluid contents disappear by absorption and iuspissa- 28 434 EXTRA-ÜTEßlNE PREGNANCY. tion, and the incrustation advances to such an extent that nothing remains but the bones, and a heap of calcareous plates ; even the sac is calcified into a shell. At other times the foetus merely shrivels to a mummylike mass through the formation of adipocere, a deposition of fat and incrustations on its surface, while it retains its shape and position ; the organs and even their most minute elements may be preserved for an extraordi- nary time in their dried condition. The lithojjoedion may lie for many years imbedded in dense masses of connective tissue with- out injury to the patient (Chiari, fViener Med. Wochenschrift, speaks of a lithopaedion that was retained for 49 years) ; the latter may meanwhile become pregnant and pass through the whole Puerperium unharmed^, or there may be merely some mechanical obstruction to labour, if the tumour lies in the pelvic cavity. Sometimes however, and this is favoured by a fresh pregnancy and labour, the lithopaedion sooner or later undergoes decomposition ; suppuration takes place in it and its vicinity ; and although by means of perforation and by a complete or partial evacuation of the lithopaedion, recover}^ is still possible, an unfavourable issue is by no means improbable. § 327. In very rare cases extra-uterine gestation takes place inside a hernial sac (inguinal or crural). It is possible that in the majority of the few cases that have been made known (Parry, tells of six, cf. Literature) , this abnormality was confused with a pregnant uterus lying in a hernia, but in that published by Widerstein-Genth {Verhandlungen d. Geh. Gesellschaft, Berlin, vol. 8, 1855, p. 97), in which there was a previously existing inguinal hernia of the ovary, an extra-uterine and at the same time an extra-abdominal pregnancy undoubtedly existed ; the foetus at four months was removed by herniotomy, and the mother recovered. Eokitansky has, under the names of secondary cervical and vaginal pregnancy, described conditions associated with abortion, in which an ovum, which had been expelled from the uterus and still remained suspended by a pedicle of decidua, continued for a while to hang in the cervix before being entirely expelled. § 328. Amongst other complications of extra-uterine preg- ' Cf. the observations by Anderson {Centralblatt f. Gyn , 1878, p. 188), Kjönig {ibid., 1879, p. 286), and Dahlmann {Arch./. Gyn, xv., p. 128). I also have seen such a case; cf. my Clinical I^'otes, 1SG9— 70, No. 264— delivery was spontaneous. EXTRA-UTERINE PREGNANCY. 435 nancy must be mentioned the development of tirins in the same foetal sac, violar degeneration (Otto, " Ueber Tubenschwanger- schaft, &c.," Dissertation, Greifswald, 1871), the recurrenc^ of extra-uterine gestation after recovery from a previous one (as an illustration of this, Haydon has recorded an instance of tubal gestation in the Lo7id. Obstetrical Trans., v., p. 280 ; and Puech, Gazette Ohstctricale, 1879, No. 21, has collected eight cases out of 180 of extra-uterine pregnancy scattered about in medical literature) , and lastly the simultaneous existence ofintra- and of extra-uterine pregnancij resulting from one conception, or from two such near to each other. (We have already spoken of uterine pregnancy taking place where one fcetus was already incapsuled.) Quite a number of the last-mentioned cases have been observed. The extra-uterine sac may rupture during the progress of the pregnancy, and the case terminate in one of the ways already referred to ; or the uterus may abort, and the extra-uterine foetus continue to develop {cf. Argles, Lancet, Sept. 16, 1871 ; Beach, Journ. of the Gyn. Soc. of Boston, v., 1871, p. 103) ; or else both fcetuses may live side by side till the normal time of labour, and cause so little disturbance that the complication is only recognised during dehvery. The abnormal foetal sac may then rupture, or may make delivery of the intra- uterine foetus more or less difficult, or even impossible ])cr rias naturcdes ; or else the intra-uterine foetus is born, while the other remains behind. The foetal sac suppurates &c. (Chabert, Arch. Tocolog., iii., p. 673), or a lithopaedion is formed (Cooke, Lond. übst. Transactions, v., p. 143 ; Greenhalgh, St. Bartholo- mew's Hospital Re2)orts, 1865 ; Pennefather, Lancet, No. 25, 1863 ; Pellischek, Oesterr. Zeitschrift f. Prakt. Heilkunde, No. 27, 1865), In a few cases the extra-uterine foetus has been removed by gastrotomy, and Piosshirt has extracted it by an incision into the vagina {Lehrbuch d. Geburtshülfe, p. 444). If the complication is recognised in time, in the way which I will immediately indicate, an attempt should first of all be made to keep the parturient canal clear for the intra-uterine child ; if however this cannot be done, or if all the circumstances of the case point to an unfavourable prognosis under expectant treat- ment, the extra-uterine foetus should be removed by gastrotomy, and the intra-uterine should only be interfered with, if such a 436 EXTRA-UTERINE PREGNANCY. step appears absolutely necessary. It can scarcely be advisable where labour is obstructed, to diminish the intra-uterine foetus with the object of preserving the extra-uterine sac and its contents, considering what a slight prospect there is of the child being saved, and of the mother recovering. Signs and Symptoms. § 329. The signs and symptoms associated with extra-uterine pregnancy, are partly those usually met with in pregnancy, and partly the result of the abnormal development and of the local disorders which it causes ; they will therefore in part be physio- logical, in part pathological. The former, especially as far as the general symptoms are concerned, may be present exactly as in uterine pregnancy, and generally are so. Menstruation almost always ceases (the contrary statements arise from pathological haemorrhage having been mistaken for menstruation), and usually only reappears after the death of the foetus, in case the mother survives the latter ; where the foetus reaches maturity, it ceases for the same period as in normal pregnancy. But irregular losses of blood, and sero-sanguineous discharges, especially during the first mouths, are by no means uncommon, and are due to the presence of a decidua in the uterus. The uterus undergoes hypertrophy, its cervix changes in the usual way, and its mucous membrane gives rise to a decidua ; the latter however presents a difference in that it does not advance beyond the stage of development to which the vera attains at the third month in an ordinary pregnancy, and in that from this time onwards the relative positions of the glands and of the interglandular tissue undergo no further alteration ; moreover the separate layers of the decidua are not always so well differentiated, nor does the glandular epithelium undergo so extensive a destruction (Kundrat, Strieker's Med. Jahrbuch, 1873, p. 175). The increase in size too of the uterus is soon arrested, indeed after the fourth month some involution may take place ; the increase is more marked in tubal than in abdominal pregnancy, and generally speaking seems to be greater, the more closely the foetal sac is connected with the uterus. The uterine souffle is sometimes distinctly audible, and may originate in the uterus or even in the foetal sac (Cazeaux ; Kennedy, BritisJt Medical EXTRA-UTERINE PREGNANCY. 437 Joimial, 1869; Koeberle). The shape of the uterus does not diflfer from that of a non-gravid, but merely hypertrophied organ. .Its jiosition varies according to the situation in which the ovum develops. If ih^ latter lies in Douglas' space, the uterus is pushed forwards and upwards, usually also somewhat to one side, since the ovum is rarely placed exactly median. As the ovum rises up, the uterus is again pushed down ; or when the ovum develops primarily at a point lying above Douglas' pouch, it may from the very first lie below, in front of, behind, or to one side of, the foetal sac. What has been said of the changes in the uterus, is true to a certain extent of those in the vagina, external generative organs and breasts. If the pregnancy does not end before the period at which the manifestations of foetal life can be made out, the heart-beat and movements of the foetus are distinctly per- ceptible, sometimes even earlier than when the ovum is placed normally, owing to its greater accessibihty. § 330. Morbid sjTuptoms are not always present ; indeed the pregnancy may reach the full term without any symptoms what- ever. Scanzoni relates a case in which a woman with a nine months' extra-uterine foetus was discharged from a lying-in hospital, through being considered not pregnant ; in the case of tubal pregnancy with a mature child which I have published {Arch. f. Gyn., {., p. 406), no symptoms appeared till the end of pregnancy, i.e. till labour. As a rule however disorders set in from the very beginning, caused by the inflammatory pro- cesses in the vicinity of the sac, and by the pressure kc. of the gi'owing ovum. This is the explanation of the pains in the pelvis and hypogastrium (especially at the sides), sometimes of a dull fixed character, sometimes occurring at intervals, and then indicative of fresh attacks of inflammation ; the latter may in a short time greatly reduce the patient. The attacks are not rarely accompanied by uterine hnsmorrhage, and by the discharge of shreds of decidua ; when this is the case, especially if the attacks have the character of "pains", they are frequently the precursor of a fatal issue through rupture of the foetal sac. The seat of the pain corresponds to the formation of a tumour, which is generally intimately connected with the uterus. Thus very often the whole course of events forms a typical picture of a subacute pelvic inflammation or pelvic peritonitis. Under these circum- 438 EXTRÄ-UTEBINE PREGNANCY. stances a healthy and quiescent state may to a certain extent and gradually return, and the pregnancy continue its course, as already described in regard to the abdominal variety ; or else the critical event, sc. rupture of the foetal sac, takes place, sometimes unexpectedly, sometimes in the midst of the symptoms men- tioned. It is especially apt to occur at the period at which the catamenia would return if pregnancy did not exist, and is accompanied by signs of collapse and of internal haemorrhage (c/. § 316). Diagnosis. § 331. A diagnosis is all but impossible during the first 3 or 4 months, and can only be arrived at in exceptional cases. This is due on the one hand to the fact that the recognition of the gravid state during this period is always connected with great difficulties ; on the other hand to the fact that when the symptoms do more or less compel the supposition of pregnancy, it is impossible absolutely to exclude uterine gestation, since even where the embryo is not in the uterus, the latter and the other portions of the generative system which are accessible to exploration, present the changes w^hich belong to the first months, and since lastly both the subjective and the objective symptoms caused by the formation of the foetal sac, will admit of another in- tei-pretation. If however the existence of pregnancy is extremely probable, a repeated proof that the uterine cavity is empty, as shown by the sound, may be indicative that the foetus is else- where than in utero ; but it must not be forgotten that such a method of procedure is not admissible, unless the supposition of the ovum being in the uterus can be entirely set aside ; and it must further be borne in mind that the possibility of passing the sound more or less deeply into the uterus does not allow of an absolutely final conclusion, inasmuch as the sound will some- times penetrate easily into the pregnant organ, and if only intro- duced once or twice, need not necessarily do damage. Generally speaking therefore, the diagnosis during the earlier period can at most be a matter of probability ; and the most valuable signs, apart from the indications of pregnancy in the genital tract, are the position and shape of the suspicious tumour, the pain or attacks of pain which do not coincide with the supposition of ordinary pregnancy, the sanguineous discharge from the uterus, EXTRA-UTERINE PREGNANCY. 439 the expulsion of portions of clecidua, as well as tlie whole progress of events. But it must not be forgotten that encysted exudations and extravasations (haematomata) may under such circumstances give rise to exactly similar symptoms ; puncture of the tumour may then supply negative or positive information by yielding liquor amnii, and such a proceeding is all the more to be recom- mended inasmuch as it has a curative action. If the patient is only seen after rupture has occurred, the symptoms associated with this accident, and the history of the case will throw light on its nature, although even then certainty is as a rule only obtained at the autopsy. § 332. The more the foetal sac continues to grow, the more easily and distinctly its contents become accessible to examina- tion, and the more it becomes separated from the uterus, the easier will be the diagnosis. If the foetus is recognised, the only further point is to establish the fact that it is not in the uterus, and this can sometimes be done by trying to isolate the latter from the foetal sac, by making sure that it is empty (with the help of the sound), and by showing that it is much too small in proportion to the foetus, while the walls of the foetal sac are much too thin to be those of the uterus. As a rule however it is just this distinction of the uterus from the foetal sac by palpation that is so difficult owing [to the very intimate and extensive connections that generally exist between the two, so that doubt may be felt even till the time of the labour pains ; when the latter commence, the dilatation &c. of the cervix, which is not in the usual proportion to the pains, and the discharge of bits of decidua would be'a guide. The greatest difficulties are met with, when the presence of the foetus cannot be distinctly made out, either because it is dead, and the foetal sac is difficult to palpate, or because much liquor amnii is present (Depaul has actually met with hydramnios in extra-uterine pregnancy). At such times confusion with ovarian cysts or with fibro-cystic tumours of the uterus is very apt to occur. The surest guide is furnished by the discovery of uterine changes due to the pregnant or puerperal condition. An exploratory puncture will give complete infor- mation, and it is entirely justified, since in case of necessity, 2.e. if the case be one of extra-uterine pregnancy, gastrotomy may follow it at once ; indeed under some circumstances an exploratory incision would be justified. 440 EXTRA-UTERINE PREGNANCY. It is almost impossible to distinguish the various kinds of extra-uterine pregnancy during the first months, although a lateral tumour might suggest a tubal or ovarian, a retro-uterine tumour an abdominal pregnancy. If the pregnancy lasts more than four months, the case is almost certain to be one of abdominal or ovarian pregnancy. The diagnosis of the further issues, of rupture, suppuration, or the formation of a lithopiedion, must be made from the symptoms that have been described. Prognosis. § 333. It will be gathered from what has been said above, that the prognosis is highly unfavourable both to mother and foetus. The latter is almost always lost, for even at the present time the cases in which it has been saved by excision are very rare. The mother usually dies, if we again sum up what has been mentioned above, from rupture of the sac and haemorrhage, from subsequent peritonitis, or from the scpticiumia and exhaustion due to the suppuration of the foetal sac. Kecovery may however take place, if the abscess cavities are emptied, and if the foetus is discharged or converted into a lithopiedion ; but a foetus that has become incapsuled and petrified may at any future time prove a source of fresh danger. Ovarian, and especially abdominal, pregnancies are the most favourable. While out of 100 cases of mixed extra-uterine pregnancy, Kiwisch only saw recovery in 18, out of 132 cases of abdominal pregnancy collected by Hecker, 7G (57'5 per cent.) terminated favourably. According to Puech (Courty, Maladies de V Uterus, 1866, pp. 994 — 96), out of 100 cases of tubal pregnancy rupture took place 98 times and death 97 times ; and in addition one case of death occurred through rupture of a vein of the broad ligament, and one through an accidental cause ; out of 199 cases where the foetus was expelled or gastrotomy performed, i.e. in the ovarian or abdominal variety, recovery took place in 146 (733 per cent). But these statistics are undoubtedly too favourable, for it is well known how much more often successful than unsuccessful cases are published. 2'rcatmcnt. § 831. The treatment of extra-uterine pregnancy will vary EXTRA-UTERINE PREGNANCY. 441 greatly, according to the period at which the patient is first seen. a. During the first 3 months, in which the diagnosis can only be made with more or less probability, nothing can be done except to treat the numerous disorders symptomatically. If it becomes more and more clear, both by the symptoms and the physical signs, that the ovum is not normally situated, it will be best to assume that it is extra-uterine, and by imncturing the sac to destroy the vitality of the ovum, i.e. to kill the embryo, and to bring about its atrophy. This may be done with less hesitation, since puncturing is permissible and indicated in those other conditions which might possibly be present (cystic new formations, encysted hsematomata and exudations) ; and although we shall but rarely actually puncture a foetal sac and thus save the life of the mother, these rare cases would be a distinct gain. The puncture must be made at the most tense and accessible part of the sac, either per vaginam or jjer rectum, and with a so-called exploring trocar ; if little runs out of the canula, the help of the aspirator may be called in, although it is apt to induce intra-cystic haemorrhage. Puncturing was recom- mended by Basedow and Kiwisch, and has been successfully- carried out by Martin (Monatsschrift f. Geh., xxi., and xxxi.), Stoltz (Gazette Medicale Strashurg, 1866), Greenhalgh (Lancet, March, 1867) and Koeberle (cf. Keller, suh "Literature") inter alios; in other cases the patients died. Friedreich (Virchow's Archiv., xxix.) punctured with a fine trocar and injected, as Joulin ("Des cas de dystocie appartenant au foetus." These, Paris, 1863) had shortly before recommended, a solution of morphia into the sac, likewise with a favourable result, and moreover without giving any pain. Prejudicial irritating injections must of course be carefully avoided. The electro -puncture of the sac carried out by Bacchetti (Gazette Medicale Toscana, May, 1853), in which the puncture of course is the chief thing, and the electric shock recommended by Duchenne (Lesouef, " Kemarques sur trois cas de grossesse extra-uter." These, Paris, 1862) and given by means of a powerful Leyden jar, will probably not be repeated owing to the irritating eflect^ ' Duchenne's treatment has lately been successfully carried out by Lovring and Landis {Centralblattf. Gyncekologie, 1878, p. 23), again by Landis {ibid., 1880, p. 62), and by Reeve {Amer. Gyn. Transactions, iv.. p. 313). 442 EXTRA-UTERINE PREGNANCY. If there are signs that the foetal sac has ruptured, an attempt may be made to combat internal hiemorrhage, by applying bags of ice to the abdomen, by iced enemata, by compressing the aorta, by sand-bags and by bandaging the lower limbs ; for the collapse stimulants and opium may be used, and if the patient survives the accident, the sequehe (peritonitis, ha^matocele) are to be treated in the ordinary way. Sometimes it may be possible to avert the almost invariably fatal issue by abdominal section (removal of the blood, and ligature of the bleeding portions, followed by drainage), or even by extirpating the entire foetal sac. But I cannot hold out much prospect of success to the latter suggestions ; for the conditions are different from those in which recurrent or secondary h;Bmorrhagc takes place after gastrotomy performed for the extirpation of tumours, indeed even at the post-mortem, it is usually very difficult to disentangle the anatomical connections of the foetal sac. ^Moreover the removal of the latter en masse involves the division and liga- turing of the whole ligamentum latum and as a rule of a quantity of adhesions, and is an amount of interference which the woman suffering from rupture of the sac can scarcely survive. Nevertheless considering the present state of intra-abdominal surgery, the proposal (Kiwisch, Koeberle-Keller) must not be rejected offhand. § 335. h. If the period at which rupture generally takes place has passed, if the frvtus continues to develop loithin its sac, if therefore the Ath to 5th month has been happily reached, an expectant treatment should be adhered to. Any interference at this stage would sacrifice the foetus, which may possibly be saved at a later time, and expose the mother to much the same risk as would accompany the death of a mature or nearly mature child. A simple harmless disintegration of the foetus, such as might occur during the first months, can no longer be looked for. It is true that, according to Puech {l.c), the suppuration of the sac and the elimination of its contents are somewhat less dangerous during the earlier than during the later months, but this is not sufficient reason for killing or puncturing the ovum. Martin however {Monatsschrift f. Geh., xxi.) saw recovery take place after such puncture, by the foetal mass being expelled per rectum, but Simpson and Br. Hicks (Loud. Obstetrical Trans., vii.) lost their patients after the operation ; the danger of EXTEA-UTEEINE PEEGIfANCY. 443 hasmorrbage from the vascular walls of the sac into the latter is very great at this period. In any case, if the condition is recog- nised and an expectant treatment adopted, it is of the utmost importance, that both the patient and her medical attendant abstain from anything that might cause irritation. If the foetus dies during the period under discussion, i.e. after reaching the 4th — 5th month, the same treatment must be adopted as in a pregnancy that has advanced further, and in which the foetus has died ; we shall speak of this immediately. § 336. c. If the pregnancy Jtas reached its natural termina- tion according to the usual reckoning, if labour pains set in and i\iQ foetus is living, the question arises whether the latter should be extracted by gastrotomy (primary g.). Such an operation seems at first sight to have everything in its favour. The child is saved, the rupture of the sac, which is so apt to occur during the " pains " or after a mature fcetus has died, and peritonitis &c. are prevented, while moreover the operation is performed at a time when the mother is still under favourable conditions. Nevertheless the danger is very great, much greater than from laparotomy performed on other grounds ; partly because it is not rare to come upon the placenta in making the incision (according to Litzmann this happens once in every 5th or 6th case), when severe hemorrhage sets in which is difficult to control ; and partly because it will in any case be necessary to leave the foetal sac and the placenta in situ, and this may afterwards repeatedly lead to the most prof use hamorrhage, inasmuch as the placental circulation is carried on for some time longer. It is quite in- admissible (as was taught by Eamsbotham long ago) to remove the placenta at the time, for the haemorrhage from the area of separation cannot be checked in these cases, as can uterine hemorrhage, by contraction of the placental site. For these reasons, primary gastrotomy under such circumstances with a living child has been very unsuccessful ; in 10 accurately recorded cases collected by Litzmann, 9 women soon perished \ and out of the foetuses only 4 survived for any length of time (more than 3 days). Thus even for the child in whose interest primary gastrotomy is mainly performed, the prognosis is unfavourable, ' Out of 10 cases collected by Keller 4, out of 20 collected by Parry 6 died ; but, as Litzmann points out, we cannot base our treatment on the statistics of those authors, since some of the cases are imperfectly recorded. 444 EXTRA-UTERINE PREGNANCY. probably because when extra-uterine, its development is not in- frequently imperfect, and because in many cases it has been injuriously affected by the labour pains which preceded the operation. The conditions therefore should be extremely favourable, before primary gastrotomy with a living foetus is decided on. The evidence must be as clear as possible that the child possesses vigour and vitality, and also that the placenta will not be met with in making the incision. In other cases it is on the whole better to await the death of the foetus, while watching the patient, keeping her quiet, lulling the expulsive efforts by opiates, and looking to a regular free action of the bowels &c. ; if there is then reason to suppose that the placental vessels and sinuses are thrombosed, the time for operating has arrived {cf. § 338). § 337. 1? primarjj gastrotomy is performed, it must like every other laparotomy be done under strict antiseptic precautions. The abdominal wall is divided along the linea alba, the foetal sac opened to the necessary length and no more, and the edges of the latter brought into exact apposition with those of the abdominal wound. The foetus is then extracted by the head or lower extremity, and the sac drawn out as far as can be done without injury to any abdominal viscera that arc adherent to it. The portion drawn out is next to be removed, the remainder together with the placenta lying in it (the end of whose umbilical cord has been ligatured) being fixed in the abdominal wound, if necessary by stitching it to the edges of the latter, which is then closed as far as the point at which the portion that was drawn out passes through. The after treatment will chiefly have to do with the suppuration and gangrene of what has been left behind, with septicaemia and secondary haemorrhage, and must be conducted on the principles pursued in complicated ovariotomies; success chiefly depends, as in the latter operation, on the most careful and minute attention being paid to every step of the operation, and during the subsequent period. In some cases, it may be possible to extirpate the greatest part of the sac ; in others, where no well defined isolated sac exists, the adhesions of the ovum must merely be separated and all its former connections must be left behind, although without ever departing from the principles which have been stated above. I EXTRA-UTERINE PREGNANCY. 445 If the placenta is met with in incising the sac, the incised part must be firmly ligatured and be drawn out, after the free application to it of a strong styptic. Lastly, if during the period which we are discussing, i.e. before the onset of, or during, the labour pains, the sac ruptures, primary gastrotomy is urgently called for when the child is aHve, inasmuch as it is scarcely conceivable that the mother will survive the consequences of the blood and ovum being discharged into the free abdominal cavity. For the same reason I would recommend the operation, even when no signs of foetal life can be made out, bat it must be done immediately after the catastrophe ; if some time has already elapsed since it occurred, if peritonitis has supervened, it is best to act, as if we had to do with a dead foetus still within its sac. § 338. d. In such a case, i.e. if the fatus is dead, the best plan is at first to maintain an expectant attitude, while treating any symptoms that arise after the death of the fcetus, and to watch to what issue the case is tending. If the first effects of the shock have passed, adhesions will almost always have formed between the foetal sac and the abdominal wall ; the placenta then gradually atrophies, its vessels thrombose, and this is the best time to remove the foetus by secondary gastrotomy. The sac is now less vascular, an incision through the placenta, if required, will be bloodless, the separation of the latter will be easier, and haemorrhage will meanwhile be absent or only moderate in quantity ; in point of fact we have merely to do with an inflamed or suppurating cavity which is shut off from the abdomen. It is however generally difficult to say when the favourable moment has arrived ; several months must doubtless elapse since the death of the foetus occurred ; if the condition of the mother permits it, it is well to wait 4 — 6 months, although not much beyond that time. If on the other hand the mother gets into an alarming condition soon after the death of the foetus and directly owing to it (and in these cases any decomposition within the fcetal sac is of especial importance), the sac must at once be emptied. Xor is there any reason to wait long, for with decomposition going on, there is scarcely likely to be much haemorrhage from the placental area, since decomposition soon leads to obliteration of the vessels. The secondary gastrotomy must of course bo performed in exactly the same way, as is directed in the preceding paragraph. 446 EXTKA-UTERINE PREGNANCY. When the patient is not seen till many months after the death of the foetus, it is generally sufficient merely to open the sac, and to extract the foetal parts. This too however must be done with every precaution, since even at this late period it is never quite certain that the sac is completely adherent to the abdominal wall, and if not, the abdominal cavity might be opened ; in these cases the usual rules directing that ordinary suppurating abdo- minal cysts be opened early, hold good. Keller has collected 19 cases in which abdominal section was performed aftei" the death of the child, but before rupture and fistulous passages had occurred ; 16 of them were successful. Parry discovered 14 deaths out of 30 cases. Litzmann out of .33 found the same number of deaths, which are equal to a mortality of 39 and 42 per cent. This is a better result than in non-interference. § 339. If during the advanced period of pregnancy a bulky portion of the ovum descends into the pelvic cavity, and pushes the posterior and lateral vaginal walls before it, the latter may be divided, and the foetus extracted through the pelvis ; this has been done by Keith, Thomas and others, sometimes with the help of instruments (elytrotomy). The operation will be specially indicated, if a large part of the child can be felt in the pelvis, since we may then feel tolerably certain that the placenta does not lie beneath the lower pole of the foetus, and therefore will not be injured during the incision. The further the ovum pro- jects into the pelvic cavity, the more boldly may elytrotomy be performed, while conversely when the foetal sac lies further from the vaginal fundus, the operator can no longer be so certain of opening the sac, and the hand which is introduced with the object of extracting the foetus might cause considerable injury in the pelvic and abdominal cavities, or bring the emptied sac into direct communication with the latter. Elytrotomy, when per- formed under the first-named conditions, has yielded remarkably good results, doubtless because, when sufficient care has been used, the abdominal cavity has not been opened, while at the same time the discharges have a free exit below. The mode of operating presents no difficulty, although the haemorrhage caused by the incision might be alarming if a lobe of the placenta or some great vessels were injured ; hence Thomas \ recommends that the sac be opened by the galvanic cautery j (Schmidt's Jahrbuch, vol. 171, p. 271). The umbilical cord must be ligatured, the placenta being left undisturbed, till it can ANOMALIES OF THE DECIDUA. 447 be removed without much violence, and without hfemorrhage. The emptied foetal cavity will be treated like an abscess cavity, by drainage and irrigation in the usual way, varied according to circumstances. § 340. When the fa?tal mass is suppurating, and the sac is about to give way, it must be encouraged to do so by poultices, and an incision should be made as early as possible at the point at which rupture is anticipated (in 32 cases collected by Parry, only 3 women died). As soon as there is an opening, any foetal parts that lie near it, should be extracted. It may be necessary to enlarge fistulous passages, to keep them open by force, or to make them accessible by dilating the rectum or the urethra. Duncan (Edinburgh M. Journal, July, 18G3) extracted quite a large fcetus through the rectum, although in all these operations the greatest caution is necessary, so as not to use such violence in removing the foetal parts, as might tear the often lacerable abscess wall ; no incision is to be made which might involve the peritoneum, and open the abdominal cavity. I need hardly add that the suppurating cavity must be carefully drained and washed out 'nith a solution of carbolic acid, while the strength of the patient is sustained by good nourishment and nursing. A woman who has escaped the dangers of an extra-uterine pregnancy, should be warned of the risk to which a fresh preg- nancy will expose her. I- h. Anomalies of the Bccidua. 1. Hypoplasia. § 341. Premature atrophy or imperfect development of the decidua vera is not rarely found when immature ova are expelled, and in itself is not injurious. The opposite effect however is produced when the reflexa. and serotina are atrophied. If the latter is very small, only a limited portion of the surface of the ovum will be in connection with the uterine mucous membrane, and the serotina will be found abnormally long, stalldike, and drawn into the bag of reflexa ; the ovum is then suspended in the latter, and supported by the uterine wall. In this way the ovum may be detached by its own weight, through the tension which it exerts on the small serotina, and as a result of uterme 448 ANOMALIES OF THE DECIDUA. contractions ; or an extravasation of blood may take place which entirely destroys the serotina, and makes it impossible, after the expulsion of the ovum, to recognise how the latter was attached. The reflexa may be absent from the very first. Under such circumstances the chorionic villi everywhere grow into the vascular vera, and the placenta is apt to be formed over too extensive an area (c/. § 359) ; this, as the enlargement of the uterus does not keep pace with the growth of the ovum, may lead to abortion, and even to the forma- tion of a placenta praevia. It is more common how- ever, although still rare, for the reflexa to be ill developed, and to disap- pear prematurely. The Fig. 68.— OTum with an imperfectly developed OVUm is then merely decidua ; external surface of the vera (Duncan, . , Researches in Obstetrics, p. 2911). Covered by chonon (tig. 68), and hangs from a stalk of serotina. Uterine contractions may, in such cases of atrophy, bring about a separation of the o\Tim, or, by the stalk being considerably drawn out, drive it into and through the internal os, so that it remains for some time lying in the cervix and is nourished to some extent by the vessels of its pedicle (cervical pregnancy — Rokitansky) . 2. Hxjpertropliy. This has already been described in §§ 305 and 306. 3. Hemorrhage — Aborted Ovum and Mola Sanguinea. § 342. Hasmorrhage into the vera and decidua (apoplexy of these parts, leading to their destruction) is either due to uterine contractions called forth by some remote cause which leads to the separation of the ovum, or else is produced by external agents (violence), by congestion (diseases and especially displacements of the uterus), or (and above all) by the already mentioned diseases of the decidua itself (c/. also § 257). Hence it will be i ANOMALIES OF THE DECIDUA. 449 intelligible how this haemorrhage is a very common accompani- ment of abortion, either as consequence or cause, and it may be difficult in an individual case to make out the exact sequence of events, and the causal connection of the changes found in the ovum. The importance of primary extravasations of blood as regards abortion will vary with their size, the period of their occurrence and especially with their situation ; a slight extravasation during the first or second month is much more injurious to the delicate ovum than a more copious one at the fifth or a still later month. Extravasation into the serotiua is more serious than a similar one into the vera ; extravasation into the reflexa is only injurious when it occurs at a time when the latter still serves for nourishing the ovum. Extravasations into the vera are found on its uterine surface, in its substance and on its inner surface ; the membrane is often destroyed to a large extent, the blood being effused between vera and reflexa. Extravasations into the serotina may also re:ich the latter situation, after breaking through the point at which the vera and reflexa are reflected ; but the blood more often extends from the placental site between reflexa and chorion, causing the latter together with the amnion to bulge into the foetal cavitj-, and it then leads to so much pressure on the ovum, that the embryo, if not already dead, perishes ; or else the foDtal cavity bursts. Now and again the chorion is broken through, and the amnion separated from it over a large area; sometimes the amnion and a quantity of blood are found free in the foetal cavity. § 343. If the ovum does not burst under the pressure of the efi"used blood, the amniotic fluid decreases somewhat in quantity after the death of the embryo. The embryo itself-as yet merely a mass of cells— undergoes maceration, and is broken up mto its elements, disappearing entirely or all but a small remnant. Sooner or later a sac formed of the amnion and chorion- these membranes being infiltrated by more or less altered eff-iised blood and with larger or small portions of the decidua still cHnging to them,— and filled with a serous or a sero-sanguineous fluid, is expelled, in which nothing but cellular detritus, or m many cases still a remnant of the umbilical cord is found- aborted ovum (false conception - Montgomery). The w ho e mass is usually sun;)unded by blood clots ; sometimes a small pb.centa 450 ANOMALIES OF THE DECIDUA. with atrophied umhilical vessels, is also found in such ova. Those vessels however will only be present, when the extravasa- tion occurred at about or after the third month ; and this is rare in these cases, for aborted ova almost always date from the second month. If the ovum soon ruptures through the pressure of the effused blood, the embryo passes out and is lost, while the coagulated blood with the membranes remains for some time in utcro, before being expelled. If it remains long, the clots become tough and firm, and (inasmuch as all the retrogressive metamorphoses of effused blood may occur) may form solid masses, which may or may not continue to enclose a small amniotic cavity, but in I Fig. C9. — Blood-mole with extravasations and blood-cysts on the foetal surface. (Hohl.) which the original structures, especially of the chorion and the decidua, can still be demonstrated — mola sanguinca. The^ decidua is often greatly thickened and hypertrophied, and inj places is firmly adherent to the uterine wall ; this may be the! reason why tbe blood-mole remains for a long time in the uterus,! and why the membranes and the coagulum undergo still further] metamorphoses. These metamorphoses lead to the deposit of lime-salts, and to pigmentation &c. — changes which induced] older authors to describe various kinds of mole. When the] chorion and amnion (or only the latter after rupture of the] ANOMALIES OF THE CHORION. 451 former) have been raised into a bladderlike swelling by an effusion of blood, the so-called blood-cysts are formed. These are cysts of variable size, containing a sanguineous fluid, or else a clear discoloured fluid derived from the blood-serum (fif^. G9). The blood-mole is rarely larger than an orange, and is usually exijelled between the third and fifth month, although occasionally much later. During this process owing to the above-mentioned abnormally firm attachment to the uterine wall, remnants are readily left behind, which may lead to secondary hannorrhage and to the formation of fibrous polypi. c. Anomalies of the Chorion — Hiiperplasia of the Chorion, Myxoma of the CJtorionic Villi, Vesicxlar Mole. § 344. The vesicular or cystic mole consists of a conglomerat of vesicles filled with pale, and for the most part clear, fluid, which are surrounded by the decidua, and in places project through it. They vary in size from a walnut to a millet seed, and are connected with each other by thin threadlike stalks. The vesicles however are not arranged like berries on short stalks starting from a common one ; on the contrary the latter pass from one vesicle to another, present spindlehke cystic dilatations of their own, and give off lateral offshoots of a similar formation at the point of bifurcation small stellate or triangular vesicles are often seen. In the fresh condition the vesicles are separated l)y coagulated blood ; lastly, they are all held together, in addition to the envelope of decidua, by a fine network lying in the middle of the bunch and resembHng that of the placenta (fig. 70). The vesicles are degenerated chorionic villi. The degeneration consists of an abundant proliferation of the villi, and of hyper- trophy of the internal mucoid matrix of the individual villus, the nuclei and cells increasing like the intercellular substance. Through a great accumulation of the latter, and a mucous degeneration of the cells (physaliphorous cells), the villi come to form the vesicles described; and inasmuch as the cystic de- generation not only aflects the apex of the villus, but also various points in its length, the vesicles, as already mentioned, appear to form rows. Accordingly in the fresh condition (and this is confirmed by my own investigations), each vesicle has an 452 ANOMALIES OF THE CHORION. epithelial covering ; next to this comes the ground substance consisting of a closer tissue with small stellate cells, which are connected with the separate fibres of the tissue ; this layer encloses the soft gelatinous mucous tissue which can be drawn out into threads and is often fluid. The vessels of the villi are almost always atrophied, although netlike capillary ramifications ANOMALIES OF THE CHORION. 453 are sometimes found in the outer stratum, especially when the degeneration is partial, and the fffitus alive. The substance forming the stalks is very much like Wharton's jellij aud consists of a firm mucous tissue, whose fibres are arranged longitudinally and pass imperceptibly into the homogeneous layer of the vesicles. The fluid contained in the latter shows a great similarity in com- position to liquor amnii, but in addition to albumin it contains comparatively much mucin. The larger vesicles have more water, but less mucin than the smaller ones ; on the other hand the amount of solid matters, and especially of albumin, increases with the age of the mole, while the quantity of mucin decreases. If the vesicular mole is formed at a rerij early date, as is the rule, the whole surface of the ovum undergoes degeneration, the embryo perishes, is disintegrated and no remnant of it can be found ; the amniotic cavity forms a small space inside the mass, and may be difficult to discover. When the degeneration sets in after the placenta is formed, it is limited to the latter, although the whole surface of the ovum generally appears on superficial observation to be covered by the cysts ; the fatal cavity in this case is usually very distinct, and the remnant of the embryo or even the whole (atrophied) fffitus is present in it. Sometimes a simultaneous increase of the liquor amnii takes place. Degenera- tion of certain lobes of the placenta in the midst of healthy ones — partial myxoma, indeed in some places in different cotyledons, is also met with, and under such conditions no injury need result to the foetus. In exceptional cases, isolated vesicles are found attached by stalks to the smooth surface of the chorion, where it is not involved in the formation of the placenta. The co-existence of a vesicular mole with a well developed ovum and healthy foetus, has several times been seen (Hildc- brandt, Monatsschrift f Geh., xviii. ; Davis, London^ Obst. Transactions, iii, ; Pepper, Am. Journal ofOhst., iv., p. 735, Arc.) ; in some cases the mole was expelled long before the mature child (Montgomery). The formation and expulsion of a blood-mole, after the expulsion of the portion which had undergone vesicular degeneration, has also been observed. A vesicular mole may attain the size of a child's head and the weight of 1—2 kilo. (ca. 2—4 lb.). Cf Elsaesscr. § 345. The mole is connected with the uterine irall by means of the decidua and, when the latter is hypertrophied. the con- 454 ANOMALIES OF THE CHORION. m. \ nection may be very firm ; thus arc to be explained the cases in which portions of the mole have remained for a very long time in the uterus, and in which partially degenerated pieces of placenta were discharged long after the expulsion of the foetus. But there are also some cases on record Oo^J^iT^fi^n J Waldeyer in Vir- chow'?, Ar cliiv., vols. 41 and 44; }s.nQ^er, Berliner Beiträge, i., p. 10), in which the degenerated "villi continued to invade the blood channels of the decidua serotina to which from an early period they had access, and in which they passed from them into the sinuses of the uterine wall ; indeed they may involve the uterine substance as far as its peritoneal coat, and to such an extent, that after the removal of the mole, the uterine wall presents a trabecular reticulated appearance similar to the internal surface of the heart, and in places is so thin as to be translucent — inter- stitial or intra-parietal, intra-vascular destructive mole formation. In the two first of the instances mentioned, death took place bj^ haemorrhage ; in Krieger's case peritonitis came on and carried off the patient. The case reported in the Lancet (Feb., 1840) by Wilton, and reprinted in Annal. f. Frauenkrankheiten , iv., p. 146, doubtless belongs to this class ; the uterus was perforated, and opened into the abdominal cavity, haemorrhage into the latter causing death. In Volkmann's case, the morbid formation merely affected the pla- centa, giving rise to an ii-regular cavity in the substance of the uterus, which ^^S- "l— Portion of the uterine wall from fig. 70 (natural size), phovvincj the way in which the degenerated villi involve the was separated muscular tissue. from the uterine cavity by a membranous septum formed of ANOMALIES OF THE CHORION. 455 decidua ; the mole projected through an opening in the septum ca. 3 cm. (1*2 in.) wdde into the uterine cavity lying below it. In Waldej'er's case, the whole superfices of the ovum was degene- rated, the decidua being unaffected and pushed forwards by the hypertrophied villi (fig. 71). The sprouting into the intra-parietal veins however is probably not so common as Waldeyer appears to believe ; if it were, the spontaneous expulsion of the vesicular mole would be rarer, the accompanying haemorrhage would be more profuse than it usually is, and we should doubtless hear of cases in which the artificial removal of the mole produced rupture of the uterine wall. Possibly some unusual morbid condition of the uterine tissues is necessary for the development of such destructive processes. § 346. The cause of the hyperplasia of the villi is unknown ; indeed it is undecided whether it indicates primary disease in the ovum, or whether it depends on some irritation due to disease of the internal surface of the uterus, or to the maternal blood. That it is not a consequence of a very early death of the embryo, as is still often supposed, and of the associated arrested growth of the foetal vessels into the villi, is clear, even though the villi may possibly continue to grow for some time after the death of the foetus. Such a supposition is contradicted by the rarity of vesi- cular moles, compared with the much more common early death of the embryo, by this pathological growth occurring after the formation of the placenta has begun (which latter event must surely be due to the vessels growing into the villi), by the net- work of capillaries which is sometimes observed in the vesicles, by the fact that atrophied embryos are met with in the moles, and by the cases of partial degeneration. The death of the foetus must therefore be looked upou as a consequence of the degenera- tion. The view which seeks to explain such degeneration by a morbid condition of the uterine mucous membrane (decidua) is supported by evidence of such disease obtained in different ways, and by the cases of partial degeneration, even if it is not correct, as Virchow stated, that moles are often met with more than once in the same woman (the case related by Majer in the Württemberger Med. Corrblatt, No. 38, 1847, of a woman who 11 times bore a mole in addition to a well formed foetus is unique ; Depaul, Clin. Ohst., i., 1872, p. 280, also records an instance of three molar pregnancies following upon each other). 456 ANOMALIES OF THE CHORION. But to assume the presence of a morbid condition, in order to explain those cases in which no disease can be found in the uterus is utterly unjustified. Under such circumstances it becomes extremely probable that the cause of the hyperplasia in many instances, if not in all, is to be sought for in an anomalous development of the allantois, all the more so as vesicular structures, have also been observed in the umbilical cord. This view can also readily explain those cases of the degeneration of one twin ovum side by side with a normal second twin, or at any rate can do so more readily than the view that only a portion of the uterine mucosa was diseased. According to the statistics of Bloch (28 cases), an advanced time of life seems to have more influence as a predisposing agent than the mere number of the pregnancies; although it is true that Primiparae are comparatively rarely afi'ected. Moreover a rapid recurrence of pregnancies one after the other appears to favour this morbid degeneration ; its recurrence in the same woman has also been several times observed, although speaking generally it is rare. The frequent co-existence of myxoma of the villi with dropsy in mother and foetus is noteworthy (Storch, Runge). § 3i7. The signs of molar pregnancy are usually the following : the woman at first shows the usual indications of pregnancy, but before long the rapidly increasing size of the uterus is in marked opposition to the calculated period of the gestation ; symptoms also of uterine irritation generally show themselves, viz. slight contractions, sacraic and lumbar pains, sympathetic gastric dis- orders, a copious, thin, slimy, sometimes blood-tinged discharge from the uterus, partly due to irritation of its mucous membrane, partly derived from ruptured vesicles ; occasionally one or more entire vesicles are found in the discharge. The general health often sufi'ers greatly, and a hydiajmic condition is, as already mentioned, not rarely seen. The rapidly enlarging uterus soon begins to manifest signs of irritation by stronger contractions, all the more so as the rapid enlargement tends to detach the ovum. During the contractions, the thin slimy fluid derived from the vesicles (sometimes also from the amniotic sac) together with blood is discharged in considerable quantity; the haemorrhage may be very severe, and has many a time seriously endangered life and even proved fatal. The mole is broken up during the course of expulsion, groups of vesicles lie in the discharged ANOMALIES OF THE CHOIUOX. 457 blood, the remainder hang in the lower segment of the uterus and are generally removed from there, since owiug to the hasmorrhage the spontaneous expulsion is often not waited for. The haemorrhage ceases, "when this process is complete, unless some portions are left behind owing to their firm attachment, ■when they give rise to symptoms which will be described under "abortion." In partial myxoma too labour is often terminated prematurely, either directly owing to the degeneration or owing to the secondary death of the fatus ; hiemorrhage and retention of the degenerated mass after labour are not uncommon. \Vhen a mole co-exists side by side with a healthy ovum, it may, as already mentioned, either be expelled before the latter (occasion- ally months before), or both are discharged together, or the mole may be so last. The diagnosis can only be made with certainty, when parts of the mole are actually seen. Even before that the relatively rapid enlargement of the uterus, its tense elastic wall without any dis- tinct fluctuation (similar to that found with soft juicy myomata), the thin, slimy or sanguineous discharge, the contractions which recur from time to time ; the stretching of the lower segment of the uterus, together with the impossibility of feeling foetal parts, of making out ballotement, or of hearing the foetal heart beat — would seem to justify the opinion that we have to do with a vesicular mole. But all these signs are unreliable, especially as they are rarely all well marked, and in individual cases present numerous variations. Of course there is no sign whatever of partial degeneration, not even when the foetus has died in consequence. § 348. The prognosis is, generally speaking, not unfavourable. It depends principally on the amount and duration of the haemorrhage, and in this respect molar pregnancies are on a pai- with those complicated by placenta praevia. The earlier such a case comes under observation, the more quickly the uterus can be emptied, if such a course is called for, and the more com- pletely this is done, the better. The only exception is in the destructive molar formation, for this, from what is said above, gives rise to the most dangerous conditions. § 349. Treatment can therefore merely deal with symptoms both before and during the labour, and must entirely depend on the urgency of the case. Amongst these symptoms, hemorrhage alone calls for energetic interference; the expulsion ol a few 458 ANOMALIES OF THE CHORION. vesicles does not do so, since after such an occurrence tlie preg- nancy may progress, and since the degeneration may he only partial or perhaps even extra-placeutal. If the haemorrhage is copious, plugging should he resorted to, and ergot given internally and suhcutaneously (ergotine). Under some circumstances, e.g. when the dilatation of the cervix is delayed, it may be very useful to dilate it by laminaria tents, followed if necessary by small india-rubber bags ; these not only cause dilatation and induce pains, but form an admirable tampon. An attempt should next be made to empty the uterus by means of expression ; internal manipulations should be deferred as long as possible, bearing in mind the possibility of breaking up the mole and of some of its portions remaining behind, and still more the possibility of destructive changes having taken place in the uterine wall and of the injury (perforation) which is so easily caused in these cases ; such a proceeding is only permissible Avhen the cervix offers no resistance whatever to the introduction of the hand into the uterine cavity, and when expulsion cannot be brought about in any other way. The emptying of the uterus by means of instruments is entirely forbidden for the reasons already stated. Considering the uncertainty of the diagnosis, it will only be advisable to stimulate the uterus to activity before the spontaneous onset of pains, when the symptoms are very severe and seriously aflfect the health of the woman. Under such circumstances, there is all the more justification, since it is not difficult to satisfy oneself that there is no living fcetus, and the same treatment is desirable in the case of hydramnion and other pathological intra-uterine products. Special care must be used in insuring thorough involution of the uterus after the expulsion of the mole. Retained portions are to be treated like similar portions left after abortion (cf. § 409). § 350. Hyperplasia, myxoma of the non-vilhms portion of the chorion. This variety was first described by Breslau and Eberth {Wien. Med. Presse, No. 1, 1867 ; Virchow's Archiv., vol. 39, p. 191) as '^ diffuse myxoma of the fatal membranes." It is characterised by a soft gelatinous thickening of the chorion ; amounting to as much as 5 mm. ("2 in.), and consisting of a mucous, otherwise homogeneous ground substance with fine delicate fibrillse and numerous round spindle- and star-shaped, in part physaliphorous, cells ; the amnion is of tough texture, the ANOMALIES OF THE AMNION. 459 so-called intermediary layer beiiifr little developed and quite absent in places. The surface of the chorion shows a number of flat, readily fluctuating elevations as large as a pea or bean. During labour the thickening was for the time being mistaken for a serous infiltration of the skin of the head; the foetus was alive, but its epidermis was detached in places ; no evidence of syphilis could be discovered. The placenta, decidua and umbilical cord showed nothing abnormal. Such mj-xomatous hyperplasia of the chorion laeve may also occur to a partial extent, as is shown both by the accumulations of a gelatinous substance in the subamniotic portions of the placenta mentioned by Rokitansky {Path. Anat., iii., 1861, p. 510), which point to it, and by the case published by Winogradow in Yirchow's Archiv., vol. 51, p. 146), where a swelling as large as a goose's egg was found in this region ; it was of delicate consistence, tremulous like jelly, without fluid contents, but entirely similar to Wharton's jelly and 3 inches distant from the placenta. d. Anomalies of the Amnion. § 351. 1. Adhesions of the amnion with the fains by means of membranous threads, cords and loops which pass from the foetus to the amnion, or from one part of the foetal surface to another, are of special importance, on account of their causative relation to foetal deformities. These flamentous eonneetions or frto- amniotic hands (Simonart) owe their origin to very early agglu- tination and adhesion of the amnion to the surface of the f^tus in consequence of inflammation, or in some cases probably to arrested development, or to the amniotic folds having developed in some abnormal manner. It can no longer (in the face of what we now Imow of the nature of inflammation) be urged in opposi- tion to the view that the anomaly arises through some inflamma- tory irritation which is transmitted from the skin of the fietus to the amnion, that the latter is non-vascular in structure; should the amniotic folds be abnormal in shape, or not be sufficiently raised from the embryo, or be so too late (for some unknown reason, perhaps on account of an inadequate or delayed secretion of liquor amnii-G. Braun), the two opposed surfaces may grow together. The adhesions then lead to arrest o development, generally to fissurelike depressions of the aflected 460 HYDROPS AMNII. parts of the embryo. When the liquor amnii increases in quantity and the amniotic sac is distended, the adhesions are easily drawn out to threads and cords which by means of tension or constriction may cause malformation or local imperfection of parts self-amputation) ; the foetus may be abnormally curved, its joints may be in a condition of rigid extension, even of over- extension. Sometimes in such a deformed foetus, at a part which is in close connection with the malformation, merely loose bands are left, for example a divided thread ; at other times nothing remains except the cicatrix, where the thread was attached ; such threads and bands have also been found attached to the amnion by one end only. According to G. Brann (^(Esterr. Zeitschrift f. jjraJd. Heilkunde, Nos. 9 and 10, 18(55), where there is an unusual accumulation of amnio-chorionic liquid during the later period of pregnancy, the amnion may tear, while the chorion remains intact ; the former may then be rolled up through the active foetal movements, and thus be twisted round the umbilical cord or round foetal parts, and in this way lead to the death of the foetus. § 352. 2. unusually great wrinkling or folding of the amnion, or abnormal development of the carunculae {cf. § 91) may possibly only arise after the death of the foetus has taken place, owing to the diminution in the quantity of liquor amnii, and to the continued growth of the amnion. § 353. 3. Winkler {Arch. /. Gyn., i., p. 350) found a cyst in the amnion, at the place where it passes on the umbilical cord ; it measured 1'5 cm. ("6 in.) in length, 1 cm. in width, and lay with its longitudinal diameter directed towards the cord ; the cyst was certainly not a rudiment of the allantois, nor did it arise from a liquefaction of the gelatinous tissue of the cord ; it was imbedded in the connective tissue of the amnion, and had originated in it. Ahlfeld {ibid., xiii., p. 165) has described a conglomerate of little cysts, which was 3 — 4 cm. long and 1 cm. ("4 in.) wide ; in this case the vesicles were lined with amniotic epithelium, and had arisen by the amnion becoming folded, and the contiguous parts growing together. e. Anomalies of the Liquor Amnii — Hydrops Amnii. § 354. Abnormal composition of the liquor amnii probably depends in most cases on the admixture with it of foetal pro- ducts. It is therefore especially common, when the foetus has HYDROPS AMNII. 4 Gl perished, although occasionally seen when the latter is alive, either diseased or healthy ; in such cases the constituents which render the liquor turbid and deprive it of its simplicity of com- position, are either derived from the contents of the foDtal intestine which have Leen evacuated, or they are products of the decomposition of its epidermis and of the fat deposited on it. It is however not easy to disprove the possibility of abnormal constituents of the liquor amnii being derived from the maternal system, since we cannot exclude the possibility of the latter assisting in the production of normal liquor amnii {cf. § 92). We spoke in § 351 of an unusually small quantitij of liquor amnii leading to the formation of amniotic bands. Sometimes the quantity is remarkably small, ev^n during the later period of pregnancy ; the uterus then appears small and firm, the move- ments of the foetus are impeded, and the mother often feels them to be strong and very unpleasant. I have seen no other bad results during pregnancy, although I am bound to admit the possibility, as authors assert, of the almost complete absence of the protection usually afforded by the liquor amnii leading to more serious consequences, especially for the foetus. During labour, the period of dilatation may be abnormally prolonged through the presenting bag of membranes not being formed at the proper time, and also through a delay in the rupture of those membranes. § 355. The commonest anomaly is an excess in the qnantiin of the liquor amnii, i.e. dropsy of the amniotic cavity. Hydrops amnii. The limit at which the quantity of liquor amnii becomes pathological cannot be absolutely settled, since its quautity varies even under ordinary conditions. We must thorofore only speak of the quantity as morbid, when it injuriously affects the relations between foetus and uterine cavity, or when the great distention of the latter causes trouble. This generally happens when the quantity of the liquor amounts to .-d litres (3-5-5 pints) ; but in not a few cases the quantity is much ^Trom what has been said in § 92, the eauscs of such an 462 HYDROPS AMNII. increase must mainly lie in the foetus and the placental and umbilical vessels, i.e. (a) in an excessive renal and cutaneous secretion on the part of the foetus, and (h) in the capillaries which were called by Jungbluth vasa propria of the boundary mem- brane of the placenta, remaining open for a longer time and to a more considerable extent than usual, in short in mechanical disorders of the foetal circulation, especially of that through the cord. With this accords the fact that a perfectly well formed foetus is rarely met with in cases of hydrops amnii (this is illustrated by a case under the care of my former assistant Dr. Hempel, in which a mature strong girl was born, in whom sub- sequently a congenital occlusion of the duodenum showed itself — Jalirhuch f. Kinderheilk., 1873), that the child is often ill developed or dead (according to M'Clintock, out of 33 foetuses 9 were born dead, 5 out of them macerated, and 10 died during the first few hours), in connection however with which we must of course not forget that the labour is generally premature ^ This view moreover accords with the observation that the placenta is often found to be large and oedematous, sometimes membranous, that hydramnios is apt to occur in twin pregnancies (11 times out of the above 33 cases), in which foetal anomalies are, as we know, not rare, and that almost always (according to M'Clintock, always) one ovum only presents the anomaly in question ; further that the excess of liquor amnii as a rule only shows itself after the fifth month and then rapidly increases, and that the health of the affected mother is sometimes quite good, sometimes presents disorders which cannot always be brought into etio- logical relation with the hydramnios, but are rather to be looked upon as sequelae. We cannot entirely exclude a maternal share in the excessive production of liquor amnii, since the foetus is not invariably diseased, nor always becomes so after birth, while in some cases evidence of maternal syphilis is forthcoming-, and since substances are known to pass from the uterine mucous mem- brane into the amniotic cavity. We must also mention in con- nection with the causation, the fact that multiparas are much ' Luneau {Centralhlatt f. Gyn., 1877, p. 160) met with an interesting case in which the child was developed above the average ; it weiged 5,750 grm. (12'5 lb.) and had a peripherj^ of the head of 40 cm. (15| in.) ; further details of the case are wanting. - Duncan (oral communication) has met vs'ith hj'dramnios in diabetes mellitus ; the liquor amnii contained large quantities of sugar. HYDROPS AMKII. 4(53 more often the subjects of hydrops amnii than primiparai (according to M'Clintock, 28 : 5); also the pecuHar circumstauce that the foetuses are in a large majority of instances of the female sex ; of those recorded in my case books they were so almost without exception. M'Clintock met with 28 girls to 8 boys\ No abnormal character of the liquor amnii, e.g. a devia- tion from its normal characters, has been observed {cf. last note but one). § 356. The discomforts produced by hydrops amnii are purely of a mechanical nature. Owing to the excessive and rapid enlargement of the uterus (pendulous abdomen), the centre of gravity is displaced forwards, and progression is impeded. The abdominal Avails are abnormally tense, and the traction upon them causes pain, especially at their fixed points. Owing to the vessels in the abdominal walls being stretched and flattened, and to the enlarged uterus pressing on the abdominal and pelvic walls, oedema of the vulva, labia and lower extremities arises, sometimes even ascites — all these symptoms being more marked in primi- than in multiparae. Should the abdominal wall oiler great resistance, the diaphragm will be pushed up ; its range of movement is thus limited and dyspnoea ensues, or togetber with palpitation of the heart occurs on the slightest exertion ; the stomach can admit but small quantities of food and digestion suffers ; the patient grows thin. The renal secretion is only diminished in the severer degrees of the disorder; the urine sometimes contains albumin, but generally speaking no change in its composition is observed. Under the influence of all these circumstances, but especially of the excessive and premature distention of the uterine walls, and of the premature distention of the lower uterine segment, sometimes also owing to detach- ment of the placenta, and in not a few cases to intra-uteriuc death, labour generally comes on prematurely (in M'Cliutock's experience, 14 times out of 33 cases) ; the natural termination of the pregnancy is rarely reached. The condition of the faHus > Benicke {Berliner Klin. Wochenschrift, 1879, p. 773) however found is Uo.^s ami only 4 girls in 20 ca.es. But I am incHned to think that he <:<'""';.<^^ "j; .^^^ .°^' hydramnios such as others would not rank amongst them ; ^^^ 'f -'^''^:^,'^^^^^^ statistics he gives of the frequency of the anomaly ('-^Vfi^l^.smn. re- births) as wen as by the average weight of his by rammoüc '^-'^^^'^HZn^t 8 lb.), which can hardly belong to premature children; and jet there is no that such fostuees are very often premature. 464 HYDROPS AMNII. at birth has been already described. The ** lie " in reference to the pelvis is generally cephalic, although an abnormal "lie" and '* attitude " are not rare ; it must however not be forgotten that premature labour and dead foetuses are common, although apart from this hydramnios undoubtedly tends to cause irregu- larity of " lie," a tendency which is easily explicable. During its first period, labour is sluggish owing to the great distention of the uterine musculature, much as in twin births; if however, as sometimes occurs, the liquor amnii is all dis- charged at once, expulsion proceeds rapidly. Uterine inertia after the delivery of the child and its after-birth, and post- partum haemorrhage are frequent ; protracted involution is the rule. For the same reason the percentage of lying-in women who fall ill after hydramnios (and even the mortality) is higher than the average. I must also mention that when one of twin foetuses is found diseased, it is usually the last-born (9 times out of 11, according to M'Clintock's experience). § 357. The diagnosis of hydrops amnii is not always easy, indeed in such a case it may be difficult to decide whether the uterus is actually pregnant ^ This however will only very rarely happen, since, apart from the history of the patient, a repeated examination wüll even in the most difficult cases make it possible to feel and to percuss the outline of the uterus, and to make out foetal parts in some region or other ; moreover the lower segment of the uterus presents changes (softening, and especially expansion) such as do not occur in the non-gravid condition, and, as I have always succeeded in doing, the uterine souffle can be distinctly perceived over an extensive area. In the majority of cases the foetal heart beat is also heard, although comparatively often it is inaudible, since a thick layer of fluid separates the auscultated area from the foetus, while the latter is generally small and not rarely dead. Hydrops amnii is most often confused with twin pregnancy. The tense condition of the uterine wall in hydramnios, the generally distinct fluctua- tion, the difficulty of making out foetal parts and of hearing the foetal heart, while the contrary signs are present with twin ova, will generally decide the question. When not, we must content ' I know of a number of instances in which the hydramni jtic uterus was mistaken for a simple ovarian cyst and tapped ; this has happ' ned once in my own ilaternijy. Greater care in making the diagnosis will prevent such mistakes. ANOMALIES OF THE PLACENTA. 465 ourselves with a diagnosis of probability ; where there is a com- plication of both conditions, nothing but labour will clear up the case. § 358. Treatment is of no direct benefit in this condition. All we can do is to be guided by the symptoms in counter- acting general and local discomforts ; to support and fix the abdomen with a binder, to enjoin a quiet mode of hfe, even if only with the object of preventing too early or unexpected a discharge of the liquor amnii. Indeed, the inconvenience and difficulty of physical exertion generally cause the pregnant woman of her own accord to adopt such a plan. When the associated disorders are so severe as to cause anxiety, the preg- nancy must be prematurely terminated in the interest of tbe mother, all the more so as there is but little prospect, for the reasons stated above, that a strong and healthy fcetus can be preserved. We must however always consider the latter to the extent of postponing the induction of premature labour to as late a date as possible. During labour the foetal membranes should be ruptured as soon as the excessive accumulation of liquor amnii leads to delay in the dilatation and to inefficient expulsive activity. But here again we must not interfere too soon, although on the other hand not too late, i.e. we should anticipate the sudden and violent rupture. The membranes should, if possible, be ruptured at a point high above the external os uteri, and always during the interval between two pains, so that the liquor amnii may flow oft' slowly and leave the " presentation " and " attitude" of the fcetus unchanged. During the after-birth period it is necessary to u-atch and compress the uterus with more than usual care, owing to its great tendency to relax ; when the latter is completely emptied, the abdomen should be bandaged, ergot given in large doses, and involution encouraged by a strict regime. f. Anomalies of the Placenta. The pathology of the placenta has only been sftidied during the last few years, so that our information on tbe subject is far from complete or satisfactory; this is epecially true in regard to the primary share which maternal and fa3tal elements respec- tively take in producing the alterations met with, and to the 466 ANOMALIES OF THE PLACENTA. relation they bear to simultaneous changes in the foetus. In what follows, I shall mention the main points that have been ascertained. 1. Form and Situation. §359. We have already spoken of anomalies oi form, in describing the normal placenta (§ 97 and preceding) and that of twins (§ 203). The variety described by Stein (the elder) as placenta memhranacea has however not yet been referred to. It somewhat resembles the placenta met with in pachydermata, inasmuch as it forms a very extensive thin organ, and is said to depend on diffuse sprouting of the chorionic villi into the decidua reflexa, or, when this is absent, into the vera {rf. § 341). It is doubtful whether this rudimentary condition is actually met with in advanced pregnancy, or whether the report of its occurrence may not possibly be due to its having been confused with a small principal placental mass co-existing with several placentas suc- centuriatae ; there are no recent researches relating to placenta memhranacea. B}^ _pZae'>st-mortem origin. In the former case it usually leads to the death of the foitus, and the expulsion of the latter follows either soon, or, as is the more common, only after some time, occasionally after some mouths. Ante-mortem torsions are produced by the active movements of the foetus or by exposure of the body of the mother to violent and prolonged shocks ; they may probably also be produced by the movements of a second fcctus lying in the same amnion (Winckel). Post-mortem torsions can only be due to the foetus being twisted in consequence of movements of the mother. Torsion appears to be commoner in multipara than in Primi- parae, as we should expect from the greater stability of the foetal " lie " in the latter. ' Hennig (I.e.) has found 70 cases recorded in which well established severe con- striction, and consequent deformity of the foetus were due to the cord being repeatedly coiled round it. ANOMALIES OF THE UMBILICAL CORD. 479 '2. — Torsion of the corJ. (Blume.) According to most observers, boys are more often affected than girls. [Thus in Martelleur's statistics, there are 37 male foetuses to 25 female.; if to these I add the 15 cases of Winckel, consisting of 10 boys and 5 girls, vre obtain a pro- portion of 47 male to 30 female foetuses=157 : 100. Billi's large collection shows the proportion of males to females to be as 13 : 9.] The length of the cord gene- rally corresponds to that of the body of the foetus, but not rarely exceeds it. Of course great length favours the occurrence of torsion, since the shorter cords are more taut than the longer, and after being twisted, more readily un- wind themselves. On the other hand it is undue twisting of a short cord which is most injurious, since such a cord can be dangerously twisted in a very short time. The number of spiral turns in the cord is usually very large, and this is in a measure the first step towards torsion ; in rare cases however the cord has been found to possess but few or even no spiral turns. The twists, as we should expect from their mode of origin, are as a rule close to the umbilicus (figs. 72 and 73), very rarely at the placental or at both ends ; sometimes well marked twists are at the same time found in the middle of the cord. The reason for the twists being so fre- quently situated at the umbilical extremity, is to be found firstly, in the poverty of jelly so often seen at this spot, and in the greater ease with which the cord can therefore be twisted, and further in the fact that although of the two attached parts of the cord, that which lies nearest to the fcetus {i.e. to the active agent in causing the twists), must be the first to suffer from the rotation, yet when the whole cord is of considerable thickness the twists which start from the foetal body, will readily pass away over the cord and Fig. 73. — Torsion at the foetal end. 480 ANOMALIES OF THE UMBILICAL CORD. produce their effect at the other fixed portion, viz. the placental end. The navel is usually somewhat dragged out in the form of a pouch ; so also is sometimes the abdominal skin, much as the amniotic lining of the placenta is drawn out, when the twists are at the placental extremity. Complete occlusion of vessels is rare, and only occurs when the torsion is very considerable ; for the most part they remain pervious, although narrowed to a considerable extent, or else one vessel only is impervious. Sometimes thrombi of varying con- sistence are found in them, and this indicates that the torsion was of rapid formation. Secondary cedema of the adjacent portions of Wharton's jelly frequently accompanies the abnormal twisting. Another moderately constant post-mortem appear- ance is blood-stained serum in the abdominal and pleural cavities ; Billi states (cf. Hecker, Klinik, ii., 1864, p. 29) that on two occasions he found the cerebellum smaller and softer than the cerebrum, and he seeks to explain the excessive foetal movements as arising from disease of the brain. A case in which the cord was completely twisted off is mentioned by Hirsch [Monatsscltrift f. Geh., xxvi., p. 333) ; but it is not certain whether this occurred during pregnancy or only during labour (it affected the first of twins). The recurrence of torsion (and of the consequent death of the foetus ?) in subsequent pregnancies is curious. The lying-in hospital at Halle (r/. Fritsch, Klinik d. Gcb. OjJcrationen, 1875, p. 353) contains a preparation taken from a woman who aborted 7 times, one after the other, for that reason. 5. Stenoses. § 377. Simple stenoses of the umbilical vessels, i.e. uncon- nected with torsion, have been described in the case of the arteries (Späth), as due to atheromatous changes. Hyrtl has figured some cases in which the umbilical vein was constricted at its insertion into the placenta by new connective tissue, which formed wide bands running along the vein, i.e. by a kind of periphlebitis, which however does not interfere with the circula- tion. But Oedmanson {Arch. f. Gyn., i., p. 523) and Winckel were the first to mention and accurately describe the contrac- tions of the lumen of the vein in the course of the cord, which are usually situated in the neighbourhood of its placental end, ANOMALIES OF THE UMBILICAL CORD. 481 originate from the actual wall of the vessel (intima and muscu- laris) and are extremely deleterious to the life of the fcetus. According to the investigations of Birch-Hirschfekl, they are caused by a very locahsed hyperplasia of the intima, consisting partly of fusiform, partly of round cells, which are probably succeeded by a more fibrous tissue, or a granular ground sub- stance with oval and round nuclei ; although the process starts in the intima, the adventitia finally also becomes implicated by an abundant accumulation of lymphoid elements. The last-named author has also in a few cases found similar localised disease in the intima of the arteries ; and he regards all these processes as due to inherited syphilis, owing to their microscopical resem- blance to the changes described by Heubner as syphilis of the cerebral arteries, which is the view the two observers first mentioned, and especially Oedmanson (although not so abso- lutely), have also adopted. Whether this view is trustworthy or not, is doubtful ; Leopold (Arcli. f. Gyn., viii., p. 22G) has described a case in which the death was due to this cause, but in which syphilis was decidedly not present. The numerous other irregularities of the vessels as regards distribution, form and size are of no practical importance. Hyrtl has carefully described them in detail. 6. Other Anomalies. § 378. The umbilical cord may adhere to the fcetus by means of amniotic bands (cf. § 351), just as it may to tbe peripheral and placental amnion (/ Liiiihs. § 384. The detachment of limbs in iitero, spontancom amjmtation, which was even as late as the time of Chaussier and Billard looked upon as a consequence of gangrene of the affected limb, mainly arises, as was first clearly shown by Montgomery, through the limb being constricted by amniotic bands (and in such cases other malformations due to the same cause frequently co-exist) or by a loop of the umbilical cord ; either of these con- stricting agents at last leads to detachment of the affected segment {cf. §§ 351 and 375), partly owing to the gradual shrinking of the bands, partly owing to the growth of the en- circled segment, while the aperture through which it passes remains of the same size. Sometimes the fracture of a bone is the cause, especially since the fractures mainly occur during the later half of pregnancy, i.e. at a time when owing to the great activity of the foetus the conditions are not very favourable for the union of the fracture ; in such a case it is not uncommon for the vessels and the skin to be divided, and for an inflammatory demarcation line to be produced. Inflammation of the skin and deeper parts may likewise at an early stage interfere with development by means of cicatricial contraction ; but such a case is not properly one of true spontaneous amputation, although in external characters it may resemble it, but one of arrested development. Very frequently the member is not completely detached, but a deep furrow is found associated with atrophy of the peripheral portion ; under such circumstances, a slight degree of violence will suffice to complete the separation. The detached portion is occasionally found in the amniotic sac ; if not found, the detachment occurred at an early period, and the yet soft parts must have been broken up and dissolved in the liquor amnii ; in the latter case the stump is found at birth to be cicatrised, while when the separation occurred later the cicatrisation may be incomplete. The hands and feet, above all the fingers and toes, are most often found deformed in this fashion, at any rate this is true of ANOMALIES OF THE F(ETUS. ■487 the cases in which abnormal bands produced the amputation ; next come the leg, fore-arm, upper arm (especially of tbc left side), and thigh, with decreasing frequency. The curious fact was observed by Simpson that a slight rudimentary regeneration of the lost member may occur on the amputation stump ; but this only extends to the construction of nails and of small projections consisting of hypertrophied cicatricial and flesli\- connective tissue (fig. 74). 4. Bacldtis. § 385. Since the bones grow m ntero according to the same laws as during extra-uterine life, and are therefore subject to the same hindrances to development and to ossification, no a priori objection can be made to the occurrence of intra- uterine rickets, and as a matter of fact a number of cases have been described in which the changes found in the foetal skeleton appeared identical with those seen in the rickets of children. In other cases, although the external ha- bitus was the same, care- ful examination revealed considerable difi"erences. This habitus, which is much the same in all cases, is cha- racterised by an unsightly plumpness, a large trunk, and above all a voluminous abdomen, a big, frequently even hydrocephuhc, head, and thick, short, curved limbs. The skin is thick, rieb in fat and often hangs loosely round the body, as if the latter had too large a covering, making it necessary for this coveriiig to be thrown into folds; this appearance is specially noticeable in the limbs, owing to the deep constrictions that they present. The abdominal viscera, especially the liver, are large. The alterations in the skeleton almost exactly correspond to those of post-natal rachitis; the diaphyses of the extremities are thick, short, curved, often fractured, while the epipbyses are soft, swelled, and entirely cartilaginous. Ibe same is true Y\g. 74. — Amputation of the left fore-arm. witji rudimentary formation of fingers. (Simpaon's Obstetric Works, edited by Priestley and Storer, ii., p. .^77.) 488 ANOMALIES OF THE FOETUS. of the ribs ; seats of fracture are sometimes ununited, some- times, united by masses of callus. Ossification is most of all delayed in the sternum, while the clavicles enjoy a greater immunity from the disease than any other bone. Pectus carinatum is absent, since it depends on inspiration ; where present (Virchow), we must suppose that the child has lived for a time. The ossification of the vertebral column is rarely quite normal. In the pelvis we find the sagittal flattening which is so characteristic of rickets ; the extension of the sacrum, the transverse flattening of the sacral vertebrae, the open and flat condition of the iliac al«, the increased width of the pubic arch, the characteristic form of brim are all well marked, far more dis- tinct than are the faint indications of them which, according to Fehling {Aixh.f. Gyn., x.), exist in the ordinary foetal pelvis. All these changes are caused by the traction exerted by muscles or ligaments (Kehrer), although to some extent also by the partial arrest of the growth of the bones, since in utero the weight of the trunk cannot be a factor. It is obvious that this muscular traction might also lead to " greenstick " fracture; indeed the bending of the iliac al» in a sagittal direction, which is now and again met with, must be looked upon as of that nature. On the other hand the reason why in some cases the shape of the pelvis is but little, or not at all, altered, is that the musculature may be but ill developed, and only exert a slight influence. Ossification of the cranial bones has been observed in the most various stages of development ; in some cases there is merelj^ a membranous sac with isolated centres of ossification, in others an enormous thickening of the cranial vault ; numerous intermediate gradations are found. § 386. As has been already pointed out, these coarser changes are met with in various fcetal diseases, and do not in themselves therefore justify the diagnosis of intra-uterine rickets. Histo- logical investigation however has revealed the fact that a change identical with that seen in the rickets of children, does actually occur in the foetus. We know that in children the morbid process may simultaneously afi'ect any stage in the development of the bone, and that it consists in too exuberant a proliferation of the cells which pave the way for the ossification, both in the cartilage of the epiphysis and in the periosteum (while the deposition of lime salts is absent or insufficient) ; further that ANOMALIES OP THE F(ETUS. 489 the formation of medullary spaces is excessive and irregular, and may finally even lead to rachitic atrophy; and lastly that u sclerosis may follow at the expense of the medullary spaces when (after the disease has run its course) the proliferated elements hecome ossified. In precisely the same way may these changes sometimes occur at the various stages of their development and in different degrees of intensity in the fatal skdeton. If the morbid process began early and ran its course within the uterus, the foetus may recover from rickets before being born — rachitin fcetalis ; if the disease only began during the later portion of pregnancy, and is therefore at the time of birth in an early stage or at any rate in full swing, it continues to run its course outside the uterus, and the case is one of the so-called rachitis congenita (Winkler). The true rachitic changes however must be distinguished from a process described by H. Müller, and which consists in a peculiar disease , of the primordial cartilage ; it is associated with exactly the same, or often a cretinoid, habitus. The carti- lage cells show no arrangement into rows near the region of ossification ; but on the contrary a development of cartilage takes place in every direction by enlargement of the cells and increase of the intercellular substance ; the usual increase iu length of the diaphyses is absent, while on the other hand the epiphysial cartilage is very large, although soft and sometimes even jellylike; the skeleton retains an embryonic form. The formation of true bony material, especially by the periosteum and in the case of bones which are not preformed in cartilage, goes on actively, giving rise to thick, short, tubular bones and to cranial bones which in places are very thick ; the bony substance itself is generally compact and small-celled. But in both diseases, both in the true rickets and in that just described, the same stage of development, i.e. the formation of rows of cartilage cells is affected, although ih opposite directions ; in the former an excessive, in the latter too limited a growth takes place. In addition to these diseases, it is possible that in the so-called osteogenesis imperfecta, another stage in the development of bone is involved, so that the latter disease must be distinguished from the two previous disorders; similarly the cases of atrophy of the whole skeleton (ostitis parenchymatosachromca) constitute yet another form of disease. 490 ANOMALIES OF THE FCETUS. § 387. True rachitis, according to Winkler, shows itself in two forms, racJiitis micromelica and r. annulans. The former is characterised hy great shortening of the limbs and by thick diaphyses, and results from the foetal variety, i.e. rickets which has run its course in the uterus ; r. annulans on the other hand, " rachitis with rings of bone and multiple fractures," is the disease which has originated late and continues in progress at birth, and is an intra-uterine affection continued during extra- uterine existence. Inasmuch as congenital rickets may after- wards lead to r. micromelica, while the latter may be due to non-rachitic processes, the practical value of this subdivision into varieties is open to question. The causes of rickets, as of other similar diseases of bone, are unknown. We may be sure that it does not depend on mere malnutrition of the mother ; this is shown by the rarity of the foetal affection, and by the fact that one twin may be diseased, while the other is healthy (Klein). There is more reason for thinking that disease of the placenta may lead to irregularity in the ossifying processes, especially as in the case of twins just referred to, the placentas were divided, while' in another case where both foetuses were diseased (Romberg), there was a common placenta ; moreover hydramnios has more than once been seen where the foetuses were affected. The hydramnios however must be looked upon as secondary to the disease of the foetus, and we have no knowledge whatever as to the nature of the placental disorder in question. 5. Goitre. § 388. Temporary swellings of the thyroid, due to disturbance of the circulation during labour, are sometimes seen in face pre- sentations, and under such circumstances can easily be explained. They have no special significance. It is otherwise with the true intra-uterine or congenital goitre. This is one of the rarer foetal diseases, probably always depends on simple parenchymatous hyperplasia, and is permanent. It occurs mainly under favour- able endemic conditions, with or without hereditary predis- position ; in sporadic cases, the inherited predisposition is rarely absent. Congenital goitre may give rise to a face or brow pre- sentation, by making the flexion of the head, which is necessary ANOMALIES OF THE FCETUS. 491 for vertex presentations, impossible {<■/. § 174) ; to the cases published by Hecker and Simpson illustrating this point, Löhlein has added another in Zeitschrift f. Gehurtshülfe, i., p. 24. But it is a more important fact that goitre may, even after extra- uterine life has commenced, lead to great difficulty of respira- tion, and even to death by compression of the windpipe ; this asthma thyroideum was very severe in two cases under my care, and in one described by Hecker (Monatsschrift f. Geh., xxxi., p. 199). G. SijpJiilis. § 389. In order to complete what has been said in § 267 (transmission of syphilis to the foetus) and §§ 372 and 377 (syphilis of the placenta and the cord), we must here describe the changes produced by syphilis in the foetus. They are found in its skin, thymus, lungs, liver, spleen, supra-renals, pancreas and intestine, on its serous membranes and in its bones ; they are most constant in the latter and in the spleen. It must how- ever be noticed that almost all of them are only found in a well marked form, in foetuses that have died shortly before, or soon after, labour either premature or at the full time ; since when death occurs in utcro at a very early date, they have not yet become fully developed, and even in the cases of death at a later period the maceration which generally ensues, obliterates a large part of them ; all the more importance therefore attaches to tbe characters seen in foetuses which have been very recently or but little affected by such maceration. Even in a fresh and highly diseased foetus, the whole of the organs mentioned will of course not be attacked at the same time. § 390. The shin frequently presents numerous ecchymoses, and occasionally some induration of the subcutaneous cellular tissue is observed. But it is the formation of vesicles, pemphigus syphiliticus, varicella syphil. confluens (Zeissl) at various stages of development, that, although somewhat rare, is most important. The vesicles are usually large, thin-walled, with more or less purulent or blood-stained contents, and are surrounded by a red areola. They are chiefly placed on the volar surface of the hands and feet, on the fingers and toes, although they may also be seen on other parts of the body. If the vesicles are confluent, the corium is exposed in large patches, and sometimes, even with a 492 ANOMALIES OF THE FffiTUS. living child, large flakes of skin can be drawn off from hands and feet. Such a condition may during labour simulate maceration . In some cases the epidermis forms scabs. The mucous membrane of the mouth, nose, pharynx and air passages shows small dark spots and rhagades, sometimes in a state of suppuration; gaps in the soft palate may thus be pro- duced, and the vocal cords may be entirely or partially destroyed. On the serous membranes, as on the skin, numerous haemor- rhagic spots are found, while in addition a serous blood-stained fluid is poured out into the cavities. The peritoneal cavity is especially apt to be afi'ected in this manner, and the hydropa sanguinolentus of that cavity has actually been described as cha- racteristic of syphilis (Martin). Such however is not the case, for the same condition is seen. in a large number of still-born foetuses which were certainly not suffering from syphilis, and it must be regarded as a result of maceration and of the disin- tegration of red blood-corpuscles. Nor must it always be looked upon as a result of peritonitis. The latter is one of the rarest affections, and in it the exudation is sometimes found still fresh, sometimes already dried and shrunk. Its connection with sj-philis has been specially insisted on by Simpson, and its cause probably lies in disease of the great abdominal viscera, although not necessarily in the liver, as Gubler believed. When the thymus is diseased, which is not often, it is usually enlarged and contains a number of for the most part only small abscess cavities, distended with pus and lined with smooth walls (Dubois), characters which can scarcely be confused with those of the ordinary, sometimes slightly altered, fluid contents of the thymus. § 391. The changes in the lungs and in the great organs of the abdominal cavity, are more common and important. They generally lead to the formation of gummatous nodules, i.e. cel- lular new formations destined to undergo retrograde changes, much like those found in the visceral syphilis of adults, and it is these retrogressive changes which, if not fatal to the foetus while still in utero, cdM^e its death some days or weeks after birth. In the lungs numerous nodules are found of the size of peas, separated from the surrounding tissue by a highly vascular areola, and distinguishable from that tissue by their paler colour. At first they are reddish-grey, afterwards yellowish ; then they ANOMALIES OF THK F(ETUS. 493 soften and become filled with caseous pus. In more advanced cases they are replaced by indurated cicatrices. Or else instead of these multiple nodules scattered through the whole lung, merely a few syphilitic deposits may be found lying here and there under the pleura, of firmer texture and in rare cases having undergone degeneration at their centres. At other times in addition to or without such nodules, the lungs are found to be more voluminous, heavy and dense than usual, containing air in parts, if the child has breathed, and of a bright- or yellowish- red colour on section. This variety is due to an interstitial diffuse infiltration (white hepatisation, white induration). The liver is considerably enlarged, so that it can usually be felt even before the abdominal cavity is opened, projecting to a varying extent towards the left side beyond the umbilicus ; it may be as much as three times as heavy as normal, of firm con- sistence and a flintlike colour on section, the usual markings having disappeared. Abundant cellular proliferations in the walls of the bile-ducts and of the vessels, as well as round them, push the normal hepatic parenchyma aside, and together with the compressed bile-ducts become transformed into dense bands of connective tissue, w^hich often traverse the enlarged organ in great bundles. Moreover small whitish nodules are found scattered copiously over the cut surface, or else there arc somewhat larger darker nodules lying more superficially, pro- jecting from the surface of the liver, and there indicated by brown spots ; they are aggregations of cells which will after- wards degenerate, if that process has not already begun in their interior. Occasionally if the child has lived longer than usual, those larger nodules may be found converted into cicatrices. The affections of the imncrms, although not at all rare, pro- bably belong to the last months of fcrtal development and are entirely analogous to other interstitial changes, especially those of the liver. It consists in interstitial growth and induration, causing the organ to be generally enlarged, heavier and firmer. A section of it is white and shiny, but the division mto acnu is no longer visible to the naked eye, since the new growth not onls affects the tissue between the larger lobes of the gland, but in severe cases that between the individual lobules of the ormer. compressing them, causing atrophy of their epithelium, tlnrkcn- incr of the walls of the vessels, and obliteration of the capillaries. ■194 ANOMALIES OF THE FCETUS. Enlargement of the spleen is one of the most common occur- rences and all the more important, as it may almost invariably be recognised even in foetuses that have undergone extensive maceration. Special disease of the splenic tissue cannot as a rule be made out, and although an increase of the stroma or even amyloid degeneration is sometimes met with, it has no specific value ; no pathological deposits have been seen. If the foetus has not undergone putrefaction, the enlarged and relatively very heavy organ will be compact, have a tense capsule, and l^resent a waxy appearance on section. The supra -renals are not very often diseased ; but in such a case they also are enlarged, dense, hard and difficult to incise, the cut surface being poor in blood and shiny. In the cortical substance are sometimes found the whitish nodules which have already been mentioned more than once, and also caseous deposits. We have recently seen similar nodules in the intestine. § 392. When the hones arc diseased, those of the skull usually escajje ; when they do not, the internal surface escapes more often than the external ; I have only once found a gummatous nodule on the right parietal bone'. On the other hand we almost invariably (Wegner, who first pointed out this fact, says invari- abl}^ find changes in the tubular hones. These generally exhibit an increased hardness and density both in the cancellous tissue of the epiphyses, and in the compact tissue of the diaphyses ; the consistence however may be normal or even diminished. But disease always exists at the point at which the diaphysial bone passes into the epiphysial cartilage, which disease may show itself in three forms, although all three are merely transitional stages of one and the same process, viz. of an osteo-chondritis. This morbid process begins with an excessive proliferation of the cartilage cells at the margin of the epiphysis, which is rapidly followed by an irregular calcareous infiltration and sclerosis of the newly formed tissue. Later on, the same tissue becomes transformed into a true osteoid substance, without the necessary formation of new vessels progressing at an equal rate ; thus is ' Parrot {cf. a'so the Bulltlin gciur. Thcrap. for April, 1879) on the other hand states that the formation of osteophytes in the shape of plates is one of the most constant occurrences, these plates being found for some months after birth on the surface uf the skull, more particularly on the frontal side of the parietal and on the frontal bones. Pan-ot believes that they grow gradually, disturb the symmetry of the skull, and give it a characteristic appearance. ANOMALIES OF THE F(ETUS. 495 laid the foundation of the rapidly retrogressive metamorphosis of the new material. The cells enclosed in the osteoid ground sub- stance undergo gi-anular or fatty degeneration, which is soon followed by inflammatory processes which lead to a demarcation on either side, and may end in complete detachment of the epiphysis. In the first stage, there is seen at the boundary of cartilage and bone a brilliant reddish-white layer, which is "sometimes as much as 2 mm. (ca. 1 in.) wide, and is bounded by a straight or sinuous line ; this layer represents the zone which is the seat of preliminary calcareous infiltration and of proliferated cartilage cells. In the second stage, that zone becomes wider, the boun- dary line irregular, and nipple-shaped projections run towards the articular surface of the cartilage, which projections owe their origin to closely placed rows of cartilaginous cells, to a premature sclerosis following the course of the vessels, and to a calcification of the intercellular substance ; as regards the cancellated osseous •material nothing more than a delay in the conversion of cartilage into bone is observed. In the third stage, the articular ends are enlarged, the perichondrium and periosteum are thickened on their external surface ; the lowest layer of the cartilage is of a bluish and transparent appearance, and is succeeded by a yellowish-grey layer 2 — 3 mm. (ca. '1 in.) broad, which is gradually lost in the substance of the diaphysis. In this position an actual caseation is found within the calcified ground substance, while in the yellowish portions of the layer a granu- lation tissue is undergoing more or less destruction by suppu- ration. By the interposition of this soft layer, the coherence between epiphysis and diaphysis is loosened, and, as already mentioned, one or more of the epiphyses may be spontaneously detached. The various bones of the skeleton are by no means equally affected in the same individual ; the lowest end of the femur generally shows the most marked changes, then come the lower epiphyses of the tibiae and bones of the fore-arm, then the upper epiphysis of the tibia, next that of the femur and of the fibula. After a considerable interval follows the upper end of the humerus, then that of the radius and ulna, finally the lower end of the humerus ; a sequence which almost exactly coincides with that mentioned in regard to rickets, and also with the breadth 496 INTRA-UTERINE DEATH. which the layer of cartilaginous proliferation possesses at the various points, when ossification is proceeding in a normal manner. This disease is of great importance, not only omng to its con- stancy, but also for diagnosis, since it undergoes relatively few changes in even a considerable time after intra-uterine death, and for that reason is of great help in enabling us to diagnose syphilis in macerated foetuses. Whether the syphilitic affec- tions of bones belong to the earliest signs of foetal syphilis, can hardly yet be decided, but at any rate when the foetus is not fully developed, only the first stage is met with. It is chiefly to be looked upon as a legacy of inveterate paternal sj^hilis. Apart from this osteo-chondritis, Wegner states that a further change sometimes occurs in the medulla of tubular bones, a change which may be diffuse, but generally starts in isolated deposits. The medullary substance presents a. yellowish-red colour, and microscopically an extensive fa^tty degeneration of the medullary cells and the walls of the vessels. § 393. I must also draw attention to the not very uncommon association of Juemorrhages of the skin and the internal organs with syphilis. These haemorrhages probably depend on the changes (which can also be seen with the microscope) in the small arterial twigs running in the tissue ; and we know that, generally speaking, the vessels seem easily to be affected by the syphilitic virus. Nor must I omit to mention Bärensprung's view that the syphilis which is confined to the lungs is more or less exclusively met with, where the disease has been derived from the mother, while when derived from the father, the liver, supra-renalsj spleen, and peritoneum are the organs of election, a view which can in several ways be shown to be erroneous (Eosen, Hecker). Intra-uterinc Death. § 394. The various morbid conditions which may lead to death of the foetus during pregnancy, as well as the manner in which they exert this influence, have been sufiiciently de- scribed in the previous section. I have here therefore merely to recapitulate that the death of the foetus may be due to : a. The direct transmission of a virus or a dyscrasia, either INTRA-UTERINE DEATH. 497 acute or chronic, from mother or father to ovum (acute infectious diseases of the mother, syphihs of the father, lead or other kind of poisoning of the mother) ; or ^ b. A rise of temperature in infections or non-infectious febrile diseases of the mother ; or c. An inadequate supply of nutritive material, dependent upon mal-nutrition (aui^mia) of the mother ; or d. To disease of the foetal appendages (membranes, placenta, cord), due of course in many cases to disease in the parents; and finally c. To external, e.g. traumatic, causes, which either kill the foetus directly, or do so indirectly by causing the decidua and placenta to be detached or broken down by effusions of blood. § 395. Instances are not very rare in which intra-uterinc death recurs in several successive pregnancies at, or nearly at, the same period of gestation, and without external provocation ; this is known as habitual death of the fcetus, and is not exactly identical with habitual premature labour or abortion, although sometimes confused with them. This fatal event in many cases occurs very early as " recurrent internal abortion," although sometimes not till the later months, when it shows a preference for the 6 — 7th month, and again for the last fortnight. It depends (a) in the great majority of cases on syphilis of the father, and when this is the cause, death rarely recurs in the same months, as would be expected from the varying rate of progress with which organs are affected in inherited syphilis, (b) In some cases maternal cachexias, particularly extreme ana?mia (owing to which the foetus does not receive enough nourishment), lead to gradual inanition, and finally to death of the foetus ; it is possible however that such maternal conditions cause the death of the foetus indirectly, by the alterations which they produce in its membranes, (c) The rarest causes of habitual death are doubtless chronic affections of the inner surface of the uterus, of the decidua and placenta. They are more apt to lead to the repeated interruption of the pregnancy, than to produce priviani death of the foetus. The latter result however is possible, inas- much as the diseased maternal "soil " is not congenial to the developing ovum. Moreover it is probable, although not quite certain, that there are independent affections of the foetal appen- dages, i.e. unassociated with constitutional diseases of the 32 498 INTRA- UTERINE DEATH. mother {e.g. stenoses of the umhihcal vessels), which may cause death in successive pregnancies. Since the causes of habitual death of the foetus are accessible to treatment, the malady itself must be so. These causes how- ever must be got rid of before a fresh pregnancy begins, although even if they continue to act after conception, an attempt may be made to render them inoperative ; but success will be rare. The means to be employed depend on general therapeutical principles. On the other hand the induction of •premature labour before the date at which experience leads us to expect the death of the foetus, is useless, if such death depends on infec- tion or organic disease of the foetus. Such an operation can only be admissible : 1, in the rare cases in which anaemia of the mother causes the death of the foetus at an advanced period of pregnancy ; in this case the foetus might after birth be brought into more favourable conditions as regards nutrition; 2, perhaps in those uterine affections which are prejudicial in the two last months, and perhaps. also where anomalies of the cord gradually cause the foetus to perish. But these last-mentioned ^etiological influences are as yet much too indefinite, and their modus O'perandi is too obscure, for us to lay down definite indications. At all events we can only hope for success from the induction of premature labour, where the autopsy of the previous foetuses showed that they were healthy. There are some curious cases in which a more or less regular , alternation occurs in the birth not only of dead and living foetuses, but even of viable and non-viable children ; Hohl for instance records such instances, and it is possible that this alternation depends on the sex of the foetus, one sex alone reaching maturity and remaining alive. § 396. The signs of the death of the foetus were dealt with in § 137. The next event is as a rule the expulsion of the ovum ; the arrest of the development of the ovum leads to retrogression of all the processes connected with it ; the circulation in the placenta ceases, the placental and a portion of the uterine vas- cular channels become thrombosed, and parturition takes place. This almost always occurs within a short period after the death of the foetus, a period vaiying from a few days to three weeks ; only in rare cases (the more rarely, the later death took place) does the foetus or the ovum remain for longer, e.g. for months. IXTRA-UTERINE DEATH. 499 in the uterus, and this is most common, if the dead embryo is one of twins {cf. § 204) ; but even single foetuses have been observed to remain in the uterus up to, and even beyond, the usual end of pregnancy. § 397. The dead fcetus either undergoes viaceration, or shrivels up. Putrefaction of course is impossible as long as the foetal cavity remains closed, and air is excluded. During the first 2^3 months of pregnancy when the embryo merely con- sists of a mass of cells, it is broken up into its elements by the maceration and completely dissolved (aborted ovum, cf. § 343). When of larger size, the form of its body is preserved, and the various organs continue as parts of one mass. The component elements however of these organs undergo maceration, and are dissolved in the liquor amuii, the fluids of the tissues and in the blood-serum, wdiich together with the broken down red corpuscles has exuded from the vessels (which therefore become empty). The epidermis is the first tissue to undergo maceration, and does so very rapidly, forming large blebs, and where still adherent it can easily be stripped or rubbed off with the hand. The sub- jacent corium swells and turns reddish-brown by imbibing the pigments of the blood. The deeper tissues grow soft, flabby, discoloured and infiltrated with hrematin. An exuded blood- stained fluid accumulates in the serous cavities, and the abdo- minal cavity especially is often greatly distended by it ; indeed the softened abdominal walls may burst in consequence. The brain is rapidly converted into a reddish-grey pulp whose elements can no longer be recognised ; amongst the organs in the thoracic and abdominal cavities the liver shows most alteration ; the lungs and muscles, smooth as well as striped, remaining longest un- changed. But there is everywhere a granular cloudiness and obliteration of the histological elements, accompanied by a deposition of pigment and fat crystals in and around them. The crystals are sometimes so abundant that tbey form a greasy layer all round the organs {lipoid transformation— Buhl). The connections between the bones become friable, and at last give way spontaneously ; those in the skull give way very early, so that even after a few days, the cranial bones may be free, movable one upon the other, and loose beneath the integuments. The latter are oodematous, especially in the most dependent portions, so that the head looks uncommonly large, sometimes as if it ÖOO INTEA-UTERINE DEATH. belonged to a monster. The whole corpse is changed in form under the influence of gravity and of external pressure {e.g. that exerted by the parts on which it rests), being flattened in some places, swelled in others. The placenta grows soft, rotten, and together with the vessels, bloodless. The umhiUcal cord is first of all discoloured, then infiltrated with blood, and in consequence of this, it at last turns reddish-brown ; its foetal extremity under- goes a thickening, which indeed begins suddenly at the edge of the capillary circle in the skin round the umbilicus ; the whole cord loses its twists, becomes cylindrical, smooth and very friable ; the vessels remain patulous. The foetal membranes for a long- time resist maceration, but at last they too become infiltrated, swollen and friable. The liquor amnii is rendered turbid by the detached epidermis, discharged meconium, and transuded blood- serum ; turns greenish-brown in colour and possesses an oflfensive stale odour, like the whole foetus ; sometimes it is acrid and irritating to the skin. These changes vary in their rate of progress, and it is possible by their means to estimate the time at which death took place ; never exactly, but with some degree of approximation. It is easy to understand that the prolonged contiguity of the uterine wall with the macerated Ovum, from which doubtless certain substances are taken up by the decidua and placenta, must be prejudicial to the health of the mother ; but the fact that no true infection can take place explains why she is not very severely afiected. § 398, \Yhen the foetus has become shrivelled or mummified^ it is dry, looks as if it had been tanned, or preserved for a con- siderable time in alcohol. The subcutaneous areolar tissue has disappeared, the skin lies close to the muscles, its colour is uniformly reddish-brown. In the serous cavities there are mere traces of a dark fluid, the viscera are small, and of soft consistence. The outlines of the body are preserved, except for the flattening which is so often present. Mummification sets in, when the foetus dies slowly or succumbs to gradual inanition, partly because no fresh liquor amnii is secreted, while that already present tends to decrease, partly because the arrest of nutrition that sets in even during life, causes the amount of blood and intercellular fluids to diminish. Mummification is therefore chiefly found where death, especially premature death, is due to progressive stenosis IXTRA-UTERINE DEATH. 501 of the umbilical vessels, and occurs all the more readily if the supply of blood is not suddenly arrested at the moment of death, as sometimes happens when only one of twins dies. For this reason mummified foetuses are most often seen with twin ova (c/. p. 275, note). § 399. The dead ovum may, as already mentioned, he retained for a long time in utero. Such a case must in the first place be . distinguished from one in which a twin fcetus which has died «arly during pregnancy is retained, while the other continues to develop ; in these circumstances the dead twin is expelled in a mummified condition, when the hving one is born either at the natural time or prematurely, and no great difficulty is found in explaining this condition (c/. § 204 &c.). It is not so easy to understand how it is that a single ovum is retained ; but here also it is important to distinguish between the cases in which the whole ovum is intact, from those in which it continues in utero nfter the rujiture of the memhrancs, i.e. after the discharge of the liquor amnii. When the former happens, we have always to do with the early death and mummification of the foetus. The general as well as some of the local signs of abortion will then set in, but they dis- appear after a while, probably because the placenta is unusually firmly connected with the uterus. Since the placenta continues to a certain extent to receive nutriment from the latter, and indeed may become remarkably enlarged, as the liquor amnii decreases and the fcetus shrivels, a condition of quiescence sets in, during which the ovum behaves, I might almost say, like a newly formed uterine mucous membrane. But in these cases the retention i-s- never prolonged beyond the normal termination of pregnancy ; when this is reached the irritation of the central nervous system Avhich supervenes on the termination of the cycle of pregnancy brings on labour. The expelled ovum, or rather its appendages, may then appear comparatively well preseiTcd, a fact which needs no special explanation. § 400. Those cases however in which the dead fatus remains in utero for a variable period, possibly even for years after tiic nortnal termination of pregnancy, are totally distinct ; and this event may not only occur where death takes place prematurely, but when it occurs at a late period or even during labour, — " missed labour " of Oldham. In these instances a parturient 502 INTRA-UTEBINE DEATH. nisus sets in at the natural date ; but it does not lead to the ordinary result, the " pains " pass by, and the uterus comes finally to enclose the foetus much as it would do a new forma- tion. We cannot say why the expulsive activity ceases without eflfecting its purpose ; sometimes there may be great obstruction, as I have already mentioned in § 299 in describing carcinoma of the cervix uteri, and of which a case is recorded by Menzies (c/. under M'Clintock) ; at other times the cause may possibly be found in an abnormally firm connection of the ovum with the uterus, or possibly to some extent in anomalous degrees of irritability. At any rate it must be observed that in these cases of missed labour, as far as I am able to judge from the literature of the subject, no liquor amnii is retained'; its discharge must therefore have been effected during the parturient activity, and when this result had been obtained quiescence ensued. The discharge of liquor amnii however must have taken place without any air entering into the uterine cavity at the time, for other- wise the foetus would undergo putrefaction, and either be expelled at once and iii toto, or gradually and piecemeal ; or else it must have become already mummified at a previous date, since under such circumstances in spite of the access of air putrefaction sometimes remains absent. Moreover it is known that with a very limited rent in the membranes with narrow parturient passages, and when no digital examinations are made, air may not enter. The retained foetus shrivels, and by means of inflammatory processes becomes closely adherent to the uterine walls. But it is possible, even after a prolonged retention, for it to lead to fresh and severe irritation and suppuration within the uterus, and this may lead to disintegration of the foetus by suppuration, a result which may even later be brought about by the admission of air during operative interference. In such a case the uterus expels the decomposed contents in larger or smaller portions, either directly or b}' abnormal channels, as in the case of extra- uterine pregnancy. In rare instances however the foetus remains for an extraordinarily long time, or indeed altogether, in the uterus, and undergoes changes similar to those accompanying the formation of a lithopaedion (uterine lithopcedion) . In animals (most often in sheep, most rarely in mares), retention of a more or less mature foetus and the formation of a uterine INTKA-UTERINE DEATH. 503 lithopasdion are by no means uncommon events {cf. Förster, Specielle Path. AnaU, 2ncl Ed., 18G3, p. 403 ; Fabbri, Bull, delle Sc. med. Bologna, 1866, Mazzio ; Franck, TMerürztlklu- Geburtshldfe, 1876, p. 265). § 401. The retention of a dead foetus is, generally speaking, not a very dangerous condition ; even where the foetus afterwards undergoes decomposition and suppuration, recovery usually takes place after its expulsion, although the patient may suffer very greatly during the process. The fact that in spite of this decomposition within the uterine cavity it is rare for severe symptoms of septic infection to appear, is to be explained by the uninterrupted and free exit for the products of decomposition which is rendered possible by the (in these cases) patulous uterine cervix, as well as by the internal wall of the uterus taking on a condition much like that of a granulating surface.' Cases in which the whole ovum is retained, may give rise to difficulties as regards diafinosis, inasmuch as when the foetus dies early and the symptoms of pregnancy disappear, there may be some doubt as to whether the affected woman was actually pregnant, and further whether she is still so, i.e. whether the ovum may not have been expelled unnoticed. A very careful critical investigation of the individual case, both in the light of the history and of the physical signs, will determine the point. Again, when such an ovum is expelled, care must be taken not to fix the date of conception from the degree of development of the ovum ; in so doing we might do mischief. All that can be definitely stated is how old the ovum was, when it perished. Treatment must be purely expectant, as regards tbe first category of cases. But in those of " missed labour," the cervix should be properly dilated, and all fa'tal remnants should be removed. This will not be more difficult than the removal of easily accessible intra-uterine new formations ; when however there is a co-existing metritis or peritonitis, very great caution must be used, or it may be better not to attempt the dilatation. Such cases however should only be left without any interference at all, where the retained foetus or its remnants appear to be entirely encapsuled (formation of lithopiediou), and produce no ill effects. 504 INTRA-UTERINE DEATH. LITERATURE. Extra-uterine pregnancy: Klob, Pathol. Anatomic der lüeibliclwn Sexualorgane. Vienna, 1864; Leopold, Arch. f. Gyn., xvi., p. 24; Hassfurther, '• Von dpr Ueberwanderung des mensehl. Eies." DisHertatlon, Jena, 1868 : Hecker, Monatsschrift f. Geh., xiii., p. 81 ; Keller. Des grosscsscs extra-vter. kc. Paris, 1872 ; Parry, Extra-uterine Pregnancy, its courses, &c. London, 1876. Tubal pregnancy: Rennig, Krankheitender Eileiter, kc. Stuttgart, 1876: Cohhstein, Arch. f. Gyn., xii., p. 355 ; Ernst Fränkel, ihid., xiv., p. 197 ; Eug. Fränkel, ibid., xiii., p. 249, xvi., p. 299 ; Conrad und Langhans, A. f. Gyn., ix., pp. 337, 341; Leopold, ibid., x., p. 248 ; Baartde la Faille, Verhandl. over Grar. tubü-uter. Groningen, 1867. Poppel, Mon. f. Geb., xxxi., p. 208 ; Leopold, A.f. Gyn., xiii., p. 354; Ahlfeld, Centralbl.f. Gyn., 1879, No. 2 &c. Ovarian pregnancy: Hess, "Ein Fall von Extrauterinsehwangerschaft (Ovarialschwang.)." Dissertation, Zürich, 1869 ; .Spiegelberg, A.f. Gyn., xiii., p.73; VvL.Q.Q)ii, Annal. Gynec.,-s..,\i.\; Patenko, ^./. 6^7/?;., xiv., p. 156 ; Benicke, Zeitschrift f. Geb. u. Gyn., iv., p. 276 ; Landau, ^l?T/i/r. /. Gyn., xvi., p. 436. Bernutz and-Goupil, "Des hemorrh. intrapelv. dans les grossesses extrauter."' Clin. med. sur les maladies des femmes, i., 1860 ; Klopsch, " Mikrosk. u. chemische Unters, eines Lithopädions." Reichert's Studien des Phys. Instit. zu Breslau, Leipzig, 1858. Gusserow, A. f. Gyn., xii., p. 75 : Litzmann, ibid., xvi., 323 ; Hofmeier, /. Geh. u. Gyn., v., p. 112 ; Barnes, London Ohd. Transact., xiv., p. 325. Hemorrhage of the decidua : Dohrn, J/o«./. 6?t'&., xxi., p. 30 ; Hcgar, ibid., xxi., Supplem., p. 1 ; Eigenbrodt u. Hegar, ibid., xxii., p. 161. Vesicular mole and myxoma: Bloch, Die Blasenviole kc.,Yvc\b\xxg. i., 1869; Weber, Petersb. med. Woch., 1877, No. 4—6; Gscheidlen, A. f Gyn., vi., p. 292 ; Storch, Virchow's Arch., vol. 72 ; Runge, Centralblattf. Gyn., 1880, p. 319; Puech, Gazette ohstetr., No. 12, 1879 ; or Centralbl.f. Gyn., 1879, p. 431. Amniotic bands: Crede, Monatsschrift f. Geb., xxxiii., p. 441; Fürst. A.f. Gyn., ii., p. 315. Hydramnios: M-Clintock, ■'• Dropsy of the Ovum." Clin. Memoirs on Diseases of Women. Dublin, 1863 ; Jungbluth, Arch, f Gyn., iv., p. 554 ; Levison, ibid., ix., p. 517 ; Küstner, ibid., x., p. 134 ; Sallinger, "Ueb. Hydram- nios." Dissertation, Zürich, 1875; Weyl, " Beitrag z. Kenntniss des vermehrten mensehl. Fruchtwassers." Separat-Abdruck ; Lebedjew, " Beitr. z. Lehre vom üydramnion," Dissertation Buss., Petersburg, 1878 ; Cf. Centr. f. Gyn., 1879, p. 17. Diseases of the Placenta: Mjril, Die Blutgefässe der mensehl. Nach- geburt. Vienna, 1870; Whittaker, Amcr. J. Obstetr., iii., p. 193; Ercolani, Memorie delle v,tallattie delta Placenta. Bologna, 1871. Ref. by Hennig in Arch. f. Gyn., ii., p. 454; translated in Arch. Tocol., \'616;Aleximg, Studien über den Bau der vien^chl. Plarenta und über ihre Erhranhungen. Leipzig, 1872 ; Hegar, Path. u. Therapie der Placentarretention. Berlin, 1862 ; Klebs, Präger Med. Woch., 1878, No. 49 ; Storch, Virchow's Archiv., vol. 72, p. 582 ; H-EMOKRHAGE FROM THE UTERUS. 505 Hegar u. Maier, ihid., vol. 38, p. 387 ; Maier, ihkJ., vol. 4.5, p. 305 ; Langhans, A. f. Gyn., i., p. 330 ; iii., p. 150 ; Fränkel, ibid., ii., p. 373 ; v., p. 1 ; Ahlfcld, Hid., xi., p. 397 ; Fenomenow, Hid., xv., p. 343. Pathology of the umbilical cord : Hegar, Beviclite d. Naturf.- Gescllsehaft in Freiburg, iv., 3, 1867; Schultze, Jena'ischc Zeitschrift, iv.. 4. 1868. Druffel, "Ueb. d. Gefahr der Nabelschnurumschlingung für d. Kind." Dissertation, Marburg, 1871 ; Hörder, Ä. f. Gyn. xi., p. 364 ; Hennig, ibid., xi., p. 383 ; Sänger, ibid., xiv., pp. 90, 312. Blume, " Zur Casuistlk der Torsion und Umschlingung der Nabelschnur." Dissertation, Marburg, 18G9. Dohrn, Mon.f. Geb., xviii., p. 147; Arch. f. Gyn., xiii., p. 234; Martelleur, "Zwanzig Fälle von Nabelschnur-Torsion." Dis.tcrtation, Marburg. 1874 ; Hille, A. f. Gyn., xiv., p. 484 ; Fasbender, Berliner Beitr., i., 1872 ; Sitzungsberichte, p. 71; Winckel, Berichte und Studien, 1874, p. 289 ; Martin, Z. Geb. n. Gyn., ii., p. 346; Rüge C, /J/rf.. iii., p. 414 ; Kehrer, .4./. ; at the bottom of it, and since haemorrhage not uncommonly continues even after the ;terus has been emptied; the danger is therefore increase if stronc pains are absent. Goodell and Henn.g estimate hat 56 out of 110 mothers die, while out of lU foetuses only . are saved a proportion which will not cause surprise; equall, 532 HEMORRHAGE DUE TO DETACHMENT OF THE PLACENTA. unfavourable are the results of cases treated in England, for Brunton found that 19 out of 32 cases ended fatally ^ § 426. It cannot be difficult to recognise the nature of the hemorrhage, if it is borne in mind that the only two other possible causes are rupture of the uterus and placenta praevia, and each of these conditions can be easily excluded by a con- sideration of their peculiar symptoms. Where there has been nothing to cause rupture, and no sign of placenta praevia, every haemorrhage is to be looked upon as of the nature we are now discussing. Internal haemorrhage is recognised by the local and constitutional symptoms that have been already mentioned, but' to some extent these same symptoms are seen in so many other sudden diseases, that in any particular instance it may be diffi- cult to arrive at a certain diagnosis. Such diagnosis may be greatly assisted, if the tense bag of membranes is felt through the OS (through the mass of blood lying outside it), and if blood- stained serum or even a clot is discharged by the side of the finger. § 427. When the external haemorrhage is moderate in quantity, the treatment involves exactly the same regimen, as was recom- mended for the slight haemorrhages which precede abortion. If at all copious, they must be arrested by firm vaginal tampons ; during which treatment however the onset of internal haemorrhage must be looked for and prevented by carefully supervising the body of the uterus with the hand. It is true that the tampons provoke expulsive activity ; but this is just what is wanted, since when the haemorrhage is considerable, an extensive detachment of the placenta has doubtless taken place ; the spontaneous onset of labour is therefore to be expected, and pains are now the most certain means of checking the haemorrhage. Hence it is well, if the cervix is properly prepared for labour, to rupture the foetal membranes, for the great diminution of the uterus which follows upon the discharge of the liquor amnii is more likely than any- thing else to check the bleeding. But the liquor amnii should be allowed to flow off slowly, the most unceasing supervision and compression of the uterus from without being kept up, and of course some form of ergot must be administered. ' Since the publication of these statistics, a further series of cases of this kind of internal hsemorrliage has been recorded, which also shows how. great is the risk that acconapanies th s htemorrhafte. Cf. inter alios Maberly, Obstetrical J. Great Britain, April, 1877, p. 40; and Weatherley, British Medical Journal, Aug. 2i, 1878. aEMORKHÄGE DUE TO DETACHMENT OF THE PLACENTA. 533 When liaemorrhage comes on after premature discharge of the liquor amnii, the use of tampons is not desirable as a general rule, since in these cases the danger of internal hrcmorrhage is very great. Nevertheless, nothing can be objected to their use in a particular case, if meanwhile such risk can be guarded against. In all such cases it is better to plug the cervix and the lower segment of the body by a Barnes' or Tarnier's bag, than to plug the vagina. This is far the quickest way of stretching the cervix and dilating the os ; the pains are made much stronger, and it is possible to terminate labour artificially much quicker than after plugging the vagina. § 428. When there is very profuse internal hemorrhage, it is not well to interfere too hastily, nor. to rupture the membranes as early as is generally recommended. For as long as the effused blood continues in the uterine cavity, and stretches its parietes, this stretching and the raised intra-uterine pressure prevents any more blood being poured out, while conversely if the uterus is emptied, fresh bleeding may at once begin. The sudden discharge of blood and the shock to the system which accompanies it (e.rj. anaemia of the brain and heart) may more- over increase the already severe collapse, till it proves fatal. It is therefore best to begin by ordering general stimulants and restoratives, to give the patient time to recover, and to enable thrombi to form at the seat of hremorrhage, and to grow firm. If now, while the body of the uterus is subjected to the most unceasing and carefuj supervision, its lower segment becomes better prepared for the exit of the fa^tus, the membranes may be ruptured, the liquor amnii allowed to flow ofl" slowly, and the exit of the foetus assisted by expression ; the latter is also the safest means of preventing fresb relaxation of the uterus and fresh haemorrhage. The mass of blood clots should, for tbo reasons mentioned, only be removed, if they lie close to the orifice of the uterus, and even then no force must bo used. The delivery must on no account be undertaken and completed in a hurry, never be an " accouchement force " ; if the dilatation of the cervix is delayed, this may be assisted by the introduction of large bags into the lower portion of the body ; they may bo useful even after the discharge of the liquor amnii, since they entirely or approximately replace the distention of the uterine wall which the liquor amnii was previously causing. The o34 PLACENTA PR.F.VIA. placenta is usually expelled together with liirge quantities of accumulated blood ; on account of the risk of subsequent bleed- ing and increased collapse their removal should never be hurried ; it is better to express them cautiously. It will bo obvious from what has been said above that recur- rent hiemorrhage due to insutticieut retraction of the uterus is especially to be dreaded with this internal bleeding. The delivered woman must therefore be watched with especial care. I shall speak of the treatment later on in dealing with that of post-partum hjemorrhage, and at the same time will discuss the treatment of acute anremia. (2) Hcemorrharje due to the Insertion of the Placenta at the Loner Segment of the Uterus — Placenta Prcevia. § 429. By placenta pnevia is meant a condition in which a more or less considerable portion of the placenta is inserted into that portion of the lower segment of the body of the uterus which is stretched by "pains," and therefore during labour. In some cases the placenta is almost uniformly spread out over this surface, i.e. extends all round the internal os, a lobe of varying size projecting over that os. In others one border of the placenta may only just reach it, or a narrow edge 2 — 3 cm. (•8 — 1"2 in.) wide may extend over the yet closed os ; or lastly a portion of the placenta may merely lie in the " area of expan- sion " without reaching the internal os. ^Jence various degrees of placenta praevia are distinguished, placenta pnevia centraUs, marginalis and lateralis. § 430. The lower portion of the cavity of the uterus may be looked upon as the segment of a hemisphere which under the influence of " pains," and in consequence of dilatation of the internal os and of stretching of the edges and the neighbouring portions of the latter, is converted into a cylindrical canal. With the onset of "fixing pains," and during the dilatation period, the lower portion of the uterus is stretched transversely, and the placenta, if inserted into this portion, must therefore be detached by the stretching, while, if normally inserted, it will be loosened through a contraction of the area of attachment. Of course the lower segment of the body of the uterus is at the same time shortened and retracted in a perpendicular direction parallel PLACENTA PR.EVIA. 535 to the axis of the uterus ; but this shortening is insignificant during the first stage of labour, and contributes no more towards loosening the placenta than it does during this stage with a normal insertion ; this longitudinal retraction has merely the eflect of causing the detached portion of the placenta to appear to travel further down, to be brought into the os uteri and nearer to the examining finger'. A similar instance of separation of the placenta through stretching of its area of insertion, is seen in many cases of hydraranies, in which a normally inserted placenta is prematurely detached by the undue distention. The stretching of the lower segment of the uterus is greatest at that portion which lies nearly at a right angle with the axis of the organ, therefore close to the internal os. It will be less at any portion, the higher up the latter is placed, the more it runs parallel to the uterine axis. The parallelism begins at a distance of at most 6 cm. (2 "25 in.) from the middle of the internal os, if measured in a continuous line, of 4 cm. (1*5 in.), if measured in a vertical direction. A circle carried transversely through the uterus at this boundary has a diameter of about 11 cm. (4*5 in.), and this is just enough to allow the foetus to pass through. The expansion therefore does not extend beyond these 6 cm. from the middle of the internal os. The placenta will be praevia, if it is situated wholly or partly in the segment thus defined, and when the latter is stretched, as it must be during labour, the placenta must inevitably be detached ; this is just as physiological an event as is the loosening which occurs with a normal insertion, when the area of attachment is diminished by concentric contraction. But while in the latter case such contraction arrests the blood which follows upon the detachment, in the former the stretching cannot do so, and herein, certainly not in any obstruction that placenta praevia offers to the delivery of the child, lies the great importance of the malposition ; it was this error which led to the former view, that because the placenta preceded the fa3tus, it must be born first, and required therefore to be detached before delivery could take place. ' This is not due, at least not to any important extent, to descent of the ovum ; for at the period of labour at which the events describtd take place, the ovum does not descend to any appreciable degree ; it is merely that the extensible total membranes are somewhat pushed, and made to bulge downwards. 536 PLACENTA PR.EVIA. It may be mentioned here that the haemorrhage is mainly derived from the uterine sinuses at the area of insertion which have been laid bare, and from the uterine arteries which open into the substance of the placenta and are likewise divided by the detachment ; the arteries however contract and close, almost as soon as they are torn throujijh. A gush may take place from the opened marginal vessel of the placenta, as well as from the great cavernous spaces at the moment that the placenta is detached, but it is only momentary, since thrombosis imme- diately closes up this source of hfemorrhage. Hence it follows that the blood cannot pass from the still adherent portions of the placenta through the detached ones, and then flow out, i.e. the placenta cannot bleed directly, as some authors (e.g. Sir James Simpson) have asserted. § 431. We are to a large extent ignorant of the causes of placenta pra3via. We merely know that the majority of cases occur in multipara, that a rapid recurrence of pregnancies is on the whole favourable (large size of uterine cavity or patency of the Fallopian orifices), that previous abortions have a pre- disposing influence, and that this dangerous condition is most often met with in the poorer classes, possibly owing to hard work at the beginning of pregnancy, and still more to the subinvolution of the uterus which is so common in this class. Recurrence of the malposition has been seen', still more frequently a co- existence of placenta prsEvia with twins. Ingleby mentions two curious cases in which the Fallopian tube was inserted into the lower portion of the uterus not far from the cervix. It is possible, as Hegar (Monatsschrift f. Geb., xxi., Suppl. 18G3, p. 28) inter alios has pointed out, that too extensive a formation of serotina may cause the placenta to project into the area of expansion of the uterus ; abnormal size and relative thinness of the placenta in placenta prajvia has also been mentioned by numerous authors, and I have seen several illustrations of it {cf. also §§ 341, 361) ; the part of the placenta that lies exactly over the internal os uteri is often in a state of extreme tenuity and atrophy, although in reference to this point it must of course be remembered that such a condition may be caused by manipulations during labour, or be a con- sequence of previous detachment. There are some observations ' Ingleby, Velpeau, Hecker ; I also have seen a case. PLACENTA PE^VIA. 537 {e.g. Küneke, Monatsschrift f. Geh., xiii., p. 344 ; Schuchardt, ibid., xxi., p. 380 ; Hecker, Klinik d. Geburtshiilfe, ii., p. 108) which seem to show that an ahnormal formation of the placenta, especially the existence of placenta succenturiata, which I have once found in such a case, may be a cause. Placenta praevia is on the whole rarer than would be supposed from the records of Lying-in Hospitals ; for an unusual pro- portion of abnormal cases seek admission into the latter. Schwarz {Mon.f. Geh., viii., 1856, p. 108) found that amongst the population of Hesse-Cassel, it occurred 332 times out of 519,328 labours, i.e. in the proportion of 1 : 1,564; in the Oberrhein-kreis of Baden 62 cases occurred amongst 52,792 labours(21,000— Schwörer, 11,000— Hegar, 20,792— I) = 1 : 852. We shall not go wrong therefore in assuming its frequency to be 1 : 1,000, since amongst the cases in Hesse-Cassel only those seen by medical men were counted, and a few may not have been recorded. In regard to these statistics however, it must not be forgotten that many instances of placenta praevia remain entirely unrecognised, since they end in a,bortion. It is probably merely a coincidence that a number of cases appear sometimes to happen together ; the same thing is seen with other rare events. Primiparae contribute about a tenth of the total number. Progress. § 432. Placenta praevia predisposes to abortion. Owing to the loose vascular connections of the placenta, and to the higher blood-pressure in the placenta when inserted low, any shock is liable to cause rupture of its vessels and detachment ; perhaps also shocks aifect the lower portion of the uterus oftener than the upper during the first months of pregnancy (coitus, espe- cially straining at stool). For the same reasons premature labour too is relatively common ; indeed I am convinced that even the haemorrhages which occur during the latter mouths of pregnancy, depend upon commencing labour, that it is not the haemorrhages which induce premature labour, as is generally supposed, but that the converse relation is tbe true one. It is on this account that haemorrhage as a general rule begins earlier, the nearer the placenta pra)via is to being inserted centrally, and that labour comes on prematurely. As already 538 PLACENTA PRJEVIA. explained, the detachment of the placenta and consequently the haemorrhage are produced by the stretching of the lower segment of the uterus. This stretching is solely effected by contractions, and it is entirely unproven that it occurs during pregnancy ; likewise is it unproven, that during the last months of pregnancy the lower segment of the uterus grows much more rapidly than the upper, and that therefore, the growth of the placenta being at a stand-still, a disproportion between it and the lower segment of the uterus is produced. If that view were true, haemorrhage ought never to be absent throughout pregnancy, which of course is not the case ; moreover we ought in the expelled placenta to find constant anatomical changes, differing according to the time of labour, changes which as a matter of fact are only exceptionally met with. It is therefore only the haemorrhage which is due to ** pains," i.e. to parturient activity, which is "unavoidable," because phy- siological ; that which occurs during pregnancy apart from " pains,*' has no other significance than that met with when the placenta is implanted normally, and is therefore " accidental." It depends on rupture of a utero-placental vessel or sinus near the internal os, on partial separation of the placenta by casual circumstances, and these circumstances, owing to the peculiar anatomical relations of placenta praevia and to the greatly increased blood-pressure in it, merely arise much oftener than with a normal insertion. While unavoidable haemorrhage is therefore always due to " pains," this does not necessarily imply that " contractions " coming on before the full time, must immediately lead to labour ; a quiescent condition may return, the " pains " may cease, the haemorrhage be checked by thrombosis of the wounded vessels, and the true work of parturition only set in later. This view explains why in most cases the first attack of haemorrhage begins only a short time before labour, "within the last fortnight of gestation"; it is a result of the commencing, but slowly pro- gressing, parturient activity. Thus also is to be explained the varying character of the haemorrhage, in so far as it depends on the variety of placenta praevia. Since the expansion of the lower segment of the uterus through the contractions progresses from below upwards and becomes less and less considerable in the same direction, the very first " pains " must with a central PLACENTA PRAEVIA. 539 insertion cause detachment and therefore hicmorrhage ; in such a case the latter must, as clinical observation shows that it docs, appear earlier and be more profuse than with marginal or lateral insertion, since in the latter the expansion of the area of placental attachment takes place later and is less extensive. It is in the latter variety of placenta prtevia moreover that pre- mature labour is rarest, and indeed labours nt full time, may be met with in which no hnemorrhage occurred during pregnancy. § 433. Bleeding usually begins quite unexpectedly and sud- denly, without premonitory signs ; often when the patient is quiet in bed, the contractions which cause the hemorrhage (sc. the expansion of the lower segment of the uterus) being unper- ceived by the woman herself. But it is still oftener caused by an apparently trivial cause, especially after movements of the body, straining at stool, and the reason is easy to see. The loss of blood will vary in quantity with the extent of expansion and of placental detachment ; the first bleeding may be so profuse as to cause extreme anaemia, and if it returns soon, the pregnant woman may die undelivered. Such cases however are exceptional ; in the majority, the first attack is slight, and when the process of expansion is arrested, and under the influence of the syncope which the bleeding produces, the hii^morrhage soon stops. Labour may either follow at once, or a period of complete intermission ensues, now and again interrupted by a guttatun flow of blood (stillicidium sanguinis). This alternation may occur more than once. The subsequent attacks of bleeding are almost always more copious than the first, but they are speci- ally severe during the first stage of the period of dilatation ; for at this time the expansion of the lower segment of the uterus progresses rapidly, and the separation of the placenta is very considerable ; during this period also the edges of the internal OS and the adjacent portions become retracted from the placenta in a very short space of time, and this also must tend to enlarge the bleeding surface. But the greater the expansion that has taken place, the further the detachment of the placenta has advanced before distinct parturient activity begins, the less will remain to be accomplished during the period of dihitatiou. Ihis throws liaht on the not uncommon clinical fact that in those cases in which the bleeding has been very profuse before labour, the loss during it is relatively slight or even absent ; and on the 540 PLACENTA PREVIA. converse fact that when the hoemorrhage only appears during the period of dilatation, it is usually very abundant. As a rule the bleeding lasts longer, the larger the portion of placenta that is inserted on the area of passive expansion ; there are however numerous exceptions to this rule, which depend on the degree of detachment that has already taken place, and largely on the varying efficiency of the natural agencies for arresting hEemorrhage which are at work in these cases. The haemorrhage usually ceases, when the lobe that is situated over the OS is detached, and also after the rupture of the membranes, owing to the diminution of the uterine surface which then sets in, and to the pressure exerted by the foetus on the bleeding' area. In rare cases the entire placenta is detached, while lying below the foetus, and passes out of the cervix (c/. infra) before it, without the haemorrhage persisting all the time ; still more rarely the child has been observed to bore a hole through a placenta whose edges are still adherent, and to pass through it. Both events probably happen by the child pushing the placenta before it, since this can scarcely be so small or the insertion so exactly central, that the whole placental circumference could lie within the area of spontaneous detachment. If in such a case the edges are but loosely adherent, the placenta will be entirely detached ; if firmly adherent and able to resist the pressure of the presenting part, it will be broken through. § 434. The character of the pains is of great importance. Unhappily they are generally feeble and ineffectual, doubtless in consequence of the general weakness of the uterine parietes which has also played a share in the aetiology, and especially of the slight development of the musculature at the lower segment, where the muscular element has made room for the great number of blood-vessels. Hence it comes to pass that this segment is but little irritable, there is no adequate stimulus to contractions, with which may also be associated the fact that the bag of membranes is not formed as early as usual. For these reasons the os uteri dilates slowly, and since the bleeding will only cease when the latter has attained a certain size, not uncommonly only with labour, the delay leads to great danger. Happily in spite of the slow dilatation of the edges and of the parts adjacent to the os, the latter becomes more and more PLACENTA PRAEVIA. 641 yielding and dilatable, even though the pains be feeble, so that it is generally possible to terminate labour much earlier than might be supposed from the size of the os. Until lately it was believed that this haemorrhage was cha- racterised by the circumstance that (in contrast with hicmor- rhage due to the detachment of a normally implanted placenta) it took place during a pain owing to the increased detachment of the placenta which the pain produced, and that the haemor- rhage ceased with the intermission. This however is not correct, as Legroux already showed ; I never saw a case in which the haßmorrhage was more profuse during a pain than during the intermission, if I leave out of consideration the expulsion by the " pain " of the blood that had been already shed, nor on the other hand have I ever seen any cessation of the haemorrhage during the intermission, which could be brought into causal connection with it. It would moreover be expected on a priori grounds that a " pain" and the uterine anaemia which it produces, that the retraction of the area of placental attachment, and the approximation of the walls of the uterine sinuses which occurs during the latter retraction and with the expansion of the lower segment, would cause the haemorrhage to diminish, or even to cease. This corresponds with our experience that when pains are strong and the labour makes rapid progress, the haemorrhage is always slight. § 435. The presentation of the fcetiis is comparatively often unfavourable ; this is not so much due to the low insertion of the placenta, as to the frequency with which premature labour accompanies placenta praevia, and to the flaccid uterine walks. I cannot concur in the view that the low insertion alters the natural shape of the uterine cavity, and is thereby apt to cause an abnormal presentation ; the adherent placenta is too tbm to exert any such marked influence. The insertion of the umbilical cord is not infrequently a marginal one, and indeed the insertion is often into the lobe lying close to the internal os, a fact which favours its prolapse; sometimes moreover the msertiou is vela- mentous, in which case the umbilical vessels may present, and be injured when the membranes rupture. ,-, , ■ ,j Placenta praevia disposes to htiemon-hage during u^vaWr-hirth period, probably owing to the general feebleness of the pains in fh affe'ction, and still more owing to the slight development of 542 TLACENTA PE.T^VIA. tlie musculature at the placental area ; partly also owiufr to tlie bruising and injury to which the latter is so often subjected during the labour which frequently requires artificial interference ; and lastly owing to the fact that the clots that should adhere to the area of attachment, and that favour thrombosis of the vessels when the placenta lies low, arc not rarely absent, or have been forcibly removed. This variety of post-partum hremorrhage is exceedingly serious, since it usually attacks a woman who is already highly anremic. § 436. The great danger associated iritli jüacoita imevia, can be easily estimated from what has been said above ; there are few complications of pregnancy which are so much to be dreaded. The risk to the mother arises not only from hsemorrhage, but also from the frequency with which puerperal diseases start from the exposed placental area. The earlier the hasmorrhage sets in, the oftener it returns before actual labour, the more anaemic the woman when the latter begins, the feebler the pains, the greater the delay till the os becomes sufficiently dilated, the worse is the prognosis ; the mode of treatment adopted of course also affects her prospects. In hospitals and towns, such cases are as a rule moi'e successful than in rural districts where assistance is generally not obtained till late ; if therefore the mortality in the former amounts to 20 — 25 per cent, (according to a series of quotations in Naegele-Grenser's Lehrhiich 21, Simpson 27*5, Barnes only 9, I not quite 16 per cent, out of 102 cases), we may estimate the general mortality including deaths from puerperal disease at 30 per cent. (Schwarz in Hesse-Cassel gives 25 per cent.) The prognosis is even worse for i\\e foetus ; its mortality in my experience has been somewhat over 50 per cent., Schwarz puts it at 75 per cent., Barnes at 64 per cent. &c. The great danger -depends mainly on an insufficient supply of oxygen to the fcetus (for it does not lose any blood from the detached placenta) due to the separation of the placenta, and to the pressure to which the deeply inserted umbilical cord is exposed during labour, and on the fact that the foetus is generally born prematurely ; to these risks must be added the frequent operative measures that are called for by the abnormal presentation, and the necessity of terminating the labour rapidly. § 437. Placenta praevia can be easily diagnosed by the cha- PLACENTA rn.EVIA. 543 racter of the liaemorrliage and by a vaginal examination. Any haemorrhage coming on during pregnancy without adequate external cause, when the patient is quiet and without any distinct painful sensations ought to arouse suspicion, especially if it soon ceases and recurs after some time. Moreover in such cases the placenta can generally before long he felt above the internal os, since the haemorrhage is caused by contractions, and these soon make the os passable to the finger ; this sign renders the diagnosis certain. A great deal depends on the practitioner getting a clear idea of the state of things at an early stage ; it is his duty therefore to seek to arrive at a clear diagnosis as soon as possible by the method mentioned above, while of course using every precaution so as not immediately to provoke fresh pains and haemorrhage. The spongy reticulated placental tissue is unmistakable, and can only be confused with firm coagula through carelessness ; there is more risk of mistaking thin portions of the placenta which have become atrophied (either from the very first, or in consequence of prolonged separation) and lie above the internal os, for thickened membranes. The other appearances in the generative organs throw no special light on the case ; at most does an unusually soft and spongy condition of the vaginal fundus and of the lower uterine segment deserve notice, as well as a perhaps sometimes unusual thickness of that segment, which makes it difficult to feel the presenting part through it. Manafiement. § 438. There are few complications in which the results depend so much on judicious management, as they do in placenta previa. The above description shows that the chief danger arises from haemorrhage ; and on its character must depend the conduct of the accoucheur; if the bleeding is alarming, his one object must be to arrest it, or if tbis cannot be done, to restrict it within the shortest possible limits. The arrest of the hiemorrhage at the area of placental attach- ment is mainly brought about by contraction or diminution of the latter, by the consequent narrowing of the wounded vessels, and to a less extent by thrombosis of their lumina. A satisfac- tory deqree of contraction however is onli) possihh, ivhen the uterus is completely emptied; and the end therefore which must 544 PLACENTA PREVIA. above all things he kept in view, is to effect this as quickly as possible. When this cannot be done, a partial evacuation may sometimes be useful. Should there be obstacles or reaso7is against either proceeding, an attempt must he made to promote coagidation at the bleeding surface. Hence in any special case, the following methods will need consideration. § 439. If the hsemorrhage is onl}' moderate in quantity, whether distinct pains are present or not, a purely expectant attitude should be adopted, much as is recommended in the case of similar haemorrhages due to abortion ; there is at least room for hope that even when the bleeding has begun before the natural end of pregnancy, the latter may continue for a while interrupted. This treatment is further recommended by the fact that under the existing circumstances the diagnosis is not as a rule quite certain ; but the patient and her friends should have their attention called to the condition, and be urged to call in assistance as soon as any unfavourable symptoms show them- selves. If the haemorrhage continues for a considerable time or becomes profuse, we must interfere and indeed endeavour to deliver as quicklg as possible by version and extraction. Early delivery offers the best chance for the child also, which may not as yet have experienced any want of oxygen ; and even if such want comes on during the proceeding, it is not so dangerous, and is more easy to remedy after delivery than is asphyxia that has developed slowly. Delivery is in these cases often possible at an unusually early period, although the cervix appears as yet to be but little canalised, owing to the very spongy condition and to the slight development of the muscular tissue in the lower segment of the uterus, all the more so as we shall gene- rally be dealing with multiparoe. Nor should the term " forced delivery " (" accouchement force ") alarm the accoucheur, since the operation itself generally requires but little force. An attempt to dilate the os to a diameter of 5'5— 6*5 cm. (ca. 2 — 2'5 inch) by the hand (more is not necessary to admit the latter and the fcetus in the great majority of cases — Duncan), often meets with quite an unexpected measure of success and must therefore always be made at the earliest moment. Chloro- form anaesthesia greatly facilitates the operation, and need not PLACENTA PR.TEVIA. 545 be feared except for persons that are already very anaemic. In case of necessity, it may be well to make a bilateral incision 2 cm. (-75 inch) deep through the edge of the os ; this will not wound the placental area. But before resorting to these mea- sures, it should be borne in mind that, if possible, they must not remain mere experiments, but actually lead on to delivery ; and further that owing to the detachment of the placenta produced by the fingers, the most profuse haemorrhage may meanwhile set in and compel the completion of the proceeding. The bed, &c., must therefore be carefully prepared. The choice of hand is unimportant ; that should be selected by which the accoucheur will be able most easily and quickly to reach the feet ; it can' scarcely be difficult to discover their situation. The attempt to determine on which side of the lower segment of the uterus least of the placenta is inserted, usually proves fruitless ; nor does the advice that the uterus be entered on the left side, because the smaller lobe generally lies on that side and less of the placenta will therefore be detached, always hit the mark ; if the hand should come upon the more extensive portion of the placenta, it may easily be moved away to one side of it, and be pushed on past that portion. Promptness, steadiness, and fearlessness are essential ; there must be no nervousness or hesitation on account of the flooding. As soon as the hand has got entirely into the cavity of the uterus, the fore-arm acts as a tampon, and the htemorrhage is usually checked ; but the operator must not allow himself to be unnerved by the blood that is lost on withdrawing his hand or on bringing the breech down into the cervix, although it is often very copious. The extraction must be done slowly and deliberately ; if the fojtal pulse permits, the expulsion as far as the navel at any rate may be left to the pains, the latter being stimulated and assisted by expression ; if the fa-tus is dead, only the most essential and gentle manipulations must be used. This caution is called for on account of the risk of the abdominal vessels becoming excessively engorged with blood, and of the consequent cerebral and cardiac anaemia, which conditions are so apt to follow rapid evacuation of the uterus ; as well as by the fact that in forced extraction the previously stretched edge of the os is apt to con- strict the neck of the child, and then to be drawn down as a result of the traction to near the vulva. :^5 546 PLACENTA PREVIA. The results which follow very early delivery are extremely satisfactory. Hofmann {Prcif/er Vicrteljahrsclirift, 1860, iii., p. 98) only lost 2 out of 33 women = 6 per cent. ; Hecker lost 3 out of 40 cases delivered in this way = 7'5 per cent. and=4*3 per cent, of all his cases; I out of 102 only 6 = 59 per cent., and these through acute auismia^ ; my total mortality is some- thing under 16 per cent., and mainly due to intercurrent and secondary diseases ; even then however it is by no means a bad one when compared with the mortality given in § 436. § 440. But if the cervix is not sufficiently canalised and dilatable, so that immediate delivery appears out of the question, lütKjfiiHfi must be resorted to, not with india-rubber bags which exert but slight pressure on the lower segment of the uterus, but in the way described in § 417. The tamponing causes the blood to coagulate both at the bleeding surface and in the lumina of its vessels, partly by means of the pressure it exerts from without and by the relative diminution of pressure in the uterine vessels caused by that external pressure, partly by the fact that the blood collecting on the tampons coagulates ; tamponing also excites and strengthens the pains, and thus helps in preparing the cervix for early delivery. If the cervix is still far from dilated, plugging the vaginal fundus can be rendered more efficient by introducing a disinfected sponge tent into the cervix, or still better a laminaria or tupelo tent, whose influence in promoting dilatation and expulsion is particularly useful in these cases. If after removal of the tampon, the cervix seems to be sufficiently prepared to allow of version, the latter must be immediately performed. When the liquor amnii is discharged prematurely, and rapid delivery is nevertheless not possible, the condition may become very serious, since the plugging involves a risk of internal hfemor- rhage, the amount of which may exceed that of the discharged waters. Happily this premature discharge almost only occurs, when the placental insertion is lateral. If the ha3morrhage should be considerable, it is a good plan under these circum- stances to plug the cervix and vagina for a short time, while con- stantly watching and compressing the uterus from without ; delivery must of course follow as soon as possible. ' Out of these 6 cases, 2 were brought into the hospital in a state of extreme ansemia, indeed at death's door. PLACENTA PRAEVIA. 547 '^ 441. The other modes of treatment that are generally recommended, possess but little value in comparison with the procedure just described, for this reason especially that (as Hecker has so justly remarked) they impose upon the "pains" the double task of checking the hiemorrhage and completing the delivery, a task which those pains are as a rule quite unable to fulfil within such a period as is compatible with the safety of the mother and of the foetus. To this class belongs in the first place Braxton Hicks' method of version, in which it is recommended that even though the cervix be but little prepared, the feet be brought down into it, by means of bimanual manipulations. Apart from the fact that the feet are not always readily got hold of, and that the manipulations about the internal os may cause extensive detachment of the placenta and lead to profuse flooding, the bleeding frequently persists after the thighs have been brought down into the cervix. The operator is then in the awkward situation which he has himself produced, of having allowed the liquor amnii to escape, and of being obliged to complete the extraction while the parts are as yet insufficiently prepared. The object of the proceeding, viz., that of plugging the bleeding surface by means of the breech, is not attained, since the bleeding surface lies higher than the latter when it is occupying the cervix ; the recommendation of this procedure rests on the erroneous assumption that the haemorrhage takes place from the upper portion of the cervix, and that the placental area remains throughout the labour in the same position that it occupied at its commencement, which is of course not the fact, since the internal os is gradually, although slowly, retracted upwards. For the same reason puncturing the nicnibntncs ichcii the h,-ad presents is as a rule not advisable. In the first place so long as the OS is but little dilated, it can only be carried out with a mar- ginal insertion. When it then operates favourably (as otlen happens), it does so by the diminution of the bleedmg area which follows upon the discharge of liquor amnii ; even although it seems as if the descending fa^talpart arrested the ha^morrliage by pressing on the bleeding area, such cessation is really due to the further diminution of that area which gradually takes place as the child descends. Hence as a matter of experience he method is only successful, if pains are present and soon 1.x the 548 PLACENTA PREVIA. presenting head in the brim, or force it still further down. Unhappily in cases of placenta praevia, inertia of the uterus is common, and the version must often follow upon the puncturing of the membranes, and if so it is of course done under less favourable conditions than if it had been performed forthwith. It is better therefore that the whole affair be done at once. § 442. Nor can I speak well of the proposal that 7chen the placenta lies in front of the child, it should he entirely or partly separated, and delivery then he left to nature. The complete detachment which was recommended by Simpson is based on the observation that the haemorrhage frequently ceases after complete spontaneous separation, probably because the bleeding surface can then become both contracted and tense. Arrest of the bleeding however does not always follow, especially when the detachment is artificial, since the uterine muscle is so often quiescent at the time. Moreover such complete detachment often presents great difficulties ; it can rarely be accomplished satisfactorily, and wastes time. Again, copious flooding may occur during the actual operation, and the bleeding area possibly be increased far beyond what is necessary ; above all it should be borne in mind that the child is inevitably sacrificed. And if, in spite of the detachment, persistent haemorrhage should compel delivery in such a case, this will be accomplished under much less favourable conditions than would obtain before such detach- ment. If therefore the cervix is so patulous that the placenta can be conveniently and easily peeled ofi", it is better to perform the easier and less dangerous version and extraction. Partial separation (of the smaller lobe) followed by puncture of the membranes (Crede, Cohen, Barnes) is in some measure open to the same objection that it prematurely increases the bleeding surface ; partly also to that already made to puncturing the membranes, namely that it takes it for granted that good pains will follow such puncture ; if such are absent, we are no better ofi" than before. Earlier methods consisted in hreaking through the placenta witli the hand, and then performing version and extraction (Merriman, Löwenhardt), a plan which was suggested by the observation that in rare instances a placenta which adhered firmly with its edge has been perforated by the presenting part of the foetus ; or in applying cold irrigations to the hleeding PLACENTA pr;rvia. 549 surface after detachment of the jmrt of the placenta which lay nearest to the os (Seyfert) ; or in crnshhuj the placenta (Pfeiffer). At the present time they can scarcely have more than a historical interest. § 443. If a patient is not seen till she has lost much hlood, and has hecome extremeli/ anamic, delivery must only be under- taken after a most careful estimation of the anaemia and risk of collapse. Unless existing hemorrhage calls for immediate interference, the woman should be allowed to recover as much as possible under the use of stimulants and restoratives. The delivery must always be performed slowly, all change of posture being avoided ; it must therefore be done in the ordinary bed. Chloroform is inadmissible in these cases, since this like move- ments of the exhausted woman might easily render the collapse fatal, and lead to pulmonary embolism. The after-hirtJi j^d'iod is to be managed like that of an ordi- nary labour (§§ 197 and 198) ; after a placenta prnovia however the uterus should be watched with special care, beginning with the last stages of the birth of the child. In spite of this care it will be necessary in a good many cases to remove the placenta artificially, owing to the adhesion of one or two thin cotyledons. After such removal the abdomen should be surrounded with a tight binder, supplemented if necessary by a compress, so as to insure good retraction of the uterus. If haemorrhage occurs from the insufficiently contracted or entirely atonic placental area, irrigations of cold water or of water and vinegar, or of tr. iodi, and even of liquor ferri perchloridi should be used to stop it; the cervix and vaginal fundus may, if necessary, bo firmly plugged, while pressure from above (made first with the hand, afterwards with a pad and binder) meanwhile prevents the uterus from ascending, and compels it to remain contracted, and to keep in the place it had assumed. Such all round pressure will prevent any blood escaping either upwards or downwards, and associated with the direct application of ha-mostatics must arrest the haemorrhage. Extreme ant^mia and weakness during and after delivery require the treatment that will be descril)e(l, when we come to deal with hemorrhage during the after-birth period. 550 PROLAPSE OF THE PLACENTA. Prolapse of the Placenta. § 444. Under this name has hcen understood since the time of Osiander {Gem. Deutsche Zeitschrift f. Gehtirtskunde, vii., p. 223) the entire detachment and expulsion of the placenta before tJie ft'tus. Although most often seen in conjunction with placenta previa (its mode of origin in these cases has heen already men- tioned in § 433), prolapse of the placenta sometimes occurs when the placenta is normally inserted, especially in the case of the second of twins. This is well illustrated by the two cases related by Hüter {Deutsche Klinik., 1852, No. 49) and Scanzoni {Lehrbuch) in which at the necropsy the placental area was found in the fundus uteri, and by one of Hecker's {Baijr. Intdli- (jcnz-Blatt, 1871, No. 17). Hennig met with a case in which a couple of days before the "forced delivery," two small placcntne succenturiatte were spontaneously discharged, while the laterally presenting placenta remained in situ {Arch. f. Gijn., viii., p. 337). It is obvious that when a normally inserted placenta becomes prolapsed, the membranes must be torn, and a want of adaptation of the lower foetal end to the lower segment of the uterus is also a necessary condition ; the accident is therefore most common in premature labours and with pelvic presentations. The diagnosis is clear if a placenta which at one time could not be discovered in the lower segment of the uterus, is during the course of labour suddenly found entirely or partly within the OS. If the patient is only seen when the placenta lies in the latter position, it can scarcely be possible to distinguish between placenta prievia, and a placenta which was at first normally inserted and has become prolapsed. Such a distinction however is of no importance as regards treatment ; for in either case this will depend on the state of the mother and of the child. The latter is not always dead, even when the placenta is prolapsed ; it may be still living, if only a short interval has elapsed between the separation and the prolapse of the placenta, but it is a ques- tion of minutes, at most 10. Such a condition however is rarely met with ; the detachment will almost always have preceded the prolapse so long, that the foetus has succumbed to asphyxia. If there still remain signs of life, the child must be withdrawn as rapidly as possible from its perilous position by artificial extrac- tion. Should the fcotus be dead, the accoucheur may look on PROLAPSE OF THE PLACENTA. 551 quietly, if there is no hfemorrhage ; but if there is, delivery must here also be at once completed, since plugging is not reliable (on account of the risk of internal haemorrhage) ; extrac- tion Avill probably always be possible, if the os is sufficiently dilated to permit a placenta to pass through. LITERATURE. Levy, " Ucber Menstruation in der Schwangerschaft." Arch. f. Gyn., xv., p. 36 L Abortion: Whitehead, 0)i the causes and treatment of Ahortion and SterU'dy. London, 1847; Hoening in Scanzoni's ^6'<^/"«/7t'rt, vii., p. 213; Dohrn, Volkmann's Sannnlung Klinischer Vorträge, No. 42, 1872; Kreis, Berliner Klin. Wochenschrift, No. 26, 1872; Veit, Zeitschrift f. Geh. u. Gyn., iv., p. 180; Fehling, Areh. f. Gyn., xiii., p. 222 ; Konräd, Wiener Klinik, Part iv., April, 1879; Boeters, Ce^itralhl. f. Gyn., No. 20, 1877; Munde, ilid., No. 6, 1878; Cordes, Annal. Gynec, vi., 1876. Fibrinous polypi: Fränkel, -I/r/;./. ^'t'///;., ii., p. 76 ; Sclii'ödcr, Scanzoni's -Beiträgen, vii., p. 1. Hemorrhage due to detachment of a normally inserted placenta : Braxton Hides, London Obst. Transact., ii., p. 53 ; Goodell, Ainer. J. of Ohst., ii., p. 281; Hennig, Arch. f. Gyn., viii., p. 336 ; Brunton, Ohst. J. of Gr. Britain, Oct., 1875, p. 437 ; Underhill. Hid., Jan., 1879, p. 641. Placenta prtevia: 'Hoist, Monatsschrift f. Gehurtslt., ii.; Barnes, Lectures on Ohst. Operations, 2 edit., London, 1871, p. 397: Duncan, Contrib. to the Mechanism of Natural and Morbid Parturition, Edinburgh, 1871 ; Cf. also Arch. f. Gyn., vi., p. 55; Jüdell, ihid., vi., p. 432; Fränkel, Berliner Klin. Wochcnsch., Nos. 22, 23, 1870 ; Hecker, Bayr. Aerztl. Int ell. -Blatt, No. 22, 1873 ; Paessler, Berliner Dissertation, 1876 ; Müller, Placenta Prcevia &c., Stuttgart, 1877; ^Q}üx<;A'i.x, Zeitschrift für Geh. n. Gyn.,\., p. 225 ; Bell, Ohst. Journal of Gr. Britain, Nov., 1878, p. 491 ; A. Simpson, ibid., Sept., 1879, p. 390 ; Taylor, Transact. Amer. Gyn. Society, iii., p. 310 ; King, Amer. J. Obst., xiii., p. 743. Prolapse of the placenta: Siebold, Monatsschrift f. Geh., vi., p. 258; Müller, Würzburger Med. Zeitschrift, vii., p. 34. END OF VOL. 1. London : Printed by Jas. Truscott &. Sox, Suffolk Lane, E.C. ^ UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. Form L9-42»i^8,'49(B5573)444 THE LIBRARY UNIVERSITY OF CALIFORNU LOS ANGELES ./ \. y