$ Wi \ 5 imimics 3 \NbBbt ** •ft* •* HEALTH SC18HCES LIBRARY ATEXT-BOOK OF OBSTETRICS BY BARTON COOKE HIRST, M.D. PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA; GYNECOLOGIST TO THE HOWARD, THE ORTHOPEDIC, AND THE PHILADELPHIA HOSPITALS, ETC. Fifth Edition, Revised and Enlarged with 767 Illustrations, 40 of them in Colors PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1906 KQr^i Set up, electrotyped, printed, and copyrighted November, 1898. Revised, reprinted, and recopyrighted May, 1899. Reprinted May, 1900. Revised, reprinted, and recopyrighted April, 1901. Re- printed December, 1901. Revised, reprinted, and recopyrighted July, 1903. Reprinted July, 1905. Revised, reprinted and recopyrighted August, 1906. Copyright, 1906, by W. B. Saunders Company. PRESS OF SAUNDERS COMPANY PHILADELPHIA — < 22 TO RICHARD A. F. PENROSE, M.D., LL.D. EMERITUS PROFESSOR OF OBSTETRICS AND OF THE DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA Gbis JBoofc is ©ratefullE De&fcatefc BY HIS FORMER PUPIL, THE AUTHOR Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofobstetOOphil PREFACE TO THE FIFTH EDITION. The author has carefully revised this edition, paying particular attention to the recent advances in our information regarding puer- peral infection and gestational toxemia, but incorporating in the text only the facts that seem at present clearly established. As in former editions, the author has endeavored to keep in mind the needs of the medical student and practitioner of medicine who must be prepared to accept the responsibility involved in obstetrical practice. 182 1 Spruce Street, Philadelphia. PREFACE. This work is the result of a practice devoted for the past twelve years exclusively to gynecology in both its branches — obstetrics and gynecic surgery. The author has served during this period as consulting and attendant gynecologist and obstet- rician in eight of the principal hospitals of Philadelphia. His experience in obstetrical complications and operations has con- sequently been exceptionally large. He has been engaged, moreover, during the whole of his professional career, in teaching medical students in clinics, hospitals, laboratories, and in the lecture-room. He ventures to entertain the hope, there- fore, that his training has fitted him for the preparation of a book which shall serve as a guide to undergraduate students and to physicians in active practice. It has been his constant aim to condense the text as far as is consistent with a comprehensive treatment of the subject. Illustrations have been extensively employed, the majority of them from original photographs and drawings. The task, impossible within a single volume, of presenting a complete bibliography of each subject has not been attempted. The student who desires such information is referred to the " Catalogue of the Surgeon-General's Library," the ten volumes of the " Jahresbericht iiber die Fortschritte auf dem Gebiete der Geburtshilfe und der Gynakologie," and to the " In- dex Medicus." References are given to articles and books which have been most helpful to the author or which have been epoch-making in the history of obstetrics. 1821 Spruce Street, Philadelphia. II CONTENTS. PAGE PART I.- PREGNANCY i 7 Chapter I. — Anatomy ij Anatomy of the Pelvis 17 The Female Sexual Organs 39 Chapter II. — Menstruation, Ovulation, Fertilization, etc. . . 50 Menstruation . . 56 Ovulation 60 The Corpus Luteum , 63 The Connection between Ovulation and Menstruation 64 Insemination 66 Changes in the Ovum following Impregnation 74 Chapter III. — The Development of the Embryo and Fetus . 76 Development during the Months of Pregnancy 76 The Mature Fetus 87 Chapter IV. — The Fetal Appendages The Amnion 94 94 The Chorion 106 The Placenta 1 16 The Umbilical Cord or Funis i?r The Decidure 1*1 Chapter V. — The Diseases of the Fetus 154 Chapter VI. — The Physiology of Pregnancy 1S1 Changes in the Uterus 1S1 Changes in the Several Systems of the Body 186 The Diagnosis of Pregnancy 190 Chapter VII. — Pathology of the Pregnant Woman 217 Diseases of the Genitalia 217 Diseases of the Uterine Muscle 223 Diseases of the Alimentary Canal 232 Diseases of the Urinary Apparatus 239 Diseases of the Nervous System 246 Diseases of the Circulatory Apparatus 249 Diseases of the Respiratory Apparatus 253 Diseases of the Osseous System 255 13 14 CONTENTS. PAGE Infectious Diseases 255 Skin Diseases 256 Abortion, Miscarriage, and Premature Labor 259 Extra- uterine Pregnancy 276 PART II.— THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM 302 Chapter I. — Labor 302 Chapter II. — The Puerperal State 337 PART III.— THE MECHANISM OF LABOR 377 Forces Involved in the Mechanism of Labor 381 Mechanism of the Several Presentations and Positions .... 384 Abnormalities of Mechanism and their Management 391 Mechanism of the Third Stage of Labor 422 PART IV.— THE PATHOLOGY OF LABOR 428 Chapter I. — Dystocia +28 Abnormalities in the Forces of Labor 428 Labor Complicated by Accidents and Diseases 560 Dystocia Due to Disease 620 PART V.— PATHOLOGY OF THE PUERPERIUM 635 Chapter I. Abnormalities in the Involution of the Uterus after Child-birth . 635 Puerperal Hemorrhages 641 Xon- infectious Fevers 658 Acute Intercurrent Affections 666 The Exanthemata 668 Puerperal Diphtheria 677 Puerperal Malaria 677 Rheumatism and Arthritis 679 Gonorrhea 681 Skin Diseases 682 Tympanites 683 Diseases of the Urinary System 684 Diseases of the Nervous System 692 Developmental Anomalies of the Breast 693 Anomalies in Milk Secretion 696 Diseases of the Mammary Glands 7°4 Relaxation of the Pelvic Joints 7 11 Chapter II. — Puerperal Sepsis 712 PART VI.— OBSTETRIC OPERATIONS 77 6 Induction of Abortion 77° Induction of Labor 77° Forceps 7^1 Extraction of the Breech 805 CONTENTS. 15 PAGE Artificial Dilatation of the Cervical Canal 808 Version 815 Embryotomy 831 Symphyseotomy 839 Hebotomy 844 Cesarean Section „ 845 PART VII.— THE NEW-BORN INFANT 854 Chapter I. — Physiology of the New-born Infant 854 Chapter II. — Pathology of the New-born Infant 863 Injuries to the Infant during Labor 863 Diseases of the New-born Infant ...-872 INDEX. • A TEXT-BOOK OBSTETRICS PART I. PREGNANCY, CHAPTER I. Anatomy of the Pelvis; Development and Anatomy of the Female Generative Organs. THE ANATOMY OF THE PELVIS. The hip-bones together with the sacrum, including the coccyx, compose the pelvis, which forms the basin-like lower portion of the trunk. In the erect position of the body the pelvis is bent obliquely backward from the vertebral column above, so that the crest of the pubis descends nearly to a level with the end of the sacrum. The pelvis is divided into two parts by a prominent rim, named the brim of the pelvis, which is formed on each side by the iliopectineal line continued behind the crest of the pubis and by the curved ridge and promontory of the sacrum. The upper part is formed by the ilia, and includes the widest space of the pelvis which pertains to the abdominal cavity. The lower part is distinguished as the true pelvis, and incloses the cavity of the pelvis. It is a complete bony girdle, formed by the sacrum and coccyx, the ischium and pubis, and a small portion of the ilium. The upper extremity of the pelvic cavity, corresponding with the brim, is the inlet, or superior strait ; the lower extremity is the outlet, or inferior strait. In consequence of the curvature of the sacrum and coccyx the pelvic cavity appears as a curved cylinder, slightly narrowed toward the outlet. It is deepest behind and shallowest at the pubic symphysis. Its lateral wall is deep and vertical. It extends from the iliopectineal line to the end of the ischial tuberosity, and is mainly formed by the body of the ischium with small portions of the ilium and pubis. The anterior depth of the pelvis (height of the symphysis) is 4 cm. (1.57 in.). The 2 17 i8 PREGNANCY. lateral depth is 9 cm. (3.54 in.). The posterior depth is 13 cm. (5.12 in.). The pelvic inlet is cordiform, with the notched base con- forming with the base of the sacrum and the rounded apex with the pubes. The outlet, rather smaller than the inlet, when completed by the great sacrosciatic ligaments has the same shape, with the notched base formed by the coccyx and the apex Fig. 1. — Female pelvis (one-third natural size) (Dickinson). by the pubic symphysis. Its fore part is the pubic arch, the base of which extends between the ischial tuberosities ; and the sides are formed by the conjoined rami of the pubes and ischia. On each side of the outlet is the deep sacrosciatic notch, formed in front by the ischium, above by the ilium, and behind by the sacrum and coccyx. It is converted into the great and small sciatic foramina by the sacrosciatic ligaments, which also sepa- rate them from the pelvic outlet. The pelvis of the female not only differs from that of the male in accordance with the usual difference in other parts of the skeleton, but also exhibits impor- tant modifications which relate to the sexual function. The female pelvis is proportionately larger, but of more delicate con- struction. It is proportionately, and often absolutely, of greater breadth, and is of less depth. The ilia spread more laterally, so as to produce greater breadth or prominence of the hips than in the male. The true pelvis has greater horizontal capacity, less depth, and is commonly less curved and less contracted at the outlet. The inlet is larger, less intruded upon by the sacral promontory, and is more circular or transversely oval. The THE ANATOMY OF THE PELVIS. 19 outlet is likewise larger, with the ischial tuberosities less conver- gent, and with the pubic arch wider, lower, more truly arched, and with the sides more everted. Fig. 2. — The funnel-shaped false pelvis. In the female the sides of the pubic arch are narrower, more flattened, and less ridged than in the male. 1 The hip or innominate bones — in the adult a single piece — are composed, in fetal life and in childhood, of three separate bones, — the ilium, the ischium, and the pubis. The three bones are united by a triradiate cartilage in the acetabulum, which begins to ossify at puberty, the ankylosis being complete in the eighteenth year. The descending ramus of the pubis and the ramus of the ischium are also originally united by a cartilage which ossifies at about the eighth year. The bony pelvic girdle in the adult is united by three joints, the symphysis pubis and the two sacro-iliac joints. The former is a synchondrosis; the junction of the pubic bones by the inter- vening cartilage is strengthened by ligaments above, before, behind, and below the symphysis. The last named is the strong- est. It is the arcuate ligament of the pubis. The pubic junction 1 This 1 irief anatomical description of the pelvis is taken, modified, from Leidy's " Anatomy." 20 PREGNANCY. will withstand a weight of 197 kg. before rupturing (Selheim). The sacro-iliac joints are true joints (amphiarthroses), with all their characteristic features. The joint surface of the sacrum is broader behind and above than it is before and below, so that the sacrum cannot be pushed forward or downward without separat- ing the innominate bones. The joints are reinforced by com- paratively weak ligaments anteriorly, but by strong ligaments pos- teriorly, the best developed of which are the sacro-iliac ligaments. The sacro-iliac joints withstand a pressure of 160 to 310 kg. The Anatomy of the Pelvis Obstetrically Considered. — To the obstetrician the pelvis is a canal and not a basin, and is to be studied mainly in its relation to the fetal body which must pass through it. The false pelvis is of minor im- portance, acting simply as a funnel-shaped structure to di- rect the present- ing part toward and into the superior strait of the true pel- vis. The ob- stetrical study of pelvic anatomy may be confined to the shape, size, position, and direction of the true pel- vis. Pelvic Shape. — The pelvis might be described as a truncated cylinder, but the description would not be exactly accurate. As a matter of fact, the pelvic canal is of different shapes at different levels, and it is necessary to study certain typical planes of the pelvis in order to understand fully the relationship of fetal to pelvic shape in labor. The first of these imaginary planes is laid at the entrance to the pelvic cavity or canal, the pelvic inlet or superior strait, and is bounded by the promontory of the sacrum, the iliopectineal lines, the crests of the pubis, and the upper edge of the symphysis. The shape of the pelvic inlet is cordi- form. In the bays on either side of the promontory rest the important nerve-trunks and blood-vessels of the pelvis, where they are guarded from the pressure of the fetal head. It was The shape of the superior strait. THE ANATOMY OF THE TEL VIS. 21 thought formerly that the shape of the pelvic inlet was elliptical, but this is only exceptionally the case, as in certain justominor pelves, in which the nerve-trunks and vessels may be subjected to such excessive pressure that disease and disability result. In studying the pelvic canal from above downward it appears that the canal expands below the pelvic inlet and then contracts again as it approaches the outlet. It is convenient, therefore, to lay off a plane at the level of greatest expansion and another at the level of greatest contraction, which are called, respectively, the plane of pelvic expansion and the plane of pelvic contraction. The shape of the pelvic canal at the plane of pelvic expansion, passing through the middle of the sym- Fig. 4. — The diameters of the superior strait. physis, the top of the acetabula, and the sacrum, between the second and third vertebrae, is almost exactly circular, being only a trifle larger in its anteroposterior than in its transverse diameter. The shape of the pelvic canal at the plane of pelvic contraction, passing through the tip of the sacrum, the spines of the ischia, and the lower surface of the symphysis, is distinctly elliptical, being a centimeter longer anteroposteriorly than it is transversely. Finally, the shape of the pelvic outlet, or inferior strait, is cordiform, from the projection forward of the tip of the sacrum and the coccyx. 22 PREGNANCY. Pelvic Size — In determining the size of an irregularly shaped canal like that of the pelvis it is necessary again to resort to certain typical planes at different levels, and to measure typical diameters in these planes. Beginning with the cordiform pelvic inlet it is obvious that its dimensions may best be expressed by the following diameters : An anteroposterior diameter measured from the middle of the promontory of the sacrum to the sym- physis pubis, about 3.17 mm. (yi in.) below its upper edge; this measurement averages, in the well-developed Caucasian woman, 11 cm. (4.33 in.). A transverse diameter, the longest distance from side to side of the pelvic inlet, measuring on the average 13.5 cm. (5.32 in.), and two oblique diameters, the right from the top of the right, the left from the top of the left sacro-iliac junction to the opposite ilio- pectineal eminences, measuring 12.75 cm. (5.02 in.). At the plane of pelvic expansion it is possible to measure but two diameters, an anteroposterior and a transverse ; the former is 12.75 cm. (5.02 in.), the latter, 12.5 cm. (4.92 in.). At the plane of pelvic contraction the anteroposterior diam- eter is 1 1.5 cm. (4.43 in.), the transverse, 10.5 cm. (4.13 in.). At the inferior strait the anteroposterior diameter, measured from the tip of the coccyx to the lower edge of the symphysis pubis, is 9. 5 cm. (3.74 in.) ; but this is not a fixed measurement, as the coccyx is normally movable and is displaced backward in labor ; the obstet- rical anteroposterior diameter, therefore, is measured from the tip of the sacrum to the lower edge of the symphysis pubis ; it is 11 cm. (4.33 in.). The transverse diameter, measured from one to the other tuberosity of the ischium, is 1 1 cm. (4.33 in.). Pelvic Position. — By pelvic position is meant the angle or inclination of the pelvis to the trunk and to the horizon. The inclination of the plane of the superior strait to the horizon, as the individual stands erect, is fifty-five degrees, and of the inferior strait, ten degrees. The inclination of the pelvis, however, changes with changes of posture. It disappears in a squatting or sitting posture, and is increased if the individual leans backward. The greater the inclination of the pelvis, the more the axis of the superior strait diverges from the long axis of the uterine cavity, and con- sequently the greater must be the divergence in direction of the presenting part from that of the rest of the fetal body when the former engages in the superior strait. Much stress was once laid upon this fact, but, by placing a woman upon her side and flexing the thighs upon the trunk, the inclination of the pelvis is made practically to disappear. The obliquity of the pelvis, therefore, need not be seriously considered, as a rule, in labor, but the habitual inclination of the pelvis as the woman stands erect must be taken into account in a study of the THE ANATOMY OF THE PELVIS. 23 Fig. 5. — The inclination of the pelvis. pelvic deformities of rachitis, lordosis, kyphosis, spondylolis- thesis, and osteomalacia ; some of the anomalies of labor in these pelvic deformities ; and the abnormal relations of the ex- Fig. 6. — Variation in sacral curves: P, Promontory of sacrum ; C, coccyx. (Trac- ings of sacra in the author's possession.) 24 PREGNANCY. ternal genitalia to the pelvis, whenever the latter shows an excessive or deficient inclination. Pelvic Direction. — By this term is meant the direction of the central axis of the pelvic canal. It was the custom in a former generation to express pelvic direction by a complicated mathe- matical formula, yielding what was called the "curve of Cams." Not only is this formula unnecessarily complicated, but it is also incorrect. The direction of the pelvic canal depends entirely upon the curve of the sacrum, which varies greatly. Taking, at random, any half-dozen or so of sacra from a collection, the utmost diversity of curvature is seen. The direction of the pelvis may be described with approximate accuracy as a line parallel with the sacral curve, and equally distant at all points from the pelvic walls. The Development of the Pelvis. — It may be easier to understand the peculiarities of the adult pelvis if one considers the forces imposed upon it and their influence upon the individual bones and upon the pelvis as a whole. The pelvis is subjected to the weight of the trunk imposed upon it from above, the counter- pressure of the limbs below, and the pull of powerful ligaments, muscles, and joints. The weight of the trunk, transmitted from above downward and from behind forward, tilts the pelvis forward by a rotary movement on its transverse axis and confers upon it the characteristic position or inclination. This force, however, is resisted by the pull of the muscular and ligamentous con- nections between the trochanters of the femora and the tuber- osities of the ischia and by the pressure of the heads of the femora on the acetabula. By the former force the tuberosities of the ischia are pulled apart and the normal width oi the pelvic outlet is secured. The sacrum bears the greatest weight of the trunk, and in consequence its top is forced downward and for- ward. The natural consequence would be to tilt the lower end of the sacrum and the coccyx backward, but they are subjected to the powerful pull forward of the ligaments and muscles attached to them and to the lateral and anterior pelvic walls. Hence the sacrum, subjected to these two opposing forces, is bent like a bow between them, and thus acquires its perpendicular curve. As the upper portion of the sacrum moves downward and forward, it drags with it the posterior superior portions of the iliac bones, to which it is attached by the sacro-iliac junctions and by the strong sacro-iliac ligaments. The natural result of the movement of the posterior portions of the in- nominate bones inward, downward, and forward, would be to throw outward the anterior extremities of these bones, were they not joined firmly at the symphysis. Subjected to the THE ANA TOMY OF THE PEL VIS. 25 force behind and restrained by their junction in front, the innomi- nate bones are bent upon themselves, and thus acquire their lateral curve. These few illustrations by no means exhaust the dynamics of the pelvis. The subject will be referred to again in the study of some of the pelvic deformities. The Bony Pelvis in Life Filled with Soft Tissues. — Besides the generative organs, the obstetrical anatomy of the pelvis must Fig. 7. — The pull of the ligaments and the pressure of the femora upon the pelvis (Schroeder) . take into account the muscles, ligaments, connective tissue, blood-vessels, lymphatics, and nerves. The Muscles. — The iliopsoas, the obturator interims, and the pyriformis clothe the pelvic walls, modifying the diameters of the pelvic cavity and acting as buffers or cushions to protect the child's body in its passage through the birth-canal. The bulky iliopsoas muscles diminish the transverse diameter of the pelvic inlet by 5 cm. (2 in.), thus making the oblique diameters of the 26 PREGNANCY. pelvic inlet the longest and insuring ordinarily an oblique position of the presenting part, but these muscles are subject to compres- sion and to some displacement under pressure in labor, and, if the pressure is great, the transverse diameter again becomes the longest ; hence the transverse position of the head in ob- structed labors. The coccygeus, the levator ani, the retractor ani, the sphincter ani, the constrictor vaginae, and the transversus perinei are the muscles of the pelvic floor giving the direction to Fig. 8. — The pelvis with its soft parts (bladder, rectum, uterus and its appendages, having been removed) (from a model in the University of Pennsylvania). the lower part of the parturient tract in labor and directing the presenting part forward, outward, and upward under the pubic arch. The levator ani is by far the most important muscle in the pelvic floor. It is a strong, horseshoe-shaped band of muscle, consisting of two symmetrical halves slung back from the anterior pelvic wall and surrounding the vagina and rectum. It is the chief factor in pushing the presenting part forward away from the THE ANATOMY OF THE PELVIS. 27 perineum and out through the vulvar orifice. It is thus the chief conservator of the integrity of the pelvic floor in labor. Its injury- robs the rectum and posterior vaginal wall of their strongest sup- port, allowing them to drop downward, outward, and forward in the rectocele, with which the gynecologist has to deal in second- ary operations upon so-called lacerations of the perineum. Fig. 9. — The pelvic canal encroached upon by the soft structures (Veit). The ligamentous structures of the pelvis of greatest interest to the obstetrician are the obturator membranes and the sacrosciatic ligaments, which close the pelvic walls, help to impart to the canal its shape and direction, and, by their situation at either end of the oblique diameters, receive upon their yielding surfaces the greatest pressure from the extremities of the long diameters of the fetal head, — an arrangement much more favorable for the child 28 PREGNANCY. than would be the compression of the longest diameters of the head between bony pelvic walls. The Connective Tissue of the Pelvis. — An intimate knowledge of the complex arrangement of the pelvic fascia is not essential Fig. io. — The pelvic diaphragm from above : a, Ischio-coccygeus muscle ; b, iliac portion of the levator ani ; c, pubic portion of the levator ani ; d, arcus tendineus (Bumm). to the obstetrician. For his purpose it suffices to remember that the arrangement of the pelvic connective tissue may be compared, roughly speaking, to a six-pointed star centering at the uterus, the three arms on each side being disposed as follows : A lateral Fig. II. — The pelvic diaphragm, seen from below: a, Ischio-coccygeus; b, iliac portion of levator ani ; c, pubic portion of levator ani ; d, urogenital dia- phragm, including muscle of the urogenital trigonum (Bumm). arm running out from the uterus between the layers of the broad ligament and becoming continuous with the subperitoneal connect- ive tissue of the lateral pelvic wall ; an anterior arm skirting the bladder ; a posterior arm skirting the rectum and continuing in THE ANATOMY OF THE PELVIS. 2 9 Fig. 12. — Schematic representation of the superior strait: a, Promontory; b, symphysis; 1, 1, iliopsoas muscles; 2, 2, rectus abdominis; dotted line, the pelvic inlet (Veit). Fig. 13. — The plane of pelvic expansion : a, Sacrum ; />, pubis ; c, lateral pelvic wall; 1, I, pyriformis; 2, 2, obturator internus ; m, m, obturator membrane; i, i, sciatic nerve. 3Q PREGNANCY. Fig. 14. — Plane of pelvic contraction : a, Tip of sacrum ; b, b, ascending ramus of pubis; c, c, ischium; I, I, obturator internus. Fig. 15. — Female pelvis, viewed from above, with ligaments (one-third natural size) (Dickinson). THE ANATOMY OF THE PELVIS. Fig. 16. — Sacrosciatic ligaments. Fig. 17. — The pelvic ligaments from above: a, Tip of sacrum; b, subpubic ligament ; c, tuber ischii ; d, sacrosciatic notch ; e, aperture for femoral vessels and nerves; h, Poupart's ligament (Hart). Fig. 18. — The pelvic ligaments from below. Lettering same as above, except x, sacrosciatic foramen. 32 PREGNANCY. the mesorectum to the posterior pelvic wall. Branching pro- cesses, in addition, follow the round ligament to the groin and mons veneris, the vessels and nerves escaping through the sacro- sciatic notch to the buttocks, the three canals of the pelvis — the urethra, vagina, and rectum — to the subcutaneous connec- tive tissue of the external genitalia and perineum. The BIood=vessels. — The ovarian arteries, leaving the aorta, enter the pelvis on their respective sides and, passing between the laminae of the broad ligament a short distance under its upper edge, send branches to the ovaries and tubes and a branch to the fundus, while the main trunk turns at a right angle downward alongside the uterus, to anastomose with the uterine artery, giv- ing off on its way numerous branches to the uterine wall. The uterine artery on both sides passes downward from the anterior trunk of the internal iliac to the neck of the uterus, giving off a large branch to the lower uterine segment and cervix, the circu- lar artery of the cervix, and numerous smaller branches to the uterine wall as it rises to meet the ovarian artery. The veins of the pelvic organs of chief interest to the obstetrician are the large trunks between the layers of the broad ligament alongside the uterus and the complicated pampiniform plexuses in the neigh- borhood of the ovaries. The lymphatic ducts of the pelvic organs are of interest mainly in the part they play in the absorption of the involuting uterus and by conveying septic micro-organisms and the products of their activity into the system. The lymph-spaces of the uterus, lying between connective-tissue bundles and clothed with endo- thelial cells, empty by means of ducts into the pelvic system of lymphatic glands. The most important groups of the pelvic lymphatic glands are the uterine, obturator, hypogastric, lumbar, sacral, and inguinal. It is interesting to note that the lymphatic ducts of the lower fourth of the vagina terminate in the inguinal glands. The enlargement, inflammation, and suppuration of the inguinal glands, therefore, indicate infection of the parturient outlet. The nerves of the generative organs are derived from the spinal and the sympathetic systems. The sexual processes, however, of ovulation and of menstruation and the action of the uterine muscle in labor are controlled by the sympathetic nerves, derived mainly from the hypogastric and ovarian plexuses. The clinical observation that paralysis of the spinal nerves supplying the pelvic organs in nowise interferes with gestation and labor, and the experiments on bitches of resecting the lumbar cord and seeing the animals exhibit rut, become gravid, and bear pups, show what a subordinate part the spinal nerves play in the sexual processes of the female. THE ANATOMY OF THE PELVIS. 33 Fig. 19. — The arteries of the uterus and ovaries : O.A., Ovarian artery ; b, artery of the round ligament ; b> ', branch to the tube ; c, c, c, branches to the ovary ; d, continuation of main trunk; e, branch to the cornu ; U.A., uterine artery; e, main trunk ; f, bifurcation ; g, vaginal branches ; h, v?e;inal branch from the cervical artery (Hyrtlj. Fig. 20. — The veins of the uterus (Hyrtl). 34 PREGNANCY. Fig. 21. — Distribution of lymphatics, externally: b, Inguinal glands; c, d, ducts of the labia; e, lymphatics of the mons veneris (Sappey). Fig. 22. — The lymphatic ducts of the uterus and its appendages injected, in a woman who died shortly after delivery. THE ANATOMY OF THE PELVIS. 35 Fig. 23. — Lymphatics of the pelvic viscera and abdomen : A, Aorta ; B, B, iliac arteries ; C, C, the bifurcation and two branches of the iliac arteries ; D, vena cava ; E, left renal vein; F, right renal vein; G, iliac veins; H, H, ureters; I, rectum; K, uterus; L, cervix; M, M, vaginal walls; N, N, Fallopian tubes; P, P, ovaries; Q, Q, round ligaments; 1, Deep lymphatic vessels of the right kidney, and ganglia into which they empty ; 2, 2, 2, 2, superficial lymphatic vessels ; 3, 3, 3, 3, the same ; 4, two ganglia that receive these superficial vessels ; 7, 7, subovarian plexus of lymphatics ; 8, 8, ducts leading from this plexus ; 9, 9, the same ; 10, 10, 11, 11, glands receiving these ducts ; 12, 12, 12, 12, lymphatic ducts, originating in the fundus uteri, and terminating in the same glands as the ovarian ducts ; 13, 13, ducts from the anterior surface and sides of the uterus ; 14, 14, glands into which they empty ; 15,15, ducts originating in cervix and upper part of vagina ; 16,16, glands into which they empty; 17, 17, efferent vessels of these glands; 18, 18, lymphatic ducts from posterior surface of the uterus and glands into which they empty; 19, lumbar gland (exceptional) ; 20, gland into which occasionally a duct from lower uterine segment empties (Sappey). 36 PREGNANCY. Fig. 24. — The nerves of the pelvis: A, Abdominal aorta; B, lumbar vertebrae with intervertebral discs ; C, the right portion of the sacrum sawn after removal of os innominatum ; D, ureter ; £, pyriformis muscle cut at its exit from the pelvic cavity : F, the curve of the rectum, corresponding to the anterior surface of the sacrum ; H, virginal uterus feebly developed ; K, right ovary displaced somewhat upward ; L, bladder; M, levator ani muscle, cut in part ; A 7 , ischiocavernosus muscle ; O, corpus cavernosum clitoridis, joining on the other side the clitoris, covered with nerve-fila- ments ; P, symphysis pubis (the whole body being inclined forward, it has become hori- zontal); T, fimbriated end of Fallopian tube; I, I, Lumbar nerves, passing out of the intervertebral foramina to form the lumbar plexus ; the lower lumbar and the upper sacral nerves joining to form the sacral plexus in front of the pyriformis muscle ; 2, sacral plexus ; 3, gluteal nerves cut ; the pud/e nerve springing by several roots from the plexus THE ANATOMY OF THE PELVIS. 37 Fig. 25. — Pelvic nerves of a puerpera four days postpartum. formed by the lower sacral nerves; 5, fine twigs passing from the pudic nerve to the ischiocavernosus muscle ; the main trunk goes under the symphysis, and ends as the dorsal nerve of the clitoris (21); 6, 6, branches of communication which carry sympathe- tic twigs to the spinal nerves and spinal twigs to the hypogastric plexus of the sympathe- tic; 7, principal trunk of the syjiipathetic in front of the lumbar vertebra;; 8, continuation of the sympathetic in front of the sacrum; 9, 9, aortic plexus : 10, hemorrhoidal plexus , following the arteries of the same name ; II, superior hypogastric plexus, or iliohypo- gastric plexus, which receives many spinal and sympathetic branches; 12, inferior hypogastric plexus, communicating with 13, anterior sacral plexus, made up of spinal and sympathetic branches ; 14, from the many ganglia placed in this plexus it has a network appearance ; 15, inferior rectal twigs, which pass down even to the sphincter, where they form a network covered by the levator ani ; 16, vaginal plexus ; 17, that part of the inferior hypogastric plexus in the shape of a line network at the upper end of the vagina gives branches to the bladder, the Fallopian tube, and the clitoris; 18, nerve twigs which run on the side wall of the uterus, giving branches to it, upward to the Fallopian tube and ovary, where they join the nerves following the ovarian artery, which correspond to the spermatic plexus in man ; 19, vesical nerves ; 20, uterine plexus; 21, dorsal nei~ve of clitoiis, which joins with the cavernous plexus of the clitoris from the sympathetic to the glans clitoridis (Rydygier). 38 PREGNANCY. Fig. 26. — Nerves of the pelvic organs of the female: I, Nerves to fundus of uterus; 2, right Fallopian tube; 3, right round ligament; 4, nerves to Fallopian tube; 5> communication between ovarian and uterine nerves; 6, ovarian plexus of veins ; J, ovarian vein ; 8, nerve passing to join ovarian plexus ; 9, fimbri- ated extremity of Fallopian tube; 10, reflected peritoneum; II, uterine nerves; 12, superior hypogastric plexus; 13, branches from hypogastric plexus to uterus; 14, inferior hypogastric plexus ; 15, vesical nerves ; 16, communicating branches to vesical plexus ; 17, cervical ganglion ; 18, branches of hypogastric plexus to cervical ganglion ; 19, first sacral nerve ; 20, branches passing to bladder ; 21, branches passing between bladder and rectum ; 22, communicating branches from second sacral to cervical ganglion ; 23, branch from third sacral nerve to cervical ganglion ; 24, second sacral nerve; 25, branches from third sacral nerve to vagina and bladder; 26, branches passing from fourth sacral to cervical ganglion (Frankenhausen). THE FEMALE SEXUAL ORGANS. 39 THE FEMALE SEXUAL ORGANS. The development of the sexual organs may be briefly de- scribed as follows : The development of the genito-urinary organs up to a certain point is common in both sexes. In late stages the duct of Wolff almost disappears in the female, while in the male it constitutes the vas deferens ; the Mullerian ducts, on the contrary, atrophy in the male, but form Fallopian tubes, uterus, and vagina in the female. The accompanying illustrations (Figs. 27, 28, 29, and 30) may aid the student to understand the subdivision of the primary cloacal chamber. As they refer to the female embryo, the Wolffian ducts are omitted. Fig. 27. Fig. 28. Fig. 29. Fit 30 Fig. 27. — cl, Cloaca which has opened into primitive hind-gut, and commu- nicates with the rectum and allantois ; the posterior portion, all, of the latter has commenced to dilate to form the urinary bladder; m, duct of Midler ; r, rectum. Fig. 28. — The cloaca has divided into a ventral portion, sn, the urogenital sinus, which communicates ventrally with the urethra, n, and the bladder, b, and more dorsally with v, the vagina, formed by fusion of the ducts of Miiller; r, rectum. Fig. 29. — The perineum or tissues separating the rectum from the urogenital sinus are well developed ; the neck of the bladder has become constricted to form the primitive urethra, and is separated from the vaginal passage, though both open into the common urogenital sinus, s, and the clitoris, c (in the male the rudiment of the penis), has appeared; r, rectum. Fig. 30. — The urogenital sinus of the female, s, remains as the cleft between the sides of the external aperture of the labia minora ; it communicates in front with the bladder, b, and dorsally with the vagina, v ; r, rectum. The essential sexual glands develop in both sexes in close association with the ducts of Wolff and Miiller, and in the neigh- borhood of the mesonephros. The cells lining the abdominal region of the primitive celom early become differentiated as its lining epithelium ; in most regions they quickly become flat scales, but over the bulging of the intermediate cell-mass they enlarge and become columnar in form. These enlarged cells remain for some time over all of the projecting surface of the intermediate cell-mass, and even extend beyond it upon the outer side of the developing mesentery. They soon become flattened over most of the mass, but remain columnar and multiply for some time on its inner and outer sides. On the latter they give 4Q PREGNANCY. origin to the Miillerian duct and some segmental tubes and soon cease to be distinct ; on the former they constitute the primi- tive germinal epithelium. The mesoblast lying beneath this epithelium gives rise to the blood-vessels and connective tissue (stroma) of the ovary or testis, as the case may be. At this stage it is difficult or impossible to detect the sex of the em- bryo from the structure of the sexual glands. In the female some cells of the germinal epithelium enlarge to form the primitive ova. Surrounded by other cells from the germi- nal epithelium, they grow into the ovarian stroma as the egg-tubes or cords and give rise to the primitive Graafian follicles. Fig. 31.- — diagrams to illustrate the development of the internal genital organs in both sexes. I, Hermaphrodite or undifferentiated condition : d, Ovary or testis, lying upon the tubules of the Wolffian body ; W, Wolffian duct ; M, duct of Miiller ; S, urogenital sinus. 2, Modifications in the female : T, Primitive Miillerian duct, forming the Fallopian tube and developing fimbriae, F, around its peritoneal opening ; h' ', ovarian hydatid ; U, uterus formed by fusion of the posterior ends of the ducts of Miiller; S, urogenital sinus; O (answering to D in I), ovary; F, parovarium, or remnant of Wolffian body and duct. 3, Modifications in the male : H, Testis (corresponding to D in I) ; E, epididymis ; //, hydatid of Morgagni ; a, vas aberrans ; V, vas deferens, or Wolffian duct ; tt, uterus masculinus, the remnant of the lower ends of the fused ducts of Miiller ; S, urogenital sinus (from Landois and Stirling). The testicle is distinguishable from the fetal ovary about the eighth week. The cells which in the female form ova, in the male subdivide and give origin to the spermatozoa, while the cells which correspond to the lining cells of the female egg-tubes develop the lining cells of the seminiferous tubules. These canals may be detected in the human embryo of ten weeks ; they branch, and during the third month are collected into groups, indicating the lobular subdivision of the adult testis. The genital cord is a cylindrical mass in which, in both sexes, the ducts of Miiller and Wolff become imbedded near the uro- genital sinus. The four ducts (two from each side) are at first THE FEMALE SEXUAL ORGANS. 41 separate. The Miillerian ducts coalesce at their lower ends and in the female enlarge to form the vagina and the posterior por- tion of the uterus ; in the male the lower fused portions of Miil- lerian ducts remain as the prostatic vesicle, or uterus masculinus. Fig- 3 2 - — Diagrammatic outline of the Wolffian bodies and their relation to the ducts of Miiller and the reproductive glands : of, Seat of origin of ovary or testes ; w, Wolffian body; w, Wolffian duct; m, m, duct of Miiller; gc, genital cord; ug, urogenital sinus; i, rectum; Z- — Diagram illustrating changes taking place in development of female generative organs (modified from Allen Thompson). In the female the anterior portions of the ducts of Miiller form the upper part of the body of the womb and the Fallopian tubes. In the female the Wolffian ducts almost entirely disap- pear, but traces of them may be found as the canals of Gartner. 42 PREGNANCY. Pathological development and distention of these ducts some- times give rise to vaginal cysts, which may obstruct labor. Meanwhile most of the Wolffian body (mesonephros) disap- pears on each side, but remnants of it may be found in adults. In the female they constitute the parovarium (epoophoron, or body of Rosenmuller). The Development of the External Genitals. — The forma- tion of the cloaca is common to both sexes, as is also its separa- tion into an anal and a urogenital portion. The urogenital sinus is at first narrow and deep, but soon becomes shallow, and meanwhile the perineal tissues separate it more and more from the anus. Before the subdivision of the cloaca a genital emi- nence appears at its ventral or anterior end about the sixth week. On each side of the cloacal slit outgrowths of skin and Fig. 34. — To illustrate the development of the human external genitals: I. h, Genital eminence ; ;', cloacal aperture; s, tail or coccyx of embryo. 2. //, Genital eminence; ;', cloacal opening; tc, commencement of labia majora or scrotum, accord- ing to sex ; s, embryonic tail. 3. Next stage, practically permanent in the female ; c, Genital eminence (clitoris); /, nymphse ; L, labia majora; a, anus. 4. Later or male condition : P, Penis ; R, edges of embryonic folds enfolding to inclose the penial urethra; S, scrotum; a, anus. 5 an d 6 illustrate the descent of the testicle (from Landois and Stirling). subcutaneous tissue (Fig. 34, 1) become prominent. At the eighth or ninth week there is a groove in the under (posterior) side of the genital eminence, with well-marked side-walls leading back to open into the cloaca. The development of the perineum divides this groove (during the third month) transversely into a smaller anal opening and a larger urogenital. This condition is- but slightly modified in the female. The genital eminence in that sex remains small and constitutes the clitoris. The side walls remain separate and form the labia minora, while the cuta- neous folds enlarge and become the labia majora (Fig. 34, 3). The urogenital sinus is, therefore, permanent in woman, and forms the vestibule, which has in front of it the clitoris, and, opening THE FEMALE SEXUAL ORGANS. 43 into it, the urethra and vagina. The skinfolds remain separate in the female to form the labia majora. x The genital organs and structures of woman are divided into the external and the internal genitalia. The former, described often as the genitalia, pudendum, or vulva, comprise the mons veneris, the labia majora, the labia minora, the vestibule, with * mim. i*sv\V ; i\ Fig- 35- — Diagram of the genitalia (Dickinson). the urethral orifice, and the clitoris ; the latter, the hymen, the vagina, the uterus, the Fallopian tubes, and the ovaries. The Mons Veneris and the Labia Majora. — The mons veneris is a flat protuberance over the symphysis pubis, consisting of fat and connective tissue covered with a tough skin clothed with coarse hair. In females the upper border of the hairy region 1 The description of the development of the sexual organs is taken, with modifi- cations, from Newell Martin's article in '• The American System of Obstetrics," edited by the author. 44 PREGNANCY. is a horizontal line ; in males the hair rises in a triangular shape to a point upon the median line of the abdominal wall. The labia majora are folds of skin containing fat, connective tissue, and involuntary muscle-fibers, continuous with the mons veneris and uniting below an inch in front of the anus. They surround the urogenital fissure. Their points of junction above and below are called the anterior and posterior commissures, just within the latter there is a crescentic transverse fold of skin, called the fourchet. The region between the fourchet and the posterior commissure is the fossa navicularis. The Labia Minora, or Nymphas. — Just below the anterior com- missure of the labia majora the nymphae begin on each side as two leaflets of delicate skin ; one, the upper, with its fellow of the other Fig. 36. — Hypertrophied nymphae [ author's case). side, constituting the prepuce of the clitoris ; the lower leaflet, with its other half, forming the frenum of the prepuce. Uniting below and to the outer side of the clitoris, the nymphae run downward to merge into the labia majora at about their middle or lower third. The labia minora are often asymmetrical. They lie apposed to each other in the middle line, completely covered by the labia majora. They vary much in size. In some races (Hottentots) they are enormous, projecting far beyond the labia majora. As an exception this condition is sometimes seen in the Caucasian race. The skin of the nymphae is in a transition stage between mucous membrane and skin. It merges on its outer side into the delicate skin of the inner surface of the labia majora, and on its inner side into the mucous membrane of the THE FEMALE SEXUAL ORGANS. 45 vestibule. The venous spaces and the unstriped muscular fibers in the nymph ae resemble the structure of erectile tissue. The vestibule is the space between the clitoris, nymphae, and vaginal entrance. It is pierced in its mid-line by the urethral orifice, — the external meatus. The bulbs of the vestibule are two masses of venous plexuses about an inch long, lying along the sides of the vestibule below the clitoris and within the nymphae. They are the homologues of the corpora spongiosa in the male. In sexual excitement, by muscular compression of their efferent vessels, they become turgid and erect. The clitoris has the structure and anatomical features of the penis, but in miniature, and modified by the cleft below, the absence of the urethra, and the separation of the spongy bodies into the bulbs of the vestibule. The cavernous bodies of the clitoris are erectile. The glans of the clitoris is surrounded at its base by sebaceous follicles secreting a smegma, which may be confined by preputial adhesions, and is likely to cause irritation by its decomposition. Bartholin's glands, or the vulvovaginal glands, are muco- serous, racemose glands about a third of an inch in diameter, lying under the mucous membrane of the lateral vaginal walls and emptying by long, slender ducts below the vestibule and to either side of the vaginal entrance. The Hymen. — The crescentic septum, occluding usually the posterior portion of the vaginal entrance, with the concavity of its opening directed upward, but presenting often an annular, cribriform, cordiform, crenelated, or cleft appearance, is a fold of mucous membrane reinforced by fibrous tissue, usually ruptured with ease, but occasionally so firm and unelastic that it even resists the impact of the descending head in labor. The hymen is usually torn at the first coitus, sometimes by gynecological examinations, or by masturbation. It is partially destroyed in labor, the remnants persisting as isolated protuberances around the vaginal orifice, — the carunculae myrtiformes. The Vagina. — The vagina is a musculomembranous canal extending from the hymen to the base of the vaginal portion of the cervix uteri. The posterior wall of the canal is about 9 cm. (3.5 in.) long, the anter.ior 6.5 cm. (2.5 in.). The axis of the canal is slightly sigmoid in shape, but corresponds quite closely to the axis of the pelvic canal. The upper portion of the canal is expanded into the vaginal vault, the recesses being particu- larly well marked anteriorly and posteriorly, constituting the anterior and posterior fornices. The vagina, therefore, is flask- shaped. The vaginal walls are composed of three structures, — the mucous membrane, the muscular coat in two layers (the 46 PREGNANCY. inner circular and the outer longitudinal), and a fibrous sheath. The anterior and posterior walls should be in contact, while the lateral walls are thrown into folds which give a transverse section of the vagina the shape of the letter H. The mucous membrane is covered with squamous epithelium, and with numerous papillae, but has no glands except a few tubular structures in the upper part of the canal. The mucous mem- brane is thrown into numerous transverse folds Qr rugae, most marked upon the anterior wall and in nulliparous women. There is an anterior and a posterior cord-like process in the median line, the anterior and posterior columns of the vagina, indicating the lines of junction of the ducts of Muller. The Uterus. — The uterus is a hollow, muscular organ, in the adult virgin measuring 7.5 cm. (3 in.) in length, 4 cm. (1.6 in.) in breadth, and 2.5 cm. (1 in.) in its anteroposterior diameter. In shape the uterus is a flattened, pyriform body, the anterior wall be- ing almost perfectly flat, the posterior more convex. It is divided into the body, the isthmus, and the neck, or cervix. The first occupies about three-fifths of its length, the last, two-fifths. In structure the uterus consists of a muscular wall with a mucous lining and a peritoneal covering. The muscle is unstriated and is arranged, roughly speaking, in three layers, — an external, a middle, and an internal. The middle layer constitutes the bulk of the wall ; its fibers are arranged in a somewhat spiral form, though no very definite arrangement is to be distinguished. The fibers of the inner and outer layers are arranged in longitudinal and circular bands. The mucous membrane of the body of the uterus is composed of columnar, ciliated, epithelial cells, resting upon a delicate basement membrane. The cilia of the uterine epithelium lash in the same direction as those of the tubes, namely, from within outward, or from above downward. 1 As there is no submucous tissue, the mucosa of the uterus rests di- rectly upon the muscle. The uterine mucous membrane is richly supplied with tubular glands, divided in their lower ends usually into two branches or forks. In the cervix the mucous membrane is thrown into longitudinal folds with lateral branches, — the arbor vitae of the uterus. The epithelial cells in the upper two-thirds of the cervical canal are columnar, ciliated, in the lower third stratified, squamous cells. In addition to the tubu- lar glands of the uterine body the cervical mucous membrane contains wide mucous crypts, the orifices of which easily become obstructed, so that they are converted into retention cysts, which commonly stud the cervix in cases of old inflammation or in- jury, — the glands or follicles of Naboth. 1 This has long been a disputed point. See Mandl. " Ueber die Richtung der Flimmerbewegung im menschlichen Uterus," " Centralbl. f. Gyn.," No. 13, 1808. THE FEMALE SEXUAL ORGANS. 47 The uterine cavity is normally fusiform, widened in its upper part into a triangular space, most contracted below at the level of the internal os uteri. It has three openings, the internal os communicating with the cervical canal and the two uterine orifices of the Fallopian tubes. The cervical canal in the nul- liparous woman is a slender ovoid in shape, contracted at its upper and lower boundaries, — the internal and the external os uteri. In a woman who has borne children the cervical canal is often funnel-shaped, the external os, or the cavity just above it, being the most expanded portion. The cervix itself is divided into two portions, the vaginal and the supravaginal. The former projects into the vaginal vault ; Fig. 37.— Section of human uterus, including mucosa (a) and adjacent muscular tissue [b) ; c, epithelium of free surface and tubular uterine glands \d) ; f, deepest layer of mucosa, containing fundi of glands ; k, strands of non-striped muscle pene- trating within the mucosa (Piersol). the latter is attached to the vaginal walls and extends a short distance above their attachments. The anatomist commonly speaks of the supravaginal portion as being entirely above the vaginal attachments and extending to the isthmus. This view, however, is erroneous, as it assumes that the lower uterine seg- ment is a part of the cervix. It is usual to describe an anterior, shorter lip of the cervix and a longer posterior one. This description is more accurate in the parous woman vvith a bilateral tear of the cervix. As may be seen in figure 38, the supravaginal portion of the cervix is longer anteriorly than posteriorly. The normal position of the uterus 4 8 PREGNANCY. is almost horizontal as the woman stands erect. It is slung between the layers of the broad ligament, supported by lateral, anterior, and posterior musculofibrous bands and folds of peri- ^, Inte^med^ U^> PORTION/ VflClNA. PormoiJ, Fi g- 3 8 -— Diagram illustrating the relations of the uterus to the vagina, bladder, and peritoneum (Dickinson). fig- 39-— Uterus didelphys : a, Right segment ; b, left segment ; c, d, right ovary and round ligament ; /, e, left ovary and round ligament ; g, j, left cervix and va- gina ; k, vaginal septum ; h, i, right cervix and vagina. toneum. It is so freely mobile that it rises and falls with every breath the woman draws. The uterus is formed by the junction and fusion of the two ducts of Miiller. An arrest of development in embryonal life THE FEMALE SEXUAL ORGANS. 49 results in a partial junction or a complete failure to unite on the part of the Mullerian ducts. The consequent deformities of the uterus may occasion abnormalities in pregnancy or complications in labor and after-delivery. If there is complete disjunction of the two ducts, the deformity is known as uterus didelphys (Fig. 39). If there is an outward junction but a complete disassociation of the two tubes except for their superficial union externally, the condi- tion is called uterus bicornis duplex (Fig. 40). If there is a junction Fig. 40. — Uterus bicornis duplex : a, a, Double entrance to vagina; b, meatus urinarius ; c, clitoris ; d, urethra ; e, e, double vagina ; f, f, external orifices of uterus ; g, g, double cervix ; h, h, bodies and horns of uterus ; ?', ?', ovaries ; k, k, tubes ; /, /, round ligaments ; m, m, broad ligaments. at the cervix but separation of the ducts above, there is a uterus bicornis unicollis (Fig. 41). There may be complete junction of the two Mullerian ducts, but the fusion of the two canals is incom- plete ; a uterus subseptus or semipartitus is the result. Finally, the form of the uterus may indicate its double origin : there may be a uterus cordiformis (Fig. 42) or a uterus incudiformis (Fig. 43). Occasionally one duct of Miiller develops normally while 5o PREGiVAXCY. the other is present as a mere rudiment. There is, in consequence, a uterus unicornis (Fig. 45). The vagina is double in uterus didelphys and often in uterus bicornis duplex. The duplicity of the birth-canal may be con- Fig. 41. — Uterus bicornis unicollis : a, Vagina; b, single neck; c, c, horns; d, d, tubes ; e, e, ovaries ; f, f, round ligaments. Fig. 42. — Uterus cordiformis : a, Indented fundus ; b, b, tubes ; c, c, round liga- ments ; d, central longitudinal ridge on posterior wall of uterine cavity ; e, e. lateral ridges of same ; f, internal os ; g, g, cervix. fined to the vagina (double vagina) or it may affect the cervix without involving the rest of the uterus, — uterus biforis (Fig. 44). The oviducts, or Fallopian tubes, are tubular structures about 10 or 12 cm. (3.93 or 4.5 in.) long, running from the cornua THE FEMALE SEXUAL ORGANS. Si Fig. 43. — Uterus incudiformis. Fig. 44. — Schematic drawing of double vagina and single uterus : A, Left vagina; B, right vagina ; C, cervical septum. Fig. 45. — Uterus unicornis : LH, Left horn ; L T, left tube ; Lo, left ovary ; L Lr, left round ligament ; AH, right horn ; A' 7\ right tube ; Eo, right ovary j R Lr, right round ligament. 52 PREGNANCY. Fig. 46. — Ill-developed uterus unicornis : a, Cervix ; b, fundus ; c, d, longitudinal axis of uterine body; e, cornu ; f, tube; g, ovary; h, ovarian ligament; i, round ligament ; k, parovarium. Fig. 47. — 111 development of right side of uterus ; congenital lateral flexion. 5fe? Plications Fig. 48. — Longitudinal section of Fallopian tube, exposing the complicated longitu- dinal plications of the mucosa which expand into the fimbriae (Sappey). THE FEMALE SEXUAL ORGANS. 53 of the uterus at the upper edge and between the layers of the broad ligament outward, upward, and at their outer extremi- ties downward and backward to the free surface of the ovary. The canal of the tube begins in the uterine wall as a fine opening (ostium internum) ; it expands to about 2 mm. (0.079 m -) in diameter, becomes wider as it runs outward, again contracts where it passes the ovary, widens again to a distinct opening 4 mm. (0.157 in.) in diameter (ostium abdominale) into the apex of the pavilion, or infundibulum, a funnel-shaped expansion at its outer extremity surrounded by fringed processes, — the fimbriae. x Fig. 49. — Transverse section of Fallopian tube, showing the complicated arrangement of the longitudinal plications which are here cut across (Ahlfeld). The fimbriated extremity is connected with the ovary by the tubo-ovarian ligament. The tube has three coats, — a mucous, muscular, and serous. The mucous membrane of the tube consists of a single layer of columnar, ciliated, epithelial cells, the cilia lashing toward the uterine cavity. The membrane is thrown into deep longitudinal folds, becoming more complex as the fimbriated extremity is approached. There are no glands in the mucous membrane. The muscular coat consists of circular fibers of unstriped muscle, 1 Older anatomists divided the tube into the isthmus, comprising the inner third, the ampulla, the outer or expanded portion, and the fimbriae. 54 PREGNANCY. with an outer, ill-developed layer of longitudinal fibers. The serous covering is- continuous with the serous covering of the broad ligament. The ovaries are almond-shaped bodies varying in size in differ- ent individuals and under different circumstances, but having- aver- age diameters of 3.5 cm. (1.38 in.) in length, 2 cm. (0.79 in.) in Fig. 50. — Section through part of ovary of adult bitch : a, Germinal epithelium ; b, b, ingrowths (egg-tubes) from the germinal epithelium, seen in cross-section ; c, c, young Graafian follicles in the cortical layer ; d, a more mature follicle, containing two ova (this is rare) ; e and/^ ova surrounded by cells of discus proligerus ; g. h, outer and inner capsules of the follicle ; i, membrana granulosa ; /, blood-vessels ; m, m, parovarium ; g, germinal epithelium commencing to grow in and form an egg- tube ; 2, transition from peritoneal to germinal epithelium (from Waldeyer). width, and 1.5 cm. (0.54 in.) in thickness. They are attached to the posterior layer of the broad ligament by the hilum. The ovary is a gland secreting eggs. It has, therefore, a gland-struc- ture, stroma, parenchyma, and gland-spaces. There are, how- ever, certain distinctive peculiarities about this gland. It is not covered by peritoneum, but by a modified form of cells resembling those of mucous membrane, — the germinal epi- THE FEMALE SEXUAL ORGANS. 55 thelium. The gland-spaces contents by a rupture of their walls. The body of the ovaryis divided into a cortex and a me- dulla. The former contains the gland-spaces called Graafian follicles (after their discoverer, Regnier de Graaf, 1673, who thought they were ova), set in a stroma of spindle-shaped connective-tissue cells. The latter contain blood-vessels, nerves, a few muscle-fibers, and irregular groups of poly- hedral cells (the interstitial cells), representing atrophic remains of the Wolffian bodies. Besides its connection with the posterior layer of the broad ligament by the hilum, the ovary is attached to the uterus by the utero-ovarian ligament, to the tube by the tubo-ovarian ligament, and to the pelvic wall by the sus- pensory ligament of the ovary (ovario - pelvic, infundibulo- pelvic ligament). have no ducts, but excrete their Fig. 51. — Section of human ovary, in- cluding cortex : a, Germinal epithelium of free surface ; /;, tunica albuginea ; c, peri- pheral stroma containing immature Graafian follicles, d ; e, well-advanced follicle from whose wall the membrana granulosa has partially separated ; f, cavity of liquor folliculi ; g, ovum surrounded by cell-mass constituting discus proligerus (Piersol). A B Fig- 52. — A, Recently ruptured Graafian follicle. B, Normal Graafian follicle about to rupture showing stigma ( Micro-photographs prepared by McConnell and J. C. Hirst). 56 PREGNANCY. CHAPTER II. Menstruation, Ovulation, Insemination, and Fertilization; The Changes in the Ovum After Fertilization. MENSTRUATION. Menstruation is the periodic discharge of a sanguineous fluid from the uterus, and perhaps from the Fallopian tubes, during the time of a woman's sexual activity, from puberty until the meno- pause. From the earliest ages of medical literature many theories have been advanced to account for menstruation. The oldest explanation was founded upon woman's supposed uncleanliness. Menstruation was thought to be an effort on the part of nature to rid the woman's body of noxious humors. 1 Again, it was explained that woman was plethoric and that nature provided a periodic vent for the superfluous blood. In modern times Pfliiger has advanced the theory that menstruation occurs in consequence of a conges- tion brought about as follows : A Graafian follicle by its growth finally produces so great a reflex irritation as to determine a local congestion, which manifests itself in a bloody discharge from the uterine mucous membrane. Sigismund, Lowenhardt, and Rei- chert propounded the doctrine that menstruation occurs because the ovum discharged prior to the menstrual period is not impreg- nated ; consequently, failing this stimulus to further growth and development, a retrograde change with bleeding occurs in the uterine mucous membrane. As a matter of fact, the cause of menstruation is one of the many life -phenomena at present beyond human comprehension. All that can be said is that a nervous influence proceeds periodically from the sympathetic ganglia in the lower abdomen and pelvis, stimulating and congesting the sexual organs. We can no more account for this nervous action than we can explain the nervous force which continues respiration from the moment of birth until death. Certain facts from comparative physiology, however, throw a glimmer of light upon the subject. For instance, it is 1 Many popular superstitions are founded upon this idea ; for example, that a drop of menstrual blood withers a flower, and that a menstruating woman in a dairy turns the milk sour. The modern physician is still influenced by this old super- stition, if the author may judge from grave discussions he has heard as to the pro- priety of allowing a menstruating nurse to be present during the performance of an abdominal section. MENSTR UA TION. 5 J asserted that if sheep fall into heat and are not gratified, the rut returns in a month. Menstruation in the female is obviously what rut is in the lower animals, and the bloody discharges from human females are probably the result of their erect posture and the pelvic congestion which is a consequence of it. The mechanism of menstruation is better understood than its causes. It is mainly a diapedesis of blood through delicate new- formed capillaries in a thickened and congested endometrium, the provision for carrying blood to the membrane being better than that for bearing it away by the efferent vessels. Some of the newly formed delicate -walled capillaries no doubt rupture. Leopold has given the following description of the uterine mu- cous membrane during menstruation : The mucous membrane is 8 mm. (0.315 in.) thick, swollen, dark brownish red, soft almost to liquefaction, but perfectly intact and separated by a sharply defined boundary-line from the paler muscular tissue of the uterus. The uterine glands, 0.5 to 0.75 mm. (0.0197 to 0.0296 in.) wide, are considerably lengthened and can be seen by the naked eye. In the superficial portion of the mucous membrane, which is very well preserved and only in certain spots lacks its epithelium and subjacent cells, may be seen an immense and enormously hypertrophied capillary net- work, the vessels of which have irregular outlines and lie in the uppermost layer of the mucous membrane. Gebhard x gives the following results of his studies : About ten days before the menstruation there is a serous infiltration of the mucous membrane, separating the meshes of the stroma. Just before the flow there is a marked dilatation of the blood- vessels. The glands increase in size, become tortuous in their course, and are dilated by secretion. The swollen capillaries in part rupture, in part permit a transudation of blood. There is an extravasation infiltrating the stroma, forcing its way upward under the epithelium, which it raises from the subjacent tissues in little hillock-like projections. The blood escapes into the uterine cavity in two ways : First, it is pressed out between the epithelial cells of the intact mucosa ; second, the greater quantity by far makes its exit through openings formed by the separation of the cells on the summits of the hillocks just described. If the bleeding is profuse, epithelium may be carried away by the blood-stream. Exfoliation of the epithelium, however, is not the rule. After the exudation and transudation of blood ceases, the swollen membrane shrinks again, the epithelium sinks to its nor- mal level and becomes attached to subjacent tissues. The ex- travasated blood in the stroma is absorbed. 1 Veit's " Ilandbuch der Gynakologie," vol. in. 58 PREGNANCY. From these observations of Leopold's and Gebhard's, and from other studies of mucous membrane removed by the curet during menstruation and observed in recently extirpated uteri, it appears that the theory of hemorrhage in consequence of degen- eration of the mucous membrane is untenable. The uterus is increased in size and softened in consistency, these changes being most marked just before the flow appears. The uterine cavity is enlarged, the cervix is slightly dilated, and the cervical glands secrete an increased amount of mucus. The tubes and ovaries are swollen, heavy, and congested. There are certain clinical phenomena of menstruation which must often be taken into account by the physician. Time of First Occurrence and of Cessation. — The onset of menstruation is influenced by race, climate, mode of life, heredity, and genital sense. In temperate climates and in the home of the Teutonic and Anglo-Saxon races, menstruation occurs oftener in the fifteenth than in any other year. In these same races transplanted to the eastern middle sea-board of the United States, menstruation appears a year or two earlier. In Hungary the three races, Slavonic, Magyar, and Jew- ish, living side by side in the same climate, begin to menstru- ate, respectively, at sixteen, fifteen, and thirteen years of age. Hindu girls of Calcutta and negresses of Jamaica, living in similar climatic conditions, begin to menstruate at the eleventh and at the fifteenth year. Climate, however, does influence the onset of menstruation. It appears at eighteen years in the girls of Lapland and at ten years in Egypt and Sierra Leone. The social conditions of a girl determine, to a certain extent, the age at which menstruation begins. If she lives in a city, subjected, perhaps, to indiscriminate association with the other sex and to sexual temptations, the function appears earlier than it does in the country, or in a girl carefully brought up in com- parative seclusion. The same rule applies to lower animals. If a bull is admitted to the pasture of a herd of heifers, heat appears earlier in the latter than it would if they were segre- gated. It is a matter of common Observation that peculiarities of menstruation run in certain families. Thus, through several gen- erations of females menstruation appears late and ends early, or vice versa. By genital sense is meant the strength of sexual feeling. In women of strong sexual passion the function of menstruation is commonly instituted earlier and lasts to a greater age than common. Precocious menstruation is not uncommonly associated with nymphomania. Menstrual Molimina. — By this term is meant the local and MENS TR UA TION. 5 9 reflex subjective symptoms of menstruation. There is a feeling" of weight and heaviness in the pelvic organs, due to their con- gestion and increase of size. There is a general nervous ex- citation, so that women disposed to hysteria and epilepsy exhibit outbreaks at this and perhaps at no other time. The breasts swell and may secrete milk. The thyroid gland is enlarged and the tonsils are swollen, so that singers may lose their voice. There is increased vascular tension, increased activity of the heart, shown by sphygmographic tracings, and the pulse is accelerated. The temperature is elevated by o. 5 C. The skin is more vascular and shows unusual pigmentation, especially in the dark rings under the eyes. v. Ott has demonstrated a regu- larly recurring wave in all the physiological processes of women, shown by heat production, muscle strength, lung capacity, force of inspiration and expiration, and tendon reflexes. The greatest activity is manifested just before the appearance of the flow, when there is a sudden subsidence. The Character of the Flow. — The discharge consists, in great part, of blood. It is alkaline in reaction. It contains, besides blood, mucous secretion from the glands along the genital canal and epithelial cells. It is dark in color, and should not clot. It has a peculiar odor from the secretions of the sebaceous glands at the vaginal outlet, excited, as are all the structures of the genital canal, to unusual activity. The Duration of the Flow. — Menstruation rarely lasts less than three days ; a continuance of four, five, or seven days, if the natural and invariable habit of the individual, may indicate nothing pathological. In the first two or three days the greatest amount of blood is lost. After that the discharge grows less until it ceases. A leukorrhea or mucous discharge for a day or two after the cessation of the bloody flow is common. The Quantity of the Flow. — The actual quantity of dis- charge during menstruation has been estimated at four to six ounces. It is not practicable for the physician, however, accur- ately to measure the amount of flow. He must estimate it by the number of napkins worn in twenty-four hours. If a woman is obliged to change her napkins during the height of the flow more than three times a day, or to wear them double, the quan- tity of the flow is excessive. The Cessation of the Flow — The menstrual flow ceases usu- ally in the forty-fifth year, becoming infrequent and more scanty over a period of six, nine, or twelve months, until it stops alto- gether. There are many exceptions, however, to this rule. A woman who begins to menstruate much later than the fifteenth year will often have the menopause before forty. Or, if she 60 PREGNANCY. begins to menstruate early, she will often continue beyond the forty-fifth year. As a rule, therefore, it may be stated that a woman menstru- ates from about the fourteenth to the forty -fifth year of her age. Precocious menstruation, however, has been recorded in the infant of one or two years old, and the discharge has continued to the sixty- fifth and even to the eightieth year. OVULATION. By ovulation is meant the discharge of a mature ovum from its Graafian follicle. The study of the process involves a consideration of the development of the Graafian follicle and its rupture ; the maturation of the ovum ; the transmi- gration of the ovum from the surface of the ovary to the uterine cavity. The Development of the Graafian Follicle and its Rup= ture. — The germinal epithelium on the surface of the ovary sends down into the ovarian stroma columnar prolongations called ecro;-cords. These cords become constricted at intervals, so that they are converted into a number of spherical gland- spaces unconnected with one another and without efferent ducts. The gland-space is surrounded by a containing membrane (the theca folliculi) divided into two layers, — the tunica fibrosa and the tunica propria. The interior of the gland-space is lined with a layer of epithelial cells, — the membrana granulosa. One of these cells, more highly specialized than the rest, the ovum (discovered by K. E. von Baer, 1827), is surrounded by an aggregation of the cells of the membrana granulosa, — the proligerous disc. The cavity of the gland-spaces is dis- tended with fluid (the liquor folliculi) containing paralbumin. As the Graafian follicle develops, it retires deeper into the in- terior of the ovary, following the direction of least resistance. Finally, however, the most mature follicle, under the influence of premenstrual congestion, rapidly secretes liquor folliculi, swells to the size of a pea or a cherry, so that it stands out plainly from the surface of the ovary. On the most promi- nent portion of its free periphery the tunica propria fails at one spot (the stigma), so that the integrity of the follicle is preserved only by the tunica fibrosa, which soon gives way under the pressure imposed upon it from within, and the follicle ruptures. The ovum and surrounding discus proligerus, usually attached to the follicle- wall just under the stigma, are washed out into the free peritoneal cavity by the escaping liquor folliculi. The Maturation of the Ovum. — The primordial ovum in OVULATION. 61 the immature Graafian follicle is an epithelial cell without cell-wall, but with cell-con- tents called the yolk, a nu- cleus called the germinal vesi- cle, and a nucleolus called the germinal spot. As the ovum matures, it acquires a cell-wall with three coats or layers, — the zona pellucida, the vitelline membrane, and the internal cell-membrane. The human ovum is holoblastic, — that is, it completely segments, — and contains much more proto- plasm, or germ-yolk, than deutoplasm, or food-yolk. In its maturation, or preparation for impregnation, the ovum shows the curious movement of its nucleus observable in all segmenting cells (karyoki- nesis), which approaches the cell-periphery, arranges itself in two star-shaped figures by the activity of the centrosome (the amphiaster stage), and D • 1) o CJ :/! o >-, '7- 5 V U I— ( o tu > *— ' C^ (> O Td ■— V ■S o O .2 - ?f to DEVELOPMENT OF THE EMBRYO AND FETUS. 79 The changes in the ovum immediately before impregnation are described in the preceding chapter. It only remains to notice the successive changes in size and development that determine the age of the ovum and embryo and that explain intra-uterine deformities and diseases. The youngest human ova seen and described have been eight to thirteen days old. 1 Peters' claim that the ovum in his famous case was only three or four days old is not generally admitted. In this case the diameter of the ovum was about 1 mm.; the chorion is furnished with thin and simple villi, the allantois is not to be detected, and almost the whole ovum is occupied by the yolk-sac. Waldeyer has described an ovum, twenty-eight to thirty days old, that measured 19 mm. (0.748 in.) in length, 16.5 mm. (0.649 in.) in breadth (about the size of a pigeon's egg), and weighed 2.3 gm. (36 grs.). The length of the embryo, in a straight line from cephalic to caudal extremity, was 8 mm. (0.315 in.), while the actual length of the dorsal line was 20 mm. (0.79 in.). During the first month the human embryo is indistinguish- able from that of other mammals. The ovum at this early period may be described as a double-walled, flattened vesicle, filled with fluid. The outer wall bears the branched villi ; the inner one is smooth. The connection of the villi with the decidua reflexa, and even with the decidua serotina, is a super- ficial one, and the ovum is easily separated from its uterine attachments. 2 The yolk-sac, at first occupying nearly the whole ovum, even at the end of the first month is larger than the cephalic extremity of the embryo. The visceral arches are distinct ; the limbs are merely rudimentary ; the cord is straight, thick, and short ; and the amnion is still quite close to the embryo, and is separated from the chorion by a clear space. During the first month the heart appears as a cylindrical body, which soon becomes S- shaped, and by the fourth week displays four distinct cavities and is covered by its peri- cardium. It is probably functionally active by the third week. 3 The brain and spinal cord are inclosed; the intes- 1 " Edinb. Med. Jour.," vol. lii ; " Verhandl. d. Ak. d. W. Amsterdam," iii, 3 ; " Historie du Develop.," pi. iii; "Arch. f. Gyn.," Bd. v, S. 170; " Abhandl. d. Konigl. Ak. d. W. zu Berlin"; " Wien. med. Wochen.," 1877, S. 502; "Arch. f. Gyn.," Bd. xii, S. 421 ; ibid., Bd. xii, S. 482; Peters, " Ueber die Einbettung des Menschlichen Eies," 1899; Leopold, " Centralbl. f. Gyn.," 1896, p. 1057; also " Uterus u. Kind." 2 See Br. Hicks, " Obst. Tr.," xiv, p. 149; Langhans, "Archiv f. An. u. Phys.," 1877, ii u. iii, S. 231; Ahlfeld, "Arch. f. Gyn.," Bd. xiii, S. 231. 3 Preyer, "Specielle Physiologie des Embryos." 8o PREGNANCY. tinal tract is also closed over, but the connection with the umbilical vesicle is still a wide one ; the first traces of a liver appear ; the primitive kidneys may be seen ; and toward the end of this period the eyes may be distinguished at the sides of the head and the rudimentary extremities become visible as four bud- like processes. The oral and anal orifices of the intestinal tract are formed by depressions in the integuments, which open into the extremities of the tract after the absorption and disappearance of the intervening tissues. Second Month. — At the beginning of the second month the ovum is the size of a pigeon's egg, and the embryo measures 8 mm. (0.3 inch) in a straight line from head to tail. During this month the embryo grows to 2.5 cm. (1 in.) in length and the ovum reaches the size of a hen's egg. The visceral clefts close, with the exception of the first, which eventually forms the external auditory meatus, the cavity of the tympanum, and the Eu- stachian tube. The first visceral arch, dividing into two branches, forms the superior and inferior maxillary processes. The latter, one from each side, approach each other and finally unite to form the lower jaw. The superior maxil- lary processes, while ap- proaching each other, are kept from uniting by the interven- tion of the frontal process. At the point of junction of the latter with the two superior maxillary processes there occurs occasionally the deformity known as harelip, from the fail- ure of the processes to unite ; but as union is always perfect before the end of the second month, the arrest of development that results in this deformity must have taken place at some time prior to the third month. During the second month, from the growth of the viscera, the body becomes less curved, and from the development of the brain the head increases in Fig. 68. — Human embryo of about six weeks, enlarged five times (His). DEVELOPMENT OF THE EMBRYO AND FETUS. 8 I size. The umbilical vesicle atrophies, and may be found at- tached to the body by a slender pedicle. The umbilical ring is somewhat contracted, but still contains a few loops of intes- tine ; so that if there is at this time an arrest in the develop- ment of the abdominal walls, an extensive umbilical hernia or exomphalos results. The umbilical cord runs straight to the periphery of the ovum. The eyes occupy a position on the sides of the head ; behind them may be seen the ears, and in front arises the external nose. The limbs are separated into their three divisions, and the first suggestions of hands and feet appear, with the fingers and toes webbed. The Wolffian bodies are much lessened in size, but the kidneys and suprarenal cap- sules are developed. The external genitals make their appear- ance, but neither internally nor externally is the sex to be dis- tinguished, for the elements of both sexes are present in equal degree. Toward the end of the second month or at the begin- ning of the third the eyelids appear. There are points of ossifi- cation to be seen in the lower jaw and clavicle. The villi of the chorion have taken on a more luxuriant growth at the point where the future placenta is to be developed, and the fetus draws its nutriment from the maternal blood. Third Month. — During this month the ovum attains the size of a goose's egg, 9.5 to 11 cm. (3.74 to 4.3 in.) long, and the embryo grows to a length of 7 to 9 cm. (2.75 to 3.5 in.) and weighs about 30 gm. (460 grs.). The umbilical cord in- creases in length to 7 cm. (2.7 in.) and becomes twisted. The umbilical ring is smaller and the intestines are retracted within the abdomen. The fingers and toes lose their webs, and the nails appear as fine membranes. The eyes approach nearer to each other and are protected by the lids. Points of ossi- fication may be found in most of the bones, and the neck separates the head from the trunk. The ribs divide the trunk plainly into chest and abdomen ; the oral and nasal cavities are separated by the palate ; the lips close over the mouth and teeth begin to form in the jaws. The sex may be distinguished by the presence or absence of a uterus ; cutaneous folds form a scrotum or the labia majora, but the clitoris and penis are still of equal length. The chorion loses its villi, except at the point where the placenta is developing. The latter, though small, can plainly be distinguished. Fourth Month. — In the fourth month the fetus attains a length of 10 to 17 cm. (4 to 6.75 inches) and a weight of 55 gm. (850 grs.). 1 The umbilical cord is more twisted than in 1 Given by Spiegelberg as Hecker's weights and measurements. Spiegelberg, " Lehrbuch," tr. by Syd. Soc., p. 118. 6 82 PREGNANCY. the preceding month, and the placenta is increased in size. The head of the fetus now amounts to a quarter of the whole length of the body, and the cranial bones are in part ossi- fied, although the fontanels and sutures gape widely. The sex is plainly seen, the genital fissure, in the case of a male, hav- ing united to form the scrotum, leaving in the median line a distinct raphe. The future prostate is indicated by a thickening at the point of meeting of the genital cord and the urethra. A fine growth of down appears upon the fetal skin (lanugo), and a few hairs are seen on the scalp. The intestines contain meco- nium ; the limbs may be feebly moved ; and the fetus may live, if born, as long as four hours (Cazeaux). Fifth Month. — During this month the fetus is about 18 to 27 cm. (7 to 10.5 inches) long and weighs about 273 gm. (8 ounces). The umbilical cord is about 31 cm. (12 inches) long. The liquor amnii exceeds the fetus in weight. The head is relatively veiy large ; the face has a senile look and is wrinkled, and the eyelids begin to open. The skin is richer in fat, is covered with lanugo, and in places with vernix case- osa, a sebaceous material containing also epithelial scales and downy hairs. Some time during the fifth month the mother usually experiences "quickening," — that is, the movements of the fetus, — and the fetal heart-sounds may be heard on auscultation. If the fetus should be born at this time, it may make efforts to cry, but it dies in a few hours. Sixth Month. — The fetus toward the end of the sixth month is from 28 to 34 cm. (11 to 13.5 inches) long and weighs 6j6 gm. (23^ ounces). The skin is better supplied with fat; the hairs of the scalp grow longer ; eyebrows and eyelashes are distinct. The umbilical cord is inserted in the middle third, between the pubic symphysis and the xiphoid cartilage. The head is still relatively large. The testicles in boys approach the inguinal rings. If a fetus at this stage should be born, it might live from one to fifteen days, but would, in all probability, eventually die from insufficient assimilation of food, from rapid loss of heat, and from imperfect respiration, owing to the undeveloped state of the finer ramifications of the air-passages. Seventh Month. — At the end of this month the fetus measures in length 35 to 38 cm. (13.75 to x 5 inches) and weighs 1 1 70 gm. (41 y^ ounces). The whole body is covered with lanugo except the palms of the hands and the soles of the feet. The large intestine contains a considerable quantity of meconium. The pupillary membrane, which had hitherto obscured the pupil, DEVELOPMENT OF THE EMBRYO AND FETUS. 83 now disappears. A child born between the twenty-fourth and twenty-eighth weeks usually dies. 1 Eighth Month. — The fetus measures in length 39 to 41 cm. (15.25 to 16 inches) and weighs 1571 gm. (31^ pounds). The hair on the scalp is more abundant ; the down on the face is disappearing. One of the testicles, usually the left, has de- scended into the scrotum. The nails are firmer, but do not yet project beyond the finger-tips. At the end of the eighth month ossification begins in the lower epiphysis of the femur. The cord is inserted a little below (0.6 to 1.2 inches) the middle point, between the xiphoid appendix and the pubic symphysis. A child born at this period may, with proper care, survive. Ninth Month. — The length of the fetus measures 42 to 44 cm. (16.5 to 17.25 inches) and the weight is 1942 gm. {4.% pounds). There is a decided increase in subcutaneous fat. The nails are not yet perfectly developed. Toward the end of this month, near the thirty-sixth week, the weight is about 5^ pounds, and the diameters of the skull about I to 1.5 cm. (0.39 to 0.50 in.) less than in a normal fetus at term. 2 The bones of the skull are compressible and easily molded to the shape of the pelvic cavity ; and if born at this time, the infant with ordinary care will certainly live. Tenth Month. — During the tenth month (thirty-sixth to for- tieth week) the fetus is developing from the condition just de- scribed — that is, characteristic of the thirty-sixth week — into the infant at term, distinguished by all the features that indicate the arrival of the fetus at maturity. It is during the last month of pregnancy that the physiology of the fetus can be studied to the best advantage. It has now reached a large size and requires a considerable quantity of oxygen 3 for its blood and nourishment 1 There persists, even yet, in the minds of some general practitioners, as well as among the laity, as the writer can testify, the idea that children born in the seventh month will be more likely to survive than those born at the eighth month. Professor Parvin (" Science and Art of Obstetrics ") shows how this superstition has descended, through more than two thousand years, from Hippocrates, who explained that the fetus is placed with its head uppermost in the uterine cavity until the seventh month, when the increasing weight of the head causes it to fall down to the os uteri. As soon as this occurs, the fetus attempts to make its escape, and if it is strong it suc- ceeds, but if the attempt fails, it is repeated at the eighth month, and if the infant now succeeds in escaping from the womb, being exhausted by its previous effort, it is likely to die. 2 Schroeder, from the measurements of 68 premature infants, gives the average biparietal diameter of the head as 8.83 cm. (3.5 in.) from the thirty-sixth to the fortieth week; 8.69 cm. (3.42 in.) from the thirty-second to the thirty-sixth week; 8.16 cm. (3.21 in.) from the twenty-eighth to the thirty-second week, showing thai this diameter, a most important one, is relatively very large even early in fetal life. 3 That the fetus obtains oxygen from the maternal blood has been proved by (1) cutting off the blood-supply to the uterus, when the fetus will die of asphyxia (Vesal, Seyl) ; (2) by the discovery, by means of spectral analysis, of oxyhemoglobin in the umbilical vein of the cord (Zweifel). 84 PREGNANCY. for its tissues, both of which it obtains from the maternal blood through the medium of the epithelial cells that form the outer- most fetal layer of the placenta (the syncytium). From the fact that the fetus undoubtedly swallows considerable quantities of liquor amnii during the latter months, at least, of pregnancy, 1 and because that liquor contains a small proportion of albumin, 2 it has been claimed that the fetus derives its whole nourishment from the amniotic fluid, while the func- tion of the placenta is confined to the oxygenation of the fetal blood, — a theory not likely to find general acceptance. Another fact, however, in its favor is the secretion of the gastric glands during the latter period of intra-uterine life. 3 The urine, secreted in considerable quantity, and, as a rule, albuminous, 4 is voided freely into the amniotic cavity. The fetus, from time to time, moves its limbs vigorously, and its heart beats from one hundred and twenty to one hundred and sixty times a minute. The circulation of the fetal blood has certain peculiarities that deserve consideration. Beginning at first by a very simple arrangement in a tubular heart and four vessels (two arteries and two veins), which carry the blood to and from the umbilical vesicle, it soon assumes the characteristics that are most plainly to be seen in the stage of pregnancy under consideration. The blood that has been oxygenated in the terminal villi of the placental tufts is returned by veins of increasing size to the large branches of the umbilical vein, which may be seen directly under the amnion on the fetal surface of the placenta. These branches, converging, unite in the umbilical vein, which is carried by the cord to the fetal body at the umbilicus. Thence it runs along the anterior surface of the abdominal cavity to the under surface of the liver, where, crivino- off branches to the lobus quadratus, lobus Spigelii, and to the left lobe, it divides into two main trunks at the transverse fissure, the larger of which enters the portal vein, while the other empties into the ascending cava and is called the ductus venosus. Thus by far the greatest quantity of oxygenated blood that is returned to the fetus from the placenta must first pass through the liver before entering the general circulation. The ascending cava conveys 1 Zweifel, " Untersuchungen iiber das Meconium," "Arch. f. Gyn.,"Bd. vii, 1875, P- 474- 2 Anderson, "Am. Jour. Obstetrics," Aug., 1884. 3 Krukenberg, " Magensecretion des Fotus," " Centralbl. f. Gyn.," No. 22, 1884. 4 Ribbert, " Ueber Albuminuric des Neugeboren u. des Fotus," Virchow's Archiv," Bd. xcviii, S. 527. DEVELOPMENT OF THE EMBRYO AND FETUS. ; 5 %h then to the right auricle a large proportion of arterial blood, but mixed with it is the venous blood from the lower extremities and the blood returned from the liver. But this great volume of blood having arrived at the right auricle, instead of descending into the right ventricle and being carried thence to the lungs, which in their unex- panded condition could not contain it, is guided across the right auricle by the Eus- tachian valve, and enters the left auricle by means of an opening in the interauricular septum, — the foramen ovale. From the left auricle the blood from the ascending cava enters the left ventricle and is driven thence into the aorta, by which it is conveyed pri- marily to the upper extremity of the fetus by the ascending branches of the arch of the aorta. Here may be seen an arrangement peculiar to fetal life, by which the blood is di- verted from the unused lungs and conveyed instead to the aorta. Just beyond the point at which these branches are given off there opens into the aorta a large branch from the pulmonary artery (the ductus arteriosus), which conveys the blood that enters the right auricle, and then the right ventricle, from the descending vena cava. Only a small quantity of blood, sufficient for their nutrition, goes to the lung's. Thus the aorta Fig. 69. — Diagram of the fetal circu- lation: a, a, Aorta; b, innominate artery; c, left carotid ; d, left subclavian; e, iliacs ; f, internal iliac arteries ; g, hypogastric arteries ; h, pulmonary artery ; i, right ventricle ; /, left ventricle ; k, ductus ar- teriosus ; /, left auricle; m, left auriculo- ventricular opening ; n, foramen ovale ; 0, right auricle ; p, Eustachian valve ; q, right auriculoventricular opening; ;-, vena cava ascendens ; s, liver ; t, hepatic vein ; u, branches of the umbilical vein to the liver ; v, umbilical vein ; w, umbilical cord ; x, bladder ; y, vena cava descendens ; z, ductus venosus (Flint). conveys a mixed blood, still further devitalized from the infusion of the venous blood from the head, neck, and upper extremities, to the trunk and lower extremities. It is by this arrangement that a greater quantity of arterial blood is conveyed to the brain, which develops so 86 PREGNANCY. rapidly during intra-uterine life. Following the blood-current down the aorta to the iliac arteries, and thence to their internal branches, two arteries, one from each branch, ascend to the umbilicus whence they pass out of the body to form the two arteries of the umbilical cord. Within the body they are known as the hypogastric arteries. The two arteries of the cord carry to the placenta vitiated blood, which, in the terminal placental villi, discharges into the maternal blood the effete products of the life -processes in the fetus and re- ceives in return a fresh supply of oxygen and nutriment, and probably a fair share of the soluble salts of the blood, as well as any other substance, medicinal x or otherwise, that the maternal blood may contain in solution or possibly even in suspension. While the passage of matter from the maternal into the fetal blood seems to occur so frequently, it would appear to be more difficult for substances, aside from the effete products of tissue activity, to pass from fetus to mother. There is reason to believe, however, that the poison of syphilis may take this course. It has also been demonstrated that certain drugs, as strychnin, may pass from fetus to mother. 2 The ease with which medicinal substances pass from mother to fetus has caused anxiety lest in the administration of powerful drugs to the mother the fetus might be injuriously affected. 3 It is possible, of course, to harm the fetus by administering poisonous substances to the mother, but it is extremely unlikely that the fetus will be much affected unless the dose to the mother much exceeds the usual therapeutic limit. But, like the adult, the fetus may become accustomed to a drug, and be able finally to endure large quantities of it in the maternal blood. 4 The temperature of the fetus in utero is slightly higher than that of its mother. Priestley, 5 in experiments on rabbits and cats, found the temperature of the fetus about i° F. 1 Chloroform, carbonic oxid gas, salicylate of sodium, benzoate of sodium, atropin, strychnin, morphin, quinin, corrosive sublimate, iodid of potassium, ether, urea, the bile-salts, soluble salts of lead, tobacco, sulphindigolate of soda, the germs of many diseases, have all been known to pass from mother to fetus. 2 Schroeder, " Geburtshiilfe," 8th ed., p. 63. 3 Parvin's "Obstetrics," 148. i I was obliged on one occasion to administer very large doses of morphin daily for a period of some weeks to a patient who was suffering from general septi- cemia in the seventh month of pregnancy. The fetus continued to move actively in utero, and I could detect no change in the fetal heart-sounds. The woman finally gave birth to a living infant. 5 " Lumleian Lectures on the Pathology of Intra-uterine Death," rep. for "Brit. Med. Jour.," 1887, p. 16. THE MATURE FETUS. 8/ higher than that of its mother. Taking the temperature in ano of a fetus coming down during labor by the breech, and com- paring it with the temperature of the vagina, 1 or taking the temperature of infants immediately after birth, 2 the fetus is found warmer than the mother by o. 5° C. Of all the organs in the fetal body, the liver is the most active. Almost all the oxygenated blood from the placenta goes first to the liver. The great quantity of meconium in the fetal intestines — a substance composed mainly of bile- salts — attests the active secretory work of this organ, and to it, also, may be attributed the source of the large quantity of glycogen 3 found in fetal tissues, especially the muscles, where this substance probably has work to perform, the nature of which is not vet understood. THE MATURE FETUS. There is no single sign that enables one to declare a given fetus to be fully mature ; but the weight, measurements, and stage of development, taken together, indicate with tolerable accuracy the length of time that the fetus has remained in ntero. By the two hundred and eightieth day a healthy fetus should weigh about 3317 to 3459 gm. (7^3 to J 2 /^ pounds), according to the statistics of Lusk and Parvin ; but in Europe, the weight of the mature fetus is somewhat less, for the statistics of Scan- zoni, Ingerslev, Hecker, Fesser, and Bailly, including a very large number of observations, give a weight of less than 3175 gm. (7 pounds). Variations in weight at term between 2728 and 4082 gm. (6 and 9 pounds) 4 are by no means rare, and the range of possi- bility in the weight of a mature fetus is a very wide one. Thus Harris 5 refers to an infant that weighed but a pound, and to another, the child of the Nova Scotia giantess, that weighed 13040.78 gm. (28^ poundsj at term. A decided departure, 1 Wurster, "Berlin, klin. Wochens.," 1869, No. 37, and " Beitr. z. Tocother- mometrie," D. i, Zurich, 1870. 2 See Barensprung, Muller's " Archiv," 1851 ; Schafer, D. i, Greifswald ; Andral, " Gaz. Hebd.," July, 1870 ; Schroeder, Virchow's " Archiv," Bd. xxxv, S. 261 ; and the " Lehrbuch," 8th ed., 1894, p. 65 ; also, Alexeeff, "Archiv f. Gyn.," Bd. x, S. 141. 3 Marchand, " Ueber das Glykogen in einigen fotalen Geweben," Virchow's " Archiv," Bd. c, S. 42. 4 An infant of over nine pounds is not common, while heavier weights are pro- gressively rare. Out of 1000 infants, Dr. Parvin saw but one that weighed II pounds (Parvin's " Obstetrics," p. 138). Of 1156 infants born in my service in the Mater- nity Hospital, the heaviest weighed 12 pounds. 5 Note to Playfair's " Midwifery." 88 PREGNANCY. however, from the normal average indicates, on the one hand, prematurity or a weak development ; on the other, the prolonga- tion of pregnancy, race peculiarities, the vigor or excessive size of the parents, especially the mother, or the preoccurrence of several pregnancies. Sex also influences the size of the infant, males being, on an average, larger than females. The length of a mature fetus is 51 to 53 cm. (20 to 21 in.). The width across the shoulders (binacromial diameter) is about 12 cm. (4.75 in.) ; the dorsosternal diameter is 9 to 9. 5 cm. (3.5 to 3.75 in.) ; the biniliac, 9.5 to 10 cm. (3.75 to 4 in.). The length of the foot is about 8 cm. (3. 1 5 in.). 1 The dimensions of the head are im- portant as a sign of the development of the fetus. The following dimensions of the fetal head may be consid- ered characteristic of the normally developed infant directly after its expulsion from the uterus : Bitemporal (B. T.) diameter, 8 cm. (3. 15 in.). Biparietal (B. P.) diameter, g l 4 cm. (3.64 in.). Occipitofrontal (0. F.) diameter, 11^ cm. (4.56 in.). Occipitomental (O. M.) diameter, 13 cm. (5. 12 in.). Maximum (M. M.) diameter, IT, 1 A cm. (5.32 in.). Suboccipitobregmatic (S. O. B.) diameter, . 9^ cm. (3.74 m.). Trachelobregmatic (T. B.) diameter, . . . 9^ to 10 cm. (3.741:0 3.94 in.). Circumferences: O. F., 34^ cm. (13.58 in.); S. O. B., 30(11.8); O. M., 37 (14-5)- These dimensions are subject to modification. Any of the causes that tend to increase the size of the infant as a whole like- wise influence the size of the head ; but even with a normal body-weight and length the head may be disproportionately large, without being diseased. Another valuable sign of maturity in the fetus is the appear- ance and extent of certain centers of ossification. 2 In the center of the lower epiphysis of the femur is found at birth a spot of ossification measuring five millimeters in diameter, while a similar but smaller spot is just appearing in the upper epiphysis of the tibia. The center of ossification in the astrag- alus is found without difficulty, for it first appears at the seventh month of intra-uterine life. The center of ossification in the cuboid bone is at birth beginning to make its appearance. The ossified spot in the lower epiphysis of the humerus only appears some months after birth. The general appearance of a new-born infant is of value as indicating whether or not the fetus had reached maturity before its expulsion from the uterus. A healthy infant at term looks 1 Negri says ("Ann. di Ostet," May to June, 1885) that when the foot measures eight centimeters the fetus is well developed and weighs about 3500 gm. 2 See Rossie, "Amer. Jour, of Obstetrics," 1886, p. 18. THE MATURE FETUS. 89 stout and well-nourished. The face is plump and is free from lanugo ; miliaria are seen about the tip of the nose, but are not nearly so evident as they were in the ninth month of intra-uterine existence. The eyes are usually opened, the limbs move vigorously, and the child seizes with its lips the nipple when presented to it, and sucks with energy. The vernix caseosa is abundant only on the back of the child and on the flexor surface of the limbs. The nails project beyond the finger- tips ; the cartilage of the ears and nose feels firm ; eyebrows and eyelashes are well developed ; the hairs of the scalp are about an inch long ; the bones of the head are hard and lie close together. The breasts in both sexes are large, and usually a thin fluid can be squeezed out of them. In boys the testicles are usually to be felt in the scrotum, although the tunica vaginalis is not yet closed. In girls the labia majora are usually approxi- mated, although occasionally the nymphse project between them. The Determination of Sex. — In all countries the number of male children born exceeds the number of females, the average proportion being 106 to 100; but, as more boys die than girls, by the time puberty is reached the sexes are about equal in num- ber. The law that governs the production of sex has long been a subject of discussion and speculation. The Hippocratic doc- trine that the right ovary produced boys and the left girls was accepted for centuries, and upon this belief was founded the precept that women who desired male offspring should lie during coitus upon the right side, while those who desired daughters must lie upon the left side. By experiments upon animals, by the observation of women in whom one ovary was destroyed by disease or removed by an operation, and by a more complete knowledge of the mechanism of impregnation, the long-accepted teaching of Hippocrates was disproved, although not until com- paratively recent times. At present it is undecided whether the question of sex is determined before impregnation occurs, — that is, whether certain spermatic particles or ovules are predes- tined to produce males, while others produce females ; whether the sex is impressed upon the ovule at the moment of conception, or whether the embryo is possessed of the elements of both sexes until one or the other acquires a preponderating influence owing to causes which may be operative during the early part of pregnancy. The first theory receives its chief support from the fact that unioval twins are invariably of the same sex, which looks as though the ovule was predestined in the ovary to the formation of one or the other sex. The last theory is based upon the study of plants and lower animals, in which the sex is only determined at some time after conception by the influence 90 PREGNANCY. of nourishment ; overfeeding being found to produce females, underfeeding to produce males. Tt is possible in the case of certain animals to alter the sex, or at least to produce her- maphrodites, even after the sexual organs have begun to be dif- ferentiated. 1 This theory is further supported by the fact that in the human embryo the elements of both sexes are always present apparently in equal force during the early part of em- bryonal life. The belief that the sex of a human embryo is impressed upon it at the moment of conception rests upon the fact that in certain conditions of nutrition or sexual vigor in one or the other parent one sex preponderates, while under opposite conditions the other sex is most frequently produced. 2 The most diverse conditions have been held accountable for departures from the normal numerical relation of the sexes at birth. Illegitimacy, 3 age of parents, 4 conception at certain periods after menstruation, 5 deformities in the female pelvis, 6 the nutrition or sexual vigor of the parents, 7 the tendency of each sex to produce the opposite or the reverse, 8 the tend- ency to produce that sex which is most needed to perpetuate the species, 9 the season of the year, 1 ° climate and altitude, x x 1 In the case of the larvae of bees from impregnated eggs, when the female gen- ital organs have begun to appear, if the nourishment is very insufficient, instead of becoming female workers these animals will actually develop into true hermaphro- dites, with the organs of both sexes (Fiirst). 2 Thury (" Zeitsch. f. w. Zoologie," 1863, Bd. xiii, S. 541) found in 29 experi- ments upon cattle that in every case, if connection occurred at the beginning of heat, females were produced ; if at the end, males. 3 Fiirst (" Archiv f. Gyn.," Bd. xxviii, S. 19) says that in illegitimate births the males fall below the average (based upon 807,332 cases). This coincides with my experience in the Maternity Hospital in more than looo cases of illegitimate births. 4 See Hofacker, " Ueber die Eigensch. welche sich von den Eltern auf die Nachk. vererben," 1828; Sadler, "Law of Population," London, 1830 ; Hecker, "Archiv f. Gyn.," Bd. vii, S. 448; Bidder, "Zeitsch. f. Geburtsh.," Bd. ii, S. 358; Ahlfeld, " Archiv f. Gyn.," Bd. ix, S. 448; Wall, " The Causation of Sex," London " Lancet," 1887, i, pp. 261, 307. 5 Thury, loc. cit. ; Coste, " Comptes Rendus," 1865 ; Schroeder, " Lehrbuch," 8te Aufl. , 1884, S. 33; Fiirst, " Knaben Ueberschuss nach Conception zur Zeit der postmenstruellen Anamie," " Archiv f. Gyn.," Bd. xxviii, S. 18. 6 Olshausen, " Klinische Beitrage," Halle, 1884; Linden, "Hat das enge Becken einen Einfluss auf die Entstehung des Geschlechts? " Dis. Inaug. , Mar- burg, 1884; R. Dohrn, "Zeitsch. f. Geburtsh. u. Gyn.," Bd. xiv, S. 80. 7 See Fiirst, loc. cit., and Schroeder, op. cit., S. 33. Also Schenk (Determination of Sex, authorized translation, Chicago, 1898), who believes that imperfect metabolism and glycosuria in the mother predispose to female offspring, while a strong nitrogenous diet and absence of sugar in the urine prepare a woman to bear male offspring. 8 See Fiirst, loc. cit. 9 Diising, " Die Regulirung des Geschlechtsverhaltnisses bei der Vermehrung der Menschen, Thiere, u. Ptlanzen," Jena, 1884. 10 According to Diising [loc. cit.), women impregnated in summer give birth to fewer boys than those impregnated in winter (conclusions based on more than 10,500,000 births). 1 1 Floss found, in Saxony, that up to 2000 feet, the greater the altitude, the larger was the number of male births (at 2000 feet, 107.8 to 100). THE MATURE FETUS. 9 1 diet, 1 and the degeneration of a race, as during the decadence of imperial Rome, 2 — have all been advanced as reasons for ap- parent excess in the number of male or female births. These theories, however, have been found false or inadequate upon further investigation. An explanation that appeals to the author's reason is that the individual stronger in mental, phy- sical, and sexual attributes will impress upon the ovule at the moment of impregnation that individual's sex. A satisfactory explanation of the determination of sex is difficult to obtain, while the production of the sexes at will has hitherto been an impossibility. Multiple Fetation. — It is the rule that but one fetus at a time is developed within the uterus of a human female. Once in about 1 20 pregnancies, 3 however, two fetuses are developed simultaneously in the same uterus, so that twins are not of un- common occurrence. Triplets are found once out of 7900, quadruplets once out of 371,126 births. Quintuplets are ex- tremely rare. There is one case of sextuplets on record.* Multiple fetation maybe the result: (1) Of the impregnation of a single ovum that contains two or more germinal vesicles, or in which the formative material of the area germinativa divides ; 5 (2) of the impregnation of two or more ova which were contained either in one Graafian follicle or in separate follicles, the latter being situated either in one or both ovaries; (3) of the penetration of the ovum by more than one spermato- zoon ; (4) of the impregnation of ovules escaping at different times from different Graafian follicles (superfetation). 6 There may be a hereditary disposition to multiple fetation. Boer reported, in 1808, an extraordinary example: 7 A woman aged forty had in 1 1 pregnancies during twenty years given birth to 32 children, to wit: quadruplets twice, triplets six times, twins thrice. The woman herself was one of quadru- plets and her mother had had 38 children. Her husband was one of twins, and there was a history of other plural births in his family. If the multiple fetation is the result of the impregnation of a single ovum, there is but one chorion and one dccidua 1 J. C. Webster, " Some Fundamental Problems in Obstetrics and Gynecology," "Amer. Med.," Dec. 10, 1904. 2 Darwin's Collected Works. 3 According to statistics collected by Veit, based on more than 13,000,000 births, twins occur once in 89 pregnancies ; in New York and Philadelphia the proportion is about I to 1 20. 4 Vassali, " Gaz. Med. Ital. Lombardia," Milano, 188S, No. 3S. 5 Ahlfeld, "Archiv f. Gyn.," Bd. ix, S. 196. 6 Slavjansky has observed a recent ovulation in a woman three months pregnant, but with extra-uterine pregnancy. "' " Wien. med. Wochens.," No. 3, 1S97. 9 2 PREGNANCY. reflexa, although each fetus is inclosed in its own amnion. 1 In these cases the sex of the fetuses is the same. The placentas are usually found intimately united when expelled at term, presenting extensive arterial and venous anastomoses — a condition that may give rise to the deformity of one of the twins, known as acardia. But in the early stages of development each placenta, even in unioval twins, is separate. When the em- bryos are derived each from a separate ovum, there should be separate deciduae reflexae, chorions, and pla- cental. Occasionally, how- ever, when the ova are im- planted close together, the placentae may be joined, there may be but one decidua reflexa, and it may be difficult to detect the double layer of chorion that should separate the two ova. Although twins are not infrequently born, the con- dition should be regarded as pathological. From statis- tics collected by Schatz, 2 it appears that in twins from different ova one is born dead in every twenty-three cases, while from the same ovum the death-rate is one in six. One fetus may outstrip its fellow in growth, and divert the greater part of the nourishment from the mother to itself, thus growing rapidly and encroaching so much upon the room that should belong to the weaker fetus that the latter is killed and finally pressed flat against the uterine wall (foetus papyraceus). Hydramnios is also very common in twin pregnancies, and occasionally one fetus is converted into an acardiac monster. If the fetuses of a twin pregnancy escape 1 Occasionally two fetuses are found in a single amniotic cavity, which is to be explained (i) by the atrophy and absorption of the contiguous amniotic walls; (2) by rupture of the amnion in the latter months from the vigorous movements of the fetus ; or (3) by the development of but a single amnion from the very beginning (Myschkin, Virchow's "Archiv," Bd. cviii, S. 133, 146). 2 " Archiv f. Gyn.," Bd. xxix, S. 438. Fig. 70. — Fetus papyraceus (author's specimen). THE MATURE FETUS. 93 the dangers of intra-uterine life, there are many complications awaiting them in labor. Should one fetus die during pregnancy, it is usually retained until term, when the living and dead children are cast off together, widely different in appearance and develop- ment ; x or else one ovum may be aborted at an early period of pregnancy, while the other goes on developing until term. 2 Even though both children have been retained in utero an equal length of time, there is usually a marked difference in their length and weight, especially if they have resided in one ovum. 3 In cases of uterus duplex, fetuses of different ages have been found in the two divisions of the uterus. Fordyce Barker reports a case of delivery of two mature children from a woman with a double uterus, one male, the other female, at an interval of two months. 4 Upon such cases, and also upon the fact that of twins in negresses rarely one is light and the other dark, showing probably different paternity, has been based the theory of superfetation ; but as there is no clear proof, as yet, of the occurrence of ovulation during pregnancy, the possibility of the impregnation of ovules which escaped from their Graafian follicles at rather wide intervals of time, say weeks or months, is doubtful. 5 1 Schultze, " Volkm. Samml. klin. Vortrage," No. 34. 2 Sirois, " L' Union medicale du Canada," July, 1887; and Warren, "Am. Jour. Obstetrics," 1887. 3 Schatz, loc. cit. 4 See Lusk, op. cit.. p. 233, ed. 1886. 5 For some interesting observations which would seem to indicate the possibility, at least, of ovulation during pregnancy, see " Ovulation_ During Pregnancy," Chris- topher, "Am. Jour. Obstetrics," 1886, p. 457. 94 PREGNANCY. CHAPTER IV. The Development, the Anomalies, and the Diseases of the Fetal Appendages: the Membranes, the Placenta, and the Umbilical Cord, The study of the development, anomalies, and diseases of the fetal appendages is necessary to a clear understanding of fetal pathology. First will be considered the development and diseases of the fetal appendages springing directly from the embryo — namely, the amnion, the chorion, the allantois, and the placenta ; lastly, the deciduae, the maternal envelope of the fetus. THE AMNION. After segmentation has occurred, and after the interior of the ovum has become reduced to a granular mass, around which is a membrane composed of a single layer of cells, at a certain point — the embryonal area — in this membrane there appears a thickening, by a heaping up of the cells. Finally this mass of cells resolves itself into two layers (ecto- and entoderm), and between these two appears another layer of cells (mesoderm). The outer layer, the ectoderm, sends a prolongation around the whole interior surface of the ovum, and this layer receives a Fig. 71. — e, Embryo ; ec, cephalic extremity ; eg, caudal extremity ; ca, ca, amniotic hood ; pp, pp, pleuroperi- toneal cavity ; y, umbilical vesicle. Fig. 72. — e, Embryo; a, amnion; oa, amniotic umbilicus ; cac, amnio- chorional cavity ; pp, pp, pleuroperito- neal cavity ; ck, chorion ; mv, vitel- line membrane ; vo, umbilical vesicle. THE AMNION. 95 reinforcement from the middle layer of cells, or the mesoderm. It was formerly believed that, as the embryo assumes a definite shape, the lateral walls folding in toward one another, and the caudal extremity approaching the cephalic end of the embryo, the outer layer of cells, forming a membrane continuous with the outer covering of the embryo, instead of being simply carried for- Amniotic cavity Amniotic cavity Amniotic cavity Periembryonal mesodermal cleft Periembryonal mesodermal cleft Amniotic cavitv Periembryonal mesodermal cleft Periembryonal mesodermal cleft Volk-sac Fig- 73- — Scheme of development of the amnion (Pfannenstiel). ward to meet in the median line in front, sends reduplications backward over the dorsal aspect of the embryo, which shortly meet and join one another; that there are consequently two cavi- ties formed, — one within the membrane doubled back upon itself; the other between the inner (the true amnion) of the two layers of membrane and the outer covering of the embrvo. The g6 PREGNANCY. latter is the true amniotic cavity, which is gradually distended by the accumulation of fluid until the membrane containing it is pushed out on all sides, uniting in front around the umbilical cord, and coming in contact throughout the whole extent of the ovum with the outer membrane (true chorion), to which it becomes loosely united by a gelatinous substance, — the tunica media of Bischoff. This theory is not tenable in view of the observations of Peters and Graf Spee, which demonstrate that the amniotic cavity is closed at a very early date. There must, therefore, be a separation in the cells of the ectoblast constituting a cavity, which as it dis- tends with fluid presses the embryonal area toward the umbilical vesicle or yolk-sac, and folds the amnion around the embryo till the latter is completely enclosed. The Fully=developed Amnion. — The amnion forms the innermost of the membranes that surround the fetus at term. It is continuous with the fetal epidermis at the umbilicus, forms a complete sheath for the umbilical cord, and covers the fetal surface of the placenta. In its structure it consists of a single layer of flat endothelial cells turned toward the cavity of the amnion, and externally of a layer of young connective tissue, in which may be seen long spindle- or star- shaped cells with long nuclei imbedded in a fibrous substance. The regular disposition of the inner layer of endothelial cells, however, is disturbed at certain points of the amnion lying over the placenta, where numbers of cells are heaped together, forming a little villus-like projection. There are, normally, no blood- vessels in the amnion, — at least, in its later stages of develop- ment; their possible occurrence in hydramnios is referred to later. The Liquor Amnii. — It is the physiological function of the amniotic membrane to furnish a fluid medium (the liquor amnii), which distends the uterine walls and allows the fetus some free- dom of movement, and, by its density, approaching the specific gravity of the fetus, robs these movements of much muscular effort. It acts as an additional protection to the fetus from ex- ternal violence, pressure, and changes of temperature ; it receives the urine secreted in the latter part of fetal life ; and, perhaps, plays a part in the nutrition of the fetus, or at least in supplying the fetal tissues with the excess of water which they possess during intra-uterine life. 1 That the fetus actually swallows considerable quantities of liquor amnii admits of no doubt, for 1 Preyer, " Physiologie des Embryos." THE AMNION. 97 lanugo and epidermis-scales have been found in the meconium, 1 and also particles of colored matter which had entered the amniotic fluid from the maternal structures (Zuntz). It is not likely that the liquor amnii plays an important part in the nutrition of the fetus, as claimed by von Ott and others ; for if it did, the birth of well-nourished children with a breach of con- tinuity in the upper part of the alimentary tract from the mouth to the small intestine would be inexplicable. The Composition of the Liquor Amnii. — The amniotic fluid is usually almost clear ; occasionally, however, opaque, whitish, greenish, or a dark brown from the presence of meconium, or of a reddish color when the fetus is macerated. The specific gravity varies from 1002 to 1028 (Schroeder), being usually about 1007 to 1011. Its reaction is slightly alkaline. It contains salts, urea, carbonate of ammonia, kreatinin, albumin, lanugo, seba- ceous matter, epidermis -scales from the fetal skin, and epithe- lium from the bladder and kidneys. The quantity of the liquor amnii differs at different periods of pregnancy ; in the early stages it develops with great rapidity, and at the middle of pregnancy has reached its maximum of about 1 to 1.5 kilograms (2.2 to 3.3 pounds) (Landois). From this time it diminishes in amount, until at the end of pregnancy its average quantity is 680 gm. (1.5 pounds). 2 The Origin of the Liquor Amnii. — The liquor amnii is derived from mother and fetus. The maternal origin 3 of the amniotic fluid has been demonstrated by Zuntz, who injected sodium sul- phindigolate into the veins of pregnant rabbits, and found a blue coloration of the amniotic fluid, although there was no coloring matter in the kidneys of the fetus. In cases in which the em- bryo is destroyed very early, moreover, an amount of amniotic fluid may be found corresponding not to the age of the em- bryo, but to that of the ovum. And it is not unusual to find hydramnios associated with some other serous effusion in the mother. 4 1 Zweifel, " Untersuchungen iiber das Meconium," "Archiv f. Gyn.," Bd. vii, 474. 2 Fehling, "Archiv f. Gyn., "Bd. xiv, S. 221. 3 Ahlfeld ("Ueber die Genese des Fruchtwassers," "Archiv f. Gyn.," Bd. xiii, pp. 160-241) gives an ingenious explanation of the manner in which the maternal structures take part in the formation of the liquor amnii : As the uterus develops by an eccentric hypertrophy, the pressure within the uterine cavity becomes less than that of the abdominal cavity, and consequently there is a disposition for the serum ot the maternal blood to exude into the amniotic cavity. As Phillips (" Edin. Med. Jour.," March, 1887, p. 811) remarks, however, the case of hydramnios in extra uterine pregnancy ("Archiv f. Gyn.," Bd. xxii, p. 57), reported by Teuffel, would seem to invalidate this theory. 4 Pfluger's "Archiv," Bd. xvi, S. 548 ; and Wiener, "Archiv f. Gyn ," Bd. xvii, S. 24. 7 98 PREGNANCY. The fetus also contributes to the formation of liquor amnii. The excretion of urine during the latter part of fetal life reaches a considerable amount. More than three pints of urine have been found retained in the fetal bladder. 1 Gusserow 2 injected benzoic acid into the mother, and re- covered it as hippuric acid in the liquor amnii, — proof that it had passed through the kidneys of the fetus. Wiener found sodium sulphindigolate in the fetal kidneys and bladder after it had been injected into the maternal tissues. The constant presence of urea 3 in the amniotic fluid after the sixth week is additional proof of the renal activity of the fetus. It is probable also that the vasa propria, discovered by Jungbluth, 4 lying close under the amnion in the early life of the embryo, have something to do with the production of the amniotic fluid. Prochownik 5 claimed that the skin of the fetus secretes amniotic fluid during the early months of gestation. There have been cases of hydramnios associated with morbid conditions of the skin, notably one instance observed by Budin, 6 in which the skin of the fetus was the seat of extensive nevi. Thus it appears that the amniotic fluid is derived from a fetal as well as a maternal source, but the relative importance of the fetal and maternal supply of liquor amnii at different periods of pregnancy is still undetermined. Abnormalities of the Amnion. — There is a striking simi- larity between the pathology of the amnion and that of other serous membranes. There is the same liability to changes of secretion, to inflammation with a plastic exudate, and to the for- mation of bands of adhesion. The function of the amnion, how- ever, and its close relation to the embryo and fetus, give rise, in case of disease, to symptoms and results peculiar to itself. Abnormalities of Secretion : Oligohydramnios. — Occasionally the quantity of fluid is so deficient as to seriously interfere with the growth of the fetus and to determine its premature expulsion. 7 Schatz 8 reports a case in which there were ulcers on the inner surface of the knees and malleoli of a fetus from constant friction due to a deficient quantity of liquor amnii, and many curious deformities of the fetus may be traced to the same 1 Lefour, "Archives de Tocol.," June 30, 18S7. 2 "Archiv f. Gyn.," Bd. xiii, S. 56. 3 Prochownik, 'Archiv f. Gyn.," Bd. xi, S. 304-561. 4 " Beitr. zur Lehre v. Fruchtwasser," Inaug. Dissert., Bonn, 1869; Vir- chow's "Archiv," Bd. xlviii, S. 523 ; "Archiv f. Gyn.," Bd. iv, S. 534. 5 Loc. cit. 6 Tarnier et Budin, loc. cit., p. 279. 7 " London Lancet," 1886, ii, p. 383. 8 "Archiv f. Gyn.," Bd. xix, S. 329. THE AMNION. 99 cause. 1 This condition is called oligohydramnios. More fre- quently the quantity of the liquor amnii becomes abnormally increased — a condition known as polyhydramnios hydroamnion, dropsy of the amnion, or, more commonly, hydramnios. Hydramnios. — It has been already stated that the normal quantity of liquor amnii at the end of pregnancy is from one to two pints. Should this quantity be much exceeded, the condition of hydramnios exists. A slight excess is frequent, but usually passes unnoticed, while an accumulation of fluid amounting to two quarts or more is not common. It is difficult, therefore, to express the relative frequency of hydramnios. Char- pentier states that it occurs in 1 in 100 or 1 in 150 pregnancies, — an estimate too low for the minor grades of the affection, but too high for cases in which the accumulation of fluid is large enough to give rise to well-marked symptoms. In the majority of cases the fluid collects gradually, but steadily, until at the end of the pregnancy it may reach the enormous quantity of six gallons or more. 2 Occasionally the fluid accumulates very rapidly, giving rise, from the sudden distention of the uterus, to symptoms of a grave character. The rapid accumulation is known as acute hydramnios. The Etiology of Hydramnios. — It may be due to (A) an over- secretion of liquor amnii or to (i?) a deficient absorption of the liquor amnii. A. The excessive collection of fluid may be derived from (I) a maternal source, (II) a fetal source, or (III) both fetus and mother may contribute to its production. I. The Maternal Origin. — It is probable that the serum of the maternal blood occasionally exudes in abnormally large quantities into the amniotic cavity. In cases of hydramnios associated with serous effusions elsewhere in the mother's body the excess of liquor amnii is probably derived from a maternal source. Fehling 3 asserts that "the thinner the maternal blood, the greater is the quantity of liquor amnii." A lymphagogue has been found in the liquor amnii of hydramnios, which is not present in the normal liquid. It has been claimed, therefore, that this substance stimulates a serous exudate from the maternal blood. 4 II. The Hydramnios May Originate Entirely from Fetal Structures. — This supposition explains by far the larger number 1 See '"Tarnier et Budin," p. 294. 2 Wilson, "Am. Jour. Obstetrics," Jan., 1887, p. 22. 3 " Archiv f. Gyn ," Bd. xxviii, S. 454. 4 E. Opitz, "Centralbl. f. Gyn.," No. 21, 1898. IOO PREGNANCY. of cases that admit of an explanation at all, for hydramnios often occurs (forty-four per cent, of all cases ( Bar)) without a demonstrable cause in either mother or fetus. The production of hydramnios, traced to the fetus, may be due : (a) To abnormal pressure in the blood-vessels of the cord, or of those directly under the amnion, where it covers the placenta (persistence of the vasa propria of Jungbluth); (b) to an excessive urinary secretion ; (c) to an abnormally profuse excretion from the fetal skin. (a) The vasa propria of Jungbluth, normally present in the early stage of embryonal development, have been found at term in cases of hydramnios, 1 and the production of an excessive quantity of liquor amnii has been attributed to their persistence. It is more probable, however, that the existence of these vessels is purely secondary, and that, although the serum of the fetal blood does exude from them into the amniotic cavity, their presence is due to an increased blood-pressure in the umbilical vein. 2 Increased internal pressure within the umbilical vein causes a transudation through the amnion, as has been proved by Salinger, 3 who found that the amount of fluid which would transude depended upon the strength of the pres- sure and the size of the cord. Any condition of the fetus, therefore, which raises the blood-pressure in the umbilical vein, thus increasing the blood-pressure in the placenta, may give rise to hydramnios. This happens, for example, in cirrhotic livers common in syphilitic children. There are many other conditions having the same effect — a cord abnormally twisted, velamentous insertion of the cord (exposing the vein to external pressure), stenosis of the umbilical vein, obstruction of the ductus Botalli, 4 tumors of the placenta, tumors of the fetus (interfering with its circulation), valvular defects of the heart, 5 etc. (^) Excessive excretion of urine is a cause of hydramnios. The action of the fetal kidneys in the production of hydramnios can best be demonstrated in cases of unioval twins, 6 in one of which it is common to find a dropsical amnion, while the other one presents usually the opposite condition, oligohydramnios. 1 Levison, " Archiv f. Gyn. ," Bd. ix, S. 517; Lebedjew, " Traite prat, des Ace," Charpentier, 1883, pp. 886, 890. 2 Vs'inckler denies the existence of a capillary system of blood-vessels under the amnion, and attributes hydramnios to the presence of a capillary lymphatic system in the cell-layer of the chorion. 3 " Ueber Hydramn. in Zusamm. mit der Entstehung des Fruchtw.," D. i. Zurich, 1875. 4 Xieberding, " Zur Genese des Hvdramnios," "Archiv f. Gvn.," Bd. xx, S. 275. 5 Cordell, " Tr. Med. and Chirurg. Fac. Maryland," 188S, p. 218. 6 Schatz, "Archiv f. Gyn.," Bd. xix, S. 329; Werth, ibid., xx, 353; Sallinger, loc. cit. THE AMNION. IOI The history of these cases is that one fetus outstrips the other in growth, and thus, acquiring a preponderating influence in the placenta which is common to both, its heart takes on a hyper- trophy to enable it to carry on the greater part of the placental circulation. The hypertrophied heart produces in its turn hyper- trophy of the kidneys and determines their increased secretion. The increased blood-pressure also determines an increased activ- ity of the excretion from the skin, and thus in a twofold manner helps to increase the quantity of liquor amnii. (e) The fetal skin is a source of hydramnios. It can readily be understood that an increased blood-supply from a hyper- trophied heart can stimulate the fetal skin to overaction. There are, however, more direct proofs of the part that the skin may play in the production of hydramnios. Budin 1 has described a case of hydramnios associated with extensive nevi, and another in which the skin was thickened and thrown into folds. Stein- vvirker 2 has recorded a case of hydramnios with " elephantiasis congenita cystica." Finally, it is not improbable that the amnion itself may take an active part in the overproduction of liquor amnii ; that, in other words, the amnion may be affected by acute inflammation (amnio- titis), followed by an increased serous exudation. This supposi- tion would explain the cases in which a blow or kick 3 on the abdomen of a pregnant woman is followed by the development of hydramnios and the formation of adhesions between the fetus and the amnion. To amniotitis has been attributed the development of acute hydramnios. Werth's 4 theory also de- serves some consideration before leaving the study of the fetal origin of hydramnios. This author believes that a hypertro- phied placenta may absorb more fluid from the maternal blood than is required for the fetal economy ; that the struggle to get rid of this excess of fluid brings about the hypertrophy of the heart and kidneys to which reference has already been made as occurring especially in one of unioval twins. III. Both Fetus and Mother May Contribute to the Productio?i of an Excess of Liquor Amnii. — This proposition has already been demonstrated in showing the possible derivation of the liquor amnii from both mother and fetus. The cause of the hydramnios, how- ever, is most frequently found in the fetus, while the combined ac- tion of both mother and fetus in a single case is rare, but may oc- cur, as in certain cases of syphilis, in which have been found dropsy of the mother and of the fetus associated with hydramnios. 5 1 Loc. cit. 2 Loc. cit. 3 " Tr. Obstet. Soc. of Baltimore," meeting Feb. 9, 1887. 4 Werth, loc. cit. 5 Meissner and Hufeland, quoted by Wilson, " Am. Jour. Obstetrics," 18S7, p. 13. 102 PREGNANCY. B. Hydramnios may be due to a deficient absorption of liquor amnii. The production of liquor amnii being normal, but its absorption deficient, hydramnios results. Thus are explained the cases of hydramnios associated with nephritis and serous effusions in the mother. It has been proved that the fetus swallows liquor amnii in considerable quantities, and it is possible that the skin absorbs some of it. Whether the cessation of these two functions results in hydramnios is uncertain. Symptoms and Diagnosis. — The symptoms of hydramnios are like those of other cystic tumors in the abdomen. There is, in addition, the history of pregnancy ; the tumor may usually be fig. 74. — Abdominal distention due to hydramnios. Woman pregnant six months with twins ; one sac contained 2'/% gals. ; the other, one pint (author's case). defined as the uterus, very much larger than it should be at the date that pregnancy has reached ; and, except in extreme cases, it is possible to detect the fetal heart-sounds, or to practice bal- lottement. As the uterus distends it gives rise, by its increased size, to pressure symptoms in the abdomen and thorax, although it is astonishing how large it grows without seriously incon- veniencing the patient. But this is not the case when the liquid is rapidly effused, as in acute hydramnios. 1 The woman suffers intense pain from the sudden distention of the uterus. Her breathing becomes labored, and complete orthopnea is developed ; her face is cyanosed and bears an 1 Acute hydramnios is rare : of 623 cases of hydramnios in the Baudelocque Clinic, only 8 were acute (Dion, " These de Paris," 1896). THE AMNION. 103 anxious expression ; constant and distressing vomiting appears, and there is fever. * The detection of hydramnios is not always easy, and may be practically impossible. It may be confused with pregnancy associated with ascites, or with a cystic tumor of the ovary or broad ligament, or with an ordinary twin pregnancy ; or the fact that the woman is pregnant may be entirely overlooked. This mistake has frequently led to the tapping of the preg- nant womb, 2 which appears to be harmless. It is possible to mistake the overdistended bladder associated with a retroflexed gravid uterus for hydramnios. When the dropsy of the amnion has not reached an excessive degree, the distinction between it and ascites with pregnancy may be made by mapping out the uterine wall and detecting resonance along the flanks in the dorsal decubitus ; and an ovarian cyst in pregnancy may be Fig. 75- — Hydramnios at term. excluded by the absence of two tumors of different consistency and shape. A twin pregnancy without hydramnios presents, on external palpation, an enlarged uterus, offering firm but irregular resistance from its solid contents. In extreme dis- tention of the uterus, which in some cases seems limited only by the utmost capacity of the abdomen, a definite diagnosis is impossible ; in such cases it is justifiable to resort to an ex- ploratory puncture of the membranes through the cervical canal, or even to an abdominal section. 3 Treatment. — If the fluid accumulates in such quantity 1 See Charpentier, " Traite Pratique des Accouchements." 2 Cases reported by Scarpa, Camper, Noel, Desmarais, Scliatz, Tillaud, Chiara, Kidd, and others, not followed by the slightest bad results. 3 Successfully performed in a case of extreme distention of the abdomen from hydramnios by Wilson, loc. cit. 104 PREGNANCY. or so rapidly as to produce alarming symptoms in the wo- man, its evacuation is indicated. This is best accomplished by rupturing the membranes through the cervix and allowing the liquor amnii to escape. By this method labor is induced, and if the child is not viable, its destruction is a necessary conse- quence. Moreover, the sudden gush of liquor amnii from the uterus may induce syncope by the rapid reduction of intra- abdominal pressure, or may result in excessive tympany from the sudden relief of pressure on the intestines. It has, there- fore, been proposed (Guillemet, Schatz) that the uterus be tapped through the abdominal wall, and a moderate quantity of liquor amnii be removed from time to time, thus preserving the life of the fetus. But the fetus in hydramnios is often deformed or dis- eased, and usually dies shortly after birth ; its life, therefore, deserves little consideration in comparison with the additional risk entailed upon the mother by puncturing the abdominal and uterine walls. It is especially in acute hydramnios that rupture of the membranes is called for, irrespective of the age or condition of the fetus. Special instruments have been devised for the perforation of the membranes, and it has been suggested that the puncture be made at a point far within the uterine cavity, and thus removed from the external os, so that the liquor amnii may trickle slowly down between the membranes and the uterine wall, and the disadvantages of a sudden escape of the fluid be thus avoided. No better or more convenient appliance can be found than the tip of the forefinger. The hand introduced into the vagina to dilate the cervix and to rupture the membranes may be clinched so as to form an efficient plug, by means of which the operator may regulate at will the escape of the liquor amnii. Abnormalities of the Liquor Amnii in Color, Consistency, and Chemical Constitution — The liquor amnii, which is nor- mally somewhat opaque and whitish in color in the last months of pregnancy, may be green or brown from the presence of meconium, or it may be tinged with red if the fetus is macerated. The consistency of the fluid in extreme cases of oligohydramnios is that of thick syrup or of mucus. It may contain sugar if the mother has diabetes mellitus. 1 Putrefaction of the Liquor Amnii — Decomposition of the liquor amnii is most likely to be associated with death and putre- faction of the fetus, but an intensely putrid odor of the fluid, with physometra, has been noted with a living child. Adhesive Inflammation and the Formation of Amniotic Bands. — Early in embryonal life, in case the amnion is not 1 Ludwig, " Centralbl. f. Gyn," No. II, 1895. THE AMNION. I05 lifted away from the newly-forming skin of the embryo, owing to an insufficient secretion of amniotic fluid or as a conse- quence of inflammation, adhesions may form between the skin and amnion, and as the amniotic cavity is distended, the adhesive material is stretched, so that it finally forms bands of varying length and thickness, either connecting the fetus with the amnion or with one or both ends detached, floating free in the liquor amnii. The composition of these bands closely resembles that of the plastic material thrown out in inflammations of the serous membranes generally. They are not provided with blood-vessels. The exudation of this plastic material from the amnion results occasionally in the formation of extensive ad- hesions between the fetus and the amnion, giving rise to grave deformities, as eventration or anencephalus, by preventing the proper arching over of the walls of the body-cavities. The formation of adhesive bands is sometimes followed by intra- uterine amputations. A de- veloping limb may be caught between two of these bands, and as it grows may be so con- stricted that the distal portion of the limb is entirely cut off from its blood-supply. Adhe- sions may also be formed be- tween various portions of the body and the amniotic covering of the placenta, or the umbilical cord may be artificially shortened by the adhesions of coils one to another and to the fetal skin. 1 In the latter part of pregnancy the amnion may burst, the integrity of the ovum being preserved by the chorion. 2 The fetus then, by its active movements, may roll the amnion into cords, which may become so entangled with the umbilical cord as to constrict it sufficiently to obliterate its blood-vessels. Cysts of the Amnion. — Cases of cystic formations in the substance of the amnion have been reported by Ahlfeld, Wine- Fig. 76. — Amniotic bands : h, Ad- hesive bands ; d, e, feet ; f, g, genitalia and anus. 1 Leopold, " Ein Fotus mit Verklebungen cier Nabelschnur, " etc., " Archiv f. Gyn.," Bd. xi, 383. 2 Schroeder, "Lehrbuch," 8th ed., p. 455. io6 PREGNANCY. kel, and Budin. 1 They are small and have no clinical signifi- cance. After the death of the fetus the amnion undergoes certain changes, resulting in a loss of its glistening surface and in a considerable thickening. The histology of this change is not yet described. THE CHORION. When the ovule first enters the uterine cavity and imbeds itself in the thickened uterine mucous membrane, the protoplasmic cell-wall of the ovum sends out numerous prolongations, which burrow into the connective tissue of the decidua, fix the egg in its position, and draw nutriment for the whole ovum from the blood- vessels of the uterine mucous membrane. This cell-wall, with Fig- 77- — A young ovum: a, Natural size; b, magnified, showing chorionic villi (author's specimen). its villus-like projections, constitutes the false chorion, which soon disappears and is replaced by the layer of cells springing from the outer layer of the blastodermic membrane and surround- ing the whole ovum (the trophoblast). This membrane, in its turn, sends out branch-like processes (the villi of the chorion), which, at first non- vascular but hollow, soon receive into the interior of each branch of the villi loops of the blood-vessels that have been carried from the fetus to the periphery of the egg by the allantois. These vascular villi absorb nutriment from the whole ex- tent of the decidua refiexa until the third month, when they atrophy and finally disappear, except at that portion of the periphery of the ovum which is in direct contact with the decidua 1 Tarnier et Budin, loc, cit., p. 274. THE CHORION. IO7 vera (decidua serotina), where the chorion villi develop still further to form the placenta. The Fully=developed Chorion. — Restricting the term chorion to that portion of the original membrane which undergoes atrophy at the third month of pregnancy, it is found to con- sist of a thin, transparent membrane made up of connective- tissue elements continuous with the substance of the umbili- cal cord and very delicate, atrophied villi connecting it with the decidua reflexa. This portion of the chorion is called chorion laeve to distinguish it from the zJ&M Fig. 78. — Human embryo at the third week, showing villi covering the entire chorion (Haeckel). chorion frondosum that forms the placenta. The fibrous mem- brane, constituting what is usu- ally called chorion at term, is derived from the endochorion, so named to distinguish it from the outer epithelial layer (the exochorion), which is to be found persisting in the epithelial covering of the placental villi. Diseases of the Chorion. — An abnormal condition of the chorion is the persistence of the chorionic villi around the whole periphery of the ovum, thus completely enveloping the fetus by the placenta (placenta mem- branacea). * The degenerations, aside from the normal process of atrophy, that may affect the chorion villi are of two kinds, — cystic and fibromyxomatous. Cystic degeneration of the chorion villi is characterized by the hypertrophy of the chorion villi, and their conversion into cysts varying in size from that of a millet-seed to the size of a grape or even of a hen's egg, connected with one an- other and with the base of the chorion by pedicles of varying breadth. It is further distinguished by the rapid growth of the ovum and the consequent expansion of the uterus, usually at the third to the fourth month ; by the escape of blood from the uterine cavity into the vagina, and by the premature expul- sion of the ovum, which is more or less covered with numbers of small, transparent cysts. Within the cavity of the ovum may or may not be found an embryo. This affection of the chorion, from the peculiar appearance of the ovum, has attracted much attention, from the time of yEtius von Ameda in the sixth century, and, from the mystery 1 See " Amer. Jour. Obstetrics," 1886, p. 851. 108 PREGNANCY. that formerly surrounded its origin and the difference of opinion that existed as to its etiology and minute anatomy, cystic degen- eration of the chorion villi, otherwise known as hydatidiform mole, or dropsy of the chorion villi, has been the subject of much discussion. First definitely described by Schenk, 1 the most extraordinary theories have been advanced to account for its occurrence. Regnier de Graaf (1678) thought that each vesicle or little cyst was an unfecundated ovule. The belief had once prevailed that each vesicle was a living embryo. 2 The opinion of Ruysch (1691) and Albinus (1754), that the ex- istence of innumerable little cysts in the uterus and their final expulsion were dependent upon some disease or alteration of the ovule, was at last generally adopted. A more definite ex- planation was not attempted until, in the early part of the nine- teenth century, it was claimed by Percy, 3 Cloquet, 4 and Mme. Boivin 5 that the vesicular disease was due to echinococci. Velpeau 6 was the first to indicate that the cysts were nothing but distended chorion villi. Since Velpeau's announcement, cystic degeneration of the villi has been attributed to hyper- trophy and edema (Meckel, Gierse) ; to disease of the blood- vessels (Bartolin, Miller, Cruveilhier) ; to disease of the lymphatics (Bidlos, Sommerring) ; to degeneration of the mucous substance within the villi, continuous with the sub- stance of the cord (Virchow) ; to a degeneration of the epi- thelial cells derived from the decidua, which replace the epi- thelial covering (exochorion) of the chorion (Ercolani); and to a pathological hyperplasia of the syncytium with liquefaction of the epithelial cells in the interior of the villi (Sfameni). A fre- quent if not invariable association of the disease with multiple corpus luteum cysts in the ovary, an overproduction of lutein cells and their infiltration of the ovarian stroma, has been demonstrated. 7 A causative relation between the ovarian disease and the degenera- tion of the chorion has consequently been suspected. Virchow's 8 explanation is that the change resulting in the cystic degenera- * * See " Tarnier et Budin," p. 299. 2 See the interesting quotation by Priestley (loc. cit., p. 36) from Ambroise Pare, that "the Countess Margaret brought forth at one birth 365 infants, whereof 182 were said to be males, as many females, and the odd one a hermaphrodite" (1276 A. D.). Pepys records in his diary that he visited the house in which this remarkable delivery occurred and saw the brass platters on which the children were carried before the bishop of the diocese for baptism. 3 "Jour, de Med.," t. x'xii, p. 171, 1811. 4 No. I, " De la Faune des Med.," Priestley. 5 "Nouvelles Recherches sur le Mole vesiculate," broch., Paris, 1827. 6 " De l'Art des Accouchements." 7 Ludwig Pick, " Centralbl. fur Gyn.," No. 34, 1903 ; Jaffe, " Arch. f. Gyn.," Bd. 70. H. 3; Scharlieb, "Centralbl. f. Gyn.," No. 49, 1903; Stoeckel, " Beitr. z. Geb. u. Gyn.," Festschrift, 1903. 8 "Die Krankhaften Geschwiilste," Bd. i, S. 405. THE CHORION. IO9 tion of the chorion villi takes place altogether in the endocho- rion, which forms the inner of the two layers that compose the chorion and is continuous with the Wharton jelly of the umbilical cord; this change consists of the overproduction of true mucous tissue within the villi, into which the mucous tissue extends at first alone, but afterward accompanied by blood-vessels. The process usually begins at a time when the villi are almost equally developed over the whole ovum, that is, before the third month, — and, therefore, when the vesicular, chorion is expelled the disease is usually found equally distributed over the whole surface, showing no evidence of special develop- ing- 79- — Cystic degeneration of the chorion villi (Bumm). ment at any one point to indicate where the placenta would have been situated. Involvement of the whole chorion is the rule, but exceptionally the placenta alone is affected, the dis- ease having begun after the atrophy of the villi over the extra- placental portion of the chorion. Still more rarely the disease is found in isolated spots upon the chorion laeve. 1 There are recorded cases in which one chorion of a twin conception was vesicular while the other remained normal. According to the 1 Winogradow, Virchow's " Archiv," 1870, Bd. li, S. 146. I IO PREGNANCY. foregoing explanation, the disease is a true myxoma of the chorion, and the epithelial cells (exochorion) covering the villi do not necessarily take part in the morbid process, but the cells of Langhans' layer and of the syncytium display an ex- uberant growth and a decided inclination to penetrate uterine tissue. Priestley's 1 investigations, undertaken as long ago as 1858, are in accord with Virchow's theory. Pathological Anatomy. — The appearance of a vesicular mole is peculiar. The mass may be as large as a man's head, covered more or less completely with decidua, which, upon incision, or in spots where the decidual covering is absent, reveals innumerable small cysts, some as large as grapes, or even as hens' eggs, connected with each other or with the base of Fig. g . — A, Extremity of a villus in early stage of cystic degeneration : a, Shows the first stage of enlargement in the cells of the villus trunk ; b, a somewhat more advanced stage, showing hyaline cells escaping from the ruptured capsule of a young cyst (Priestley). B, Terminal villus of cystic chorion : a. Stellate connective tissue ; b, c, inner and outer layers of wall ; d, early stage of b (Braxton Hicks). the chorion by pedicles of varying thickness. The liquid in the cysts is usually clear and translucent. A microscopic examination of a section through a villus in the early stages of cystic degeneration shows the distended cells of which Priest- ley speaks, or else there may be seen the outer cellular and inner fibrous wall of a villus, while within the interior are stellate connective -tissue cells, in the interstices between which may be found mucous tissue. The fluid in the cysts contains mucin and albumin in consid- erable quantities. Within the center of the vesicular mass is usually found a shriveled or distorted fetus surrounded by its amnion, which 1 Loc. cit., p. 37. THE CHORION. I I I may contain an abnormal quantity of fluid (hydramnios). Occa- sionally, no trace of the embryo is discovered, or at most there may be seen only the remnant of an umbilical cord. More rarely the fetus, although dead, is apparently well developed for the date of pregnancy, 1 and if the degeneration of the chorion has not been too extensive, a living, healthy infant may be born with a vesicular chorion. 2 It has been stated that between the amnion and chorion is found a thin layer of jelly-like substance continuous with the Wharton's jelly of the umbilical cord. There is a case on record 3 in which this substance formed a layer four or five millimeters thick, originating from a mucous Fig. 8l. — Hydatidiform mole (Mc- Connell and J. C. Hirst). Fig. 82. — Hydatidiform mole, high power, showing two layers of cells (Mc- Connell and J. C. Hirst). degeneration of the connective-tissue layer of the chorion, with- out involvement of the villi of either the chorion laeve or fron- dosum, thus constituting a peculiar, and to the present time unique, variety of myxoma of the chorion. The relation of the cystic chorion to the two deciduae is often abnormal. Occasionally the membranes retain their normal relative position of external deciduae, median chorion, and internal amnion ; but frequently the enlarged villi of the chorion perforate either one or both deciduae over surfaces 1 Priestley, loc. cit , p. 42. 2 Schroeder, " Lehrbuch d. Geb.,*' 8th ed., p. 442; and Sym, " Edin. Med. Jour.," Aug., 1887, p. 102. 3 " Wiener med. Presse," 1867, Bd. i; and Virchow's "Archiv," Bd. xxxix, S. I. 112 PREGNANCY. of varying extent. Thus, specimens have been described x in which the cystic mass was inclosed between the decidua vera and the reflexa, or in which the villi have perforated not only both decidual, but also the muscular wall of the uterus, and even its peritoneal covering. 2 The relation of myxoma of the Fig. 83. — Uterus with perforating hydatidiform mole. a, Uterine veins and chorion villi ; b, vessels of the decidua serotina ; c, internal os ; d, cervix ; e, eroded portions of the uterine wall ; f, uterine veins and degenerated chorion villi. (Buram. ) chorion to syncytial cancers is quite intimate. In a large pro- portion of the latter growths there is associated a cystic disease of the chorion villi. Findlay's statistics 3 of 250 cases of the 1 Priestley, he. cit., p. 40. 2 Cory, quoted by Priestley, p. 41. Volkmann, Waldeyer, Jarotzky, Krieger, Wilton, quoted by Schroeder, op. cit., p. 444. 3 "Am. Journ. Med. Sci.," March, 1903. THE CHORION. I I 3 disease show a development of chorion-epithelioma in 16 per cent. The cases formerly reported of malignant degeneration of the chorion were unquestionably of this character. There may be a metastasis of whole chorion villi, without a malignant degeneration of the epithelial cells, 1 or the chorion epithelium may undergo malignant degeneration after metastasis. 2 Clinical History and Diagnosis. — There are three prominent symptoms associated with the cystic degeneration of the chorion : (1) Rapid increase in the size of the uterus ; (2) discharge of blood or bloody serum, and (3) the escape of vesicles. The last symptom is of rare occurrence, and the first two do not always manifest themselves in a typical manner, so that the clinical phenomena in a case of vesicular mole do not always permit of a definite diagnosis. If there is an escape of blood at intervals during the early part of pregnancy, if the uterus rapidly enlarges toward the third month, and if careful palpa- tion elicits no sign of the presence of a fetus within the uterine cavity, the existence of a cystic chorion may be suspected. If, as rarely happens, characteristic cysts are expelled, there can be no doubt as to the nature of the case. The sudden distention of the uterus usually causes distressing nausea and vomiting. Occasionally, after the development of the chorion villi, the dis- ease is arrested and the ovum is retained for many months, so that in such cases there may be all the symptoms of pregnancy, with a previous history of bleeding, but the womb at the time of examination is much smaller than it should be at the date which the pregnancy has apparently reached. Vesicular mole is most apt to occur in women who have already borne children or who have reached middle age. Hirtzmann 3 found that, of 35 cases, 25 occurred in women over twenty-five years of age. As an exception to this rule, Strieker 4 reports a case of pre- cocious menstruation in a child who in her ninth year gave birth to a true vesicular mole. It is hardly necessary to state that cystic degeneration of the chorion villi is necessarily a result of impregnation, and can not occur in a virgin uterus. In 100 cases collected by Dorland, 5 68 occurred between the twentieth and fortieth year. In 210 cases collected by Findley, 8 the average age was twenty-seven; the extremes were thirteen and fifty- eight years. Cystic degeneration of the chorion often occurs 1 Gaylord, "Tr. of the Gyn. Section, College of Physicians of Phila.." 1898. 2 Zagorjanski-Kissel, " Ueber das primare Chorioepitheliom ausserhalb des Bereiches der Ei-ansiedelung," "Arch. f. Gyn.," Bd. lxxvi, H. 2; also " Ueber das Chorioepitheliom in der Vagina bei sonst gesundem Genitale," Monograph, Hiibl, Wien, 1903. 3 "These de Paris," 1874. 4 Virchow's " Archiv," Bd. lxxvii, S. 193. 5 "Am. Journ. of Obstet.," 1896, p. 905. 6 " Am. Journ. of Obstet.," March, 1903. 114 PREGNANCY. in women who have previously given birth to healthy children, but it not infrequently recurs in the same individual. Depaul * mentions a woman who had this affection three times, and Mayer 2 has observed the disease in eleven successive pregnancies. The degenerated chorion usually determines the expulsion of the ovum at some period between the third and sixth months of gestation. 3 If, however, the disease does not begin until after the villi of the chorion laeve have atrophied, or if the degeneration is confined to a comparatively limited area, the pregnancy usually proceeds to term. But, if the embryo is absorbed and the chorion becomes adherent to the uterine wall, the pregnancy may be abnormally prolonged to twelve or thirteen months (Schroeder). The adhesion of the cystic villi to the uterine wall has more serious results than the mere prolongation of pregnancy. It is often due to the perforation of the uterine wall by a proliferation of the syncy- tial cells of the chorion villi, and consequently when the mass is ex- pelled there may be fatal hemorrhage from the uterine sinuses (Volkmann, Waldeyer), or, as in Wilton's case, 4 the peritoneal covering may be torn and fatal hemorrhage may ensue into the peritoneal cavity. The retention of a portion of the chorion may be followed by its decomposition within the uterine cavity, giving rise to general septicemia ; or fragments of cystic chorion retained in utero may be expelled at a date remote from the original preg- nancy. With these accidents, of not infrequent occurrence in the course of the disease, it is not surprising that the maternal mor- tality is eighteen to twenty-five per cent. 5 Etiology and Frequency. — The occurrence of vesicular disease of the chorion can not be attributed to any single cause. The connection between disease of the endometrium (Virchow) or of the uterine walls (fibroid tumor (Schroeder) ) and vesicu- lar mole is clearly established in a large proportion of the cases, especially in those in which there is a frequent recurrence of the disease ; but this explanation does not suffice for the degeneration in the chorion of one fetus while that of its twin remains healthy. In this case the disease is of fetal origin, — per- haps the result of the death of the fetus. Indeed, it has been claimed that the death of the embryo necessarily precedes the cystic degeneration of the chorion. That this view is incorrect is demonstrated by the birth of living children in cases of not too extensive degeneration of the chorion. It has been claimed that vesicular mole is the result of absence of the allantois (Hecker), or that possibly the allantois may contain no blood- 1 " Lecons de Clin. Obst.," 1872. 2 " Tarnier et Budin." p. 306. 3 In Dorland's 100 cases the mass was expelled in 63 per cent, between the third and fifth months. 4 "Lancet," Feb., 1840. 5 Dorland, loc. tit.; Findley, loc. cit. THE CHORION. I I 5 vessels (Schroeder), thus depriving the villi of their blood- supply. Stenosis of the umbilical vein has been found associated with cystic chorion, and, therefore, it has been asserted that the cystic degeneration may have been due to dropsy of the chorion villi (Maslowski, Robin). A pathological hyperplasia of the syncytium, possibly stimulated by an overgrowth of lutein cells on the ovary, followed by liquefaction of the cells in the interior, is the latest and most generally accepted theory to account for the disease. As to the frequency of this affection, there are no reliable statistics. Mme. Boivin * saw the disease only twice in 20,375 pregnancies, while in the Charite in Berlin it occurred four times in 2130 pregnancies. Three cases have been under my care in fifteen years. Every obstetrician of large practice has seen at least one case. Cystic degeneration of the chorion villi occurs probably once in two or three thousand pregnancies. The treatment is mainly symptomatic. In cases of hemor- rhage, it may be necessary to tampon the vagina until the os is sufficiently dilated to permit the expulsion of the cystic mass, or its extraction by the lingers, or by placental forceps. If the diagnosis of cystic disease of the chorion is made during preg- nancy, and if abdominal or combined palpation gives no signs of the presence of a fetus, the immediate induction of abortion is advisable so that the chorion shall not reach an inordinate size and penetrate the uterine wall, causing hemor- rhage or possibly perforation of the uterus. A prolonged re- tention of the mass also predisposes to malignant degenera- tion of its epithelium. After the expulsion of the diseased ovum, if there are symptoms pointing to the retention and decompo- sition of fragments of the chorion within the uterine cavity, the natural impulse would be to remove the retained substances ; but it must be borne in mind that the attenuation of the uterine wall in circumscribed areas may be so great that the slightest interference, the introduction of a curet, or the administration of an intra-uterine douche, may cause its rupture with a fatal result. 2 The uterus should be packed with gauze after its evacuation to stimulate its contraction and to control hemorrhage. The patient should be kept under observation for months and years. If there is a tendency to metrorrhagia there should be a micro- scopic examination of endometrium removed by curettage. If evidence of chorion-epithelioma is discovered, a hysterectomy is urgently indicated. 1 "Clin. Mem.," 1S63. 2 For a case resulting fatally after the injection of perchloric! of iron, see Priestley, loc. cit., p. 41. n 6 PREGNANCY. Fibromyxomatous Degeneration of the Chorion. — If fibrous tis- sue predominates between the degenerated villi, the mass is solid instead of cystic. Virchow * first called attention to this condition in the placenta, and gave it the name of myxoma fibrosum placentae. In the midst of healthy cotyledons one was discovered affected by a fibromucous degeneration. A similar structure may be found in the peripheral layers of the umbilical cord. To complete the study of diseases of the chorion it is necessary to mention a chronic inflammation of the membrane. 2 In the case, already referred to, in which the amnion was rup- tured during pregnancy, the irritating effect of the liquor amnii upon the chorion produced a thickened and hyperplastic con- dition of that membrane. THE PLACENTA. The placenta, as a separate organ, dates from the third month of pregnancy. At this time the chorion villi atrophy over the whole periphery of the ovum, except at the point where it comes in direct relation with the true mucous membrane of the uterus — the decidua serotina. Here the villi take on an extraordinary growth, forming buds of epithelial cells (syncytium) upon their surface, which rapidly take on the shape of new villi, thus send- ing out branches in every direction, into each of which a loop of blood-vessels is projected. Separating the villi from one another, and dipping down to the base of the chorion between the parent stems of the villous projections, are processes of the decidua, carrying capillary loops of maternal blood-vessels. Very early in the history of the ovum 3 the arterioles of this sys- tem open directly into the intervillous spaces of the placenta, so that the placental villi are bathed directly in maternal blood. So far almost all authorities are agreed, but as to the relation of the terminal villi to the uterine mucous membranes, the action of the chorional and decidual epithelium, the changes that convert the uterine capillaries at first surrounding the villi into the large blood-sinuses that are later found in the placenta, many conflicting theories have been advanced. As to the rela- tion between the placental villi and the uterine mucous mem- brane, it has been variously stated that the former enter the mouths of the uterine glands (Bischoff); that they sink into crypts in the uterine mucous membrane, which are new forma- 1 Op. a'/., S. 414. : Lebedeff, quoted by Tarnier, op. cit., p. 313. 3 In Leopold's ovum of 7 to 8 days this arrangement was already vMble. " Uterus u. Kind,'' Leipsic, 1897. THE PLACENTA. 117 tions especially adapted for their reception (Turner); that the villi do not sink into glands or crypts, but are intimately invested with a layer of decidual epithelium, or with an endothelial cover- ing derived from the maternal blood-vessels (Ercolani); and that this cell-covering acts as a glandular structure, secreting from Fig. 84. — The fetal surface of the placenta (Minot). the maternal blood a peculiar substance, the so-called "uterine milk," which acts as nutriment for the fetal blood (Ercolani, Hoffman). It is now well established, however, that the placental villi imbed themselves in the soft interglandular substance of the decidua serotina, often projecting into the mouth of the small veins, and that the connective-tissue cells multiply and hyper- trophy around them (decidual cells). The epithelium of the n8 PREGNANCY. Fig. 85. — The capillary system of a placental villus (from Minot). uterine mucous membrane disappears, except in the glands. The chorion villi are at first covered with two distinct layers of cells; an inner layer composed of single large nucleated cells arranged side by side with dis- tinct cell walls (Lan- ghans' layer), and an outer layer or band of protoplasm in which are imbedded nuclei at irregular intervals (the syncytium). Both of these layers are probably derived from the chorion and not from the uterine epi- thelium or the endo- thelium of the uterine blood - vessels. Early in embryonal life (the third month) the Lang- hans' layer disappears and the syncytium remains as the sole epithelial covering of the villi. In the youngest ova yet observed the trophoblast contains lacunae to which blood is conveyed from the maternal circulation by little curling arteries that wind their way up through the decidual cells to empty directly into the placental sinuses. These arteries are provided with only a delicate endothelial wall. From Leopold's x ob- servations it appears that the arterioles of the decidua be- come more and more dis- tended as they approach the placental villi, so that their ter- minal expansions may be com- pared to a sea into which pro- ject peninsulas and capes of decidual masses and placental villi. It has been claimed that the syncytial cells of the latter have the power to penetrate the endothelium of the decidual arterioles and thus open a direct communication between the placental villi and the maternal blood. By this anatomical 1 Loc. cit. Fig. 86.- -Normal placenta (McConnell and J- C. Hirst). THE PLACENTA. 119 Fig. 87. — A, Placenta in its most generalized form ; B, structure of placenta of pig; C, structure of placenta of cow ; D, structure of placenta of fox; E, structure of placenta of cat ; F, structure of placenta of sloth ; on the right side of the figure the flat maternal epithelial cells are shown in situ ; on the left side they are removed, and the dilated maternal vessel with its blood-corpuscles is exposed ; G, structure of human placenta; E, fetal, and M, maternal placenta; e, epithelium of chorion; e' ', epithelium of maternal placenta ; d, fetal blood-vessels ; d / , maternal blood- vessels ; v, villus. The succeeding references apply to G only : ds, Decidua serotina of placenta; t, trabecule of serotina passing to fetal villi; ca, curling artery; up, uteroplacental vein (from Balfour, after Turner). 120 PREGNANCY. arrangement the fetal and maternal blood is, of course, kept separate. The former circulates within the capillary system of the villi; the latter bathes the exterior of the villi. The FuIly=developed Placenta. — The placenta at term is a circular mass, measuring about seven inches in diameter, about two-thirds of an inch to an inch in thickness at the point of insertion of the cord, and weighing about sixteen ounces. Upon Fig. 88. — Section of placental villi of a normal placenta at term : M, Fetal mesoderm ; S, syncytial masses ; V, V / , fetal vessels ; L, maternal lacunae, con- taining maternal blood (Durante). Fig. 89. — Surface of villus at three weeks, showing syncytial band, A, and Langhans' cells, B (500 enlargement) ; C, stroma of villus. the surface of the placenta into which the cord enters is seen a smooth, shining membrane, continuous with the sheath of the cord, — the amnion. The fetal side of the placenta contrasts strongly with the maternal surface. The latter is of a dark-red hue, divided by deep sulci into lobules of irregular outline and THE PLACENTA. 121 extent, — the cotyledons. Over the maternal surface of the pla- centa is stretched a delicate, grayish, transparent membrane, which is made up of the cells that compose the upper layer of the decidua serotina. This constitutes the maternal portion of the placenta. In separating from the uterine wall, therefore, the line of separation does not divide the fetal from the maternal struc- tures, but is found in the mucous membrane of the uterus, in the lower portion of the cellular layer of the decidua. Around the periphery of the placenta may be seen a large vein, the circular vein of the placenta, which returns a part of the maternal blood from the organ, the remainder returning to the maternal circula- tion by means of the continuity between the placental lacunae and the uterine sinuses. The situation of the placenta within the Fig. 90. — Diagram of uterus and placenta in the fifth month : Ch, Chorion ; am, amnion; V, V, villi; L, L, lacunae; s, serotina; v, small arteries; /, glandu- lar layer ; m, uterine muscle (Leopold). uterus may with equal frequency be found upon the posterior or the anterior wall ; occasionally, however, upon one of the lateral walls, more frequently the right. A perpendicular section through the middle of a placenta that is still attached to the uterine wall reveals an intimate connection between the two. The delicate terminal villi, and even branches a millimeter in thickness, are imbedded in the upper portion of the decidua, and held in place by their extremities bulging out into club-shaped masses, so that the exercise of considerable force will not extract them from the uterine mucous membrane, but will, instead, always lacerate the maternal structures. The functions of the placenta are manifold. Not only does it 122 PREGNANCY. act as a lung, or, rather, gill, in oxygenating the fetal blood, but it maj' be said to take the place of the alimentary tract in absorbing nutritive material from the maternal circulation. It plays, moreover, the part of an excretory organ, getting rid of the surplus carbonic acid gas in the fetal blood and of the other waste-products of tissue-activity. Bernard has shown that in the earlier months of pregnancy the placenta has a glycogenic function. The epithelial cells of the chorion villi exercise selection in the passage of substances between the fetal and the maternal blood. Some pathogenic micro- organisms — as, for instance, those of variola — pass easily from mother to fetus, while the bacilli of tuberculosis, a disease often present in pregnant women, are almost never found in the fetus. Certain drugs, also (iodid of potassium, benzoic acid, bichlorid of mercury), enter the fetal from the maternal blood, while it is asserted that others, as woorara, will not pass to the fetus from the mother. Again, while nutritive material must pass from mother to fetus, the escape of the same material from the fetal into the maternal blood would prove destructive to the fetus. Anomalies of the Placenta. — The placenta may present de- viations from the normal in size, position, shape, weight, or num- ber. Its structure may present anomalies the result of diseases or accidents, and there may be anomalies of function. Anomalies of Position, Size, and Weight. — The position of the placenta is normally near the fundus uteri. A low insertion is a Cause of placenta prcevia. The size of the placenta varies considerably. Its thickness is in inverse ratio to its extent, and the younger the ovum, the greater the relative size of the placenta. The placenta has been known in rare cases to extend around the whole periphery of the ovum. This condition is called placenta membranacea, and is explained by the equal de- velopment of all the chorional villi. The placenta ma}' be abnormally thick and enlarged in all directions, from the hyper- plasia due to a chronically inflamed endometrium. An abnorm- ally small placenta maybe associated with an ill-developed child, may depend upon an interstitial overgrowth with subsequent re- traction, or may be due to atrophy of the decidua. Anomalies of Shape and Number. — The placenta, usually round or oval, may have a horseshoe or crescentic shape, especially if it is inserted near the internal os, which is surrounded by the two arms of the crescent. In multiple pregnancies (not unioval) each child has its own placenta (Fig. 91). A single child may have two (placenta duplex), three (placenta tripartita), or more placentae (placenta multiloba), or a single placenta may be reinforced by one or more small accessory placental develop- PLATE 3. Anomalies of the Placenta: I, Placenta with irregular lobes (Auvard) ; 2, placenta in two unequal lobes (Auvard) ; 3, irregular placenta (Auvard) ; 4, small accessory placenta (Ribemont- Lepage) ; 5, placenta succenturiata ( Ribemont- Lepage) ; 6, "battledore" placenta, oval (Auvard) ; 7, placenta with velamentous attachment of cord (Ribemont- Lepage) ; 8, placenta with two equal lobes (Ribemont-Lepage). THE PLACENTA. 1 23 ments (placentae succenturiatae), which are in direct communi- cation with the blood-sinuses of the decidua vera. If the villi of these accessory growths do not communicate with the maternal blood, they are called placentae spuriae. Taurin ! has reported a case of annular placenta, extending almost completely Fig. 91. — Placentae of triplets. around the ovum as it does in some animals, but separated indis- tinctly into three lobes. Edema of the Placenta. — A serous infiltration of the whole placenta is often observed with a dead and macerated fetus. 2 The same condition is often associated with general anasarca of the fetus, with some obstruction of the umbilical vein or of the venous system of the fetus, or with a greatly hypertrophied pla- centa which absorbs more fluid than the fetal economy can dispose of (Werth). The minute anatomy of the placenta may remain normal in this disease and the placenta may continue to perform its physiological functions. Degeneration of the Placental Villi. — The morbid processes abrogating the physiological activity of the placental villi are, hypertrophy, fibrous and fatty, caseous (phthisical placenta), calcareous, and myxomatous degenerations. Placental hemor- rhages, placental syphilis, and solid tumors of the placenta have, 1 " Nouv. Arch. d'Obstet.," 1893, p. 486. 2 Tarnier et Budin, op. cit., p. 329. 124 PREGNANCY. as a result, the destruction of all or a part of the placental villi as factors in the nutrition and aeration of the fetal blood, but these conditions are considered separately. Cellular Hypertropliy. — Ercolani 1 has described a "cellular hyperplasia and hypertrophy of the parenchyma of the placental villi," characterized by such an extensive multiplication of the cellular elements in the villi as often to obliterate the blood- vessels and to give the placenta a hard, dense appearance and feel that has been called by other writers sclerosis of the placenta, and has been attributed to the overproduction of fibrous tissue. Cellular hypertrophy is seen in syphilitic disease of the villi. Fibrous and Fatty Degeneration of the Placenta. — A fibrous and fatty change in the placental villi is common. Isolated ex- amples of it may be found in almost every placenta, especially toward the periphery. The two processes are always associated, except when the degeneration of the placenta follows the death of the fetus. In this case there is a simple fatty change with- out other pathological process (Barnes). It has been claimed by some observers, as Barnes 2 and Kilian, 3 that fatty degenera- tion of the placenta is the primary pathological process, originat- ing independently of other degenerative changes ; and that this degeneration is only an exaggeration of the condition always found in the placenta toward the end of pregnancy; but most modern investigators agree with Robin and Ercolani that the fatty change is subsequent to other degenerative processes, usu- ally an abnormal development of fibrous tissue, — interstitial pla- centitis. It has been denied that an inflammation of the placenta can occur. There are. however, the same multiplication of con- nective-tissue cells and a subsequent contraction that is always seen in a chronic inflammation. The fibrous change may originate in the decidua serotina, the placental villi, or the intervillous spaces. If the disease affects the decidua serotina, it is associated with chronic inflammation of the remainder of the endometrium, and is really an endometritis. As it progresses, the placenta becomes secondarily involved, either by the encroachment of the hypertrophied decidua upon the intervillous spaces, and the con- sequent compression of the villi, or by the agglutination of the decidual layers resulting in a firm adhesion of the placenta to the uterine wall. Hegar, Maier, and many others have described this disease as interstitial endometritis. 4 The same microscopic appearance may be seen in a hyper- 1 " Delle Malattie della Placenta," Bologna, 1871. 2 "Med.-Chir. Trans.," 1851. 3 " Neue Zeitschr. f. Geburts.," 1850. 4 Virchow's " Archiv," 1871. THE PLACENTA. 1 25 trophied decidua throughout its extent, and is not confined to the placental site. It is, however, possible to find an endome- trium in an advanced stage of hyperplastic inflammation, while the upper layer of the decidua serotina remains unchanged, even although the placental site itself is immensely thickened by new- formed connective tissue and enlarged blood-sinuses. In such a case the placenta remains unaffected. The fibrous degeneration may have its seat in the placental villi alone. The process that transforms a healthy villus contain- ing blood-vessels into a bundle of connective tissue can be studied in the extraplacental villi of the chorion, which normally undergo a fibrous degeneration, as they begin to atrophy at the third month of pregnancy. The mucous tissue in the interior of the villi is converted into fibrous tissue, the blood-vessels are obliterated, and the villi shrink, atrophy, and become more or less infiltrated with fat. This same process may be seen in isolated villi of almost every placenta. If the degeneration is more extended, the functions of the placenta are naturally abrogated. " Placental infarcts," so commonly seen as whitish nodes in the majority of pla- centae, are examples of a fibrous degeneration due, according to Williams, to an endarteritis of the vessels of the villi, a coagula- tion-necrosis and the formation of canalized fibrin. 1 According to Neumann, 2 the interchange between fetal and maternal blood maybe prevented by the great hypertrophy of the placental villi and their consequent encroachment upon the maternal blood-spaces. There may be an overgrowth of connective tissue in the intervillous spaces. It has been ascribed by Simpson, Roki- tansky, Scanzoni, Priestley, and others to an inflammation fol- lowed by a cellular exudate which organizes into connective tissue. Priestley has described, under the name of placental phthisis, a pathological condition of the placenta brought about in this way: The first stage of the disease consists of an exuda- tion or deposit thrown out among the villi, probably due to some modification of a low inflammatory process, the result of which is a sort of "hepatization" of the part affected. The mass thus formed either remained dense and firm throughout, or else in the center might be found a crumbled and disintegrated substance resembling the result of cheesy degeneration of tuberculous masses in the lung. As a result of this disintegration there may be found evidences of old hemorrhages in blood-clots at different stages of organization. The result of fibrous degeneration of the placenta, wherever 1 " The Frequency and Significance of Infarcts of the Placenta, Rased upon the Microscopic Examination of 500 Consecutive Placentas," Whitridge Williams, Johns Hopkins Hosp. Rep., vol. ix. 2 See Priestley, Virchow's "Archiv," 1871, p. 54, 126 PREGNANCY. the disease originates, is to prevent the performance of its most important vital functions, and if the pathological condition in- volves a large area of the organ, it must prove destructive to the fetus. The deprivation of their blood-supply determines the fatty degeneration, or in some cases amyloid degeneration, 1 of the placental villi. This fatty infiltration is the more marked, as a rule, the older the original lesion. Thus, Bustamente's 2 de- scription of a " sclerotic " placenta as presenting a reddish, spotted, lobulated, or smooth mass resembling the thymus, would be applicable to a fibrous placenta, in which fatty degeneration had not advanced very far. In the latter case the organ would pre- sent a paler, yellowish hue. The diagnosis of fibrofatty degen- eration of the placenta is impossible during pregnancy. Such a condition may be inferred if there is a history of previous repeated occurrences of the disease. Myxomatous Degeneration. — The myxomatous degeneration that has already been studied in the chorion villi may be confined to the placenta, while the extraplacental chorion remains healthy. Myxoma fibrosum placental has already been described. This affection has been observed by Virchow, 3 Storch (two cases), 4 Hildebrandt, 5 and Sinclair. 6 Calcareous Degeneration. — Depositions of small quantities of lime in the placenta are not at all uncommon. They are usually to be found in that portion of the maternal placenta lying nearest the villi, or they may originate in the villi themselves. Cham- bord 7 has found as many as five hundred concretions in one placenta. It has been said that extensive calcification of the pla- centa is more apt to occur after the death of the fetus, but Tar- nier asserts that there is no relation of cause and effect between the two, and that the occurrence of large calcareous deposits in the placenta with still-born children is a mere coincidence, as it is also in cases in which calcareous degeneration is associated with syphilis. 8 Placental Syphilis. — From the end of the last century, when Astruc first called attention to the fact that syphilis of either parent was apt to result in the birth of still-born and macerated children, until the appearance of D'Outrepont's paper 9 in 1830, the opinion prevailed that the cause of the repeated fetal deaths 1 Green, "Am. Jour. Obstet ," 1880, p. 279. 2 '• These de Paris," 1868. 6 Loc. cit., p. 414. 4 Virchow's "Archiv," 1878; andBreus' "Wien.med. Wochens.," i88i,No 40. 5 " Monat. f. Geb.," Bd. xxxi, S. 346. 6 "Jour. Obstet. Soc," Boston, 1871. 7 "Lyon Medicale," 1873, p. 431. 8 See also Frankel, "Archiv f. Gyn.," Bd. ii, S. 373; Winckler, "Archiv f. Gyn.," Bd. iv, S. 260 ; Langhans, "Archiv f. Gyn.," Bd. iii, S. 150. 9 " Ueber die Krankheiten u. Abnorm. der Placenta," " Gem. Deutsche Zeitschr. f. Geburtsh.," Bd. v, 518. THE PLACE XTA. I2 7 must be sought for in syphilitic disease of the viscera. It was the last-named author who first called attention to the influence of the diseases of the placenta upon the nutrition and the life of the fetus. Shortly afterward followed Simpson's well-known work, 1 and ever since the changes associated with syphilis have been carefully studied. Virchow was the first to investigate the lesions in the maternal and in the fetal portions of the organ and to consider apart the changes in the decidua serotina (endometritis placentaris gummosa) and those in the extra- placental decidua (endometritis decidualis). No considerable advance was made in the knowledge of placental syphilis Fig. 92. — Section of villi, showing small-cell infiltration and the deformed shapes of villi : A, A, Luxuriant cell-development in the interior ; V, V, lumen of blood-vessels with hypertrophied walls ; B. villus in which only a trace of blood-vessels can be seen at S ; C,C, villi without trace of vascular canal ; D,D,D, epithelial covering (Frankel). until Slavjansky and Kleinwachter 2 called attention to the development of fibrous nodes "of a syphilitic nature" in the fetal portion of the placenta and to the degeneration of the epithe- lium in the placenta materna. In 1873 appeared Frankel's paper in which he claimed to be the first to demonstrate that the " de- forming granular hyperplasia and hypertrophy of the placental villi," described by Ercolani, without reference to its connection with syphilis, was the most frequent form of placental syphilis. According to Frankel, this infiltration of the villi with K'Edin. Monthly Jour, of Med. Sci.," Feb., 1845; "Obstet. Works," vol. ii, P- 445- 2 See Frankel, " Ueber Placentar Syphilis," " Archiv f. Gyn.," Bd. v, S. 6. 128 PREGNANCY. granulation-cells, and their consequent increase in size and distorted shapes, are characteristic of syphilis and make certain the diagnosis of the disease. The seat and extent of the lesion vary with the manner and time of the fetal infection. If the ovule is infected by the impregnating spermatic particle, the placenta, if diseased at all, constantly presents the granulation- cell infiltration of the villi and the degeneration of their epithelial covering. If the mother is infected during the fruitful coitus, there may be endometritis placentaris characterized by an enormous overgrowth of the decidual cells or the overgrowth of connective tissue as well as syphilitic disease of the villi. If the mother is syphilitic before conception, the disease of the placenta takes the form of endometritis placentaris gummosa. If the mother is infected during the latter months of pregnancy, the placenta usu- ally remains unaffected. Frankel bases these conclusions upon the examination of more than one hundred speci- mens, and his views have been confirmed by Hen- nig x and McDonald. 2 Specimens of syphilitic placentae in my posses- sion show the condition of the villi described by Frankel, and also an endo- metritis placentaris gum- mosa, in which the decidual cells are enormously in- creased and overgrown, encroaching deeply upon the intervillous spaces and undergoing degeneration in places. In one case, in which the mother was in- fected at about the fifth month of pregnancy, the placenta materna at birth was greatly thickened, and showed under the microscope an extraordinary development of connective tissue. The fetal placenta and the child itself were perfectly healthy. In their macroscopic appearances syphilitic placentae may differ considerably. If the child has been dead some time, the placenta may be almost white in appearance and soft and greasy in feel. 3 If the child is expelled alive at term, the placenta is often unusually large and of a pinkish color, due to the thickened i "Archiv f. Gyn.." Bd. vi, S. 141. 2 " Br. Med. Jour," Aug., 1875, p. 234. * Charpentier, " Syph. hereditaire," 1870, " Presse Med. Beige," No. 8. Fig. 93. — Syphilitic disease of the placenta, showing: Frankel' s disease. THE PLACENTA. 1 29 decidua, which prevents the true color of the organ from appear- ing. There may be organized clots, showing a previous hemorrhage into the placenta or the occurrence of thrombosis in the lacunae; or there may be nodes 1 of varying extent, lamellated in structure and undergoing degenerative changes in the central portions. Frequently there is extensive calcareous degeneration. The consequence of syphilitic disease of the placenta is usually disastrous to the fetus and often dangerous to the mother. The cellular infiltration of the villi obliterates the blood-vessels within them, and consequently abrogates their functions. The same effect may be produced by the hyperplasia of the decidua serotina and the consequent encroachment of the decidual tissue upon the intervillous blood-spaces, or the destruction of the villi may be brought about by the formation of the nodular masses that have been noticed. All these processes, if, as is the rule, they invade the whole area of the placenta, must, of necessity, be fatal to the fetus. The endometritis placentaris that is often a prominent feature of placental syphilis may prove dangerous to the mother by matting the layers of the decidua serotina together, thus subjecting the woman to the perils of hemor- rhage, septicemia, or inversion of the uterus that are incidental to adherent placentae. The accurate diagnosis of placental syphilis is impossible during pregnancy. The condition may be inferred with con- siderable certainty, however, should a history of syphilitic infec- tion be obtained from either parent. The treatment is referred to later under the head of Fetal Syphilis. Placental Hemorrhages. — The term placental hemorrhage is used to indicate circumscribed collections of blood that have undergone more or less change. The blood may be found as a fresh clot, sometimes occupying a large area, especially when abortion follows the premature detachment of the placenta; the extravasated blood may be encapsulated, surrounded by a fibrous wall of varying thickness, within which is a reddish or a brownish fluid ; the cyst may contain nothing but clear serum, while the coloring-matter of the blood is deposited upon the cyst-wall or upon the surrounding villi. 2 The encysted hematocele may con- tain large numbers of white blood-corpuscles undergoing fatty degeneration, giving rise to a liquid resembling pus. It is such cases, according to Tarnier, that have been described as abscesses of the placenta by Brachet, Cruveilhier, O'Farrell, and Simpson. 1 Ziller, " Studien liber Erkrankungen der Placenta," etc., Tiibingen, 1S85. 2 Ercolani has described a case of "placental melanosis" in which there was no trace of blood-extravasation, but the villi were infiltrated with pigment granules ('• Archiv de Toe," 1896, p. 193). 9 130 PREGNANCY. The fibrin may predominate, as in the cases of throm- bosis of the placental sinuses described by Bustamente l and Slavjansky, 2 in which, if the clot is slowly formed, the re- sulting mass consists of laminated fibrin, as in aneurysms undergoing obliteration. In other cases the serum is rap- idly absorbed, and there is left a mass of red globules con- taining white corpuscles, either heaped together or scattered through the mass. Finally, the clot may organize, and thus form a distinct neoplasm in the placenta. The placental villi surrounding the extravasated blood usually undergo a fibro- fatty change. The causes of placental hemorrhage are manifold. The pre- disposing causes are pelvic congestion and albuminuria (Win- ter, Fehling) ; the slow-moving blood-current in the placental sinuses and the excess of fibrin in the blood of pregnant women, predisposing to thrombosis ; and diseased conditions of the placental villi. The determining cause may be a sud- den, powerful action of the heart ; syncope, favoring the for- mation of a thrombus ; or external violence. In the early months of pregnancy hemorrhage is most frequently due to a true apoplexy, a rupture of the delicate new-formed blood-vessels in the decidua. Later, it is more frequently thrombosis in the sinuses, or the laceration of the delicate blood-vessels that perfor- ate the upper layer of the decidua serotina to enter the placental sinuses. 3 The consequence of placental hemorrhage to the fetus de- pends upon the amount of blood extravasated. Should the quantity be large, either the number of villi strangulated by the clot is so great that the fetus is at once asphyxiated, or else the escaping blood is able, especially in the earlier months, to strip the placenta off from the uterine wall, with the same result. The effect of placental hemorrhage upon the mother is usually unno- ticeable, except in case the fetus is killed, when the whole ovum may be prematurely expelled. In some instances, however, the blood forces itself between the placenta and uterus, and, bur- rowing its way downward through the layers of the decidual, makes its appearance externally as a hemorrhage from the uterus. Or else the blood, unable to escape, collects at the placental site, or possibly over a large area, sometimes in such quantities as to form distinctly an additional tumor of the uterus 1 Loc. cit. 2 " Archiv f. Gyn.," 1873, Bd. v, 360. 3 My friend Dr. Robert H. Hamill, of Philadelphia, has shown me a specimen exhibiting an interesting variety of placental hemorrhage. Immediately beneath the amnion there was a large clot occupying more than half the area of the placenta, and evidently containing all the blood of the fetal body. The fetus, corresponding in development to the fourth month, had bled to death into its own placenta from the rupture of a large branch of the umbilical vein. THE PL A CENTA. 1 3 I appreciable through the abdominal walls, and also to give rise to all the symptoms of internal hemorrhage. Placentitis. — An interstitial placentitis has already been de- scribed. Older authors paid particular attention to inflammations of the placenta, and Simpson described three stages of the dis- ease — the first characterized by congestion, the second by plastic exudation, the third by suppuration. Numerous instances have been recorded in which "pus" was found in the placenta, but the majority of the cases reported will not bear modern investigation. There are, however, authentic instances of such an occurrence. 1 Cysts of the placenta are not rare. In the majority of cases they are the result of hyperplasia of the cells of Langhans' layer and subsequent liquefaction of a secretion from these cells. They are sometimes due to a circumscribed, unusually fluid myxoma. 2 Jacquet 3 has described small cysts springing from the blood-vessel walls. Tumors of the Placenta. — The tumors of the placenta formed in the fibromyxomatous degeneration of the villi have already been noticed. Organized blood-clots have also been described as tumors of the placenta. Hecker 4 speaks of a fleshy sub- stance expelled from the uterus post-partum, although the pla- centa had come away entire, as possibly a placental tumor. This may, however, have been nothing but a uterine polypus or a piece of hypertrophied and angiomatous serotina. 5 Malignant groivths at the placental site have long been recog- nized under the name of malignant placental polyps. In 1888 Sanger described a sarcoma of the decidua serotina. His article attracted great attention and was immediately recognized as most important both in the nature of the tumor described and in its histology. The attention of physicians all the world over being directed to the matter, malignant tumors of the placental site were found to be rather common. The author saw two in three years. It was soon realized, however, that the majority of the growths observed were carcinoma and not sarcoma, and a close study of their histology demonstrated the fact that the cancer has its origin in the syncytial cells of the chorion villi. Even in the metastases the syncytium of the placenta is everywhere reproduced. From recent sections of the original tumor studied by Sanger, it appears that it really was a sar- coma. It is now admitted that both sarcoma and carcinoma may develop at the placental site, the former from the decidual cells (deciduo-sarcoma, deciduoma malignum), the latter from the 1 See Schroeder, " Lehrbuch," ed. of 1884, p. 450. 2 "Archiv f. Gyn.," Bd. xi, S. 397. 3 "Gaz. med. de Paris," Oct. 14, 1S71. 4 "Klinik der Geburtsh.," 1864. 5 See paper by the writer in "Am. Jour. Obstetrics," Dec, 1887. 132 PREGNANCY. syncytium (chorio-epithelioma, carcinoma syncytiale, syncytial cancer, syncytioma malignum). Cancer of the placental site is vastly more common than sarcoma. Gaylord has collected 55 reported cases; Veit, 1 89; Teacher, 2 189; and Briquel, 3 254. Both of these malignant growths have a rapid course, ending fatally in from three to six months. Metastases are numerous and occur early. A metastatic growth of syncytial cancer is pos- sible without a trace of the original tumor. Schmorl 4 reports a syncytial cancer of the vagina with numerous metastases, the uterus being healthy. It is supposed that the original growth m Fig. 94. — Syncytial cancer: Masses of fibrin, A, containing islands of proliferated syncytial cells. is removed with the exfoliation of the decidua serotina, or that there is a metastasis of chorion villi, followed by malignant de- generation of their epithelium. Stoeckel, Runge and Jaffe, and Pick 6 have demonstrated an invariable association with chorio-epithelioma, in all the cases they examined, of an over-production of lutein and frequently of 1 "Tr. of the Section on Gyn.," College of Physicians of Philadelphia, 1898. 2 "Journ. of Obstet. and Gyn. of the Brit. Empire," August, 1903. 3 "Tumeurs du Placenta et Tumeurs Placentaires," p. 620, Paris, 1903. * "Centralbl. f. Gyn.," 1896 5 Zagorjanski-Kissel has collected 17 cases; loc. cit. 6 "Centralbl. f. Gyn.," No. 34, 1903; see also Krebs, "Centralbl. f. Gyn.," Oct. 31, 1903, No. 44; "Arch. f. Gyn.," Bd. lxxi, H. 3. THE PLACENTA. 133 multiple corpus luteum cysts and an infiltration of the ovarian stroma by lutein cells. The association of hydatidiform mole and chorio-epithelioma is intimate. Briquel found that in 45.5 per cent, of 217 cases the degeneration of the villi had preceded the cancer. Symptoms and treatment : Uterine bleedings with a foul- smelling discharge weeks, months, and even years 1 after an abor- Fig. 95. — Chorio-epithelioma of the vagina without involvement of the rest of the genital tract (Hiibl). tion or delivery at term should arouse suspicion of a malignant growth. If neoplastic masses are removed, and recur with the original symptoms in a few weeks, the suspicion is strength- ened. A microscopic examination of the material removed may make the diagnosis certain, but the penetration of the myometrium by syncytial cells, always observed in pregnancy and exaggerated in cases of retained fragments of placenta or other diseases of the endometrium, must be remembered. Metastases are often ob- 1 Veit mentions cases occurring two, three and one-half, and three and three- fourths years after delivery. " Handbuch der Gynak.," iii, 2, p, 585. 134 PREGNANCY. Fig. 96. — Syncytial cancer (Gottschalk). served in the vagina. The uterus is large and soft, the os patulous. The treatment is a hysterectomy at the earliest possible moment after making the diagnosis. Veit has collected 29 successful op- erations out of 89 cases. Chorio-epithelioma has been demonstrated in dermoids of both the ovary and testicle, in a young virgin and in the brain of a man, derived from a trophoblast de- veloped in the course of a dermoid growth. 1 Other tumors of the placenta are myxomata fibrosa, localized hyper- trophies, angiomata, 2 and organized thromboses. Bode and Schmorl 3 re- port as a tumor of the placenta (fibroma) a fi- brous degeneration of a placenta succenturiata. They have collected the reports of thirty placental tumors. Albert (loc. cit.) adds six cases to their list. Placental polyps developing at the placental site after labor are due to a sort of stalactitic deposit of blood-fibrin on a mass of 1 Zabinsky, "Zentralbl. f. Gyn.," No. iS, 1904. 2 Albert, ''Archiv f. Gyn.," Bd. lvi, H. I, p. 144. 3 "Archiv f. Gyn.,'' Bd. lvi, H. 1, p. 73. Fig- 97- — Metastasis of syncytial cancer in liver, showing cells from Langhans' layer and true syncytial cells. THE UMBILICAL CORD. 135 decidua or a fragment of placenta. Localized tumors in the placenta are rare. Leopold in more than 7000 specimens found such a tumor only once. 1 THE UMBILICAL CORD OR FUNIS. The early development of the umbilical cord, or the formation of the allantois, has been studied upon the lower animals, as in all the human embryos observed the connection between the embryo and the chorion was already established. Indeed, accord- ing to His, the human embryo is from the first in connection with the periphery of the ovum. Very early, therefore, in embryonal life there may be observed a sac-like projection from the posterior end of the intestinal tract, which, at first solid, but later contain- ing a canal, grows outward and backward, owing to the presence of the large umbilical vesicle anteriorly, until it comes in contact with the periphery of the ovum. Within this sausage-shaped 2 Fig. 98. — A, Umbilical arteries forming spirals (z, i) around the vein ; con- strictions indicating the presence of folds (d, e) ; circular folds (d, e) ; lateral openings showing the arterial walls ; B, vein opened upon the side showing a con- striction (i>) corresponding to an interior valve [e) ; semilunar valves (c, d, e) ; C, section of vein and arteries showing valve of vein (a), a semilunar arterial valve (£), and a circular arterial valve (ir- '• ■ — - W'\'i. 1 W Fig. 169. — Fetus in its membranes. Fig. 170. — Dead embryo in a capsule of thickened decidua. Absorption of the liquor amnii. Fig. 171. — Young embryo, thickened decidua, and ruptured ovum. Fig. 17?. — Ruptured membranes, embryo, and newly formed placenta. ABORTION, MISCARRIAGE, AND PREMA TURE LABOR. 267 and hemorrhage, the former is, in early abortions, usually the sub- ordinate one. The hemorrhage is not often excessive, but may become alarming. The blood is not expelled in a steady flow, but from time to time as coagula. When the uterus discharges its contents the appearance of the substance expelled differs as the ovum is cast off entire with its shaggy, chorional coat, or surrounded by the decidua, which is often much thickened ; as the embryo, enveloped by its amnion, is extruded without the decidua and chorion, or as the embryo, its delicate umbilical cord being ruptured, is expelled alone. The appearance of the embryo varies, of course, with the different periods of preg- nancy : if still inclosed in its amni- otic sac, a thin-walled, transparent vesicle may be found floating in the blood or imbedded in a clot, and within the sac the embryo is seen floating in the liquor amnii. In other cases the ovum resembles a ball of flesh, which, on being opened, discloses an embryo con- fined within a sac with very thick Fig . i 73 ._Embryo of about four walls, composed mainly of greatly weeks, with its membranes entire. hypertrophied decidua. Or, again, the substance expelled from the uterus may be a fleshy mass, the deciduous membrane, in shape a cast of the uterine cavity, within which there is an empty cavity. The embryo in these cases has either died and been absorbed, or else has been pre- viously cast off unnoticed in the bloody discharge. If the ovum proper is cast off entire, — that is, with its cho- rional covering intact, without adherent shreds of deciduous membrane, — it presents an appearance quite characteristic, espe- cially if floated in water ; the chorional villi show to the best advantage, giving the ovum much the appearance, except for its color, of a chestnut-bur. Most frequently it is the embryo alone, or at most the ovum, in whole or in part, covered often by the ovular decidua, that is discharged, while the uterine decidua remains behind within the uterus. 1 The retention of this membrane after abortion can not be regarded with indifference. The thickened uterine decidua, sud- denly cut off from the greater part of its blood-supply by con- 1 Duhrssen, " Zur Pathologie unci Theiapie des Abortus," " Archiv f. Gyn.,'' Bd. xxxi, H. 2. 268 PREGNANCY. traction of the uterine wall, becomes a mass of dead flesh within the uterus, and soon putrefies, or else portions of the decidua attract an increased blood-supply, retain their original develop- ment, and even increase in size, forming new growths within the uterus which give rise to frequent and alarming hemorrhages or to persistent metrorrhagia. It is this complication of abortion that often makes the prog- nosis uncertain, and is perhaps the main factor in raising the mortality after abortions almost as high as that of childbirth at term. In New York City, between the years 1867 and 1875, inclusive, 197 deaths were reported as a result of abortion, — a number doubtless far short of the truth. In the Rotunda Hos- pital of Dublin, during the mastership of Dr. Johnston, 234 abortions occurred, with but I death, and that from heart dis- ease. 1 But of 120 cases treated in the clinic and polyclinic of the Charite in Berlin, 2 died. 2 Of 82 abortions in the Obstet- rical and Gynecological Institute of Florence, 3 5 resulted fatally to the women, — a death-rate of six per cent. In the Charite at Paris (1883-86) there were 57 cases of abortion without a death; and in the Maternite, 153 cases with 1 death (Tarnier). In the Woman's Hospital of Bern, of 484 abortions, 4 ended fatally. 4 Hospital statistics, however, as to the death-rate after abortion, are unsatisfactory. The reliable records of some large out-door dispensary service would throw light upon the matter. Diagnosis. — It may be necessary in cases of suspected abor- tion to determine the existence of pregnancy ; that fact being established, it becomes necessary to distinguish between threat- ened abortion, inevitable abortion, and an abortion partially or wholly accomplished. The Diagnosis of Threatened Abortion. — If a patient presents a history of suppression of the menses; if she has been exposed to the possibility of impregnation ; if there are, in short, the signs of early pregnancy, and a hemorrhage occurs from the uterus, associated with more or less pain, a threatened abortion is probable. Irregularities in menstruation, the suppression of the function from causes other than pregnancy, and its reestablish- 1 Lusk's "Obstetrics," 1886, p. 313. 2 Diihrssen, loc. cit. This same author mentions the statistics of 520 cases of abortion collected in the inaugural thesis of Lechler (Berlin). Half of these, treated by active interference, showed 4 deaths, — 3 from intercurrent affections, 1 the result of abortion. 3 Fasola, " 82 aborti nel trienno, 1883-85/' " Annali di Ostet. e Gynecol.," March, 1887. 4 '' Swiss Dissertations," F. Moser, Bern, 1900. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 269 ment by a profuse flow, accompanied by pain, might well arouse a suspicion of abortion. In these cases, however, the signs of pregnancy are absent and the os is not patulous. But this is by no means true of every case ; and if the symptoms should be due to an effort of the uterus to expel a polypoid tumor, the case may so closely resemble one of abortion that the diagnosis is only made after the expulsion of the uterine contents or the dilatation of the os. In cases of doubt the diag- nosis should rest on abortion and the woman should be treated accordingly. The Diagnosis of Inevitable Abortion. — It is always desirable to determine when a threatened abortion becomes inevitable, for if its prevention is no longer possible, the treatment should be radically altered. Unfortunately, the signs which usually denote an unavoidable expulsion of the ovum can not always be depended upon. If there is persistent hemorrhage, abortion will usually occur, but even in spite of a bleeding which may continue for a considerable time or return at intervals during the whole duration of gestation, the pregnancy may go on to term. If the cervix becomes markedly softened and the os dilates, the ovum will ordinarily be cast off; and yet the os has dilated sufficiently to admit two fingers, but has again retracted, and pregnancy has pursued its course. If portions of the uterine contents should be expelled, it would seem that abortion was surely inevitable ; but Playfair, Charpentier, and Doleris have reported cases in which pieces of decidua were expelled from the uterus without the interruption of pregnancy. In Playfair's case four or five fragments of decidua, each as large as a fifty-cent piece, were cast off in the third month of pregnancy as a result of the introduction of a sound into the uterus ; but the woman went on to term. The only two conditions which can be said to render the abortion almost inevitable are the rupture of the membranes and the death of the embryo ; but even were it pos- sible to ascertain with certainty, during the early months of pregnancy, that the membranes were ruptured or that the embryo was dead, cases might be recalled in which the liquor amnii was resupplied after puncture of the pregnant uterus with a trocar (Chiara), and after rupture of the membranes, and there has been a retention of the ovum after the death of the embryo for months or for an indefinite number of years. If the hemorrhage is persis- tent ; if the os dilates ; if there is felt presenting within the os a cystic tumor — the ovum ; 1 if the pain is considerable ; and, above 1 It is well to bear in mind in this connection the possibility of the cervical pregnancy of Rokitansky, already referred to, of which several cases have been reported. 270 PREGNANCY. all, if portions of the ovum are expelled, abortion may be pro- nounced inevitable. Tarnier x calls attention to a sign which is valuable as indicating an unavoidable abortion. This is the effacement of the acute angle formed anteriorly between the neck and body of a pregnant uterus. The disappearance of this angle indicates a contraction of the longitudinal fibers of the uterus and a descent of the ovum. The Diagnosis of an Abortion Partially or Wholly Accomplished. = — It is always important to determine, in a case diagnosticated as one of abortion, whether a part or the whole of the uterine con- tents has been expelled. To make the diagnosis of an abortion partially or wholly effected it is necessary to examine everything discharged from the uterus ; the clots should be floated in water, and should be carefully teased apart, when an embryo, alone or enveloped by its membranes, may be discovered. But frequently the embryo and ovum are so small that they are lost in the com- paratively great volume of blood that surrounds them, or the discharges are removed from the patient and are not preserved. In such cases an internal digital examination ordinarily serves to determine the true nature of the case. The os is usually patulous; the finger, passing into the cavity of the uterus, detects shreds of deciduous membrane more or less closely at- tached to the uterine wall, and often a placenta, still adhe- rent, or some portions of the. fetal membranes may be plainly distinguished. If the abortion has been wholly accomplished, — that is, if all the uterine contents, including the hypertro- phied decidua, have been completely expelled, — the uterus is firmly contracted, the os is small, and a digital examination of the uterine cavity is difficult or impossible. The diagnosis must depend upon the history of the case, upon the examination of the discharge, upon the enlarged uterus, — which does not at once return to its normal size, — upon the lochial discharge, and upon the establishment of the milk secretion. The last phe- nomenon is all the more marked the later the date of pregnancy at which abortion or miscarriage occurs, and is more evident in multiparas than in primiparae ; but Budin has observed a young girl in whom the menses were suppressed for only twenty days, and then returned as a profuse flow, who exhibited shortly after- ward all the signs of commencing lactation. In some cases the disappearance of all the presumptive signs of pregnancy, which had been before well marked, would justify the opinion that an abortion had occurred ; but it might denote nothing more than the death of the embryo, which can be re- 1 Tarnier and Cazeaux, vol. i, p. 574. ABORTION, MISCARRIAGE, AND PREMA TURE LABOR. 2J I tained within the uterus for varying periods of time, and when cast off may give rise to unjust suspicions as to the woman's moral character. Thus, if a woman whose husband has been absent many months should expel from her uterus an embryo corresponding perhaps to the second month of intra-uterine life, it by no means invariably follows that she has been unfaithful. Finally, if in the early months of pregnancy there is hemor- rhage and a discharge of deciduous membrane, it is always wise, while making the digital examination, to feel on either side of the uterus for a tumor that might indicate a tubal pregnancy, and to inquire for the characteristic pain of that condition. A large proportion of the cases of extra-uterine pregnancy in the author's case-books were mistaken by their medical attendants for an in- complete abortion. Prognosis of Abortion and Miscarriage. — The destruction of the embryo is inevitable. Statistics have been given show- ing that every abortion or miscarriage entails a risk upon the woman. The hemorrhage, if rarely so great as to be immedi- ately fatal, may, by its persistence, so weaken a woman that she quickly succumbs if attacked by an intercurrent affection, or the syncope produced by loss of blood may favor the forma- tion of heart-clot. The retention of masses of decidua or of placenta is often followed by their decomposition, by chronic salpingo-oophoritis, or even by fatal septicemia. Tetanus is another complication which, in rare cases, helps to raise the mortality. 1 Criminal abortions, with the additional risk of trau- matism from the unskilful use of instruments, and the probability of infection from unclean hands and implements, would probably show a very high rate of mortality if it were possible to collect accurate statistics. The prognosis of abortion depends in great part upon the treatment. If every case could be treated by an aseptic and skilful curettage, the mortality of abortion would be nil. Treatment. — If a pregnant woman presents any of the con- ditions which a physician's experience or knowledge teaches him may lead to the premature interruption of pregnancy, the treat- ment of these conditions constitutes the preventive treatment of abortion. Much has been said upon this subject when the diseases of the embryo and fetus and of the ovum were under consideration. The proper conduct to pursue in the other com- plications of pregnancy just described may be briefly indicated. In cases of irritable uterus the woman must be jealously guarded against any nervous shock, undue physical exertion, 1 For twenty-one cases of tetanus after abortion see Bennington, " British Gyn. Jour.," 1885. 272 PREGNANCY. errors in diet, sexual intercourse — anything, in a word, that would furnish the uterus an excuse for throwing off its contents. In exaggerated cases of this condition prolonged rest in bed, especially at the time corresponding to the menstrual periods, or perhaps for the whole duration of pregnancy, may be neces- sary to secure the birth of a mature infant. If the pregnant uterus is displaced downward or backward, it must be restored to its proper position, and be kept in place by a suitable pessary or by tampons until its increasing size prevents its displacement again. Uncontrollable vomiting or coughing must be treated appropriately. Asthma, which in some cases determines a pre- mature interruption of pregnancy, is best treated by change of climate. 1 In general muscular spasms, as in eclampsia, chol- emia, chorea, epilepsy, hysteria, and tetany, the convulsions must be combated by appropriate remedies. The infectious and febrile diseases of pregnancy must be managed on general principles, without special regard to the danger of abortion, which is often unavoidable. Chronic metritis and endometritis, fibromyoma of the uterus, lacerated cervix, perimetritis and cellulitis, disease of a tube or an ovary, and appendicitis, must be treated before impregnation. If, in spite of every precaution, the signs of threat- ened abortion manifest themselves, the treatment resolves itself into: (i) The treatment of threatened abortion; (2) the treat- ment, if necessary, of inevitable abortion; and (3) the after- treatment. The Treatment of Threatened Abortion. — The two main principles of the treatment to avert a threatened abortion should be perfect rest and the administration of drugs that diminish nervous sensibility and weaken muscular action. The first can only be secured in bed in a perfectly supine position. The room should be darkened and kept quiet, that the rest may be mental as well as physical. The second object of the treatment is accomplished by giving opium, bromid of potas- sium, and chloral. Opium enjoys a well-deserved reputation in these cases. It may be administered by the mouth as lauda- num, hypodermatically as morphin, or, best, by the rectum as extract of opium in suppositories. Women on the verge of abor- tion usually display a remarkable tolerance of opium, and to be effective the dose must often be large. As much as a dram (3.9 gm.) or more of laudanum has been given within twenty-four hours without ill effect, but, of course, the patient must in such cases be carefully observed. With the opium it is often an advantage to combine moderate doses of chloral and bromid of 1 See note by Harris to Playfair's " Midwifery," p. 243. ABORTION, MISCARRIAGE, AND PREMA TURE LABOR. 273 potassium. Viburnum prunifolium 1 has been much vaunted as almost a specific in the prevention of abortion, and its use has become general throughout America. The verdict is favorable. It may be given in the form of a fluid extract, in teaspoonful doses three times a day. My routine medicinal treatment is a suppository of a grain (0.065 gm.) of the extract of opium morn- ing and evening, and a dram (3.75 c.c.) of the fluid extract of viburnum three times a day. 2 Treatment of Inevitable Abortion. — As soon as all hope of arresting the abortion is destroyed by the appearance of signs pointing to the unavoidable expulsion of the uterine contents, the treatment must be radically altered. Absolute rest is no longer necessary, while the administration of drugs that diminish sensi- bility and weaken muscular action is positively harmful, for it prolongs a process which in the interests of the patient is best completed as speedily as possible. But days often elapse before the greater part of the uterine contents is expelled, and it may be weeks before she is rid of the thickened decidua, which usually remains behind, or of the adherent placenta, which is often retained in the uterus after the escape of the embryo and the remainder of the ovum ; and all this time there may be recurring hemorrhages of an alarming character or a constant dribbling of blood. The lochial discharge is profuse, brown in color, and probably foul- smelling. In such a case the evacuation of the uterus must be considered. If the hemorrhage is profuse before the os is at all dilated or any portion of the ovum is discharged, there is no difference of opinion as to the necessity of controlling the bleeding. This is best effected by a vaginal tampon of sterile or iodoform gauze. A Sims speculum facilitates its introduction. The tampon should be removed after twelve or twenty-four hours, and replaced by a fresh one if necessary; often as the first tampon is removed, the ovum or fetus comes with it and the immediate symptoms may in great part subside. Rut the uterus may not yet be empty; in the early months the large mass of decidua is almost entirely retained ; later, the placenta is fre- quently retained. Whether to treat the case expectantly until serious symptoms develop, or to remove at once the substances in the uterus which may give rise to future complications, is a problem that must frequently confront every practitioner. In the hands of a general practitioner without special knowledge of gynecological technic, the best results are probably secured by 1 Tenks, "Viburnum Prunifolium," "Trans Amer. Gyn. Society," vol. i, p. 1 ,^o. 2 Negri has recommended large doses of asafetida if there had previously been a tendency to abort or to give birth to dead children. IS' 274 PREGNANCY. the expectant treatment, so long as there is no fever, no excessive hemorrhage, or no odor of putrefaction. In the hands of a trained gynecologist the best and safest treatment of an abortion is an aseptic evacuation of the uterus by a placental forceps, the finger, or a curet. Expectant Treatment. — When an abortion becomes inevitable, ergot may be substituted for the drugs that have been em- ployed to inhibit muscular action, but it should be remembered that the prolonged use of ergot in full doses complicates the case if later it is found necessary to evacuate the uterus, and the drug itself may cause retention of the ovum by constricting the cervix. If there is much bleeding, tampons are to be used in the manner already indicated, and renewed every twelve hours until the ovum is expelled, or else so well separated from the uterine wall that it may be gently expressed or easily extracted by the fingers. The greatest care must be exercised to avoid rupture of the membranes, which will probably lead to the retention of a por- tion of the ovum, whereas its expulsion as a whole is particu- larly desirable in cases managed expectantly. If a part of the embryo or its appendages remain behind in the uterus, the woman is kept quiet in bed and small doses of ergot are adminis- tered. The vagina and, if possible, the uterine cavity are kept clean by sublimate injections, i : 4000, or sterile water. If the discharge becomes foul, the temperature rises, or hemorrhage occurs, the uterine cavity must be evacuated. The technic is described later. Active Treatment. — The tampon is used to control bleeding. When the dilatation of the os is sufficient to admit a finger, efforts are made, in early abortions, to turn out the ovum by sweeping the finger around it, and then extracting it with the finger hooked behind it ; or Hoennig's method of expression may be tried. 1 These methods are most successful when the ovum is lodged in the cervical canal and lower uterine segment, its escape being prevented by an undilated external os. The hemorrhage is usually profuse. The ovum being wholly or in part expelled, everything left behind in the uterine cavity, whether thickened decidua or placental tissue, must be extracted. For an adherent placenta nothing is better than the finger, which can be made to reach the fundus by pressing the uterus down from above through the abdominal walls, the patient being anesthetized if necessary. The placenta is peeled off from the uterine wall, and afterward easily extracted. So much force is often necessary to do this that the use of an unyielding and 1 The uterus is squeezed between the fingers in a combined examination, and the uterine contents are pressed out as a stone is expressed from a cherry. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 2J$ insensible instrument is not advisable. To clear out the thickened decidua, which almost invariably remains behind in early abor- tions, nothing is so good as a broad dull curet. Duhrssen has demonstrated that the decidua removed from the uterus in this manner is not roughly torn off, but is separated in a natural manner in the cellular layer. An indispensable adjuvant to the curet is Emmet's curetment forceps, used as a placental forceps, to extract fragments of decidua loosened by the curet. If the os is so retracted that neither a finger nor an instrument can be inserted, the introduction of Hegar's graduated cervical bougies the use of branched dilators or of a metranoicter for twelve hours obviates the difficulty. After the uterine cavity is evacuated, it should be irri- gated. 1 The After=treatment of Abortion. — If active treatment has been pursued, the after-treatment is simple, for the lochial dis- charge is slight and the involution of the uterus rapid. Until involution is perfected the woman should be confined to bed. It is never safe, even in the earliest cases, to allow her to get up in less than a week or ten days. The after-treatment when an expectant plan has been pursued has already been indicated. Should septicemia develop, it is treated as after delivery at term. Missed Abortion. — By this term is meant the death of the embryo, threatened abortion, the subsidence of symptoms, and the retention of the ovum for a varying length of time. 2 Missed abortion may give rise to undeserved suspicions of a woman's virtue or to ludicrous mistakes in diagnosis. I was called in con- sultation to see a young woman who discharged at term an ovum about the size of a lemon retained in utero some seven months after the death of the embryo. The young wife and her husband were wealthy and heartily welcomed the prospect of a child. They had provided an elaborate and expensive outfit for the baby, includ- ing a coach. At the end of nine months from the date of the last normal menstruation, labor-pains appeared. The family physician made repeated examinations and assured the husband and wife that the progress was satisfactory. At length, after twenty-four hours of hard pains, a little two-month ovum was expelled, to the inexpressible astonishment of the parents and the chagrin of the doctor. Miscarriage. — Much that has been said of abortion is applic- able to miscarriage as well ; but by the time pregnane) - has 1 I have tried every model of a two-way uterine catheter on the market and rind Fritsch's modification of Bozeman's the best. 2 The fetus has been retained in utero five, eleven, and even fifty-one years — L. C. Peter, "Amer. Gyn. and Obstet. Jour.." Feb., 1899. 276 PREGNANCY. reached a period from the fourth to the seventh month it is not likely that the condition will be overlooked, so that one great difficulty in the diagnosis of abortion, the doubt as to the exist- ence of pregnancy, does not, as a rule, obtain in cases of mis- carriage. In these cases, too, it is easier to detect the two acci- dents which make the expulsion of the ovum almost inevitable — rupture of the membranes and the death of the fetus ; for the liquor amnii has reached such a quantity that its escape would almost always attract attention, while the death of the fetus, fol- lowed by a cessation of fetal movements and of growth in the uterus, by a disappearance of the reflex and psychical disturb- ances characteristic of pregnancy, and also, perhaps, by the ap- pearance of the milk-secretion, is not likely to pass unnoticed. The pain associated with miscarriage is greater than in abortion, and assumes the type of labor-pains. During the periodic con- tractions of the uterus the organ can be felt through the abdom- inal walls, becoming hard and firm and relaxing again as the pain passes off. The expulsion of the ovum resembles also a labor at term, as the fetus usually is first expelled and the mem- branes and placenta follow after. As pregnancy advances this sequence becomes more and more the rule, but occasionally the ovum is cast off entire, even at a late period of pregnancy. I have seen such an occurrence at the seventh month, and it has actually been reported to have occurred at term. Miscarriage is chiefly distinguished from abortion by the for- mation of the placenta, and from premature labor by the adhe- sion of the placenta to the uterine wall, its retention, and con- sequent serious hemorrhage or infection. EXTRAUTERINE PREGNANCY. By extra-uterine or ectopic pregnancy is meant the develop- ment of an impregnated ovum outside of the uterine cavity. The condition was described by Riolanus, Benedict Vassal (1669), and by Regnier de Graaf. Abdominal sections for extra-uterine pregnancies were performed by Nufer (1500) and by Dirlewang (1549). Bohmer (1752) differentiated the tubal, ovarian, and abdominal forms of ectopic gestation. Schmidt (180 1) described interstitial pregnancy. Frequency. — The exact proportion of extra-uterine to intra- uterine gestations is difficult to determine. It has been said to be about I in 500 normal pregnancies. Winckel, however, saw but 16 cases in 22,000 births, and Bandl, in Vienna but 3 out of 60,000. An experienced specialist in the larger cities of America usually sees from three to fifteen cases annually. EXTRA-UTERINE PREGNANCY. 277 Classification Based upon the Situation of the Developing Ovum. Tubal. Tubo-uterine, or interstitial. The ovum develops in that portion of the tube which runs through the uterine wall. Tubal proper. Tubo-ovarian. The ovum is attached to the ovarian fim- bria. Ovarian. The ovum develops in a Graafian follicle. Abdominal. In primary abdominal pregnancy the ovum at- taches itself to the peritoneal investment of the uterus, the broad ligament, or the intestines. Secondary abdominal. Ovario-abdominal. The ovum, beginning its growth in the ovary, pushes its way out into the abdominal cavity. Fig. 174. — Bifurcation of tubal canal (Hennig). Tubo-abdominal. The ovum, at first contained in the tube, escapes into the abdominal cavity by rupture or by a gradual separation of the fibers in the tubal coat. There is a form of tubal pregnancy often called secondary ab- dominal or tubo-abdominal, in which the ovum grows downward and backward behind the peritoneum. This should be known as a broad-ligament or retroperitoneal pregnancy. Utero-abdominal. The ovum grows at first in the uterine cavity, but, in consequence of a spontaneous rupture or separation of an old scar in the uterine wall, becomes an abdominal pregnancy, retaining its connection with the uterus by the placenta. Etiology. — The causes of ectopic gestation are obscure. 278 PREGNANCY. Conditions delaying the progress of the ovum from the ovary to the uterus until a stage of development is reached at which the ovum imbeds itself in maternal tissues are predisposing causes of ectopic gestation. Any disease of the mucous membrane of the tube depriving its cells of their cilia, forming mucous polypi or otherwise obstructing its caliber, predisposes to an arrest of the impregnated ovum in its passage to the womb. So does any condition interfering with the normal peristalsis of the tube. Chronic salpingitis, therefore, is often found associated with and preceding tubal pregnancy. Peritoneal adhesions from a precedent salpingitis * or appendi- citis constricting or distorting the tubes and congenital or acquired stenosis may also obstruct the tu- bal canals. A diverticulum in the tube, an accessory tubal canal, accessory abdominal ostia, and atresia of the tube have been noted in connection with ectopic gestation. An exaggeration of the characteristic serpentine course of the tube may make the progress of the ovum difficult and may arrest it before it can reach the uterus. Fibromyomata of the uterus and tumors of the broad ligament have caused tubal obstruction. Anything which increases the size of the ovum before it has emerged from the tube may be a cause of extrauterine pregnancy; thus, ex- ternal transmigration, twins, or an unusually long tube may result in such a development of the ovum before its arrival in the uterine cavity that it imbeds itself in the tube. Clinical History. — In each of the situations noted above the course of gestation may be somewhat different, and each may present an individual clinical picture on account of the difference in the surrounding anatomical structures which are involved. The general presumptive signs of pregnancy are commonly the same as in intra-uterine gestation, but there is usually severe pain. 1 The majority of my cases have had a history of previous salpingitis, and I have treated several of them for gonorrhea months and years before the tubal gestation occurred. In one case I found a four weeks' ovum and embryo in the middle of a gonorrheal pus tube that had been under observation for a year. The operation was performed for what was supposed to be an exacerbation of the salpingitis. Fig. 175. — Decidual cast of the uterine cavity in extra-uterine preg- nancy (Zweifel). EXTRA-UTERINE PREG NANCY. 279 Extra-uterine pregnancy occurs oftenest between the twentieth and thirtieth years. The youngest woman affected was fourteen, the oldest forty-seven years of age. Changes in Uterus and Vagina. — In all the forms these changes are alike. Most of the alterations characteristic of intra-uterine pregnancy are found: hypertrophy of the vaginal mucous membrane, with increased blood-supply (purple tinge) and increased secretion ; a soft cervix and a patulous os ; an enlarged uterus, and, in the majority of cases, a development of a deciduous membrane, undergoing the same change as in intra- uterine gestation preparatory to its separation and extrusion, which occurs in extra-uterine gestation usually between the eighth and twelfth week, the membrane being expelled as a complete cast of the uterus and even of the tubes, or in shreds. The usual clinical history of ectopic gestation is absence of menstruation until the death of the embryo or rupture of the sac, when the menses return with the discharge of the decidua. The metrorrhagia which thus begins may continue for a long time. The other changes in the maternal organism may van- with the situation of the developing ovum. Clinical History and Pathology of Tubal Pregnancy. — Usually the woman has had children, but a long time has elapsed since the birth of the last child. The most frequent situation of an extra-uterine gestation is the outer third of the tube (the ampulla 1 ). In this position it may grow upward into the abdominal cavity, distending the tube-walls to the point of rupture, or it may grow downward between the layers of the broad ligament, and then backward and upward behind the posterior parietal layer of the peritoneum (broad-ligament gestation). The tubal walls show r irregular hypertrophy from the development of their muscle-fibers. The point of rupture is at the site of original attachment of the ovum, the cells of the chorion villi burrowing into the tubal wall and weakening it. Fever is often seen, sometimes to a high degree, even before rupture. The usual temperature, however, before rupture is between 99 and ioo° F. After rupture there may be a low temperature indicative of hemor- rhage. Reaction may quickly occur, and fever is not incom- patible with profuse intraperitoneal hemorrhage. Exceptionally, the tubal gestation may proceed to full term. In these cases the ovule has probably at first grown downward and backward. If perforation of the tubal wall occurs, it usually takes place between the eighth and twelfth weeks, but it may occur as early as 1 Martin's statistics of 55 cases of extra-uterine pregnancy give this situation in 49. 28o PREGNANCY. the fourteenth day, 1 or not till after the sixth month. If the tube ruptures upon the upper or posterior aspect of the sac, the sac-con- tents are extruded into the peritoneal cavity with an intra-peritoneal hemorrhage. If rupture occurs on the lower aspect, the con- tents of the ovum and the blood find their way between the layers of the broad ligament and the pelvic fascia, giving rise to an extraperitoneal hematocele. The first variety is usually fatal ; the last is not always directly dangerous to life, but the layers of the broad ligament may rupture when distended with blood, and the bleeding then becomes intraperitoneal and unlimited. The bleeding may also be limited by peritoneal adhesions shut- fl Fig. 176. — Broad ligament pregnancy (Zweifel). ting off the peritoneal cavity and forming a closed sac in the iliac region. From adhesions to intestines, complications, such as perforation and obstruction of the bowel, may occur. Recent studies of the behavior of the ovum in relation with the tubal wall and the mucous membrane explain the difference of opinion once prevalent as to decidua formation and also explain the clinical course of tubal gestation. The ovum may imbed itself either in plications of the tubal mucous membrane or directly in the muscular tubal Avail. In the former case the bed of the ovum is in the connective tissue of a stem of the mucous membrane folds. The maternal tissues, including blood-vessels, are eroded by the cells of the trophoblast; the thin capsule of the ovum is penetrated and, hemorrhage occurring into the lumen of the tube, 1 Ross. "Am. Jour. Obstet.," October. 180,5. According to Hecker's statistics of 45 cases, rupture occurred 26 times in the first two month.-, II times in the third, 7 in the fourth, and once in the fifth. In two of my cases rupture occurred no later than the fourteenth day. EXTRA- UTERINE PREGNANCY. 28l fc •fig. 177 — A ruptured broad ligament pregnancy. -■ Fig. 178- — Ruptured broad ligament pregnancy. Fig. 179- — Ruptured broad ligament pregnancy. The embryo ill situ. 282 PREGNANCY. escapes from the fimbriated extremity into the peritoneal cavity (tubal abortion). In the latter case the trophoblast makes a nest for the ovum in the tubal wall, burrowing into the muscle at the base of the plications of the mucous membrane or in the isthmus where these plications are not developed. At the point where the ovum attaches itself the cells of the villi penetrate toward the periphery of the tube, opening the walls of blood-vessels and penetrating the tubal wall to the serous covering, which eventually gives way. Thus the so-called rupture of tubal pregnancies occurs, with intraperitoneal hemorrhage. Fig. 180. — Interstitial pregnancy, fourth month ; vaginal hysterectomy, a, Cav- ity of the ovum; b, uterine cavity; c, left tube; d, cervix; e, partially detached placenta; /, right tube; g, right ovary (Burnm). There can be no true decidual formation in the nest which the ovum makes for itself in muscular tissue, beneath the tubal mucous membrane, for the cells of the intermuscular connective tissue do not undergo this metaplasia, but in other portions of the tubal mucous membrane distant from the ovum, even in the other tube, there is an irregular development in limited areas of decidual cells. The cells in the bed of the ovum, often described as decid- ual cells, are really derived from the trophoblast (Langhans' cells). There may "be a reflexa formation, irregularly and feebly EXTRA-UTERINE PREGNANCY. 283 developed as the ovum grows and projects into the lumen of the tube, but there is often an underlying layer of muscular tissue and the capsule of the ovum soon degenerates and is penetrated by the trophoblast, so that the villi of the latter contract attachments with the plications of the tubal mucous membrane or, in the isthmus, with the opposite tubal wall. There may be multiple (twin and triplet 1 ) extra-uterine gesta- tion; coincident intra- and extra-uterine pregnancy; pregnancy first in one tube and then in the other; simultaneous pregnancies in both tubes 2 ; or two successive pregnancies in the same tube. 3 Hydramnios was noted in one case of tubal pregnancy 4 and a thoracopagus was found in another. 5 Several cases of hydatidi- form mole and also cases of chorio-epithelioma have been observed in tubal pregnancies. 6 Clinical History of Interstitial Pregnancy. — In these cases the ovum develops in the uterine wall, the inner side of the sac often projecting into the uterine cavity, and having on its outer side the round ligament and the whole length of the tube. The usual termination of this kind of ectopic gestation is rupture into the peritoneal cavity. Hecker collected twenty-six cases, all ending in rupture before the sixth month. Rupture into the uterine cavity and expulsion of the fetus through the cervix are possible. Rupture into or growth between the layers of the broad ligament is also possible. 7 Clinical History of Tubo=ovarian Pregnancy. — The ovum develops between the fimbriae of the tube and the ovary. The sac may rupture with the usual consequences of such accident. It is possible, however, to see a development of the fetus to maturity. The ovum may lodge upon the ovarian fimbria and may thence grow inward between the layers of the broad ligament. 1 Sanger, "Centralbl. f. Gyn.," No. 7, 1893. Krusen, " Tr. Phila. Co. Med. Soc," October, 1901. 2 Mania has collected 8 cases, " Zeitschr. f. Geburtsh. u. Gyn.," Bd. xxxviii, H. 1. 3 Coe, " N. Y. Med. Record," May 27, 1893 ; Dorland, " Repeated Extra- uterine Pregnancy," "Amer. Jour. Obstetrics," Aprd, 1898; Royster, " Combined Intra- and Extra-uterine Pregnancy at Term," ibid., 1897, vol. xxxvi, p. S20; Mosely, ibid., 1896, thirty-eight cases of intra- and extra-uterine pregnancy. Zinke, ibid., xlv, No. 5, 1902, 88 cases. Neugebauer, 129 cases. Heinricius and Kolster report two fully developed fetuses in one tube, one macerated, the other well pre- served, "Archiv f. Gyn.," Bd. lviii. Pestalozza has collected 108 cases of repeated tubal pregnancies: "Arch. Ital. di Gin.," No. 5, p. 474, 1900. Naples. 4 "Archiv f. Gyn.," Bd. xxii, S. 57. 5 "Centralbl. f. Gyn.," 1894, p. 232. 8 Werth, "Winckel's Ilandbuch," 2 2 , p. 822. 7 Werth gives forty as the number of interstitial pregnancies in the literature which be^r criticism. " Winckel"s Ilandbuch," 2 2 , p. 739. 284 PREGNANCY. Clinical History of Ovarian Pregnancy. — The ovum, im- pregnated while it is still within the Graafian follicle, reaches some degree of growth and development within the ovary. The tube and ovarian fimbria are free, the uterus is connected -by the ovarian ligament with the gestation sac, the wall of which consists in great part at least of ovarian tissue. The condition is exceed- ingly rare, but there are a few indubitable cases on record. 1 A case reported by Baer went to term. Muller and vYiderstein have 4£ Fig. 181. — Tubo-ovarian pregnancy. Sac ruptured. reported cases of the prolapse of a pregnant ovary into the inguinal ring and canal. Clinical History of Abdominal Pregnancy. — Primary ab- dominal pregnancy is exceedingly rare. Many gynecologists deny its occurrence, but there have been a few authentic cases. 2 The conditions in the free abdominal cavity favor the progress of pregnancy to the mature development of fetus. The peritoneum is converted into clecidua-like membrane wherever the ovum comes in contact with it, and from this source the chorion and placenta 1 Cases are reported by Potenko, Werth, Paltauf, Leopold, and Martin. See Winckel, " Geburtshulfe"; Kelly, article in "American Text-book of Obstetric?." Ludwig, " Wien. klin. Woch.," 1896, has collected 18 cases besides one of his own. Leopold claims that there are thirteen authentic cases recorded, " Archiv f. Gyn.," Ed. lix. Catharine von Tussenbroek demonstrated a specimen removed by Kouwer, of Harlem, " Tr. Ill Congress of Gyn. and Obst.,"' Amsterdam, 1899. Micholitsch found two cases among 120 cases of extra-uterine pregnancy operated on in Wertheim's Clinic ("Zeitschr. f. Geb. u. Gyn.," Bd. xlix, H. 3). 2 Schlechtendahl has reported a case of primary abdominal pregnancy in which a fetus fifteen centimeters long was found incapsulated near the spleen. The tubes and uterus were normal (" Frauenarzt," 1887, ii, pp. 81-86). Braun'sand Zweifel's cases (•' Archiv f. Gyn.," Bd. xli, II. 1 and 2), in which the placenta was attached to the posterior uterine wall and to the sigmoid flexure, and Koberle's case, in which impregnation occurred through a vagino-abdominal fistula after hysterectomy, were unquestionably, to my mind, primary abdominal pregnancies. EXTRA- UTERINE PRE GNANC Y. •85 X \ Fig. 182. — Reported as an ovarian pregnancy. Fig. 183. — Reported as aD ovarian pregnancy. r- hi) Fig. 184.— August Martin's case of ovarian pregnancy. The intact tube is seen lying above the ovarian sac containing the fetal envelopes. The ovarian liga- ment runs from the sac to the uterine cornu. 250 PREGNANCY. derive nutriment. The ovum is surrounded by a fibrous and vas- cular capsule. In abdominal and in advanced tubal gestation abortive labor-pains appear at term. The child dies at or shortly- after this period, and the liquor amnii is absorbed after the death of the fetus. The abdomen is consequently reduced in size and the tumor is changed in consistency. The fetus may be con- verted into a lithopedion and may remain as an innocuous tumor in the abdomen for years (see Termination of Extra-uterine Pregnancy, and Changes in Fetal Body after Death). The child is likely to be small and ill-formed, but occasionally over- grown children are reported, no doubt on account of an existence of the fetus prolonged beyond the usual duration of pregnancy. In advanced cases of abdominal pregnancy the fetal movements are exceedingly painful to the mother. Abdominal pregnancies may end in rupture of the sac or there may be profuse hemor- rhage into the sac-cavity. Clinical History and Pathology of Utero=abdominal Preg- nancy. — This condition is very rare. The pregnancy is at first intra-uterine, but the ovum escapes into the abdominal cavity through an opening in the uterine wall, retaining a connection by the placenta with the uterine cavity. The process of extru- sion must be gradual. These cases follow either a Cesarean section or a rupture of the uterus at a previous labor. The fetus may grow to full term. 1 Terminations of Extrauterine Pregnancy. — Death and Ab- sorption of the Young Embryo with Absorption of the Liquor Amnii, and Atrophy of the Gestation Cyst. — Of all the terminations of ectopic gestation, this is the most favorable. It is exceptional, and should never be counted on in practice. The embryo must die before the second month to be completely absorbed. At the best, chronic salpingitis with adhesions persists, and the woman may, therefore, be left a chronic invalid. Rupture of the sac and profuse hemorrhage occur most com- monly in tubal gestation, when the growth is upward toward the abdominal cavity. At least two-thirds of all ectopic gestations end in rupture of the sac or in tubal abortion. Rupture may occur when the ovule grows downward between the layers of the broad ligament; also in tubo-uterine, tubo-ovarian, ovarian, and abdominal pregnancies. The accident commonly destroys the embryo, which may escape into the abdominal cavity. Up to the second month the extruded embryo may be absorbed. Later, it may be found lodged among the intestines, perhaps far removed 1 " Ausgetragene secundare Abdominalschwangerschaft nach Ruptura uteri, im. vierten Monat," Leopold, " Archiv f. Gyn.," Hi, 2, 376. Fullerton, "Annals of Gyn.," October, 1891. . EXTRA- UTERINE PREGNANCY. 287 from the pelvic organs and usually surrounded by clotted blood. 1 Rupture of the tubal wall has been reported without hemorrhage, the head of the embryo fitting into the gap and acting as a tam- pon. The hemorrhage may be fatal in as short a time as two Fig. 185. — Ruptured tubal pregnancy ; sac involving the isthmus. 2 Fig. 186. — Ruptured tubal pregnancy ; sac involving the whole length of the tube. hours; it usually takes from eight to sixteen hours, however, for the woman to bleed to death. The hemorrhage may be fatal as late 1 Burford reports an extraordinary case in which the tube ruptured, the fetus was extruded through the rent, the cord was torn across, and the fetus with the cord attached was found in the abdominal cavity inclosed in an adventitious sac. The placenta remained in the tube and the rent in the latter, through which the fetus escaped, had healed. " Brit. Gyn. Jour.," 1892. 2 Figs. 177 to 179 and 185 to 194 inclusive, also figs. 181 to 183, are from photographs presented to me by the late Dr. Formad, for some time coroner's physician of Philadelphia. He obtained the specimens in his official capacity, while investigating the cause of sudden deaths. PREGNANCY. Fig. 187. — Ruptured tubal pregnancy ; sac involving the ampulla. Fig. 188. — Ruptured tubal pregnancy; sac situated wholly in the isthmus. The size of the sac is very small to occasion, on rupture, a fatal hemorrhage ; its situation, however, near the uterus, is a very dangerous one. The decidua lining the uterine cavity is plainly seen. u --Jhfc v < V Fig. 189. — Ruptured tubal pregnancy; sac occupying the middle third of the tube. EXTRA- UTERINE PREGNANCY. 289 as the second, third, or fourth day, or there may be successive hemorrhages, perhaps days apart, until the patient is gradually exhausted or is suddenly destroyed by an unusually profuse outpour of blood. Surprisingly small tubal gestation sacs ma)', **m> Fig. 190. — A very small gestation sac in middle third of tube. Rupture ; death. Fig. 191. — Ruptured tubal pregnancy ; the sac occupying the ampulla and fimbriated extremity of the tube. Fig. 192. — Ruptured tubal pregnancy ; the sac situated at the uterine insertion of the tube. 19 29O PREGNANCY. on rupture, give rise to fatal hemorrhage. In such cases the ovum is usually imbedded in the tube near the cornu of the uterus. The determining cause of rupture is not always apparent. It may occur while the patient is lying quietly in bed, but may follow the straining of defecation or urination, coitus, a blow upon the abdomen, a gynecological examination, an operation like curet- ment, or any sudden physical effort or mental excitement. The trophoblast having eroded the tubal wall to and even through the peritoneum, it requires little or no extra strain to establish a com- munication between the bed of the ovum, with its opened blood- vessels, and the peritoneal cavity. Rupture of the sac or of a blood-vessel in its wall, with profuse hemorrhage, has occurred long after the destruction of the embryo and cessation of growth in the sac (two years in one case). Rupture of sac with extrusion of its contents, and interstitial hemorrhage into the sac-walls, without escape of blood into peri- toneal cavity or between the layers of broad ligament, was the termination of one case of tubal gestation under my obseruation. This occurrence might be followed by atrophy of the ovum and sac. Tubal moles are frequently seen as the result of an old tubal pregnancy ; the ovum is infiltrated and surrounded by blood, clotted and often organized. The tubal walls are also infiltrated with blood and are much thickened. The whole mass constitutes a solid tumor of the tube in which the embryo may not be found, and atrophied chorion villi in small numbers are only discovered after a careful microscopic search. Growth of the Fetus after Third Month ; Its Death at or before Maturity and the Changes that Occur Afterward. — A continued de- velopment of the fetus in the later months of pregnancy is seen most often in abdominal or in tubo-ovarian pregnancies, though it is possible in the tubal gestation with retroperitoneal growth (broad-ligament pregnancy). The fetus after death may be converted into a lithopedion or may be mummified, and in these conditions may remain in the abdominal cavity indefi- nitely (in Sappey's case fifty -six years), or may be removed by operation through the abdomen, vaginal vault, or possibly by the rectum. The soft parts may macerate and may be absorbed, leaving the bones, which remain as an innocuous abdominal tumor or ulcerate into the bladder, intestines, or through the anterior abdominal wall. Ulceration into the bladder is a par- ticularly unfortunate complication. I have seen an old lady die of peritonitis caused by the ulceration of a parietal bone through the transverse colon. Her history indicated an abdominal preg- nancy having its origin many years before. The fetal body may putrefy from the contiguity of the intes- EXTRA- UTERJXE PRE GNANC J '. 291 tines and their contained micro-organisms and the consequent access of bacteria to the highly putrescible sac-contents. In the same way the gestation-sac is converted into an abscess. Terminations of Ovarian Pregnancy. — There may be an arrest in the development of the ovum at an early period. In one case the small, cystic, ovarian tumor containing the fetal bones Fig. 193. — Tubal abortion. Fig. 194 — Tubal abortion. was retained in the abdomen for years. In another case the fetus went on to full development, then died, and was removed in a good state of preservation at least one year later. Rupture of the sac and profuse hemorrhage may occur. In tubo- uterine or interstitial pregnancies the ovum and em- bryo may be discharged into the uterine cavity, and may be 292 PREGNANCY. evacuated by the natural passages. There are at least two such cases well authenticated. Rupture of the sac and hemorrhage into the peritoneal cavity is, however, the rule. In Mascka's case the head of the fetus passed into the abdominal, the breech into the uterine, cavity. In cases of tubal abortion (so named by Werth) there is an internal rupture of the tubal wall, of its connection with the ovum, or the epithelial cells of the chorion villi penetrate the wall of a vessel of some size, and blood is poured through the fimbriated extremity of the tube into the abdominal cavity. The blood clots filling the pelvis in such a case may have a peculiar sausage-like form imparted to them by the tubal canal. The whole ovum may possibly be extruded through the abdominal orifice of the tube, and in one case in which the fimbriated extremity was Fig. 195. — Diagram showing pelvic hematocele posterior to the uterus, which is crowded forward with the bladder behind the symphysis pubis, while the rectum is compressed behind against the sacrum (Skene). closed by inflammatory adhesions the outer end of the tube was converted into a hematoma. Kustner claims that tubal abortion is much more frequent than rupture. In 75 cases the former occurred 59, the latter 16, times. 1 In my own later cases, in which account has been taken of this matter, tubal abortion is very much more frequent than rupture. It is possible that a tubal pregnancy may rupture in its early stages, the embryo be expelled into the abdominal cavity, retain- ing its connection with the tube by the cord and placenta, and 1 "Volkmann's Samml. klin. Vorlrage." X. F., Nos. 244, 245. EXTRA-UTERINE PREGNANE ' I '. 293 the fetus thus continue to further or to full development. This is called a secondary or tubo-abdo)iiiual pregnancy. 1 Rupture in cases apparently of this character may not have occurred. There may have been a retroperitoneal growth of the ovum and an enormous dilatation of the tubal walls. Grozvth and development of the placenta after fetal death has been described, but has not yet been demonstrated beyond doubt. It would seem impossible, arguing, from the behavior of the placenta in utero after fetal death. Profuse hemorrhage into the gestation sac, forming a large hematoma, occurred in one case under my observation. Fig. 196. — Diagram of intraperitoneal rupture of tubal pregnancy. Free blood in Douglas' cul-de-sac, and among the intestines: S, Symphysis; R, rectum (Dickinson). Hematoceles and hematomata in the abdomen, pelvis, and pelvic connective tissue in one-third or more of the cases are due to the hemorrhage from a ruptured gestation sac. The blood may collect in front of the uterus (ante-uterine hematocele), more commonly behind the uterus (retro-uterine hematocele), may be encapsulated in the neighborhood of either broad ligament, or may be contained in the pelvic connective tissue on either side 1 Lusk has collected three such cases. The fetus survived the rupture of the tube, or the extrusion may have been gradual by a .separation ul the lib; is in the tube wall. 294 PREGNANCY. of the uterus. These accumulations of blood may suppurate, and may thus prove fatal. They may be evacuated by puncture through the abdomen or often through the vaginal vault. If not too large, they are absorbed. Symptoms of Extrauterine Gestation. — The Subjective Signs. — In the early weeks or months the subjective signs of ectopic pregnancy may be indistinguishable from those of normal intra-uterine gestation. In the tubal variety, which is by far the commonest, there may be no indication of any abnormality until rupture occurs or blood escapes into the peritoneal cavity from the fimbriated extremity of the tube. In the vast majority of cases, however, rupture or bleeding is preceded by severe cramp- like pains, usually in one or the other iliac region, often accom- panied or followed by the discharge of deciduous membrane. The pain of extra-uterine pregnancy is its most distinctive symptom. It is described by the patient in strongest terms; oc- curring in paroxysms, with intervals free from suffering; appear- ing at any time from a few days to months after a normal menstrua- tion; situated often in one groin, though frequently indefinitely referred to the lower abdomen; extending down one leg or up to the epigastrium; and so severe as to occasion profound systemic disturbance — syncope, followed by nausea and vomiting, a cold sweat, hysterical outbreaks, complete disability, and every ap- pearance of excessive shock. The temperature is almost always slightly elevated. There may be high fever, and the general health may be much impaired. When advanced development occurs, as in abdominal and in some cases of tubal gestation, no symptoms may arise until the time for labor has passed, when pain and other complications, due to the peculiar character of the ab- dominal tumor, may appear. There is usually cessation of men- struation for one or two periods; then a return of the flow as an irregular bleeding, which may last for months. In some cases ir- regular bleedings begin with conception and last until rupture — there is no cessation of menstruation. In others one period is slightly delayed; those after and before are normal. Again, the delayed period may be unnatural in character. In exceptional cases the menstruation occurs at the normal time, but is more profuse or scantier than normal. In 80 cases upon which I have operated there was no absence of menstruation in 18; a cessation of menstruation varying from 10 to 90 days in 62. There was metrorrhagia lasting from 2 to 120 days in 62 cases; there was a discharge of decidua in 40 cases. Other symptoms noted have been irritable bladder or dys- uria; marked constipation or even obstruction of the bowels if the tumor is on the left side; edema of the corresponding limb EXTRA-UTERINE PREGNANCY. 295 and aching pain in it, especially at the groin ; or numbness and loss of power. Pulsating vessels may be felt in the vaginal vault. x Objective Signs. — In tubal pregnancies an exquisitely sensi- tive tumor may be felt to one side of, behind, or possibly in front, of the uterus, quite firmly fixed after the third or fourth week, and doughy in consistence. 2 The uterus is much smaller than would be expected from the duration of the pregnancy. After the third month ballottement may possibly be practised upon the tubal tumor. The uterus is usually displaced forward, backward, or to the side opposite the tumor. The decidua is expelled from the uterus in a large proportion of cases (50 per cent, of my own). If the discharged membrane can be obtained, it will present, under the microscope, unmistakable character- istics of decidua. It may be extruded in fragments or as a com- plete cast of the uterus. Symptoms of Interstitial Pregnancy. — A diagnosis is diffi- cult or impossible. The uterus enlarges to a greater degree than in any other variety of ectopic gestation, and it may be im- possible to determine whether or not it is symmetrically enlarged. The condition is recognized after an abdominal section or upon a careful intra-uterine exploration. Abdominal pregnancy may be recognized when the ovum occupies Douglas' pouch, as the fetal parts may be made out with startling distinctness through the posterior vaginal vault. A sacculated uterus, however, might easily be mistaken for an abdominal pregnancy. Diagnosis. — A diagnosis of extra-uterine pregnancy can usually be made before rupture. In spite, however, of careful attention to the patient's history and a painstaking physical ex- amination by an expert, a diagnosis before rupture is sometimes impossible. Usually the condition is not recognized in general practice until rupture has occurred. At this time a history of early pregnancy, a paroxysm of frightful pain, sudden collapse, symptoms of internal hemorrhage, with abdominal distention, and a vaginal examination showing a pelvic tumor with possibly the physical signs of effusion into peritoneal cavity make the diag- nosis perfectly clear, and indicate an immediate celiotomy. These 1 Hofmeier claims that the pulsation of arteries on one side of the cervix and not upon the other is a valuable sign of extra-uterine pregnancy ; and, moreover, that it is a sign of life in the ovum, ceasing when the embryo dies and the ovum stops growing. 2 For three or four weeks the tubal tumor is free; quite suddenly it sinks into the pelvis from its increasing weight, and wherever it comes in contact with the pelvic peritoneum the latter is changed into a decidua-like structure to which the tul e walls adhere. 296 PREGNANCY. symptoms have been closely simulated by rupture of a varicose vein in the broad ligament, by rupture of an ovarian cyst or torsion of its pedicle, by acute suppurative salpingitis, by fulminating appendicitis with intrauterine pregnancy, by criminal abor- tion followed by infection, in which a false history is purposely given, and by pelvic tumors coincident with intra-uterine preg- nancy. But as all these conditions demand the same treat- ment, a mistake in differential diagnosis is of no consequence. If the cramp-like pains of ectopic gestation lead a patient to consult a physician ; if she give a clear history of impregnation ; if she present all the earlier signs of pregnancy, with the discharge of blood and membrane which the microscope shows to be deci- dual; if there is a very sensitive tumor in the neighborhood of the uterus, on which ballottement may, perhaps, be practised, and \{ the uterus is not so large as it should be, — the diagnosis is justified, and the necessary treatment, also, involving, as it does, a serious operation. Among the conditions in the pelvis that may make the diagnosis impossible are : Abortion, in con- sequence of or coincident with some growth near the uterus ; pyosalpinx, with an indistinct or untrustworthy history of preg- nancy ; intra-uterine pregnancy, with rapid development of a fibroid on one side of the uterus ; development of an impreg- nated ovule in one horn of a unicornate or bicornate uterus, or on one side of a double uterus; appendicitis complicating intra- uterine pregnancy and the implantation of the ovum in one corner of the uterus, whence it grows into the uterine cavity, but mean- while causes such severe paroxysms of pain and distends the uterus so unevenly that interstitial pregnancy is suspected. A common error constantly occurring in general practice is to mis- take an extra-uterine pregnancy for an incomplete abortion. I find in my notes of eighty cases this mistake made by the attend- ing physician in thirty- two. Prognosis. — Without surgical treatment about two-thirds of the cases die; one-third escape the immediate danger of death. 1 Treated by abdominal section, the mortality should be about five per cent., or lower if the operator sees the patient in time. Of the patients who do not die directly in consequence of the tubal gestation a large proportion remain invalids, and many die at a * In 265 cases without surgical intervention, 36.9 per cent, recovered, 63.10 per cent, died (Winckel's " Geburtshiilfe," 2. Aufl., S. 254). In 100 cases col- lected by Kiwisch, the mortality was 82 per cent. ; in 132 collecred by Hecker, 42 per cent. ; in 150 by Hennig, 88 per cent. ; in 5 00 cases collected by Parry up to 1876 the mortality was 67.2 per cent. ; in 626 cases collected by Schauta, from 1876 to 1890, 241 ended spontaneously, 75 in recovery, and 166 in death, a mortality of 68.8 per cent. Martin states that of 585 cases operated upon, 76.6 per cent, recov- ered ("Centralbl. f. Gyn.," No. 39, 1892). EXTRA-UTERINE PREGNANCY. 297 remote period from various complications, as bowel obstruction, ulceration, suppuration, hemorrhage. Treatment. — As soon as the diagnosis is established with reasonable certainty, the removal of the gestation sac by celiotomy is the only treatment worthy of consideration. The only safe plan is either to operate immediately one's self, or to refer the patient to a competent surgeon without delay. The Technic of Abdominal Section for Tubal Pregnancy. — The operation is often performed in an emergency, and must, therefore, be hurried. Plenty of time, however, should be taken to secure an absolutely aseptic condition of the field of operation in the patient, of the surgeon, assistants, dressings, and imple- ments. If possible, the patient should be transported to a well- appointed hospital. If there has been much bleeding and the patient's condition is bad, hypodermic stimulation and submam- mary injection of salt solution should precede the operation, the anesthesia should be limited and the operation should be fin- ished in the fewest minutes possible. It is possible to conclude the operation, to the last abdominal stitch, in less than eleven minutes and with less than an ounce of ether. No attention should be paid to the blood that gushes in enormous quantities from the abdominal cavity when the peritoneum is incised. It has already been shed and is of no use to the patient. The side affected should have been learned by the history, 1 if not by the physical signs. This tube should at once be grasped between the thumb and fingers of one hand, the broad ligament should be transfixed by a pedicle needle to the inner side of the round ligament, and ligated en masse with three turns of the ligature, one to each side of the pedicle needle, the third around the whole stump. The tube and ovary are then cut away. The abdominal cavity should next be flushed with a large quantity of sterile water 2 or normal salt solution. Drainage is rarely necessary. The author has not drained a case for some years, though formerly he drained every one. If drainage is deemed necessary, gauze packing should be used. For twelve or twenty-four hours after the operation vigorous stimulation and an active treatment for the acute anemia are necessary if there has been profuse hemorrhage. 'It is often impossible to tell from a physical examination which tube is in- volved, but I have found the history of pain down one leg and not the other of great value in diagnosticating the side affected. 2 I have practically given up douching the abdominal cavity after abdominal sections, except in extra-uterine pregnancy. There is no other means which so rapidly and surely removes blood-clots from the alidomen. It is, moreover, a great advantage to leave the large quantity of hot water which remains in the abdominal cavitv after irrigation. Gallons are required, and it is inconvenient to prepare such a quantity of normal salt solution. There is, moreover, no disadvantage in the use of sterile water. 298 PREGNANCY. Submammary or intravenous injections of normal salt solution are invaluable. If the operation is performed before rupture or after a moderate hemorrhage from a tubal abortion its technic does not differ from salpingectomy for other indications. The vaginal operation for tubal pregnancy in the first three or four months has the serious disadvantages that, on account of uncontrollable hemorrhage, a vaginal hysterectomy or hasty abdominal section may be necessary, and if the tube is simply incised and not removed, a diseased and useless pelvic organ is left behind to be the source of future trouble. It is impossible through a vaginal incision to evacuate the blood and blood- clots lying in large quantities in remote portions of the abdominal cavity. Moreover, as in all vaginal sections, nicety and precision of work is impossible through the vaginal vaults. In interstitial pregnancy, on account of the difficulty of diag- nosis, treatment is not usually attempted until rupture and hem- orrhage have occurred, when an abdominal section must be per- formed. The sac should be emptied, and its edges should be sewed to the abdominal wall; after the bleeding vessels are se- cured, the sac should be drained. If this technic is impossible, ligation of the uterine and ovarian arteries is indicated, drainage of the sac, or possibly supravaginal amputation of the uterus. It is justifiable, if the diagnosis is clearly established, to evacuate the gestation sac into the uterine cavity after thorough dilatation of the cervical canal. A mistaken diagnosis, however, would lead to a premature termination of a normal intra-uterine preg- nancy. Tait describes a case in which he found it possible to incise the sac, turn out its contents, and drain it, after fetal death. 1 Engstrom treated a case successfully by incising the uterine wall, extracting the dead fetus and its appendages, making and enlarg- ing an opening between the gestation sac and the uterine cavity, sewing the uterine wall firmly together, as after .a Cesarean section, and closing the abdomen without drainage. 2 Ovarian pregnancy is treated by excision of the sac with the ovary. As a matter of fact, the operation is undertaken in these rare cases for an ovarian tumor, and the operator discovers, to his surprise, after opening the abdomen, the contents of the ovarian tumor. In advanced extra-uterine pregnancy the operator should delay interference until the fetus is viable, when the fetus and, if pos- sible, the fetal sac should be enucleated and extracted whole. It may be necessary to cut the cord off short, stitch the sac wall to the abdominal wall, and drain the sac. Forty operations (1889- 1 London "Lancet," 1894, 1, p. 38. 2 " Central bl. f. Gyn.," No. 5, 1896. Werth, to 1904, has collected 31 opera- tions for interstitial pregnancy, " Winckel's Handbuch," 2 2 , p. 940. EXTRA-UTERINE PREGNANCY. 299 1896) after the seventh month of gestation, with living and viable infants, have been collected by Dr. R. P. Harris. 1 In this number there were ten maternal deaths; twenty-seven infants survived the operation. Von Both has collected 83 cases; in the first 30 operations there were 25 deaths; in the 53 following, 15; and in the last 8 operations, only i. 2 Sittner's 3 statistics show from 1887 to 1900 forty-eight operations with removal of placenta and fetal sac with a mortality of 12.5 per cent.; thirty-five opera- tions during the same period without the removal of the placenta, with a mortality of 42.8 per cent. In the last five years of the period the mortality of the two procedures was respectively 5.5 per cent, and t,t, per cent. When death of the fetus has occurred, it is best not to subject the woman to the danger of the several possible ultimate terminations, but to per- form celiotomy and to remove the fetus and its entire surround- ing sac. If the exsection of the sac is found to be difficult or dangerous, on account of hemorrhage, the implantation of the placenta on the intestines, or its inaccessibility, it is permissible, some weeks after fetal death, to cut the cord off short, leaving behind the atrophied remains of the placenta. If this is done, the sac- wall should be stitched to the abdominal wall, and thus drained for a length of time until the placenta comes away. Mean- while daily irrigations are required and antiseptic powders (tannic or salicylic acid) may be dusted in the sac-cavity. In case the gestation sac is low down in Douglas' pouch, bulging the poste- rior vaginal wall, vaginal section and the delivery of the fetus by the natural passage may be considered ; but the dangers and disadvantages of the vaginal operation should be carefully weighed; these are : Difficulty of extracting the fetus, if it is large, uncontrollable hemorrhage, puncture of an intestine, infection of the general peritoneal cavity, either at the time of the operation, or in subsequent irrigations of the sac, and adhesions involving the uterus and appendages after the woman's recovery from the operation. 4 Vaginal section is applicable in case of an old gesta- tion sac undergoing suppuration and containing a much macerated or disintegrated fetus. In some cases of intraligamentary preg- nancy it is possible to open the sac extraperitoneally by an inci- sion above Poupart's ligament. It is always advisable, however, to make a preliminary abdominal section to learn the relations of the gestation sac. 1 Kelly's " Operative Gynecology," vol. ii. 2 "Centralbl. f. Gyn.," No. 15, 1899. 3 "Arch. f. Gyn.," Bd. lxiv. 4 For a good bibliography of the removal of extra-uterine fetuses through the vagina and by the rectum see J. T. Winter, "Am. Jour. Obstet.," 1892, p. 34. 300 PREGNANCY. Pregnancy in One Horn of a Uterus Bicornis or Unicornis. — Pregnancy in an ill-developed horn of a uterus unicornis may exactly resemble a tubal or interstitial pregnancy, and will probably end in rupture at the apex of the cornu. 1 This is par- ticularly true if the impregnated ovule develops in a rudimentary horn, in which the conditions are almost the same as in a tube, except that rupture takes place later. On the other hand, a pregnancy in a uterus bicornis may terminate prematurely, or even at term, by expulsion of the product of conception through the natural passage. Fig. 197- — Pregnancy in the rudimentary horn of a uterus unicornis, which has become, secondarily, abdominal (author's collection, Obstetrical Museum, University of Pennsylvania). The diagnosis of pregnancy in a uterine horn is difficult or impossible. It is mistaken, usually, for tubal gestation. The removal of a gestation sac in a rudimentary uterine horn is commonly easy, as a convenient pedicle is formed by the attach- ment of the horn to the lower segment of the better-formed half of the uterus. Hydrorrhea Gravidarum. — A watery discharge from the vagina of a pregnant woman may have four sources : catarrhal endometritis, rupture of the membranes, discharge of fluid from a hydrosalpinx [hydrops tuba profluens),' 1 and edema of the uterine walls. The last is a very rare cause indeed, and I am somewhat skeptical as to the possibility of serum leaking from the uterine walls, but it has apparently happened in a few cases. 3 In 1 Three cases of pregnancy in rudimentary horns are reported by Turner, Werth, and Solin (Lusk's "Obstetrics"). Kussmaul collected thirteen cases ; Manierre 39, 24 of which ended fatally by rupture, "Am. Gyn. and Obst. Jour.," vol. xv, No. 3. Werth gives the number published to 1904 as an even hundred, "Winckel's Hand- buch." 2 2 , p. 984. 2 " Hydrorrhcea Gravidarum and Hydrosalpinx," Covvles, " Obstetrics." Nov., 1899. 3 Chazan, " Centralblatt. f. Gyn.," r\o. 5, 1894, p. 105. EXTRA-UTERINE PREGNANCY. 30 1 catarrhal endometritis the fluid is discharged suddenly in con- siderable quantities ; it reaccumulates and is again discharged, the recurrent hydrorrhea continuing, perhaps, until term, al- though usually after the second or third discharge labor is brought on. The fluid discharged in a case of catarrhal endo- metritis is thin mucus. In a typical case under my observation there was a discharge of more than a pint of fluid at the seventh month of pregnancy, while the patient was lying quietly in bed. It was supposed that the membranes had ruptured and that labor was imminent, but no pains appeared, and after confinement to bed for a week the patient was allowed to get up. A month later there was another profuse discharge, — certainly more than a pint, — again occurring while the patient was quietly at rest in bed. Twelve hours later labor-pains appeared ; in the latter part of the second stage of labor the membranes ruptured and about a quart of liquor amnii was discharged. A careful examination of the membranes failed to detect a perforation remote from the seat of rupture. Rupture of the membranes and the discharge of liquor amnii in pregnancy are commonly followed by labor-pains within thirty- six hours. It is not very unusual, however, for three or four days to elapse from the time of rupture to the onset of labor. I have several times seen a month intervene between the rupture of the membranes and the beginning of labor, and in one case under my care the membranes were perforated at four and one- half months without inducing labor. The patient was the wife of an English officer in India. She had been told by a skilful Indian masseuse that she was pregnant, but an English physician whom she consulted assured her she was not, and, to prove that he was correct, inserted a sound into the uterine cavity. There was immediately a gush of liquor amnii. In spite of a journey of some 1 500 miles from the interior to the coast, the long voy- age from India to England, and thence to the United States, liquor amnii flowing from the vagina at every roll of the ship or jolt of a carriage, labor did not appear until term, four and a half months from the time the membranes were punctured. There was found, after delivery, a round, regular opening in the membranes, about the caliber of a lead-pencil, midway between the seat of rupture and the placenta, which was attached at the fundus. PART II. THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM. CHAPTER I. Labor* This chapter deals with an important practical subject, — the management of a woman in labor. The questions involved in this study confront every practitioner of medicine at some time. Every physician is popularly supposed to be able to manage a labor, and such cases are among the first that he is called upon to attend. To a beginner in obstetric practice there is much that is embarrassing. The novel and intimate relations with his patient ; her evident dread of the necessary examinations more or less revolting to every woman ; the doctor's keen conscious- ness of a lack of experience ; mistrust of his capacity to re- cognize the stage of labor, the presentation and position of the fetus; the knowledge that his every movement is watched by critical friends or attendants of the patient, who possess, perhaps, just what he lacks, — practical experience, — all unite to produce a most unenviable frame of mind in the practitioner attending his first few cases of labor. Some consolation, however, can always be found in the reflection that labor is a natural and a comparatively easy process, in the large majority of cases; that a physician's duty is one mainly of inaction and non-interference, and that most probably the labor will terminate fortunately for mother and child, in spite of his inexperience. But it is evident that no one can predict what may occur in any given case. There may sud- denly arise some accident of the gravest nature, which must be immediately recognized and promptly treated. It is under such 302 LABOR. 303 circumstances that a physician's education and knowledge are put to the test. It is plain, therefore, that in a work on obstet- rics it must be the writer's aim to impart the requisite knowl- edge to cope with all sorts of dangerous emergencies. This consideration makes it necessary to dwell at length upon all the possible complications, accidents, and difficulties of the child- bearing process, leaving upon the student's mind the impression that parturition is a more dangerous process than is really the case. It is well to recollect, therefore, that nature alone, in the majority of cases, with very little artificial aid, is capable of termi- nating safely the birth of the child; but at the same time it should not be forgotten that at any moment a dangerous complication may occur, which must be immediately recognized and promptly dealt with. It is convenient to begin the study of labor with a definition of the process. Labor is that natural process by which the female expels from her uterus and vagina the ovum at its period of full maturity, which is reached, on the average, two hundred and eighty days after the first day of the last menstruation. The process is divided into three main stages or acts, — the expansion of the birljh-canal, the expulsion of the fetus, and the delivery of the remainder of the ovum. This is a brief description of an important and complex function in woman, but as one studies the causes, the premonitory signs, the symptoms, and the phe- nomena of labor, it will be seen that it is comprehensive and correct, but that it needs some amplification. To analyze the first declaration as to the time that labor occurs, the intelligent student would naturally inquire why it is that labor comes on just two hundred and eighty days, or forty weeks, or ten lunar months from the beginning of the last men- strual flow. 1 This question has given rise to endless speculation in all ages of medicine, some of it very far from the truth. Several explanations may be offered, each reasonable, and each no doubt in part accountable for the occurrence of labor in the majority of cases at a distinct and specific time. The period of two hundred and eighty days, or forty weeks, or ten lunar months must at once direct attention to the fact that labor comes on 1 Hippocrates explained the onset of labor by the hunger of the fetus, which im- pelled it to make its exit from the womb to seek something to eat. The following explanations have been offered in recent times : thrombosis of the veins at the placenta site ; excess of C0 2 in the maternal blood ; excess of CO., in the fetal blood ; defi- ciency of C0. 2 in the blood ; pre^ure upon the ganglia in the supravaginal portion of the cervix ; excess of urea in the blood, etc. See Blumreich, " Experimente Zur Frage nach den Ursachen des Geburtsemtrittes," "Arch. f. Gyn.," Bd. lxxi, II. I. 3°4 LABOR AND THE PUERPERIUM. at the tenth menstrual period since pregnancy began. At the menstrual period in the non-pregnant uterus there is always dis- tinct muscular action, induced probably by the presence of a foreign body — blood — in the uterine cavity. During pregnancy it has long been known that by the unconscious memory of living tissue there recurs, at regular intervals corresponding to the menstrual period, a disposition to muscular action, which is sometimes so exaggerated as to bring about an expulsion of the ovum, — an accident especially to be feared at such times in women prone to abort. Here, then, is a cause predisposing to uterine muscular effort at each recurrence of the time for the absent menstrual flow, especially the tenth, and this, therefore, must be accepted as one at least of the causes of labor. It is described conveniently as periodicity. A study of all the hollow muscles in the body shows that they admit of distention up to a certain point, but, that point being reached, they are immediately stimulated to con- traction. This is well illustrated in the stomach of the young infant, which nurses until the organ, overfilled, contracts and expels the excess of food which its cavity can not contain. Pre- cisely the same action may be seen in the pregnant uterus. It admits of distention up to a certain point, until it is well filled by the mature fetus, when the great tension of its walls, no longer endurable, stimulates them to muscular action which terminates in the expulsion of the ovum. This cause of labor is defined as over distention of the uterus. In the human ovum that has reached full maturity there occurs a degenerative process, a fatty change, in the connections which bind the ovum to the uterus, that brings about a separa- tion more or less extensive between the uterine wall and the ovum, and the latter, becoming a foreign body in the uterine cavity, is cast off. This cause of labor is called the maturity of the ovum. Finally, heredity, the unconscious memory of tissue trans- mitted from generation to generation, plays an important role in the causation of labor. Thus, at the end of two hundred and eighty days the fetus has reached such a size that it is just possible for the woman, at the expense of much effort, to expel it through the birth-canal. Had it grown much larger, its expul- sion would be difficult or impossible. On the other hand, an infant born much before two hundred and eighty days is not sufficiently well developed to endure the lower temperature that it encounters, and the necessity for obtaining its own nourish- ment and oxygen, and consequently it may not survive. There- LABOR. 305 fore, it is plain that only those women who gave birth to their offspring about the two hundred and eightieth day of pregnancy could successfully perpetuate the human species. Those that fell in labor later probably died ; those whose young were born earlier were not able to rear them ; and so the habit of bear- ing children at the end of forty weeks from conception, trans- mitted from generation to generation through many ages, became, perhaps, the most powerful influence in determining the duration of pregnancy. To recapitulate, then, labor comes on at about the two hundred and eightieth day from the beginning of the last menstrual period, by reason of the influence of periodicity; the overdistention of the uterine cavity; the maturity of the ovum, and heredity. All these causes being operative together, it requires a slight stimulus or none at all to inaugurate effective uterine contractions. Ex- ercise, a dose of purgative medicine, a jolt or a jar may provoke muscular action on the part of the uterus that ends in the expulsion of the child. This knowledge is sometimes put to practical use. If it is desirable that labor should not be delayed, a dose of castor oil the night before the expected date and 15 grains of quinin the next morning, especially in primiparae, often bring on effective pains. Before entering upon a study of labor the student should be sure that he is able to recognize its occurrence. The diagnosis of labor, therefore, is a necessary preface to the study of its physiology and management. First and fore- most, in the woman supposed to be in labor, the existence of pregnancy should be determined. Many ludicrous and some tragic errors have been committed by a disregard of this rule. 1 There is a valuable premonitory sign of labor which should always be inquired for : the subsidence of the uterine tumor at periods varying from four weeks in the primigravida to two weeks or less in the multigravida before the actual advent of labor. This sinking of the uterine tumor is the result of the engage- ment of the lower uterine segment with the presenting part of the fetus in the superior strait and in the cavity of the pelvis. It has its cause, probably, in the action of the muscles inclosing the abdominal cavity. Just as the stomach, the heart, and the uterus 1 One of my students, on duty in the out-patient obstetric department, receiving his first call, hurried to the woman's house, spent some fifteen minutes sterilizing his hands, and made a prolonged vaginal examination, much to the patient's surprise, as she had sent for a physician on account of rheumatism. She was not pregnant. On one occasion I figured as an expert witness in a trial for damages on account of an attempted Cesarean section. The patient, a rachitic dwarf, was not even preg- nant when the operation was performed. 20 306 LABOR AND THE PUERPERIUM. bear distention up to a certain point, so the abdominal mus- cles allow a certain distention of the abdomen to occur, but resent anything beyond it. This point is reached in primi- gravidae at about the thirty-sixth week of pregnancy, but later in multigravidae owing to a greater laxity of their muscles. The abdomen being distended to its utmost, the abdominal mus- cles contract vigorously and drive the lower part of the uterus down through the superior strait into the cavity of the pelvis by diminishing the area of intra-abdominal space, thus accomplish- ing the first step in the expulsion of the child, the passage of the head, presuming it to be a cephalic presentation, through the superior strait, long before the labor itself begins. This sinking of the fetus and uterus occurs often suddenly, so that the pregnant woman may rise one morning entirely relieved of the distressing abdominal pressure symptoms that had previously, perhaps, tormented her. But the relief in one direction is fol- lowed by an aggravation of the varices about the vulva, anus, or lower limbs, by neuralgic pains extending down the thighs, by increased vaginal secretion, — all due to the greater pressure within the pelvic cavity. So constant is this phenomenon, the descent of the pregnant uterus near term, that, should it fail to occur, some cause for the failure should be looked for. It is usually found to be a malposition of the fetus or a deformity of the pelvis. There are three signs indicating that labor has actually begun : (i) Recurrent pains of characteristic duration, situation, and nature ; (2) the escape of a small quantity of blood-tinged mucus from the vagina, and (3) the dilatation of the os. The characteristic pains of commencing labor recur at intervals of from five minutes to half an hour, usually being about fifteen minutes apart. The pain is located in the abdomen, or is de- scribed as passing from the umbilicus in front to the sacrum behind, or in some cases is confined altogether to the back. It comes on suddenly. The woman is walking about the room, or perhaps conversing, when suddenly she pauses, bends over, contorts the facial muscles, sets her lips, and clinches her teeth. The pain rarely lasts more than a minute; when it passes off the woman resumes her interrupted occupa- tion. If the hand were laid over the abdomen when the pain came on, the uterus would be felt as a firm, hard, well-defined body, more globular than in its relaxed condition. As a consequence of the dilatation of the internal os, the lower portion of the ovum begins to sever its connection with the uterine wall, small blood-vessels are torn, and there LABOR. 307 is a slight oozing of blood, which stains the large plug of tenacious mucus that has filled the cervical canal during preg- nancy. The cervix being gradually obliterated from above downward by the descending ovum, the blood-stained plug of mucus is expelled from the cervix into the vagina, whence it escapes externally and becomes what is popularly called the s/iozi', which is regarded, and rightly, too, as a valuable sign of beginning labor. But the uterus may contract quite vigorously and bloody mucus may escape externally in many a case when labor has not really begun. The most reliable sign, after all, is the obliteration of the cervical canal and the dilatation of the os. If these conditions become plainly appreciable, one may safely diagnosticate a beginning labor, although it would be well to bear in mind exceptional cases in which the os has actually dilated up to an inch or more, but has afterward retracted and remained undilated until true labor finally appeared. 1 Having made a diagnosis of beginning labor, the physician is immediately plied with questions by the patient or her family as to its probable duration. This is a question that is put to every practitioner of obstetrics in almost every case, but, unfortunately, it can not be given a definite answer. It is a common experience to see a variation in the length of labor from one hour or less to many hours ; indeed, in rare cases to a week or more. So that it is impossible to predict with any degree of accuracy how long a given labor might last. One can usually obtain an approximate idea, however, by bearing in mind the average duration of labor in multiparas, eight hours, while in primiparae the time is usually double that or longer. One should recollect that a large parturient canal with a normal fetus, or one undersized, along with vigorous muscular action, means a quick labor ; that the opposite conditions mean delay. In the case of multiparas one should always inquire into the history of past labors, for many women have marked individual peculiari- ties in regard to the duration of parturition, in some the process being usually rapid and easy, in others the reverse. A consid- eration of all these factors will enable one to form some definite idea in his own mind of the probable duration of labor, but he would do wisely to keep his opinion to himself. To the in- quiring family a non-committal statement should be made, such 1 I have seen a young primigravida with the os dilated so that I could put four fingers side by side into it, and with the membranes bulging into the vagina, who walked about the house for a week in this condition before labor-pains appeared. In this and in similar cases, however, the cervical canal was not effaced. 308 LABOR AND THE PUERPERIUM. as "the length of the labor will depend on the strength of the pains." * Before proceeding to a consideration of the management of labor, the student will find it of service to observe the process as a passive spectator. Nothing is so conspicuous in the first stage of labor as the contractions of the uterine muscle. It has been asserted that the uterine walls contract in a sort of peris- taltic wave, beginning at the cervix, running up over the fundus, and returning again to the cervix ; but this action has never been actually demonstrated, and it is more convenient, if, indeed, it is not strictly correct, to regard the uterus as a hollow muscle which contracts at once and equally in all its parts. The effects of these contractions are : (i) To drive the liquor amnii in the direction of least resistance, which is through the internal os into the cervical canal, where, contained in the membranes, it dilates the cervical canal in the very best manner for the mater- nal tissues, as a hydrostatic dilator. (2) To drive down the fetal mass in the same direction by diminishing the area of the intra-uterine space. (3) To distend the lower uterine segment and upper cervical canal by mechanical pressure, and, finally, to dilate the os in the same manner after the circular, sphincter-like muscle of the cervix has been paralyzed by stretching and pro- longed pressure. The average duration of the uterine con- tractions during labor is one minute. The intervals between them decrease as labor goes on, and the pains become more powerful until, finally, there should intervene between them but two or three minutes. No one could observe the process of parturition in the capacity of a scientific observer without re- garding the action, appearance, and condition of the woman. It will be found that her whole bearing and manner present two distinct types in the course of the process. At first the advent of each pain is announced by a sudden setting of the teeth, a distortion of the facial muscles, suffused eyes, and a flushed face, and, the pain increasing in intensity, she suddenly emits a sharp cry of pain. The woman, if in bed, assumes almost any attitude that is most comfortable to her. In a normal first labor of some seventeen hours' duration, this condition of affairs lasts about fifteen hours, when a marked change may be observed in the woman's action. If she were left 1 As those labors which end in the day-time often begin at night, and vice versa, an obstetrician's rest is disturbed in a very large proportion of his cases. There is, consequently, a prevalent idea that almost all confinement cases occur at night. As a matter of fact, forty per cent, only are delivered between the hours of 1 1 P. M. and 7 A. M. , according to the statistics of West, based on 2019 cases ("Amer. Med. Jour.," 1854). LABOR. 309 entirely to herself she would be very likely to assume a squatting posture in bed or upon the floor, — a position assumed by the women of many savage tribes during the latter stage of labor. Now, as a pain comes on the woman draws a deep breath, clinches her teeth, fixes her diaphragm, and evidently, from her behavior, calls into play the action of the abdominal muscles with all her might. Her face is suffused, the eyebrows knit, and beads of perspiration stand out upon her brow. As long as the breath can be held this straining action is continued, Fig. 198. — The bag of waters or pouch of membranes. until the air is suddenly expelled from the lungs with a charac- teristic grunting sound, the diaphragm is again relaxed, and the abdominal muscles cease for a moment to act until a full in- spiration is taken, when the straining again begins, and continues until the uterine contraction passes off. If a vaginal exami- nation were made at this time, a reason would be found for the change in the clinical aspect of the case. It would be discovered that the os is fully dilated and that the presenting part is begin ning to descend, either carrying the membranes before it or rise, as is more common, the membranes rupture just as the os is fully dilated and the child's presenting part is driven through the rent in the amnion and chorion. In this condition of affairs is found a good explanation for the action of the abdominal 3io LABOR AND THE PUERPERIUM. muscles ; so long as the presenting part acts simply as a wedge, dilating the os, but not descending to any appreciable degree, the muscles of the abdomen are useless, and are, in fact, inhibited, for their action would drive the presenting part against the undi- lated cervix with such force as to give great pain, if not to do great damage. The main obstruction to the descent of the child, the cervix, being removed, the abdominal muscles are called into play, and act effectively in the displacement of the fetal body downward along the birth-canal. For convenience definite names are given to these stages of labor, presenting each such distinctive features. The period of dilatation is called Fig. 199. — The distention of the vulva and the appearance of the child's scalp. the first stage ; the period of descent or expulsion is called the second stage. The first stage begins with the onset of labor and ends with the complete dilatation of the os. The second stage begins with the dilatation of the os and ends with the complete expulsion of the child. As labor is not complete until the whole ovum is expelled, there is a third stage of labor, that period of time from the extrusion of the fetus until the pla- centa and membranes are expelled. To return to the clinical phenomena of labor. The wo- man has passed from the first to the second stage. . As the latter progresses the pains become more frequent and more violent, the suffering is increased, and her complaints grow LABOR. 3H louder. Finally she declares, perhaps, that she must rise to evacuate her rectum and bladder, and the reason for this feel- ing is clear when one sees the perineum bulging far outward, the anus widely dilating, the rectum becoming slightly everted, and the presenting part, the head, filling up the whole lower part of the pelvis and pressing as firmly on the bladder in front as it does on the rectum behind. And now, with his eye upon the vulva, — for this part of the labor, in the best interests of the Fig. 200. — The escape of the head and the resumption of its oblique position (external restitution). patient, ought always actually to be observed, both in a scientific study of the process and in its management, — the physician sees the labia separate during a pain and the child's scalp come into view, but, with the subsidence of the pain, disappear. With the next uterine contraction a little more of the head appears, again to disappear as the pain passes off, and so on with every pain for perhaps twenty minutes or an hour, although every time, as more and more of the head appears, it looks to the inexperienced observer as if that pain must be the last, until 312 LABOR AND THE PUERPER1UM. finally the vulva is stretched to its utmost limit and the largest diameters of the head are engaged, when, with a sudden shriek of pain from the woman, the child's head is born. There comes then a pause in the uterine action ; the head may protrude from the vagina for a minute or much longer, while the woman's natural powers are being recuperated, after their tremendous ex- ertion, for a fresh effort. Meanwhile, the child's face turns im- mediately after birth toward one or the other tuber ischii, and Fig. 201. — The transverse rotation of the head (external rotation). from the constriction about the neck becomes livid, and it seems that the child's life is threatened by strangulation. The medi- cal attendant feels at first an almost irresistible impulse to pull on the head and terminate labor. But this is a useless, indeed, a reprehensible procedure, for the child is perfectly safe, its respiration still going on normally in the placenta, and to ex- tract the shoulders rapidly through the overstretched and bruised maternal tissues is almost certain to lacerate the peri- LABOR. 313 neum. Moreover, the child is insensible at this time ; it has been almost comatose during its passage through the pelvic canal, and is now recovering, its brain-centers, especially that of respi- ration, becoming ready to respond to the stimulus to act when the child is born. Any unnecessary interference, therefore, at this stage of labor may harm both mother and child. The woman's uterus having regained power, in a few minutes begins to contract. The abdominal muscles aid it. The child's face turns still more to one side or the other until it looks quite transverse. The expulsive force still acting, the anterior shoulder appears under the symphysis pubis, the posterior shoulder shortly afterward sweeps over the perineum and escapes ; the Fig. 202. — The support of the head and the escape of the anterior shoulder. anterior shoulder follows it, and the rest of the body, too small to present any longer an effective resistance, is expelled im- mediately and the child is born. Its birth is announced, as a rule, at once by a lusty cry, which expands its lungs and initiates the pulmonary respiration. Immediately after the ex- pulsion of the child the woman becomes perfectly quiet and composed, no matter how noisy she may have been before. The passive pleasure of relief from suffering is so great that it becomes a positive enjoyment simply to be quiet, and the woman does not wish to be disturbed. In the course of some fifteen or twenty minutes, in a perfectly natural and 3 H LABOR AND THE PUERPERIUM. normal case, such as is now under description, the patient again experiences pain ; the uterus is again contracting, and the woman is again instinctively aiding it with her abdominal muscles, until after one or two such pains the placenta with the membranes is expelled. The manner in which the placenta is separated from the uterine wall and is expelled from the uterine cavity is a matter still under dispute, and there is the greatest difference of opinion in regard to it. "If," says Dr. Berry Hart, the distinguished obstetrician of Edinburgh, " the delivery of the placenta de- pended upon obstetricians knowing how it separated, no woman in labor would complete her third stage." This lack of definite information is unfortunate, for an accurate idea of the mechanism of labor in the third stage is most desirable if one would treat this period of labor intelligently. To explain the first phenom- enon, the separation of the placenta, many theories have been ad- vanced, of which I shall give only the three most reasonable, each of which has its prominent adherents. These three theories are : (i) The diminution in the area of the placental site ; (2) the de- trusion theory, which is founded on the belief that the uterus seizes the placenta and pushes it off from the uterine wall ; and (3) the theory that an effusion of blood occurs behind the placenta, and that this " retroplacental effusion," as it is called, pushes off the placenta from the uterine wall. Of these three theories, I am an adherent of the first. In a strictly normal case the retraction of the placental site is alone sufficient to account for the separation of the placenta. It has been demonstrated that, as the uterus contracts, the placenta follows the retrac- tion of the uterine walls up to a certain point without becom- ing detached, until the placenta is reduced to about one-half its natural size. Now, this is easily explained if one recol- lects the structure of the placenta, like nothing so much as a sponge, with its branching villi and intervening natural blood- spaces. But as soon as these villi are squeezed together so that the placenta forms one solid mass, it can no longer follow the retraction of the uterine wall, but is that moment, in a typically normal case, sprung off from its attachment to the uterus, and is for a varying period of time loose within the uterine cavity, until, acting as an irritating foreign body upon the uterus, it is finally driven out into the cervical canal and upper part of the vagina by the uterine contractions that its presence within the uterus excites. In the cervix and vagina, however, the placenta may remain a long time without exciting the benumbed and almost paralyzed muscles of these regions to action. And thus it is that, in civilized women, at LABOR. 315 least, it is often impossible to leave the third stage of labor entirely to nature, for the placenta may remain so long undeliv- ered that its succulent mass may putrefy and so become a source of septic infection. In describing a perfectly normal case of labor, I must presume that the placenta is expelled by the natural forces, and must describe the manner of its expulsion. But here, again, one encounters the greatest difference of opinion, even about so apparently simple and trivial a matter. One set of observers, led by the English obstetrician, Matthews Duncan, declares that in natural labor the placenta comes out edgewise, and that any other mode of exit indicates something abnormal ; while Schultze, of Germany, and his followers de- clare that the placenta always escapes like an inverted umbrella. My observation compels me to adopt the latter view. In consequence of the enormous effort put forth, the nervous excitation, the acute suffering, and the injury inflicted upon the soft structures of the birth-canal, it is not surprising that sys- tematic thermometry of the recently delivered woman shows almost always some elevation of temperature in the first twelve or twenty-four hours after child-birth. After a brief observation of the main clinical phenomena of labor, the student is better prepared to take up a consideration of its management. The advice offered applies to private and not to hospital practice, and to the beginning of the process. In the vast majority of cases a physician is engaged to attend a woman in confinement a considerable length of time before labor is expected, and there are certain important points in the pre- liminary management of the patient which it is important to appreciate, but they have been considered in the section upon the management of pregnancy. The present section begins with the first intimation that the doctor receives of beginning labor, the summons to attend his patient in confinement. The call may come at the most inconvenient time, — late at night ; in the early hours of the morning ; at the beginning of a meal ; in the midst of a press of other work, — but no one should practise ob- stetrics who does not make it an inflexible rule to give such a summons precedence over everything, over personal con- venience and all other engagements. It is customary, in this connection, to offer advice to young practitioners in regard to their personal demeanor and appear- ance when about to attend a woman in labor. While such ad- vise is usually superfluous, it does no harm to remind the phy- sician of the especial requirements of obstetric practice. He should remember that the irritability and increased sensibility characteristic of pregnancy are even more exaggerated during 3 l6 LABOR AND THE PUERPERIUM. labor. Any unusual appearance in the medical man — slovenliness of dress, abruptness of speech and manner, harshness of voice, the odor of liquor on his breath or of tobacco in his clothing — may disgust his patient. Bearing in mind the increased sensi- tiveness of women in labor, recollecting that the agony which they are about to endure, and that the despondency due to dread of im- pending suffering, if not of death, demand the greatest sympathy and consideration, no one fitted by nature for the practice of medi- cine will go far astray in his conduct toward his parturient patients. A more important question arises as soon as a physician is summoned to a case of labor. What shall he take with him ? As a part of his management of the pregnant woman he has directed the patient or her friends to have at hand the articles enumerated in the list of directions to mother and nurse on pages 364-366. A fairly well-equipped obstetrician should take with him in his obstetric bag, to an ordinary case of confine- ment, the following articles: A metal box containing scissors, needles, suture material, at least two hemostats, and a needle-holder. Two boxes or bottles of iodoform gauze (1 yd. in each); a package of sterile gauze (1 yd.). A box of five per cent, carbolated vaselin. A tube of aseptic silk ligatures for the cord. A small package of absorbent cotton. A hypodermatic needle, with the customary pellets. A bottle of the fluid extract of ergot. An obstetric forceps. A bottle of bichlorid of mercury tablets. A small Gaiffe or other electric battery, and a soap-box and nail-brush. A placental forceps (Emmet's). A surgeon's gown. A metal box, a stand, and a lamp should fit in the bag, for boiling the forceps and other metal instruments. Arrived at the dwelling to which he has been summoned, the physician finds the woman in the room selected for her con- finement, which should be, if possible, the sunniest and best ventilated in the house, and in care of a nurse in whom he has confidence from past acquaintance or from good recommenda- tion. He has been summoned because the woman believes her- self to be in labor, but she may be mistaken, or, on the other hand, may be much farther advanced than she imagines. It is the physician's first care to determine this point, and to do it he must make an examination. This the patient fully expects and will in no way object to, but it must be done in a manner as little revolting to her feelings as possible. After a few indifferent LABOR. 3 l 7 remarks in a quiet tone to the patient; a few questions in regard to the time the pains first came on, their duration, character, and situation, and the intervals of time between them ; after feeling the pulse, perhaps, and looking at the tongue, and assuring her that her general condition is very good indeed, the nurse is in- formed that the patient is to be prepared for abdominal palpation. While the nurse is arranging the patient on her back with a single layer of some thin material, as a bed-sheet, spread smoothly over the abdomen, the physician himself either leaves the room or turns his back upon the bed while he dons a surgical gown and gives his hands a preliminary washing. This whole subject of the obstetric examination is so im- portant that space may well be devoted to its consideration. Abdominal palpation is described fully in the chapter upon The Mechanism of Labor. It is, therefore, only necessary to state here that, after determining the position of the fetus in utero, and investigating its condition by listening to the heart-sounds, the nurse is directed to place the patient upon that side toward which the fetal back is directed and to prepare her for a vaginal examination. For this purpose the parturient woman is placed upon her side, with the hips brought well to the edge of the bed, the thighs flexed upon the abdomen, the legs upon the thighs. The clothing is rolled up above the waist, or so arranged that it shall not interfere with the access of the examining hand, and the bed-sheet is draped over the patient so that a wide margin of it falls over the side of the bed. While this is attended to the physician is cleansing his hands by a method fully described in the chapter on the preventive treat- ment of puerperal sepsis ; that is, by a ten minutes' scrub in four changes of hot sterile water, followed by a scrub with a fresh brush in benzine and alcohol and an immersion of the hands in a i : iooo sublimate solution. In addition to the hand disinfec- tion, it should be an invariable rule to wear rubber gloves that have been boiled or have been soaked in a I : iooo sublimate solution. The physician uses the hand for the internal examination next the patient, as he takes his seat alongside of the bed, facing her genitalia. Even-thing being in readiness for the vaginal examination, the examining finger is dipped into a jar of car- bolated vaselin, the nurse lifts up the sheet covering the but- tocks, the obstetrician raises the upper buttock with his free hand, wipes off the vulvar orifice with pledgets of cotton soaked in a I : 2000 sublimate solution, and by the sense of sight inserts the forefinger of the examining hand directly into the gaping vaginal orifice. Nothing is more foolish than the ancient practice of grop- ing about under a sheet for the woman's genitalia, thus dangerously soiling the examining hand which had been made sterile by a pains- 3 l8 LABOR AND THE PUERPERIUM. taking disinfection, only to be infected again before its insertion into the vagina. The ability to derive easily all the desired infor- mation from a vaginal examination only comes from practice and an education of the tactile sense. It would be well, therefore, for the practitioner, in the beginning of his obstetric experience, to bear in mind a series of questions in their natural sequence, which he desires to have answered, and to persist in his earlier cases until repeated and long-continued examinations have satis- fied his mind. Thus : the character of the vaginal discharge ; the state of the perineum, whether relaxed, rigid, or torn perhaps from a previous labor ; the rigidity and distensibility of the vaginal walls and the quantity of secretion upon them, — nature's lubricant; the capacity of the pelvis ; the condition of the cervix, whether it is rigid or yielding, thickened, edematous, or thinned out ; the degree of dilatation of the os ; the portion of the fetal ellipse which is presenting itself at the os ; the engagement of the presenting part in the pelvis ; the position that the present- ing part may have assumed ; the rupture or the integrity of the membranes ; and, if the examination continues during a pain, the effect of the expulsive forces upon the fetal mass. All these are questions of great importance in their bearing upon the diag- nosis of the woman's present condition and upon the prognosis as to the character, duration, and termination of the labor. Having satisfied his mind upon all these points, the obstetri- cian enters upon the management of labor. The very first step in the treatment of the first stage of labor should be the evacuation of the rectum. The capacity of a nor- mal pelvis is none too great to permit the passage of the fetal body ; but if the pelvic canal is occupied by a distended rectum full of feces, labor may be delayed, the woman's suffering is materially increased, and the danger of a tear in the greatly dis- tended vagina is considerably augmented. It is only the rectum and sigmoid flexure that need be emptied, and this result is best secured by an enema of a pint of soapsuds with a teaspoonful of turpentine in it. A well-trained nurse will already have done this, perhaps before the doctor's arrival, if she thinks that labor has really begun. The enema acts quickly and effectually, whereas a purgative administered at the beginning of labor, as has been recommended by some obstetricians, begins its action possibly when the os is too much dilated to allow the woman to use a commode. The lower bowel being emptied, the woman, with advantage and comfort to herself, may be allowed to walk about the room or to sit up in a chair, the physician making an ex- amination from time to time to determine the progress of labor and to avoid the serious accident of a precipitate delivery in LABOR. 319 the erect posture, an accident dangerous to the mother and usually fatal to the child. This statement leads to the inquiry how often and how long to examine a parturient woman in the first stage of labor, and how long she should be allowed to re- main out of bed in a standing or a sitting posture. In a normal case during the first stage of labor, the intervals between the examinations are from two to four hours, or even longer. But two or three examinations need be made during the whole labor. As to the time for putting a woman in labor to bed and keep- ing her there, it is usual to lay down the rule that as soon as the os has reached the size of a silver dollar the woman should be confined to bed. Many patients might be allowed to be up longer than this, while others with a history of, or conditions predisposing to, quick labors must be put to bed earlier. Many patients express a desire to go to the water-closet at about this time, but their request can on no account be allowed. Many a woman has discharged her infant into the seat of a water-closet or into the well of a privy, either by design or under the impression that she was having an evacuation of the bowels. 1 Before the woman is put to bed it should be arranged for the labor in the manner illustrated in figure 203. The mattress is protected by a mackintosh and the bed-sheet is guarded by a pad of nursery cloth. As the first stage of labor advances, the suffering of the woman increases with each succeeding pain. She complains, N perhaps, bitterly, and the suffering becomes so great, in occa- sional instances, that the patient seems to be maniacal or to become completely exhausted, not so much from muscular effort as from an agony that is beyond endurance. She appeals to her medical attendant to do something to relieve her suffering, and her appeal is enforced by all the appearances of the greatest anguish, perhaps, that a human being is called upon to endure. Any sympathetic person must feel impelled to grant this request, to resort to some of the well-known agents for lessen- 1 The resident physician on my service at the Howard Hospital was called to a house in the neighborhood, and fished out of the privy-well, twelve feet deep, an infant which had been immersed in the contents of the well up to its neck for eight hours. The mother had deliberately sat upon the seat until her baby dropped from her. She had then thrown three bricks down upon it. In spite of these disadvantages the child was extracted alive, by means of a pole and some twine. It was received into my wards at the Philadelphia Hospital, where it thrived. On another occasion one of the patients in the University Maternity locked herself in the water-closet, dropped her baby down the bowl, and turned on the water. A nurse's attention was at length attracted to a stream of water running across the floor of the corridor. 1 he water-closet door was broken open, the woman pulled off the seat, and the child, whose head accurately stopped up the exit-pipe of the bowl, was extracted alive, though it had been under water probably five minutes. All cases of this kind do not end so fortunately. 320 LABOR AND THE PUERPERIUM. ing pain that medical science is now possessed of. The only consideration that could deter him would be the fear that these remedies entailed dangers upon the woman that he dare not risk even to secure the immense relief of pain that they would afford. It has been demonstrated that such a fear is not justified by facts. The dangers and disadvantages that, it is claimed, result from the use of anesthetics in labor are : a prolongation of the process by weakening the uterine contractions and increasing the intervals between them ; a disposition to postpartum hemor- rhage ; an increased liability to sepsis after labor by a relaxation of the uterine muscle, and a subinvolution of the uterus. These objections are ill-founded if the anesthetic is administered Fig. 203 — Bed arranged for child-birth. The mattress is protected by a mackin- tosh, over which a clean sheet is spread. The upper bed-clothes are rolled up at the foot of the bed. The woman's buttocks rest upon a square yard of nursery cloth. The chair is for the obstetrician ; at his feet is a waste-bucket, into which the pledgets of cotton used to clean the anus are thrown. The table, in easy reach, has upon it a large basin of sublimate solution, I : 2000, in which are many large pledgets of cot- ton ; a small tin cup on an alcohol lamp to boil the scissors for the cord ; a half dozen clean towels ; a pot of carbolated vaselin ; a tumbler of boric-acid solution with squares of clean soft linen in it for the child's eyes and mouth ; a tube of sterile silk for the cord. in a proper manner. Accurate observation in some of the large German lying-in hospitals has demonstrated that an anesthetic, if not pushed too far, has no influence on the power, duration, or frequency of the pains. By relieving suffering that causes ex- haustion, the danger of postpartum hemorrhage is avoided. LABOR. 321 Subinvolution is never seen as a result of anesthesia, unless it is pushed too far. In some women labor is little more than an inconvenience or a discomfort, and by no means an agony. Women have been known to expel a full-term child when they were hardly conscious that labor had begun. 1 To resort, therefore, to an anesthetic when there is no suffering is obviously absurd. Granting, however, that in many cases anesthesia in labor is an advantage, if not a necessity, the physician must select the an- esthetic, and must determine when and how he shall use it. The choice lies between ether and chloroform. Cocain, it was thought at one time, would be an efficient local anesthetic, but it proved a failure. Belladonna, applied locally to the cervix, is also useless, although it diminishes rigidity; the same may be said of chloral, taken internally. Repeated hypodermatic injections of hydro- bromate of hyoscin, gr. yi-g- (scopolamin), and morphin, gr. \, are sometimes useful, but do not compare in efficiency with ether or chloroform. 2 Spinal anesthesia by the injection of cocain solution into the lumbar spine, while enthusiastically tried for a time, deserves no consideration in the management of an ordinary case. 3 The choice in the eastern seaboard of the United States will usually be ether. Chloroform is in disfavor in this part of the world, al- though, perhaps, unjustly. Ether is an efficient, convenient, and satisfactory agent in obstetrical practice, except, of course, in the treatment of eclampsia. There are, however, two precautions to be observed in its administration, — not to give it too long, and not to give too much of it. The first error is avoided by beginning its administration as late in labor as possible; it is better to put off the resort to an anesthetic until the second stage of labor, when the suffering in the first stage is not too great. One avoids giving too much: (1) By using a light towel thrown over the face and dropping only a few drops at a time, just below the tip of the nose, at the end of an expiration, so that the whole vapor is sucked into the lungs with the succeeding inspiration; (2) by only beginning the administration of ether as the pains come on, and discontinu- ing it between them; and (3) by endeavoring to produce not complete anesthesia, but only analgesia. As labor advances and the first stage is about to pass into *Dr. B. B. Cates, of Knoxville, tells me of a case in which there was no pain whatever during labor, but at every uterine contraction the patient said she felt as though she had a croquet ball in her mouth (globus hystericus). 2 " Schmerzverminderung und Narkose in der Geburtshiilfe mit spezieller Beriick- sichtigung der Kombinierten Skopolamin Morphium Anresthesie," Steinbiichel, Leipzic u. Wien, 1903. 3 " Medullary Narcosis," W. L. Rodman, "Therapeutic Gazette," Jan. 15, 1901 ; good description of technique "Transactions of Southern Surgical and Gynecol. Assoc, for 1900," " Year-Book of Medicine and Surgery," 1901-1902, " La Presse Medicale," Nov. 9, 1901, No. 9. 21 322 LABOR AND THE PUERPERIUM. the second, one should expect the rupture of the membranes and the escape of liquor amnii; so he will wisely make some prepara- tion for the occurrence. Provision must be made for the sudden escape, often rather startling to the patient or to an inexperienced practitioner, of a pint or more of liquor amnii, which must be caught in some clean towels or mopped up by sterile absorbent cotton. If the membranes fail to rupture at the end of the first or at the beginning of the second stage of labor, the physician must consider whether he shall artificially break the bag of waters. In the case of a primipara such interference is not justifiable. The bag of waters is a perfect hydrostatic dilator, acting without great force, and in primiparae a slow, gradual, and conservative dilatation of the maternal soft parts is most desirable, to avoid lacerations of the cervix, vagina, or perineum. In multiparae the artificial rupture of the membranes is admissible after the completion of the first stage of labor ; the interference certainly hastens the expulsion of the child, and as the soft parts of a woman who has already borne children are distensible there is not the same necessity for care to preserve nature's conservative dilator. Under no circumstances, in an ordinary uncomplicated labor, should the membranes be ruptured before the full dilata- tion of the os. Any one who has observed what in the nurse's parlance is called a dry labor — that is, one in which the mem- branes rupture early — will not dispute this assertion. Occasion- ally, even in primiparae, the first intimation that a woman receives of the beginning labor is the escape of the liquor amnii, the mem- branes having ruptured before the os is at all dilated. In these cases the labor is longer, the woman's suffering is much greater, and the likelihood of damage to the maternal tissues is very con- siderably increased. Occasionally, however, in the case of a mul- tipara in the second stage of labor with unruptured membranes, the physician must be prepared to perform the rather trivial manceuver of artificial rupture of the membranes with skill and without injury to the fetal or maternal structures. This sounds simple enough, and yet experience has shown that certain precautions are necessary. In the first place, the membranes are not to be ruptured during a pain, for the sudden gush of liquor amnii might carry with it a loop of the cord. It must be clearly established that the tissues to be punctured are the membranes, and not the child's scalp or the distended lower uterine segment. It is often possible to hook the finger-tip into a fold of the mem- branes and to tear them by pulling outward. They may also be pinched through between the forefinger and the thumb or middle finger. If these manual methods do not succeed, the Emmet curette forceps may be used to pinch and tear a fold of the mem- branes. LABOR. 323 During the second stage of labor a new and a very important element enters into its mechanism, — the powerful action of the abdominal walls. Indeed, it has been claimed that the con- traction of the abdominal muscles is the principal, the uterine force the secondary, expulsive power in this stage of labor. By the employment of a "puller" which fixes the chest above and the pelvis below, the power of the abdominal muscles may be utilized to its utmost extent. This is done by fixing the feet, protected by a pillow, against the foot-board of the bed, and attaching to one corner of it a rope or a twisted sheet on which the woman can pull with her hands. The straining accompanying the uterine action, denoting that the second stage of labor has begun and that the presenting part is descending into the birth-canal, lasts in the typically normal case about an hour and a half or two hours, when, if the physician observes the genitalia, — and the period of labor has arrived when it is desirable actually to observe the process, — he notices that the anus is opened and the rectal mucous membrane is exposed to view ; with every pain small masses of feces are extruded from the anus which must be wiped away always toward the coccyx with large pledgets of cotton soaked in sub- limate solution ; the perineum bulges outward, and the vulvar orifice opens a little, disclosing a small portion of the child's scalp. With every pain the perineum becomes more distended, the vulva gapes more widely, until, finally, the perineum, by the tremendous tension to which it is subjected, becomes almost as thin as paper, and it seems a physical impossibility for the head to escape through the vulva without tearing the over- stretched tissues that form the pelvic floor. In fact, frequently the fetal head does make a way for itself through the perineum, instead of over and in front of it as nature intended, and after labor there is found a more or less extensive laceration of the pelvic floor. Schroeder's statistics show that in primiparae the fourchet, the little fold of skin at the posterior commissure of the vulva, is torn through in 61 per cent., while in 34 per cent. of all primiparae and in 9 per cent, of multiparas the peri- neum is more or less lacerated. If the patient is placed upon an examining or operating table a few days after labor and a careful examination is made of the genital canal, the proportion of lacera- tions in the anterior and posterior vaginal walls involving the underlying muscle will be found at least twice as great as Schroe- der's statistics indicate. The problem presents itself, therefore, to every obstetrician in every case to avoid these accidents if possible. Although the management of a perfectly normal labor is here considered, so frequent an accident is laceration of the 324 LABOR AND THE PUERPERIUM. birth canal, and so constant is the danger of it, that it is necessary to take up, in this connection, the study of its causes, in order to devise an effective preventive treatment. The causes of laceration of the pelvic floor may be divided under three heads: (i) A relative disproportion in size between the outlet of the birth-canal and any part of the fetus, which makes the escape of the latter a physical impossibility unless the aperture is enlarged by tearing its least resisting border ; (2) such a rapid expulsion of any part of the fetal body that the maternal tissues can not gradually dilate, but give way before the sudden strain imposed on them ; and (3) any abnor- mality in the mechanism of labor which pushes the present- ing part backward against the center of the perineum and prevents its propulsion forward under the symphysis pubis. In the first category, relative disproportion, might be put those cases in which the head is too large or the vulva too small ; and, further, those cases in which the head presents its largest instead of its smallest diameters, as happens in insufficient flexion in vertex presentations. Under the second heading, precipitate expulsion, might be put all cases in which the expulsive forces are too strong- • cases of straight sacrum, in which the fetal head is shot through the pelvic canal and suddenly puts great strain on the perineum ; cases in which too powerful traction is made with the forceps. Under the third head, an abnormal backward direction of the presenting part, might be placed those cases in which a pelvis of a male type, with approximated pubic rami, pushes the head backward and throws a greater strain on the perineum ; cases again, in which the woman, just as the head is passing through the vulva, suddenly straightens her legs and brings them close together ; further, cases in which a straight sacrum allows the head to descend directly upon the perineum instead of directing it forward toward the vulvar opening, as a normally curved sacrum should do ; and, finally, cases in which overfiexion brings the vertex to bear directly upon the center of the perineum. It must appear, from these many different causes, that the preventive treatment of laceration of the perineum differs con- siderably in order to meet the diverse conditions that threaten the integrity of the pelvic floor ; thus, if there is a very great relative disproportion between the head and the vulva and the opening must be artificially enlarged, instead of allowing the perineum to tear, perhaps into the rectum, it is better to nick the margin of the vulva on the side, and allow the tear to occur where it can not extend too far, and can do no harm. This simple operation is called cpisiotomy. It should be distinctly LABOR. 3 2 5 understood that it is called for only in rare and exceptional cases. Personally, I have no confidence in it whatever, as I believe it to be based upon an incorrect idea as to the mechanism of pelvic tears. After the delivery of the child and the placenta the small wound is to be closed by catgut or silkworm-gut sutures. If the danger to the perineum comes from a precipitate expulsion of the head, the proper preventive treatment is a retardation of labor, either by holding the advancing head back with the hand or with the forceps, or by giving an anesthetic to control the voluntary muscles. Faulty mechanism, as over- flexion or extension, may be corrected by the forceps. It is evident, therefore, that no single plan of preventive treatment, no inflexible method of "supporting the perineum," as it is called, will avail in all cases. There is, however, a routine practice directed against the commonest cause of "lacerated perineum" that may prevent a laceration, or at least a very extensive tear extending into the rectum. There are excuses for the lesser grades of laceration, and it is true that no physician, be his skill what it may, can absolutely avoid this accident ; but a complete destruction of the perineum, a tear through the rectum, is rarely justifiable. It is most frequently the result of some blunder, carelessness, or error of technic. As the head distends the vulva almost to the utmost, it fails to recede as it has done after the previous pain, but remains in view until the next uterine contraction, which, with the abdominal contraction that accompanies it, suddenly expels the head through the widely stretched external outlet. The expulsive force acting suddenly and being much greater than is necessary to overcome the slight resistance now offered by the soft parts, lacerates the tissues instead of dilating and stretching them. This being the most frequent cause of lacerated perineum, it is easy to devise a means to meet and overcome the difficulty. The main requirement is to regulate the expulsive force so that it is just sufficient to over- come the slight resistance offered by the distended perineum, and as an auxiliary measure to restrain the progress of the head should this force become too great or be exerted too suddenly. It is obvious that one can not govern the force of the uterine contractions, which are involuntary ; but one can regulate the force and duration of the abdominal contractions by appealing to the woman's will. Thus, the physician can call upon her to strain forcibly or gently, as the case may require, bringing into more or less active play the expulsive action of the abdom- inal walls ; he can command her to stop straining, or to open her mouth and breathe rapidly, which amounts to the same thing, 326 LABOR AND THE PUERPERIUM. thus inhibiting the greater part of the expulsive force; or, if a powerful uterine contraction should come on, or if the woman should exert her voluntary muscles too violently, or should fail to obey the command to stop straining, the expulsive forces may be neutralized simply by making such firm pressure against the child's head with the hand that it will not budge. At the same time the outspread hand, which can most conveniently be used for the purpose, is applied to the distended perineum so that the thumb and forefinger encircle the posterior commissure of the vulva. This hand helps to flex the head when the occiput is anterior ; it restrains the progress of the head, and it pushes it forward under the arch of the pubes, away from the overstretched muscles of the pelvic floor. This is the best plan of supporting the perineum, as it is called, though it is not really a support of the perineum at all, but a diminution of the expulsive forces and a regulation of the progress of the fetal head, which is supported, restrained, and directed by pressure, partly through the perineum, partly directly upon the head itself. 1 Presuming that these precautions have been successful, that the perineum has been safely retracted over the child's head, and that the head is born, the face at first appears white, but almost immediately turns quite purple and looks as if the child must be choking to death. It is, as a rule, however, in no seri- ous danger. The head being the only part of the fetal body free from pressure the blood is determined to it, and is prevented from returning freely by the pressure about the neck, thus giving the child's head, as it protrudes from the vagina, a most alarm- ing appearance of deep asphyxia. There is, however, in some cases, a more serious element in the asphyxiated look of the child ; in one out of four labors the cord is found coiled about the child's neck, usually only once, and that lightly, but occa- sionally many times, nine coils having been recorded in one case, and so tightly occasionally as to completely strangulate the infant, not by pressure upon the neck, but upon the cord. This anomaly occurring so frequently, and having such serious results, must always be borne in mind, and as soon as the head is born and the neck becomes accessible the medical attendant must at once ascertain whether the cord encircles it or not, by sweeping a forefinger between the child's neck and the maternal symphysis. If the cord is found in this situation, it should be gently 1 Sarwey in "Winckel's Handbuch" (vol. i 2 , 1904) gives some fifteen different methods of supporting the perineum. There is no one of them that insures the woman against injury. The plan advocated by the author is a modified Ritgen manoeuvre, the physician seated alongside the bed facing the woman's vulva, and the patient lying upon her side. LABOR. 32/ pulled upon, and whichever portion yields should be drawn out, so enlarging the loop that it may be slipped over the head; or, if that is impossible, making the loop at least large enough I Fig. 2l>4 — Retarding the escape of the head and pushing it away from the peri- neum. The patient is on her left side. The physician sits alongside the edge of the bed, facing the vulva. The woman's knees are held apart by a pillow between them. to allow the shoulders to pass through ; or if that, again, is not feasible, if the cord so firmly constricts the child's neck that the loop or loops can not be loosened, it may be hastily ligatured with a double thread and then cut between the ligatures. The child, in such a case, must, of course, be extracted immediately, else it will be fatally asphyxiated. The cord not being felt, or having been attended to, if found around the neck, the physician next turns his attention to the child's head. The head is protruding from the vulva, the face is swollen and almost purple, looking as if the only hope for the fetus lay in speedy delivery ; the labor is almost concluded, the medical attendant sees his anxiety and attendance almost at an end, and for all these reasons, especially if he is inexperi- enced, he feels strongly impelled to terminate a process that seems to endanger the fetus, that has caused his patient much suffering, and himself, perhaps, fatigue, by pulling on the head and rapidly extracting the fetal body. If he does so, however, the shoulders hastily pulled through the vulva will almost 3^8 LABOR AND THE PUERPERIUM. surely lacerate the perineum, perhaps deeply. Many a case of lacerated perineum, even into the rectum, is explained in this way. A still more serious consideration is that immoderate traction upon the head may seriously injure the child's spine and the spinal column. As experience has shown that the fetus is not subjected to great danger in this situation, and as premature efforts to extract it entail upon both woman and child a danger more imminent than that which it is endeavored to avert, it is better to do nothing at this stage of labor but simply to support the head upon the hand, waiting for the action of the natural expulsive forces, which will rotate the shoulders, and with them the head, and shortly after expel the rest of the body. While the child's head protrudes from the vulva the opportunity should be taken to cleanse the eyelids with squares of clean soft linen, soaked in boracic acid solution, gr. x to f§j of distilled water, or by injecting this solution into the eyes with a pipette. After waiting a minute or two, the physician may stimulate the uterus by rubbing or kneading it, and may assist its contractions by pressure upon the abdominal walls over the fundus. This is all the assistance required in a normal case. With this slight addition to the natural forces the shoulders descend and rotate ; the anterior shoulder slips out first under the symphysis pubis, the posterior shoulder and arm quickly follow, the anterior arm then emerges, and, the shoulders being born, the rest of the body is immediately expelled so rapidly that it is difficult to follow the mechanism. It is admissible, if one is careful not to use too much force, to pull the child's head backward to facilitate the birth of the anterior shoulder, forward to assist the birth of the posterior shoulder (Figs. 205 and 206). Indeed, it is an advantage to do so, if traction is not made too soon or too forcibly. The moment the child escapes from the birth-canal it emits a lusty cry, which is usually synchronous with a sigh of intense satisfaction from the mother, who has in an instant been entirely relieved of long and intense suffering. There are now two patients on the physi- cian's hands at once, and, although he must in practice devote his attention to both equally and at the same time, it is more conve- nient here to consider their management separately. Although the child's expulsion from the mother gives her such immense relief, it by no means terminates the labor nor brings her an immunity from all danger ; indeed, the chief, the most common danger of parturition, hemorrhage, may be said to begin with the expulsion of the child, and sometimes a most difficult and dangerous complication of labor, adhesion of the placenta to the uterine wall, only manifests itself after the complete escape of the child from the birth-canal. There are, therefore, two problems LABOR. 329 with which to deal in the third stage of labor in almost every case, no matter how normal it may appear, — the delivery of the placenta and the prevention of hemorrhage. As hemorrhage may occur before the expulsion of the placenta, and therefore stands first in point of time; as this accident is of the gravest nature and its prevention of the greatest importance, the first thought of the Fig. 205. — fulling the infant's head toward the maternal sacrum to facilitate the escape of the anterior shoulder (l)umm 1. medical attendant should be the routine means to adopt in every case to prevent its occurrence. Provided the uterus contracts and remains contracted, the enormous blood-vessels in its walls are obliterated and hemor- rhage is impossible. On the other hand, if the uterus remains flaccid and uncontracted while the placenta is being separated, 33° LABOR AND THE PUERPERIUM. or if the organ, at first contracted, afterward relaxes, hemorrhage of the most alarming character must as necessarily occur. The whole problem, therefore, of preventing hemorrhage after delivery resolves itself into a problem of securing and of maintaining uterine contraction. Firm Contraction of the Uterus After Labor is Secured by Ex- ternal and by Internal Stimuli to Contraction. — The internal stimulus consists of a dram dose of the fluid extract of ergot in a little water, administered as soon as the child's body is born. It has been claimed that ergot should never be administered before Fig. 206. — Pulling the infant's head toward the maternal symphysis to extract the posterior shoulder ( Bumm) . the expulsion of the placenta for fear of hour-glass contraction of the uterus. But it requires at least fifteen minutes after ergot is administered by the mouth before its action is felt by the uterus; meanwhile, in a normal case the placenta is expressed, the in- fluence of the ergot is felt at the time it is most needed as a rule, just after the conclusion of the third stage of labor. The external stimulus consists of manipulation of the uterus. Luckily the uter- ine muscle is irritable, and shows its irritation by contracting its fibers. Luckily, again, it is accessible. One can easily grasp LABOR. 331 it through the abdominal walls ; can rub it and exert direct pressure upon it, these actions exercising a powerful irritant in- fluence upon the uterus and bringing about, in the ordinary case, firm contraction. This is the most efficient, readily applied ex- ternal stimulus to uterine contraction, and one that must be in- variably applied, and that, too, continuously from the moment the infant's body is expelled until a milder form of external stimulus which is to maintain uterine contraction is adjusted, — the obstet- rical binder. The moment that the child escapes from the woman's body the physician or nurse seizes the uterus through the ab- dominal wall and exerts constant pressure upon it, irritating it still more from time to time by a kneading or a rubbing motion. If the woman is fortunate enough to have a good nurse, this duty may safely be left to her, while the doctor washes his hands and takes a brief rest. Some fifteen minutes having elapsed, the placenta being delivered, the woman having been cleaned and made more comfortable, the constant pressing and kneading of the uterus may be replaced by the more gentle and more continu- ous external stimulus of the binder and abdominal pad. The binder holds an important place in the treatment of English- speaking women. In some civilized countries it is not used at all, and, it must be confessed, it is unnecessary, from the medical point of view, after the first twenty-four hours. The obstetrical binder, however, adds greatly to the woman's comfort by maintaining the intra-abdominal pressure and thus preventing cerebral anemia. It undoubtedly preserves the figure, — a fact to which no woman is indifferent, — it diminishes the risk of permanent diastasis of the recti muscles, and it lessens the danger of postpartum hemorrhage by maintaining a tonic con- traction of the uterus. For all these reasons the use of the ob- stetrical binder is well justified — is, in fact, demanded — in the intelligent management of the puerpera. The best binder is a piece of unbleached muslin, about a yard and a quarter long and wide enough to reach from the trochanters to the floating ribs. It is pinned together from above downward, and is made to fit more snugly and comfortably by making gores at the sides above and below the hips. The pad should consist of one or two folded towels put above the navel to fill the hollow in the epigastrium left by the evacuation of the womb and its reduction in size. The second problem of the two that confront a physician in the management of the woman in the last stage of labor is the delivery of the placenta. To superintend this process intelli- gently it is necessary to recall the chief phenomena of the mech- anism of the third stage of labor. The placental structure resembles a sponge, and as the uterine 332 LABOR AND THE PUERPERIUM. wall contracts and retracts, the placenta follows the reduction in the size of the placental site by a corresponding reduction in the placental area, up to a certain point. The placenta diminishes in size until all its villi come in actual contact with one another; until, instead of being a spongy organ with the intervillous blood- spaces separating the villi from one another, the whole organ becomes a solid mass, and can — : — ■>— -.. "^ not accompany a further reduction in the area of uterine wall to which it is attached, so that the smallest additional contraction of the uterine muscle must spring off the whole placental mass at once. This point is reached when the placenta has been reduced to about one-half of its natural area — a fact that has been demonstrated on uteri removed by the Porro Cesarean section or on postmortem examinations of patients who had died during or directly after labor. The expulsion of the placenta after its detachment is easily under- stood ; lying in the uterine cavity as a loose foreign body, all that is re- quired is the vigorous action of the uterine muscle to drive it out. But, once beyond the province of the thick, muscular portion of the uterus, above the contraction- ring, there is no further force to expel the placenta, for it lies in the semiparalyzed lower uterine segment (see Fig. 207), cervix or vagina, where it may remain for hours or days, until it undergoes de- composition. 1 As the lower animals never require an artificial delivery of the after-birth, many obstetricians of the eighteenth century argued that the delivery of the placenta should be left entirely to nature. The result was disastrous, as may be imagined. It is, therefore, a necessary part of the management of the third stage of labor to secure the separation of the placenta by stimulating the uterus to contract and by aiding it to expel 1 V. Campe ("Zeit. f. Geburtsh. u. Gyn.," Ed. x, H. 2) i 1 120 observations found that in 24 instances the placenta had not been expelled in twelve hours. Fig. 207. — Dilated lower uterine segment and cervix after labor, from a fiozen section (Benckiser and Hofmeier). LABOR. 333 its contents by exaggerating its expulsive power. These two objects are best obtained by what is known as Crede's method, a method first proposed to the profession in a systematic manner by the late Professor Crede, of Leipsic, 1 in 1861. A similar plan had been in use in Dublin for a long time before, and many primitive and savage people have employed, perhaps for ages, methods based upon the same principle. Fig. 208. — The expression of the placenta. Fig. 209. — The reception of the placenta in a basin. In applying Crede's method the uterus is seized in a grasp illustrated in figure 296, is kneaded and rubbed until it con- tracts with vigor; only then, and only in conjunction with the uterine contraction, should it be firmly pressed down in the direction of the axis of the pelvic inlet, while it is compressed 1 " Monats. f. Geburtskunde," xvii, p. 274. 334 LABOR AND THE PUERPERIUM. between the lingers and thumb with considerable force. The placenta is squeezed out as the stone is pressed out of a cherry. It should be expressed twelve or fifteen minutes after the child is born, as complete separation has not occurred in the average case till this time has elapsed. As it slowly emerges from the vulva it should be caught in the obstetrician's hand, while a nurse holds a basin pressed close into the mother's lower buttock, to receive the blood that usually spurts out with the after-birth. The mem- branes trail after the placenta, running up into the vagina and the uterine cavity. To extract them without tearing them, and thus leaving a portion behind, they should be seized between the whole length of the thumb and forefinger and gently pulled, first forward toward the symphysis, then backward toward the sacrum, the uterus meanwhile being allowed to relax. It is a mistake to turn the placenta over several times to make a " rope " of the membranes. To return to the infant. The head and shoulders having escaped, the rest of the body slips out almost immediately, the child's arrival being announced usually by a vigorous cry, a purely reflex action caused by the sudden shock which the new-born experiences on suddenly emerging from an aquatic existence, in which its immediate surroundings have a temperature of about 99°, into the atmosphere and a temperature not over 70 . This violent shock produces not only a spasmodic action of the diaph- ragm and the muscles of respiration, but also of the bladder, and of all of the muscles of the body as well, so that often urine is voided directly after birth, and the arms and legs are moved about quite violently. As soon as the child is born, it is well to see that its air-passages are clear and not clogged by mucus or blood that might have been inspired during labor. This is done by crooking the little finger and introducing it back of the epiglottis; if, however, the child at once emits a vigorous cry, it is proof enough that the respiratory tract is not obstructed. The infant is then placed on its right side, this posture favoring the closure of the foramen ovale and facilitating the passage of the blood from the ascending cava over the Eustachian valve into the right auricle. The position should also be so arranged as to turn the child's face from the mother's genitals and to protect the infant's air-passages from the maternal discharges incident to the third stage of labor, care being taken, also, not to put the cord too much on the stretch, for all this time, of course, the infant remains attached to the mother by the umbilical cord. Now arises the question, in every case, as to the advisability of severing the cord at once and getting the child out of the way. The placenta, it has been argued, no longer performs its vital functions ; the child breathes, LABOR. 35 and, therefore, it might be better to cut the cord, to remove the infant from the bed, and to turn it over to the nurse. This plan, however, does not take into account the fact that there remains a considerable quantity of fetal blood in the placenta ; that it is an advantage to have all of this blood, if possible, returned to the infantile body where it belongs, and that, further, the deple- tion of the placenta renders its expulsion easier. The blood in the placenta will return to the child's body, if time is allowed for it ; on the one hand, the action of the respiratory muscle exerts a suction upon the placental vessels, which aspirates the blood from the placenta ; on the other hand, the pressure upon the placenta by the uterus drives the placental blood into the fetal body. To demonstrate the advantage of late ligation of the cord, Budin x conducted a series of experiments, with the following results : the cord ceased beating in 22 cases, on the Fig. 2IO. — The position in which the child should be placed after birth. average, in two and one-half minutes. In these cases the average weight of the placenta was 520 gm. (i| lb.), and the amount of blood that escaped from the umbilical vein in 20 cases was 92 gm. (3.2 oz. Avoir.) less in late than after immediate section of the cord. Thus, by immediate ligation 92 gm. (3.2 oz. Avoir.) of blood are lost to the infant's body. Moreover, in contrasting the weights of children after immediate and late ligation of the cord there was a gain of two to three ounces in favor of late ligation. It is better, therefore, to wait two or three minutes after the birth of the infant before cutting its cord. 2 The proper time having arrived, the cord should be ligated about two fingers' breadth from the child's 1 Publications du "Progres Medical," 1876; also "Obstetrique et Gynecologie," 1886. 2 There has been some criticism of Budin's proposition to ligate the cord late; several German authors have attributed a number of infantile complications to it, but the objections to the plan are ill founded. 336 LABOR AND THE PUERPERIUM. body with a piece of stout surgeon's silk or narrow bobbin, steril- ized. The ligature is tied firmly once around with a double knot. The ends are then doubled around again and are tied with a single and a bow knot, so that the nurse, after the child is washed, may slip this last knot and may then retie the ligature firmly. This precaution surely avoids a primary or secondary hemorrhage from the cord, which sometimes occurs in consequence of a shrink- age of the mucous tissue, making the original ligature too loose. The obstetrician is now ready to cut the cord. The child is slippery and hard to hold; its legs and arms are jerked about in a very disconcerting manner to the beginner, so that carelessness in the use of scissors at this juncture might result in injury to the Fig. 211 — Cutting the cord. fingers, the toes, or, in the male child, to the penis. The manner of cutting the cord illustrated in figure 211 surely avoids all such accidents. The child's connection with its mother being severed, it is wrapped in a blanket ready to receive it and is put in some safe place, where it will not be trodden nor sat upon. Its own crib is the best place for it. The cut end of the cord attached to the placenta is not tied, but is allowed to drain into a basin, so as to lessen as much as possible the bulk of the placenta. In case of twins, however, a double ligature on the cord is required, else the second child might bleed to death on account of anastomosis between the vessels of the placenta. THE PUERPERAL STATE. HJ CHAPTER II. The Puerperal State. The moment that labor terminates with the expulsion of the placenta, there begins an effort on the part of nature to restore to their normal condition the organs and systems that have been in an active state of development for nine months before ; there is destroyed in a few weeks what it has taken months to build up, and with this destructive process goes on with equal rapidity one of growth and repair. There is a reduc- tion of the sexual, the circulatory, and the nervous systems to their normal capacities and functions by the destruction of redundant material ; at the same time there is a repair of the injuries of child-birth, the formation of a new endometrium, and the rapid development of an entirely new and complicated func- tion, lactation. And yet, by a provision of nature which is almost beyond comprehension, these two opposed processes of decay and regeneration go on at the same time in one body,, involving whole systems and organs, without manifesting themselves in the slightest derangement of the individual's health. Under no other circumstances could an organ weighing two pounds, and as large as the liver, degenerate and in great part disappear without the gravest symptoms of constitutional disorder. In no other condition could the whole composition of the blood be materially altered ; the heart changed in size, power, and capacity ; the nervous system modified in sensibility ; a large body-cavity, stripped of its mucous membrane and again resupplied with a new lining ; large organs, as the breasts, suddenly assuming great functional activity, without very marked evidence of dis- ease ; and yet in the puerperal state there are all these remarkable changes while the woman in appetite, feeling, and temperature is in perfect health. But it is obvious that in a condition which, though it is called physiological, borders so closely on the patho- logical, very little is required to pass the boundary-line into dis- ease. Anomalies of excess and deficiency in the natural processes are common ; the raw surface of the uterus with the wounds of the vagina and vulva give ready entrance to infectious bacteria and their toxins, and the whole individual seems especially sen- sitive to unfavorable external influences, both mental and physical. Consequently this is the period in the history of the child-bearing woman that is most beset with difficulties and dangers and most likely to be marked by accidents and complications. The pre- 338 LABOR AND THE PUERPERIUM. ventive and curative treatment of these complications is one of the most difficult tasks in obstetrics, and success here, as else- where in medicine, depends to a great extent upon a thorough knowledge of the natural processes. The puerperal state, or the puerperium, comprises the time from the termination of labor until the uterus has regained its natural size. This is a period, in the normal case, of six weeks. 1 The study of the physiological phenomena in the puerperium, or puerperal state, involves a study of the reduction of the uterus directly after delivery to the uterus of the healthy non-pregnant woman, — a process called technically " the involution of the uterus" ; it involves a study of the involution of the vagina, of the destruction of the deciduous mucous membrane, and the regeneration of the endometrium ; of the retrograde changes that occur in the uterine ligaments and peritoneal covering and in the ovaries ; of the alterations by which the blood and the heart regain their normal condition and of the changes in the pulse ; of the changes in the body-weight, the temperature, the skin ; the action of the bladder and of the alimentary canal. An important factor also in the puerperium is the establishment of the milk secretion. The Involution of the Uterus. — Three theories have been advanced to account for it : (i) A fatty degeneration of the muscle-fibers and the absorption of the fine granular fat-globules to the complete destruction of the uterine muscle, its place being taken by a new growth of muscle-fibers developed from the embryonal muscle-cells in the outer layers of the myometrium. (2) A partial degeneration and an atrophy of the large muscle- fibers seen in a pregnant uterus at term. (3) The conversion of the muscle-cell contents into a peptone, its absorption into the blood-current and discharge through the kidneys, giving rise to the peptonuria of puerperal women (Fischel). Kilian, 2 in his examination of rabbits' uteri thirty to thirty- six hours after they had expelled their young, found fat-globules in the epithelial covering of the uterus, noticed that the muscle- fibers looked fainter and paler than in pregnancy, and saw in their interior very fine, shining fat-globules; alongside of these degenerated muscle-fibers Kilian found some quite young fibers, as he had seen them in the uteri of young animals. Heschl 3 1 The word puerperium comes from pitcr, a child, and pario, to bear, and denoted, in the original Latin, the child-bed period, the lying-in period ; so it is an appropriate term to designate this one of the four periods in obstetrics, — pregnancy, labor, the puerperium, and lactation. 2 "Die Structur des Uterus bei Thieren," Henle u. Pfeuffer's " Zeits. f. ration- elle Medicin," 149 u. 1850, Bd. viii u. ix. 3 " Untersuchungen iiber das Verhalten des menschlichen Uterus nach der Geburt," "Zeits. der k. k. Gesellschaft der Aerzte in Wien," 1852, viii, -2. THE PUERPERAL STATE. 339 confirmed Kilian's observations, and went even further in de- claring that the muscle-cells were completely destroyed by fatty degeneration ; this writer saw, in the outer portion of the uterine body, at first nuclei ; which, developing cell-contents around them, gradually transformed themselves into typical unstriped muscle-fibers. Thus, after labor the uterine muscle was destroyed and a new development of muscle-tissue occurred to take its place. Robin x claimed that the involution of the uterine muscle Fig. 212. — a, Uterine muscle-fibers nine days postpartum; b, uterine muscle- fibers eight days postpartum ; c, uterine muscle-fibers in the eighth month of pregnancy. is essentially an atrophy of the individual muscle-cells. Kolliker 2 says that the involution of the puerperal uterus consists of a diminution in the size of the contractile fibers in the muscle- layer and a fatty degeneration. Mayor, 3 from a study of fourteen specimens dating from the first day after delivery until the ninth 1 " Diet, encycl. des Sc. med.," 2e serie, t. x, p. 14. 2 " Gewebelehre," 5- Aufl., p. 565. 3 ' Etude histologique sur 1' Involution uterine," "Archives de Physiol, norm, et path.," ix, x, 1887, p. 560. 340 LABOR AND THE PUERPERIUM. month of lactation, concludes that the fatty degeneration of the muscle-fibers is more pronounced than Robin thought, but not as complete as Heschl believed ; it does not seem to cause the destruction of the muscular elements. Mayor, therefore, attributes to atrophy the chief role in the involution of the uterus. Winckel x holds that the reduction of the puerperal uterus is due to fatty degeneration. Sanger, 2 from the observa- tion of twelve uteri obtained from four hours to fifty-five days after labor, recognizes the fatty degeneration in the muscle- cells, but does not believe that they are destroyed. 3 Micro- scopic sections of five uteri in my possession, obtained respec- tively in the last week of pregnancy, two hours, thirty-six hours, seventy-two hours, and seven days after labor, indicate that fatty degeneration plays a most important part in the reduction of the large muscle-cells characteristic of pregnancy to the much Fig. 213. — Muscular tissue of the pregnant and of the puerperal uterus. smaller muscular fibers of the unimpregnated uterus. My own belief is that the redundant material within each cell is destroyed by some degenerative process (chiefly fatty), but that the cell is not destroved in toto. Measurements made by Sanger 4 show plainly that the reduction of the uterus after labor is effected by a diminu- tion in the size of the individual fibers, and not by their destruction.^ 1 " Lehrbuch der Ceburtshiilfe." i88q. 2 Abst. in Schmidt's " Jahrbiicher," No. 3, 1888, p. 250. 3 Sanger says that " the fat-globules and other degeneration products do not enter, as such, into the circulation, but are oxidized on the spot. There is no such thing as a puerperal lipemia" ("Die Riickbildung der Muscularis der puerperalen Uterus"). ' Loc. cit. s Fiber-length in pregnant uterus 208.7 f- " " in first few hours postpartum 15S- 3 /'■ " " until the fourth day postpartum 117.4 ^. " " in first half of second week postpartum .... 82. 7 fi. " " in beginning of third week postpartum .... 32.7/'- " " at end of fifth week postpartum 2 4-4 /"• THE PUERPERAL STATE. 341 The shrinkage of the uterus in the process of involution is ex- pressed by the following average measurements: Height of fundus above symphysis, directly after labor, 10.9 cm.; on the first day the fundus rises to 13.5 cm.; on the eighth day it has sunk to 7.3 cm. The breadth of the fundus at the tubal insertions is n cm. directly after labor; 12.2 cm. on the first day; 8.1 cm. on the eighth day. The uterine cavity measures 14.8 cm. on the first day; 10 cm. by the fourteenth day. Fig. 214. — Lochia on the second day (lochia cruenta), showing a few cocci and streptococci : a, Decidual cells ; b, red blood-corpuscles ; c, white blood-corpuscles ; d, epithelium (Winckel). Fig. 215. — Lochia on the fourth day: «, Decidual cells ; b, white blood- corpuscles ; c, a few red blood-corpus- cles ; d, epithelium ; e, micro-organisms (Winckel). Fig. 216. — Lochia on seventh day ; afebrile case: a. Blood-corpuscles ; b, diplo- cocci and monococci ; c, white blood-corpuscles ; d, epithelium ; 6>, decidual cells (Winckel). There is a greater unanimity of opinion in regard to the invo- lution of the serous covering, connective tissue, blood-vessels, and mucous membrane of the puerperal uterus. Mayor 1 found, in the peritoneal covering of the uterus after delivery, a number of folds in the membrane; at the bottom of these folds the endothelial cells seemed to be transformed into a spherical shape. Kilian 2 found the cells in this region infil- 1 Loc. cit. 2 Loc. cit. 342 LABOR AND THE PUERPERIUM. trated with fat-globules. Bernstein 1 in a study of involution in the rabbit's uterus, paid especial attention to the behavior of the connective tissue. He found that the reduction of this tissue in the puerperal uterus was effected by a fatty degeneration of the connective-tissue cells, and by a drying out, as it were, of the connective-tissue fibers; these, deprived of the excessive blood- supply of pregnancy, dry up and shrink. Bernstein incidentally mentions the fatty degeneration of the peritoneal endothelium, and expresses the opinion that the muscle-cells, while they do undergo a fatty degeneration, are not completely destroyed. The chief changes in the blood-vessels seem to be shrinkage, the obliteration of many large vessels by a connective-tissue growth in the intima, associated with fatty degeneration of the media, 2 and the development in the adventitia of the vessels not obliterated of new elastic fibers. The involution of the endometrium is now clearly under- stood, thanks to the investigations, first, of Friedlander, 3 then of Kundrat, 4 Engelmann, 5 Langhans, 6 Leopold, 7 Wormser, 8 and others. When the ovum is cast off at term, it carries with it, in the strictly normal case, the whole ovular or epichorial decidua and the upper cellular layer of the uterine decidua, leaving behind on the uterine wall the lower cellular layer and the glandular por- tion of the uterine mucous membrane. This membrane, deprived in great part of its nutriment by the contraction of the uterine wall and the obliteration of many of its blood-vessels, loses its vitality in that portion furthest removed from its source of nutri- ment — the superficial layer of decidual cells. These die and are cast off with the lochial discharge in a condition of coagulation- necrosis, fatty degeneration or disintegration. By the shedding of these cells the glandular layer of the decidua is laid bare. Now the involution of the endometrium ceases and a regeneration of the membrane begins. The epithelial cells within the glands take on an active growth and reproduction; the interglandular con- nective tissue shares in the new development; by its growth it rises in embankments between the glands, making them deeper, and so in time reproduces the characteristic utricular glands of the uterine mucous membrane. This process requires some time. Mayor says: "On the twenty-fourth day after delivery I have 1 " Ein Beitrag zur Lehre von der puerperalen Involution des Uterus," D. i, Dorpat, 1885. 2 Balin, " Ueber das Verhalten der Blutgefasse im Uterus nach stattgehabter Geburt," "Archiv f. Gyn.," Bd. xv. 3 " Physiol. Anatom. Untersuchungen iiber den Uterus," Leipsic, 1870; "Archiv f. Gyn.," Bd. ix. 4 " Wien. med. Jahrbiicher," 1873. 5 Ibid. 6 "Archiv f. Gyn.," Bd. viii. » Ibid., Bd. xii. 8 Wormser, "Die Regeneration der Uterusschleimhaut noch der Geburt.," "Arch. f. Gyn.," Bd. lxix, H. 3 (good recapitulation on p. 565). THE PUERPERAL STATE. 343 not found glands in the region of the placental insertion. The mucous membrane, although reconstructed at the second month, is then furnished with fewer glands, less regularly disposed, and of a greater caliber than in the normal state." The uterus is not the only organ of the sexual system that experiences a retrograde change after labor. The ovaries and tubes, the broad and round ligaments, the pelvic connective tissue, blood-vessels, and lymphatics, all undergo modification. That portion also of the birth-canal — the lower uterine segment, the cervix, the vagina, and the vulva — which is dilated to an extreme degree to allow the passage of the fetal body, must likewise exhibit rapid involution to regain its wonted tone and caliber. In these structures the process is mainly one of retrac- tion of overstretched tissue ; but there is, in addition, a certain amount of degeneration and atrophy of the redundant cells that the increased blood-supply and increased stimulus to growth of pregnancy called into existence. Particularly is this true of the lower uterine segment and cervix, which in their involution dis- play an intermediate process between that by which the reduc- tion of the uterine body is effected and that by which the lower portion of the parturient tract regains its normal state. The involution of the uterine adnexa progresses satisfac- torily if the uterine involution itself is normal. The reduction of the overstretched vagina and vulva is sure to occur if these parts have not been seriously lacerated, although, like all over- stretched muscular canals, they never quite return to their original caliber. From the large sinuses at the placental site, laid bare after the separation of the placenta ; from the innumerable little ves- sels of the decidua that have been torn in the separation of the ovum from the uterus ; from the rents of various degrees that have been made in the cervix, vagina, and vulva during labor, it is inevitable that there should be, for some time after delivery, an oozing of blood in considerable quantity. As the residue of the decidua and the blood-clots remaining in the uterine cavity are disintegrated, the products of this decomposition must also escape externally. And as the whole genital canal, lined by a mucous membrane, is stimulated and irritated by foreign sub- stances and a large blood-supply, it is obvious that the mucous secretion of the genital tract will be considerably increased, and must make its escape also from the vagina. This composite discharge after labor, made up of blood, degenerated epithelial cells, the debris of disintegrating animal material, mucus, and large numbers of harmless micro-organisms, is called "the lochia." 1 It is important to appreciate the normal character of 1 A word derived from the Greek hr/of, pertaining to a woman in child-bed. 344 LABOR AND THE PUERPERIUM. this discharge, for changes in its quantity, odor, or constituent parts often point to some morbid process. The older writers on obstetrics paid great attention to this feature of the puerperal state, and gave to the discharge three names, which indicate the three changes that it undergoes in appearance. For the first five days it is called lochia rubra ; for the next two days, lochia serosa ; and after that, lochia alba. At first, as might be ex- pected, the discharge is almost wholly bloody — the lochia rubra. As the repair of the injuries of parturition progresses and the hem- orrhage ceases, the discharge is a serous exudation and a catarrh of the mucous lining of the genital tract — the lochia serosa. The dead tissue in the genital canal is cast off in increasing quan- tities as the involution of the birth canal progresses ; disintegrated and fatty epithelial cells are mixed in the discharge; micro-organ- isms are found in it, while the pus from the granulating wounds all along the genital tract forms an important constituent of the discharge after the sixth or seventh day. To the lochial dis- charge at this period is given the name lochia alba. The last stage of the lochial discharge lasts from the seventh until the tenth, twelfth, or fourteenth day, or even longer. Two other features of the lochial discharge are also of clinical inter- est — the quantity and the odor. The amount of discharge at the three different periods may be expressed scientifically thus : During the first four days the amount of discharge is I kilo- gram, or 2.2 pounds ; during the next two days, 280 grams, or about 10 oz. Avoir.; and until the ninth day, 205 grams, or about 7 oz. Avoir., the entire loss amounting to 3^ pounds. These figures, however, are of no value to the practical clinician. No physician in private practice can accurately measure the amount of lochial discharge ; so that the convenient method of estimating it has been adopted of noting the number of napkins or pads that are soiled in the twenty-four hours. The normal puerpera should not require a change of the vulvar pads oftener than six times in the twenty-four hours for the first four or five days. The importance of being able to distinguish between a normal and abnormal amount of lochial discharge is obvious. Otherwise a dangerous hemorrhage might be overlooked; a diminution or even suppression of the lochia might be unnoticed. The odor of the lochia during the period of sanguinolent discharge is that of fresh blood or raw meat. Later, when the mucous secretion forms a considerable part of it, the predomi- nant odor is that peculiar to the secretion from these parts. If masses of decidua, placenta, membranes, or blood-clots are retained in uterq and saprophytes gain access to them in a situation favorable to their decomposition, the lochia at once takes on a putrid odor. This is frequently the first signal of a THE PUERPERAL STATE. 345 possible toxemia. While recognizing the value of a putrid odor as a danger-signal, it must be remembered that absence of odor is possible with dangerous streptococcic or staphylococcic infection. The involution of the uterus has been described as a continual process, moving on evenly from beginning to end. But as it de- pends primarily upon the contraction of the uterine muscle-fibers it is indicated graphically by a series of waves, representing contrac- tions of the uterus of more or less force and frequency and inter- missions of less firm contraction ; the retraction of the uterine mus- cle, however, maintaining fairly well what is gained by contraction. Each case has a certain degree of individuality ; in one the con- tractions are firm and the intervals between them short ; in another it is the reverse and all gradations may be found between the extremes ; but while there are in every case individual pecu- liarities, the action of the uterus after labor is governed by a few general laws. Directly after labor there is a firm contraction which reduces the size of the uterus in all directions below the measure- ments obtained a few hours later; then follows a relaxation, the fundus rising 2 cm. or more and its breadth increasing by more than a centimeter. Suckling the child stimulates the contraction and retraction of the uterus. If the child is not nursed involution is slower and less complete. In primiparas, the uterus being more powerful, better supplied with muscular tissue than it will ever be again in a subsequent confinement, contracts so vigorously, relaxes so little, that after the expulsion of the placenta the uterine cavity is almost obliterated, and the amount of bloody lochia is reduced to a minimum. On the other hand, in mul- tiparas, the uterine muscle being in some degree weakened by stretching and perhaps by some destruction of muscle-substance that has occurred in previous pregnancies, the uterus after labor does not contract so firmly and the relaxations between the contractions are greater in degree and duration. If the uterine muscle has been overstretched, as it is in plural pregnancies or in cases of hydramnios, or if the labor has been exceedingly long or unusually precipitate, very firm contraction does not ap- pear after labor and there are apt to occur periods of over-relaxa- tion. This condition, in civilized women, is so very common that it is necessary to study it under the head of the physiology of the puerperium, and yet the consequences of a failure on the part of the uterine muscles to contract with maximum intensity after labor are always unpleasant, and may be disastrous. A relaxation of the uterine muscle-fibers implies a loosening of the countless living ligatures that bind the large vessels of the puerperal uterus. The immediate effect is an escape of blood into the uterine cavity. Oozing out gradually from the imperfectly closed blood-vessels and sinuses, and, finding space in the enlarged uterine cavity to 346 LABOR AND THE PUERPERIUM. collect, it forms clots often of considerable size, which act upon the uterus, like any foreign body in it, as an irritant, exciting it to active contractions which only cease when the foreign substance is expelled. These active contractions of the uterus are always painful, with a pain like that of a cramp in any muscle. These painful contractions, affecting the uterus after delivery, caused primarily by lack of firm contraction, and immediately by the presence of clots of blood in utero, are called, after-pains, — the painful contractions of the uterus after labor. For the reasons already given they are not experienced by primiparae unless the uterus has been unduly distended or the labor has been too pro- longed or too precipitate. On the other hand, they are a constant phenomenon in multipara;, and the physician's treatment of them constitutes almost always a part of his routine management of the puerperal state in such patients. Apparently a trifling matter, it is really one of considerable importance. In the first place, the pain is sufficiently distressing to demand relief, but, more impor- tant still, these after-pains indicate, to the educated physician, the presence within the uterus of blood-clots or other putrescible material; and until they are expelled, and the uterus is induced to remain in a state of firm contraction, the woman is not entirely safe from septicemia. Moreover, it is necessary to be familiar enough with the clinical features of after-pains to be able to dis- tinguish them from the pain of peri-uterine inflammation. This should not be difficult. The intermittent character of after-pains; their cramp-like nature; exacerbations when the child is suckled; the fact that pressure does not increase the pain, and that the pulse and temperature are unaffected, suffice to distinguish the painful contractions of the uterus after labor from the pain of inflammation. The appropriate treatment of after-pains is suggested by their cause and nature. It is the administration of ergot to stimulate vigorous contraction and firm retraction of the uterine muscle, and of opium to diminish the pain of the contraction. A mixture of fluid extract of ergot and paregoric is a useful prescrip- tion, though, in cases of extreme pain, ergot by the mouth and morphin hypodermatically give a better and quicker result. Although the most remarkable changes that occur in a woman's organism after labor are seen in the genital organs, the whole body undergoes a modification. The respiratory, circulatory, nervous, and excretory apparatuses are affected, with accompanying peculiarities of respiration, pulse, temperature, weight, the excretion of urine and sweat, and the evacuation of the bowels, while the nervous system shows a gradual change from the nervous irritability characteristic of pregnancy to the de- gree of equanimity that the individual may have before possessed. THE PUERPERAL STATE. 347 Alterations in the Circulatory Apparatus of the Puerpera. — The pulse of a woman during labor is rather rapid, full, and bounding ; directly after delivery it becomes preternaturally slow ; if the individual's normal pulse-rate were 70 to 80, it might, during labor, rise to 90, but directly afterward it sinks, perhaps, to 60 or even lower. It is occasionally as low as 40 in a perfectly healthy young woman. In looking for the cause of this altera- tion in pulse-rate one must recall the influence of gestation upon the heart and the alterations in the constitution of the blood during pregnancy. The whole volume of the latter is in- creased, but not by an equal increase of all the constituent parts ; the corpuscles are relatively decreased in proportion to the liquor sanguinis ; the watery element of the blood is propor- tionately increased, making the condition of the blood during pregnancy one of hydremia. There is a relative decrease of albumin, blood-salts, and the percentage of hemoglobin, a relative increase of the fibrin-making ferment. Expressed definitely, this decrease is to the extent of about 700,000 red blood-corpuscles per cubic millimeter and about eight per cent, of hemoglobin. Within the first twenty-four hours after labor the decrease in red blood-corpuscles and hemoglobin is yet more marked, on account, no doubt, of the escape of blood in the third stage of labor and immediately after it. But after the first twenty-four hours the blood begins to recover its normal constitution, and at the end of two weeks it is so far on the road to perfect involution that it is much nearer a normal condition than it was in the latter half of pregnancy, although it is still somewhat deficient in red blood-corpuscles and in hemoglobin. The leukocytes decrease rapidly after labor, reaching their minimum number twelve hours post-partum; the number then increases as a moderate leukocytosis until lactation is established, whereupon the number is again diminished. These changes, however, do not explain the cause of a slow pulse in the puerperal state: it is discovered in the heart. It is claimed that the area of cardiac dullness is increased in pregnancy, and that there is a hypertrophy of the walls of the left ventricle. As the whole volume of blood is increased in pregnancy, and as additional resistance to the circulation is offered by increased intra-abdominal pressure and by direct pressure of the uterus upon the pelvic vessels, it is reasonable to assume that the heart, in addition to being hypertrophied, is also dilated. The additional force and capacity of the heart is acquired to meet the additional demands of pregnancy : A greater volume of blood is propelled through the vessels by an enlarged and strengthened heart, beating with a normal rapidity. Labor comes on, the uterine cavity is emptied, and suddenly 348 LABOR AND THE PUERPERIUM. the increased vascular power has become unnecessary if not dangerous. The amount of work done by the heart is repre- sented by two factors ; the rapidity plus the strength of the beat and the power of the heart can be lessened by diminishing either one of these factors. It is obvious that the increased power of the hypertrophied heart-muscle can not be abrogated in a moment. It is equally obvious that the other factor in heart- power can be modified at once to suit the new and lesser requirements. And this, probably, is the method nature adopts to avoid excessive heart-action and an excess of blood in important organs after labor. The heart-beats are reduced some twentv to thirty in a minute. Changes in the Urinary System After Labor. — The phy- sician is often annoyed in obstetrical practice to find that many women after labor are unable to urinate and consequently require the use of a catheter, which must be employed in many cases by the physician himself, especially in country practice. To comprehend the changes in the urinary system it is necessary again to revert, for a moment, to pregnancy. The main changes in the kidney, bladder, and urine in that con- dition may be thus summarized: The kidneys, by reason of additional supply of blood and extra work to do, are hyper- trophied ; the urine is increased in water, diminished in solid constituents, except chlorids. The bladder, in pregnancy, from the pressure of the gravid uterus behind, is unable to expand in a normal manner, but must accustom itself to a distention, chiefly upward. When the uterus is empty and has shrunk to half its former size, the bladder has room at once to distend in all directions, and can thus hold a very large quantity of urine before its walls are subjected to the same degree of tension to which they were accustomed dur- ing pregnancy. Thus large quantities of urine may collect before there is a disposition to urinate. Moreover, the abdomi- nal walls, so long kept on the stretch, are suddenly released from the intra-abdominal pressure, and do not for some time regain their tone ; so that the action of the abdominal muscles, which are, perhaps, the chief factors in emptying the blad- der, is, to some extent, inhibited. In some women recently delivered the abdomen is scaphoid, so that a contraction of the abdominal muscles actually decreases, instead of increasing, intra-abdominal pressure. There is a third reason for the retention of urine after labor : The tissues immediately behind the symphysis pubis bear the brunt of the pressure of the child's head as it descends the birth-canal ; and this pressure is exerted not directly forward, but to one side or the other, by the oblique position of the head; the tissues about the urethra are left edema- THE PUERPERAL STATE. 349 tous after labor, from the contusion they have suffered, and the urethra is dragged a little to one side, so that in a twofold man- ner the urethral canal is partially occluded, namely, by the edema of surrounding parts and by the acquired tortuosity in its course. The urine itself does not differ much from that of pregnancy. The water is increased; the urea and solids are both relatively and actually below the normal. Glycosuria is quite common. Blot claims that the sugar in the urine is the result of the absorp- tion of lactose from the mammary glands, and that the larger the secretion of milk, the greater the quantity of sugar in the urine, and therefore he proposed that the quantity of sugar in the urine be taken as a test for the suitability of a wet-nurse. It has been claimed, by others, that the sugar has a hepatic origin. About 50 per cent, of puerperas have albuminuria. Fischel declares that peptonuria is a constant phenomenon of the normal puerperium. 1 The sweat=glands after labor are unusually active. The skin of a pregnant woman is often harsh and dry, and during labor, unless the muscular effort is great or the weather warm, the same condition of the skin persists. But in the puerperal state the sweat secretion is profuse ; the skin is constantly moist, and during sleep the secretion may become excessive. This action of the sweat-glands plays an important part in the involu- tion of the whole organism after labor. It is one of the factors by which the hydremia of pregnancy is corrected, and by the dissipation of heat that accompanies the rapid evaporation of water all over the body the temperature in the puerperal state is retained at a normal level, in spite of many provocations to fever. The lungs after labor take on a slightly different action. Their capacity is increased, for the pressure from below is re- moved and the play of the diaphragm is freer. Each inspiration drawing in more air than before, the number of respirations in the minute is lessened; the breathing is deeper, fuller, quieter, and slower than it was during pregnancy, and the expired air contains an excess of water and of effete products, the result of tissue de- struction. As a result of the great excretion of water from the kid- neys, the skin, and, to a lesser extent, the lungs, the thirst of the lying-in woman is increased ; the appetite, on the other hand, is much diminished. One can understand the last statement if he re- calls the fact that more than a pound of meat in the involuting uterus is absorbed into the system during the puerperium, and if he remembers that the woman is lying in bed absolutely quiet and expending no force whatever in muscular action. There is still another factor to account for the disinclination toward food. Dur- ing pregnancy there is no one tissue, except that contained within 1 "Arch. f. Gyn.," Bd. xxiv u. xxvi, S. 120 u. 400. 350 LABOR AND THE PUERPERIUM. the developing uterus, which increases with so much rapidity as the subcutaneous fat. It seems as if there were provided by na- ture a store of material which shall take the place of food in sup- plying heat and force during a period when woman in her natural, primitive state could not be supposed to provide for herself. This deposition of subcutaneous fat during pregnancy and its subsequent absorption during the lying-in period account for the remarkable changes in weight which may be noted in a woman during pregnancy and after labor. This is a matter of some practical importance, which does not usually obtain the attention that it deserves. It has been studied systematically by Gassner and later by Baumann. According to Gassner, the gain in weight during pregnancy and the loss afterward are about one- thirteenth of the body- weight. This, I am inclined to think, from some investigations of my own, is an underestimate, and Bau- mann's observations bear me out; he found that the loss of body- weight was about one-tenth after labor, the greater part of it, of course, occurring in the first week, when a woman of average weight loses some nine or ten pounds. All the remarkable changes observed in the lying-in woman occasion no manifestation of disease, not even fever. This assertion some years ago w T ould have been incorrect, for fever was so common in the puerperal state that it was regarded as physio- logical ; it occurred usually within the first few days after labor and as, at this time, there were marked manifestations of con- gestion in the breasts, due to the inception of lactation, it was called milk fever. In reality it was the fever of infection. If, however, the temperature in the puerperal state is studied closely, it must be confessed that there is some little irregularity, but that irregularity is measured, in the normal case, by tenths of degrees. Directly after labor, for instance, the body-heat is always a little raised. Although there is distinctly no such thing as milk fever, the temperature is slightly affected when the breasts suddenly assume activity; but the rise is rarely more than a few tenths of a degree. So many causes, transitory in their effect, can produce slight disturbances in the temperature of the lying-in woman, who is peculiarly sensitive to external influences, that the rigid boundary which divides fever from a normal temperature at other times must be a trifle relaxed. Thus, it is agreed among obstetricians not to regard as fever a transient rise of temperature, lasting only a few hours, which does not go above 100.5 . This is the so-called physiological limit to the rise of temperature in the puerperal state. The Mammary Changes in the Puerpera. — Heretofore the involution of important organs and systems in the puerperal THE PUERPERAL STATE. 351 state has claimed attention. The mammary action after delivery is a process of evolution. The mammary glands, as their name denotes, are glandular organs, only reaching their full develop- ment, as a rule, in the female ; situated, usually, toward the lateral aspect of the pectoral region ; occupying the space bounded above by the third and below by the sixth rib, to the inner side by the edge of the sternum, to the outer side by the axillary line. They are derived from the epiblastic layer of the blasto- dermic membrane, and belong essentially to the skin, as do the cv Fig. 217. — CE, Cuboidal epithelial cells ; F, fat globules stained black with osmic acid, and seen both in the cells and in the central cavity of the acini ; CV, connective-tissue frame with blood-vessels. Magnified 600 diameters (C. Heitzmann). A B Fig. 218. — Mammary gland of dog, showing the formation of the secretion : A, Medium condition of growth of the epithelial cells ; B, a Liter condition (after Heidenhain). sweat and sebaceous glands. They are closely akin to the latter, occurring in rare instances on indifferent parts of the body, as the axilla, the abdomen, or even the thighs, where a sebaceous gland has undergone a specialized development. In the female they are hemispherical in shape ; they are held in their normal position upon the pectoral muscles by the super- ficial fascia, which splits into two layers, one running above, the other below, the breast. Externally, a little below the middle 352 LABOR AND THE PUERPERIUM. of the organ, is a protuberance, — the nipple ; around this is an area of pigmented skin, — the areola ; in this space are a number of large sebaceous glands, — the glands of Montgomery. Internally the breast is divided into excretory ducts, lobes, and lobules ; between the lobes and lobules are connective tissue and fat. The lobules are ultimately divided into little vesicles ; these empty into a small excretory duct ; the small excretory ducts from contiguous lobules unite to form a single large, lactiferous canal ; of these there are some fifteen or twenty, each conveying the secretion from a separate lobe to the nipple ; just before emerging upon the surface of the nipple each duct is dilated to Fig. 219 Mammary gland : I, Lacteal ducts; 2, glandular acinus (Playfair). Fig. 220. — Colostrum and ordinary milk-globules, first day after labor ; primipara aged nineteen (after Hassall). form a small ampulla or reservoir for the milk ; as it passes through the skin of the nipple it is again contracted. The epi- thelium of the gland is continuous with that of the integument ; in the superficial portions of the lactiferous ducts it is squamous; in the deeper portions of the gland, columnar. The function of the gland is the secretion of milk. Colostrum. — During the latter part of pregnancy a thin, opalescent fluid may be squeezed out of the breast ; directly after labor this fluid is somewhat increased in quantity, and be- comes a little whiter and more opaque. THE PUERPERAL STATE. 353 At the end of about forty-eight hours a decided change takes place in the breasts ; they suddenly enlarge ; the skin over them becomes tense ; the cutaneous veins are engorged with blood, and show swollen and distinct beneath the skin ; the nipple projects ; to the feel the breasts are hard and lumpy ; to the woman they are painful and tender on pressure. If the child is applied to the nipple, there runs out, almost without suction, a quantity of human milk — a fluid different from the colostrum just described. It is white, opaque, of a specific Fig. 221. — The production of milk. Section of the mammary gland of a nursing puerpera (Bumm): I, Epithelium of acinus inactive; 2, epithelium compressed by milk in acinus; 3, 4, 5> epithelium actively secreting milk; 6, intra-acinous connec- tive tissue ; 7, capillaries ; 8, secreting epithelial cells with large fat drops in the protoplasm, the nucleus pressed into cell wall; 9, milk. gravity about 1025, is said to have a sweet, agreeable taste, and is without odor. The influences which determine milk secretion after childbirth are still a mystery. Lactation is observed even though the spinal and sympathetic nerve connection with the genitalia is severed. Indeed, lactation has occurred in the mammary gland of a rabbit transplanted to its ear five months before. It may be an ovarian secretion, perhaps that from the corpus luteum, which stimulates milk production, but this theory does not account for milk secre- 2 3 354 LABOR AND THE PUERPERIUM. tion in the infant during the first few days after birth, in young girls, in cases of imaginary pregnancy, in women with pelvic or abdominal tumors, and in men. The quantity of milk secreted in the twenty-four hours is dif- ficult to determine. It might seem easy enough to draw the milk from the breast at stated intervals with a breast-pump and to measure it, but it is difficult to get a breast-pump as mechanically effective as a child's mouth, and, moreover, the secretion of milk depends, to some extent, upon the maternal emotion ; the breast might almost be described as an erectile organ ; certainly, the sight of the child arouses a maternal instinct which sends, an additional blood-supply to the mammary gland and undoubtedly increases the supply of milk. It has been estimated that at first the quantity of milk is about 300 to 400 grams (10 to 13^ fl. oz.) ; by the seventh day it is 400 to 500 grams (14 to 17 fl: oz.) ; after the second week, 1 500 to 2000 grams — 1 ^ to 2 liters (3 to 4 pints). In a microscopic section of a mammary gland, procured during lactation, there may be seen large epithelial cells in the process of proliferation. Toward their inner periphery may be seen globules of fat. One of two things must happen to account for the production of the milk : either the whole cell, which has begun to show signs of fatty degeneration, or rather fatty metamorphosis, is cast off, then bursts and discharges its con- tained fat, as well as other cell-contents, into the liquid medium which has exuded from the blood, or else each cell, having accu- mulated its store of fat, discharges it in little globules, along with the casein, which must also be derived from the cell- contents. The latter process is the one generally accepted. The Diagnosis of the Puerpcrium. — Occasionally it is impor- tant for a physician to be able to decide by an appeal to his own senses, without regard to the woman's statement, whether or not she has been recently delivered. Women accused of infanticide, for example, may deny their recent delivery. The diagnosis, in such a case, is not difficult. The large uterus, reaching to the umbilicus ; the bloody discharge, showing, under the micro- scope, decidual cells ; the secretion in the breasts ; the charac- teristic fragments of decidua that may be scraped out of the uterine cavity with a curet ; the rents in the cervix, the vaginal mucous membrane, and the perineum ; the relaxed abdominal walls, and the striae upon them, — all unite to make the diagnosis easy to establish and absolutely sure. Management of the Puerperium. — The prevention of in- fection must be the chief care of both doctor and nurse in charge of a puerpera (see The Preventive Treatment of Puerperal Sepsis). THE PUERPERAL STATE. 355 Having secured, so far as possible, a perfect cleanliness of physi- cian, patient, all her surroundings and attendants, and of the air of the room in which the woman lies, one has performed by far the most important part of his duty in the management of the puerperal state, and has averted the commonest and most fatal accident of this period — septic infection. Being secure of this most desirable result, the physician may turn his attention to some lesser matters, of no little importance, however, to the comfort and even safety of the patient. Visits. — It is wise to wait in the house for an hour after the woman's delivery, to see that there is no hemorrhage. She should be visited again in about twelve hours ; then once a day for the first two weeks, every other day during the third week, and once or twice in the fourth week. For the first week at least the following items should be investigated routinely at each visit : The pulse ; the temperature ; the odor, quantity, and char- acter of the lochia ; the condition of the bladder and size of the womb, learned by abdominal palpation ; the condition of the breasts and nipples ; the occurrence of after-pains ; the evacua- tion of the bladder and bowels, and last, but by no means least, the condition of the infant. Many physicians fall into the habit of neglecting the baby altogether. There could be no worse policy, not to speak of higher considerations. The mother resents an indifference to her infant's condition, and a failure to make a routine investigation at each visit of the child's feeding, sleeping, and gain in development ; of its umbilicus, its bowel and bladder evacuations, and digestion, often results in a failure to correct some abnormality until it is too late. Many a sudden and inexplicable death in the new-born could have been avoided by greater watchfulness and care. Rest and Quiet. — The woman recently delivered is the picture of perfect restfulness and repose. There is reason enough for this mental and physical quiet after delivery. The relief from great suffering and tremendous muscular effort would naturally induce a feeling of lassitude, and fortunately it is preeminently the case after labor, for this condition of perfect repose is most favorable for the occurrence of the complicated phenomena of the puerperium without detriment to the woman's health. It seems almost superfluous to insist upon the advisability of ac- cepting this hint from nature in the management of the puerperal state, — of preventing any mental or physical disturbance, mus- cular effort, a glaring light, loud conversation, and, more than all, the entrance into the lying-in room of a single person whose presence is not necessary, — and yet this is a matter that in many cases requires the physician's express attention. Among more 35 6 LABOR AND THE PUERPERIUM. ignorant people particularly, and especially if there has been some unusual complication or accident in the labor, the patient, upon the second visit, may be found restless, with a rapid pulse, an anxious expression, and an elevated temperature, and on in- quiry it is learned that a constant stream of her female neigh- bors has been pouring into her room with minute inquiries into the particulars of the case, and often with gloomy forebodings as to the result, based upon their recollection of just such a case which ended fatally. It was the custom in France in the seven- teenth century to baptize the infant on the third or fourth day, when a collation was served in the lying-in room, to which all the friends of the family were invited, who were expected to drink the mother's health with much hilarity and many congratulations, — a ceremony lasting through a whole afternoon. Mauriceau speaks of this as a "very ill custom." We must agree with him, and should be inclined to go to the opposite extreme in enforcing rest and seclu- sion during the whole lying-in period. The physician must give specific directions in regard to the following matters, under the head of Rest and Quiet : 1. The position that the patient must occupy in bed, and how long she must retain it. The length of time she must remain in bed. The earliest date she may stand upon her feet, and the time when she may go down-stairs. 2. The degree of quiet and decorum to be observed in the room ; and — 3. The admission of visitors. The rules in regard to these matters, expressed, as rules, dogmatically, might run as follows : 1. The patient shall lie flat on her back and shall not be allowed another posture for at least a week. 1 For the first six hours after labor the head shall not be supported by a pillow, but shall be on a level with the body, in order to avoid a disposition to cerebral anemia and syncope, from the greatly decreased abdominal pressure. The woman must lie in bed until the involution of the uterus is so far complete that the fundus uteri has sunk to the level of the symphysis pubis or below it. It is a safe rule to insist upon strict confinement to bed for fourteen days. Then the patient may be allowed to shift herself from the bed onto a lounge rolled alongside of it, passing the day upon the lounge and sit- ting up as long at a time as she can without fatigue. At the 1 This rule is sure to be a little relaxed by the patient and nurse. If the former is allowed to roll about the bed at will, the ligaments of the uterus are stretched as the uterus falls from side to side with the movements of the patient, and displace- ments ultimately are more likely than if she had kept quiet. There is, besides, the rather remote danger of displaced thrombi and sudden death from embolism. THE PUERPERAL STATE. 357 end of three weeks she begins to walk about the room, and at the end of four goes down-stairs for the first time. 2. The woman's rest must be mental as well as physical ; therefore, no loud noises should offend her ear, no glaring light should irritate the eye, and no extended conversation should be allowed in the lying-in room ; at any rate, for the first few days. 3. No visitor should be allowed in the lying-in room except the patient's mother and her husband, and it is sometimes neces- sary to restrict the visits as to frequency and length. These rules in regard to quiet after labor will suit the aver- age case among the upper classes. They must, however, be modified on occasion. The length of time, for instance, required for the involution of the uterus varies greatly in different classes of society. An Tn^iqn tribe on the march does not halt because a woman falls in labor ; she retires to the bushes, gives birth to her infant, cuts the cord, dresses the child, and plunges into the nearest stream to cleanse herself; remounting her pony, she soon rejoins her tribe with the new-born infant slung on her back. The involution of her uterus goes on rapidly, in spite of this heroic treatment. In the Frauenklinik in Munich, in which the author once served as volunteer interne, and where the pa- tients are mainly strong Bavarian peasant girls, the fundus of the uterus was usually beneath the symphysis pubis on the sixth day. On that day the patient left her bed ; the following morning she walked out of the hospital with her infant in her arms. In the more artificial life of the upper classes much of the primitive woman's physical vigor is surrendered for increased mental cul- ture. In these women labor is usually difficult and painful, if not dangerous ; the puerperal state is often more complicated than it should be, and involution of the uterus may be delayed. No patient should be allowed to leave her room before a careful vaginal examination has been made, to ascertain the position of the uterus. 1 This one examination, however, is not sufficient. Even after involution is almost completed, when the woman resumes, to a certain extent, her normal activity, a uterine displacement is not unlikely to occur. Overexertion or exposure will almost certainly bring on a renewal of the bloody lochia ; the involution of the uterus may be arrested before its perfect completion ; even septic inflammation may attack the uterus and its appendages as late as the fourth week. It should be an invari- 1 If the uterus is found retroverted between the third and fourth week, it should be replaced, and the patient instructed to assume the knee-chest posture twice a day for five minutes at a time. I find the postural treatment of displacements of the puerperal uterus permanently successful in a considerable proportion of cases. A pes-- sary is contraindicated before the sixth week. 358 LABOR AND THE PUERPERIUM. able rule of practice, therefore, to examine every child-bearing woman six weeks after her delivery, digitally and with the specu- lum, noting the position of the uterus, its involution, the condition of the pelvic connective tissue and uterine appendages, possible injuries to the cervix, anterior vaginal wall, and pelvic floor, erosions of the cervix, the condition of the abdominal wall, and the character of the uterine discharge. Abnormalities are often found at this period, which were not noticeable or were not present before the woman left her room. The question whether the routine administration of ergot would insure perfect involution or hasten its completion has occurred to many minds, and has found its answer in practical experimentation. Numbers of women have been placed on a routine treatment of ergot three times a day, and the progress of these cases has been carefully compared with that of an equal number of women left to nature. The result of these observations has not been favorable to ergot as a sure means of shortening the duration of the puerperal state: nothing was gained in point of time, while disadvantages were found in this plan of treatment that might have been foreseen. The stomach rebels against a prolonged use of the drug in considerable quanti- ties. While contracting the uterus, it has an astringent action also on the breast and so diminishes milk secretion, and, passing from the maternal blood into the milk and into the infant's stomach, it exerts an unfavorable influence upon both mother and child. The diet is a matter of no small importance, about which there is considerable difference of opinion. On the one hand, it is held that the woman after labor is weak from loss of blood and from fatigue; that she must, therefore, receive the most nourishing food in the largest possible quantities. More- over, that the demand which will soon be made upon her economy for the nourishment of the child is an additional reason for the administration of a generous diet from the first. But a close observation of nature should lead to the opposite view. A large part of the involuting uterus is absorbed into the system; some two pounds of meat are thus, as it were, de- voured, the greater part of it in the first few days of the puerperium. A large quantity of fat is stored up in the body during pregnancy with the express purpose, it would seem, of providing a means of supporting the woman during the early part of the puerperal state. Thus nature provides a sustenance which in quantity certainly appears sufficient for at least the first few days after confinement, and in form and manner of ingestion, so to speak, is best calculated to support the woman's strength, with none of the expenditure of force involved in mastication and digestion. Moreover, it must be remembered THE PUERPERAL STATE. 359 that almost all the vital functions are performed in a sluggish manner for the first few days after labor. The pulse is less rapid, the respiration slower, the bowels are inactive, and there should be no voluntary muscular effort. All this seems to argue for the wisdom of a system which allows, for the first few days, nourishment small in quantity, of a form easily ingested, and of a quality readily digested. After the third day, however, a new element must be taken into account. At that time there begins the milk secretion, which undoubtedly entails a great drain on the whole system to provide the large quantity of fat and nitrogenous material which are excreted when the breasts have assumed their full activity. To meet this additional demand upon the resources of the body the simple diet of the first few days should be materially, though gradually, increased ; for the first onset of the physiological mammary action is usually so violent as to stop just short of a pathological condition, — inflam- mation, — and suddenly to exhibit large quantities of nutritious food at this time would very likely cause a transgression across the boundary-line between health and disease. This, however, is mere theoretical reasoning, and if applied in practice it fails to give the best results, the system dependent upon it should be ruthlessly discarded, no matter how reasonable it may appear. But a practical test has given the result that might be expected. No one who has compared the two methods — one, of giving a forced diet from the first ; the other, of giving a very light diet, chiefly of milk, for the first two days, and afterward gradually increasing it until, on the sixth or seventh day, the patient is taking the food that would be suitable to any healthy person confined in bed without physical exercise — can fail to notice that the latter plan secures a far greater immunity from congestion of the genitalia and breasts, from irregularity in the milk secretion, and from disturbances of the stomach and bowels. Urination. — The tendency to retention of urine that is so often met with, especially among women city bred and in easy circumstances, has already been noticed. This is an abnor- mality in the puerperal state of civilized woman that is, per- haps, as annoying as any one feature of a normal case. Its causes have already been described. Its detection would seem perfectly easy, and yet it is just as easy to overlook it without the careful attention which should be, but is not always, directed toward this point. It is a common experience for a consultant to be asked to see a woman some days after labor, because the attending physician thinks that alongside the uterus there is a large and peculiar abdominal tumor, and the patient suffers great pain. What is taken for the uterus is an immensely distended 360 LABOR AND THE PUERPERIUM. bladder, reaching half-way or quite to the umbilicus; the peculiar abdominal tumor is the uterus itself pushed far upward and to one side, almost always the right. Catheterization removes immedi- ately both tumor and pain. The mistake on this point often arises from the trust that the physician puts in the woman's statement that she has urinated regularly. One should never trust any one's assertion as to action of the bladder, but should always examine for himself, by abdominal palpation, to see if it is full or not. A nurse sometimes falsely asserts that her patient has urinated, because she is ashamed to confess her inability to pass a catheter. If the urine must be drawn, the catheter is used by a trained nurse, should there be one. In her absence the physician himself must attend to the catheterization ; even if a skilful nurse is in attendance, the physician is not infrequently appealed to, as the nurse can not discover the urethra, or is unable to insert the catheter. It is well, therefore, under all circumstances, to know how to use a catheter and to have a definite opinion as to the kind of instru- ment that should be employed. A soft-rubber catheter is to be preferred, because it is incapable of doing any harm, does not irritate the urethra, and is easily cleansed and kept clean. After being used it should be rinsed out and should be kept per- manently immersed in a 1 : 2000 solution of sublimate. Before being used it must be dipped in a basin of sterile water, and its tip should then be oiled. The hands of the individual who inserts it must be aseptic. It saves time and is safer to wear rubber gloves, which have been soaked in a 1 : 1000 sublimate solution or have been boiled. To introduce the catheter, it is necessary to expose the urethra to view, to wipe off its orifice, as well as the surrounding mucous membrane, with a piece of absorbent cotton moistened with a sublimate solution, 1 : 2000. The catheter is then inserted directly into the urethra, so that it does not carry with it into the bladder some of the decomposing vaginal discharge, which would be likely to set up a very trouble- some or a very dangerous cystitis. The old practice of locating the urethra by the sense of feel, using the finger of the left hand and then introducing the catheter held in the fingers of the right hand, under a sheet, is unreservedly condemned. In the Directions to Nurses, appended to this chapter, occurs the passage, "Twelve hours after labor the woman shall be catheterized, and after that three times a day if necessary." Twelve hours may seem a rather long period to allow urine to collect after labor ; but the bladder is capable of great distention at this time ; almost all the natural processes are sluggish ; the kidneys directly after labor are not very active, THE PUERPERAL STATE. 36 1 and if the catheter is used too soon, the patient is very likely committed to its use throughout the greater part of the lying-in period, whereas if the woman can be induced to urinate naturally at first, there will be no difficulty afterward. At the same time it would be unwise to allow an overdistention of the bladder ; twelve hours, therefore, is a good compromise time for the first use of the catheter. After that three times a day is usually quite sufficient ; it should not be used less frequently, and if the patient's feelings demand it, the bladder must be emptied more frequently. By this plan it is necessary to use the catheter in about thirty per cent, of primiparae. It is possible, by a longer delay, to reduce this proportion materially. In the Baudelocque Clinic they wait twenty-four hours or longer and have used the catheter in 6666 cases only twenty times. 1 Before resorting to catheterization every effort should be made to induce the woman to urinate naturally. Sometimes this is accomplished by putting hot water in the bed-pan, by the use of a turpentine stupe over the bladder, and by the sound of running water. The Bowels. — On account of the small amount of food in- gested during the early part of the puerperium, the flaccidity of the abdominal walls, the torpor of the intestinal muscles from long pressure, and the general muscular inactivity, there is a re- markable sluggishness of the bowels, and an exaggeration of the constipated habit almost invariably acquired in pregnancy. This is no great disadvantage at first, as the food is principally liquid and small in quantity, so that there is very little detritus to be thrown off by the intestines. It is not advisable, however, to allow the feces to accumulate too long. If the woman eats in a day perhaps a third of what an ordinary person would devour, by the third day there would be a considerable collection in the lower bowel ; at this time, too, the diet is a little increased, and the sudden onset of milk secretion on the third day always seems, at least, to threaten an inflammation of the breasts, which might be averted by a derivative and depletive course. For all these reasons, therefore, it is customary to administer as a routine treatment a laxative on the evening of the second or third day. A good routine prescription is a half-bottle of citrate of magnesia on the evening of the second day, the rest of the bottle the follow- ing morning before breakfast, and, if the bowels are not moved two hours later, a simple enema. If the patient is plethoric or the mammary glands are swollen and tender, a more active saline purge is preferable. The Mammary Glands. — There are many conditions of the breasts, not pathological but troublesome to deal with, of such 'Recbt, "These de Paris," 1894. 362 LABOR AND THE PUERPERIUM. frequent occurrence that they must be considered in the manage- ment of a normal case. In almost every instance the establish- ment of lactation is accompanied by some local disturbance. The increased blood-supply to the breast, the proliferation of cells, and the transudation of a serous exudate are phenomena usually characteristic of inflammation. The enlarged breast, the engorged veins under the skin, the hard, tense feel of the gland-tissue, and the great tenderness, all seem to point to an inflammatory attack instead of a natural physiological process. This state of the breasts usually demands treatment to ameliorate the discomfort and to prevent the transition of a natural process closely bordering on the pathological to a condition of actual disease. If the engorgement of the breasts is marked and the accompanying symptoms of heat, pain, and fullness are pro- nounced, the administration of a saline purge is usually sufficient to relieve some part of the mammary congestion. Care must be taken, in addition, to empty the breast. For this purpose nothing is Fig. 222. — Diagram pattern for Murphy-Cooke breast binder. By enlarging until each square represents a square inch, and tracing an outline, a binder of ordinary size will be secured. If the binder is cut from folded muslin, only one-half the pat- tern need be made. so good as the infant's mouth, which should be applied to the nip- ple regularly every two hours. If the child dies, does not empty the breast, or is weaned, a breast-pump must be used, and the nurse, in addition, should rub and massage the breast with oiled fin- ger-tips in a direction toward the nipple, thus making the skin more supple and emptying the breast at the same time. The constant dragging upon the nipple when the child is nursing, the pinching and squeezing it receives from the infant's gums, and its continual THE PUERPERAL STATE. 363 moisture from milk and the secretions of the infant's mouth, all tend to bring about an unhealthy condition of the skin upon and around it. It becomes at first irritated and inflamed, then ex- coriated, chapped, and fissured, and, consequently, exceedingly sensitive and painful, so that suckling the child is dreaded. Nor is this the only disadvantage ; in the little cracks and fissures the milk collects and decomposes ; the patient or nurse may, in careless handling of the breasts, deposit, in these raw places, pathogenic micro-organisms, and the consequence is very likely to be septic infection of the connective tissue of the breast and the formation of a mammary abscess — of all the minor complica- tions of the puerperal state the one to be most dreaded. The preventive treatment of this complication is an important part of the management of the puerperal state. The main thing, ob- viously, is to keep the skin healthy and clean. This is done by carefully washing the nipples after every nursing with absorbent cotton, warm water, and Castile soap ; by cautioning nurse and patient against handling the breasts with fingers not asep- tic, and by smearing the skin of the nipples and that of sur- Fig. 223. — The Murphy breast-binder. rounding parts with sweet-oil after every washing, applied by a piece of clean linen or a pledget of fresh absorbent cotton. There is another point in the management of the breasts, which, if it does not aid in preventing so serious a disturbance as mam- mary abscess, does increase the patient's comfort by relieving the feeling of distention and weight which is experienced during the first few days of lactation. This is the adjustment of a suitable mammary binder. The Murphy binder or its modification by Cooke is best for this purpose (Figs. 222 and 223). The Child. — While devoting careful attention to the man- 364 LABOR AND THE PUERPERIUM. agement of a woman after confinement, the physician must not forget that he has another patient on his hands, of almost equal importance, — the infant. Fortunately, the management of a healthy infant is easy. If a few common- sense rules are observed, nature does the rest. The management of the new-born child consists simply in seeing that food is administered at proper and regular intervals, that attention is paid to bodily cleanliness, and that ample opportunity is afforded for an almost unlimited amount of sleep; with ordinary precautions in regard to warmth. The proper interval between the nursing should be two hours during the day, four to five hours in the night. If the child is taught regular habits in this respect, the burden of its care-takers is immensely lightened. The infant arouses itself and is ready for nursing at the proper feeding-time, and in the intervals sleeps peace- fully. Regularity in nursing is of importance, further, from its favorable influence upon the constitution of the milk. Too frequent nursing results in a concentrated milk, which is difficult to digest. Too infrequent nursing results in a watery milk, which is not nutritious. If the infant is allowed to be irregular in the hours for feeding, bathing, and sleeping, it grows fretful, wakeful, and capricious in its appetite. A word of caution is necessary about the infant's bath. The temperature of the water should be about 90 ; certainly not much higher, nor, on the other hand, too low. Nurses are often extraordinarily insensi- tive to hot water. The temperature of the bath, therefore, should not be tested by their hands, but by a bath-thermometer. The bath should be given about midday, in the warmest part of the room, preferably in front of an open fire. There are many apparently small, but really important, details in the preparation for and management of labor and the puer- perium, which might easily be forgotten. It is convenient, there- fore, to give patients and nurses a printed list of instructions. DIRECTIONS FOR THE MOTHER. Send a specimen of urine (mixed night and morning), about four ounces, every two weeks until the last month, then every week. Report at once scanty urination, severe headache, swelling of the feet or face. Have ready for the labor: towels, ether (one-half pound), brandy (two ounces), vinegar (four ounces) ; four ounces tincture of green soap; a bottle of antiseptic tablets (corrosive sublimate); a large, coarse, new sponge ; a skein of bobbin ; a fountain syringe ; bed-pan; new, soft-rubber catheter ; a small package of absorbent cotton ; a one-ounce bottle of carbolized vaselin ; two yards unbleached muslin (for binder); a one-pound package of salicylated cotton; five yards of carbolized gauze ; eight yards of nursery cloth. THE PUERPERAL STATE. 365 The last is to be boiled for half an hour in clothes-boiler, dried thoroughly, pinned up in a clean sheet, and put away out of the dust. A mackintosh or rubber cloth is necessary to protect the mattress : two yards of rubber cloth, one yard wide, is sufficient. Prescription No. 1 1 is to be procured about four weeks before expected confinement. It is to be applied to the nipples, night and morning, with absorbent cotton. Prescription No. 2 2 is to be obtained about a week before- hand and kept in readiness. Instead of providing these articles separately, a complete outfit for labor, with everything requiring it, sterilized, put up in a closed package or box, may be ordered. The author recommends the out- fit described in the appended list. Two sterilized bed pads (30 ins. square). Two sterilized mull binders (18 ins. wide). Six sterilized towels. Stocking drawers, sterilized. Ten yards sterilized gauze. Five yards carbolized gauze. One pound package salicylated cotton. One pound sterilized absorbent cotton ( half pounds) . Rubber sheet 1 yard X 1^ yards, sterilized. Rubber sheet 1^ yards X 2 yards, sterilized. Two tubes sterilized petrolatum. One tube K-Y lubricating jelly. Tincture green soap. Fluid extract ergot. One hundred grams chloroform (Squibb's). One hundred grams ether. Boric acid, powdered. Bichloride tablets. Talcum powder. Four quart sterilized douche bag with glass nozzle. Douche pan, sterilized. Two agate basins, sterilized. Bath thermometer. Sterilized nail brush. Safety pins. Sterilized tape. Sterilized soft rubber catheter. Sterilized glass catheter. One pair sterilized rubber gloves No. 7)4. Baby-clothes. Four to six dozen diapers. Four to six pairs knit (woolen) socks. Three to four shirts (woolen). Four flannel night-skirts. "l . „ , . . , , .., . . • . , , , . „. ! All skirts to be made with waists instead " " day-skirts. > c , , T-, . ,.i , . . . t of bands. Four to six white day-skirts. ) Six to ten slips. " " dresses. Material for four or five flannel bands (45- to 50-cent flannel). Soft pillow (good size, 14 x t8 inches). 1 R • Glycerol of tannin, Aqua, aa, ^j 01. rosce, gtt. ij. 2R. Ext. ergot, fid., fgj. 366 LABOR AND THE PUERPERIUM. Soft pillow covers. Knit wrapping blankets. Sacques, wrappers, bibs, caps, blankets, veils, etc. Baby's Basket. Large and small safety-pins. Talcum powder (box and puff). Fine, soft sponge. Soft brush (for hair). Castile soap. Cold cream. Alcohol for rubbing child. Blunt scissors for nails, etc. Old linen for cleaning mouth. Soft towels for bath. Bath-blanket. Wooden forms for drying socks. DIRECTIONS FOR THE NURSE. Give rectal enema as soon as pains begin (pint of soapsuds, dram of turpentine). Wash the external genitals thoroughly with soap and warm water. As soon as labor begins, fill three pitchers with water that has been boiling for half an hour; tie clean towels over their tops. This water is to be used for all purposes about the patient and for making the antiseptic solutions. No vaginal injection to be given unless ordered. Take the temperature three times a day, — morning, noon, and evening. Place pad of nursery cloth under patient; change it when soiled. Occlusive bandage to be made up of salicylated cotton and carbolized gauze, with sterile hands, and to be changed, for the first five days, every four hours. The external genitals to be washed off four or five times a day with warm corrosive sublimate solution, 1 : 4000, made up with boiled water. Use absorbent cotton for this purpose. If, at the end of twelve hours, the bladder can not be emptied naturally, use a catheter. Afterward, if necessary, catheterize patient three times a day. The patient is to lie on her back ; she may be moved from one side of the bed to the other several times a day ; her limbs may be rubbed with alcohol and water or bathing-whisky once a day. The nurse's hands must be protected by sterile rubber gloves before catheterizing the patient, cleansing the genitals or breasts. Diet. — First 48 hours. — Milk (i}4 to 2 pints a day), gruel, soup, one cup of tea a day, toast and butter. THE PUERPERAL STATE. 367 Second 48 hours. — Milk toast, poached eggs, porridge, soup, cornstarch, tapioca, wine-jelly, small raw or stewed oysters, one cup of coffee or tea a day. Third 48 hours. — Soup, white meat of fowl, mashed pota- toes, beets, in addition to above. After sixth day, return cautiously to ordinary diet, — that is, three meals a day, meat at one of them, of an easily digested character, — white meat of fowl, tenderloin of beef, etc., — and a glass of milk at least three times a day, between meals and before going to sleep at night ; also a glass in the middle of the night. Child. — After being well rubbed with sweet-oil, the child is to be washed on the nurse's lap. The bath-tub may be used by the end of the first week. Water not over ioo° F. The cord is to be dressed with salicylated cotton. Ob- serve carefully for bleeding. A good dusting-powder for the navel is salicylic acid 1 part, starch 5 parts. The child should be bathed daily, about midday, in the warmest part of the room. Use Castile soap and a soft sponge ; avoid the eyes. Diapers changed often enough. For chafe, use cold cream and talcum powder. Nursing. — The child is to be put to the breast every four hours for the first two days. No other food is to be given it. After the second day it should be nursed every two hours, from 7 a. m. to 9 p. m., and twice during the night (1 a. m. and 5 a. m.). After every nursing the nipples are to be carefully dried and then smeared with a little sweet-oil for the first week or two, applied with fresh pledgets of absorbent cotton. The Final Examination at the End of the Puerperium. — The recently delivered woman should be subjected to three careful examinations: The first shortly after labor, or as soon as it is convenient, to detect the injuries of child-birth; the second before she leaves her room, to determine the position of the uterus ; and the third at the end of six weeks after deliver}-. The final examination should be conducted in a methodical manner, as follows : The Inspection of the Vulva. — As a woman lies on an exam- ining table or across the bed with her thighs separated, the labia majora should be in close apposition, closing the vulvar orifice and concealing the vaginal entrance. A gaping vulvar orifice and vaginal introitus indicate subinvolution of the vagina, over- stretching of the tissues, and injury of the perineal center or body. By placing the thumbs on either side of the labia and stretch- ing them apart a view of the lower third of the vaginal canal is 3 68 LABOR AND THE PUERPERIUM. Fig. 224. — Perfect preservation of the vulvar orifice and pelvic floor in a primipara, six weeks after labor. Fig. 225. — Gaping vulvar orifice from injury to the perineal body, retraction of the ends of the transversus perinei and bulbo-cavernosus muscle, overstretching and subinvolution of the vagina. THE PUERPERAL STATE 369 Fig. 226. — Gaping vulvar orifice, Fig. 227. — Gaping vulvar orifice injury of urogenital trigonum muscle, and with rectocele and cystocele from a prolapse of lower anterior vaginal wall. former labor. Fig. 228. — Complete tear of the peri- neum directly after labor. 24 Fig. 229. — Same patient six weeks later, before operation, which had been postponed on account of al- buminuria and infection. 37o LABOR AND THE PUERPERIUM. obtained; injuries in the posterior sulci to the levatores ani mus- cles are visible; lacerations of the anterior sulci manifest them- selves by a dropping of the lower anterior vaginal wall downward and forward, making a pouch of mucous membrane filling the distended vaginal entrance. This is the injury which later, if not repaired, results in cystocele. If there is a complete tear of the perineum through the sphincter, it should immediately be detected on inspection, or certainly when the labia are separated. If there is any doubt about it, the forefinger of the left hand, protected by a finger- cot, in the rectum, and the thumb in the vagina determine the thickness of the tissues between the two. Fig. 230. — Complete tear of the perineum six weeks after labor; sphincter muscle masked by large hemorrhoidal vein. The Digital Examination of the Vagina (Indagation). — First the integrity of the levatores ani muscles is tested as follows: The forefinger of the left hand is inserted to the second joint, pressure is made in each posterior sulcus downward and outward toward the tuber ischii; if the muscle is lacerated, the finger sinks into a deep cleft almost or quite to the bony pelvic wall. The forefinger is then swept over the posterior vaginal wall from one descending ramus of the pubis to the other; if the levator ani is injured on either side, the cleft in it is plainly felt. Next the integrity of the urogenital trigonum muscle 1 and fascia is tested by 1 For the best description of this muscle the student is referred to Waldeyer's "Das Becken." It runs across the anterior vaginal wall from one ischiopubic June- THE PUERPERAL STATE. 371 pressing the forefinger into each anterior sulcus upward against the lower edge of the pubic bone. A muscular cushion is felt in the normal case. If there is a submucous iaceration of the mus- cle, the finger comes in close contact with the sharp edge of the bone. The left anterior sulcus is usually the site of injury, as the long diameter of the fetal skull almost always lies in the right oblique diameter of the maternal pelves. The finger is n< >w inserted more deeply in the vagina to feel the cervix in order to detect the kind and degree of injury it may have suffered. The direction of the cervix is of no importance in diagnosticat- Fig. 231. — Testing the levator ani muscle in the right posterior vaginal sulcus, this case there was a deep tear. ing uterine position ; it may look forward in anteflexion and backward in retroflexion. The position of the uterus is next investigated — of all single items of information in this examination, the most important. A combined examination is necessary. If the corpus uteri can be grasped between the finger or fingers in the anterior vaginal vault and the fingers of the other hand upon the hypogastrium, and the fundus points sufficiently far forward for the weight of the intra-abdominal contents to rest upon the posterior uterine wall, the uterus is in satisfactory position. If it is impossible to tion to the other. It is the only muscle actually inserted into the vagina, and is the strongest support of the lower anterior vaginal wall ; its laceration, which frequently occurs in labor, is the first step in the f rmation of a cystocele. 372 LABOR AND THE PUERPERIUM. Fig. 232. — Examining the position of the uterus. < >■ *. Fig. %33' — Protrusion between gaping recti muscles of coils of intestines, in which peristalsis could be seen. THE PUERPERAL STATE. 373 take this bimanual grip of the uterus, the internal fingers are shifted to the posterior vaginal vault, and if there is a retro- 1 ' ^MH^. ■A m V / \ / ■X / ' Fig. 234. — Pyramidal elevation of the abdomen when the woman strained. Fig. 235. — Retraction instead of protrusion of the abdominal wall between the recti muscles when the patient attempts to rise to a sitting posture. flexion, the corpus uteri is easily traced backward toward the sacrum and the angle of flexion is plainly felt in the lower uterine 374 LABOR AND THE PUERPERIUM. segment. Pressure from above through the abdominal wall facilitates the palpation of the retroflexed uterus. During the bimanual examination the size and consistency of the uterus are noted to determine the degree of involution. Finally, the broad ligaments, the tubes and ovaries, and the utero-sacral ligaments are palpated by a combined examination to detect inflammatory swelling, displacements, fixation, and peri- toneal or cellulitic exudate. The specular examination of the vagina and cervix follows the digital examination to detect ulcerations of the vagina or injuries in its upper part, and particularly to determine the kind and degree of injuries to the cervix, the existence of eversion and erosion of the lips. A bivalve speculum (Collins) is most con- Fig. 236. — Testing the separation of the recti muscles. venient to examine the cervix. The author's skeleton bivalve speculum gives the best view of the vaginal walls. The abdominal wall is palpated and inspected to test its tonicity, and particularly to detect a diastasis of the recti muscles. The separation of the latter is measured by sinking the outspread fin- ger-tips of one hand crosswise between the muscles. If there is doubt as to the degree of separation, while the fingers are held in position, the physician helps the patient to rise to a sitting- posture by grasping her hand. In a normal case the muscles are THE PUERPERAL STATE. 375 Fig. 237. — Palpation of a floating kidney in the erect posture. Fig. 23S. — Examination of the coccyx. 376 LABOR AND THE PUERPERIUM. approximated as the patient rises. If there is diastasis, the degree of separation is evident, as the muscles are clearly outlined when they contract. By inspection, protrusion of intestines can be seen in extreme cases. If the woman strains, the abdominal wall is thrown outward in a wedge shape between the muscles. Rarely it is retracted instead of protruded. The kidneys are palpated to determine their position and mobil- ity. The woman sits bolt upright, her back and head supported, her arms hanging down limp alongside of her, and all her muscles relaxed as much as possible. The outspread fingers of the physi- cian's hands grasp the kidney through the anterior and the poste- rior abdominal walls. If the kidney is in good position, the fingers of the anterior hand must be inserted under the floating ribs. Another method is to examine the patient on her feet, the trunk flexed and the arms supported on the back of a chair (Fig. 237). The coccyx is examined to detect injury of its joints as illustrated in Fig. 238, the woman being placed in Sims' position and the physician's forefinger protected by a rubber finger-cot. It is only by such a methodical and thorough examination that the physician avoids overlooking the ill consequences of labor. The invalidism of women following child-birth could be enormously reduced, a reproach to medicine could be removed, if this plan were uniformly adopted. There is no valid excuse for a rectocele, injured cervix with all its consequences, including cancer, cystocele, uterine displacements of puerperal origin, including prolapse, subinvolution, and endome- tritis following child-birth, coccygodynia from a ruptured joint in labor, pendulous belly with ptosis of the abdominal viscera from a relaxed abdominal wall, and diastasis of the recti muscles. All the injuries of child-birth, including those of the cervix and of the anterior vaginal wall, can be successfully repaired primarilv. At the latest they can be repaired by an intermediate or by a secon- dary operation at the end of the puerperium, instead of allowing the woman to endure years of suffering and invalidism with such impairment of physical and nervous strength that she can never be restored to her original health. Every one of the conditions enumerated above is amenable to appropriate treatment, and none of them should be allowed to become chronic. PART III. THE MECHANISM OF LABOR. The mechanism 1 of labor is the manner in which a fetus and its appendages traverse the birth-canal and are expelled. It takes into account the complicated structure of the maternal and fetal parts, considering their movements and the mechanisms of their motions. It is necessary to define, further, certain terms that will be used constantly in the study of the mechanism of labor. By presentation is meant that part of the fetal body which presents itself to the examining finger in the center of the plane of the superior strait. The term position may be applied to the position of the child in utero, whether it is longitudinal, oblique, or transverse ; or, in another sense, it is the varying relations which the present- ing part of the fetus bears to the surrounding maternal structures at the plane of the superior strait. The presentation and position of the fetus are determined by abdominal palpation, by auscultation, and by vaginal exami- nation. Abdominal Palpation. — For this kind of obstetrical exami- nation the woman should be placed on her back, with the abdomen exposed. The examiner, standing to one side of the patient, by a series of stroking, patting, and rubbing motions with his hands, determines the height of the fundus uteri, the tension of the abdominal walls, the irritability of the uterus, the quantity of liquor amnii, the size of the fetus, its position, and its presentation. It has been claimed that in favorable cases the placenta can be felt, and that its position can thus be diagnosti- cated (Spencer). It is further asserted that if the greater bulk of the uterus is anterior to the insertion of the tubes, the pla- centa is anterior, and vice versa (Leopold). 1 From the Greek /ijjxavrj, contrivance, machine (from r<>ot ,«'/.v°C. a manner, a way, a means). -7 378 THE MECHANISM OE LABOR. The Diagnosis of Fetal Position and Presentation by Abdomi- nal Palpation. — The examiner stands alongside the patient, facing her head; the tips of the fingers of both hands, moving together and at equal distances from the middle line, are carried up the sides of the abdomen by a series of tapping movements ; and upon one side (for example, the left, in the L. O. A. position) is Fig. 239. — Abdominal palpation: locating the fetal back. Fig. 240. — Abdominal palpation : finding the lower extremities of the fetus. noticed a firm, broad, even sense of resistance, contrasting with the cystic, tumor-like sensation of the other side, with the occasional encounter of firm, irregular bodies, — the fetal extremities. This firm, broad, even resistance is produced by the fetal back, and, to confirm this fact, the extremities are felt for by a rubbing motion with one outstretched hand on the opposite ABDOMINAL PALPATION. 379 side. They are felt as cylindrical, irregular bodies, slipping away from the hand, and changing their position from time to time. Having located the back and the extremities, the portion of the fetal ellipse presenting at the superior strait is next ascertained. The examiner now faces the woman's feet, and, with the out- stretched hands, the fingers parallel with and the middle finger over the center of Poupart's ligament, on either side, the fingers dip down beneath the ligament into the pelvic cavity. If the head is presenting, it is felt as a hard, regular, round body, the greater mass of the occiput, the sharp point of the chin, and the groove between occiput and back being often distin- guishable. At the same time, the density of the head, its com- pressibility, its approximate size, and its relative size to the pelvis may be learned. Fig. 241. — Abdominal palpation : locating the fetal head. By auscultation the fetal heart-sounds are located, and their rate and intensity are noted. The uterine bruit and the funic souffle are often heard. The former is a low-pitched musical murmur synchronous with the maternal heart-beat. The latter is a high-pitched whistling murmur synchronous with the fetal heart-beat. The position on the abdomen at which the fetal heart-sounds are heard with greatest intensity is of diagnostic value in confirming the find, by abdominal palpation, as to posi- tion and presentation. By vaginal examination the finger detects the varying por- tions of the fetal body which may present at the superior strait, as the cranium, the face, the shoulder, the buttocks, the knees, feet, and, exceptionally, the elbow or hand. The position of the fetus in utcro is longitudinal in 99^ per cent, of all cases. The cephalic extremity presents in about 951^ per cent., 95 per cent, being vertex presentations. In about one-half of I per cent, of cases the face presents ; the brow very rarely. In about 3 per cent, of all cases the breech 380 THE MECHANISM OE LABOR. presents, and in about one-half of I per cent, the fetus occupies a transverse position in utero. An explanation of the great frequency of cephalic presentations is found in a voluntary assumption of that position by the fetus, because it affords it the greatest degree of comfort and the best opportunity for growth and development, the largest room being found in the fundus uteri for the lower extremities, which are freely moved and exercised. 1 An explanation of the great frequency of presentations of the vertex is afforded by the mechanical arrangement of the connec- tion between fetal head and body, diagram - matically represented by two bars attached to each other, — that representing the head joined to that representing the spinal col- umn, not at its middle, but at a point nearer one end of the bar (Fig. 242). An equal force exerted upon both ends of Fig. 242— Diagram the lever represented by the child's head illustrating the cause of mi ,, • ,, , n r , , the frequency of vertex wl11 result m the greater flexion of the presentations. longer bar, which is that portion of the fetal skull in front of spinal column. The positions of the various presentations are named by the relationship which the most prominent anatomical feature of the presenting part bears to the acetabula or to the sacro-iliac junc- tions of the maternal pelvis. They are, therefore, four in number. Positions of Vertex Presentations. — I. L. O. A., left occipito- anterior, the occiput looking to the left acetabulum. 2. R. O. A., right occipitoanterior. 3. R. O. P., right occipitoposterior, the occiput looking to the right sacro-iliac joint. 4. L. O. P., left occipitoposterior. Of all vertex presentations about seventy per cent, are L. O. A., thirty per cent. R. O. P. The long axis of the fetal skull very rarely lies in the left oblique diameter of the maternal pelvis. Explanation of the Frequency of L. O. A. and R. O. P. — The position of the rectum shortens the left oblique diameter of the pelvis ; therefore the long diameter of the head, seeking the direction of least resistance, adjusts itself in the right oblique 1 It is probable that other factors often enter into the assumption of a cephalic presentation by the fetus. The fact that the cephalic extremity is the heavier, and so falls toward the pelvis as the woman stands erect, and the growth of the uterus in a perpendicular rather than a lateral direction, forcing the long axis of the fetus to coincide with the long axis of the uterus, are no doubt instrumental in determining a cephalic rather than a pelvic presentation ; but if one accepts this explanation unre- servedly, he could not explain a breech presentation at all, nor could he account for the return of a fetus to a breech presentation after it had been turned by external version. Sir James V. Simpson's theory, therefore, given in the text is, on the whole, the most satisfactory. FORCES INVOLVED EY MECHANISM OF LABOR. |8l diameter of the pelvis and the projection of the lumbar spinal column, to which the fetus by choice adapts its anterior concave surface, usually results in the back being turned forward and tilted a little toward the right, because of the usual right lateral version of the pregnant uterus. Thus, the left occipito-anterior position of the vertex is the commonest position in labor. Should the child's back be directed to the right, the occiput is turned posteriorly, because the chin would be pushed forward by the sigmoid flexure and rectum, this being a stronger force in the arrangement of the head than the child's inclination to adapt its concave abdominal surface to the convex surface of the maternal lumbar spine. THE FORCES INVOLVED IN THE MECHANISM OF LABOR. There are certain forces operative in every labor irrespec- tive of fetal presentation and position. These are the forces of expulsion contributed by the uterine muscle and the abdominal muscles, and the forces of resistance con- tributed by the lower uterine segment, the cervix, vagina, vulva, the pelvis, and the fetal body. The forces of expulsion are furnished by a great part of the uterine muscle (the upper uter- ine segment) and by the mus- cular action of the abdominal wall. That portion of the uterine canal which must be dilated to allow the escape of the fetus is called the lower uter- ine segment. Its boundaries are : above, the firm attachment of the peritoneum to the uterine Fig. 243. — Diagram showing the diminution of the upper uterine seg- ment and the expansion of the lower segment during each contraction. wall, and, below, the internal os. That portion of the uter- ine wall above the point at which the dilatation of the uterine cavity begins is called the tipper uterine segment; the boundary-line between these seg- ments, often marked by a perceptible ridge, especially in ob- structed labors, is called the contraction ring, or the ring of Bandl. 382 THE MECHANISM OF LABOR. The manner in which the uterine muscle exerts its force upon the fetal body is by a diminution of the intra-uterine area. The uterine muscle in contraction somewhat increases the longi- tudinal diameter of the uterus, but decidedly diminishes the transverse and anteroposterior diameters. The contraction of the abdominal muscles likewise diminishes the area of intra- abdominal space. The degree of force exerted by the combined action of uterine and abdominal walls has been estimated to be from seventeen to fifty-five pounds. The forces of resistance are furnished by that portion of the parturient tract which must be dilated, — i. e., from the contraction ring to the vulva, including the lower uterine segment, the cervix, the vagina, and the vulva. The dilatation of the cervix is effected, if the membranes are preserved, by the displacement of the most easily displaceable of the uterine contents, the liquor amnii, in Fig. 244.— Diagram illustrating Fig. 245. — Diagram illustrating alteration in shape of a cross-section the alteration in the shape of a sagittal of a uterus during its contractions. The heavy line represents the non-contracted, the dotted line the contracted uterus (compare Fig. 230) (Dickinson). section of the uterus during its contrac- tions. The heavy line represents the non-contracted, the dotted line the con- tracted uterus (Dickinson). the direction of least resistance, — through the cervical canal. A pouch of the membranes insinuated in the canal subjects the surrounding ring of cervical muscle to water-pressure, equally exerted in all directions, but felt by the cervix only in a lateral or horizontal direction. If the membranes are ruptured and the presenting part impinges directly on the cervix and lower uterine segment, the former is subjected to a lateral pull from all sides at once, as the presenting part pushes from above downward. The presenting part, moreover, whatever it be, is somewhat con- ical in form, and subjects the cervix to a lateral push as it is wedged into the cervical canal (Fig. 246). The dilatation of the lower uterine segment and of the cervix is not, however, simply mechanical, the serous infiltration of the lymph-spaces and the PLATE 8. I d (parietal ycmsph ik^^rr* .•"•*• Fetal skull seen (i) from the side, (2) from above, (3) from behind, and (4) from in front, showing sutures, fontanels, ami diameters (Dickinson). FORCES INVOLVED IN MECHANISM OF LABOR. 3S3 separation of the muscle-fibers lessening the power of resistance gained by cohesion of muscle-bundles. The dilatation of both the lower uterine segment and the cer- vical canal is also assisted by the longitudinal muscle-fibers in these regions drawing the cervix up over the presenting part. Finally, the circular muscle of the cervix, subjected to the strain of constant push and pull, becomes fatigued and, at length, para- lyzed. Below the cervix dilatation is effected mainly by the mechanical stretching of the walls of the birth-canal. The bony walls of the pelvis, in a normal case, only offer enough resistance to delay the progress of the presenting part suffi- ciently to insure a gradual dilatation of the soft, resisting structures. The Fetal Body. — The head is by far the most important anatomical division of the fetal body in labor, on account of its bulk and density. The fetal head may be divided into the yielding and the unyielding portions. The former consists of the cranium, composed of the two frontal, the two temporal, the Fig. 246. — Diagrams illustrating the lateral "pull " and "push" on the cervix. two parietal, and the occipital bones. These bones are separated from each other as follows : The two frontals by the frontal suture, the frontal from the parietal by the coronal suture, the two parietal by the sagittal suture, and the two parietal from the occipital by the lambdoidal suture. At the junction of the lambdoidal and the sagittal sutures there is a membranous space, called the posterior fontanel, triangular in shape. At the junction of the frontal, coronal, and sagittal sutures there is also a membranous space, called the anterior fontanel, kite- shaped, and larger than the posterior fontanel. This portion of the skull, the cranium, yields to pressure, and is reduced in size by an overlapping of the bones. The unyielding portion of the skull comprises the face and the base of the skull. The bones of this region are fixed and unyielding. A transverse vertical section of the skull is somewhat wedge- shaped, the wedge tapering toward the neck. A longitudinal medial section is distinctly conical in form. 3§4 THE MECHANISM OF LABOR. Possible Presentations of the Head. — Vertex. — By this term is meant that conical portion of the skull with its apex at the smaller fontanel and its base at the planes of the biparietal and trachelobregmatic diameters, — the face; the brow; the larger fontanel ; the parietal eminence ; the ear. THE MECHANISM OF THE SEVERAL PRESENTATIONS AND POSITIONS. The Mechanism of Labor in a Vertex Presentation and a Left Occipito=anterior Position. — It is convenient to begin the study of each presentation with a consideration of its diagnosis. The diagnosis of position and presentation is made by abdom- inal palpation, auscultation, and vaginal examination. By these Fig. 247. — Left occipito-anterior position of a vertex presentation. methods of examination in the position and presentation under discussion the fetal back is found to the left, the extremities to the right and above, the head below ; the heart -sounds are heard most distinctly about an inch below and to the left of the umbili- cus ; the examining finger in the vagina detects the vertex pre- senting, with the occiput directed toward the left acetabulum ; the sagittal suture is in the right oblique diameter of pelvis ; the smaller fontanel, recognized by the junction of the lambdoidal and the sagittal sutures, is the most dependent portion of the presenting part ; the tip of the occipital bone is overlapped by the parietal bones. As the direction or axis of the pelvic canal diverges from that of the uterine cavity, running, at first, more MECHANISM OF PRESENTATIONS AND POSITIONS. 385 posteriorly, there is usually a lateral inclination of the head so that the sagittal suture is posterior to the normal position of the oblique diameter of the pelvis, and one parietal bone (the anterior) is deeper in the pelvis than the other one. The mechanism of labor in a left occipito-anterior position of a vertex presentation may be taken as a type of the mechanism of all labors, the variations in the process imposed upon it by Fig. 248 — Vertex presentation, left occipito-anterior position. the different positions and presentations of the fetus being readily understood if the typical mechanism of the commonest presenta- tion and position is thoroughly mastered. It is convenient to divide the mechanism of labor into a number of steps or acts, as follows : First Step. — Accommodation of the size of the fetal skull to the size of the pelvic canal by flexion ; accommodation of the shape of the fetal skull to the shape of the pelvic inlet by molding ; accommodation of the direction of the head to the direction of 25 3 86 THE MECHANISM OF LABOR. the pelvic canal by lateral inclination. These movements occur prior to labor, when the head enters the pelvic inlet with the subsidence of the uterus. Fig. 249. — Genital tract with fetus removed, showing divergence of the pelvic axis from that of the uterine cavity: a, a, Membranes; b, b, contraction ring; c,c, point down to which membranes are unseparated ; d, promontory ; e, region of os internum (above which fragments of deciduaare found, and below it cervical glands) ; f, bulging of wall into neck of fetus ; g, g, os externum ; k, pouch of Douglas ; i, posterior vaginal wall (elongated and thinned) ; j, rectum ; k, stretched anal canal ; /, placenta ; ni, uterovesical peritoneum ; n, region of os internum (above which fragments of membranes are found, and below it portions of cervical glands) ; o, lower limit of bladder ; p, anterior vaginal wall (not elongated ) ; figure 276, showing engagement of the shoulders in the pelvis. 412 THE MECHANISM OF LABOR. ' - ■ Fig. 278. — Same as figure 275, showing escape of extremities. Fig. 279. — Breech presentation — rotation of the hips. ABNORMALITIES IN MECHANISM. 413 entered the pelvis with its long diameters in the oblique diameter of the pelvis, opposite to that in which the shoulders engaged. The head descends the birth-canal to the pelvic floor in a position of extension. The occiput, which is always the part first to strike the pelvic floor, is rotated forward under the Fig. 280. — Breech presentation. V\"aldeyer's section of an X-para at full term, who died from hemorrhage some hours after both her legs had been cut oft by a loco- motive : a, First lumbar vertebra; b, placenta; c, fractured first sacral vertebra; d, coronary vein; e, blood extravasation; f, pouch of Douglas; ; r , cervical canal; k, os externum ; i, rectum ; /, umbilicus ; k, os internum ; /, uterovesical reflection of peritoneum; ;;/, bladder; «, symphysis pubis ; 0, vagina. pubic arch. There follows then the delivery of the head in the following order : Chin, face, forehead, anterior fontanel, sweep- ing successively over the perineum and appearing in the vulvar orifice. Prognosis. — The fetal mortality of breech presentations is about thirty per cent., including badly managed cases in gen- 4H THE. MECHANISM OF LABOR. eral practice. There is some added danger of injury to maternal soft parts, on account of the necessity for rapid and sometimes violent extraction of the after-coming head. Treatment. — Before labor external version may be attempted. It will not always be found practicable, and after the fetal body has been turned there is a disposition on the part of the fetus to resume its original position. The application of two long cylin- drical compresses to the sides of the uterus, and a firm abdomi- nal binder, may prevent a return of the breech presentation. When labor has begun, inaction should be the physician's policy until the fetal body is born to the umbilicus, unless maternal or Fig. 281. — Delivery of the after-coming head when it is flexed. fetal life is threatened or an indication for rapid delivery arises. As soon as the trunk appears the patient should be placed in the lithotomy position across the bed, and delivery of the shoulders and head should be effected by pressing upon the fundus with one hand, the other hand being inserted in the vagina to favor anterior rotation of the shoulder, anterior rotation of the occiput, and to direct the passage of the head through the vagina (Wiegand's method ; see Delivery of the After-coming Head). Abnormalities in Mechanism. — The most frequent and impor- tant anomalies are backward rotation of the occiput and excess- ABNORMALITIES IX MECHANISM. 415 ive rotation of the breech. Backward rotation of the occiput is very exceptional. The mechanism of the delivery of the head in these cases differs as the head remains flexed or becomes extended. When flexed, the chin, face, forehead, and anterior fon- tanel slip out under the symphysis in the order named, and the head is delivered. When extended, the chin catches upon the symphysis, the head is extremely extended and is born by the occipital protuberance, small fontanel, cranial vault, and face slipping over the perineum. The following rules for managing the extraction of the head in these cases should be remembered : If the head is flexed, the body of the child should be carried downward ; if it is extended, the body should be carried upward over the mother's abdomen. Excessive rotation of the breech occurs as the result of a prolapse of a posterior extremity, and is of no great practical importance. Fig. 282. — Chin arrested at symphysis ; head extended (Chailly-IIonore). The Mechanism of Shoulder Presentations. — A transverse position of the child in utero almost always resolves itself into a shoulder presentation as the result of uterine contraction when labor begins. Presentations of the umbilicus (Fig. 291) and of the back (Figs. 288, 289) are possibilities, but are extremely rare. Shoulder presentations are classified according to the positions of the back and head. When the head is to the right, the back may be in front or behind. The same is true when the head is to the left. The back is directed anteriorly twice as often as posteriorly, and the head more than twice as often is found toward the left-hand side of the maternal pelvis. Diagnosis. — Abdominal palpation reveals the fetus in a trans- verse position. The heart-sounds are more distinct at a point corresponding to the interscapular region of the child, but some- times can not be heard. A digital examination shows the characteristic anatomical peculiarities of the shoulder and adja- 4i6 THE MECHANISM OF LABOR. Fig. 283. — Shoulder presentation. Fig. 2S4. — Shoulder presentation. ABNORMALITIES IN MECHANISM. 417 Fig. 285. — Shoulder presentation. I. Fig. 286. — Shoulder presentation. 27 4i8 THE MECHANISM OF LABOR. Fig. 287. — Transverse position of the fetus; extremities presenting. Fig. 288. — Back presentation; the left arm is projecting. The trans- verse furrow gives the appearance of a breech presentation (Budin). Fig. 289. — Back presentation, the two arms projecting from the external genital organs (Budin). ABNORMALITIES IN MECHANISM. 419 Fig. 290. — Trunk presentation, dorsal variety (Budin). Fig. ?9i. — Presentation of the umbilicus. 42o THE MECHANISM OF LABOR. cent parts — namely, the axilla, the clavicle, the spine of the scapula, the acromion process, the head of the humerus, and the ribs. Causes. — The causes of a shoulder presentation may be divided under three heads : (i) Abnormalities in the shape and position of the uterus, as a pendulous abdomen ; a uterus bicornis ; the broad uterus accompanying a kyphotic spine ; the distorted uterus due to uterine fibroids and other abdominal tumors, and to multiple pregnancy. (2) Conditions preventing Fig. 292. — Spontaneous evolution. engagement of the cephalic or the pelvic extremity of the fetus, as deformities of the pelvis ; abnormally large child ; monstrosi- ties ; placenta praevia. (3) Abnormal mobility of the fetus, as occurs in hydramnios, after fetal death, or in premature births. Mechanism. — Strictly speaking, there is no mechanism of shoulder presentations. The course of these cases is impaction of the shoulder, enormous dilatation of the lower uterine seg- ment, ascension of the contraction-ring, destruction of the fetus by prolonged pressure, and death of the mother by rupture of the uterus or by exhaustion. As a matter of fact, however, nature ABXORMALITIES IN MECHANISM. 42 1 can, in very exceptional cases, effect delivery by one of three methods : Fig. 293. — Rare form of mechanism, known as birth with doubled body 1 one- sixth natural size, redrawn from Kiistner). Fig. 294. — Impending rupture of uterus in a shoulder presentation : oe, External os ; oi, internal os ; cr, contraction- ring (Schroederj. Fig- 2 95- — Frozen section of shoulder presentation. If the mother had survived, spon- taneous evolution might have occurred (Chiara). Spontaneous version. The transverse position is converted into a longitudinal position by the uterine contractions. Spontaneous evolution. The breech slips past the shoulder 422 THE MECHANISM OF LABOR. and is delivered first, the rest of the body following as in a breech presentation. The body doubled up (corpore reduplicato) is expelled in one mass. This termination is possible only in premature births with a small child, usually macerated. Treatment. — The treatment of shoulder presentations may be summed up in a single word — version. If the child is dead ; if the shoulder is tightly impacted and the lower uterine segment is so distended that the slight additional strain upon its walls of turning the child will probably determine a rupture of the uterus, the child should be decapitated. MECHANISM OF THE THIRD STAGE OF LABOR. The mechanism of the third stage of labor is divided into two acts — the separation and the expulsion of the placenta. The most probable explanation of placental separation is found in the Fig. 296. — Pinard and Varnier's section of the uterus of a V-para who died from collapse (rupture of uterus with hemorrhage) shortly after the expulsion of the fetus : a, Fundus uteri ; b, membranes still attached ; c, retraction-ring ; d, retroplacen- tal blood-clot; e, inverted placenta; /, contracted os externum; g, cord presenting. theory of a diminution in the area of the placental site, which the placenta follows to a certain point, when, becoming solid by the approximation of the villi and the obliteration of the lacunae, it MECHANISM OF THE THIRD STAGE OF LABOR. 423 can no longer follow the contraction and retraction of the uterus, and is sprung off from the uterine wall. It requires usually several pains to accomplish this result ; so that the placenta is not, as a rule, completely detached until about fifteen minutes after the delivery of the child, when it may be found lying in the dilated pouch of the lower uterine segment and cervical canal. The walls of this portion of the birth-canal are so flaccid from pressure paralysis and overdistention that the placenta Fig. 297. — Crede's method of expressing the placenta (photographed from nature) (Dickinson). might remain there many hours, perhaps days, unexpelled. Hence it is that artificial assistance is almost always required to express the placenta. The placenta is usually expelled like an inverted umbrella, the fetal surface coming first with the membranes trailing after it. It occasionally, however, escapes edgewise. Abnormalities in the Mechanism of the Third Stage of Labor. — Retention of the placenta occurs very frequently. As the placenta is fully separated, the hemorrhage is slight. The 424 THE MECHAXISM OF LABOR. placenta simply lies in the dilated lower uterine segment and the upper portion of the vagina. The treatment is the proper application of Crede's method of expression. Sometimes the placenta lies across the os Fig. 298. — The expulsion of the placenta edgewise (Varnier). uteri so that atmospheric pressure determines its retention. In such cases a finger may be hooked over one edge to pull it down. Adhesion of the placenta to the uterine wall occurs about once Fig. 299. — The expulsion of the placenta inverted (Varnier) in 312 cases. The adhesion is rarely complete ; a part of the placenta is usually detached. Hemorrhage is a necessary con- sequence. The placental sinuses are torn when the placenta is MECHANISM OF THE THIRD STAGE OF LABOR. 425 detached, but the womb can not contract and close them, because of the attached area and in consequence of the retention of the whole placental mass within the uterus (see Fig. 300 ).. Causes. — Adhesion of the placenta usually occurs in a woman who has had endometritis ; often as a consequence of syphilis. There is usually an excess of connective tissue in the Fig. 300. — Partial detachment of the placenta. Vertical mesinl section from a case of eclampsia, delivered in articulo mortis by forceps : a, Placenta still attached ; />, placenta separated from its site and hanging free; c, membranes; d, blood; <*, membranes (Stratz). decidua, glandular atrophy, and penetration of the myometrium by the chorion villi, which have burrowed into it. Diagnosis. — Crede's method of expression fails completely to express the placenta; the womb will not firmly contract, and there is alarming hemorrhage. Treatment. — The hand should be inserted along the cord as 426 THE MECHANISM OF LABOR. a guide to the placenta. A detached edge should be sought, under which the lingers are inserted, and the separation is com- pleted with the finger-tips, moving them from side to side. Occasionally it is necessary to pinch through a dense spot of adhesion with the thumb and forefinger. The placenta being separated, the fingers should be closed about it. The fundus should be stimulated by friction through the abdominal wall, and the uterine contractions should be allowed to expel the hand Fig. 301. — Method of manipulation for artificial separation of the adherent placenta (Dickinson). and the contained placenta. It is unwise to pull the placenta out, even when it is completely detached, for the combined mass of the placenta and hand may act like the piston of a syringe and draw the uterus inside out. Ahlfeld has reported a case in which he found it impossible to detach an adherent placenta. He packed the uterus with gauze; on removing the packing twenty-four hours later the MECHANISM OF THE THIRD STAGE OF LABOR. 427 placenta, which had meanwhile become detached, was extracted clinging to the last strip of gauze. 1 Prognosis. — Many women die from hemorrhage; about seven per cent, from sepsis. Most exceptionally the placenta is retained in utero for months without doing harm. 2 The rarest anomalies in the mechanism of the third stage of labor are hernia of the placenta through the muscular coat of the uterus and prolapse of the normally situated placenta. The latter is most likely to happen with twins, after rupture of the uterus, or in premature labor, but it has been observed at term, without injury to the uterus, and in a single pregnancy. There is not necessarily profuse hemorrhage nor other disadvantage to the woman, but the fetus dies unless it is extracted at once. 3 1 "Zeitschr. f. prakt. Aerzte," Bd. viii, H. 13. 2 Wallace, "Indian Medical Record," abstract in London " Lancet," 1891, re- ports the retention in utero of an almost full term placenta for two months without inconvenience to the mother. Loisnel ("Nouv. Arch. d'Obstet.," May, 1892, sup- plem ) reported a case in which the fetal head, after decapitation, was left in the uterus for three months without symptoms of sepsis. Herrgott, in the discussion of this report, stated that he had seen the placenta retained within the uterus for seven months after childbirth. 3 " Prolapsus Placentae," Ingerslev, " Centralbl. f. Gyn.," No. 40, p. 941, 1893 ; " Zur Kasuistik des Prolapsus Placentae bei normalem Sitz derselben," ibid., No. 5> 1893. " Hernia of the placenta through the muscular coat of the uterus during labor," J. G. Lynds, "Med. News," 1893, p. 77. PART IV. THE PATHOLOGY OF LABOR. CHAPTER I. ANOMALIES IN THE FORCES OF LABOR. In a normal labor the active forces of expulsion (the uterine and abdominal muscles) and the passive forces of resistance (the fetus, the pelvis, and the maternal soft structures) are so nicely balanced that the expulsive forces are just sufficiently resisted to insure a slow and gradual passage of the fetus along the birth- canal. The walls of the birth-canal and the structures around the vulvar orifice are by this arrangement slowly and gradually dilated, and are not violently torn apart, as they would be by a more rapid expulsion of the fetus. This balance between the powers of labor is easily disturbed. There may be anomalies by deficiency and anomalies by excess in the component parts of the forces of expulsion and in all the sources of resistance. Thus, the uterine muscle may be too weak or too strong com- pared with the resistance it must overcome ; and so also with the action of the abdominal muscles. The resistance furnished by the pelvis, the soft structures, and the fetus may be excessive or deficient. Deficient Power of the Uterine Muscle ; Inertia Uteri. — In this condition the uterine muscle is unable to overcome the normal resistance offered by the weight of the fetal body, by the friction of the pelvic walls, and by that of the undilated maternal soft structures. Inertia uteri is manifested, in the vast majority of cases, during the first stage of labor. The weakened uterine force, therefore, is almost always neutralized by the obstruction of an undilated cervix. There is scarcely another condition in obstetric practice that can be traced to such a variety of causes or that demands so many different plans of treatment. Etiology. — Deficient power of the uterine muscle in labor 428 ANOMALIES IN THE FORCES OF LABOR. 429 may be due to a defect of the muscle itself, to some anomaly of innervation, or to a mechanical interference with the full and effective action of the muscle. Examples of the first-named cause may be found in imperfect development of the uterus or in anomalies of development, as in uterus bicornis. The uterine muscle may be exhausted by rapidly succeeding pregnancies. It may be overdistended by twins or by hydramnios, thus losing the power gained by cohesion of muscular bundles. The uterus may be weakened by some cause — as an adynamic fever or a wasting disease — that weakens the whole organism, but it does not necessarily follow that uterine weakness always accompanies a reduction of body-strength. Women in the last stages of phthisis or in the midst of an attack of typhoid fever or pneu- monia occasionally exhibit a uterine power in labor above the normal. The uterus may be weakened by profuse hemorrhage, as in placenta praevia. It may be rendered incapable of exerting normal force in dry labors. The liquor amnii having drained off completely early in the first stage, the uterus retracts upon the child's body, thus being subjected in certain regions to severe and long-continued pressure, and becoming in those spots anemic and friable, while in the areas free from the pressure of the child's body the uterine wall becomes congested, swollen, and edematous. Above all, the uterine muscle may be fatigued. This is the commonest cause of uterine inertia. It is seen oftenest in primip- arae, in whom inertia is more than twice as common as in mul- tiparas, on account of the difficulty of dilating the rigid cervical tissues. Inertia may appear in consequence of any serious obstruction in labor. At first the pains are feeble, infrequent, and inefficient, but as labor continues the uterine contractions gather force. The inertia from this cause is likely to be only temporary, seen at intervals between periods of stormy uterine action or of long-continued tonic spasms, until finally ex- haustion of the whole organism threatens the patient's life or the uterus ruptures. It has been asserted that an anomaly of innervation in the anatomical sense, a deficient supply of the terminal nerves in the individual muscle-cells, is a cause of uterine inertia, but it is not yet clearly demonstrated to be so. An inhibitory nervous im- pulse to the uterine muscle, on the contrary, is a frequent cause of uterine inaction. It is the result of some emotion or of great pain. That the "doctor has frightened the pains away" on his first arrival has become proverbial in the lying-in room. The presence of any one who is a cause of embarrassment or is disagreeable to the patient may have the same effect. In hyper- esthetic women the uterine contractions may be so exquisitely 43 O THE PA THOL OGY OF LAB OR. painful that their first onset is followed by an inhibitory impulse which cuts them short almost immediately. Every clinical observer has seen the phenomenon of rapidly recurring, very painful uterine contractions, which are, however, of short dura- tion, and which secure no appreciable dilatation of the cervical canal. A woman may be tortured thus for hours in the early part of the first stage of labor, when this inhibitory nervous im- pulse is commonly observed. With the continuance of labor the individual becomes more or less indifferent to her surroundings or more inured to suffering, and the inhibitory nerves, probably derived from the spinal cord, apparently lose the power of responding to the stimulus of pain. Among the mechanical causes of inefficient uterine action during labor are fibroid tumors of the uterine walls, displace- ments of the uterus, old peritoneal adhesions, and fresh out- breaks of periuterine inflammation. Diagnosis. — The recognition of uterine inertia should always be easy. The contractions of the muscle are of short duration and are separated usually by long intervals, and by palpation the observer may convince himself that they are feeble. The uterus during the pain does not assume the hard consistency which it does in consequence of normal vigorous action. The patient's expression, action, and demeanor point to deficient force during the pains. The woman is more placid, the face is less contorted, and there is less outcry during the contractions than in the normal parturient patient, except in those cases in which excessive pain inhibits uterine action. In these cases, however, abdominal palpation and the short duration of the pains are plain signs of the inertia. Finally, labor is delayed. During the first stage dila- tation is slow or does not progress at all, and in the second stage the presenting part does not advance. One fatal error in the diagnosis of inertia uteri should be avoided : the physician should be sure that labor is not delayed by some obstruction. It has happened in a careless and superficial examination that the ob- server has taken the distended and thinned lower uterine segment for an inert uterus. In such a case the measures adopted to stimu- late the supposedly inactive uterine muscle to overcome an obstacle that is insuperable might easily be interrupted by rupture of the uterus. A methodical and careful examination avoids this error. The source of obstruction is discovered. The firmly, perhaps tetanically, contracted upper uterine segment may be contrasted with the inactive lower segment by palpation of the whole anterior surface of the uterus. The contraction-ring should be visible, and the whole uterus stands out with unusual prominence, from ANOMALIES IN THE FORCES OF LABOR. 43 I the anteversion that always accompanies prolonged and powerful uterine coniraction. Treatment. — From the diversity in the causes of inertia uteri it follows that no single plan of treatment can be depended upon. If uterine action is inhibited by emotion, the cause of nervous disturbance should, if possible, be removed. An objectionable person should leave the room. If excessive pain prevents effective contractions, an analgesic should be administered. Nothing is better for this purpose than chloral administered in 15-grain (0.97 gm.) doses, repeated, if necessary, twice at inter- vals of fifteen minutes. A quarter of a grain (0.0162 gm.) of morphin hypodermatically comes next in order of efficiency. If the uterine muscle is simply apathetic, it can be aroused by some direct irritant. The insertion of a bougie as for the induction of labor answers the purpose well. A more effective but more troublesome measure is the dilatation of the cervical canal by Barnes' or Voorhees' bags, which not only irritate the uterine muscle, and so bring on strong contractions, but also artificially dilate the cervical canal, and thus relieve the uterine muscle of a great part of its task in the first stage of labor. If the head is well engaged in the pelvis, however, the insertion of the bags is difficult, and they are likely to cause malpositions. In such cases, if the os is dilated to the size of a silver dollar, nothing is so effective as the application of forceps, — not to drag the head through the undilated cervical canal, but to pull it at intervals firmly down upon the cervix. The impact of the head upon the cervix acts as a powerful reflex irritant, and excites as strong contractions as any direct irritant can do. Not only so, but the pull of the head upon the cervix gradually dilates the canal as effectually as could strong propulsion from above. As soon as effective pains are' established and the dilata- tion of the cervical canal progresses satisfactorily, the forceps should be removed. Inertia uteri so profound as to demand the somewhat radical measures just described is, fortunately, rare. More commonly the physician sees the minor grades, in which there is simply a flagging of uterine effort during the first stage, especially in primiparas, accompanied by every evidence of temporary physical and mental exhaustion. After a period of rest effective contrac- tions reappear, even if nothing whatever is done to aid the patient. The more complete the rest, the more vigorous is the uterine action when it is resumed, and for this reason the administration of chloral and opium is often followed, after a time, by a satisfactory progress in labor. But these drugs neces- sarily retard the termination of labor by the time of rest they 432 THE PA THOL G Y OF LAB OR. secure. It is ordinarily desirable, therefore, to resort to drugs of a stimulant character that shall at once revive the flagging uterus and so hasten the delivery. Many medicaments have been recommended for this purpose, but, of them all, alcohol, quinin, and ergot alone deserve consideration. The last was employed extensively at one time, but clinical experience forbids its use to-day. The contractions of the uterus induced by ergot are likely to become tetanic. The uninterrupted contractions interfere with the fetal circulation ; they may cause fatal intra- uterine asphyxia, and they often produce such exaggerated blood-pressure and stagnation of the current in the fetal body as to induce extravasations in important viscera, especially the brain. Further, the circular fibers of the cervix come under the influence of the drug, and by their firm contraction neutralize the contraction of the longitudinal fibers of the uterine body, and thus retard labor almost indefinitely ; and, worst of all, should there be some obstruction to the descent of the child in the maternal pelvis or in the fetal body, the administration of ergot predisposes to rupture of the uterus. For these sufficient reasons this drug, as a stimulant to the uterine muscle in the first and second stages of labor, should be banished from the obstetri- cian's pharmacopeia, except in the single instance of the birth of the second of twins. Owing to the recommendations of Albert H. Smith and of Fordyce Barker, quinin has had, and still has, a great reputation as a stimulant to the uterus in labor. My experience with the drug does not permit me to subscribe unre- servedly to its efficacy as a uterine stimulant in labor. Quinin has the positive disadvantage, moreover, of occasionally producing a violent postpartum hemorrhage. It is, however, undeniable that in multiparas, in the first stage of labor, 15 grains of quinin often proves a valuable uterine stimulant. In the minor grade of inertia under description, so often seen in primiparae, and almost always the result of exhaustion, nothing is so useful as alcohol, in the shape of a wineglassful of sherry, taken slowly with a bis- cuit, and given with the positive assurance that it will bring back the pains and hasten the conclusion of labor, for the patient often needs moral and mental support as much as she requires a physical and muscular stimulus. An impression prevails among general physicians that inertia uteri in the first stage of labor, before rupture of the membranes, may safely be disregarded. In a measure this view is correct. There is often a partial dilatation of the os and then an entire cessation of uterine contractions for many hours and even for days. I have seen one case in which the cervical canal was sufficiently dilated to receive four fingers, and it remained so for more than a week, the patient all the while going about on ANOMALIES IN THE FORCES OF LABOR. 433 her feet in perfect comfort, without a single painful contraction of the uterus. But should inefficient uterine contractions be accompanied by much pain, as happens in some cases of inertia, the long-continued first stage should not be regarded with indif- ference. The patient in time shows the irritant and depressant effects of long-continued suffering in an elevated temperature, an accelerated pulse, and a lessened resisting power of body-cells, the last playing an important role in the predisposition to sepsis after labor. Another consequence of delayed, painful labor may be seen in sensitive, nervous individuals who are at first thrown into a state of excitement and then from gloomy forebodings of harm to themselves and to their infants, pass into an almost maniacal condition of terror and dread. It should be a rule of practice, therefore, to watch carefully all cases of inertia uteri, and to interfere as soon as the patient's mental condition or her pulse, temperature, and general vigor are demonstrably affected by the delay in labor. Excessive Power in the Expulsive Forces of Labor. — An actual excess of power in the expulsive forces in labor suffi- ciently great to expel the fetus precipitately is extremely rare. A relative excess is not uncommon. The child's body- may be so small, the pelvis so abnormally large, the maternal soft parts so relaxed, that the ordinary power exerted by the uterine and abdominal muscles is far in excess of that required to over- come the weak resistance offered, and the child is fairly shot out of the birth-canal. The rapid delivery may cause serious re- sults to both mother and child. In the woman the structures of the pelvic floor may be lacerated severely ; the sudden evac- uation of the uterus predisposes to hemorrhage from inertia ; the placenta may be detached prematurely ; and the sudden evacuation of the abdominal cavity predisposes to dangerous syncope. For the child the chief danger is the possibility of unexpected delivery of the mother in the erect posture. The umbilical cord may rupture, and the child, falling to the ground, may be fatally injured. Precipitate and unexpected labors occur most frequently when women are seated upon the water-closet. The child is evacuated into the waste-pipe or down a well and may be destroyed. Some astonishing examples of infantile vitality, however, are furnished by such cases. Unfortunately, the physician is usually not at hand to pre- vent a precipitate delivery and to avert its consequences. Should he find an infant descending the birth-canal with a rapidity dangerous to itself and to its mother, he can easily retard its progress by pressure with his hand against the presenting part. 28 434 THE PATHOLOGY OF LABOR. Excess in the Resistant Forces in Labor. — Deformities of the Pelvis. — A comprehensive and satisfactory knowledge of deformities in the female pelvis has been gained only in the latter half of the nineteenth century, since the appearance of Michaelis' work in 185 1. 1 Until the announcement by Arantius in the last quarter of the sixteenth century that a contracted pelvis is a serious obstacle in labor, the prevailing belief had been that difficult labors from mechanical ob- struction by the maternal bones were due to a failure on the part of the pelvis to expand sufficiently for the passage of the child. This idea was entertained for a number of years after Arantius' time. According to Litzmann, Hemrich von Deventer (165 1 to 1724) should be regarded as the real founder of our knowledge of the pelvis and its anomalies. He described the inclination of the pelvis, the axis of the pelvic inlet, the con- tracted pelvis, and the fiat pelvis. Pierre Dionis was the first to point out (17 1 8) the relationship between rachitis in childhood and a deformed pelvis in the adult. William Smellie's con- tributions to the study of the female pelvis were remarkably full and clear, when one considers how little was known before his time. His description of the rachitic pelvis, his reflections on its cause, and his accounts of illustrative cases may be read with profit to-day. Roderer, Stern, Cooper, Vaughan, Denman, Baudelocque, and Fremery added much to the stock of knowl- edge during the latter half of the eighteenth century. The men to whom we owe most of our present information about the pelvis and pelvimetry are Naegele, Kilian, Rokitansky, Michaelis, Robert, Litzmann, Neugebauer, and many others to whom refer- ence will be made in the sections devoted to the particular varie- ties of deformed pelvis. 2 Frequency of Deformed Pelves. — It is difficult to estimate the frequency in America of pelves sufficiently deformed to influence decidedly the course of labor. Statistics from our lying-in hospitals afford little aid to a correct conclusion, because the inmates are chiefly European immigrants and negresses. In the Boston Lying-in Hospital, however, deformed pelves were found in two per cent, of native-born and in six per cent, of foreign-born women (Reynolds). 3 The statistics of Williams in Baltimore and of Crossen in St. Louis give a frequency of about seven per cent, among the white women of large American cities. Among negresses deformities of the pelvis are almost three times 1 " Das enge Becken." 2 Litzmann, " Drei Vortrage iiber die Geschichte von der Lehre der Geburt bei engem Becken," in his "Geburt bei engem Becken," etc., 1884. 3 "Trans, of the Amer. Gyn. Soc," 1890, p. 367. ANOMALIES IN THE FORCES OF LABOR. 435 as frequent as in white women. 1 My experience in hospital and consulting practice convinces me that deformed pelves are by no means rare among native-born women in the densely populated centers of the Eastern States. 2 No general practi- tioner, in a large city at least, can hope to avoid such cases, and it is likely that each year will afford him one or more striking examples. It follows that an ability to recognize deform- ities of the female pelvis is a necessary accomplishment for every practitioner of medicine who may be called upon to attend women in confinement, and that a knowledge of pelvimetry is as essential to the intelligent and successful practice of obstetrics as are percussion and auscultation tp the practice of medicine. European statistics bearing on the frequency of contracted pelves give the following results : Michaelis found in 1000 parturient women 131 contracted pelves ; Litzmann, 149. Winckel found in Rostock 5 per cent., in Dresden 2.8 per cent., and in Munich 9.5 per cent, of contracted pelves among pregnant and parturient women. Winckel believes that 10 to 15 per cent, of child- bearing women have contracted pelves, but that in only 5 per cent, is the obstruction serious enough to be noticed. Kalten- bach puts the frequency of contracted pelvis at 14 to 20 per cent. In Marburg it was found to be 20.3 per cent., in Gottin- gen 22 per cent., in Prague 16 per cent. Schauta estimates it at 20 per cent. In French statistics the frequency is from 5 to 16 per cent. ; in Austrian, from 2 to 8 per cent. ; in Russian, from 1 to 5 per cent. Classification of Anomalies in the Female Pelvis. — All classifica- tions are merely a convenience for the teacher and student. It is rarely possible to draw sharply defined lines between varying manifestations of a condition. The majority of German authors follow Litzmann' s classification of abnormalities of the female pelvis, by which they are broadly divided into those of size and those of shape. Modern French authors adopt the still less satisfactory division of oversize, undersize, and anomalies of inclination. Schauta's classification is, in my opinion, the most convenient, and I have utilized it, with a slight modification. 3 1 j. W. Williams, " Obstetrics," vol. i, Nos. 5 and 6. 2 In the Maternity, the Philadelphia, the University Hospitals, and in the South- eastern Dispensary Service, there have been over 10,000 births during my connection with these institutions. The proportion of deformed pelves is about the same as that found by Reynolds, Crossen, and Williams in their hospital statistics, so that I have had the opportunity of observing more than 630 deformed pelves, including many of the rarest types. In my own private patients, however, I have hardly ever seen a deformed pelvis, and I imagine they are extremely rare in the healthy agricul- tural districts of America. a Midler's " llandbuch." 436 THE PA THOL OGY OF LAB OR. ANOMALIES OF THE PELVIS THE RESULT OF FAULTY DEVELOPMENT. Simple flat pelvis. Generally equally contracted pelvis (justo-minor). Generally contracted flat pelvis (non-raZnlticy Narrow funnel-shaped, fetal, or undeveloped pelvis. Imperfect development of one sacral ala (Naegele_rjelyis). Imperfect development of both sacral alse (Robert pelvis). Generally equally enlarged pelvis (justo-major). Split pelvis. Assimilation pelvis. ANOMALIES DUE TO DISEASE OF THE PELVIC BONES. Rachitis. Osteomalacia. New growths. Fractures. Atrophy, caries, and necrosis. ANOMALIES IN THE CONJUNCTIONS OF THE PELVIC BONES. Abnormally firm union (synostosis), which is found in elderly primiparae, particularly at the sacrococcygeal joint and in the joints between the coccygeal bones : Synostosis of the symphysis. " " one or both sacro-iliac synchondroses. " " the sacrum with the coccyx. Abnormally loose union or separation of the joints : Relaxation and rupture. Luxation of the coccyx. ANOMALIES DUE TO DISEASE OF THE SUPERIMPOSED SKELETON. Spondylolisthesis. Kyphosis. Scoliosis. Kyphoscoliosis. Lordosis. ANOMALIES DUE TO DISEASE OF THE SUBJACENT SKELETON. Coxalgia. Luxation of one femur. Luxation of both femora. Unilateral or bilateral club-foot. Absence or bowing- of one or of both lower extremities. ANOMALIES IN THE FORCES OF LABOR. 437 Diagnosis of Pelvic Anomalies; Pelvimetry. — Deformities of the female pelvis may be detected by the history of the patient, by her appearance, by palpation of the exterior and interior of the pelvis, and by external and internal measurements of the pelvic diameters that are accessible, or of salient points on the woman's body corresponding as nearly as possible with the internal measurements desired, the relations between the last two having been ascertained by many observations on dead and living bodies. It has recently been proposed to utilize the Roentgen rays in the diagnosis of pelvic deformities, but this method, while it shows anomalies of form, as in a Naegele pelvis, 1 is inferior to digital and instrumental pelvimetry in deter- mining the extent of anomalies in size. 2 For taking pelvic measurements the examiner's fingers, a tape-measure, and a modified mathematician's calipers — a pelvimeter — are usually employed. Baudelocque (1775) was the first to devise the pel- vimeter in ordinary use. He laid the foundations of pelvimetry, and his instrument and methods are in use at the present time (Figs. 303-306). It is convenient to describe the measurements of the diameters of the pelvic inlet, pelvic cavity, and pelvic outlet separately. Measurement of the Anteroposterior Diameter of the Superior Strait. — This measurement, the most important in the pelvis, can not be taken directly. It must be estimated by several plans. Baudelocque was the first to point out the relation be- tween the measurement from the depression under the last spinous process of the lumbar vertebrae to the upper edge of the symphysis pubis, and the true conjugate diameter of the pelvic inlet. To this external measurement the name "external conju- gate" was given, but it is often called "the diameter of Bau- delocque" (Fig. 306). Its discoverer believed the relation between the external and internal diameters to be constant.. — that the one exceeded the other by 8 to 8.75 centimeters, — but in this he was mistaken. The line of the external diameter does not usually coincide with the line of the internal, and the thickness of bones and superimposed structures differs, of course, in each individual. In thirty cases in which Litzmann had an opportunity to compare the measurement of the external conju- gate taken during life with the actual measurement of the true conjugate taken after death, there was an average difference of 9.5 centimeters, but the maximum difference was 12.5 centi- meters and the minimum 7 centimeters, — a variation of 5.5 1 Budin, " L'Obstetrique," 1897, p. 500. 2 See Lewy and Thumin, "Deutsche med. Wochenshr.," 1897, No. 32; also Mullerheim, ibid., No. 39. 43§ THE PATHOLOGY OF LABOR. Fig. 302. — Osiander's pelvimeter. Fig. 303. — Modern combination of Baudelocque's and Osiander's pel- vimeter. Fig. 304. — Martin's pelvimeter. Fig. 305. — Harris-Dickinson portable pelvimeter. ANOMALIES IN THE FORCES OF LABOR. 439 centimeters in a small number of cases. Michaelis found a difference of 0.6 to 3.2 centimeters and Schroeder 1.25 to 3 centimeters between the external conjugate of the living body and that of the dried specimen. The measurement of the exter- nal conjugate, therefore, is not to be relied upon in making an estimate of the size of the true conjugate. It simply serves to indicate the probability or the improbability of pelvic contrac- Fig. 306, — Measuring the external conjugate diameter upon the living female (Dickinson). tion. An external conjugate of 16 centimeters or under means certainly an anteroposteriorly contracted pelvis; between 16 and 19 centimeters the pelvic inlet is contracted in more than half the cases; between 19 and 21.5 centimeters there are but ten per cent, of contracted pelves; and above 21.5 centi- meters it is almost certain that the conjugate diameter of the pelvic inlet is not contracted at all. The external conjugate 440 THE PATHOLOGY OF LABOR. can not be measured accurately without some practice. The beginner in pelvimetry will do well to remember the following rules : Have the patient dressed for bed. Place her upon her side, with the thighs slightly flexed and the clothing rolled well up out of the way, the lower part of the body being covered with Fig- 307. — Kite- or lozenge-shaped figure on the back, indicating position of the depression under the last lumbar vertebra and the posterior superior spines of the ilia. a sheet. The examiner stands at the patient's back, facing her head. The depression below the last spinous process of the lumbar vertebras is found by rubbing a finger-tip over the lumbar spines from above downward until the finger sinks into the de- pression sought and feels no more prominent spinous processes ANOMALIES IN THE FORCES OF LABOR. 44I below. 1 Occasionally this point is perceptible, a lozenge-shaped figure being made by the depression under the last lumbar vertebra, the posterior superior spines of the ilium, and the tip of the sacrum (Fig. 307). The knob at the end of one branch of the pelvimeter is placed firmly in the depression under the spinous process of the last lumbar vertebra, and is held there with one hand, while the fingers of the other hand find a point on the symphysis pubis about y% of an inch below its upper edge, on which point the other branch of the pelvimeter is firmly set; the pelvimeter is so placed that the indicator is turned toward the examiner; the measurement is therefore easily read off as Fig. 30S. — Stein"s instrument for direct measurement of the conjugate. soon as the pelvimeter is in proper position. It is on the average, in well-built women, 20J centimeters. The best measurements for determining the length of the anteroposterior diameter of the pelvic inlet are those taken from the lower edge of the symphysis pubis to the promontory of the sacrum, — the diagonal con jug-ate diameter. — and the distance between the upper outer surface of the symphysis pubis and the promontory of the sacrum. The diagonal conjugate diameter is one side of a triangle, the other two sides of which are the height of the symphysis and the true conjugate. The distance between the outer upper surface of the symphysis and the pro- montory of the sacrum differs from the true conjugate by the thickness of the upper portion of the symphysis. Smellie was accustomed to estimate roughly the length of the true conjugate by a digital examination, basing his estimate on the ease with which the promontory could be reached. In the latter part of the eighteenth century Johnson 2 proposed, for estimating the 1 Michaelis preferred the measurement from the tip of the last lumbar spinous process, instead of from the depression below it. 2 Robert Wallace Johnson, "A New System of Midwifery," etc., London, 1769. 442 THE PATHOLOGY OF LABOR. size of the pelvic inlet, a method which consisted of inserting the fingers of one hand in the mouth of the womb and then spreading them between the promontory and the sacrum. A few years later the elder Stein devised a graduated rod for measuring the distance between the lower edge of the symphysis pubis and the division between the second and third sacral vertebrae. This dis- tance he believed to be one-half to one inch greater than the true conjugate. Stein later constructed the instrument for the direct measurement of the conjugate shown in figure 308. Many in- struments have since been constructed on this principle, but they are impracticable in the living female, for obvious reasons. Baude- locque was the first to propose the measurement of the diagonal conjugate and the subtraction from it of an average figure (half an inch) to determine the length of the true conjugate. His method, exactly as he described it, is still in use, with the excep- tion that two fingers instead of one are employed in measuring the distance between the symphysis and the promontory. To measure the diagonal conjugate correctly, the examiner must have the skill that comes of practice, and he must conduct his Fig. 309. — Measuring the diagonal conjugate diameter (Dickinson). examination in a careful and methodical manner. The patient is put in the lithotomy position and is brought to the cdgtt of the table or bed on which she lies, so that the buttocks project well over it. The examiner cleanses his left hand and anoints the first two fingers with an unguent ; he then inserts these fingers, held stiffly extended, inward and upward, until the tip of the second finger finds and rests upon the promontory of the sacrum. Care must be exercised not to take the last lumbar for the first sacral ANOMALIES IN THE FORCES OF LABOR. 443 vertebra or vice versa, nor the second for the first sacral vertebra, — mistakes easily made in cases of so-called "double promontory." With the tip of the second finger resting firmly in place upon the middle line of the promontory, the radial side of the hand is elevated until the impress of the arcuate ligament under the lower edge of the symphysis is plainly felt upon it. With a finger- nail of the other hand a mark is made upon this point of the ex- amining hand, which is then withdrawn (Fig. 309). The distance between this mark and the tip of the middle finger held extended is taken by a pelvimeter. This distance is the diagonal conjugate. By the observation of many subjects, alive and dead, an agreement has been reached that 1.75 centimeters should be subtracted from the diagonal conjugate to obtain the true conjugate diameter. But the acceptance of this average difference depends upon a normal height of the symphysis, 4 centimeters ; a normal angle between the axis of the pubis and the true conjugate, 105 ; a normal thickness of the symphysis, and a normal height of the promontory (Figs. 310 to 314). These factors, however, are not constant, and if they vary much from the normal, the most skilful and most ex- perienced obstetrician may be woefully misled in his estimation of the true con- jugate. I have had under my care a rachitic dwarf in whom there was more than 3 centimeters' difference between the diagonal and true conju- gates, and Pershing found, among ninety pelves in the museums of Philadelphia, a difference varying from 0.8 centimeters to 3.6 centimeters. It is declared that these sources of error may be eliminated by the following corrections : For even- degree of increase in the conjugatosymphyseal angle add half the number of millimeters to the sum to be subtracted from the diagonal conjugate, and vice versa ; also, for every 0.5 centimeter increase in the height of the symphysis over the normal add 0.3 centi- meter to the sum to be subtracted from the diagonal conjugate, and vice versa. While these rules are admirable for the study of the dried specimen in a museum, they are not easily applied .110 Fig. 310. — Effect of different inclinations of the pubis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). 444 THE PATHOLOGY OF LABOR. to the living pregnant female. The height of the symphysis can be measured in the living subject, but an allowance for Fig. 311. — Effect of different thicknesses of the symphysis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). variations in this respect eliminates error in only a small propor- tion of cases. The variations in the angle of the symphysis, a much more important source of error, can only be surmised. In cases upon the border- line between the re- lative and absolute indications for Cesa- rean section in which SkV\ \r'3'/aJw *^ e difference of a \ ^ -^V"»Mr centimeter would de- cide one for or against the operation I prefer the measurement between the upper outer edge of the symphysis pubis and the promontory of the sacrum for the Fig. 312. — Effect of different heights of the promontory upon the relationship between the true and the diagonal conjugate diameter (Ribemont- Dessaignes). ANOMALIES IN THE FORCES OF LABOR. 445 Fig. 3I3- — Effect of different heights of the symphysis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). Fig. 314. — Effect of the lessened slant outward of the symphysis in a rachitic pelvis upon the relationship between the true and the conjugate diameter (Ribemont- Dessaignes). 446 THE PATHOLOGY OF LABOR. estimation of the true conjugate, having demonstrated its supe- rior accuracy in practice. For taking this measurement the patient is put in the dorsal posture, with the buttocks projecting beyond the edge of the table or bed on which she lies. A mark with the point of a lead-pencil is made on the skin over the symphysis pubis, about y& of an inch below the upper edge. The two fingers of the left hand are inserted in the vagina, as in measuring the diagonal conjugate. The tip of the middle finger, having found the middle line of the promontory, is moved a little to the patient's right, and tip b of the pelvimeter, shown in figure 315, is made to take its place. While the examining physician holds the shaft of the pelvimeter firmly in Fig. 3 1 5- — Author's pelvimeter: tr., i$}4 cm.; obi., 12^ cm. 1 (model in author's collection, University of PennsylvaniaJ. the difference between the two. Betschler was the first to point out the distinctive features of this form of pelvis. In Europe it is the commonest variety of deformed pelvis. Schroder states that it is seen more frequently than all the other forms put together. In America it is also common, but the equally generally contracted pelvis is encountered here as often or per- haps oftener. Out of a series of 316 pelves in women of Ameri- can birth, I have found eighteen (a percentage of 5.6) with the measurements characteristic to some degree of a simple flat pelvis. Characteristics. — In the simple flat pelvis the sacrum is small and is pressed downward and forward between the iliac bones, but is not rotated forward on its transverse axis. The antero-pos- terior diameter is contracted, therefore, throughout the whole of the pelvic canal. The contraction, however, is not often great. It 1 The abbreviations c. v., tr.. and obi. will be used throughout to designate the true conjugate, the transverse, and oblique diameters of the pelvic inlet. 456 THE PA THOL OGY OF LABOR. is scarcely ever below 8 and is usually not under 9.5 centi- meters. x The transverse diameter is as great as, or possibly greater than, that of the normal pelvis. Occasionally, however, in pelves approaching the type of the generally contracted flat pelvis the transverse diameter may be found somewhat diminished. There is in these pelves quite frequently a double promontory formed by the abnormal projection of the cartilaginous junction between the first and second sacral vertebrae. The line drawn between the lower promontory, or the second sacral vertebra, and the symphysis is often as small as, or smaller than, the true con- jugate. 2 Etiology. — The simple fiat pelvis has been ascribed to heredity, to an arrested rachitis, to overwork before puberty (especially the carrying of heavy weights), to premature attempts to walk or to sit up, and to the weight of a heavy trunk upon a pelvis ill fitted to bear it on account of weakness of its ligaments. It is probable that in the majority of these pelves the form is inherited and congenital. It has been found by Fehling in a number of/etuses and new-born infants. Diagnosis. — The simple flat pelvis is easily overlooked. There is nothing in the patient's appearance or history to sug- gest the deformity, unless she has had difficulty in previous labors. The characteristic signs are the diminished anteropos- terior diameter, determined by internal and external measure- ments, and a transverse diameter as great as, or greater than, normal, or perhaps a trifle under the normal measurement. This last point is determined by measurements externally and by the internal palpation of the pelvic canal. In measuring the conju- gate diameter of the flat pelvis one must take into account the lessened inclination of the symphysis outward, its height, some- what below the normal, and the low position of the promon- tory. Usually the average sum of 1 3^ centimeters is a sufficient amount to subtract from the diagonal conjugate. If there is a double promontory, as is frequently the ca^e in this form of pelvis, the conjugate must be measured from the promontory nearest to the symphysis, usually the lower (Fig. 324). Influence upon Labor. — From the failure of the presenting part to enter the pelvis during the last weeks of gestation there 1 Engelken has described a specimen with a true conjugate of 4.8 centimeters, a diagonal conjugate of 7.5 centimeters, with transverse and oblique diameters of the inlet 13.3 and 12.4 centimeters respectively. This specimen is unique. 2 Crede found, in nine pelves with a double promontory, the conjugate from the true promontory longer in four and shorter in three cases than the conjugate meas- ured from the false promontory. In two cases the two conjugates were of equal length ("Klin. Vortrage iiber Geburtshulfe," Berlin, 1S53). ANOMALIES IN THE FORCES OF LABOR. 457 is frequently some degree of pendulous abdomen, especially in women with abdominal walls relaxed from previous pregnancies. The uterus is sometimes broader than common, and is often tilted to one side. The presenting part, if the head, may be loose above the superior strait, resting on one iliac bone or on the symphysis, or it may be pressed down firmly upon the brim in a transverse position, to accommodate its longest diameter to the longest diameter of the pelvic inlet. Mal- presentations are com- mon, as is also pro- lapse of the cord and of the extremities. The membranes may protrude in a cylin- drical pouch from the external os as the liquor amnii is forced out of the uterus with- out obstruction from the imperfectly en- gaged head. From the same cause an early rupture of the membranes is likely. According to Litz- mann, natural forces end the labor in sev- enty-nine per cent, of cases, but in fifty per cent, the head is not fully engaged until the os is completely dilated. The later statistics of v. Boennighausen and Kissinger show a spontaneous termination by labor in a much smaller proportion of cases. According to the former, 36 per cent, in pelves with a conjugate above 8 cm., and none with a conjugate below 8 cm.; according to the latter, 85 and 1 7 per cent, respectively. The dila- tation of the os proceeds slowly, for the head does not descend low enough to press upon the cervix. Consequently the dilatation must be affected by a retraction of the cervix over the head or by the distended membranes. Should the latter rupture, the os, although considerably dilated, may retract until the head at length descends and again dilates it. After the obstruction at the superior strait is passed, — where, of course, it is greatest, — the head usually de- scends the remainder of the birth-canal with ease and rapiditv, but labor may be prolonged by an exhaustion of the natural forces in the attempt to secure engagement. The apparent anomalies in Fig. 324. — The two conjugates of a double prom- ontory : Prom., true promontory ; /'. P. , false prom- ontory ( Ribemont-Dessaignes). 458 THE PA THOL OGY OF LABOR. the mechanism of labor characteristic of this deformed pelvis are in reality the best possible provision for the spontaneous obviation of the obstruction. The transverse position of the head at the inlet, the increased lateral inclination, and the imperfect flexion are designed to accommodate the size and the shape of the head to the unnatural size and shape of the pelvic inlet. An explana- tion of these peculiarities in the engagement of the head may be found in the altered relation of expulsive and resistant forces. The head, forced down upon the flattened brim and free to move upon the neck, rotates until its longest diameter is adjusted to the greatest diameter of the inlet — the transverse. It seeks the direction of least resistance, as any inert body will when propelled through a contracted canal. But the transverse position of the head alone is not sufficient to overcome the obstruction. The biparietal diameter of the head is too large to enter the conjugate of the pelvis. The occiput, the bulkiest portion of the skull, seeks the greater space to one side of the promontory, and is pushed against the lateral brim of the pelvis — the iliopectineal line. Here it is arrested. Further propulsion of the head is secured by a movement of partial extension, which brings the small bitemporal instead of the larger biparietal diameter of the head in relation with the contracted conjugate. Still, the obstruc- tion may not be overcome. Both sides of the head may be unable to enter the pelvis at once. One side is propelled into the pelvic canal, the other is held back. That side which encounters the most resistance will naturally be the last to enter. Thus it is that usually the anterior parietal bone, slipping more easily past the symphysis, enters first. To this result also the inclination of the pelvic axis to the axis of the trunk contributes. Owing to the anterior position of the whole sacrum and to the diminished anteroposterior diameter of the pelvic outlet ; on account, also, of the transverse position of the head and of its imperfect flexion, rotation of the head on the floor of the pelvis occurs late, and occasionally fails altogether, the head being expelled from the vulva in its original transverse or in an oblique position. The localized pressure to which the maternal structures are subjected results sometimes in necrosis of cervical tissue over the promontory and of the anterior vaginal wall behind the sym- physis. On the child's head the caput succedaneum is not exaggerated, because the head, when once firmly engaged in the pelvis, descends the birth-canal rapidly, but there is apt to be a depression on that portion of the skull applied to the promontory — namely, on the posterior parietal bone between the greater fontanel and the parietal eminence, usually quite close to the ANOMALIES IN THE FORCES OF LABOR. 459 sagittal suture (Fig. 325). Sometimes a succession of these depressions or a gutter-shaped groove may be noted in a line running- outward and forward on the child's skull. More fre- quently the course of the head and face over the promontory is marked by a red streak running from the depression before noted in a line parallel with the coronal suture toward the temple if the head is well flexed after engagement, or to the outer corner of the posterior eye, or, in case of extreme flexion, to the cheek (Fig. 326). Usually the posterior parietal bone is depressed below the anterior, which overlaps it at the sagittal suture. The pos- terior side of the skull is also flattened from the greater and more prolonged pressure to which it is subjected. Ordinarily Fig. .325. — Depression in the parietal bone caused by the pressure of the promontory (Winckel). the lateral inclination of the child's head is in a direction from before backward, so that the anterior parietal bone presents at the center of the superior strait. Occasionally this inclination is so exaggerated that the ear is the presenting part. Exceptionally the lateral inclination takes the opposite direction, the anterior parietal bone catches on the rim of the pubic bones, and the posterior parietal bone is the first portion of the child's head to enter the pelvis. The presentation of the posterior parietal bone occurs even in normal pelves as a rare exception, but is seen in about ten per cent, of contracted pelves (Schauta), and is the result in them very likely of firm abdominal walls and an increased inclination of the pelvic inlet to the axis of the trunk. 460 THE PATHOLOGY OF LABOR. In these cases the anterior parietal bone is pushed under the posterior at the sagittal suture. When the posterior side of the head by descent finds room in the hollow of the sacrum and moves backward, the anterior portion of the skull glides over the symphysis and the sagittal suture moves from its original position, just behind the symphysis, toward the median line of the pelvic canal. In addition to these anomalies of mechanism Breisky describes what he calls an " extramedian " engagement of the head in cases of flat pelvis in which there is considerable -Mm /■pill if Fig. 326. — Marks made by the promontory on the child's head and face (Fritsch and Kiistner). lordosis of the lumbar vertebrae. The head in extreme flexion is forced down upon half of the pelvic inlet, and enters the pelvic canal on this side alone. Directly the obstructing promontory and lumbar vertebra are passed the head descends the pelvic canal with rapidity and ease. This mechanism was noted nine- teen times in Breisky's clinic among 2002 labors. 1 1 "Die Becken Anomalien," by Friedrich Schauta, in Miiller's " Handbuch dei Geburtshiilfe," Bd. ii ; Hetschler, " Annal n der klinischen Anstalten," i, pp. 24, 60; ii, p. 31; Engelken, " Dis.-Inaug.," Miinchen, 1878; " Zur Kentniss der extra- median Einstellung des Kopfes," Kohn, " Prager Zeitschrift f. Heilkunde," Bd. ix. ANOMALIES IN THE FORCES OF LABOR. 46 1 Justominor Pelvis. — In this type of contracted pelvis the form of the female pelvis is preserved, but the size is diminished. Three divisions of this pelvis are commonly made : The juvenile, in which the bones are small and slender ; the masculine, in which the bones are large, heavy, and thick ; and the dwarf, or pelvis nana, in which the pelvis is very diminutive in size and the pelvic bones are not joined by bony union, but are separated by cartilage as in the infant. The innominate bones are divided into their three parts, and the sacral vertebrae are distinct from one another. The justominor pelves pass by insensible grada- tions into the simple flat, the transversely contracted, and the generally contracted flat pelves. In the larger cities of the United States the justominor pelvis is very frequently encountered. It is certainly as common here as is the simple flat pelvis, and if one were to judge from hospital patients, among whom there is a large proportion of shop- and factory girls, this variety of contracted pelvis would be regarded as the commonest. Characteristics. — While it is convenient to speak of the justo- minor pelvis as the normal female pelvis in miniature, the de- scription is not strictly accurate. There are peculiarities due to an arrest of development which give to the equally generally contracted pelvis some of the features of an infantile pelvis. The alas of the sacrum are narrower than they should be in comparison with the bodies of the vertebrae. The sacrum is short and is not pushed as far forward between the iliac bones as it usually is ; it shows also a diminished forward inclination, and on its anterior surface a greater lateral and a less marked perpendicular concavity than common. The distance between the posterior superior spinous processes of the iliac bones is relatively great, on account of the posterior position of the sacrum and its slight rotation forward. The conjugatosym- physeal angle is greater than normal, by reason of the lessened inclination outward of the symphysis and the pubic bones. The promontory is high and not prominent, and the inclination of the pelvic entrance to the abdominal axis as the individual stands erect makes a more obtuse angle than it does in the normal pelvis. The bones in this form of contracted pelvis are com- monly small and slender, except in the rare masculine pelvis, in which they are firm and thick beyond the normal. Women with a justominor pelvis are ordinarily of slight build and below the medium height ; but this pelvis may be found in individuals of ordinary stature, and sometimes actually in tall women with a large frame. The true dwarf pelvis is very rare. It is found only in women of dwarf stature. The bones arc slender and fragile. 462 THE PA THOL OGY OF LAB OR. and the cartilaginous junction between the original divisions of the pelvic bones is preserved. There is extreme contraction of the pelvic canal. In the commoner kinds of justominor pelvis the contraction is not often very great. The conjugate diameter is seldom below nine and scarcely ever as low as eight centimeters. The pelvic outlet in some cases is laterally contracted ; in others it is com- paratively roomy. Etiology. — The justominor pelvis is the result of arrested development ; it may be found in women descended from a stock that has deteriorated phys- ically, or in women sub- jected during childhood, infancy, or intra-uterine existence to unfavorable hygienic surroundings or conditions. Diagnosis. — The jus- tominor pelvis is easily confused with a rachitic pelvis, but the distinction is readily made by careful pelvimetry. All the meas- urements, while equally reduced, bear their normal proportion to one another, except in the case of the external conjugate diam- eter, which is apt to be longer than would be ex- pected, on account of the posterior position of the sacrum and its lessened inclination forward. In estimating the true conjugate diameter from the diagonal conju- gate one must often take account of the increase in the conju- gatosymphyseal angle, and must remember that the sum to be subtracted from the diagonal conjugate is not infrequently greater than common. The symphysis is less in height than in the normal pelvis, but the error of computation from this source may be disregarded. Lohlein lays special stress upon the importance of measuring the pelvic circumference in making the diagnosis of this form of contracted pelvis. It is always far below the normal, ninety centimeters. An internal examination of the pelvic cavity and inlet should be made carefully, to determine approxi- Fig- 3 2 7- — Dwarf pelvis (model in author's collection). ANOMALIES IN THE FORCES OF LABOR. 463 mately their capacity, with a special regard to the approximate length of the transverse diameters. Influence on Labor. — The mechanism of labor shows far fewer anomalies in this than in any of the other forms of con- tracted pelvis. The head, from the greater resistance encoun- tered, is strongly flexed. It may be placed transversely, but is quite commonly oblique, and may even be anteroposterior in position if there is a tendency to lateral contraction of the pelvic canal. By the perfect flexion of the head the obstruction to the progress of labor is in great part obviated. If anything inter- feres with this movement of the head, as a faulty application of the forceps, engagement and descent may become impossible. Pelvic presentations in labor are a great disadvantage by reason of the difficulty experienced in freeing the arms and in bringing the head last through the generally contracted pelvic canal. To secure its rapid passage, the child's head must be flexed strongly by the oper- ator's finger in its mouth before an attempt is made to secure engagement in the superior strait. While the woman escapes local- ized necroses of the soft tissues following labor in the justominor pelvis, there is greater likelihood of rupturing pelvic joints in this than in any other variety of contracted pel- vis, and there is also an extraordinary liability to eclampsia (Fig. 328). The caput succedaneum, which is very large on account of the early fixation of the head and the long labor, is situated directly over the smaller fontanel. There is an overlapping of the cranial bones, both laterally and antero- posteriorly. The generally contracted, flat, nonrachitic pelvis presents the combined features of the flat and the generally contracted pelvis. Characteristics. — All the diameters are below normal, but the conjugate is less in proportion than any of the others. This pelvis has many of the features of a rachitic pelvis, but the anterior half of the pelvic circumference is not markedly broad- ened ; indeed, it is often the reverse. The sacrum is small and is not rotated on its transverse axis ; it is placed further back Fig. 328. — Justominor pelvis with rup- tured pelvic joints, following forceps applica- tion : C. v., 9^ cm. ; tr. , I2j^ cm.; obi., n^f cm. (author's collection). 464 THE PATHOLOGY OF LABOR. between the innominate bones than in the normal pelvis, and very much further back than in the rachitic pelvis. The pro- montory is high and is not prominent. The influence of this deformity of the pelvis upon labor is that of a flat pelvis, but the difficulties are greater than in the case of the simple flat pelvis, for there is less compensatory room in a transverse direction. The generally contracted, non-rachitic, fiat pelvis is comparatively rare. The flattening, according to Litzmann, is due to a short- ening of the innominate bones, especially at the iliopectineal line. In estimating the true conjugate diameter of the generally contracted flat pelvis it is safer to subtract 2 instead of 1 ^ cen- timeters irom the diagonal conjugate, on account of an increase in the conjugatosymphyseal angle, the result of the high posi- tion of the promontory and the diminished slant outward of the symphysis. Etiology. — The generally contracted flat pelvis is due to hereditary influence or to an arrest of development in the embryo, fetus, or infant. It is claimed, however, that it may be produced by premature attempts to walk and by long standing upon the feet in very early life. Diagnosis. — The recognition of a generally contracted flat pelvis is difficult. The measurements usually resemble those of a generally equally contracted pelvis, but the conjugate diameter is less than one expects in that form of contracted pelvis, and the mechanism of labor is that of a flat pelvis. The diagnosis can be made by finding the reduced conjugate diameter and by the ease with which one can reach the lateral pelvic wall in the palpation of the interior of the pelvic canal. A certainty of diag- nosis can be obtained during life only by the direct measurement not only of the conjugate diameter, but also of the transverse, by the methods of Lohlein and of Skutsch. The Narrow, Funnel=shaped Pelvis ; Fetal or Undeveloped Pelvis. — This variety of pelvis is contracted transversely at the pelvic outlet, or both in the transverse and anteroposterior diameters, without abnormalities in the spinal column. The depth of the pelvic canal is much increased by the length of the sacrum, of the symphysis, and of the lateral pelvic walls. The sacrum is narrow, has little perpendicular curve, and is placed far back between the ilia (Fig. 329). Schauta ascribes this form of contraction to an anomaly of development by which the pelvic walls are length- ened downward and the weight of the body is thrown backward upon the sacrum. It is said to be very rare, but it has been found quite frequently in those hospitals where the outlet of the pelvis is regularly measured. It comprises from five to nine per cent, of all contracted pelves, according to Breisky, and Fleisch- ANOMALIES IN THE FORCES OF LABOR. 465 Fig. 329. — Narrow, funnel-shaped pel- vis: C. v., \o)/ 2 cm.; tr. (inlet), 83^ cm.; tr. (outlet), 7 cm. ; ant. post, outlet, 7^ cm. (specimen in the author's collection). mann found twenty -four examples in 2700 parturient women. 1 A slight manifestation of the deformity is often called a " mascu- line " pelvis, by reason of the diminution in the breadth of the pubic arch. This degree of the funnel-shaped pelvis is frequently encountered (Fig. 330). Diagnosis. — The diag- nosis of a narrow, funnel- shaped pelvis is made by a comparison of the measure- ments of the pelvic inlet with those of the outlet. The former are found to be normal or even greater than normal, while the measure- ments of the outlet are di- minished. If, as is the rule in extreme degrees of this deformity, the inlet and cavity are contracted, the outlet is still smaller in proportion. A careful palpation of the pelvic canal is an important aid to a correct diagnosis. The pelvic walls are felt to converge as they approach the outlet ; the narrowness of the pubic arch is appre- ciated, and the approxima- tion of the tuberosities and spines of the ischiatic bones is noticeable. Influence upon Labor. — The peculiarities of mech- anism in labor are malpo- sitions of the head at the outlet (as backward rota- tion of the occiput), oblique and transverse position of the head, and imperfect flexion. There is also an insufficiency of the expul- sive forces, the greater part of the fetal body being con- tained in the lower uterine segment, cervix, and vagina, while the upper muscular segment of the uterus is in great part emptied and therefore powerless. Fig. 330. — Minor grade of narrow, funnel- shaped pelvis with contracted pubic arch (from a plaster cast in the author's collection). 1 " Prager Zeitschrift f Heilkunde," Bd. ix, H. 4 and 5. SO 466 THE PATHOLOGY OF LABOR. By the approximation of the pubic rami the presenting part is forced backward, and serious lacerations of the perineum are to be feared. The pressure of the head upon the lower birth- canal may result in necrosis of soft structures or in lacerations along the descending rami of the pubis and the ascending branches of the ischium. The tissues over the projecting spines of the ischiatic bones are also the seat of tears or of necroses. The narrowing of the pubic arch may lead to serious injuries if the forceps be applied. I have seen long, clean cuts in the anterior vaginal walls and profuse hemorrhage fol- lowing the use of instruments. In well-marked examples of the narrow, funnel-shaped pelvis, with a transverse diameter at the outlet not much below 7.5 cm. (3 inches), symphyseotomy gives the best chance of a successful termination for mother and child. Higher grades of contraction with a diameter of 5 cm. (2 inches) and under demand Cesarean section. In lesser grades the woman may be delivered spontaneously or by forceps. Obliquely Contracted Pelvis from Imperfect Development of the Ala on One Side of the Sacrum {Naegele Pelvis). — This pelvis was first described in 1834 by Franz Carl Naegele, 1 but had been noticed as early as 1779 without a full understand- ing of its significance (Fig. Characteristics. — The pelvic inlet has an oval shape, with the small point of the oval directed to the atrophied side of the sacrum. The sacral ala is atrophied or is absent not only in that portion of the bone entering the sacro- iliac joint, but also in the transverse process along its whole length. The sacro-iliac joint on this side is ankylosed in the vast majority of cases, but not invariably. The sacrum is narrow, asymmetrical, and turned with its anterior face toward the deformed side of the pelvis. The promontory is not only turned in this direction, but is also pulled over to the diseased side. The innominate bone on the Obliquely contracted pelvis. 1 "Die Heidelberger klinischen Annalen," Bd. x, p. 449. More elaborately described in his folio atlas. " Das Schrag verengte Becken, nebst einem Anhang iiber die wichtigsten Fehler des Weibl. Beckens Ueberhaupt," mit 16 Tafeln, Mainz, i8 3 7- ANOMALIES IN THE FORCES OF LABOR. 467 deformed side is pushed as a whole upward, backward, and inward, and its anterior face is pushed inward and backward. The tuber- osity of the ischium, as a necessary consequence of the displace- ment of the innominate bone, is higher than its fellow, projects further into the pelvic canal, and is so turned that it looks rather anteroposteriorly than laterally. The spine of the ischium is brought quite close to the corresponding edge of the sacral bone and juts prominently forward into the pelvic canal. The whole in- nominate bone on the diseased side lacks its normal curvature at the iliopectineal line, and may run almost straight from the sacro- iliac junction to the symphysis pubis. The opposite innominate bone has a greater curvature than common, especially in its anterior half; otherwise it is practically normal in structure, position, and inclination. The symphysis pubis is pushed toward the healthy side of the pelvis, and its outer surface, instead of looking directly forward, is inclined to the diseased side. The pubic arch likewise faces somewhat in this direction ; its aperture is asymmetrical and irregularly contracted, as the ischiac and pubic rami on the diseased side are pushed inward upon the pelvic canal and over toward the healthy side (Fig. 331). Etiology. — The cause of the obliquely contracted pelvis under description is an absence of the bony nuclei in the ala or lateral process on one side of the sacrum. The lateral process conse- quently fails to develop, and the innominate bone is brought in re- lation with the bodies of the sacral vertebrae. As a result, there must be some distortion of the innominate bone even in fetal and infantile life, but this is increased to an exaggerated degree when the individual begins to walk. Instead of receiving the pressure from the lower extremity approximately on the keystone of an arch, as does a normally curved innominate bone, the deformed bone in a Naegele pelvis transmits the pressure in almost a straight line upward and backward, so that the extremity of the posterior arm of the arch slides past the sacro-iliac joint instead of resting firmly on it as an arch does on its abutments. The irritation and strain of this unnatural movement bring about in time the atrophy and ankylosis of the joint. That the deformity in this kind of oblique pelvis does not follow a primary ankylosis of the sacro-iliac joint is proven by the fact that the innominate bone is pushed backward and upward on the sacrum — a movement that would be impossible were this joint first ankylosed. As a further proof of primary lack of development and secondary ankylosis, there is no trace of inflammation in or about the ankylosed joint, and the alae or transverse processes of the sacrum are atrophied or are absent along the whole length of the sacrum, and not only in that 468 THE PA THOL OGY OF LAB OR. portion of it which enters into the composition of the sacro-iliac joint. Diagnosis. — The recognition of an obliquely contracted pelvis from arrested development of the sacral alae may be very difficult. There is nothing to direct the attention of the phy- sician to the possibility of the deformity. There is no history of previous disease or of accident, no scar of an old fistula over the joint, and the patient does not limp. The diagnosis can be made only by a methodical external and internal palpation of the pelvis and by careful measurements. If the outspread hands are laid over the innominate bones, it is noticed that the dorsal surfaces are directed obliquely forward and backward as they lie upon the diseased and healthy sides. An internal palpation of the pelvis detects one lateral wall much nearer the median line than the other, and the diagonal conjugate is found to run not anteroposteriorly in direction, but from before backward and from the healthy to the diseased side of the pelvis. There are a number of points from which measurements may be taken that show inequalities where in the normal pelvis the dis- tances should be the same or should differ by a very small sum. Naegele recommended the following measurements : (1) The distance of the tuber ischii on one side from the posterior superior spinous process of the ilium on the other ; (2) from the anterior superior spinous process of one ilium to the posterior superior spinous process of the other ; (3) from the spinous process of the last lumbar vertebra to the anterior superior spines of both ilia ; (4) from the trochanter major of one side to the posterior superior spinous process of the opposite iliac bone ; (5) from the lower edge of the symphysis pubis to the posterior superior spinous processes of the iliac bones. In addition to these measurements, others of value have been suggested by Michaelis and by Ritgen. These are the distances from the middle line of the spinal column to the posterior superior spinous processes of the iliac bones, and the distance from the lower edge of the symphysis to the ischiac spines, and from these spines to the nearest point on the edges of the sacrum. In this latter measurement it is found that the distance from the symphy- sis to the ischiac spine is longest on the diseased and shortest on the healthy side, while the distance from the ischiac spine to the edge of the sacrum is very much shorter on the diseased than on the healthy side. The last, which is a very important meas- urement, can easily be taken by laying finger-breadths between the points to be measured. As in all anomalies of form in the female pelvis, an x-ray photograph shows the condition often surprisingly well. ANOMALIES IN THE FORCES OF LABOR. 469 Influence on Labor. — The mechanism of labor in an obliquely- contracted pelvis is, in the main, that of labor in a generally- contracted pelvis. The shape of the pelvic entrance and canal is symmetrically ovoid, and the head can enter the contracted space only by extreme flexion. There are none of those anoma- lies of position, flexion, and inclination of the head which are seen in the flat pelvis. As the head descends the birth-canal, anomalies of mechanism may appear resembling those described in the narrow, funnel-shaped pelvis — namely, abnormal and Fig. 33 2 - — Pelvis of Naegele. Reproduction of an x-ray photograph taken from a living woman (Budin). imperfect rotation and anomalies of flexion. Depending upon the degree of deformity, there is more or less interference with the progress of labor to complete obstruction. The head is almost invariably found entering the pelvis and passing through the canal with its longest diameter in coincidence with the longest oblique diameter of the pelvis, from the diseased sacro- iliac joint to the opposite iliopectineal eminence. Prognosis. — In the recorded cases the results of labor in the Naegele pelvis have been bad. Of 28 women reported by Litz- mann, 22 died in their first labor, 5 of them undelivered. Three 470 THE PA THOL OGY OF LAB OR. of these women died in consequence of- their second labor, and 2 after the sixth. Out of 41 cases, 6 were delivered spontane- ously, 12 by the forceps, 14 by craniotomy, 5 by version and extraction, 4 by premature labor, and 2 by Cesarean section. The following accidents were noted in the course of labor or shortly afterward : Rupture of the uterus or vagina, vesico- vaginal fistula, fracture of the horizontal ramus of the pubis, rupture of the sacro-iliac joint and of the symphysis. In another series of cases, 28 women furnished forty-two labors with the following results: 21 died as the result of the first labor, 3 of the second, and 1 after the sixth. These women were delivered seven times by craniotomy, once by Cesarean section, four times by premature labor, and in a number of instances by forceps. Out of 41 children in Litzmann's statistics, there were only 10 delivered alive, 2 of these by Cesarean section and 2 by premature labor. The 6 other living children were all born of the same mother. 1 Treatment. — Forceps and version are not, as a rule, success- ful in the treatment of labor obstructed by an obliquely con- tracted pelvis unless the degree of deformity is slight. The induction of premature labor and the performance of Cesarean section are the most successful means of delivery, but the former should be resorted to only when the distance between the lower edge of the symphysis pubis and the sacro-iliac joint of the healthy side is not under 8.5 centimeters. In twenty forceps operations thirteen women died. The proposition of Pinard to do what he calls ischiopubiotomy has not met with favor. The room gained by the movement outward of the innominate bone on the healthy side, the other being, of course, immovable, will be sufficient only in pelves so slightly contracted as to allow a delivery by much simpler means. Transversely Contracted Pelvis the Result of Imperfect DeveU opment of Both Sacral Alse. — This pelvis was first described in 1842 by Robert, and is generally known as the " Robert pelvis" (Fig. 333). It is the rarest of all contracted pelves. Schauta was able to find but six examples recorded in child- bearing women. Ferruta has reported another case. 2 Herman gives eight as the number of recorded cases; Sonntag, 3 nine. The anatomical conditions are the same as in the Naegele pelvis, except that both sides of the sacrum are affected instead of one. Other parts of the sacrum besides the alae may show imperfect development. There is a case reported in which the whole lower portion of the bone was absent. The sacrum in the Robert's 1 The writer is indebted for these statistics to Schauta [toe. cit.\. 2 " Studii di Ostetricia e Ginecol.," Milan, 1890. 3 v. Winckel's " Handbuch," 2 3 , p. 1959. ANOMALIES IN THE FORCES OF LABOR. 471 pelvis is extremely narrow, and the posterior superior spinous processes of the iliac bones are brought close together. The degree of contraction in the transverse diameter is so extreme that natural labor is out of the question. An asymmetry of the Robert pelvis has been observed, one side showing a greater degree of the deformity than the other, and thus approaching the type of an obliquely contracted pelvis. The cause of this deformity is an absence of the bony nuclei in the sacral alae of both sides. Secondarily, as in the Naegele Fig. 33J. — Transversely contracted pelvis: C. v., 9^ cm.; tr. (outlet), 5 cm.; tr. (inlet), 8 cm. (model in Mutter Museum, College of Physicians, Philadelphia). pelvis, there is usually an ankylosis of the sacro-iliac joints. That this ankylosis is secondary and not primary is demonstrated by the same condition which proves that ankylosis is not a primary cause of the oblique contraction and ill-development of one side in the Naegele pelvis — namely, a displacement of the ilia on the sacrum necessarily occurring before the ankylosis. The treatment of labor obstructed by a transversely contracted pelvis of this kind is Cesarean section. Justomajor Pelvis. — A generally equally enlarged pelvis is found in women of gigantic stature, but it may also occur in a woman of medium height. The pelvis of the Nova Scotian giantess was large enough to give passage to a child weighing 28^ pounds. The largest pelvis that has ever come under my notice was found in a woman somewhat below the average height, without an abnormally great development of any other portion of her frame. Diagnosis. — The diagnosis of a justomajor pelvis is made mainly by external measurements. If all of them are found far in excess of the normal while preserving their normal relative proportion the diagnosis of a justomajor pelvis is justifiable. 47 2 THE PA THOL OGY OF LAB OR. The internal examination, if considered necessary, shows that the promontory is quite inaccessible, and that it is much more difficult than common to reach the lateral pelvic walls. This anomaly of the pelvis does not, of course, obstruct labor ; on the contrary, it predisposes to precipitate delivery, although the resistance of the soft parts may be quite sufficient to delay the process considerably, even though the pelvis present no obstacle whatever. During pregnancy it is noted that the uterus has a tendency to sink deep within the pelvic canal, so that pressure- symptoms of the pelvic viscera and blood-vessels are common in the latter weeks of gestation, and these symptoms may become so exaggerated as to make locomotion difficult. In labor there may be anomalies in the mechanism dependent upon insufficient resistance to the engagement of the head. Thus imperfect flexion at the superior strait may be observed, and there may be a tardy rotation of the head on the pelvic floor. Split Pelvis. — The split pelvis, which is due to a defect in the development of the lower portion of the trunk in front, is almost invariably associated with exstrophy of the bladder. This pelvis has very rarely been observed in the child-bearing woman ; there are on record but seven examples complicating labor. The split pelvis presents no obstacle in parturition. There are the same peculiarities in labor as in the justomajor pelvis — namely, a tendency to precipitate birth, and anomalies in the mechanism the result of imperfect resistance. After labor it is almost certain that there will be a prolapse of the uterus. The diagnosis of this deformity presents no difficulties, and no ob- stetic treatment is called for in labor (Fig. 333). The assimilation pelvis is of greater interest to the anatomist than to the practical obstetrician. It is characterized by an assimilation of the last lumbar vertebra to the type of the first sacral vertebra or vice versa. The anomaly of development may affect one or both sides of the vertebras. There may be an as- sociated double promontory, some asymmetry of the pelvis, slight anomalies in the transverse, anteroposterior, and vertical diame- ters of the pelvis, but not enough disturbance of pelvic size and shape to influence labor seriously. It is practically impossible to diagnosticate an assimilation pelvis during life. The Rachitic Pelvis. — In the healthy life and growth of bones two opposed processes are found : On the periphery there is an active proliferation of cells to form the bone-structure, while in the interior, bone-substance is being constantly absorbed by the marrow. In rachitis the absorption of bone-substance goes on more rapidly than it does in healthy bone, and at the same time there is in the periphery a very much more rapid proliferation of cells, which do not, however, develop normal bone-structure. ANOMALIES IN THE FORCES OF LABOR. 473 Their growth and multiplication result in the formation of an osteoid material deficient in lime-salts and much more pliable than healthy bone. The result of this pathological process in the pelvic bones is to make the pelvis yield more than it should to the mechanical forces that are brought to bear upon it. In the rachitic pelvis the size and shape of the pelvic canal Fig. 334. — Split pelvis (Schauta). are modified by three factors : the pressure from the trunk above and the counterpressure from the extremities below ; the pull on the pelvic bones by ligaments and muscles ; and an arrested development. Characteristics. — The effect of rachitis in the pelvic bones Fig. 335. — Flat rachitic pelvis: C. v., $}£ cm.; effective trans, diam., 11 cm. (Mut- ter Museum, College of Physicians, Philadelphia). upon the shape and size of the pelvic canal is not uniform. Several varieties of contracted pelvis may result. The com- monest is the flat pelvis with some contraction of all the diam- eters, but a most marked diminution in the anteroposterior diameter (Fig. 335). There may be found, in addition to this 474 THE PA THOLOG Y OF LABOR. common form, a simple flat rachitic pelvis without alteration of the transverse diameters, a generally equally contracted rachitic pelvis (Fig. 336), and a so-called "pseudo-osteomalacic" pelvis, in which the effect seen in osteomalacia is produced by pressure upon the bones softened by rachitis. There are other rare forms of asymmetrical development, in connection usually with spinal disease of rachitic origin, that are described elsewhere. Fig. 336- - Generally equally contracted rachitic pelvis (author's collection). Characteristics of the Flat, Generally Contracted Rachitic Pelvis. — The sacrum is pressed forward and downward between the iliac bones, and is rotated on its transverse axis, mainly by the pressure of the trunk upon it, but partly by the pull down- Fig. 337. — Flat rachitic pelvis, with unusual descent of the promontory, rotation of the sacrum, and lordosis (Mutter Museum, College of Physicians, Philadelphia). ward of the psoas muscles upon the spinal column and the pull upward upon the posterior surface of the sacrum by the erectores spinae muscles (Fig. 335). The effect of this movement would naturally be to throw the tip of the sacrum and the coccyx ANOMALIES IN THE FORCES OF LABOR. 475 directly backward, so that the posterior surface of the sacral bone would run an almost horizontal course as the woman stood upon her feet. The, attachments of the sacrosciatic ligaments and muscles to the lower sacrum and coccyx, however, prevent this backward movement of the bone as a whole, and, pulling the lower portion of the bone forward, cause a sharp bend in it, usually at the junction of the fourth and fifth sacral vertebrae. The sacrum is narrowed in its transverse diameter, and the lateral concavity of the anterior surface is effaced by the forward movement of the bodies of the verte- bras between the alse. The anterior surface of the sa- crum, indeed, may be con- vex from side to side. By the pull of the strong sacro-iliac ligaments run- ning from the sacrum to the posterior superior spi- nous processes of the iliac bones the latter are pulled downward and forward by the descent of the sacral promontory, and are con- sequently made to ap- proach one another behind, but they do not keep pace with the movements of the sacrum, and consequently project more prominently than common on either side. The natural result of this movement forward and inward on the part of the posterior superior por- tions of the ilia would be to throw the anterior half of the innominate bones outward, but this movement is opposed by their junction at the symphysis, and to a less degree by the attachment of Poupart's ligament to their anterior superior spinous processes. The ilia, however, restrained by a somewhat yielding force, are thrown to a certain degree outward and back- ward, so that their upper edges run almost horizontally outward, and the distance between their anterior spines becomes little less Fig. 3$&. — Flat rachitic pelvis with bowed femora: C. v., 5 cm.; tr., 12^ cm. (Mutter Museum, College of Physicians, Philadelphia). 476 THE PATHOLOGY OF LABOR. than, the same as, or even greater than, the distance between their crests. A further result of these combined forces pulling the innominate bones inward and forward behind and hold- ing them in place in front is to produce in them an abnormal curvature, as in the case of the sacrum, or as in a bow bent between one's hand and the ground (Fig. 339). The point of angulation or greatest curvature is found on the ilio-pectineal line, back of the median transverse line of the pelvic inlet, near the sacro-iliac joints. On account of the flexion of the innominate bones the transverse diameter of the rachitic pel- vis is relatively increased, but, as the whole pelvis is com- monly below the normal in size, this diameter rarely exceeds, if, indeed, it equals, the normal transverse measurement. A further consequence of the exaggerated curvature of the innom- inate bones is to throw the acetabula forward, so that the Fig. 339. — Schematic representation of the anterior position of the acetabula in a rachitic pelvis. The pressure of the femora from before backward contributes to the flattening of the pelvis (Schroeder). counterpressure of the lower extremities is exerted more antero- posteriorly than in the normal pelvis (Fig. 339). The pubic rami and the symphysis are diminished in height and show a lessened slant outward. The cartilage at the junction of the symphysis projects inward upon the pelvic canal, standing out above the level of the bones to such a degree that it is some- times a source of injury to the head or to the maternal struct- ures. The force of resistance at the symphysis to the outward movement of the innominate bones sometimes bends the ends of the pubic bones inward upon the pelvic canal, giving to the pelvic inlet the shape of a figure 8. From the traction of the adductor and rotator muscles of the thigh upon the tuberosities of the ischiatic bones (increased in rachitis by the positions of the acetabula and the bowing of the femora), the latter are pulled outward and forward so that the pubic arch is greatly widened ANOMALIES IN THE FORCES OF LABOR. 477 and the transverse diameter of the pelvic outlet is increased. The anteroposterior diameter of the outlet is somewhat dimin- ished by the excessive perpendicular curvature of the sacrum, but the contraction is relatively much less than in the conjugate of the inlet. The whole pelvis is tilted forward on its transverse axis, so that the inclination of the superior strait is increased and the external genitalia are displaced backward. The bones of a rachitic pelvis are usually slighter and more brittle than common. They may, perhaps, show no peculiarities in structure, or in rare cases they may be found much thicker and heavier than normal. In the generally equally contracted rachitic pelvis — a rare type — is seen mainly an arrest of development, the consequence of rachitis in very early life, which retarded growth without much affecting the shape of the pelvic inlet and canal, from the Fig. 340. — Pseudo-osteomalacic pelvis. fact that the pelvis had not been subjected to the pressure of the trunk during the active stage of the disease, because it ran its course to complete recovery before the child attempted to sit up or to walk. Possibly, also, the disease in some of these cases is not severe and lasts but a short time. As the deformity is the result of arrested development, a transverse contraction is found as in the fetal ill -developed pelvis. The diagnosis of the rachitic origin of this type of pelvis is made by the relations of iliac spines to crests, perhaps by the history of rachitis in early infancy, and possibly by the signs of the disease in other portions of the body. In the pseudo-osteomalacic pelvis (Fig. 340) the rachitis has progressed to an extreme degree and has been long continued. Efforts to walk have been made while the disease was in active 478 THE PATHOLOGY OF LABOR. progress, and possibly the weight of the trunk has been exag- gerated by attempts to carry heavy burdens. As a consequence of the pressure of the trunk and the counterpressure of the lower extremities, the pelvis bends under the forces imposed upon it. The sacrum sinks far down into the pelvic canal and is sharply curved or bent from above downward ; the innominate bones are bent at a sharp angle laterally, and the acetabula are pressed inward upon the pel- vic canal. When at length the bone disease has run its course, the pelvis is firmly set, by the hardening of the bones, in its unnatural posi- tion and shape. The differ- ential diagnosis between this pelvis and the true osteo- malacic pelvis is made by the direction of the iliac crests, by the firm constitu- tion of the bones after the disease has been arrested, and by the signs of rachitis in other' portions of the body. Osteomalacia, be- sides, has certain peculiari- ties of its own that enable one to recognize it without difficulty. Diagnosis. — The diag- nosis of a rachitic pelvis is made by external and inter- nal measurements, by pal- pation of the exterior and interior of the pelvis, by the woman's history, and by her appearance. An individual who has had rachitis in childhood is usually of small stature, with short, thick, curved' extremities ; a low, broad brow ; a large, square head ; a flat nose ; a " chicken breast," and enlarged joints. The lumbar lordosis and the rotation of the sacrum produce a sway -back, most noticeable when the woman lies on her back upon a hard surface. When she stands erect the pregnant uterus near term falls abnormally for- ward and downward, on account of the short abdomen and lack of engagement of the presenting part (Fig. 341). The mostcharac- Fi£ 3.4 1- -Pendulous belly of rachitis (Charpentier). ANOMALIES IN THE FORCES OF LABOR. 479 teristic facts in her history are that she walked first at three or four years of age and was late in getting her teeth. By the pelvimeter the normal relation between the iliac spines and crests is found disturbed. The difference in distances between the former and between the latter is much reduced. The posterior superior spinous processes are approximated, and the depression under the last spinous process of the lumbar vertebra approaches or is actually in the line drawn between them. The external antero- posterior diameter of Baudelocque is below the normal. Inter- Fig. 342. — Appearance during life of the highest grade of rachitis ; pseudo- osteomalacia (Pippingskjold). Fig. 343. — Skeleton of a rachitic dwarf (Medical Museum, University of Pennsylvania). nally, the diagonal conjugate is found considerably reduced. The symphysis has less of a slant outward than it should have ; the promontory is found low and prominent ; the sacral bone is sharply bent upon itself, and the pelvic canal is remarkably shallow. On account of the increase in the conjugatosymphys- eal angle due to the lessened slant outward of the symphysis, at least two centimeters should be subtracted from the diagonal conjugate. The difference between the two would be greater were it not for the low situation of the promontory, which com- pensates to a certain extent for the lessened slant of the sym- 48o THE PATHOLOGY OF LABOR. physis, but does not entirely neutralize it. If a double promon- tory is found, which in these pelves is not uncommon (Fig. 347), the measurement should be taken from the promontory nearest the symphysis. Occasionally the lordosis of -the lumbar vertebrae, the result of spinal rachitis, is so great as to constitute itself an obstruction above the pelvic inlet. In such a case the effective Fig. 344.— Rachitic dwarf ; height, 4 feet, I inch. Conj. vera, 6 cm. Cesarean section (Howard Hospital). conjugate must be taken from a point above the sacrum to the symphysis pubis. Influence on Labor. — The influence of a flat rachitic pelvis on labor is much the same as the influence of a simple flat pelvis, except that the contraction, and consequently the obstruction to labor, is greater in the rachitic form, and that the promontory of the sacrum is more prominent and more sharply defined. The anomalies of mechanism at the inlet are the same in both varie- ties of pelvis, but they are exaggerated in the flat rachitic pelvis. As soon as the obstruction at the inlet is overcome, the descent ANOMALIES IN THE FORCES OF LABOR. 481 Fig. 345. — Woman with congenital rachitis (Ribemont-Dessaignes). Fig. 346. — Flat rachitic pelvis complicated by coxalgia. Cesarean sec- tion (seen in consultation with Dr. Geo. I. McKelway). Fig. 347. — Rachitic pelvis with double promontory : C. v., from first and from second sac. vert., b l / 2 cm. ; tr., 12^ cm. (Mutter Museum, College of Physicians, Philadelphia). 3i 482 THE PATHOLOGY OF LABOR. Fig. 348. — Pressure of the promontory upon the head in a contracted pelvis. (Smellie). Fig. 349. — Overlapping of the cranial bones in a futile attempt of the head to engage in the superior strait of a rachitic pelvis (Smellie). ANOMALIES IN THE FORCES OF LABOR. 483 of the head and its escape are more rapid in the rachitic pelvis, because of the shallow canal and the expanded outlet. Injuries to the child's head and to the maternal tissues from pressure are Fig. 350. — Extreme degree of osteomalacia of trunk and extremities (Kaufmann). common. In the former, a sharp indentation may be seen on that portion of the skull pressed against the promontory in the efforts to secure engagement, the so-called "spoon-shaped" depression, with fracture of the parietal bone. Localized necroses are not infre- quently seen in the maternal structures, where they have been nipped between the child's head and prominent portions of the pelvic bones — namely, in the cer- vical tissues over the promontory, or very rarely in the posterior vaginal vault, and in the anterior vaginal wall behind the symphy- sis and the ridge of the pubic bones. When the slough sepa- rates, openings may be estab- lished between the birth-canal and the peritoneal cavity, the bowel, the bladder, and a ureter. Osteomalacic Pelvis. — Osteomalacia, a soft condition of the Fig. 351. — Schematic representation of an osteomalacic pelvis (Schroeder). 4§4 THE PATHOLOGY OF LABOR. Fig. 352. — Minor grade of osteomalacic pelvis bones in consequence of an osteomyelitis and an osteitis, is ex- ceedingly rare in America. There are certain parts of the world where it is frequently seen, notably Italy, Germany, and Austria, but in America there are but three or four examples on record. The bones of the pelvis in this disease become so soft that they yield to every force imposed upon them. They bend be- fore the pressure of the trunk from above, the extremities from below, and the pull of the muscles attached to the pelvic bones. The flexi- bility of the pelvis in extreme cases of osteomalacia may be appreciated when it is stated that the superior iliac spines may be bent backward until they touch the spinal column ; the horizontal rami of the pubis may be pushed inward until they almost obliterate the pelvic inlet ; and the tuberosities of the ischium may be approximated until they nearly close the pelvic outlet. Not only are the pelvic walls so compressed that they almost obliterate the pelvic canal, but the spinal column also, sinking under the weight of the trunk, bends far for- ward and descends low into the pelvis, occupying the little remaining room in the inlet and canal, and be- coming itself a serious ob- struction to the engage- ment of the presenting part. From the lateral pressure of the thigh-bones the ischia and pubes are pushed inward and backward, making, by the former movement, a sharp beak-like projection of the pelvic inlet between the pubic rami, and by the latter much diminishing the size of the pelvic canal (Figs. 351 and 352). The sacrum is rotated on its transverse axis and is driven far down into the pelvic canal — an exaggeration of the move- ment seen in a rachitic pelvis. The lower portion of the sacrum and the coccyx are pulled far forward by the mus- Fig. 353. — Osteomalacia, showing asymme- trical contraction at outlet. ANOMALIES IN THE FORCES OF LABOR. 485 cles attached to them, so that the sacrum is bent at a sharp angle in its lower third. The innominate bones are bent laterally at a point slightly anterior to the sacro-iliac junction, and the iliac bones may be folded upon themselves horizontally. The inclina- tion of the pelvis as a whole is much increased. The diagnosis may be based upon the following symptoms : The disease begins usually during preg- nancy or lactation, with dull aching pains in the extremities, the back, the lumbar region, and over the anterior portion of the pelvis. Every movement increases these pains. As the disease progresses, the bones of the spinal column are so bent and compressed that the individual is dimin- ished in stature to an extra- ordinary degree. She may lose as much as a foot and a half in height (Fig. 353). The gait of an osteomalacic patient is peculiar. In order to compensate for the approximation of the thighs brought about by the collapse of the pelvis, the individual must turn almost through a half-circle in order to bring one foot in front of the other. By palpation of the pelvis ten- derness upon pressure is discovered over its anterior walls. The flexibility of the pelvic bones may be demonstrated by direct pressure, and an internal examination reveals, in the early stage of the disease, the peculiar beak-like space behind the symphysis, and later the almost entire oblitera- tion of the pelvic outlet and canal by the sinking in of the pelvic walls. If it is possible to make a satisfactory internal examina- Fig. 354. — Author's case of osteomalacia. 4-86 THE PA THOL OGY OF LABOR. tion of the pelvis, the low position and the projection of the promontory at once attract attention, and the sharp angulation on the anterior face of the sacrum can be felt. On account of the exaggerated inclination of the pelvis, it may be necessary to make an examination with the patient upon her side. An osteo- malacic pelvis has been taken for a kyphotic, a Robert, a pseudo- osteomalacic, a cancerous, or a fractured pelvis, but a careful, methodical examination of the patient should always lead to a correct diagnosis. Influence Upon Labor. — The results of labor in osteomalacic pelves show that the obstruction is a serious one, although by reason of the flexibility of the pelvis in some cases the head can distend the pelvic canal sufficiently to pass through. In 85 cases collected by Litzmann, 47 ended fatally. In another series of 128 cases the labor had a spontaneous termination in 27 cases, in 4 there was premature delivery, and in 5 abortion ; 4 times the labor was naturally terminated ; in 8 cases version was per- formed, in 4 the child was extracted by the feet, in 25 forceps were employed, in 1 1 craniotomy was performed, and in 36 Cesarean section ; rupture of the uterus occurred in 5 women before any operation was undertaken. In still another series of cases reported from Milan, the flexibility of the pelvis was so great that the child was delivered in only two instances by Cesa- rean section. The most successful treatment is the performance of Cesarean section, and the operator should at the same time remove the ovaries, or, what is better, perform a complete Porro operation. It is beyond dispute that the cessation of sexual functions favorably modifies or actually cures the disease. Tumors of the Pelvis. — The commonest pelvic tumors are bony excrescences, usually found over one of the pelvic joints. 1 The excrescences are originally cartilaginous projections which become ossified by an extension of bony tissue from the two bones between which they lie. These exostoses may be found over the sacro-iliac joints, over the crests of the pubis, at the iliopectineal eminences, and over the promontory of the sacrum (Figs. 356, 357, 358, 359). They may attain the size of a pigeon's egg, though they are usually not larger than a pea or nut. In the exostoses occupying the seat of the pubo-iliac junctions, directly above the acetabula, the bony growth is apt to assume a sharp, thorny shape, projecting with its point into the pelvic inlet. Kilian was the first to direct attention to this fact ; he called a pelvis thus deformed " acanthopelys " (Fig. 360), or a "pelvis spinosa." Another possible seat for a bony pro- 1 Daniel admits only four authentic cases of osteogenic exostoses complicating labor, including one reported by the author. "Annales de Gyn.," August, 1903. ANOMALIES IN THE EORCES OF LABOR. 487 jection is along the crests of the pubic bones, the exostosis taking here the form of a long, sharp edge, and probably owing its origin to an ossification of the attachment of the iliac fascia, a transformation of tissue analogous to the ossification some- times seen in Gimbernat's ligament. These bony outgrowths Fig. 355. — Cvstic enchondroma (Zweifel). Fig- 356- — Button-like exostosis on the promontory (Schauta). Fig. 357. — Exostosis on the symphysis (Schauta 1 ). are a serious obstruction in labor, not so much from their encroachment upon the room of the pelvic inlet, as from the sharply localized pressure which they exercise upon the maternal structures and upon the fetal head. In the four cases 4 88 THE PATHOLOGY OF LABOR. reported by Kilian, death, it was claimed, resulted in each case from a perforated uterus. Other tumors of the pelvis obstruct- ing labor are enchondromata, fibromata, sarcomata, carcino- mata, and cysts (Figs. 355, 361). These tumors are rare, and Fig. 35S. — Exostoses at sacro-iliac junctions. Fig. 359. — Exostoses around the pelvic brim (model in the author's collection). their importance as obstacles in labor depends, of course, upon their size. Cysts of the pelvis are formed usually in sarcomata and in enchondromata, or are hydatid cysts. Cancer of the pelvic bones is always a secondary growth or is metastatic. It ANOMALIES IN THE FORCES OF LABOR. 489 may result in a number of small tumors in the bony pelvic walls, or may take on the form of cancerous infiltration with a conse- quent softening of the bones like that of osteomalacia. The treatment of labor obstructed by tumors of the pelvis is ordi- narily the performance of Cesarean section. There is one case on record (Abernethy's) in which the tumor, an enchondroma, was removed by an incision in the posterior vaginal wall, but in the vast majority of cases these growths can not be reached or Fig. 360. — Acanthopelys. Fig. 361. — Enchondroma (Behm). safely excised. In 49 cases of labor obstructed by a pelvic tumor, 50 per cent, of the women and 90 per cent, of the children lost their lives (Winckel). Fractures of the Pelvis. — Out of 13,200 fractures reported from nine large hospitals in America and in Europe, but T 8 ¥ of one per cent, were fractures of the pelvis. When one considers that almost all grave injuries of the pelvis end fatally, the rarity of a pelvic deformity dependent upon a united fracture of a pelvic bone in a woman of child-bearing age may be appreciated. Most 49Q THE PATHOLOGY OF LABOR. frequently the fracture is found in the pubes, next in the ilium, next in the ischium, next in the acetabulum, and least frequently of all in the sacrum. The effect of a fracture of the pelvis upon the shape and size of its canal depends on the location of the fracture. The deformity may be due to distortion of the pelvic walls, to excessive callous formation, or to ossification of the pelvic joints nearest the seat of fracture. In a fracture of the acetabu- lum the result of hip-joint disease, the head of the femur may Fig. 362 — Fracture of the pelvis (Otto), Fig. 363. — Fracture of the acetabulum in consequence of coxalgia (Otto) project into the pelvic canal (Fig. 363). Fracture of the pubes results in an irregular distortion of the pelvic inlet, most marked, of course, on the injured side (Fig. 362). A fracture of the upper portion of the sacrum may result in a spondylolisthetic deform- ity (Fig. 364). Fracture of the lower portion of the sacrum is followed by a dislocation of the lower fragment inward. In a case under my observation the lower half of the sacral bone was turned in at right angles to the rest of the bone by the pull of ANOMALIES IN THE FORCES OF LABOR. 491 the pelvic muscles attached to it. A fracture of the sacral alae may cause an oblique contraction of the pelvic inlet like that of the Naegele pelvis (Tig. 365). Neugebauer 1 reported an ex- Fig. 364. — Transverse fracture of the sacrum with spondylolisthetic deformity (Neugebauer). Fig. 365 — Fracture of the right ala of the sacrum (Fritsch). traordinary case of bilateral fracture of the pubic rami in which there was union with callous formation on one side and an ununited 1 " Jahresbericht iiber d. Fortschr. a. d. Gebiete der Geburtsh.," etc., vol. iv, p. 188. 49 2 THE PA THOL OGY OF LAB OR. fracture on the other, the fragments moving on each other two or three centimeters when the woman walked. Caries and Necrosis. — The only effect of these diseases of the pelvic bones is the production, in rare cases of tuberculosis of a sacro-iliac joint, of an oblique contraction of the pelvis. When the sacro-iliac joint is affected, the ultimate result is the same as that produced by imperfect development of the sacral ala in a true Naegele pelvis. There is loss of tissue, ankylosis of the joint, and an arrest of development in the affected part if the disease occurs in early childhood. Ankylosis and Relaxation of the Pelvic Joints. — Synostosis may develop in any of the pelvic joints ; in the symphysis it occurs not infrequently, and often at an early age. A number of operators have encountered difficulty on this account in at- tempts to perform symphysiotomy. In otherwise unobstructed labor synostosis of the pubic symphysis is not a serious condi- tion, although it limits the slight expansion which every normal pelvis should exhibit preparatory to and during labor. If synostosis of the sacro-iliac joint develops in the indi- vidual's early childhood, it is followed by ill-development of the sacral alae on the affected side, and of that portion of the in- nominate bone concerned in the formation of the joint, an obliquely contracted pelvis of the Naegele type being the result ; but such cases are rarer than those in which lack of development in the sacral alae is the primary occurrence. If the synostosis of the joint occurs after puberty, the effect upon the pelvis and upon the course of labor is practically nil. If both joints are early ankylosed, a form of laterally contracted pelvis like the Robert pelvis is the result. This kind of contracted pelvis is rarer than the transversely contracted pelvis due primarily to lack of development in the sacral alae. The sacrococcygeal joint becomes ankylosed, as a rule, between the thirtieth and fortieth years, but as the joint between the first and second coccygeal vertebrae is ordinarily unaffected, the pelvic outlet is capable of expansion during labor in its anteroposterior diameter nearly as well as if the sacrococcygeal joint were normal. Rarely, there is an ankylosis of all the coc- cygeal joints as well as of that between the sacrum and the coc- cyx. In these cases labor can be terminated only by a fracture of the coccyx or a rupture of a coccygeal joint, usually the first. The expulsive forces of labor may be sufficient to cause the fracture, and the bone has been heard to give way with a loud crack as the head was passing through the pelvic outlet. This accident, however, is more likely to be caused by the artificial extraction of the head. ANOMALIES IN THE FORCES OF LABOR. 493 An abnormal relaxation of the pelvic joints may be a simple exaggeration of the natural process by which the pelvic canal is made somewhat expansible preparatory to labor. It is more likely, however, to be due to some pathological condition within the pelvic joints, as an inflammatory process followed, perhaps, by suppuration, an accumulation of fluid within the joint, osteo- malacia, caries, or new growths. In pregnancy the pathological relaxation of the pelvic joints may occasion some difficulty in locomotion. During labor an exaggerated relaxation of the joints predisposes to their rupture. The Spondylolisthetic Pelvis. — The spondylolisthetic pelvis was first described in 1839 by Rokitansky, who reported two cases ; Kiwisch and Kilian each followed with a description of a specimen ; but we owe our knowledge of the condition mainly to the indefatigable researches of Neugebauer, 1 who collected more than one hundred cases and specimens, and to the discov- eries of Lane, who has done much to clear up the etiology. The name "spondylolisthesis" 2 indicates the condition — a slipping down or dislocation of the vertebrae. To affect the pelvis the spondylolisthesis must be in the lumbosacral region (Figs. 365- 3^). Characteristics. — As the name denotes, there is a dislocation of the last lumbar vertebra in front of the sacrum, the body of the former slipping down in front of the first sacral vertebra, so that its inferior border, or in advanced cases its anterior surface, comes in contact with the anterior face of the sacrum, to which it becomes united by bony union. There is, also, of necessity, an exaggerated lordosis of the lumbar vertebras and a descent into the pelvic inlet of at least the fourth and third, and even of the second, lumbar vertebrae, which diminish by their bulk and anterior projection the anteroposterior diameter of the pelvic canal. It is only the body of the last lumbar vertebra that is displaced, and not the arch, held fast by the lower posterior articular surfaces, nor the laminae surrounding the spinal cord ; so that the latter does not necessarily suffer compression by the displacement of the vertebrae, although this result has been noted in a few cases (Fig. 367). To allow the displacement of the 1 Franz Ludwig Neugebauer, " Bericht iiber die neueste Kasuistik und Littera- tur der Spondylolisthesis," etc., " Zeitschrift f. Geburtshulfe und Gyniikologie," Bd. xxvii, H. 2,1893; "Spondylolisthesis et Spondylizeme," " Resume des Re- cherches litteraires et personelle depuis 1S80 jusqu'en 1892," Paris, G. Steinheil, 1892 ; " Contribution a la Pathogenie et au Diagnostique du Bassin vicie par le Glissement vertebral," " Annales de Gynecologie," Feb., 1884; " Zur Entwicke- lungsgeschichte des spondylolisthetischen Beckens und seiner Diagnose," Halle and Dorpat, 1882, p. 294; see also " Archiv f. Gynakologie," Bd. xx, H. I, und Bd. xxi, H. 2. The best article in English is by J. Whitridge Williams, " Tr. Am. Gyn. Society," vol. xxiv, 1899, with full bibliography to date. 2 anov6vAoq, vertebra, and 'oliotttiaiq, a slipping out or down. 494 THE PATHOLOGY OF LABOR. body of the last lumbar vertebra the interarticular segment of the spinal arch and the pedicles are enormously lengthened from behind forward and are bent at an angle downward (Fig. 368). After a time this segment may exhibit a transverse fracture or a solution of continuity from pressure and attrition. The deform- ity is always gradual in development. If it begin during the child-bearing period, successive labors become increasingly diffi- cult. As the vertebra descends, it pushes the sacrum backward Fig. 366. — Spondylolisthesis, well marked (Schauta). Fig- 367 Spondylolisthesis, beginning (Schauta). Fig. 368. — Last lumbar vertebra of spondylolisthesis (a), contrasted with a normal fifth lumbar vertebra (Neugebauer). and downward, and with it depresses the posterior portion of the pelvic brim. To compensate for this movement the anterior half of the pelvic brim rises and the height of the symphysis is increased. This movement of the pelvis diminishes very markedly its inclination, and disturbs the normal relationship between the bones and the soft structures that overlie them. The base of the triangle formed by the pubic hair in women is well below the upper edge of the symphysis, and the external genitalia are pulled so far forward that the vulvar orifice is ANOMALIES IN THE FORCES OF LABOR. 49 5 directed anteriorly as the patient sits or stands. There are, more- over, the same displacements of the pelvic bones that are seen in kyphosis — a rotation backward of the sacrum on its transverse axis ; a rotation outward of the upper portions, and inward of the lower portions, of the innominate bones on their antero- posterior axes. The descent of the lumbar vertebrae drags the large arteries of the lower trunk into the pelvic inlet, so that the iliac vessels and the bifurcation of the aorta may be felt in a vaginal examination. The degree of contraction in the conjugate diameter of the inlet depends upon the descent of the last lumbar vertebra and the degree of the lordosis. The contraction is usu- ally not excessive, but it may be so great as to pre- clude the possibility of the engagement of the fetal head. Etiology. — The etiology of spondylolisthesis at the lumbo-sacral junction is still obscure. It has been attributed to direct injuries of, and to faults of devel- opment or ossification in, the interarticular segments of the spinal arch. It is certain that these are pre- disposing causes, but the observations of Lane ap- pear to demonstrate that the commonest cause of the deformity is an exaggerated pressure from the trunk above exerted often upon healthy bone. As a result of this pressure a joint is formed in the intervertebral disc, and the interarticular segments of the last lumbar vertebra undergo stretching, pressure, angulation, and atrophy until the bone is actually severed. Following or accompanying these changes in the arch, the body of the last lumbar vertebra is gradually dis- placed downward and forward. Spondylolisthesis has followed an injury, presumably a fracture, of the lumbar vertebrae. Frequency. — Neugebauer collected I I 5 cases, to which num- ber Williams added 8. The author has seen one case in a single woman, aged 59 (Fig. 369). Of the 124 cases, 8 were in men. Diagnosis. — The diagnosis of a spondylolisthetic pelvis is not Fig. 369. — Author's case of spondylolisthesis. 496 THE PATHOLOGY OF LABOR. easy ; it can be made only by close attention to the patient's history, by a careful observation of her appearance, by an inter- nal and external examination of the pelvis, and by pelvimetry. In the history of the case it may appear that the individual was the subject of a serious accident, such as a fall from a height or a fracture of the pelvis by the passage over it of a heavy weight, or it may be learned that she has carried excessively heavy bur- dens for a long time. The woman's height is diminished and the length of the abdomen is shortened. Viewing the patient from behind, there appears what is called the saddle-shape or "sway" back, the lumbar vertebrae projecting visibly far forward and being displaced downward, throwing into bold relief the Fig. 370. — Breisky's case of spondylolisthesis. posterior superior spinous processes and the rims of the iliac bones, and producing quite a deep furrow along the course of the spinous processes of the lumbar vertebrae. The apposed articular processes of the first sacral and the last lumbar verte- brae stand out as button-shaped prominences on the inner surface of the posterior rims of the ilia. The buttocks are flat and are pointed below, giving to the region a cordiform appearance. In front there is a pendulous belly; a deep crease is observed run- ning across the lower abdomen a short distance above the sym- physis. Laterally, the floating ribs are seen almost to rest upon the crests of the ilia or actually to sink between them, and the soft structures of the flanks are thrown outward in prominent ANOMALIES IN THE FORCES OF LABOR. 497 folds. The trunk is shortened, and the limbs appear relatively too long (Fig. 370). The patient's body being thrown forward by the deformity of the spine, an effort to maintain an equilib- rium is made by carrying the shoulders far back; as the individual walks, a disposition to fall forward may be noted, and she states, perhaps, that she is unable to carry any load upon her arms in front of her body, for fear of toppling over upon her face. She may also complain of pain or of a grating sensation and sound in the small of the back (crepitus). The gait is peculiar ; the toes are not turned out, and the feet are swung around each - . £XL ' IcT ^1 H \ ■; / - i m 3 m |i 1 m^ E ; % * 1^ f m M m 11 JP^ m n mm 2- i 1 1 > c\ Fig. 371. — Footprints of author's case of spondylolisthesis. other so that the footprints fall in a straight line (Fig. 371). Upon an internal examination of the pelvis, — best conducted, accord- ing to Neugebauer, in an upright or lateral position, — the lordosis of the lumbar vertebrae is at once discovered. The angle formed by the attachment of the last lumbar vertebra to the sacrum may be detected with ease, especially in a rectal examination, and it should be noted that the body of this vertebra does not possess lateral projections, transverse processes, or alae. By their absence the bone is distinguished from a projecting 32 498 THE PA THOLOG Y OF LABOR. promontory. Pulsating iliac arteries may be felt, and it is pos- sible even to reach the bifurcation of the aorta, — as first pointed out by Olshausen, — but this symptom is not pathognomonic. It is possible to reach the bifurcation of the aorta in a vaginal exam- ination in the extreme lordosis of some rachitic pelves and of the osteomalacic pelvis, in lumbrosacral kyphosis, and in some cases of dorsolumbar kyphosis. The external palpation of the pelvis demonstrates the absence of inclination. A measurement of the pelvis may show a diminution in the external conjugate diameter, an increased height in the symphysis pubis, an increased distance between the posterior superior iliac spines, and a diminished distance between the anterior iliac spines and the crests. The external conjugate may not be decreased at all ; it may even be increased if meas- ured from the top of the sacrum, which is pushed backward. There is some diminution in the diameters of the outlet. The internal conjugate diameter must be measured from the lumbar vertebra nearest the symphysis pubis, usually the fourth. This is called the "false" or "effective " conjugate diameter of the spondylolisthetic pelvis. On account of the decreased in- clination of the pelvis it is not necessary to subtract more than the ordinary sum from the diagonal conjugate. In fact, the diagonal conjugate may approach very nearly the length of the true, or may actually measure less. Influence Upon Labor. — The influence of a spondylolisthetic pelvis upon labor is that of a flat pelvis. The obstruction in the former may be overcome more easily on account of the bow- like shape of the projecting vertebra and the coincidence of the uterine and pelvic axes. The obstruction to labor depends entirely upon the projection of the lumbar vertebrae. This pro- jection may be so slight as scarcely to influence the progress at all, or it may be so great as to make delivery by the natural channel quite impossible. There is noticed in labor something of the same mechanism that is seen in the flat pelvis for the pur- pose of overcoming the obstruction — namely, decreased flexion, transverse position, and exaggerated lateral inclination of the head. On account of the forward dislocation of the external genitalia and of the pelvic floor, lacerations of the latter are the rule, and the tears are often complete into the rectum. This liability to injury is explained by the fact that the presenting part impinges directly upon the middle of the pelvic floor as it descends the birth-canal, instead of being directed forward to the vulvar orifice. Fistulae of the anterior vaginal wall are likewise common, from the localized pressure to which this region is subjected while the head is passing the obstruction at the inlet. ANOMALIES IN THE FORCES OF LABOR. 499 The presenting part is thrown forward by the projecting ver- tebrae, and is received upon the prominent ridge of the pubic bone, greater in height and higher in situation than in the nor- mal pelvis. Treatment of Labor Obstructed by Spondylolisthetic Pelvis. — The management of labor in these cases is governed by the same principles that obtain in the management of labor in a flat pelvis. If the effective conjugate is over 9.5 cm., the woman can be delivered spontaneously, by forceps, or by version. With an ef- fective conjugate of 7 to 9.5 cm., the in- duction of prema- ture labor and the performance of symphyseotomy x might be con- sidered ; or cranio- tomy should be done if the child is dead. If the effective conjugate is at or under 7 cm., delivery must be effected by a Cesarean section. These rules pre- suppose, of course, a child of average size. After the wo- man's convales- cence from her delivery she should be referred to an orthopedic surgeon for the adjustment of a brace which makes her more comfortable and might retard the progress of her disease. Kyphosis. — The kyphotic pelvis was first adequately described in 1865 by Breisky, although its peculiarities had been recog- nized by Litzmann in 1861 and by Neugebauer in 1863. The condition was called by Herrgott "spondylizema," a name adopted by Neugebauer and others (Figs. 373, 374). 1 Symphyseotomy has been performed twice for spondylolisthesis hv Morisani and Williams. Both operations were fatal. The effective conjugate is apt to be less than it seems, so that in case of doubt as to the measurement Cesarean section should be performed. Fig. 372. — Angulation of the spine in kyphosis. 500 THE PATHOLOGY OF LABOR. Characteristics. — The degree of deformity in a kyphotic pel- vis depends upon the situation of the hump : the nearer this is to the sacrum, as a rule, the greater is the deformity in the pelvis. Lumbosacral kyphosis is almost as frequent as the lumbar and dorsolumbar combined. There is a compensating lordosis of the lumbar spine, but not enough to keep the center of gravity of the trunk from being too far forward. In conse- Fig. 373. — Kyphotic pelvis from above (Barbour). Fig. 374. — Contracted outlet of a kyphotic Fig. 375. — Kyphosis: greatest pelvis (Barbour). transverse diameter at outlet, 7 cm - (Mutter Museum, College of Physi- cians, Philadelphia). quence, the weight of the trunk is transmitted in a direction from before backward, so that the sacrum is rotated on its transverse axis in a direction the reverse of that seen in rachitis — namely, backward and scarcely at all downward. The result of this movement is to make the sacrum straighter, narrower, more curved from side to side, and longer (Fig. 373) ; to pull the pos- terior superior spinous processes of the iliac bones closer to- ANOMALIES IN THE FORCES OF LABOR. 50 1 gether, and to separate the anterior spines more widely. The diminished width between the posterior superior spinous pro- cesses is caused partly by the pull of the sacro-iliac ligaments. The sacrum can not move in any direction without dragging the ilium on each side by these ligaments, thus approximating their upper posterior surfaces. The diminution of the interspinous Fig. 376. — Lumbosacral kyphosis, front and profile views (author's case). measurement posteriorly depends also upon the narrowness of the sacrum. To compensate for the movement of the upper portion of the sacrum backward, the lower portion of the bone projects forward, into the pelvic outlet. To preserve the body from falling forward, the legs are slightly flexed and the pelvic inclination is almost entirely lost. This posture puts 502 THE PATHOLOGY OF LABOR. the iliofemoral ligaments on a stretch, which pull outward the upper portions of the innominate bones. To compensate for the movement outward of the iliac bones the lower segments of the innominate bones move inward upon the pelvic outlet; in other words, there is a rotation of the innominate bones upon their anteroposterior axes. The result of these movements in the pelvic bones is to enlarge the pelvic inlet in its anteroposterior diameter, and to contract the canal toward the outlet, where the diminution of the diameters is most marked in the transverse (Fig. 374). In the cases of lumbosacral kyphosis the upper portion of the sacral bone may be involved in the necrotic process and the sacrum may exhibit deformities by destruc- tion of its tissues (Fig. 380). The other characteristic deformities of the kyphotic pelvis are most marked in this type, unless, as in one instance, the body is bent almost double, and it is necessary to rest the anterior portion upon an artificial support, as a cane. In this case the pelvis, although relieved of the weight of the trunk, is obstructed by the overhanging lumbar vertebrae to such a degree, perhaps, that the inlet is practically obliterated (pelvis obtecta). In all cases of exaggerated lumbosacral kyphosis the pro- jecting lumbar spine blocks the pelvic inlet and seriously obstructs labor. The conju- gate diameter must be measured to the lumbar or even to the dorsal vertebrae, and is exceedingly short. In 2 1 labors compli- cated by this deformity of the pelvis, 66 per cent, of the mothers and 75 per cent, of the children were lost (Winckel). Influence on Labor. — The influence of the kyphotic pelvis upon labor is usually not felt until the presenting part has de- scended to the pelvic floor. In consequence of the shortened perpendicular diameter of the abdominal cavity there is always a tendency to a transverse position of the fetus in utero, but this position is ordinarily corrected by the first few labor-pains. The head presents in 95 per cent, of cases, the breech in 2 per cent, according to the statistics collected by Klein, 1 embracing 172 Fig. 377-— Lum- bosacral kyphosis (rear) . 1 " Archiv f. Gyn.," Bd. 1, H. I. ANOMALIES IN THE FORCES OF LABOR. 503 births in 95 women. When the head arrives at the pelvic floor, if the occiput is directed backward, as it is in a third of the cases, anterior rotation will very likely be prevented and there will be a Fig- 37S. — Head arrested by spines of ischia in a kyphotic pelvis (Budin). Fig- 379. — Vertical section of kyphotic pelvis, showing the head arrested by the spines of the ischia (Budin). persistent posterior position. A posterior rotation of the occiput originally directed anteriorly is not rare. It occurred in five of Klein's cases and in one of the author's. If the occiput is 504 THE PATHOLOGY OF LAB OP. directed anteriorly, the transverse diameter of the head may be caught between the approximated spines or tuberosities of the ischiatic bones, and labor be brought to an indefinite standstill (Figs. 378, 379). The head usually enters the pelvis obliquely or transversely. Rotation only occurs as the head emerges from the outlet. Face presentations occur in a large proportion of cases — four per cent, of the head presentations. Management of Labor in Kyphotic Pelves. — An exact meas- urement of the pelvis is essential to a determination of the proper means of delivery. If the child is of normal size, pregnancy may be allowed to go to term in pelves measuring 8.5 cm. and more in the transverse diameter of the pelvic outlet. Any asymmetry of the ischia constitutes a serious complication, necessitating operative interference that might be avoided in a symmetrical pelvis with smaller diameters. Below 8.5 cm. down Fig. 380. — Lumbosacral kyphosis (pelvis obtecta). to 6 cm. in the transverse measurement of the outlet, labor should be induced at the thirty-sixth week. With a measure- ment less than 6 cm. Cesarean section is indicated absolutely. If the woman is first seen in labor at term, the head, if it is presenting, should be allowed to descend to the pelvic floor and the woman should be encouraged to make vigorous ex- pulsive efforts. If the occiput shows a disposition to rotate posteriorly, the movement should not be interfered with, for the greater bulk of the occipital region finds more room poste- rior to the tuberosities than it does anteriorly. The author has seen an occipito-anterior position of the vertex, in a kyphotic pel- vis, remain stationary until the head rotated from an anterior to a posterior position, when the vertex was expelled without further difficulty. With a transverse diameter of 8.5 cm. spontaneous ANOMALIES IN THE FORCES OF LABOR. 505 delivery may be possible, though it may be necessary to use forceps. Below 8.5 cm. the forceps may be tried cautiously, but symphysiotomy is likely to be required. In no other form of contracted pelvis is this operation so successful. Klein found, by experiments on the cadaver, that by a separation of the symphy- sis to 6 cm. in a kyphotic pelvis, the tuberosities moved 4.5 cm. further apart. Symphysiotomy, therefore, might be expected to be successful in a transverse diameter of 6 cm. or even a trifle less. If the child is dead or if the graver obstetrical operations are not admissible, craniotomy should be performed, in case the forceps fail. In employing forceps the operator must remember the dangers of rupture of the symphysis and deep tears of the vaginal walls to which kyphotic subjects are particularly liable. Version has given the worst results of all the obstetrical operations in kyphotic pelves. It is, therefore, as a rule, contraindicated, although in one of the author's cases, complicated by eclampsia, it proved the Fig. 3S1. — Asymmetrical contraction of the outlet from kyphoscoliosis. best way to extract the child. Klein's statistics show that in fifty- eight to sixty per cent, of cases the labor must be terminated by operative interference. Diagnosis. — The diagnosis of a kyphotic pelvis presents no difficulties. The hump-back is obvious, and the history is easily obtained that the spinal deformity developed early in life. The pelvic measurements diagnostic of this deformity show an increased separation of the iliac crests and the anterior spines, an abnormally long conjugate diameter of the inlet, a diminished distance between the posterior superior spines, an approximation of the tuberosities of the ischiatic bones, and some diminution in the anteroposterior diameter of the pelvic outlet. The buttocks are flat and pointed below, the external genitalia are displaced forward and upward, and the upper edge of the symphysis is above the upper edge of the pubic hair. Care should always be exercised to detect asymmetry in these pelves, to discover an 506 THE PATHOLOGY OF LABOR. arrested development with general contraction which is common, and to diagnosticate lateral contraction at the pelvic inlet. These complicating deformities constitute often insuperable obstacles in labor, even though the transverse diameter of the outlet is not excessively contracted. Klein gives the following table, showing the contrast between kyphotic, normal, and rachitic pelves, taking a typical example of each, the measurements being made upon the dried specimen : Sp. il. ant. sup., Cr. il., Conj. extern., Spin. il. post, sup., Height of anterior surface of sacrum, Height of posterior surtace of sacrum, Diagonal conjugate, True conjugate, Transverse diameter of pelvic inlet, . Spines of the ischia, Tuberosities of the ischia, Cfl > j J < 0- J •< 11 in 2 ° OS C 2 j ~U! 22.3 28.1 25 26.8 28.7 27 3 16.3 18 18.5 7-7 5-7 6.4 10.4 14.2 8.2 9-3 9-4 7.2 12.5 19-3 13.6 10.9 17-7 13.2 12.9 14.5 11. 8 10.2 9-5 6.6 11. 4 10. 1 4.6 Si4 21.7 25.2 15-5 3-5 8 6.2 14-5 13.6 11. 2 5-9 4-5 27.25 27-75 H-5 8.7 7.6 14.2 13-5 13.2 Prognosis. — The outlook for the mother and child depends upon the degree of the deformity and upon the management of the labor. In the minor grades of contraction in the cases collected by Klein, the maternal mortality was 6.6 per cent. In the graver cases it was 16 per cent. Neugebauer puts the maternal mortality at 24.3 per cent. The mortality of the in- fants has varied in the different statistical tables from 36 to 49 per cent. Frequency. — The kyphotic pelvis is said to be somewhat infrequent, but the practitioner in active practice will surely encounter several examples in the course of his career. The writer has had under his care eight well-marked cases of kyphotic pelvis, in two of which Cesarean section was necessary. In three delivery was spontaneous. One required forceps, another, version. Klein found, in 42,113 labors, only 7 women with kyphosis — a proportion of 1 : 601 0. Scoliosis. — In the scoliotic pelvis there is some degree of oblique contraction. The innominate bone, toward which the lumbar vertebrae are bent, receiving the greater part of the weight of the trunk, is pushed upward, inward, and backward by the ANOMALIES IN THE FORCES OF LABOR, 507 extra pressure exerted upon it by the head of the femur. The acetabulum on this side is displaced anteriorly and upward ; the symphysis is pushed over to the opposite side. The degree of asymmetry is rarely sufficient to constitute an obstruction in labor. The scoliotic pelvis is, however, most often rachitic, and in addition to the asymmetry of scoliosis there may be the con- traction of a rachitic pelvis (Figs. 382, 383). Kyphoscoliosis. — In a combination of kyphosis and scoliosis of the spinal column the pelvis shows, perhaps, the combined Fig. 382. — Scoliosis. Rachitic pelvis: C. v., 8.25 cm. Craniotomy on a dead child (author's case). Fig. 387. — Scoliotic rachitic pelvis. features of both, but the kyphosis, being of rachitic, not of carious, origin, is not angular, and is situated high in the dorsal region, where it may be compensated for entirely by lumbar lordosis (Figs. 384, 385). The kyphoscoliotic pelvis is usually an asymmetrically contracted rachitic pelvis (PI. 9, Fig. 1). Lordosis. — Primary lordosis not the result of pelvic deform- ity or of spinal disease is very rare. Aside from some illustra- tions of it in an article by Neugebauer {loc. <-//.), the writer knows of no reference to the subject except his own (PI. 9, 5c8 THE PATHOLOGY OF LABOR. Fig- 3^4- — Kyphoscoliosis (Leopold). Plate 9. I, Lumbodorsal kyphoscoliosis (Schauta) ; 2, lordosis from paralysis of spinal muscles (author's case) ; 3, skeleton of a girl withcoxalgia (Medical Museum, University of Penna.) ; 4, rear view, 5, side view, of obliquely contracted pelvis, the result of tuberculous disease in one knee-joint (author's case) ; 6, scoliosis from unilateral atrophy of spinal muscles (author's case). ANOMALIES EY THE EORCES OF LABOR. 509 Fig. 2). 1 It may readily be seen what an influence this deformity would have upon coition and parturition, and how it might be an insuperable obstacle to the natural completion of the latter. Fig. 385. — Kyphoscoliosis. Pelvis of rachitic type: C. v., 8.50 cm. (seen in con- sultation with Dr. Geo. I. McKelway). Anomalies Due to Diseases of the Subjacent Skeleton. — Coxalgia. — The deformity of the pelvis due to coxalgia in early childhood is of two types. In one there is an oblique contraction by a displacement of the innominate bone on the health}' side up- 1 Hirst, " The Influence of the Habitual Inclination of the Pelvis in the Erect Posture upon the Shape and Size of the Pelvic Canal," " University Med. Maga- zine." 5io THE PATHOLOGY OF LABOR. ' \ \ m •Vw M /] -ffj ; y : 4 M 1 1 * 1 '4 a ' 1 ^ ' £t" *m»*mm *** . V '*, ■ Fig. 386. — Skeleton of woman shown in figure 385, who died in consequence of labor. Fig. 387. — Same case as figure 386. ANOMALIES IN THE FORCES OF LABOR. 511 ward, backward, and inward, on account of the pressure of the femur, the weight of the body being received mainly upon the sound leg. This form of coxalgic pelvis, as a rule, presents no serious obstacle to delivery unless it is associated with a rachitic deformity (Fig. 388). Special attention, however, should always be paid to the length of the conjugate diameter of the inlet, and to the transverse diameter of the outlet. In the other variety of coxalgic pelvis the deformity is also an oblique con- traction, but it is the bone on the diseased side which is driven inward upon the pelvic canal. This displacement of the innomi- nate bone is the result of an arrested development on the corre- sponding side of the pelvis, and is usually associated with an atrophy of the sacral ala and an ankylosis of the sacro-iliac joint. The contraction of the pelvic canal is much more serious in this Fig. 388. — Coxalgic pelvis (Mutter Museum, College of Physicians, Philadelphia) form, and there may be all the difficulties in labor encountered in the true Naegele pelvis. The ankylosis of the hip-joint and the fixation of the thigh in coxalgia may be a source of serious embarrassment in labor, especially in the application of forceps and the extraction of the fetal head through the pelvic outlet. Luxation of the Femora. — Dislocation of the thigh-bones, if congenital or occurring early in childhood and not corrected, has some effect upon the size and shape of the pelvis, but usually not enough seriously to obstruct labor. If one thigh is dislo- cated, the weight of the body may be thrown mainly upon the other leg, and this may produce an oblique contraction of the pelvis of the kind already described. If the thigh-bone is displaced forward, the anterior half of the pelvis may be driven in a little upon the pelvic canal, and the head of the thigh- bone, as in one case reported, may project over the horizontal. 512 THE PATHOLOGY OF LABOR. Fig. 389. — Anterior dislocation of femur. Fig. 390. — Congential luxation of both femora : C, Crest of ilium ; F, trochanter of femur (Henry). Fig. 391. — Congenital dislocation of femora, rear view, showing wide separation of the thighs with the feet together (author's case). ANOMALIES IN THE FORCES OF LABOR. 5 I 3 ramus of the pubis into the pelvic inlet (Fig. 389). In the con- genital luxation of both femora backward upon the iliac bones there is an excessive rotation forward of the sacrum, an increased width of the pelvic canal, and from the drag of the attached muscles and ligaments between the thighs and the pelvis the ischiatic tuberosities are pulled outward, upward, and backward, so that the pelvic canal is made shallow and its outlet very wide. The heads of the femora move up and down on the ilia when the patient walks, and the distance between the lower edge of the symphysis and the inner condyles of the femora is shortened. There is a peculiar waddling gait, a marked lordosis, and the shoulders are carried far back. The rear view of the patient shows an unusually wide separation of the thighs as the individual stands erect with the heels together. In the absence of one lower extremity the pelvis may be contracted obliquely to a serious degree, as in La Chapelle's case, 1 by the pressure on one side of the remaining leg. Any condition which throws the weight of the body mainly on one leg Fig. 392. — Congenital luxation of both femora. may produce the same effect, as is shown in a case of the author's (PL 9, Figs. 4, 5), in which there was tuberculous disease of a knee-joint early in infancy, followed by marked shortening and atrophy of the leg. The weight of the body falling mainly on the sound leg, the corresponding innominate bone is pushed upward, backward, and inward, diminishing the area of in- trapelvic space on its own side. Torggler reports an inter- esting case of this kind in which the disability of one leg was due to scleroderma. 2 In the absence of both lower ex- tremities there is the characteristic " sitz-pelvis," in which the innominate bones are usually rotated on an anteroposterior axis, 1 " Pratique des Accouchements," iii, p. 413; according to Schauta, the only case on record. 2 " Centralbl. f. Gyn.," 1889, p. 612. 33 5 1 4 THE PA THOL G V OF LABOR. so that the crests of the ilia are approximated and the tuberosi- ties of the ischia are separated. Minor deformities of little prac- tical importance may be the result of unilateral or bilateral club- foot or of the bowing of one or both lower extremities. In the former there is an increased inclination of the pelvis, an approxi- mation of the acetabula and of the ischiatic tuberosities, and a narrow pubic arch (Fig. 393). Fig. 393. — Pelvic deformity, the result of double club-foot (Meyer). The Management of Labor Obstructed by the Commonest Forms of Contracted Pelvis : a Simple Flat, a Rachitic Flat, and a Generally Contracted Pelvis. — There is nothing in medicine requiring more experience and good judgment than the management of labor obstructed by a contracted pelvis. It is extremely difficult to formulate hard-and-fast rules for the guid- ance of the inexperienced when so many factors must be taken into account. The rules given below govern the writer's prac- tice in the average case, but due attention must be paid to the history of past labors, the size of the child, its development, and the compressibility of its head, the age of the woman, the build of both parents, and the probable strength of the ex- pulsive forces, greatest in the primipara and less with successive labors. If the diagnosis of a conjugate diameter of 9.5 cm. or less is made during pregnancy, the physician must choose induction of premature labor, forceps, version, symphyseotomy, or Cesarean section at term. If the conjugate diameter measures as low as 9.5 cm., it is a safe plan to induce labor two to four weeks before the expected termination of pregnancy. This course entails no great additional risk upon the child if its parents are in a position to afford it the best care and nursing, and it is much the safest plan for the mother, the induction of labor, done prop- ANOMALIES IN THE FORCES OF LABOR. 5 I 5 erly, having no maternal mortality. 1 It is true that many women with a conjugate of 9.5 cm. can deliver themselves without difficulty at term. Spontaneous delivery with a measurement as low as eight centimeters and under has been recorded. But the majority of women with a conjugate of 9.5 cm. will ex- perience abnormal delay and difficulty in labor, with added risk to themselves and to their children ; and in a certain propor- tion of cases a conjugate of 9.5 cm. proves an insuperable obstruction in labor, and is the cause of ruptured uterus or death from exhaustion in the mother or of injury to the child's brain. These results are to be feared especially if the child is over- grown or if the mother's expulsive powers are weak — two con- ditions impossible to predict with absolute certainty. For these reasons, then, the rule to induce premature labor when the con- jugate is at or below 9.5 cm. is a safe one. If the conjugate measures between seven and eight centimeters or more, the most successful treatment is still the induction of premature labor at the thirty-sixth week. By this plan the majority of women with a conjugate of eight centimeters or a trifle less are delivered spontaneously or with no more serious operation than the appli- cation of forceps. If the conjugate measures seven centimeters or less, the induction of premature labor four weeks before term can not be expected of itself to secure a spontaneous delivery. Cesarean section gives a better result for both mother and child. In such cases, therefore, the physician may wait until term or shortly before it, so that his operation shall. secure the birth of a child vigorous in development. With a conjugate diameter of the superior strait at and below 7 cm., the woman should be allowed to go to term and should usually be delivered by Cesarean section. If the physician sees the patient for the first time in labor, or only discovers the deformity after labor has begun, he must choose one of the following modes of delivery : A waiting policy, to allow the engagement of the head by natural forces ; the ap- plication of forceps ; the performance of version, symphyseotomy, or Cesarean section. While the child is alive, craniotomy should not be considered. The selection of the best mode of delivery in contracted pelves is one of the most difficult problems in obstetrics. If the patient is a primipara and the conjugate is above nine centimeters, natural forces, in the majority of cases, if the fetus is not overgrown, will secure the engagement of the 1 This statement is based upon the writer's experience in private practice, and not upon hospital statistics. It does not hold good for labors induced before the thirty-sixth week. In the discussion at the international congress at Amsterdam, in August, 1899, the maternal mortality was acknowledged to be about I per cent., and for the infants Barnes gave a mortality of 33 per cent., Bar 26 per cent., Becker 50 per cent., Herzman 26 per cent., and Black 50 per cent. 5 1 6 THE PA THOL OGY OF LABOR. head, 1 although it may be by the expenditure of considerable force, after long delay, and only after prolonged molding and an adaptation of the size of the head to the size of the contracted inlet by apparent anomalies in the position and flexion of the former. It is wonderful how successfully an obstruction may be overcome even in cases of contracted pelves with a conjugate of eight centi- meters or less. But while waiting for spontaneous delivery, the physician may see the uterus suddenly rupture or may find the child's head after birth seriously injured. It is permissible in most cases to wait for the full, or almost full, dilatation of the os, keeping careful watch upon the woman's pulse, temperature, and general condition, upon the situation of the contraction-ring and the distention of the lower uterine segment, and taking whatever operative measures may be required in plenty of time to forestall the possibility of uterine rupture. The application of forceps to the head above the superior strait for the purpose of securing its engagement by forcible traction should in general be condemned, but it must be admitted that there are important exceptions to this rule. If one is skilled in the application of the forceps, bears in mind the transverse position of the head, and can gage the degree of traction which may be exerted without injury to the child's skull or to the maternal soft structures, he will occasionally succeed in securing an engagement with the in- strument that would otherwise, perhaps, be impossible. As a rule, however, it is safe to say that the choice lies between in- action and the performance of version. By the latter operation the smaller end of the wedge represented by the child's head is engaged in the contracted inlet, and there can be exerted upon the head coming last, both by traction on the body from below and by pressure on the head through the abdominal walls above, a degree of force that is impossible with forceps. It is well, however, to bear in mind the danger entailed upon fetal life when version is performed in a contracted pelvis. There is a con- siderable risk 2 that the head will be retained long enough above the superior strait, or in it, to asphyxiate the child beyond re- vival. 3 Or the pressure upon the head by the pelvic walls may 1 Froml88l to 1887 there was spontaneous delivery in 163 out of 444 cases of con- tracted pelvis in the Vienna Hospital, and in 47 women the conjugate was not above 8.5 centimeters (Braun u. Herzfeld, " Der Kaiserschnitt u. seine Stellung zurkiinst- lichen Friihgeburt, Wendung, atypischen Zangenoperationen, Kraniotomie bei u. zu den spontanen Geburten," Wien, 1888, ii, p. 144). In the Moscow Maternity there were 84 contracted pelves among 4000 births in 1894; 71 percent, of these cases were spontaneously delivered (Kiister, " Centralblatt f. Gyn.," No. 10, 1895). 2 The infantile death-rate will be at least twenty-five per cent., or more likely higher (Nagel, " Die Wendung bei engen Becken," " Archiv f. Gyn.." Bd .\>xiv). 3 Nagel reports sixty cases of version for contracted pelvis, with a fetal mor- tality of twenty -five per cent, (ibid., p. 168). ANOMALIES IN THE FORCES OF LABOR. 51/ fracture the skull and crush the brain, and the force employed in extraction may break the neck. If in the judgment of the oper- ator the danger entailed upon the fetus by version is too great, natural forces having failed to secure engagement, and if he has tried the forceps cautiously without success, his choice must rest between symphyseotomy and Cesarean section. The former will be selected only in isolated instances with most favorable con- ditions if the conjugate is above seven centimeters ; the latter, always in cases of greater contraction than seven centimeters, and occasionally as a relative indication with a conjugate as large as 8.5 cm. These rules for the treatment of labor obstructed Fig. 394. — Walcher posture : the conjugate of the brim is a black line, and the amount of space gained is a dotted continuation of this line. by a contracted pelvis presuppose, of course, a fetal body and head of average size. This point must always be investigated carefully by abdominal palpation or by mensuration of the fetal head, although it is difficult to determine. 1 If the physician has reason to believe that the child is oversized, he must allow himself sufficient latitude to insure delivery. If the child is undersized 1 The relative size of head and pelvis may be determined approximately by the method of Miiller and Schatz. The fetal head is grasped between the extended fingers of the physician, and is pressed down steadily and for some time upon the pelvic brim, the direction of the force coinciding with the axis of the superior strait. If this manceuver succeeds in pressing the head within the pelvis, then natural forces will surely secure engagement. If it fails, the converse hy no means necessarily follows. Other methods of antepartum fetometry are described on page 454. 5 1 8 THE PA THOL OGY OF LABOR. (a condition easier to detect by palpation than overgrowth), spontaneous delivery may be expected through a pelvis that would not permit the passage of a child of normal size. Klein and Wal- cher declare that by raising the buttocks and letting the limbs hang down as much as possible the conjugate diameter is length- ened by almost a centimeter. Clinical tests of the method are described, attended with success. 1 The Walcher posture has been indorsed by a number of observers in Germany and in Fig. 395. — The Walcher posture. other countries. The author has found it of decided advantage, and recommends its systematic trial. Obstruction to Labor on the Part of the Soft Maternal Structures in the Parturient CanaL — Congenital Anomalies of Development in the Uterus.— A double or septate uterus may com- plicate labor in several ways. The bulk of the unimpregnated half may obstruct delivery, especially if this half is retroverted and is increased considerably in size in sympathy with the de- velopment of the impregnated side, and is hardened in consist- ency by sympathetic contraction during the labor-pains. The 1 "Zeitschrift f. Geburts. u. Gyn.," Bd. xxi, H. 1, and "Med. Korresp. Bl. des Wiirtemb. Aerztl. V.," Bd. lx, 5. Lebedeff and Bartosziurcz, by experiments on 25 cadavers, found that the Walcher position lengthened the conjugate of the inlet from 1-3 mm., "International Congress for Gyn. and Obstet," Amsterdam. Pinzani in 62 observations found an increase of i-S mm., ibid. ANOMALIES IN THE FORCES OF LABOR. 5 1 9 septum itself may prove an obstacle in labor, and sometimes labor is obstructed by the strong vesicorectal ligament that runs between the horns of a bicornate uterus. If the placenta is at- tached to the septum, alarming hemorrhage may occur from im- perfect contraction of the sparsely supplied muscular fibers in it. Malpresentations of the fetus and a faulty direction and insuffi- cient power of the expulsive force are common. Rupture of the uterus is to be feared on account of the ill-developed uterine walls. Laceration of the septum frequently occurs. It has been noted that a decidual membrane may be retained within the non-pregnant half of the uterus, where, undergoing putrefaction after delivery, it may give rise to septic infection. There seems also to be a disposition to the retention of membranes in the pregnant side of the womb. Retention of the placenta is not uncommon, partly because of insufficient expulsive force, partly on account of its situation, — perhaps attached in both divisions of the uterine cavity. The- vard 1 reports the retention of the placenta in a double uterus for fifty days, when it was spontaneously discharged. It has hap- pened, in cases of double uterus and vagina, that the physician ex- amined the wrong side, and was ignorant of the progress of labor until the child was about to be born ; also that he examined first one side and then the other, finding first a dilated and then a contracted external os. In one woman with a double uterus there was noted a dis- position to become pregnant in regular alternation first on one side and then upon the other. 2 It is said that ovulation in these cases occurs in one ovary one month ; in the other, the next. 3 Closure and Contraction of the Cervix. — The cervix may ob- struct labor by reason of atresia, cicatricial infiltration, contrac- tion, and rigidity, or there may be longitudinal or transverse septa in the canal. Atresia of the cervix in a pregnant woman is acquired after impregnation (conglutinalio orificii uteri externi); it is rarely, however, complete. There is always an indication at least of the external os in a dimple evident to the sense of sight if not to that of touch. By pressing upon this point with a finger- nail or with the tip of a uterine sound, a small artificial opening may be made. Directly this is secured, the dilatation of the ex- ternal os proceeds in a remarkably rapid manner, although hours of vigorous labor-pains before had been insufficient to begin it. If this plan fails, a crucial incision must be made in the cervical 1 " Nouvelles Archives d'Obstetrique et de Gynecologie," 1890, p. 640. 2 Southermann, •' Berliner med. Wochen.," 1S79, 41. 3 Guerin-Valmale, "De revolution de la puerperalite dans l'uterus didelphe," " L'Obstetrique," May, 1904. 5 2 O THE PA THOL OGY OF LABOR. tissues at the site of the external os. The dilatation of the small opening thus made is then left to nature. If hemorrhage follows the incisions, the bleeding points should be secured by sutures after the conclusion of labor. An active treatment is always called for. Without it the uterus may rupture, the vaginal portion of the cervix may be torn off from the womb, or the head may emerge completely covered by the enormously distended cervix as by a caul. 1 Cicatri- cial contraction or infiltration of the cervix is the result of old, unre- paired tears, of operations upon the cervix, of cauterization, of syphilis, or of cancer. In the first instance the resistance to dilata- tion is scarcely ever great, and what there is may be almost always overcome by hydrostatic dilators, by the application of the forceps and forcible delivery of the head through the cervical canal, or by the performance of version followed by rapid extraction. If the cicatrices are of syphilitic or of cancerous origin, the obstruc- tion is more serious. It may be overcome by radiating incisions with scissors or with a probe-pointed bistoury, but it is not un- likely to demand the performance of abdominal or vaginal Cesa- rean section. Rigidity of the cervix is seen normally in all primiparae, and to an exaggerated degree in elderly primiparae. It yields often to copious douches of warm water directed against the anterior wall of the cervix and frequently repeated — as often as once every fifteen minutes if necessary. Chloral internally and bella- donna ointment applied directly to the cervix have been recom- mended, but these remedies are not to be depended upon except in the slight rigidity characteristic of all primiparae. If there is delay in such cases, fifteen grains of chloral every fifteen minutes for three doses may advantageously be given. An anesthetic, after all, is the most valuable medicinal agent that we possess for the relaxation of this as well as of other rigid tissues. The rigid cervix yields at length to the steady pressure of the presenting part, and it is rarely necessary on account of rigidity alone to resort to artificial dilatation or to incisions. In the course of a slow dilata- tion of the cervical canal and external os the anterior lip may be- come incarcerated between the head and the pelvic walls. In con- sequence of the pressure and the disturbance of circulation in the part the cervical tissues rapidly become edematous, and the bulk' of the anterior lip becomes so great as actually to constitute a mechanical obstruction to the descent of the head. It is usually possible in such cases to push up the anterior lip over the head and above the symphysis in the intervals between the pains. If there is hypertrophy of the anterior lip in consequence of an old 1 Jeutzen, :< Archives de Tocologie," Paris, 1S90, H. 8. ANOMALIES IN THE FORCES OF LABOR. 521 laceration and eversion, or, all the more, should there be hyper- trophy of the whole infravaginal portion of the cervix, the ob- struction may become quite serious, and it may be impossible to push the cervix above the head. In such cases forcible traction on the forceps or radiating incisions in the cervix may be necessary. Longitudinal septa in the cervical canal are usually seen with duplicity of the uterine cavity from failure of the Mullerian ducts to fuse completely. Occasionally the lack of fusion is confined to the cervical canal alone {uterus biforis). Rarely, transverse septa have been found in the cervical canal. 1 It may be neces- sary to cut them before the child can pass into the vagina. Fig. 396. — Double vagina. Closure and Contraction of the Vagina or Vulva. — There may be obstruction of the lower birth-canal by longitudinal and trans- verse septa, by cicatrices, by hematomata, by partial atresia, either congenital or acquired, by unruptured hymen, by anus vaginalis, by vaginal tumors and cysts, by cystic and solid tumors of the vulva, by enlarged carunculae myrtiformes, by varices, by vaginismus, by congenital narrowness of the vagina 1 Cases are reported by Midler. Breisky, Budin, Henry, Bidder, and Blanc (Pozzi's "Gynecology," vol. ii, p. 456). 522 THE PATHOLOGY OF LABOR. and vulva, and by rigidity of the tissues, especially in elderly primiparae. Longitudinal and transverse septa are not ordinarily very dense in structure, and they give way commonly before the advance of the presenting part. If they do not yield, it is easy to cut them in one or more places, the hemorrhage being con- trolled, if necessary, by sutures afterward, or, in the case of trans- verse septa, by a double ligature applied first, the septum being cut between, though there is not much tendency to bleeding even in those as thick as one's finger (Fig. 398). Fig. 397. — Transverse septum of the vagina (Heyder). Fig. 398. — Anus vestibularis. Dot- ted lines show the limit of mucous membrane ; thickened skin marks the normal site of the anus (Dickinson). Hematomata. — Hematomata of the parturient tract usually occur at the vaginal orifice, and most often between the birth of twins. They are considered here only as mechanical obstacles to labor. If the blood-tumor is large enough to constitute an obstruction to the escape of the child, its walls must be incised and its contents be turned out, and if hemorrhage follows, it must be checked by a firm tampon, preferably of iodoform gauze, in the cavity of the tumor. Extensive cicatrices in the vagina from syphilitic, malignant, or other ulceration, or from former injuries, may be stretched sufficiently by hydrostatic dilators or may be severed by multiple incisions, followed by the application of forceps if the head is ANOMALIES IN THE FORCES OF LABOR. 523 presenting ; but they may be too dense and extensive to yield to these measures, and a Cesarean section may be required. Unruptured Hymen. — An unruptured hymen is not neces- sarily a bar to conception. There are a number of cases on record in which a persistent hymen with a small orifice has ob- structed to some degree the escape of the child's head in labor. In two cases under the author's notice the advance of the pre- senting part ruptured the hymeneal membrane without difficulty, but it has been found necessary by others to incise it. 1 Atresia of the Vagina. — The canal may be obstructed by an annular membrane like the hymen. Although Cesarean section has been done for this condition, it is not required. The advance of the presenting part has dilated the narrowed vaginal canal with less difficulty than it experiences in dilating the cervical canal. The author has seen three cases. At the worst, the obstruction should be overcome by digital, instrumental, or hydro- static dilatation. In complete or almost complete acquired atresia of the lower portion of the vagina, in which insemination has taken place by way of a dilated urethra and a vesicovaginal fistula, the imperforate portion of the vagina may be opened by a transverse incision, the rectum and bladder being guarded by a finger in the one and a sound in the other. In a case of acquired atresia of the vagina in which the canal throughout its whole length was narrowed to a sinus barely admitting a probe, the author was obliged to do a Cesarean section. Anus vaginalis or vestibularis may complicate labor by the accumulation of feces in the rectum, due to the unnatural position of the anus (Fig. 398). In one case in which this anomaly was associated with contraction of the vulvar orifice it was necessary to cut the perineal structures upward from the rectum toward the pubis, in order to permit the escape of the child's head. Cystic and Solid Tumors of the Vagina and J T ulva, Edema, Elephantiasis, Suppuration, and Gangrene. — In the case of solid tumors excision may be necessary, by transfixing the pedicle if they have one, and ligating it to prevent hemorrhage, or by an incision of the vaginal wall over them and their enucleation, fol- lowed by the immediate extraction of the child, and the control of hemorrhage by the needle and thread or by direct pressure. In a case of elephantiasis vulvae under the author's care there was no difficulty in labor. The labia were amputated two weeks afterward. In the case of large cystic tumors a puncture is sufficient to remove the obstruction. Giider 2 collected 60 cases 1 Ahlfeld, " Zeitschrift f. Gelmrtshiilfe und Gynakologie," Bd. xxi, p. 160 ; ibid., Bd. xiv, p. 14. 2 " Ueber Geschwiilste der Vagina als Schwangerschaft und Geburtskompli- kfttionen," " Diss.-Inaug. ," Bern, 1S89. 524 THE PATHOLOGY OF LABOR. of vaginal tumors complicating labor — 23 cysts and echinococcus sacs; 18 fibroids, fibromyomata, and polypi; 14 carcinomata, 1 sarcoma, and 4 hematomata. Delivery was accomplished by the following diverse methods : Spontaneously, 14; by forceps, 18; by version and extraction, 2 ; by traction on the feet, 1 ; by removal or puncture of the tumor, 16 ; by Cesarean section, 7 ; by in- duction of premature labor and craniotomy, 2 ; by premature labor, 3 ; by laparo-elytrotomy, 1 ; by craniotomy 1 ; by pushing back the tumor and extracting the child past it, 2. Among the mothers there were 15 deaths; among the children, 13. In 11 of the mothers and in 22 of the children the result was not reported. Edema of the vulva may be the result of kidney insufficiency Fig- 399-- -Edema and beginning gangrene of the vulva from prolonged pressure in an obstructed labor. Cesarean section (author's case). or of pressure in a prolonged labor. The increased bulk of the dropsical labia may interfere with the escape of the presenting part, or, what is more likely, the edematous tissues lose their elasticity, obstruct labor by their rigidity, and are prone to deep tears at the time of birth and to gangrene afterward. Punctures or incisions in the labia may be necessary to escape more serious injur\ T , but it is well to avoid them if possible, for they are apt to be followed by infection and gangrene. An abscess of Bartholin's gland is seldom large enough to retard labor, though it has done so (Muller), but it is likely to cause trouble afterward. It should be opened freely in the early part of the first stage of labor, curetted, swabbed out with car- bolic acid and glycerin, and packed with iodoform gauze, or completely exsected by a deep dissection. ANOMALIES IN THE FORCES OE LABOR. 525 Gangrene of the vulva is very rare before the termination of labor. Should it exist, it might determine an operator in favor of Cesarean section in a doubtful case, on account of the rigidity of the vulvar tissues, the certainty of laceration, and the likeli- hood of grave infection. Enlarged Carunculcs Myrtiform.es and Varicose Veins. — These tumors do not possess sufficient bulk, as a rule, seriously to ob- struct the last stage of labor. They may, however, be so bruised by the passage of the head as to slough afterward, or the veins in them may be ruptured, giving rise to subcutaneous or frank bleed- ing of an alarming character. Vaginismus may be overcome by an anesthetic. Congenital narrowness of the vagina and vulva is usually overcome by the advance of the presenting part, though often at the ex- pense of vaginal and perineal lacerations. It may be neces- sary to resort to hydrostatic dilatation, or even, in rare in- stances, to Diihrssen's plan of multiple incisions. In the case of extreme narrowness of the vulva there may be a central tear of the perineum, through which the presenting part begins to emerge. To avoid a rectal tear in such a case the perineum should be cut from the anterior border of the perforation to the posterior commissure of the vulva (Fig. 400). Rigidity of the tissues in the cervix, the vaginal wall, and at the outlet occasions delay in the majority of all primiparae, but especially in the case of elderly primiparae — those over thirty years of age. Eckhard found the infantile mortality in such cases to be 19.81 per cent., the maternal mortality to be three times as great as in younger primiparae ; and the necessity for operative interference increases steadily with the age of the primiparae until, in those past forty, almost two-thirds are delivered by some operative procedure, usually forceps. Craniotomy should be done if the child is dead. Version is the least successful opera- tion in these cases. Displacements of the Uterus. — The uterus in labor may be displaced forward ; to either side ; downward ; or backward, by the so-called "sacculation " of the womb. It may be twisted on Fig. 400. — Central tear in the perineum, with contracted vulvar ori- fice (Ribemont-Dessaignes). >6 THE PATHOLOGY OF LABOR. its pedicle, the cervix, or it may form part of the contents of a hernial sac in inguinal or ventral herniae. Anterior Displacement of the Uterus in Labor ; Pendulous Belly. — This is a common anomaly in labor, seen to some degree in all cases of obstructed labor, as in deformed pelvis, and in all cases in which the length of the abdominal cavity is decreased, as in kyphosis. A peculiar example of forward displacement is seen in those rare instances of hernia of the parturient womb between the recti muscles or to one side of the median line dur- ing the second stage of labor (Fig. 40 ij. The pregnant womb Fig 401. — Hernia of the gra%'id womb (Rosner). may fall forward also into an umbilical hernia or into a ventral hernia following celiotomy. The removal of the obstruction to labor in the first class of cases ordinarily obviates the anterior displacement. If the displacement depends not upon obstruction, but upon flaccid abdominal walls, the application of an abdominal binder cor- rects the anteversion. In cases of hernia of the uterus through ANOMALIES IN THE FORCES OF LABOR. 527 the anterior abdominal wall, artificial delivery with forceps or re- version may be necessary; when the uterus is evacuated, it can easily be returned into the abdominal cavity. A tight abdominal binder and the diminution of intra-abdominal pressure after de- livery promotes the approximation of the separated recti muscles. In inguinal hernia the pregnant womb in the hernial sac is usually unicorn or bicorn (Fig. 402). Delivery may be effected by version, and this may be followed by a reduction of the hernia, but it is best to lay open the sac, incise the womb, extract its contents, and then amputate it. Adams 1 has collected ten cases of inguinal hernia of the gravid womb, including Dorin- gius's, which he calls "crural." In eight Cesarean section was done ; in one the delivery was spontaneous. Labor Complicated by a Former Operation to Suspend or Fix the Womb Anteriorly. — The number of operations performed for posterior displacement of the uterus on women of child-bearing age has become so large of recent years that ample opportunity has been afforded to judge of the influence of anterior fixation Fig. 402. — Inguinal hernia containing a gravid womb (Winckel). and suspension of the uterus on pregnancy and childbirth. Dor- land 2 has collected the statistics of 179 pregnancies following operations for ventrosuspension, ventrofixation, and vaginal fixa- tion. It appears from these statistics that, the firmer the womb is fixed and the lower the fundus is fastened, the more certainly will there be serious disturbances in pregnancy and dangerous 1 Adams, "Hernia of the Pregnant Uterus," " Amer. Jour. Obstetrics," vol. xxii, p. 225. 2 " University Med. Mag.," Dec, 1896. 528 THE PA THOL OGY OF LABOR. complications in labor. Thus, abortion occurred in 14 per cent, of the ventrosuspensions and in 27 per cent, of the vaginal fixations. In 12.29 per cent, of all the cases there was dys- tocia, requiring in three instances Cesarean section. The com- plications noted in labor were : inertia uteri, transverse position of the child, abnormal positions of the head, cervical rigidity, uterine rupture, placental anomalies, postpartum and puerperal hemorrhages, and a mechanical obstruction in labor from the thick anterior wall of the uterus, held firmly down over the pelvic inlet, the distention of the uterus in pregnancy having been accom- plished by the expansion mainly of the posterior uterine wall. Pregnancy was seriously disturbed in 8.37 per cent, of the cases, not including those in which abortion occurred, by pain and trac- tion at the site of the incision, dysuria, and excessive nausea and vomiting. A sure indication of the difficulty to be expected in labor is afforded by the behavior of the fundus and cervix of the womb in pregnancy. If the former remains fixed over the pelvic inlet and the latter is steadily drawn upward and backward until it reaches the promontory of the sacrum or actually ascends above it, the labor will be so seriously complicated in all probability that, in the hands of an expert abdominal surgeon, the best results mar be obtained by opening the abdomen and severing the ad- hesions between the fundus uteri and the abdominal wall. If version is demanded in labor at term, great care must be exercised not to rupture the overstretched posterior uterine wall. The best preventive treatment of difficulty in pregnane}- and labor after the operative treatment for posterior displacement is the choice of the appropriate operation and its proper perform- ance. Vaginal fixation should not be selected. Shortening of the round ligaments has not yet given rise to any difficulty in subsequent pregnancies and labors, 1 nor has ventrosuspension, properly performed. If the operator uses fine silk and includes only a portion of the rectus muscle with the peritoneum in the abdominal portion of the stitch, the artificial suspensory ligament is so flexible and stretches so easily that no difficulty need be apprehended if the patient conceives. In only one of the numer- ous women operated upon by the author has there been the slightest complication traceable to the operation in pregnancy and labor, and this was not much more than serious inconvenience during the first six months of pregnancy from drag upon the suspensory ligament. ' Stratz has reported one case of difficulty from a thickened inflamed right round ligament, but the woman had gall-stones and jaundice, and it is not clear that the symptoms were referable to a former Alexander operation. Centrbl. t. Uyn., iNO. 28, 1900. ANOMALIES IN THE FORCES OF LABOR. 529 Lateral Displacement. — A tilting of the uterus to the right side is a physiological occurrence in pregnant and parturient women. The lateral inclination is sometimes exaggerated to such a degree that a great part of the expulsive force is lost by the propulsion of the presenting part against the lateral wall of the pelvis. The displacement may be corrected by turning the woman on the side — usually the right — toward which the fundus uteri is in- clined, and placing under her flank a rolled blanket or a pillow. Sacculation of the Uterus. — A backward displacement of the gravid womb in rare cases goes on to full development by what is called " posterior sacculation," the distention of the uterus to accommodate the full-grown fetus being accomplished by stretch- ing the anterior uterine wall, the posterior wall and the fundus remaining fixed within the pelvis (Fig. 405). In these cases the cervix is high above the pelvic inlet and is pressed close against the anterior abdominal wall, the posterior vaginal wall bulges out- ward and downward, and fetal parts can be felt through it with a distinctness that suggests ab- dominal pregnancy. Cesarean section has in one instance at least been performed on account of this anomaly, but a study of recorded cases shows it to be unnecessary. By the artificial dilatation of the cervical canal and the performance of podalic version, delivery may be effected without difficulty. Partial P rolapse with Hyper- trophic Elongation of the Cervix. — It is impossible for pregnancy to proceed to term with com- plete prolapse of the womb, although the size of the uterine tumor projecting from the vulva in some cases has given rise to a belief in this possibility (Fig. 403). A careful examination has always shown the major portion of the uterine body to be within the pelvic and abdominal cavities. Commonly, the fundus is at a normal level, and the descent of the cervix has been accomplished by stretching the lower uterine segment and by hypertrophic elongation of the cervix itself. When the contraction of the 34 Fig. 403. — Partial prolapse of the womb in labor (Wagner). 53° THE PATHOLOGY OF LABOR, uterine muscle begins in labor, a partial prolapse of the womb is usually spontaneously corrected by the retraction of the cervix Fig. 404. — Prolapse of a double uterus in a pregnant woman (Maygrier) -^1 Fig. 405. — Sacculation of the uterus (Oldham). Fig 4o5. — Partial prolapse of the womb and hypertrophy of the cervix (Faivre). within the vagina. This the author has seen in several instances. In exceptional cases, however, — usually on account of a rigid cervix, — the prolapse becomes aggravated or suddenly makes its ANOMALIES IN THE FORCES OF LABOR. 531 appearance, and the cervical tissues, growing edematous and be' coming enormously swollen, constitute, by their bulk and in- creased rigidity, a serious obstruction to the delivery of the child. Fig. 407. — Partial prolapse of the womb and hypertrophy of the cervix : A, Lateral position; B, dorsal position ; C, cervix ; V, bladder (Faivre). Fig. 408. — Displacement of the cervix (Dickinson). This difficulty was overcome in an ingenious manner in a case reported by Faivre ' The woman was placed in the dorsal posi- 1 " Nouvelles Archives d'Obstetrique," 1890. 532 THE PA THOL OGY OF LAB OR. tion across the bed, a forceps was applied to the child's head, and an assistant, standing astride the woman's body, hooked his ringers into the cervix and pulled upward to counteract the traction of the forceps upon the child's head and the incarcerated cervical tissues. It may be necessary in such a case to enlarge the cervical canal by radiating incisions. The hemorrhage following is con- trolled temporarily by clamping sutures over the wounded surfaces without uniting them (Figs. 406, 407). Displacement of the Cervix. — It is not uncommon, in prim- iparae with a narrow cervical canal, for the cervix to be displaced backward, so that the external os, almost inaccessible to the ex- amining finger, points directly backward or even backward and upward. The anterior lower uterine segment is much distended by the presenting part and occupies the whole vaginal vault. The expulsive force in labor is exerted against the lower uterine seg- ment, and the cervical canal remains undilated. The difficulty may be overcome by applying an abdominal binder and by hooking the cervix forward with the ringer during two or three pains (Fig. 408). Tumors of the Genital Canal. — Carcinoma of the Cervix. — In 34 per cent, of the cases cancer of the cervix interrupts gestation at various stages (Muller). If the disease is not too far ad- vanced ; if it is confined to one lip of the cervix, and that the anterior ; and if there is not too much cicatricial infiltration around its periphery and the cervical walls, labor may be ter- minated spontaneously, but this is exceptional. The per- formance of Cesarean section is commonly the proper treat- ment for labor obstructed by carcinoma of the cervix, and this operation should be selected if there is good reason to doubt the possibility of spontaneous or artificially assisted delivery by the natural passage-way. If the disease is far advanced, the woman's life is surely doomed in the near future, and the child at any rate should be saved, even at considerable risk to the mother. It may be desirable to operate before the fetus has reached maturity, if the disease is making such rapid progress that the woman is likely to die before the natural end of pregnancy, or if the cancer is still in the operable stage. An abdominal or vaginal pan- hysterectomy should follow the Cesarean section, if possible. Fibromata. — Fibroids of the uterus and cervix low enough in situation to become incarcerated in the pelvis are likely to be insuperable obstructions in labor, besides complicating par- turition by favoring abnormal positions of the child, by pre- disposing to adherence of the placenta, to prolapse of the ex- tremities and cord, and to hemorrhage during and after labor. If the tumor grows on the anterior wall of the uterus, the first few labor-pains and the contraction of the longitudinal fibers of the cervix may dislodge it above the pelvic brim, though it had ANOMALIES IN THE FORCES OF LABOR. 533 been impossible to do this before by manipulation. The author has seen one such case. It is also possible for tumors on the anterior wall of the cervix to be pushed out of the vulva in front of the presenting part, thus making room for the escape of the latter. If, however, the tumor is situated laterally or posteriorly, its artificial displacement upward into the abdominal cavity, so that the child may escape past it, is often impracticable (Fig. 409). On the contrary, the attempt at descent of the presenting part in labor may fix it more firmly in the pelvic cavity. 1 In this case, if attempts under anesthesia to dislodge the tumor and to push it above the pelvic brim fail, a Porro-Cesarean operation should be performed, even though the tumor is not of so great a Fig. 409. — Large fibroid blocking the pelvis (Spiegelberg). size as absolutely to prevent the delivery of the child. The physician must consider the effect upon it, owing to its low vitality, of the pressure to which it will be subjected by dragging 1 It is barely possible that a tumor low down on the posterior wall of the cervix, the most unfavorable of all positions, may be suddenly elevated after many hours of labor, and thus allow a spontaneous delivery ; but this event is not to be counted on ; n practice. 534 THE PATHOLOGY OF LABOR. the child past it (Fig. 410). Sloughing, gangrene, and fatal in- fection are likely to follow. This was the history of the case illustrated in figure 410, communicated to the author by Dr. J. P. Simpson, of South Carolina. If the fibroid is submucous and grows from the cervix, it may be enucleated when labor begins. The bed of the tumor should be packed with gauze after labor. 1 It is, unfortunately, a common error to overlook a fibroid tumor obstructing the pelvis in labor, or to mistake it for the fetal head. The woman is allowed to die of ruptured uterus, exhaustion, or hemorrhage, while the physician is waiting for the descent of the presenting part, or is endeavoring to apply the forceps to what he takes to be the head. Ordinary care and a little experience in making obstetrical examinations should guard a practitioner against such an egregious mistake. The prognosis of 1 ab o r complicated by a fibroid tumor depends upon the early recognition of the growth and upon the treatment. In general practice the results have hitherto been bad. Xauss found a maternal mor- tality of 54 per cent, among 225 women and an infantile mortality of 57 per cent, in 1 17 cases. Siisserott found in 147 cases a maternal mor- tality of 50 per cent, and an infantile mortality of 66 per cent. 2 In Lefour's statistics of 300 cases of fibroids complicating labor, the mortality of deliver}' by the natural passage was 25 to 55 per cent, for the mothers, jj per cent, for the children. 3 1 Sutugin is an enthusiastic advocate of vaginal operations for all cases of fibroids impacted in the small pelvis. For intramural tumors the cervix is split until the tumor is reached. For subserous tumors the vaginal vault is opened. Nine such operations sub partu are reported with only one death (Jahresb. ii. d. Fortsch. a. d. Gebiete der Geburtsh.," etc., vol. v, p. 175). 2 Sutugin, loc. cit. A valuable table of statistics showing the result of various treatments for fibroids in the child-bearing process was presented by Armand Routh at the British Medical Association Meeting in 1903. See also Tate, " Am. Journ. ofObst.," November, 1902; Partridge, " Prov. Med. Journ.," Sept., 1903. 3 Phillips, :< Brit. Med. Jour.," 1888, i, p. 331. Fig. 410. — Small fibroid past which the child was extracted. The tumor became gangrenous, and the woman died (Simpson). ANOMALIES IN THE FORCES OF LABOR. 535 A fibroid tumor may prolapse into the pelvis after the birth of the child and prevent the delivery of the placenta. The au- thor has performed Cesarean section (Porro) twice, myomectomy twice, and hysterectomy twice in the puerperium for fibroids complicating the child-bearing process without a death, although in four cases the tumor was necrotic. The tumor may practically disappear during the involution of the uterus. Every year the author sees a case or two of spon- taneous cure in this way. There is, however, a strong disposi- tion to infection after labor in the weakly resisting structure of a fibromyoma. In two-thirds of the author's operative cases celi- otomy was required during the puerperium — myomectomy twice and hysterectomy twice. Fig. 411. — Large subperitoneal fibroma reaching from the fundus uteri to the liver; removed by myomectomy on tenth day of puerperium for infection ^recovery). Polypi. — Polypoid tumors obstructing labor usually spring from the cervical canal or the anterior lip of the cervix, and are commonly mucous in character. They may, however, be fibro- nryomatous, fibrous, or sarcomatous, and may have a situation high in the uterine cavity or in its wall. They ma)- increase very markedly in size during pregnane}-. The pedicle is usually small, and in the case of cervical polypi their removal is easy. The opera- tion should be postponed, however, until the woman falls into 536 THE PA THOL OGY OF LABOR. labor, for any operative interference in this region would very likely interrupt gestation. When the dilatation of the os begins, the pedicle may be transfixed and ligated and the tumor be cut away. Even if these growths are not sufficient in bulk to obstruct parturition mechanically, they have been known to give rise to profuse hemorrhage in the first few days of the puerperium, and their removal is desirable, therefore, even though they be small in size. In the case of fibromyomatous polypi of the uterine body, the tumor has on rare occasions been torn from its pedicle during labor and has been expelled in front of the child. Fig. 412. — Subperitoneal fibromata. The growth attached to the lower uterine segment was impacted in the pelvis, insuperably obstructing labor. Celiohysterecto- my : woman recovered, although she had been in labor four days ; child dead (author's case). Tumors of Neighboring Organs. — Ovarian Cysts. — An ovarian cyst is a rare complication of labor. In 17,832 births in the Berlin Frauenklinik, an ovarian cyst was found only five times. McKerron, 1 however, was able to collect 1290 cases of ovarian tumor complicating the child-bearing process. The number of abortions in pregnancies complicated by ovarian cysts is some- what larger than common. Of 321 pregnancies complicated 1 "Pregnancv, La! or and Childbed with Ovarian Tumor," London, 1903. ANOMALIES IN THE FORCES OF LABOR. 537 by ovarian cysts, there was premature interruption in 55 (Remy). If the cyst is discovered during pregnancy, its removal should be attempted. Ovariotomy during gestation is not necessarily a difficult or dangerous operation, nor does it, as a rule, interrupt pregnancy. 1 If the tumor is first discovered after the woman has fallen into labor, and if it has been displaced downward into the pelvic cavity and is incarcerated, resisting all efforts to dis- place it upward, even under anesthesia, its puncture through the vaginal vault, after a thorough cleansing of the vaginal mucous membrane and with a thoroughly aseptic technic, might 1 m v \rf ;J y i" * "s » '■' Fig- 4*3- — lJcrmoid cyst containing hair and teeth and puerperal uteius, removed in a Porro-Cesarean section (author's case). suffice if one were sure that the cyst were monolocular and not a dermoid; but it is impossible to know this beforehand. It is better to perform a Cesarean section followed by the removal of the tumor. 2 By this plan many dangers in the puerperium are escaped. Twisted pedicle, intracystic bleeding and shock, occlusion of the bowels, rupture of the cyst, suppuration of the 1 Dsirne has collected statistics of 135 operations with a mortality of 5.9 per cent. Pregnancy is interrupted by the operation in about 20 per cent, of cases (Flaischlen, " Zeitschrift f. Geburtshiilfe," xxix, p. 49). Heil's statistics of 241 operations gives a mortality of 2. 1 percent, and interrupted pregnancy in 19.47 per cent. ("Munch, med. Wochenschr.," Jan. 19, 1904). 2 1 have performed Cesarean section twice for large dermoids impacted in the pelvis ob-tructing labor, with a successful result for both mother and child. My experience in ovarian cysts complicating the childbearing process amounts to nine operations in eight individuals: two, small dermoids, removed in pregnancy; 3 operated on in labor; 2 Cesarean sections ; one vaginal puncture, the latter being a multilocular cyst, the two former, dermoids ; 4 removed in the puerperium on account of infection. One of the last-named died from septic intoxication, the only fatal result. One was removed on the sixth day of the puerperium on account of gangrene and peritonitis the result of a twisted pedicle. 538 THE PATHOLOGY OF LABOR. cyst-contents, and consequent peritonitis are all surely avoided. A number of cases treated thus should give a better mortality record than has hitherto been secured. Another plan of treatment which has yielded good results is vaginal ovariotomy, 1 if the tumor is of moderate size. The posterior vaginal vault and Douglas' pouch are opened, the tumor is punctured and extracted col- lapsed, the pedicle is ligated and the tumor excised. The vaginal wound is either packed with gauze and united after delivery or closed before the extraction of the child. In Heiberg's statistics of 271 cases there was a maternal mortality in pregnancy of more than 25 per cent, and a fetal mortality of more than 66 per cent. In deliveries by forceps without puncture of the cyst the maternal death-rate has been 50 per cent.; with puncture, almost as great; and after version without puncture, more than 50 per cent. Flai- schlen recommends the vaginal puncture, or, if necessary, a vaginal incision and thorough evacuation of the tumor, then the delivery of the child, and on the following day at the latest an abdominal section for the removal of the tumor. This procedure does not seem to me so good a plan as the coincident Cesarean section and ovariectomy. Should the physician prefer vaginal puncture, — which requires, of course, no special surgical skill, — he should remember that if the tumor is densely adherent, possesses thick walls, and possibly is a dermoid cyst, puncture through the vaginal vault is likely to be followed by gangrene of the tumor-contents and walls and by general infection. The infection of the tumor necessi- tates a hurried abdominal section in the puerperium, with the pa- tient in a bad condition to endure it. Moreover, if the cyst is multi- locular, it may be impossible to reduce its size sufficiently by vaginal puncture to permit the delivery of a living infant. The author has experienced both the disadvantages of this plan of treatment. It has been claimed that an ovarian cyst obstructing labor should be removed by celiotomy and that then the labor should be terminated by the natural passage, but to subject a woman to a labor that might prove tedious and exhausting or might require a difficult forceps operation directly after an abdominal section does not seem to the author good surgical judgment. Spontaneous delivery in spite of an ovarian cyst incarcerated in the pelvis has been noted after the cyst ruptured, after it had been spontaneously dislodged upward above the pelvic brim, or had ruptured the vaginal vault or the rectum. As an ovarian cyst must be impacted in the pelvis to obstruct the delivery of the child, it is easily understood that there is more difficulty and danger in labor from a small than from a large tumor (Fig. 414). After the child is born, a cyst that had before been above. the brim may descend into the pelvis and obstruct the delivery of the placenta. ANOMALIES IN THE FORCES OF LABOR. 539 If the ovarian cyst has not been removed during pregnancy, is in the upper part of the abdomen, out of the way in labor, it may be disregarded until the woman is delivered. It is good practice to remove it in the first 48 hours of the puerperium, thus avoiding the possibility of twisted pedicle and infection, or at the latest as soon as the puerperal convalescence is completed. Vaginal Enterocele. — Vaginal hernia is a very rare obstruction in labor. The author has been able to collect but 27 cases from medical literature. Of these, only two were anterior entero- celes ; the others were lateral and posterior. The distention of the hernial sac in labor is apt to become excessive, and to threaten its rupture with protrusion of intestinal loops. An effort should be made to reduce the hernia as soon as it is discovered. The reduction may be facilitated by placing the woman in the knee- breast posture and by inserting the whole hand into the vagina. If this treatment is instituted in pregnancy, it should be followed by the insertion of a large tampon or a globe pessary and by pro- longed rest in bed ; in labor the presenting part should imme- diately be brought down past the hernial ring. If there are adhesions about the latter, preventing the reduction of the hernia, Fig. 414. — Ovarian tumor incarcerated in the pelvis during labor. Fig. 415. — Cystocele obstructing labor. the tumor should be supported and held to one side by assistants while the child is artificially extracted by forceps or after version. Should the sac rupture and the intestines protrude, the child must be delivered hastily, the intestines be cleansed thoroughly and replaced, and the opening be sewed up. In the case of a very large irreducible vaginal hernia, Cesarean section would be preferable in a labor at term. Other growths or tumors in the pelvic inlet and cavity obstruct- 5 40 THE PA THOL OGY OF LAB OR. ing labor have been fibrocystic tumors of the ovarian ligament, re- quiring an abdominal section ; fibroma of the ovary ; sarcoma of the ovary ; a displaced adherent kidney at the pelvic inlet, necessitat- ing version and forcible extraction, or possibly, as was done suc- cessfully by Cragin, vaginal section and removal of the tumor ; l hydatid cysts of the pelvis, demanding Cesarean section; 2 a dis- placed and enlarged spleen; masses of exudate, caseous lymph glands, and an aneurysm of the gluteal artery. A cystocele and a rectocele should be replaced if they pro- trude to a great extent in front of the head, and should be held back until a forceps is applied and the head is pulled past them (Fig. 415)- Version and extraction have occasionally been found necessary. Large fecal masses in the rectum must be re- moved by an enema or must be dug out. 3 Calculi in the blad- der should, if possible, be discovered and removed by the urethra or by vaginal lithotomy before the second stage of labor. They may become nipped between the head and the pubic bones, and may pinch a hole through the anterior vaginal wall and bladder if they are overlooked or neglected. 4 The diagnosis of vesical calculus in the parturient woman is difficult : it has been taken for a pelvic exostosis or some other pelvic tumor, and in one case at least Cesarean section was performed on account of this mistake. Fortunately, vesical calculus in the female is rare. In 10,000 women examined by Winckel in fifteen years, it was found only once. The following conditions in and about the rectum may pre- sent mechanical obstacles to delivery : Cancer, anus vestibularis or vaginalis, foreign bodies, contraction of the levator ani mus- cles, benignant tumors, such as cysts of the rectum, ovarian cysts which have perforated the rectum, and retrorectal dermoid cysts. Each of these conditions must be treated according to the indi- vidual indications. Incisions in the perineum may be required, foreign bodies must be removed, resisting muscles on the pelvic floor may be overcome by an anesthetic and by the application of forceps, and cystic tumors should be punctured or removed 1 Runge reports four cases (" Archiv f. Gyn.," xli, p. 99). The writer has had one. AlbersSchoenberg reports another in which the uterus ruptured ( " Centralblatt f. Gyn.," Dec. 1, 1894). Cragin has collected six cases including his own ("Am. Jour, of Obstet.," vol. xxxviii, p. 37). 2 " Les Kystes Hydatiques du Bassin et de 1' Abdomen au point de vue de la dystocie," J. Franta, "Ann. de Gyn. et d'Obstet ," Mar., 1902. 3 Corradi reports a case in which seven pounds of hardened feces were removed before the woman was delivered. 4 Kotschurowa has reported a case in which labor lasted three days. At the end of that time a gangrenous tumor protruded from the vulva, which proved to be the bladder and anterior vaginal wall. The midwife in attendance perforated the tumor with her finger, whereupon a calculus eighty-five grains in weight was dis- charged ( " Tahresbericht ii. d. Fortschr. a. d. Gebiete der Geburtsh.," etc . vi, 225) ANOMALIES IN THE FORCES OF LABOR. 541 after ligation of their pedicles. Cancer of the rectum may demand Cesarean section by reason of the size of the tumor and the cicatricial infiltration of the birth-canal, as in Freund's case. Obstruction in Labor on the Part of the Fetus. — Over= growth of the Fetus. — Excessive overgrowth of the fetus is rare. In 1000 children in the Maternity Hospital of Philadelphia only one weighed more than 1 2 pounds. The largest child the author has ever seen weighed 15 pounds, weights of 15, 16, 18, 23^, and 28f pounds have been recorded. The causes of overgrowth in the fetus are prolongation of pregnancy, over- size and ad- vanced age of one or both par- ents, and multi- parity. Rarely, it may be inex- plicable. The first named is, in the writer's experience, the most common cause. In six per cent, of women pregnancy may be expected to be prolonged be- yond the three- hundredth day, and for every day that the fetus is retained in the womb beyond the usual time there is an increase in its size and weight above the normal. So much difficulty and danger may be experienced from this cause that it is a good rule in practice to allow no woman to exceed the normal duration of pregnancy by more than two weeks. By inducing labor at that time one occasionally interferes unnecessarily, but he often avoids complications and difficulties of the most serious nature. Oversized and advanced age of one or both parents may be a cause of overgrowth in the fetus — the latter usually because it predisposes to a prolongation of pregnancy. It is commonly Fig. 416. — Overgrowth of head obstructing labor. 542 THE PATHOLOGY OF LABOR. asserted that the size of children increases in successive pregnan- cies up to the fourth or fifth, and then remains stationary or even decreases ; but there are important exceptions to this rule. The writer has seen the tenth child vastly exceed in size the nine pre- ceding ; it weighed 1 5 pounds, and it was necessary to deliver it by Cesarean section. The other children had been born natu- rally through a fiat pelvis with a conjugate diameter of nine centi- Fig. 417. — Dicephalus. Fig. 418. — Dicephalus. Fig. 419. — Lymphangioma. Fig. 420. — Craniopagus. Fig. 421. — Ischiopagus parasiticus. meters. The increase in size of successive children must be borne in mind in cases of contracted pelvis. The first two or three infants may be delivered spontaneously, but the larger size of the fourth or fifth may make natural delivery impossible. 1 1 Lehmann in 712 labors through 198 contracted pelves found increasing diffi- culty in delivery with each succeeding labor. In first labors 50 per cent, ended spon- taneously ; in second, 43.8 ; in fourth, 38.4; in fifth, 33 "^ 5 and in labors after the fifth only 9.8 per cent. ("Diss. Inaug.," Berlin, 1891). ANOMALIES IN THE FORCES OF LABOR. 543 Overgrowth of the fetus is the most difficult condition in obstetric practice to diagnosticate with precision. A careful pal- pation of the head and body and an attempt to push the former into the pelvic inlet may give one an approximate idea of the Fig. 422. — Dipygus (Wells) Fig. 423. — Dipygus parasiticus. Fig. 424.— Prosopothoracopagus. Fig. 425.— Xiphopagus. Fig. 426— Janiceps. relative size of fetal body and pelvic canal, and the methods of antepartum fetometry already described may enable the physician to estimate the size of the fetal head accurately, but as a matter of fact the large size of the fetus is usually discovered in practice only after prolonged delay when attempts at artificial delivery 5 44 THE PA THOL OGY OF LABOR, especially by version, have failed. By this time the fetus is com- monly dead, and should be delivered by embryotomy. But the practitioner must be on his guard against futile attempts to de- liver an infant too large, even when mutilated, to pass through the pelvis. The writer has seen, in consultation practice, several maternal deaths due to this cause. Premature Ossification of Cranium ; Wormian Bones ; 1 Large Heads ; Malformations and Tumors of the Fetus. — No single rule Fig. 427. — Dicephalus : neither head engaged. of treatment can be laid down for the management of these cases. Forceps, version, or some form of embryotomy is usually de- manded. Spontaneous labor, however, is possible even in cases of monstrous bulk in which delivery through the birth-canal 1 Dr. Grace Peckam ("New York Med. Record," April 14, 1S88) has reported three still-births, attributed in each instance to the development of Wormian bones in the smaller fontanel, and to the consequent interference with overlapping of the cra- nial bones at the sutures. This observation has not yet been verified by others. ANOMALIES IN THE FORCES OF LABOR. 54. : Fig. 428. — Hydrencephalocele (anterior). Fig. 429. — Sacral teratoma obstructing labor. 35 546 THE PATHOLOGY OF LABOR. would seem out of the question. Thus, in double monsters joined loosely by the front or back (xiphopagus, the Siamese twins ; pygopagus, the Hungarian sisters), one child maybe born Fig. 430. — Sacral teratoma. by the head, the other afterward by the breech, or vice versa. In dicephali one head may be pressed into the neck of the other or may rest upon the iliac bone of the mother until the first head makes its escape from the vulva. Even in thoracopagus, the Fig. 431. — Myxoma of neck (Longaker). Fig. 432. — Sacral tumor (Mutter Museum, College of Physicians). commonest double monstrosity, in which two trunks are inti- mately joined front to front, spontaneous labor is possible by the mechanism shown in figure 435. On the other hand, the ANOMALIES IN THE FORCES OF LABOR. 547 greatest difficulty may be encountered in labor, and a Cesarean section may be necessary. 1 Fig. 433. — Anasarca. Fig. 434. — Mechanism of labor with dicephalus (Kiistner). Fig. 435. — Mechanism of labor in thora- copagus (Kiistner). Fetal tumors obstructing delivery may be hydrencephaloceles, lymphangiomata, myxomata, sacral teratomata. Cystic tumors should be punctured. Solid tumors may call for version or for 'There are two recorded deliveries of thoracopagi by Cesarean section (Hirst and Piersol, " Human Monstrosities"). 548 THE PA THOLOG V OF LABOR. embryotomy. In a case of sacral teratoma, the child presenting by the umbilicus, the author found it necessary to eviscerate the infant before it could be extracted. The tumor has been ampu- tated, embryotomy and version have been performed. The tumor not infrequently ruptures and often the labor is easy because the fetus is premature. 1 Craniotomy may be required in monstrous enlargement of the cephalic extremity, as in syncephalus or in diprosopus. Decapitation may be necessary in duplicity of the cephalic extremity, as in dicephalus or in thoracopagus. In Reina's case of tricephalus the first head was perforated and then amputated, the second was perforated, crushed, and amputated, and the third was amputated. Diseases and Death of the Fetus. — All diseases of the fetus that increase its bulk may obstruct labor. Cystic tumors, effu- sions in the serous cavities, anasarca, an enlarged liver, polycystic disease of the kidneys, 2 and distended bladder from atresia of the urethra 3 are examples. Liquid accumulations should be evacuated by puncture or by incisions. Hydrocephalus is the most important of the diseases increasing fetal bulk. It is not very rare, 4 is often overlooked, and is a frequent cause of ruptured uterus. The diagnosis may be made by a vaginal examination, by abdominal palpation, and by a com- bined examination, or, if necessary, by anesthetizing the woman, introducing the whole hand into the vagina, and thoroughly palpating the enlarged head resting above the pelvic brim. The gaping fontanel, the great width of the sutures, the fluctua- tion within the cranium, the large size of the head appreciated by bimanual examination, and possibly the abnormal mobility of the cranial bones, and in some cases their extreme tenuity, indicate the condition. Hydrocephalus is very often overlooked in practice as the result usually of a careless, superficial examination. A painstaking and methodical investigation of a suspected case should obviate this error. There are cases, however, in which there is no increased width of the sutures, no enlargement of the fon- tanels, and such slight enlargement of the head that it can not be appreciated; and yet the fluid contents of the cranium pre- vent compression of the skull and make the engagement of the 1 For interesting statistics of this condition see Utbmol'er, "Ueber Geburten bei Iteisstumoren," " Monatsehr. f. Geb. u. Gyn.," Dec, 1903. Of the collected cases 126 have been girls, 60 boys. The frequency is reckoned at I-34, 582 births. 2 Fussell, "Med. News," Philadelphia, 1891, p. 40. 3 Schvvyzer (" Archiv f. Gyn.." Bd. xliii) has collected 13 cases of dilatation of the fetal bladder from atresia of the urethra, stenosis of the urethra, and obstruction of the urethra by a valve-like formation of mucous membrane. Miiller reports a case and quotes another (" Archiv f. Gyn." Bd. xlvii, H. I). 4 Schuchard found it sixteen times in 12,055 births; I.achapelle and Duges, fifteen times in 43,555 ; Merriman, once in 900. In 159 cases there were 38 maternal deaths, 20 of which were from rupture of the uterus. ANOMALIES IN THE FORCES OF LABOR. 549 head impossible. The writer has seen one such case (see Fig. 436). Hydrocephalus should always be suspected if the head in labor remains above the brim, although the pelvis is normal in size and no good reason can be found for the failure of engagement. The treatment of labor obstructed by hydrocephalus is punc- ture of the cranium with a perforator and evacuation of its fluid contents. A child with this disease deserves no consideration. After the reduction in the size of the head the labor may be left to the natural forces. If these prove insufficient, a cranioclast may be fastened to the skull and the child be extracted artificially. A cardinal rule in the treatment of these cases is to avoid at- tempts to deliver with forceps — a common error in practice, and one that has cost many a woman her life from ruptured uterus, */ f Fig. 436- — Hydrocephalus: very moderate distention of the cranium, but sufficient to prove an insuperable ob- stacle in labor. Fig. 437. — Hydrocephalus: enormous collection of fluid (author's collection: specimen presented by Dr. Alex. Fulton). from deep tears when the instrument slips, as it will, and from extensive sloughs after delivery. If the pelvic extremity of the hydrocephalic fetus presents, — as it does in almost a third of all cases, — and if the head remains inaccessible above the superior strait, so that it can not easily be punctured, the spinal canal may be opened, a catheter be passed 550 THE PATHOLOGY OF LABOR. through it into the cranial cavity (Van Huevel's method), and the fluid thus be evacuated (Fig. 438). Usually, however, there is no special difficulty or danger in the delivery of the after- coming head of a hydrocephalic infant. The force required for its extraction not infrequently ruptures the walls of the ventricles and converts the case into one of external hydrocephalus, or possibly drives the fluid out of the foramen magnum into the tissues of the neck and back, so reducing the bulk of the head as to permit its extraction. At any rate, the condition can Fig. 438. — Tapping a hydrocephalus through the spinal canal (Varnier). scarcely escape the notice of the medical attendant, and a diag- nosis is made before the lower uterine segment is dangerously stretched or ruptured. The head may be punctured through the roof of the mouth, through the foramen magnum, or behind the ear. ANOMALIES IN THE FORCES OF LABOR. 551 The difficulty in the delivery of a hydrocephalic fetus is not in direct proportion to the quantity of fluid in the ventricles and the size of the head. In cases of extreme distention, the cranial vault is likely to rupture, while in moderate grades of hydro- cephalus the quantity of brain-substance surrounding the ven- tricles and the strength of the brain-membranes forbid this means of spontaneous delivery. Malpresentations and faulty positions include shoulder, face, brow, deviated vertex, and compound presentations. All but Fig. 439. — Compound presentation : head and hand. Braun's section of a multipara who committed suicide by hanging in the last month of pregnancy : a, Venous sinuses ; b, uterovesical reflection of peritoneum ; c, symphysis pubis ; d, bladder; e, vagina; f, first lumbar vertebra ; g, promontory of sacrum; //, rectum; i, cervix ; J, pouch of Douglas. the last are considered elsewhere. By compound presentation is meant the presentation of two or more parts at the same time, as a head and a hand, a head and a foot, a hand and a foot, 552 THE PA THOL OGY OF LAB OR. nuchal position of the arm, or the head and all four extrem- ities. A compound presentation is met with about once in 250 labors. It is usually a head and a hand. The following table is furnished by Pernice from 2891 births in the clinic at Halle : Hand and head, 26 Arm and head, 8 Hand and umbilical cord, 5 Both hands, 4 Foot and hand, ..... 2 Two hands, umbilical cord, and foot, I Face, hand, and cord, I Kietz found in 7555 labors the foot and head presenting in 23. x The cause of compound presentations is usually a lack of Fig. 440. — Compound presentation : head and foot (author's case). conformity in the presenting part with the pelvic inlet, as in mal- position of the fetus, a head of abnormal size, a displaced uterus, twins, hydramnios, contracted pelvis, and anomalous shape of the uterus. In the treatment of compound presentations before rupture of the membranes an attempt should be made to overcome the difficulty by postural treatment. The woman should be placed on that side opposite the prolapsed extremity. After rupture of 1 "Diss. Inaug. ," Berlin, 1890. ANOMALIES IN THE FORCES OF LABOR. 553 the membranes an attempt should be made to dislodge the pro- lapsed extremity and to restore it to its natural position. Version may, however, be required if this attempt fails, or even crani- otomy if the child is dead. If the head and extremities present, and if the former is engaged, it is usually best to apply forceps and to disregard the prolapsed extremities. In the case of nuchal position of the arm, an effort should be made to dislodge the latter, but it may be necessary to fracture it before the delivery of the child can be secured. Fig. 441. — Twins; breech and face presentations. Multiple Births. — Twin labors are usually easy and uncom- plicated (75 per cent.), but complications are more frequent than in single labors. Malpresentations are common. The following table from Spiegelberg, based on 1138 labors, gives the combined presentations in the order of their frequency : Both heads presenting, 40 per cent. Head and breech, 31-7° " Both pelvic presentations, S.60 " ''■ Head and transverse, 6. 18 " " Breech and transverse, 4-14 " " Both transverse, 35 " " 554 THE PATHOLOGY OF LABOR. It may be noted that a transverse position is found in 10.67 per cent, of cases. Mechanical difficulties in labor are frequent : the uterine muscle is usually weakened by overstretching, and there may be trouble in the third stage of labor in the delivery of the placenta. Some form of operative interference is demanded in about 25 per cent, of all cases. Fig. 442 — Impaction of heads in twin labor. Fig. 443 — Locking of heads in twin labor. In the majority of cases (79 per cent.) the interval between the delivery of twins is less than an hour. 1 A longer delay than this indicates the likelihood of some obstruction to the birth of the second infant or a failure of expulsive forces. 1 In the " Semaine Med.," 1904, ii, 27, Paulin reports an interval of twenty-one days between the birth of twins. It was subsequently discovered that there was a uterus bicornis unicollis. This is probably the explanation of the cases occasionally reported of the birth of children weeks and even months apart. ANOMALIES IN THE FORCES OF LABOR. 555 jg&^. Serious difficulty in twin labors may arise in one of three ways: Both heads present at once, one a little in advance of the other, the second impacted in the neck of the first (Fig. 442); the first child descends by the breech, and the head of the second child is caught by the chin of the first and pushed into the pelvis (Fig. 443) ; one child sits astride of the other, which is transverse. If both children should be found attempting to engage by the head in the superior strait at one time, one child should be retarded while the other is artificially extracted. If this is impossible, the first head should be extracted by forceps, the second be treated in like manner, and then the trunks should be delivered one after the other. Embryotomy is a last resort, but is scarcely ever necessary. A coiling of the cords (Fig. 444) and their entanglement may be a source of difficulty and delay in unioval twins. It may be necessary to cut one or both cords between ligatures before the children can be delivered. In case one child presents by the head and the other by the feet, both may come down together, and the two heads become locked in the pel- vic entrance and canal. An effort may be made to push back the child presenting by the head. If this suc- ceeds, the child presenting by the breech should be extracted immedi- ately, for it is in imminent danger from asphyxia. It may be possible with forceps to pull the child pre- senting by the head past the body of its fellow presenting by the breech. Failing in these attempts, the child presenting by the breech will almost surely have died, and there will be no pulsation in its cord. It should then be decapitated, whereupon the infant presenting by the head can be extracted without difficulty by forceps. In any case of twin labor, as soon as the first child is born, and the cord, ligated with a double ligature, is cut, the attendant should immediately investigate the position and presentation of the second child. A neglect of this rule leads very often to the impaction of an unrecognized shoulder presentation in the second child, and its consequent death. If an abnormality is discovered in the presentation of the second child, it should at once be cor- V Fig. 444. — Entanglement of cords in twins (Winded). 556 THE PATHOLOGY OF LABOR. rected. Then, after waiting perhaps half an hour, the amniotic sac should be ruptured, and ergot should be administered in a full dose to secure a speedy delivery, or, if the stomach will not retain it, the hypodermatic syringe should be used, for, the birth- canal having been dilated thoroughly, there is no obstacle to the birth of the second infant in twin labors, and consequently no objection to the employment of ergot, which not only hastens the conclusion of labor, but promotes subsequent contraction of the much-distended uterus, and so prevents postpartum hemorrhage. As a further precaution against this accident which is always Fig. 445. — Twins, head and breech (modified from Hunter). threatened in twin labors, the fundus should be kneaded and compressed by the nurse for an hour or two after birth. There may be difficulty in the delivery of the placentae in twin labors. Commonly the children are born first and the placentae afterward. Their bulk may make expression difficult, and it is often necessary to make some traction upon the cords — first upon ANOMALIES IN THE FORCES OF LABOR. SS7 one and then upon the other — to determine which placenta will come first and to assist in its expulsion. Occasionally one and rarely both placentae may be expelled after the birth of the first child. In a case of the writer's the placenta of the first child, prolapsing in front of the second, necessitated a difficult forceps operation for the extraction of the second. On account of the frequent and extensive anastomoses between the vessels of the placentae in unioval twins it is a necessary precaution to tie the cord of the first child with a double ligature and to cut it between the ligatures ; otherwise the second infant might bleed to death. The prognosis of twin labors is always doubtful. There are so many possible dangers for both mother and children that multiple labors must be regarded as distinctly pathological. Albuminuria in the mother is the rule in multiple pregnancies, and eclampsia is ten times more frequent than in single births. 1 There is a disposition to inertia uteri during and after birth from distention of the cavity, and consequently a likelihood of post- partum hemorrhage. Some operative interference or intra- uterine manipulation is called for in about twenty-five per cent, of cases, and this, in addition to the frequency of kidney insuf- ficiency, predisposes to sepsis. Finally, there may be insuperable obstruction in labor if locked twins are not managed properly, and the woman may die of ruptured uterus or of exhaustion. The maternal mortality in the Budapest Maternity was four times as great as in the single births, and Klein wachter's statis- tics give a mortality of thirteen per cent. For the children there is greater danger than for the mother. Twin pregnancy is almost always prematurely interrupted, and even if it is not the children are, as a rule, under the normal size and weight. There is always the possibility that the development of one child at least will be seriously interfered with by the lack of room in the uterine cavity. Hydramnios of one sac and oligohydramnios of the other are not uncommon. In labor there are frequently complications from malposition, operative interference, entangle- ment of or pressure upon the cords, and more rarely the engage- ment of both bodies at once in the pelvic canal. In Klein- wachter's and Kezmarszky's statistics the fetal mortality was nearly forty per cent. Of thirty-eight children in cases of locked twins, only six survived, — a mortality of eighty-four per cent. Cases are on record in which an extra-uterine fetus has obstructed the delivery of the intra-uterine twin. It has been necessary to make a vaginal incision through which the former was extracted before the latter could be born. Death of the fetus during or before labor, followed by rigor 1 Of 627 cases of eclampsia, 69 were multiple pregnancies (Winckel). 558 THE PA THOLOG Y OF LAB OR. mortis, has proven a source of obstruction in labor by the rigidity of the child and the consequent interference with the normal mechanism of its delivery, especially of the shoulders and trunk. 1 Ankylosis of the large joints of the extremities may have the same effect to a less degree. Labor Complicated by Abnormalities in the Fetal Appendages. — Membranes. — If the membranes are too thin, they may rupture prematurely, and thus give rise to what is called a " dry labor," in which the birth-canal must be dilated by the hard, unyielding presenting part instead of by that conservative hydrostatic dilator, the bag of waters. Such labors are longer and more painful than the average, and there is a greater likelihood of lacer- ations in the cervix and a more frequent demand for an artificial termination with forceps. If the membranes are too thick, they rupture late, being preserved perhaps until the child's head presents at the vulvar orifice, or even until the complete escape of the head from the mother's body. In these cases the head and face are covered by the membranes as though by a veil, and care must be taken to free the mouth and nose quickly, that respiration may be instituted without interference. The mem- branes thus covering the head and face are spoken of as a " caul." It is possible for the whole ovum to be extruded unbroken at term. The writer has seen this occur as late as the seventh month, and it is actually recorded at the full period of gestation. Difficulties in labor may be encountered in consequence of an abnormality in the quantity of liquor amnii. If there is too little, the labor has the same clinical features as though there had been a premature rupture of the membranes. If there is too much liquor amnii, there may be inertia as the result of overstretching of the uterine muscle-fibers. Umbilical Cord. — If the umbilical cord is too short, it may cause premature detachment of the placenta or may prevent the advance of the child. The diagnosis of a short cord in labor is always difficult. It may be suspected, however, if there is exaggerated pain at the placental site, marked recession of the head after each pain, and an obvious retardation of labor without other ascertainable cause. Forceps should be applied in such a case if the presentation is cephalic. If the cord is too long, it may possibly prolapse should there be other conditions in the labor favorable to such an accident ; or it may be coiled about the child's neck, trunk, or extremities, and may consequently be fatally compressed during labor (Fig. 446). Obstruction of a mechanical character in labor on the part of 1 Feis, " Ueber intrauterine Leichenstarre," "Archiv fur Gynakologie," Bd. xlvi, H. 2. ANOMALIES IN THE FORCES OF LABOR. 559 the placenta is seen only in placenta praevia and in prolapse of the placenta. The placenta may be adherent as the result of syphil- itic or other inflammation of the endometrium during pregnancy, and, becoming partially detached in the third stage, may cause alarming hemorrhage. It is very commonly simply retained in Fig. 446.— Placenta praevia : umbilical cord, caught in the axilla, encircling the shoulder and prolapsed (Hunter). the lower uterine segment or in the vagina, whence it may be expressed by the proper application of Crede's method. In some cases the atmospheric pressure obstructs the delivery of a retained placenta so effectually that it is necessary to hook one's finger over the edge of it, to allow the access of air behind it, 5 60 THE PA THOL OGY OF LAB OR. before its expression is possible. Retention of the placenta may be due to its great bulk, as in twin placentae, or to tumors increasing its size. In such cases it may be necessary to extract the placenta manually. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. Hemorrhage. — One of the gravest and, unfortunately, one of the commonest accidents during and directly after labor is hemor- rhage. The causes of hemorrhage during the first and second stages of labor are placenta praevia, premature separation of a normally situated placenta, rupture of the uterus, lacerations along the lower birth-canal, and rupture of a blood-vessel or of a hematoma. The causes of hemorrhage during the third stage of labor and directly afterward are relaxation of the uterus, lacera- tions of the birth-canal, rupture of blood-vessels or of hema- tomata. Placenta Praevia. — By placenta praevia is meant the attach- ment of the placenta to the lower uterine segment. In some varieties of the condition the placenta presents itself first to the examining finger, and may even emerge before or in front of the child ; hence the name. History. — Early writers (Guillemau and Mauriceau, 1609- 1668) recognized placenta praevia, but they explained it as an accidental prolapse of the placenta. Portal (1685) described it more correctly, though indistinctly. Schaller (1709) demon- strated the condition in the dissection of a body. From Levret's time placenta praevia was well understood. Rigby (1789) defines it as the attachment of the placenta to that part of the womb which always dilates as labor advances — a definition that is strictly accurate to-day. It is to Rigby, too, that we owe the term "unavoidable hemorrhage " to describe the hemorrhage of placenta praevia, as opposed to the "accidental hemorrhage" from premature detachment of a normally situated placenta. Frequency. — Placenta praevia varies in the frequency of its occurrence in different localities and at different times, as the following table demonstrates : Cases of Number of Placenta Reporter. Labors. Previa. Proportion. C. V. Braun 7,853 15 *~5 22 Hugenberger 8,036 42 1-191 Lomer. 6,862 136 1-50 Winckel (1S73-78) 6,324 7 1-903 Winckel (1879-87) 8,500 30 1-283 Miiller 876,432 813 1-1078 Lusk i,55o o 0-0 Schwarz 5 T 9>3 28 33 2 i-I5 6 4 Mid wives' report in Saxony (1878) . .119-553 78 I-I53 2 LAB OR CO A/PL ICA TED BY A CCIDENTS A A 'D DISEA SES. 5 6 1 The frequency of placenta praevia may be estimated at about I in 1200 labors. If the situation of the placenta were investi- gated by a careful examination of the rent in the membranes after every labor, placenta praevia would be found quite fre- Fi g 447-— Central placenta pnevia, the os partly dilated (Hunter). quently. In my experience it has occurred about once in 300 labors ; but in only a quarter of the cases was the condition manifested before and during labor by its most characteristic symptom, hemorrhage. 562 THE PA THOL OGY OF LAB OR. Etiology. — A perfectly satisfactory explanation for the occur- rence of placenta praevia has not yet been found. Clinical ob- servation shows that any chronic inflammation or congestion of the womb predisposes to it. Hence placenta praevia is three to six times more common in multiparas than in primiparae, and is more often met with in the working classes. Uterine myomata and carcinoma of the cervix are predisposing causes, on account, no doubt, of the endometritis that accompanies them. Ingelby reports two cases of abnormally low situation of the tubal orifices, in one of which placenta praevia occurred three times ; in the other, ten. Multiple pregnancies, according to Winckel, furnish four times as many cases of placenta praevia as do single preg- nancies, and a woman beginning to bear children late in life is liable to placenta praevia in subsequent pregnancies. Uterine malformations are apparently a predisposing cause. A case is reported by Schwarz of uterus bicornis in which placenta praevia recurred three times. Hofmeier and Kaltenbach 1 furnish the best explanation for the abnormal situation of the placenta. These observers have demonstrated, by the examination of young ova, that the chorion villi in the lower pole of the ovum may develop in an hyper- trophied decidua reflexa, thus carrying the placenta down to and across the internal os. At first an adhesion between the decidua vera and the reflexa is prevented by catarrhal discharge, but as the ovum develops the reflexa may adhere to the vera, thus fixing the placenta in its abnormal situation, permitting its con- tinued growth, and giving rise to an apparent hypertrophy of the decidua serotina. Gottschalk's 2 observation of a young ovum imbedded at the edge of the internal os demonstrates that an abnormally low attachment of the ovum in the uterine cavity may be accountable for placenta praevia. Varieties. — Four divisions are made of cases of placenta praevia — central, partial, marginal, and lateral. In the first the center of the placenta lies over the internal os ; in the second the greater mass of the placenta lies upon one side of the lower uterine segment, usually the right (56:37, Muller), though the internal os is completely covered by it ; in the third a margin of the placenta projects over the internal os ; in the fourth the placenta is situated upon one side of the lower uterine segment and only the edge of it projects into the cervical canal, if it does so at all, when the os is fully dilated. This classification is justified upon clinical grounds. In central and partial placenta praevia the hemorrhage begins early in pregnancy, is profuse and 1 " Lehrbuch der Geburtshiilfe." 2 " Verhandl. d. deutsch. Gesellsch. f. Gynak.," Bd. vii, 1897, S. 2S9. LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 563 frequently repeated, and in labor is more dangerous than is the hemorrhage of the lateral variety. There is an added difficulty, too, on account of the obstruction offered by the placenta, stretched across the internal os, to the spontaneous descent of the child, or to the physician's efforts to reach and extract it. In lateral placenta praevia hemorrhage usually does not occur till labor is well advanced, and often does not appear at all. Lateral and marginal placenta praevia are the commonest varieties. In 270 cases the placenta was marginal and lateral 217 times ; cen- tral and partial 53 times (Winckel). Strictly speaking, central placenta praevia is very rare. There is almost invariably more of the placenta on one side of the internal os. B Funrial. Fig. 448. — Varieties of placenta praevia: in A there are seen the normal, lateral, and marginal implantation ; in B there are represented the implantation of the pla- centa at the fundus, which is rare, and implantation over the internal os ; in C lateral implantation and that of a cotyledon immediately over the internal os ; and in D partial implantation (Dickinson). Clinical History. — A woman with placenta praavia may begin to bleed as early in pregnancy as the second month, but the first hemorrhage usually occurs in the last trimester. There is a sudden gush of blood, often without apparent cause and without pain. 5 64 THE PA THOL OGY OF LAB OR. The bleeding commonly recurs in increasing amounts and at de- creasing intervals as pregnancy advances. In very rare cases the blood leaks away continuously (stillicidium), though this is more characteristic of the premature separation of a normally situated placenta. The cause of the hemorrhage during preg- nancy is the impact of the embryo and fetus upon the placenta, the pressure of the ovum upon the lower uterine segment, and the imperfect attachment of the placenta in certain areas to the uterine wall. A prediction of the amount of bleeding in labor can not always be made by the amount of blood lost or the fre- quency of the hemorrhages in pregnancy. The first hemorrhage may occur in labor, which may be ushered in by a tremendous outpour of blood, even in lateral placenta praevia. Ordinarily, however, the greater the bleeding during pregnancy, the more likelihood is there of serious hemorrhage in labor. The bleed- ing in labor is easily explained. The placenta is attached in that portion of the uterine cavity which must be dilated to allow the advance of the presenting part. The stretching of the uterine walls expands the area of the placental site, and necessarily de- taches the placenta, while the reversal of the ordinary mechanism of placental detachment keeps the gaping mouths of the torn uteroplacental vessels wide open, and allows the blood to pour from them till the hemorrhage is checked by syncope, by throm- bosis, by the pressure of the presenting part, or by a vaginal tampon. The source of the bleeding in rare cases is a rupture of the circular sinus of the placenta, a laceration of the fetal vessels or of the cervix. The bleeding is usually most profuse just as the uterine con- traction passes off. During the height of the pains it may cease altogether, from the pressure of the presenting part or of the intra-uterine contents upon the placental site. As the placenta occupies a portion of the space in the lower uterine segment and may prevent the descent of the presenting part, abnormalities in the presentation and position of the fetus are common. Transverse and oblique positions are ten times, breech presentations four times, more frequent than in normal labor. In the first stage of labor, inertia uteri is common, partly be- cause the cervix is not pressed upon and reflex irritation is absent, partly on account of the loss of blood. The os is usually patulous, even before labor begins, and the cervical canal is easily dilated. Occasionally, however (twelve per cent.), the os is contracted and the cervix rigid. The insertion of the cord is often marginal or velamentous, and prolapse of the cord is common. The placenta is often anomalous in shape, size, thickness, and LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 565 weight. There is frequently a placenta succenturiata. As the os dilates the placenta may be torn and thus separated into two parts. An adherent placenta may be expected in more than a third of the cases (Miiller, thirty-nine per cent.). After labor there is a tendency to inertia, and consequently to postpartum hemorrhage, and there is an extraordinary liability to septic infection. Placenta praevia, as a complication in labor, would be much more common than it is if it did not so often interrupt pregnancy. The frequency of abortion and miscarriage is placed in different statistics at forty to sixty per cent. In quite a large proportion of cases placenta praevia would be unrecognized in labor without a careful examination of the membranes and placenta afterward. Even in the marginal variety the presenting part, unobstructed, may descend quickly, exerting such pressure upon the placental site that bleeding does not occur. Symptoms and Diagnosis. — Repeated hemorrhages during the latter part of pregnancy make the diagnosis of placenta praevia almost certain. On digital examination the cervix is found enlarged in all directions ; the vaginal vault is soft and boggy ; the presenting part can not be plainly felt ; pulsating vessels are detected around the cervix ; the external os is dilated and the cervical canal is patulous to the internal os, through which a finger can easily be pushed. Under favorable conditions the placenta may be felt through the abdominal walls, as was first pointed out by Spencer. Finally the maternal face of the placenta or its margin is felt over the internal os, the uneven surface of the cotyledons and a gritty feel distinguishing it from a blood-clot, the membranes, or the presenting part. During the first stage of labor the causes of hemorrhage are lacerations of the birth-canal, rupture of blood-vessels, and placenta praevia. The hemorrhage of placenta praevia occurs early, with unruptured membranes, with feeble pains or in their absence altogether, and the symptoms of uterine rupture and of lacerations along the lower birth-canal are absent. In the rare event of a ruptured blood-vessel along the lower birth-canal, the blood does not flow from the uterine cavity. Treatment. — If a placenta praevia is detected during preg- nancy, gestation should be terminated at the end of the seventh month, or at any time thereafter that the diagnosis is estab- lished. The hemorrhage before the thirty-second week is scarcely ever dangerous, 1 though in one case I was obliged to induce abortion before the fifth month on account of a loss of blood that was almost incessant. After the seventh month the 1 In the 128 deaths of Miiller's statistics there was not one before the seventh month. 566 THE PATHOLOGY OF LABOR. Fig. 449. — One leg has been drawn down, so that the os is tamponed and the placenta directly compressed by the hips of the child (Mtiller). LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 567 woman may bleed to death at any time before medical aid can reach her. The induction of labor and its conduct should be as follows : Send for an assistant to administer an anesthetic ; place the woman in the lithotomy position, with her knees sup- ported by nurses or attendants ; cleanse both hands and arms as for a surgical operation and put on sterile rubber gloves; wash out the vagina with tincture of green soap and hot water by means of pledgets of cotton; give a vaginal douche of bichlorid of mercury 1 .-4000; dilate the cervix by inserting first one finger, then a Fig. 450. — Placenta previa: vagina tamponed with gauze (Dickinson). second, and next the thumb of the right hand; search on the woman's left side for the edge of the placenta; pass two fingers beyond it; perform bipolar version, assisted by the left hand externally; rupture the membranes; seize a foot and extract it until the knee appears at the vulva; then withdraw the anesthetic. If the bleeding has been alarming up to this time, it will cease as soon as the child's breech is impacted in the pelvic canal. From time to time the protruding leg may be gently pulled upon to hasten the dilatation of the cervical canal, but plenty of time must be allowed for it ; otherwise the head is caught by the circular fibers of 568 THE PATHOLOGY OF LABOR. the cervix and the child is asphyxiated by the pressure upon the cord. At the expiration of an hour or more the child may be safely extracted. If the operator finds a rigid cervix and ex- periences great difficulty in its manual dilatation, he may employ Voorhees' bags; but under anesthesia, and with a fair amount of strength in one's fingers, hydrostatic dilatation is scarcely ever required. Instrumental dilatation (Bossi's dilator) is not recom- mended, as the hemorrhage would be more profuse than it is with Fig. 451. — Braun's colpeurynter used as a metreurynter in placenta praevia: a, bleeding uteroplacental vessels (Bumm). the pressure of the hand or a bag in the lower uterine segment which partially controls it, and the deep lacerations of the cervix caused by rapid instrumental dilatation add to the bleeding. If a physi* cian discovers placenta prasvia for the first time in labor by a profuse outpour of blood when the dilatation of the cervical canal begins, he should immediately pack the vagina as full as it can possibly be packed. The best material for this purpose is iodoform or sterile gauze if it is at hand, but a clean towel torn into strips will answer. The tampon serves the double purpose of controlling the hem- orrhage and assisting the dilatation of the os. After a delay of LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 569 an hour or two to allow time for the os to dilate, the patient is anes- thetized and the operator proceeds as before described. If there is great difficulty in finding the margin of the placenta and the membranes beyond it, too much time should not be lost in the search. The placenta should be perforated and the child's leg pulled through the perforation. If the operator distrusts his ability to perform the version as quickly as it should be done (for the hemorrhage is likely to be furious during the attempt), he may adopt a plan of treatment proposed by Wigand at the end of the eighteenth century. This consists in tamponing the vagina firmly and allowing the tampon to remain in place till the os is fully di- lated. If the labor lasts too long, the tampon must be removed, the vagina douched, and a fresh tampon inserted. It is well to unite with the tampon treatment the procedure recommended by Barnes — separating the placenta by a sweep of the fingers around and beyond the internal os. This plan was suggested by the clinical observation that when the placenta separated and the presenting part descended the hemorrhage ceased. The com- bination of the Barnes and the Wigand treatment gives fairly good results for the mother, though it increases the risk of the sepsis. For the child it would seem to be bad, but we have testimony from Wigand, Murphy, and Winckel to the contrary. The fetal mortality is 48.5 per cent. (Winckel). In cases of marginal placenta praevia in which hemorrhage first occurs after the os is fairly well dilated, in which the head presents and is easily accessible, the best treatment is rupture of the membranes, ap- plication of forceps, and traction upon the head till the bleeding ceases; whereupon the instrument may be removed and the labor is allowed to terminate spontaneously. The use of a dilatable rubber bag L (Braun's colpeurynter or Voorhees' bags) in the lower uterine segment (Fig. 451) should be considered in cases of lateral and marginal placenta praevia. It is inserted collapsed and sterile (boiled) through a cervical canal admitting one or two fingers; it is distended with water by a David- son syringe, the bag resting against the fetal surface of the placenta; it is usually necessary to rupture the membranes alongside the edge of the placenta to place it properly; the tube, attached to the bag is clamped with an artery forceps; from time to time traction is made upon it to hasten the dilatation of the os. As soon as the bag can be pulled through the cervical canal by moderate force it is removed; forceps is applied if the head is presenting, a foot is pulled down in breech presentations, or bipolar version is per- formed. It may finally be necessary to detach an adherent placenta, to 1 See the excellent article, with good bibliography, by De Lee, " Chicago Medi- cal Recorder," 1901, p. 309, "The Use of the Colpeurynter in Obstetric Practice." 570 THE PATHOLOGY OF LABOR. control a postpartum hemorrhage, and to treat the woman for acute anemia. Cesarean section for placenta praevia, in the author's judgment, is not to be recommended. Its mortality in 25 cases has been 20.8 per cent, for the mother and 66.6 per cent, for the infants. 1 The maternal death-rate by version in the hands of experts is about 1 per cent., while the child has at least one chance out of two. Unless there is some reason more than ordinarily urgent for saving the latter at any cost, it does not seem right to subject the mother to an extra risk, such as would be involved in a Cesarean section performed by physicians in general. An expert might expect good results, but he would usually obtain the same by less radical Fig. 452, — Showing separation of the placenta with external bleeding (Dickinson) means. Occasionally, as in Webster's case of a thirteen-year-old girl with a narrow vagina and vulva, and in a case of the author's complicated by contracted pelvis and overgrown fetus, Cesarean section should be performed, but ordinarily version, the tampon or the metreurynter will give better results. Prognosis. — The study of the mortuary statistics of placenta praevia is not very profitable. It appears that the maternal death- rate in general has been about forty per cent., including the deaths from sepsis. But with the plan of treatment just described, car- ried out by men who understand aseptic methods, the mortality almost disappears. Thus, Lomer (16), Hofmeier (37), Behm (35), and the writer (36) have had 116 cases, with 2 deaths (Hof- 1 Deaver, " Journ. Am. Med. Assoc," April 30, 1904. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 57 I meier's and the author's). For the children a mortality of fifty per cent, and over may be expected. The outlook for the child is worse the more nearly the placenta prsevia is central. Premature Detachment of a Normally Situated Placenta. — The placenta may become detached during pregnancy or before the third stage of labor, though it occupy a normal position near the fundus uteri. The necessary consequence is hemorrhage, often called "accidental," to distinguish it from the "unavoidable" hemorrhage of placenta praevia. If the lower margin of the pla- centa is detached, the blood separates the membranes from the uterine wall and escapes externally. The bleeding may, how- ever, be entirely concealed (1) if the center of the placenta is alone detached ; (2) if the upper margin is detached and the blood accumulates between the membranes and the uterine wall ; (3) if the membranes are ruptured far from the internal os and the blood mingles with the liquor amnii ; (4) if the cervix is ob- structed by a blood-clot, the membranes, or the pre- senting part (Goodell). Concealed hemorrhage is, fortunately, rare. Causes. — The cause of premature detachment of the placenta may be ob- scure. The accident may ml occur during sleep and without ascertainable cause. The causes are often, how- ever, those of abortion : nephritis, congestion of the pelvis, external violence, physical effort, emotion. Prolongation of pregnancy, with irregular uterine con- tractions, was accountable for one of my cases. Death and disease of the fetus, hydramnios, a short um- bilical cord, and multiple pregnancy may cause it. It occurs more frequently in multiparas and toward the close of pregnancy. Frequency. — Holmes 1 estimates the frequency at 1-200 preg- Fig. 453. — Premature detachment of the placenta occupying its normal site. Frozen section of an undelivered woman dead of eclampsia. A blood-mass under the placenta (after Winter). "'Ablatio placentas" of 200 reported cases. "Am. Jour, of Obstetrics," vol. xliv, 1901; a study 572 THE PATHOLOGY OF LABOR. nancies, but in only 1-500 cases is the separation serious enough to demand attention. Symptoms and Diagnosis. — Accidental hemorrhage, especially if concealed, should be recognized without delay. The accident usually occurs before labor begins or in the first stage. The uterine contractions become weak and finally cease, being replaced by per- sistent and severe pain, usually at the placental site. There is shock, the signs of internal hemorrhage become more and more apparent, and the uterus is distended by the accumulation of blood within it. Feeble but persistent contraction of the upper part of the uterine muscle maybe felt. If there is a retroplacental effusion, a local- ized bulging at the placental site may be made out by abdominal palpation. The symptoms resemble somewhat those of rupture of the uterus. In both there are hemorrhage, shock, and perhaps sudden excruciating pain. But in rup- Upperend_ of clot ' /Tembr-. ture of the uterus the accident occurs late in labor, the mem- branes are broken, the pre- senting part recedes, the uterus is well contracted, and per- haps its contents are evacu- ated into the peritoneal cavity; while in accidental hemorrhage the detachment of the placenta occurs early in labor, the membranes are not ruptured, the presenting part does not recede, and in con- cealed hemorrhage the uterus is distended by the accumu- lated blood. In frank acciden- tal hemorrhage the diagnosis rests between detachment of a normally situated placenta and placenta prsevia. The pres- ence or absence of the latter is determined by a careful in- ternal examination. In exceptional cases a frank accidental hemorrhage appears as early in pregnancy as the fourth month. Abortion usually follows, but I have seen two cases in which the bleeding continued uninterruptedly for weeks, a large blood-clot formed between the site of the placental separation and the external os, and septic symptoms supervened. /1£mbrane^Sj^= Lower end ofcfot Fig. 454. — Accidental hemorrhage. Blood collected between placenta and part of membranes and the uterine wall (Pinard and Varnier). LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 573 In spite of these unfavorable conditions pregnancy continued, and the fetus lived until I was obliged to terminate gestation on ac- count of the anemia and the symptoms of systemic infection. Prognosis. — The mortality in accidental hemorrhage is high. Goodell's statistics give 54 maternal deaths out of 107 cases, and of the 108 children (there being one case of twins) only 7 were saved. Holmes' statistics {Joe. cit.) give a much lower mortality. Treatment. — The main object of treatment is to evacuate the womb as speedily as possible, so that the uterine muscle may contract. At the same time it must be remembered that the woman is in no condition to endure much additional shock. The best procedure is to dilate the cervix with rubber bags or with the fingers, to perforate the membranes, and then to extract the child by the quickest plan available. If the presenting part is not engaged, the child should be rapidly extracted by the leg. If the head is engaged and a rapid forceps operation is practicable, the instrument should be employed. If not, crani- otomy should be performed. Ergot should be administered hypodermatically, for postpartum hemorrhage is to be feared. A Porro-Cesarean section should be considered in the gravest cases, in which a continuance of hemorrhage and the shock of a forced delivery are more to be dreaded than abdominal section and puerperal hysterectomy. Rupture of the circular sinus of the placenta may give rise to symptoms indistinguishable from those of premature detach- ment, and calling for the same treatment. 1 Postpartum Hemorrhage. — Hemorrhage may occur during the third stage of labor, or in the first twenty-four hours of the puer- perium, from relaxation of the uterine muscle, from injuries along the birth-canal, from ruptured vessels, tumors, malignant growths, or ulceration in the parturient tract. Postpartum Hemorrhage from Relaxation of the Uterine Muscle. — When the placenta is separated from the uterine wall and the large maternal blood-vessels communicating with it are neces- sarily torn across, every woman after labor would bleed to death were it not for the following provisions on the part of nature to prevent hemorrhage : Leukocytes begin to block the uterine sinuses in the latter weeks of pregnancy, and the excess of the fibrin-making elements in the blood of pregnant women, together with the sluggish blood-current in the sinuses, favor the forma- tion of firm blood-clots in their orifices when they are torn ; the uterine muscle contracts the moment the uterine cavity is emptied, so that the blood-channels running through the uterine walls are 1 Mynlieff has collected 30 cases, "Diss. Inaug., Amsterdam," refer. "Jahres- bericht," vol. xii, 1899, p. 757. 5 74 THE PA THOL OGY OF LAB OR. ligated throughout their whole length by the contracting muscle- fibers that encircle them ; the quality of retraction in the uterine muscle maintains what is gained by contraction. It is to the last two actions mainly that a woman owes her immunity from hemor- rhage after labor. The causes of postpartum hemorrhage are, therefore, those which interfere with uterine contraction. They are : Systemic weakness from disease ; unfavorable hygienic surroundings or anxiety ; weakness in the uterine muscle-fibers themselves, as when they are undeveloped, fatigued, overstretched by hydram- nios or twins, inactive by reason of surrounding inflammatory products, exhausted by many previous labors, or too suddenly called upon to contract by a rapid labor, especially if it is instru- mental ; anomalies in the innervation of the muscle-fibers ; a mechanical obstacle to firm contraction, as a retained placenta or clots within the womb, old adhesions upon its peritoneal surface, or a tumor such as a uterine fibroma, an ovarian cyst, a dis- tended bladder or rectum, that by its bulk keeps the womb distended or displaces it. Some sudden effort may displace the clots in the uterine sinuses and thus favor hemorrhage, as coughing, sneezing, sitting up in bed, or defecation. Heart and lung disease or arterial tension from any cause may produce a congestion of the womb that predisposes to postpartum hemorrhage. Symptoms and Diagnosis. — There is no difficulty in recogniz- ing postpartum hemorrhage when the blood soaks through the mattress and runs across the floor in a stream. The bleeding should be detected early, however, that it may be arrested at once. There is usually a sudden gush of blood, followed by the expulsion every few seconds of several ounces of liquid blood and clots. The uterus is relaxed and it is difficult to outline it through the abdominal wall. There is an absence of that firm, round, easily palpable tumor usually filling the hypo- gastrium, characteristic of a firmly contracted womb. The con- stitutional signs of hemorrhage become rapidly more and more evident. The face is blanched, the pulse is quick and feeble, vision fails, there is air-hunger, and the woman, to satisfy her in- stinctive craving for more oxygen in the rapidly emptying blood- vessels, makes a curious sound between that of a gape and a sigh. Finally, there are restlessness, jactitation, convulsions, coma, and death. In exceptional cases one tremendous outpour of blood, last- ing not more than five minutes, kills the patient. One can not always judge the extent of the hemorrhage by the amount of blood that escapes externally. The dilated womb may contain enough within its cavity to cost the woman her life. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 575 Very rarely, indeed, an uncontrollable postpartum hemorrhage is seen from a firmly contracted and an uninjured uterus. It occurred once from a ruptured aneurysmal vessel; again in con- nection with nephritis, presumably from atheromatous or diseased vessels; in one case from a ruptured hematoma of the cervix; in another from ulceration of the cervix that opened the uterine artery ; in another from a ruptured varicose vein in the cervix. Cases have been reported of paralysis of the placental site, with firm contraction of the remainder of the womb. l In high altitudes postpartum hemorrhage is said to be much more common than at lower levels, from the lessened atmos- pheric pressure. I have been told, by physicians practising in the high regions bordering upon the Rocky Mountains and in South Africa, that they have this complication to contend with very frequently. Treatment. — Postpartum hemorrhage may occur after any labor. Measures to prevent it consequently form part of the routine management of labor, as already described. If any of the predisposing causes of uterine relaxation exist during labor, additional precautions should be taken. As soon as the presenting part emerges from the vulva a syringeful of the fluid extract of ergot should be injected into the woman's thigh, the placenta should be expressed without too much delay, and the womb should be kneaded and compressed more vigorously and for a longer time than usual, until it remains firmly contracted and shows no disposition to relax. Then a large abdominal pad should be laid above the umbilicus and a firm abdominal binder should be adjusted. The nurse should receive instructions to watch the patient's appearance closely, to count the pulse fre- quently, and occasionally to turn down the bedclothes and observe the quantity of the discharge. Should hemorrhage occur in spite of these precautions, it must be controlled with the least possible delay, for so much blood is lost in a short time that the woman may die of acute anemia, even though the bleeding be finally checked. The beginner will do well to bear in mind the following plan of action that he may put it into immediate effect, without de- pending too much upon his presence of mind, readiness of re- source, or self-command — qualities that perhaps are lacking when he is first confronted with one of the most alarming acci- dents of obstetric practice : Seize the fundus uteri with one hand through the anterior abdominal wall ; knead, compress, and rub it vigorously with the fingers applied to the posterior uterine wall, the palm to the ' Miiller's ;< Ilandbuch," Veit, vol. ii, pp. 121, 130. 576 THE PATHOLOGY OF LABOR. fundus and the thumb in front, until the womb is felt firmly con- tracting. If external irritation does not effect the desired result, insert the free gloved hand into the vagina, pass it into the uterine cavity, feel for retained fragments of the placenta, blood-clots, or other substances that might by their bulk prevent contraction, re- move them, and while doing so rotate the hand somewhat roughly, so as to bring it in contact rather forcibly with the uterine wall ; at the same time continue the kneading, rubbing, and compression externally. If the combined irritation of the exterior and interior of the womb fails to secure firm contraction, try next the irri- tating effect of cold. Rub a piece of ice upon the hypo- gastrium. If the effect of cold is not immediately satisfactory, do not persist in its use, for the ultimate effect is relaxing rather than stimulating. A ready and convenient method of violently chilling the hypogastric region is to pour some ether Fig. 455. — Packing the puerperal uterus with gauze to control postpartum hemor- rhage (Edgar). upon it. The irritation of cold externally having proved in- effective, the uterine cavity should be packed with iodoform or sterile gauze. In the intrauterine tampon we possess the surest and most reliable means of controlling postpartum hemorrhage. 1 ^iihrssen, "Ueber die Behandlung der Blutungen post partwn ," Volk- mann'sche Sammlung, 347. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 577 The technic of inserting the tampon is shown in figure 455. The end of the strip should be inserted as far as the fundus by a long placental forceps, and the whole uterine cavity firmly packed with the successive layers. Other agents of value in promoting uterine contraction are hot water, electricity, and styptic or irritating drugs, such as Monsel's solution, iodin, and turpentine. An intra-uterine injection of very hot water (120 F.) is effective, but it is difficult to regulate the temperature in private practice, and if this means fails, valuable time has been lost. A strong faradic current is extremely efficient, but a battery is scarcely ever at hand when it is needed. Fig. 456. — Holmes' uterine tube and packer. Monsel's solution will stop the bleeding, but it leaves such firm and adherent clots in the uterine cavity that septicemia will very likely follow from their decomposition, and there is danger, besides, of an extension of the thrombosis to the uterine and pelvic vessels. Iodin and turpentine have done good service by their irritating qualities, but there is danger of metritis from their use, and they might leak into the abdominal cavity through the tubes. Great vir- tue has been claimed for special modes of compressing the uterus (Fig. 457) that are supposed to close the mouths of the bleeding vessels. Fritsch advocates pressing the uterus forward and down- ward over the symphysis pubis, putting a large compress behind and above it, and applying a tight abdominal binder. When these methods are effective it is by irritating the uterine muscle, rather than by the pressure exerted upon the vessels of the placental site. Compression of the abdominal aorta has been proposed as a means of checking postpartum hemorrhage by diminishing the blood supply to the womb. This plan, in mv opinion, is absurd. 37 578 THE PATHOLOGY OF LABOR. When it has apparently succeeded it was by the irritation of the womb, or of the sympathetic nerves supplying it, on account of the deep abdominal pressure above the fundus. A plan well worth remembering that has succeeded when others have failed is to seize the lips of the cervix with bullet forceps and to pull the uterus forcibly downward. All operators know that hemorrhage during an operation on the uterus may be controlled in this way. Finally, the bleeding may cease spontaneously by thrombus Fig. 457. — Bimanual compression of the uterus. formation or by syncope, but these agencies are never to be awaited in practice. The physician's duty is not always done when he has checked the bleeding. An acute anemia must be dealt with that, if dis- regarded, is as dangerous as a continuance of the hemorrhage. There is a rapid, feeble pulse ; or, it may be, an entire ab- sence of radial pulsation. The body-surface, especially of the extremities, is cold, and there is a disposition to syncope on the slightest effort. There is loss of vision, and the acute anemia of the brain may even lead to convulsions. With the dangers of heart-failure and cerebral anemia in mind, the physician, while engaged in stopping the bleeding, directs the nurse to raise the foot of the bed on some books, bricks, or the seats of chairs, and, if there is a tendency to repeated syncope , to give a hypodermic injection of ether; or of nitroglycerin (two drops of one per cent, solution). As soon as the hemorrhage is checked, an enema of a pint of hot water containing about forty grains of common salt should be given. The patient should, in addition, be surrounded by hot bottles, should be well covered with blankets, and should LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 579 be kept at absolute rest, with the body and head on a straight line and the foot of the bed well elevated to keep as much blood as possible in the brain. Heart-stimulants — digitalis, strychnin, nitroglycerin, and ether — should be given hypodermatically if the heart-action fails to improve. There is likely to be nausea and vomiting, but, as soon as the stomach will retain what is put in it, the woman should receive very small quantities of hot milk, hot concentrated coffee, hot water and brandy, frequently repeated. When reaction is once established, a hypodermatic injection of morphin hastens the patient's recovery from the effects of the hemorrhage and prevents secondary shock by promoting physical quiet, calming nervous restlessness, and producing some degree of Fig. 458. — Intravenous injection. cerebral congestion. In desperate cases in which the measures just described are without satisfactory result, a pint to a quart of a sterile normal salt solution (0.6 per cent.), at blood heat, should be injected by gravity into the loose cellular tissue be- tween the shoulder-blades (hypodermoclysis), under the breasts, or directly into an artery or a vein. A convenient apparatus for this purpose is shown in figure 458. A good substitute for the transfusion apparatus is a large aspirating needle and a fountain syringe or funnel. With this appliance, with which every obstet- rician should be provided, fluid may be forced into the cellular tissue under the breasts or into a blood-vessel. The funnel and 58o THE MECHANISE OF LABOR. needle should have a place in every well- supplied obstetric-instru- ment bag. The extremities should be bandaged toward the trunk (auto- mfusion) so as to force as much blood as possible to the heart, the large blood-channels, and the brain. Compression of the abdominal aorta helps to this end. Actual transfusion of blood from one person to another, or from some animal, is no longer advisable. It is rarely practicable, and the results are no better than, if as good as, those obtained by the injection of salt solution. The physician should make it an invariable rule to stay with his patient until her condition is entirely satisfactory. The anemia persisting after the hemorrhage is checked and reaction' is estab- lished should be treated by a full liquid diet, animal broths, and iron. The intense headaches of cerebral anemia that may per- sist or recur for some time are best treated with opium. Lacerations of the Walls of the Birth=canal. — Any portion of the soft structures surrounding the birth-canal, from the fundus uteri to the vulva, is liable to spontaneous rupture, or to trau- matic perforation during labor. Rupture of the Uterus. — The uterus may be ruptured by over- distention of the lower uterine segment. It may burst open from top to bottom in certain diseased conditions of its walls. It may be penetrated by the operator's. hands or by instruments. Its wall may be perforated by a localized necrosis and ulceration. If the rupture involves all the coats and opens a way into the peritoneal cavity, it is called complete. If it spares the peritoneal covering of the uterus, it is called incomplete. Frequency. — The statistics of the frequency of ruptured uterus vary greatly. Bandl found . . . Tolly found . . . Lask found . . . Collini found . . McClintock found Ramsbothan found Garrigues found . Winckel found . . Harris found . . Koblanck found . in I2CO labors. " 3403 " " 6000 " 482 " 737 " 4429 " " 3-5000 " 666 " " 4000 " 462 " Rupture of the uterus is much more common in the poorer than in the richer classes, chiefly because the former have less skilful medical attendants. Multiparas are more liable to the accident than primiparae (88 per cent. : 12 per cent., Bandl). Dis- ease of the uterine wall, as fatty degeneration, a myoma, a pre- vious injury to or operation upon the uterus, as a former rupture or Cesarean section, are predisposing causes. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 58 1 Causes. — The most frequent cause of ruptured uterus in labor is overdistention of the lower uterine segment, due to some ob- struction which prevents the descent of the child through the pelvic canal. 1 Bandl first pointed out this fact. 2 In a normal labor the lower pole of the uterine ovoid is gradu- ally dilated until the fetal body passes through it into the vagina. If there is an insuperable obstacle to the descent of the child, as a contracted pelvis, rigid soft parts, a tumor in the pelvis, over- growth or enlargement of the child, hydrocephalus, an impossible presentation or position, the contraction of the upper uterine seg- ment continues until the child's body is driven in great part out of it, but, descent of the child being prevented, it is crowded into the enormously distended lower uterine segment and cervical canal, while the firmly contracting upper uterine segment is drawn up under the ribs until it sits- upon the child's body like a cap. There is a sharply defined line between the firmly con- tracted thick wall of the upper uterine segment and the very thin wall of the distended lower uterine segment, a line visible and palpable running across the abdomen between the symphysis and the umbilicus, approaching nearer the latter the greater the distention of the lower uterine segment, the upper boundary of which is normally about the level of the pelvic brim. This line is called the "contraction-ring" or the "ring of Bandl." It ordinarily coincides with the coronary vein of the uterine wall and with the firm attachment of the peritoneum to the uterus. It is not, as it was once supposed to be, the margin of the inter- nal os or the upper limit of the cervical canal ; it is the boundary- line between that portion of the uterine muscle which contracts firmly in labor, diminishing the area of intra-uterine space and driving the child out of the uterine cavity, and that portion of the uterine muscle which must be distended in labor to allow the passage of the child through the pointed end of the uterine ovoid. If there is a greater bulk of the fetal body in one side of the lower uterine segment, the contraction -ring is higher upon that side and thus runs an oblique course across the abdomen. There is a limit, of course, to the capacity of the lower uterine segment and to the stretching and tenuity of its walls. That limit being reached, the overstretched wall tears and the fetus may pass from the uterine into the abdominal cavity. In rare cases the uterine wall is weakened by a previous rupture, by a blow or fall during pregnancy, by the scar of a Cesarean section, or by the removal 1 A contracted pelvis is the most common cause of uterine rupture, and a justo- minor pelvis is the kind of contracted pelvis most often accountable for it. In 1218 ruptures a contracted pelvis was the cause in 570 (Koblanck, '■ Uterusruptur, " Stutt- gart, 1S95). 2 " Ueher Ruptur der Gebarmutter, " Wien, 1S75. 5 82 THE PATHOLOGY OF LABOR. of a portion of the uterine wall in the excision of a myoma ; the wall may be weakened by fatty degeneration, associated, perhaps, with excessive general obesity ; x prolonged pressure upon a small area may destroy its vitality and lessen its resistance. In such cases rupture of the uterus may occur early in labor, or even in pregnancy, without distention of the lower uterine segment. Finally, external violence has ruptured or perforated the womb, instruments inserted in the vagina have pierced its walls, the appli- cation of Crede's method to express an adherent placenta 2 and the insertion of the operator's hand in the uterine cavity to perform version have been the immediate cause of rupture. 3 Fig. 459. — Laceration of lower uterine segment : a, Right ovary ; b, rectum ; c, laceration; d, left tube (Winckelj. Morbid Anatomy. — The tear in the uterine wall almost always begins in the lower uterine segment, and usually runs trans- versely. It may be upon the anterior, lateral, or posterior sur- face. The edges of the tear are usually ragged, swollen, and infiltrated with blood. The peritoneal covering of the uterus is often stripped off for a considerable distance beyond the tear, and in the sac thus formed between the peritoneum and the body of 1 In a case of uterine rupture seen with Dr. U. G. Heil, of Philadelphia, the woman had become suddenly and enormously obese before her last pregnancy. _ She had experienced no special difficulty in the births of her other children, but in the last the uterus ruptured after a few hours of moderate labor-pai;as. 2 " Monatschr. f. Geb. u. Gvn.,'' Sept., 1903. 3 Koblanck (loc. cit.) gives the following causes in So rases: Contracted pelvis, 8; transverse position of fetus, 7 ; other abnormal positions, 4 ; hydrocephalus, 4 ; over- growth of child, 1 ; misfit of presenting part in pelvis, administration of ergot, 1 ; vio- lence, 5; version, 29; Hofmeier's grip, 1 ; forceps, 11 ; decapitation, 1 ; myoma, I. LAB OR CO MP LIC A TED BY A CC IDE NTS AND DISEASES. 5 8 3 Fig. 460. — Transverse or semicircular tear of the lower uterine segment. Fig. 461. — Laceration of lower uterine segment. 584 THE PA THOL OGY OE LAB OR. the uterus the placenta may lie concealed, or even the fetus may be contained. There may be an enormous subperitoneal hema- ■toma or profuse intraperitoneal hemorrhage. The tear may run upward toward the fundus, or may extend so far transversely as almost to sever the upper and lower uterine segments. The rent may extend through the mucous and muscular coats without in- volving the peritoneum. The latter, in rare cases, may alone be split, and it is recorded in one case that the peritoneal and mus- cular coats were torn while the mucosa remained intact. 1 If the tear is extensive and complete, the fetal body will probably pass Fig. 462. — Perforating lacera- tion of the cervix : a, Posterior lip ; b, anterior lip ; c, perforation. Fig. 463. — Perforating laceration of the cervix : a, Perforation ; b, peritoneum ; c, muscle ; d, posterior lip of the cervix ; e, vaginal laceration (Winckel). into the abdominal cavity, and intestines may prolapse into the uterus and into the vagina. 2 In one remarkable case 3 there was a tear of the lower uterine segment and of the right lateral fornix of the vagina, through which the fetus entered the vagina, passing to one side of the undilated cervix. Fetal death is usually syn- 1 J. M. Withrow (" Lancet-Clinic," December, 1891) reports a case of ruptured uterus, the rent beginning in front, midway between the insertion of the tubes, ex- tending up over the fundus and down along the posterior wall to Douglas' pouch, involving the peritoneal coat and the muscular tissue, but not the mucous membrane. The uterus, filled with water after removal from the body, did not leak. A large dose of ergot had been given during labor. 2 Crossen reports a case in which it was necessary to resect 13 feet of intestine prolapsed through a rent in the anterior wall of the uterus, "Am. Gyn. and Obstet. Jour.," vol. xii, p. 45. 3 "Slajmer, " Centralblatt f. Gyn.," No. 18, 1895. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 585 chronous with the rupture of the womb, and if the child's body passes into the peritoneal cavity it rapidly putrefies, generating gases of decomposition so quickly that its bulk is enough in- creased to make its extraction difficult. From the decomposition of the fetal body, or perhaps from the entrance of atmospheric air, there may be emphysema of the pelvic connective tissue and of the cellular tissue of the thighs, buttocks, mons Veneris, and abdomen. Septic peritonitis of a viru- lent kind usually develops with great rapidity. In a minority of cases the site of the rupture is walled off by a rapid outpour of lymph and by agglutina- tion of coils of intestines, leaving a comparatively small cavity to be drained through the tear. This cavity may secrete ascitic fluid in large quantities for a time, and during the woman's convalescence there may be a profuse watery discharge from the womb. I have seen two such cases. Occasionally a large area of intraperitoneal space is drained through the tear. Even the fetal body may be encapsulated, and a lithopedion may be formed. In the uterine ruptures or perforations due to pressure necroses the opening is round in shape, regular in outline, and small in extent. The opening is almost always on the posterior wall over the promontory of the sacrum. In the rare cases of exostoses of the pelvis the bony outgrowth may pinch a hole in the uterine wall. In these cases the opening corresponds to the site of the exostosis. Clinical History, Symptoms, and Diagnosis. — Rupture of the uterus usually occurs after labor has lasted a long time, after rupture of the membranes, and with a well dilated os. There is usually an obstruction in the labor that should have been recog- nized, the lower uterine segment is enormously distended, and the contraction-ring is palpable and visible near the umbilicus ; the pains have been vigorous and frequent, the woman's suffering has Fig. 464. — Uterus perforated by the pres- sure of the promontory : a, Perforation ; b, laceration of the cervix; c, c, c, vaginal tears; d, contraction ring; e, posterior lip of cervix (Winckel). 586 THE PATHOLOGY OF LABOR. been extreme, and the abdominal muscles have been employed, perhaps, with each contraction, though the presenting part does not descend the birth-canal. Suddenly there is a sharp, excruci- ating, lancinating pain ; the woman may cry out that something has happened to her ; the uterine contractions cease, blood flows from the vagina, perhaps in alarming quantities, and the patient presents every evidence of shock. On making a vaginal ex- amination the physician finds that the presenting part has re- ceded ; hitherto easily reached, perhaps at the very outlet of the pelvis, it may be altogether inaccessible, and on passing the hand into the uterine cavity the rent may be felt, or intestines may be found within the uterus and protruding from the os. On abdominal palpation the upper uterine segment may be felt firmly contracted to the size of the uterus after labor, and the child's body may be easily detected in the abdominal cavity alongside of it. If the rupture of the womb is not complete, or is not large, it may not be discovered until the child is born, and may never be suspected at all unless the woman develops septic peritonitis after labor or discharges ascitic fluid from the uterus. There may be no pain at the time of rupture, no hemorrhage, no abnor- mality of uterine contractions. Even with a complete tear of large dimensions and escape of the child into the peritoneal cavity there is occasionally an astonishing absence of symptoms. I have seen a case in which the child passed into the abdominal cavity twenty-four hours before I was summoned, and yet there was no alarming symptom of any kind until suddenly, at the end of twenty-four hours, the signs of virulent septic peritonitis appeared. In another case in which I opened the abdomen a month after labor for what was thought to be an intraperitoneal abscess, the fundus uteri was found ruptured from tube to tube, the rent being shut off from the general abdominal cavity by exudate, which was undergoing suppuration. The accident of labor most commonly mistaken for ruptured uterus is premature detachment of a normally situated placenta. The distinction between the two should be made easily by attention to the fol- lowing differences in symptoms: Rupture of the Uterus. Occurs late in labor. Membranes ruptured. Uterus diminished in size by evacuation of some or all of its contents into the abdominal cavity. Recession of presenting part. Discharge of blood from vagina. Exploration of the interior of the womb easy, and rent accessible to touch. Accidental Hemorrhage. Occurs before labor or early in the first stage. Membranes unruptured. Uterus dis- tended, perhaps irregularly in retro- placental effusions. Position of presenting part unchanged. No external bleeding in the concealed variety. Exploration of the interior of the womb impossible. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 587 As the placenta is often detached when the uterus ruptures, and as it may prolapse in front of the child, a ruptured uterus may be mistaken for placenta praevia. If the physician should have reason to suspect that the uterus is ruptured during labor, he should extract the child without delay and should then explore the uterine cavity, preferably under anesthesia, from top to bottom. By unvarying adherence to this rule he will not be guilty of the serious fault of overlooking a ruptured womb with few symptoms until septic peritonitis occurs and all treatment is unavailing, or until the bleeding, internal or external, is so profuse that the patient can not be revived. The symptoms during the puerperium indicative of a ruptured womb in labor are : septic peritonitis, profuse uterine hydrorrhea, secondary hemorrhage (as late possibly as the twelfth day), and prolapse of the intestines. The last is the only positive sign, unless, on the occurrence of the others, a digital or instrumental examina- tion of the uterine cavity reveals the rent. Prognosis. — The prognosis of ruptured uterus depends upon the site, extent, and degree of the tear, and upon its treatment. In ten cases of rupture of the anterior wall in the Berlin Mater- nity every one ended fatally, and in three ruptures at the fundus the result was the same. 1 Incomplete ruptures are not so fatal as those in which the peritoneum is also involved, and the result depends somewhat upon the escape of meconium, liquor amnii, blood, placenta, and fetus into the peritoneal cavity. Before the advent of asepsis and the improvement in the technic of abdom- inal surgery the mortality of ruptured uterus averaged about 90 per cent. Of late years the mortality has been much reduced. In 60 cases of complete rupture without active treatment the mortality was 78.8 per cent., in 70 cases treated by irrigation and drainage the mortality was 64 per cent., and in 193 cases treated by ab- dominal section the mortality was only 55.3 per cent. 2 In about one-half the fatal cases death occurs within the first twenty -four hours. The great majority of the remainder die within three days. In some fatal cases, however, death occurs as late as the tenth or fourteenth day. The causes of death, in the order of their fre- quency, are sepsis, hemorrhage, and shock. The mortality of the infants is usually over 90 per cent. In the 80 cases from the Berlin Maternity 10 children were saved, but this is an unusually large proportion. If the woman recovers from the rupture, she runs a great risk of a repeated rupture in a subsequent pregnancy 1 I have performed hysterectomy for a complete rupture of the uterus across the fundus, with success, in one case. 2 Schultz, " Internat. med. Rundsch ," Jan. 10, 1892. 588 THE PA THOL OGY OF LABOR. and labor. There are cases on record, however, of women safely delivered in a subsequent labor. Couvelaire, 1 in 17 women who had had a ruptured uterus and again become pregnant, reports 9 cases of repeated rupture, with 6 deaths. Treatment. — The preventive treatment of uterine rupture con- sists in obviating, in time, the obstructions in labor that predis- pose to the accident. If a woman has had a ruptured uterus and becomes pregnant again, she should be delivered by Cesarean section before she falls in labor. The treatment of the rupture itself differs as the rent is com- plete or incomplete, as its situation admits of good drainage or otherwise, and it depends greatly upon the escape of foreign matter into the peritoneal cavity. The first care of the physician must be to extract the child and to control the hemorrhage. If the child has escaped into the abdominal cavity, no effort should be made to extract it by the natural passages, but it should be removed through an abdominal incision. If the rent is small, and the child has only in part passed from the uterine cavity, it should be delivered rapidly by version, the application of forceps, or by craniotomy. The last is to be preferred. The placenta may be removed by the vagina, even though it has passed into the abdominal cavity ; but if difficulty is experienced in finding it, if the cord should break off by the efforts to pull the placenta through the rent, or if the placenta lies hidden under the perito- neum stripped off the womb, its extraction should be postponed until the abdomen is opened. In an incomplete tear it is sufficient to pack the rent with iodoform gauze, in order to control hemor- rhage and to secure good drainage. This may be preceded by irrigation, which may be repeated with advantage when it becomes necessary to renew the gauze packing. If the rent is complete, but small, and situated low down upon the posterior wall ; if there has been little, if any, foreign matter injected into the peritoneal cavity, the same treatment will suffice ; but if the tear is exten- sive, if considerable blood has passed into the peritoneal cavity, and, all the more, if the peritoneum has become contaminated by the. entrance of liquor amnii, of the placenta, or of the child itself, an abdominal section will be necessary. With the abdomen open a decision must be made between several plans of procedure. Usually, it is best to amputate the womb, if possible, below the site of the tear. Occasionally, if the wound is not too ragged and can be thoroughly approximated, it will be sufficient to unite it with deep and superficial sutures, care being taken to cover over the line of rupture with inverted peritoneum. In case the peritoneum is stripped off the womb for a considerable distance, 1 " Rev. prat. d'Obstet. et de paed.," Oct.-Dec, 1903. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 589 and it is impossible to secure a good stump, a flap of peritoneum may be dissected off the uninjured side of the womb and used to cover over the upper portion of the stump and its denuded sur- face ; or it may be preferable to do a panhysterectomy, sewing up the opening left in the vagina in such a manner as to cover any denuded surfaces. If the tear is on the anterior wall, or at the fundus, an abdominal section is necessary. On opening the abdomen one of the procedures detailed above may be adopted, or it may be possible, as it was in one of Leopold's cases, to splint the womb by gauze packing in the pelvis and abdomen, so as to bring the torn surfaces firmly together. In an abdominal section for ruptured uterus the toilet of the peritoneal cavity must be made, of course, with the greatest care. It is better, if possible, to cleanse the abdominal cavity with pads of gauze, rather than to flush it with water ; but the latter plan is sometimes necessary to remove small clots of blood scattered throughout coils of intestines or hidden in the depths of the pelvis. Resection of the intestines and intestinal anastomosis is occasion- ally required. In one of my cases the medical attendants had pulled off both arms of the child in attempts to extract it, and then through a rupture of the lower uterine segment had pulled two feet of ileum loose from its attachment to the mesentery. Injuries to the Cervix. — The cervix is injured to some extent in every labor, but serious tears, that cause at the time profuse hemorrhage and give rise to symptoms subsequently, are com- paratively rare. The causes of serious injuries to the cervix are : precipitate delivery, premature rupture of the membranes, forcible extraction of the child by the forceps or after version before the os is thoroughly dilated, incarceration of the anterior lip of the cervix between the child's head and the pelvis, and abnormal rigidity of the cervix. The tear is usually bilateral, occasionally unilateral, in rare cases multiple, and in one instance under the writer's observation directly in the anterior median line. In rare instances the tear, instead of being longitudinal, may be circular, and in consequence the vaginal portion of the cervix may be completely torn off from the womb. The cervical tear manifests itself immediately after delivery of the child, usually by some hemorrhage, occasionally by profuse and dangerous bleeding. A digital examination of the vagina directly after the extraction or expression of the placenta informs the physician of the condition of the cervix, and, if the cervix is inspected through a speculum during the puerperium, a torn cervix that needs attention should never be overlooked. The hemorrhage from a torn cervix directly after labor may be controlled in two ways. First, by ligatures, which are per- fectly certain to effect the desired result, but which are not always 590 THE PATHOLOGY OF LABOR. easy to insert, and which increase the danger of septic infection, unless the attendant possesses gynecological skill and has the necessary equipment for operating in a perfectly aseptic manner. Fig. 465. — Repair of a stellate tear of the cervix. Fig. 466.— Spontaneous repair of a stellate laceration of the cervix. Drawn from life, three months after labor. The easiest, and on the whole safest, plan for checking the hem- orrhage from a torn cervix in general practice is to insert a Plate io. Lacerations of the cervix : I, Two weeks after labor ; 2, one week after labor ; 3, four days after labor; 4, immediately after labor. The degree of involution shown in No. I should be awaited before repairing the cervix. LAB OR CO MP LIC A TED BY A CCIDENTS AND DISEASES. 5 9 1 tampon in the form of a half ring in the lateral vault of the vagina. The best tampon material is iodoform or sterile gauze. I have never known this device to fail in checking hemorrhage from a torn cervix. It is a moot question whether a torn cervix should always be repaired in the early puerperium. In general practice, the following arguments are usually advanced against the primary re- pair of the cervix: Stitches placed in a relaxed cervix directly after labor will probably not be tight enough at the end of twenty-four hours to close the wound. To place them properly requires considerable skill, and necessitates dragging the cervix into view by bullet forceps. The necessary instruments are rarely to be found in the general practitioner's armamentarium, and many lacerated cervices heal spontaneously, if the woman is kept quiet on her back in bed for a sufficient length of time, without vaginal douching or other interference that could disturb the approxima- tion of the edges of the tear. In a. well-equipped clinic or in the private practice of a specialist the repair of lacerated cervices dur- ing the puerperium is recommended. It is the author's practice. It is better to wait five to seven days after labor. Clinical experi- ence has shown that there is less danger of infection in the inter- mediate than in the primary operation. The operation should be performed as follows: The woman is placed in the dorsal posture on a table, her buttocks projecting well beyond its edge, the thighs flexed on the abdomen, the legs upon the thighs. An anesthetic is not absolutely necessary. The most agree- able to the patient is a mixture of nitrous oxid gas and oxygen. The anterior and the posterior lip of the cervix should each be caught by a bullet forceps. The cervix is pulled into sight, and by separating the bullet forceps the tears are made to gape. Sutures (silkworm gut or forty-day chromicized catgut) are then inserted in exactly the same manner as for the secondary operation by Emmet's straight cervix-needles. Three sutures on a side are usually sufficient. If the tear is stellate, each laceration is repaired by the requisite number of stitches (Fig. 465). It may be necessary to freshen the torn surfaces with the edge of a knife or a sharp curet or even to denude with scissors. Circular Detachment of the Vaginal Portion of the Cervix Dur= ing Labor. — Rarely the whole vaginal portion of the cervix is torn off from the womb and emerges from the vulva in front of the child's head. This accident may be the result of extreme rigidity of the cervix, or of the cervix being caught between the walls of the pelvis and the child's head, if the former is con- tracted or the latter is very large. I have seen three cases, all due to extreme rigidity of the cervix (Figs. 467, 468). In each 592 THE PATHOLOGY OF LABOR. case the woman was an elderly primipara, and was quite obese. One of them was delivered a year later under my charge without difficulty. In one case (Fig. 467) there was a narrow tab of cer- vical tissue left in the median line posteriorly. Although the injury at first sight appears serious, there is no hemorrhage, nor is the puerperal convalescence disturbed. This accident could almost always be averted by multiple incisions in the cervix. Lacerations of the Vagina. — The vagina may be torn by the insertion of the hand, by the rapid extraction of the child, by Figs. 467 and 468. — Author's cases of annular detachment of the cervix. the extension of tears from the cervix, by the propulsion of the child's body against the posterior wall without sufficient deflec- tion forward to facilitate its escape from the vulvar orifice, and, most frequently of all, by the blade of a forceps which does not LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 593 fit the child's head properly, or which is not used with sufficient care as to the direction of the force that is applied in the extrac- tion of the head. The tears of the vagina accompanying a lacerated perineum or injured pelvic floor are described under the latter heading. Tears of the vagina extending from the cervix involve usually the lateral vaginal vaults, occasionally opening deep rents into the base of the broad ligaments, and involving possibly the uterine arteries or even the ureters. The hemorrhage from these tears is best controlled by ligating the bleeding vessels if they can be found, or by firmly tamponing the rent if it is impos- sible to locate the bleeding points. Drainage must be secured by gauze packing, and, when the wound begins to granulate, daily washing with sterile water should be employed. The tears of the posterior vaginal wall sometimes result in perforations of the rectum, and in consequence a portion of the child, as an extremity, may emerge from the anus. 1 These perforations should be repaired immediately after labor by buried running sutures of catgut and interrupted stitches of silkworm gut. The tears of the anterior vaginal wall made by a forceps- blade are almost always clean-cut, and are apt to bleed pro- fusely. They should be closed by a running catgut suture. In one case under my care the hemorrhage was so profuse that it was impossible to see the wound at all, and there was danger of the woman bleeding to death while I attempted to sew it up. After several abortive attempts the wound was successfully' repaired without further bleeding by pushing a tampon into the vagina and following the tampon as it was pushed up along the course of the wound with a needle and thread, until the upper end of the tear was reached. Lacerations of the anterior and posterior vaginal vaults penetrat- ing to the peritoneal cavity are usually associated with rupture of the uterus. They are to be treated by gauze packing and drainage. Lacerations and Abrasions of the Vulva, of the Vestibule, and of the Vaginal Entrance. — The most frequent site for injuries in this region is the upper portion of the vestibule and the tissues on one side of the clitoris or of the urethra. Tears in this situation bleed profusely, and they are so common that it is a valuable rule of practice always to look in this region for injury when there is a hemorrhage from the vagina after labor with a well -contracted womb. The bleeding points are in plain sight, and the hemor- rhage is easily controlled by a stitch or two, deep enough to undersew the whole depth of the tear. A catheter should be 1 Piering, " Central blatt f. Gyn.," No. 48, 1891. See also Engelmann, ibid., No. 46, 1900. 3S 594 THE PATHOLOGY OF LABOR. Figs. 469, 470, and 471.— Lacerations and abrasions of the vestibule and vaginal entrance (Bar). LABOR COMPLICATED Bi ACCIDENTS AND DISEASES. 595 Figs. 472, 473, 474. — Lacerations and abrasions of the vestibule and vaginal entrance (Bar). 596 THE PA THOLOC Y OF LABOR. placed in the urethra to guard against occluding it. In abrasions of the labia and of the vestibule, care must be taken that the raw surfaces shall not unite, causing atresia of the vagina. This can easily be prevented by laying oiled lint over the raw surfaces, and by the use of douches. Figs. 475 and 476. — Perforations and lacerations of the nymphse (Bar). Lacerations of the Perineum. — The causes and preventive treat- ment of lacerations of the perineum are considered elsewhere. The repair of the injury is dealt with in this section. The com- monest form of torn perineum is shown in figures 479 and 480. It may be seen that the tear rarely involves the perineum alone, but usually extends up the posterior wall of the vagina, on one or both sides of the posterior column. Experience teaches, more- over, that lacerations of the perineum alone, when they do occur, have very little effect upon the patient's after-condition, even though they reach to the anus and sever the transverse perineal muscle (see Figs. 483, 484). The greatest care should be ex- ercised, therefore, to ascertain the extent of the injury to the vagina which may be associated with the tear of the perineum. This is best done by placing the woman in the dorsal position across the bed or on a table, with her thighs well flexed upon the abdomen and widely separated, and with the buttocks projecting beyond the edge of the bed or table. A nurse or other assistant, whose hands are protected by sterile gloves, holds the labia apart, and the physician cleanses the torn surface of the posterior wall of the vagina with pledgets of cotton soaked in bichlorid of mercury solution. In this way the exact nature and the extent of the PLATE II. '# X. % n j\ LABOR COMPLICATED BY ACCIDENTS A AD DISEASES. S97 injury may be seen. If the tear is complete, — that is, through the sphincter, — the fact should be evident on inspection. If there is any doubt about it, the forefinger of the left hand is inserted in the anus, the thumb in the vagina ; the thickness of tissues between, or their absence, can thus be appreciated. It is a seri- ous error to overlook a complete tear. Many suits for damages have been based on this ground. The laceration may be im- mediately repaired; but the author prefers repairing all the in- juries of childbirth at the end of five to seven days after delivery, making a formal plastic operation. After trying the different periods for repair work from a few minutes after labor to the Fig. 477. — Testing the thickness of tissues between the rectum and the vagina. end of the puerperium, the end of the first week has been found the best time. Immediately after labor the tissues are bruised and edematous; the bloody discharge is profuse and embarrassing; it is impossible to make an accurate diagnosis of the extent of the injury and it is unwise to repair the cervix. By waiting a week the tissues are in more favorable condition for good union, and it is possible to make a careful examination of the- whole genital canal and to repair every one of the injuries of childbirth. If the woman is infected, has kidney disease, or has had a serious hemorrhage it is desirable to wait several weeks. The operation should be performed on a suitable table, with sufficient assistants and implements and under anesthesia. 59 8 THE PATHOLOGY OF LABOR. The operation for lacerated perineum and torn vagina is per- formed in the same manner as the secondary operation upon the perineum, after the plan of Emmet, or by inserting vaginal or perineal sutures, or both, according to the kind and degree of the Fig. 47S. — Abrasions of the vulva and lacerations of the vaginal sulci (Bar). Fig. 479. — Deep laceration of the perineum and of one sulcus ; splits in the vaginal mucous membrane (Bar). 'il>. '-. % Fig. 480. — Laceration of the perineum and of one sulcus (Bar). n(^W&^ Fig. 481. — Laceration of the peri- neum and of the sulci ; a"brasions of the vulva (Bar). laceration as shown in figures 485, 486, 487, and 488. If the perineum is torn through the sphincter into the rectum, the best mode of suture is shown in figure 491. Silkworm-gut sutures are PLATE 12. A ,:A: Complete tears of the perineum (painted from life a few hours after the injury) : I, Tear involving some of the fibers of the sphincter, but not all ; 2, median com- plete tear, with abrasion of the vulva, and two large hemorrhoidal veins exposed, one on either side ; 3, complete median tear, with sphincter muscle hidden by three large hemorrhoids; 4, lateral complete tear, involving left vaginal sulcus. LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 599 inserted first in the rectum and knotted there, with the ends left long enough to hang an inch or more outside the anus. Two stitches should be inserted from the rectal side, through the ends of the torn sphincter muscle ; and directly above the sphincter a Fig. 4S2. — Laceration of the vaginal sulci without a tear of the perineum proper (Bar). Figs. 483 and 4S4. — Lncerations of the perineum without involvement of the pelvic floor. Such tears would nut affect the woman's health or comfort subse- quently (Bar). stitch should be placed triangularly in the torn perineum, skirl ing the whole extent of the rectal tear, entering and emerging upon the skin of the perineum just above the anus. This resem bles somewhat the stitch recommended by Emmet for a torn sphincter and rectum, but of itself it is not to be depended upon. THE PATHOLOGY OF LABOR. Fig. 485. — Vaginal sutures for the Fig. 486. — Perineal sutures for lacera- repair of a laceration through the perineal tion of the perineal body, bodv. Fig. 487. — Vaginal and perineal sutures Fig. 488. — Vaginal and perineal su- for laceration of the perineal body. tures for laceration of the posterior vagi- nal sulci and of the perineal body. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 6oi Fig. 489. — Vaginal and perineal su- tures for an extensive tear involving the whole length of the perineum down to the anus. Fig. 490. — Rectal and anal sutures in a complete tear of the perineum. Fig. 491. — The sutures for a complete laceration of the perineum in either a primary or a secondary operation : A, A, the harrier or splint stitch. 602 THE PATHOLOGY OE LABOR. As a reinforcement of the sphincter and rectal stitches, however, it does good service. The torn perineum is then repaired by stitches inserted as in the Emmet or Hegar secondary operation. In the rare cases of central tears of the perineum, an attempt should be made to repair the injury by vaginal and perineal sutures, but a secondary operation for a perineovaginal fistula may be necessary. Injuries of the Anterior Vaginal Wall. — There is quite fre- quently a submucous laceration of the muscle and fascia of the uro- Fig. 492. — A suture for the repair of laceration of the muscle and fascia of the uro- genital trigonum in the left anterior vaginal sulcus. genital trigonum (Waldeyer) in the anterior sulci, usually most marked in the left. This muscle is the main support of the lower anterior vaginal wall. Its laceration allows the anterior wall to drop backward and outward. The constant drag of this prolapsed portion of the wall upon the structures above results in the forma- tion of a cystocele in the course of time. The injury can be recog- nized by pressing a finger upward against the pubic bone. The presence or absence of the muscle is easily determined. The laceration can be repaired by interrupted sutures running across and beneath the sulci, under the mucous membrane, and return- ing again superficially directly under the mucous membrane. The LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 603 author believes that the primary repair of this injury will as surely prevent cystocele as the careful repair of the posterior wall pre- vents rectocele. His experience with it, however, while exten- sive, is too recent to justify a positive statement. Inversion of the uterus is the rarest of all the acci- dents to a parturient woman. In the Vienna Maternity, from 1849 to 1878, in more than 250,000 labors, there was not a case" In the Rotunda Hospital, in Dublin, there were 100,000 labors, Kigs. 493, 494, 495, 496 — Varieties of central tear of the perineum (•' Precis d'Obstetrique "). with only one inversion of the womb. Winckel has not seen a case in 20,000 labors. My own experience amounts to six cases — five complete and one partial. 1 In general practice, especially among the poorer classes, inversion of the womb is not so rare. The accident happens with equal frequency before and after the de- 1 Three cases were seen directly after labor ; two were reduced by taxis ; the other spontaneously. One case of complete inversion was reduced five days after labor by taxis; another three months after labor by the author's operation. The sixth case of inversion was due to a myomatous polyp at the fundus. It was complete, but was easily reduced by taxis after the removal of the polyp. 604 THE PATHOLOGY OF LABOR. livery of the placenta. It is reported to have occurred on the third and fifth day of the purperium. l The inversion may be partial or complete, the former when the fundus simply protrudes into the uterine cavity, the latter when the womb is turned completely inside out. In a complete inversion the fundus is just within the vulva ; the cavity of the womb is formed by the peritoneal sur- face, the orifice looking upward into the peritoneal cavity. From this cavity the tubes and the ovarian and round ligaments run upward ; the ovaries are usually above and to either side of the orifice. In the rarest instances inversion of the womb may be associated with inversion of the vagina. In such a case the in- verted womb is also prolapsed. Causes. — Inversion of the uter- us may occur spontaneously. In the so-called paralysis of the pla- cental site, — a condition in which this portion of the uterine wall be- comes so relaxed and flabby that it sags down into the uterine cav- ity, — the projecting portion of the wall, it is said, is seized upon by the remainder of the uterine mus- cle as a foreign body, and de- pressed further and further toward the cervical canal, as a polypoid tumor might be expelled. The explanation, however, is strained. A contraction of the uterine mus- cle under these circumstances would reinvert the womb. A much more plausible explanation for spontaneous inversion is found in an adherent placenta and en- tire relaxation of the uterine walls. In this condition of affairs the mere weight of the placenta is enough to drag the fundus down into the uterine cavity. A most favorable predisposing cause is furnished by a complete inertia uteri at the close of the second stage of labor. The expressive force of the abdominal muscles not only expels the child's body, but drives down the uterus after it. Inversion of the uterus may be most frequently explained by traction on the cord in the third stage of labor, when the placenta is adherent. It may occur in consequence of a short cord pulling upon the placenta during labor. In a case under my observation the cord was 1 Fisher, "Br. Med. Jour.," 1S96, vol. ii, p. 1 17S ; and Burton, "Am. Jour, of Obstet.," vol. xxxvi, p. 548. Fig. 497. — Partial inversion of the uterus. LABOR COM PL ICA TED BY A CCIDENTS AXD DISEASES. 60 5 wound three times around the child's neck. It is sometimes due to too vigorous compression of the fundus in efforts to ex- press the placenta, and I have seen it occur on one occasion in an effort to extract an adherent placenta, in which the hand and the placenta grasped within it acted like the piston of a syringe and drew the fundus down into the uterine cavity. Another case under my observation appeared to be due to the universal ad- herence of the membranes after the detachment of the placenta. The weight of the latter, dragging on the uterus by the mem- — — — j> Fig. 498. — Complete inversion with prolapse : A, Mons veneris ; B, labia majora ; C, labia minora ; D, clitoris ; E, urinary meatus ; F, external anterior bor- der of the vagina ; G, external border of the os uteri ; H, the internal surface of the uterus, now external (Boivin and Dug6s). branes, turned it inside out. A necessary predisposition to inversion of the womb is relaxation of its walls. If the uterus is firmly contracted, the accident can not occur. Symptoms. — Inversion occurs suddenly, and is usually asso- ciated with profound shock, and often with some hemorrhage. The patient at once passes into a most alarming condition, that can scarcely fail to attract any one's attention. The only causes for her condition would be hemorrhage, rupture of the uterus, 6o6 THE PATHOLOGY OF LABOR. syncope, or inversion. An immediate vaginal examination should always be made, whereupon the nature of the trouble should mani- fest itself at once. The inverted uterus is found filling up the vagina, and almost projecting from the vulva. By abdominal palpation one notes the absence of uterine tumor in the hypo- gastrium, and can detect, moreover, a groove or slit running across what remains of the cervix. If necessary, a rectal exam- ination would reveal the absence of the womb and the depression in the cervix where it is inverted even more plainly than these signs could be detected by abdominal palpation ; but a rectal ex- amination should scarcely ever be necessary. The cervix itself remains uninverted as a collar about the lower uterine segment. Fig. 499.— Partial inversion of the uterus. Between the cervix and the uterine wall a sound or the finger ma\- be inserted a little way, but it is impossible to find a uterine cavity. This fact should always make the distinction between an inverted womb and a fibroid polypus or other tumor projecting from the uterine cavity. Mistakes, however, of the most serious character have been made in this connection. In one case the inverted womb was torn away in the belief that it was a fibroid tumor, and in another the wire of an ecraseur was adjusted about an inverted womb, and was about to be screwed tight, when the true character of the mass in the vagina was detected. Treatment. — Occasionally, a spontaneous reduction of the inversion occurs, especially when inversion is partial. This occurred in one of the six cases under my observation. If the LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 607 Fig. 500. — Inversion of the uterus and the author's operation for its correction : I, Complete inversion, 3 months after labor; 2, discission of the cervix through its entire length, supravaginal as well as infravaginal portion ; 3, inversion corrected and sutures introduced ; 4, sutures fastened. 6o8 THE PATHOLOGY OF LABOR. inversion is complete, spontaneous reduction can not be expected. If the placenta is still attached to the uterus, it should be first re- moved, and then pressure exerted with the fingers upon the lower uterine segment in a direction forward and slightly upward. To do this, the hand must be inserted well into the vagina and back toward the sacrum, and the fingers must then be directed well for- Fig. 501. -Inversion of uterus showing necessity of pressure forward in taxis for its reduction. ward toward the anterior abdominal wall, in the direction of the axis of the superior strait. The mistake is almost always made of pressing upward against the sacrum, so that the efforts to reduce the womb may fail altogether, and a chronic or permanent inversion may be left for the surgeon to deal with after the puerperium is com- pleted. With the proper direction of force in one's effort to reduce LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 609 an inverted uterus, failure ought to be almost unknown, if the repo- sition of the womb is undertaken at once, as it always should be. If there has been a deep tear of the cervix, the best place to begin the reinversion is just below the upper margin of the tear. I suc- ceeded by this plan in one case after two other physicians had failed and after my own attempts at reduction by pressure on the lower uterine segment posteriorly had been futile. Strange as it may seem, the inversion has been overlooked for some days or altogether in quite a large proportion of the Fig. 502. — 1, Complete inversion of the uterus; 2, first manoeuver to reinvert the lower uterine segment ; 3, second manceuver to widen cervical ring and afford counterpressure by an assistant. cases. If the cervix is allowed to contract firmly, as it will in a few hours, the reposition of the womb becomes extremely difficult. In one of my cases, seen in consultation, five days had elapsed since the woman's delivery. She had suffered great pain, had considerable fever, with a foul discharge, and had a very rapid pulse, yet no vaginal examination had been made, 39 6 1 THE PA THOL OGY OF LAB OR. although the patient was in charge of a professed expert in gynecology ! The uterus was completely inverted. Reposi- tion was finally accomplished by the following plan: One hand, made into a cone shape, was inserted in the vagina and the finger-tips were pressed steadily against one side of the lower uterine segment, forcing it into the cervical ring. After steady pressure for almost an hour, the cervix yielded considerably. Then an assistant helped in the dilatation of the cervical ring, in the manner shown in figure 478, and at the same time made counterpressure downward upon the cervix. The womb was returned to its natural position shortly after this manceuver was tried. The woman recovered. If taxis fails, the cervix may be cut in two in the median line posteriorly from the external os to the lower uterine segment. As soon as the obstruction of the contracted cervical muscle is removed the uterus may be reinverted without difficulty. The wounds in the cervix and vaginal vault are closed with interrupted sutures. Some of those in the supravaginal portion of the former may have to be buried, and should be of catgut. This operation has distinct advantages over those of Barnes, Gaillard Thomas, Browne, and Kiistner. 1 The separation of the anterior cervical wall from the bladder and its complete discission may be more effectual than posterior discission. 2 If it should be impossible to reinvert the uterus after complete discission of the cervix, Spinelli's operation — dividing the posterior or anterior uterine wall as well as the cervix — may be tried. Prognosis. — The mortality of inversion of the womb has been extremely high. In one series of 109 cases there were 80 deaths, and 72 of these within a few hours after labor. In another series of 54 cases there were 1 2 deaths (Winckel). The six cases under my care recovered. The causes of death are : shock, hemorrhage, sepsis, peritonitis, and exhaustion from long- continued loss of blood. Injuries of the Urinary Tract; Genitourinary Fistula;. — The commonest fistula is vesico-vaginal, due to pressure necro- sis of the vesico-vaginal septum in a prolonged labor. The bladder wall has been punctured or ruptured by the blunt hook ; by forcible delivery with forceps, in cases of cystocele distended with urine; by craniotomy instruments; by spicules of fetal bone; by unskilful extraction of the head after version; by a vesical calculus caught between the fetal head and the maternal symphysis and by rough intravaginal manipulations. The first 1 Bernard Browne, " Tr. Am. Gyn. Soc," 1899. 2 Oui, "Ann. de Gyn. et d'Obstet," Oct., 1901. Good bibliography. Also Reuben Peterson, "The Conservative Operative Treatment of Chronic Inversion of the Uterus," "Am. Gyn.," June, 1903. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 6 1 I symptom to attract attention is incontinence of urine. A visual examination, the use of a sound in the bladder, injections of col- ored fluid into the bladder, indagation, and, if necessary, cystos- copy, make the diagnosis certain. If there is no loss of sub- stance, the injury may be primarily repaired. Sometimes the opening, if small, is closed spontaneously by granulation tissue. Usually a secondary operation is required, which should be performed, if possible, four to six weeks after labor. Rupture of the symphysis occurs not infrequently, 1 usually in consequence of some disease within the joint itself, occasionally as the result of great force in the extraction of the head with for- ceps or after version. The accident may be recognized at the time of its occurrence by feeling the bones give way, or by actu- ally hearing them snap. But it may not be detected until the woman complains of great pain in the symphysis, and of inability to sit up or walk when she rises from bed. Not infrequently rup- ture of the symphysis is followed by suppuration of the joint. The accident must be treated by a firm binder around the hips, and sand-bags such as are used after a symphysiotomy, and by keeping the patient in bed four or five weeks. Suturing the ends of the bones with silver wire may be required. If the joint suppu- rates, it should be opened as early as possible and should be well drained. The prognosis of the injury is not serious. Recovery may be expected as a rule, without impairment of locomotion or other disagreeable consequences, if the symphysis alone is in- jured. Rupture of the sacroiliac joints has the same causes as rupture of the symphysis, and is often associated with it. Inflam- mation and suppuration in these joints often follow their injury. The symptoms in the puerperium are, great pain over the joints on attempting to walk, a feeling of insecurity in the pelvic bones, a wabbling gait, and loss of power in one or both lower limbs, with fever if the joints are inflamed or suppurate. The only treatment available is firm support of the pelvis by a pelvic binder, sand-bags alongside the pelvis, and extension to the lower limbs, or, best of all, the orthopedic surgeon's wire cuirass to immobilize the whole body. Prolonged rest in bed — six to twelve weeks — is necessary. In the case of suppuration of the joints, an incision into them from behind to evacuate the pus and to allow of drainage is indicated. The mortality of injury to the sacro-iliac joints in labor has been thirty per cent. Fracture of the Pelvic Bones. — This very rare accident in labor has usually been the result of the unskilful use of forceps. 1 Ahlfeld collected ioo cases, to which number Schauta added 14 (Midler's "Handbuch"). In 91, 149 labors this accident occurred three times. About 130 cases are on record. Kayser, "Arch. f. Gyn.," Bd. Ixx, II. I, 1903. 6 1 2 THE PA THOL OGY OF LABOR. It is serious but not necessarily fatal. In a case reported by Studley, 1 of a fracture of the horizontal and of the descending ramus of the pubis, the woman recovered. Bird 2 also reports a recovery after a fracture of the horizontal ramus of the pubis before the application of forceps, and the author has seen one case with like result, in which forceps was applied and powerful traction was made. Fracture of the sacrococcygeal joint, or of the coccyx, occurs very rarely in elderly primiparse, in whom not only the sacrococcygeal joint, but the joints of the coccyx as well, are ankylosed. The fracture may be caused spontaneously by the expulsive efforts of the mother driving the presenting part down upon the pelvic floor ; but it is more commonly the result of the application of forceps and the forcible extraction of the head through the pelvic outlet. There are, in my experience, four types of injury to the coccyx in labor. In one there is an oblique fracture of a coccygeal vertebra involving a joint and resulting in painful mobility of the bone. In the second there is ankylosis of the two fragments with the lower one drawn in at a right angle, where it is out of the way and causes no inconvenience or discom- fort except in a subsequent labor. In the third the lower frag- ment is ankylosed in a perpendicular position, causing great pain when the patient attempts to sit. In the fourth there is a strain, sprain, or an actual rupture of a coccygeal joint, with abnor- mal mobility and chronic inflammation of the intervertebral disc, with consequent hypertrophy and softening. This last form is by far the commonest. The injury often results in the condition known as coccygodynia after the completion of the puerperium. Diastasis of the Abdominal Muscles. — Reference has been made to the escape of the uterus from the abdominal cavity between the recti muscles in labor. After delivery these muscles stand widely apart and threaten the woman with pendulous belly, ptosis of the abdominal viscera, and even with abdominal hernia when she rises from bed. Diastasis of the recti muscles is not uncommon after labor. It is usually observed without precedent actual hernia of the parturient uterus. The condition can usually be corrected by a firm abdominal binder during puer- peral convalescence or longer. If it is not, and does not yield to abdominal massage, electricity, and Swedish exercises, the operation of diminishing the width of the aponeurosis proposed by J. C. Webster 3 may be indicated : Namely, slitting the ante- rior sheaths of the recti muscles, sewing their outer edges to- 1 "American Tournal of Obstetrics," April, 1879. 2 "American Journal ' f Obstetrics," Jan., 1902. 3 "Journal of the American Medical "Association," Dec. 22, 1900. LABOR COMPLICATED BY ACCIDENTS A AD DISEASES. 613 gether, and turning the intervening structures into the abdom- inal cavity in the shape of a tuck. Fig. 503. — Webster's operation for diastasis of the recti muscles, modified. The sheaths of the recti muscles are split after dissecting back the skin and subcutaneous fat of the abdominal wall. Fig. 504. — Webster's operation for diastasis of the recti muscles, modified. Mattress sutures of formalin catgut are inserted through the outer edges of the two sheaths, and silkworm-gut sutures are passed between them, through the skin, subcutaneous fat, and outer edges of the sheaths. Fig. 505. — Webster's operation for diastasis of the recti muscles, modi- fied. The outer edges of the two sheaths are united by a running suture of formalin gut ; the mattress sutures and interrupted sutures are tied. Fig. 506. — Webster's operation for diastasis of the recti muscles, modi- fied. The skin-wound between the interrupted sutures is closed with Michel's clamps. Rupture of Some Part of the Respiratory Tract and Sub- cutaneous Emphysema. — During the straining of the second stage of labor, the larynx or trachea may be ruptured. This 614 THE PATHOLOGY OF LABOR. accident is followed by emphysema of the neck and face. The accident, if confined to the trachea or larynx, and resulting only in emphysema of the face, is not dangerous. If the emyhysema is more extensive, however, or if there is a rupture of the pul- monary vesicles, with emphysema of subpleural and interlobular connective tissue, with embarrassment of heart and lungs, the prognosis is not so good. As soon as the nature of the injury is recognized the patient must be forbidden to strain, and should be delivered as quickly as possible by forceps or version. 1 Sudden Death During or Directly After Labor. — The causes of this acci- dent to the parturient woman are set down, as far as possible, in the order of their frequency. Shock. — A few sudden deaths dur- ing and after labor may be explained by surgical shock, which is more likely to follow a serious accident, such as ruptured uterus in labor, but may re- sult from the strain and suffering of parturition in weak, hyperesthetic individuals, without any serious com- plication. Heart=failure may be due to ad- vanced kidney disease, to fatty de- generation of the heart itself, to a fibroid patch in its walls, to rupture of an aneurysm, to myocarditis, and to a number of other conditions that might interfere with normal heart-action. In women with diseased and weak hearts so small a matter as an intra-uterine injection has caused heart-failure. Accidents of Labor. — Any of the serious accidents of labor may pro- duce death by shock or by hemor- rhage, as accidental, unavoidable, or postpartum hemorrhage ; rupture or inversion of the womb. Rupture of Hematomata. — A rupture of a hematoma, exter- nal or internal, may kill a patient by shock or by hemorrhage. In a case under my care a hematoma in the outermost part of the left broad ligament, rupturing eighteen hours after delivery, caused death in a very short time by internal bleeding. 1 Scheffelaar Klots has collected 40 cases, " Ztschr. f. Geb. u. Gyn.. " Bd. xli. H. % Fig. 507. — Median section of coccyx imbedded in paraffin, showing an oblique fracture run- ning through the second verte- bra. The vacant space between the lower end of the anterior fragment and the main body of the bone was filled with an ex- uberant mass of spongy bone- tissue that dropped off when the bone was taken out (author's case). LABOR COMPLICA TED B Y ACCIDEXTS AXD DISEASES. 6 1 5 Fig. 508. — Coccyx ruptured in second joint by a forceps delivery. Ankylosis of all the other joints (author's case). Fig. 509. — Coccyx ruptured in first joint by a fall on the ice in eighth month of pregnancy. Injury aggravated by labor (author's ca.-r . 6 1 6 THE PA THOL OGY OF LAB OR. Syncope. — There is a disposition in many women after labor to faint, but even complete syncope at this time is rarely fatal. If it depends, however, upon hemorrhage, thromboses may form in the heart, or those in the uterine sinus may be prolonged, and embolism may result. Prolonged syncope, associated with air- hunger and other symptoms of profuse internal hemorrhage, is almost always fatal. Embolism and Thrombosis of the Pulmonary Artery. — This may be the result of syncope, or may be caused by the detach- ment of an embolus from the pelvic blood-vessels. The embolus, it is claimed, may be a globule of air, 1 or may be fat from the pelvic connective tissue. The symptoms of the acci- dent are : sudden shock, a rapid-running pulse, heart -failure, rapid respiration, air-hunger, followed usually in a few moments by death ; but the accident is not invariably fatal. I have seen one well-marked case recover. The only treatment possible is stimulation, slight elevation of the body, and lowering of the head, with absolute quiet. Profound Mental Impressions. — Profound emotion may cause a woman's death during or directly after labor. The following case was described to me by a friend who witnessed it. A widow, in good position, applied for treatment for abdominal tumor. She was told that she was pregnant, but she vehemently denied the possibility of her condition. A little later her phy- sician was summoned to attend her in what he found to be labor. He told her again of her condition, but she again denied it, and throughout the whole of her labor she indignantly protested that it could not be so. Finally, when the child was delivered, it was held up before her as a proof that her physician was correct. She passed at once into a maniacal condition, crying out that the child was a tumor, that she had not been pregnant at all, and after a few minutes she died. A careful postmortem examination revealed no physical cause for her death. Other causes of sudden death during and after labor that have been reported are : a brain tumor, rupture of a gastric ulcer, acute purpura haemorrhagica, rupture of peritoneal adhesions, rupture of the aorta, rupture of a cyst in the auricular septum of the heart, retro-peritoneal hemorrhage from the head of the pancreas, 2 and angina pectoris. Effect of Maternal Death upon the Fetus. — The fetus rarely survives its mother's death more than a few minutes, and usually 1 Since I saw my friend, Professor H. A. Hare, inject whole syringefuls of air into the jugular vein of a dog without detriment to the animal, I confess to a skepti- cism in regard to air-embolism as a cause of death in the child-bearing woman. 2 Van de Velde, " Jahresbericht," vol. xii, p. 764. LABOR COMPLICA TED B Y ACCIDEXTS AXD DISEASES. 6 1 7 the death of mother and child is synchronous. An interesting case was reported to me by a surgeon on an American man-of- war in the harbor of Rio Janeiro during the revolution in Brazil. A pregnant woman, near term, was struck by a fragment of an exploding shell. She was killed immediately. She had scarcely fallen to the ground when a Brazilian surgeon, who was standing near, cut open her abdomen and uterus with a penknife, but the child was extracted dead. Tarnier reports an extraordinary case in which it appeared that the child lived for two hours after its mother's death. During the Commune in Paris the rioters fired upon the Maternity Hospital. A pregnant woman, sitting upon her bed in a ward, was shot through the head and instantly killed. After a while she was discovered dead, and Tarnier was summoned to do postmortem Cesarean section, as fetal heart- sounds were still heard. Beginning the operation with his assist- ants, the rioters fired upon the operators, and it was necessary to remove the woman to the cellar before the attempt could be repeated. After an interval of an hour and three-quarters, or more, the operation was at length performed, and a living child extracted from the mother's womb. In case of death in a pregnant woman near term, the fetal heart-sounds should be listened for carefully, and, if they are heard, an immediate attempt should be made to extract the child. This can be done by postmortem Cesarean section, or, better, I think, by forced dilatation of the cervix, version, and rapid ex- traction. I have had one experience in such a case, in which the dilatation of the cervix and the extraction of the child pre- sented no difficulties at all, and were completed in a very few moments. If the patient is seen in articulo mortis, it is unques- tionably better to deliver her by forcible dilatation of the cervix and version rather than to await her death and then to perform a postmortem Cesarean section. Postmortem Delivery. — There is reported from time to time the birth of a child in its mother's coffin, giving rise to the horri- ble suspicion that the pregnant woman had been buried alive, and had fallen into labor when she awoke from her trance and realized her dreadful position. These cases, however, may be explained by the accumulation of gas within the abdominal cavity due to decomposition, which so increases the intra-abdominal pressure as to drive the fetus out of the woman's body. Such cases are more common in hot climates, where decomposition progresses rapidly. 1 Accidents to the Fetus, — Prolapse of the Cord. — The cord is 1 Stumpf claims that postmortem deliveries may be due to a rigor mortis of the uterine muscles, " Monatschr. f. Geb. u. Gyn.," Bd. viii, p. 64. 6i8 THE PATHOLOGY OF LABOR. said to be prolapsed when it presents with or slips beyond the presenting part. Frequency. — According to Winckel, the frequency of prolapse of the funis varies in different clinics from I : 65 to 1 : 500. Churchill found it once in 245 labors; Christisen, once in 65; Meachem, once in 93 ; Bland, once in 1897 labors. Causes. — The causes of prolapse of the cord are, in the first place, a lack of conformity of the presenting part with the shape and size of the pelvic inlet, as in a flat pelvis or a compound pre- sentation, and with this condition an exaggerated length of the cord, placenta prsevia, marginal insertion, hydramnios, sudden Fig. 510.- -Trendelenburg posture over a chair to guard a prolapsed cord from pres- sure and to facilitate its reposition (Dickinson) . rupture of the membranes and violent expulsion of the liquor amnii ; deliver}- in the semirecumbent, sitting, or erect posture, and violent jolts or jars such as a parturient patient would ex- perience during transportation to a hospital in an ambulance. The diagnosis should present no difficult}'. There is nothing else in the cervical canal or vagina, during labor, which feels like the cord or should be mistaken for it. It is sometimes actually visible at the vulvar orifice, and ma}-, in case of doubt, be pulled out and inspected. If the child is alive, the pulsating vessels in the cord may be felt. I was once called in consultation, how- ever, by a young physician who believed that a coil of intestine had prolapsed into the vagina. LABOR COMPLICATED BY ACCIDENTS A. YD DISEASES. 619 Fig. 511. — Impro- vised repositor. The prognosis for the child is grave. The mortality in gen- eral is more than fifty per cent. The child obviously dies of asphyxia from pressure upon the cord; hence the clanger is twice as great in head presenta- tions (sixty-four per cent.) as in breech presenta- tions (thirty-two per cent.). The danger to the mother lies in the operative procedures which are often required for the reposition of the cord, such as version and rapid extraction. Treatment. — The cord should be replaced by manipulation with the woman in a knee-chest posture, or, better, the Trendelenburg posture — over the back of a chair. It is advisable to hook a loop of the cord over an extremity or the chin to prevent its prolapsing again, which is extremely likely. The whole hand must be inserted in the vagina, and perhaps within the lower uterine segment; so that anesthesia is usually required. While the anesthetic is administered, and while the physician makes his preparations for the reposition, the patient should be kept in the Trendelenburg- posture, so as to guard the cord from fatal pres- sure. If the cord is satisfactorily replaced so that it will not come down again, forceps should be applied to the head to fix it firmly over the pelvic inlet. If the os is not sufficiently 7 dilated to allow the application of forceps, a dilatable rubber bag (Barnes', Braun's, or Voorhees') should be inserted in the cervix or in the lower uterine segment and distended with water to prevent pro- lapse of the cord while the cervical canal is undergoing efface- ment and dilatation. If manipulation fails to replace the cord, podalic version should be performed without waste of time. The breech being firmly impacted in the pelvis, the case is managed as one of breech presentation — by delay until the os is well dilated and the cervix paralyzed, and then by rapid extraction. If the head is presenting and is engaged so that version is out of the question, the cord should be so disposed as to be least pressed upon (for example, opposite the left sacro-iliac junction in a left occipito -anterior position of a vertex presentation) and the head rapidly extracted with forceps. In prolapse of the cord with a breech presentation, the cord should be replaced by manipulation in the Trendelenburg posture ; a foot should be seized and brought down until the breech is firmly impacted in the pelvis. The instrumental reposition of the cord is usually unsatis- factory and unnecessary. Manipulation accomplishes more than 6 2 O ■ THE PA THOL OGY OF LABOR. can be done by a repositor. Occasionally, however, it might be convenient to remember the device illustrated in figure 511. A loop of string or tape is tied double around the end of a stiff catheter or bougie. The free loop is caught over the cord and the end of the instrument which is carried high up into the uterine cavity. Should it be desirable to withdraw the instru- ment, it can be done without pulling the cord out with it. Rupture of the Cord. — It has been shown by experiments that the healthy umbilical cord can stand a strain of 8% pounds on the average, the weakest 5 y 2 pounds, and the strongest 1 5 pounds. It is obvious, therefore, that the weight of an ordinary fetus may be enough to rupture the cord, and it is almost certain to do so if the weight is increased by a drop or violent expulsion, and if the placenta remains attached. Hence, precipitate delivery in the erect posture is often accompanied by rupture of the cord usually at the umbilicus, although in one of my cases it tore off at the placental insertion. Spaeth and Budin have each reported a case of rupture of the cord while the woman was recumbent, and the latter has also reported a case in which the weight of the placenta, suddenly expelled and dropping the full length of the cord, snapped the latter in two. A ruptured cord usually does not bleed. If it is torn off at the umbilicus and the vessels bleed, they should be pulled out by a tenaculum and ligated, or, if this is impracticable, hare-lip pins should be inserted under the umbilicus and a figure-of-eight liga- ture applied. The treatment of rupture of the umbilical cord is pre- ventive. Labor in the erect posture should, of course, never be allowed, and a precipitate labor must be retarded ; violent traction upon a coiled cord has ruptured it. It is better, in such cases, to cut the cord between ligatures and to extract the child quickly. ' DYSTOCIA DUE TO DISEASE. Convulsions. — Convulsions in the child-bearing woman may be defined as muscular spasms, with or without unconsciousness, occurring during pregnancy, parturition, or the puerperium. Causes. — The convulsions may be due to eclampsia, hysteria, epilepsy, tumors of the brain, cysticercus, 1 and meningitis ; to the profound anemia following postpartum and other hemorrhages, and to apoplexy ; or there may be an exaggeration of the nerv- ous irritability characteristic of the child-bearing period, in con- sequence of which convulsions may arise from some trifling irri- tation, as that of an overdistended bladder, overloaded bowels, 1 Pestalozza, " Rivist. Critic, di Clinic. Medic," 1900. DYSTOCIA DUE 7 DISEASE. 62 I the introduction of the hand in performing version, the pressure of the head upon the perineum, and excessive after-pains. Puer- peral convulsions, therefore, is a symptom indicative of a variety of pathological conditions. Eclampsia is a name given to the most frequent variety of convulsions in the child-bearing woman, the result of kidney insufficiency and of a gestational toxemia. It is derived from a Greek word signifying to shine or flash out, and was conferred upon the condition on account of its sudden onset. 1 Causes. — Since Lever's 2 discovery of the albuminuria usually preceding and accompanying eclampsia, kidney insufficiency has been regarded as the chief cause of eclampsia, but recent studies in the toxemia of pregnancy, while not diminishing the importance of imperfect elimination by the kidneys in the etiology of eclampsia, have established other factors in the causation of the disease. The several theories advocated at present start with the common assump- tion that the ovum or fetus is the source of toxins contaminating the maternal blood. What these toxins are and where they origi- nate is still unknown. Kollmann 3 points out that the fibrin-form- ing elements of the blood are much increased in eclampsia. To these globulins, albuminous, large molecular bodies which furnish the excess of fibrin, is ascribed the toxicity of the maternal blood. There is much to support this view. Experimentally these sub- stances have been demonstrated to be toxic, producing eclamptic symptoms. The negative results of cryoscopy in the urine of eclamptic patients indicate that there is an excretion of high atomic large molecular substances. Whether these substances, if thev are the toxins of eclampsia, are derived from fetal metabolism or from the syncytium of the placenta is disputed. The author favors the former view for the following reasons: The toxemia of early pregnancy, which is probably due to the syncytial growth, differs in its clinical manifestations from the toxemia of the latter half of pregnancy; eliminative treatment and dietetic management to spare the kidneys and liver favorably influence the toxemia of the second half of pregnancy, but have no effect on the toxemia of the first half. The symptoms of the toxemia of the latter half of pregnancy usually disappear with the death of the fetus; in multiple pregnancies albuminuria and eclampsia are ten times more fre- quent than in single pregnancies; in hydatidiform mole with its enormous overgrowth of syncytium eclampsia is rare; only two cases are recorded. 1 Hippocrates used the word £%kafi(f)tg to designate a sudden rise of temperature. In the middle of the eighteenth century I'oissier de Sauvages mistaken])- applied the word to convulsions. The correct term would le eclactisma (iyJMy-:Zj^- "to kick backward " ). 2 "Guy's Hospital Reports," 1S43. :i " Centralbl. f. Gyn.," 1S97, No. 13. 622 THE PA THOL O G Y OF LAB OR. The toxins in the maternal blood are conveyed first to the liver, where they are converted into substances fit for elimination by the kidneys. If the liver fails in its functions or breaks down under the strain imposed upon it, the maternal blood contains toxic material irritating to the kidneys, the central nervous system, and the capil- laries everywhere. The kidneys manifest the irritation of their capil- laries and of their epithelium by the symptoms of parenchymatous nephritis. Clinically it appears that even if the hepatic function is imperfectly performed functionally active kidneys are competent to excrete the imperfectly oxidized excrementitious matters in the maternal blood. On the contrary, with impaired excretory power in the kidneys, a cumulative toxemia develops, ending in eclampsia. The following facts support this view: Hepatic degeneration, in some cases to the grade of acute yellow atrophy, is a constant con- dition in post-mortem examinations of eclamptic patients; a small proportion of cases display no kidney insufficiency prior to the eclampsia do to 16 per cent.). But some form of kidney disease is discovered post-mortem in the large majority of cases: In 18 out of 81 autopsies Herzfeld found the ureters compressed at the pelvic brim and dilated; in more than four-fifths of the cases eclampsia is preceded by albuminuria and other signs of kidney breakdown; as the kidney symptoms increase in severity eclampsia becomes more imminent; with improvement in the kidney symptoms the danger of eclampsia decreases; examinations of the urine show apparently an imperfect oxidization of the nitrogenous bodies ex- creted. 1 Nicholson 2 has advanced the theory that the thyroid gland is the most important factor in furnishing an antibody for the toxins of pregnancy. Adequate hypertrophy and hypersecretion of the gland, which is the rule in pregnancy, safeguards a pregnant woman against toxemia; inadequate activity predisposes her to it. In spite of the enormous amount of investigation to which this subject has been subjected in the last decade it is not yet possible to explain the etiology of eclampsia fully. The only facts on which there is agreement at present are that there is a toxin or toxins in the blood of the pregnant woman derived from the ovum or fetus; that these substances affect mainly the liver and kidneys; that a breakdown of either of these organs results in a toxemia ; that the accumulated toxins probably are intensely irritating to the capillaries; that either in consequence of an acute anemia of the brain, due to contraction of the capillaries or to a direct irrita- tion of the central nervous system, convulsions appear. 1 Massen, Ludwig, Savor. Whitney, Clapp; " Centralbl. f. Gyn.," 1S95, Xo. 42; "Am. Gyn.," August, 1903. 2 "Jour, of Obstet. and Gyn. of the Br. Empire,'' July, 1902; "Brit. Med. Journ.," Oct. 3, 1903. DYSTOCIA DUE TO DISEASE. 623 From the clinical point of view it is a mistake to minimize the importance of the kidneys. The examination of the urine gives us the first premonitory signs of gestational toxemia in the latter half of pregnancy in more than four-fifths of the cases, and a treat- ment to avoid strain on the kidneys and to promote free urinary excretion is the only effective preventive treatment of eclampsia except the termination of pregnancy. There must be taken into account also the extreme irritability of the child-bearing period, predisposing to convulsive outbreaks. 1 Five per cent, of eclamptic cases are reflex and not toxemic (Duhrs- sen). The kidneys in pregnancy may become insufficient for the work of disposing of excrementitious matters from both maternal and fetal bodies, by reason of the kidney of pregnancy, of ne- phritis, of increased intra-abdominal pressure, or of direct pres- sure upon the ureters. It is important in practice to appreciate that the kidneys may be diseased and yet functionally sufficient, or that they may be healthy anatomically, but functionally insuf- ficient for their double work. Frequency. — Eclampsia occurs about once in 300 cases of pregnancy. It is most frequently seen in primiparae, and more frequently in women illegitimately pregnant. It most often occurs during labor, is next in frequency during pregnancy, and occurs least frequently during the puerperium. It is ten times as frequent in multiple pregnancies as in single pregnancies, and occurs with greater frequency in climatic conditions which inter- fere with the free activity of the skin and throw extra work upon the kidneys. Symptoms. — Eclampsia should always be feared if there are signs of kidney disease or disturbance during pregnancy, for diseased kidneys are more likely to be insufficient than healthy kidneys, 1 and in more than four-fifths of the cases gestational tox- emia is first manifested by marked and increasing albuminuria. The prodromal symptoms of the attack itself are: Sharp pains in the head, epigastrium, or under the clavicle; muscas volitantes, with failure of vision, great restlessness, or stupor. A few mo- ments after the appearance of the prodromal symptoms the attack comes on with a stare; the pupils are at first contracted; the eye- lids twitch, the eyeballs roll, the mouth is pulled to one side, the neck is then affected, and the head is pulled first toward one shoulder and then toward the other. The spasm finally spreads to the trunk and upper extremities; the arms are strongly flexed, the fingers are bent over the thumb, and the upper extremities 1 Meyer- Wirz, " Klinische Studie ueber Eklampsie," "Arch f. Gyn. ," Bd. lxxi, H. 1. 624 THE PA THOLOG Y OF LABOR. work spasmodically to and from the median line in front of the chest. The spasm of the respiratory muscles with the closure of the teeth and lips give rise to a jerky sort of breathing with a characteristic sucking sound. The lower extremities are rarely affected, although the thighs may be flexed tonically upon the abdomen. Consciousness is lost during the convulsive attack and for some time afterward; with each recurring fit the stupor deepens, until at length there is unbroken coma. The convul- sion lasts for a minute or two. The temperature usually rises higher with each convulsion. The patient often has no recollec- tion whatever of events during, preceding, and following the whole period of her convulsive attacks, though she may have seemed to be perfectly conscious the greater part of the time. The urine is almost always albuminous after the first or second convulsion; albuminuria precedes the convulsions in more than four-fifths of the cases. The percentage of urea and of most of the urine salts except the chlorids is not necessarily lowered, though the total excretion is diminished owing to a scanty secretion of urine sometimes to a complete anuria. The urine may con- tain methemoglobin and oxyhemoglobin as well a? free blood, numerous casts, and desquamated cells. Pathology. — The lesions of eclampsia are by no means confined to the kidney, in which, however, extensive degeneration of the epithelium or interstitial nephritis is almost invariably found. In 18 out of 81 autopsies Herzfeld found the ureters much dilated by compression at the pelvic brim. 1 In the liver, kidney, brain, and lungs are numerous thromboses of the small capillaries, extrava- sations, and necrotic areas. Emboli of liver cells are found in the important organs. There is degeneration of the myocardium. In the lungs there may be edema or pneumonia and infection from the inspiration of foreign material from the mouth. There are also in the lungs emboli of giant polynuclear cells which Schmorl attributes to the surface of the placental villi, having, indeed, demonstrated their exfoliation, absorption into the circu- lation from the intervillous blood spaces, and their passage through the heart to the lungs, where they are arrested because they are too large to pass the capillaries. 2 Schmorl attributes eclampsia to the exfoliation of these giant cells. 3 The assertion that only 5 per cent, of women with diseased kid- neys develop eclampsia is not strictly true; even if it were, the pro- portion of one in twenty contrasted with one in three hundred 1 " Centralbl. f. Gyn.," No. 40, 1901. 2 Pels Lensden lias found these giant cells in the lungs of non-eclamptic patient.-, " Ztsch. f. Geb. u. Gyn.," xxxvi, S. 1. 3 " Pathologisch-Anatomische Untersuchungen iiber Tuerperal-Eklampsie," Leipzig, 1893. DYSTOCIA DUE TO DISEASE. 625 shows the influence of imperfect kidney action in the etiology of gestational toxemia and eclampsia. As a matter of fact, only a minority of patients with diseased kidneys go through pregnancy without some of the manifestations of toxemia. Differential Diagnosis. — The convulsions of eclampsia must be distinguished from those of epilepsy, hysteria, brain disease, hemorrhage, or of some source of irritation within the body, as mentioned above. The distinction should be made without diffi- culty by an examination of the urine. If the patient is catheter- ized, and the urine is heated in a spoon over a gas-lamp flame, it will turn almost solid by the coagulation of albumin in it. About sixteen per cent, of the cases of true eclampsia show no albuminuria before the convulsions appear, but in every case, after the second convulsion at least, the urine contains albumen, almost always in large quantities. The other conditions causing convulsions in the child-bearing woman have their distinctive signs that serve to make the differential diagnosis easy. Prognosis. — In general practice it may be stated that the mor- tality of eclampsia is thirty per cent., but in different localities, and at different times, the mortality varies widely. For example, the mortality in nine lying-in hospitals in this country during a period of five years was 38.4 per cent, in 78 cases. The mor- tality of the Royal Maternity in Edinburgh has been 66.6 per cent. That of Guy's Charity, in London, averages 25 per cent. In 209 cases in the Maternite, in Paris, from 1850 to 1856, the mortality was 33 per cent. Winckel reports 92 cases, with 7 deaths — a mortality of 7.6 per cent. Veit reports more than 60 cases, with 2 deaths — a mortality of 3.3 per cent. In 46 cases in the Charite, in Berlin, there were 6 deaths, 2 of these being due to complications, so that the mortality of the eclamptic cases was 8.5 per cent. It is claimed that in Germany in general the mor- tality in the last ten years has been reduced to between 7 and 10 per cent, but during this period, in 80 cases in the University Maternity of Berlin, the death-rate was 21.25 per cent. In the Maternity of the University of Pennsylvania the mortality in 70 cases was 33 per cent. The causes of death may be edema of the brain, of the lungs, or of the larynx ; apoplexy, asphyxia, exhaustion, heart-failure ; thrombosis and embolism in important vessels, especially the pul- monary arteries, insufflation of foreign substances (food, blood) into the lungs, and bronchopneumonia, or an overwhelming accu- mulation of the poison of eclampsia in the system. The mortality is greatest during pregnancy and least in the puerperium. The greater the number of convulsions and the shorter the interval between them, the graver the outlook; but death may follow the 40 626 THE PATHOLOGY OF LABOR. first convulsion and recovery has been observed after sixty-nine. 1 Rapid pulse and high temperature are unfavorable symptoms. Nothing is so uncertain as the result of eclampsia. The physician does wisely never to give up hope of recovery until death actually occurs, and, on the other hand, not to be too confident even in apparently favorable cases. The mortality of the child, if eclampsia occurs during preg- nancy or labor, is about 50 per cent. 2 The following statistics are taken from the records of the Uni- versity Maternity : Patients, 70. Ages, fifteen to forty-one. Primiparae, 55. Multiparae, 15 ; of whom four had 2 children ; one, 3 ; three, 4 ; one, 5 > two, 6 ; three, 8; and one, 10. The one with 8 had had eclampsia in last six preg- nancies. The women with 3, 5, an two at ^>}'zi nme at 7> two at T}i, and four at 8 months. Cases at term, 51. Convulsions varied from I to 41 in number. Urine. — Anuria in 3 cases. 5 y ij m f° ur days in one case. Albumin from -jL to solid. Urea from 0.001 to 0.055 percent. Albumin, trace till first convul- sion and then solid, 10 cases. In one case convulsions appeared twelve hours after delivery ; in another, four days after delivery. Time of Convulsions : Before delivery only = 41, of which 10 died. After " " = 14, of which 8 died. Before and after delivery = 15, of which 5 died. Complications: Mania, 4 cases (3 multiparae, 5, 4,8): 1 permanent ; I lasted eight days; I, four days ; I, seven days. Blind, 3 cases. One woman was comatose seventy-eight hours, yet recovered. He?niplegia, I case ; died. Hyperpyrexia, 107 , 10S , llo°, 3 cases. Low temp., 94 , I case. Albuminuric retinitis, 5 cases. Albuminuria persisted in 5 cases ; cleared up in 42 cases. Deaths, 23. Twelve hours or less after admission, 12 ; more than twelve hours, II ; died undelivered, 4 ; died from ether nephritis after recovery from eclamp- sia, I. Deaths in Primiparae = 20 = ^56.3 r r ") ■ , ,- -,, t, , . ,, , y ° J ,_ including all cases. Deaths in Multiparae = 3 = 20 <7 1 & Total death-rate, 33 % ', excluding cases brought in by the ambulance in a hopeless condition, 19 f c ■ Child. Thirty-five children still-born, including all premature cases. Excluding 15 cases under eight months = 20 dead, 37 alive (2 twins), 26.3 by bulk in boiling. Urea = 0.001 to 0057. Labor induced to avert eclampsia, 11 ; none developed convulsions. Convulsions, II ; 2 died. Multiple pregnancies : twins once. Casts present, 26 ; mostly hyaline and granular. Marked edema, 7 ; two of these women developed eclampsia. Persistent vomiting, 7 ; all induced labor. See above. Patients who had had eclampsia before but escaped under treatment, 40. Treatment. — The preventive treatment of eclampsia has been in part referred to in the section upon the Management of Preg- nancy, and under the head of Gestational Toxemia and of Kidney Diseases during Pregnancy. As already stated, routine examina- tions of the urine should be made every two weeks until the last month, and then weekly. If any abnormality is found or reported, such as a very high or low specific gravity, diminution in total quan- tity in the twenty-four hours, albumin or casts, or if the patient reports headache, disturbance of vision, edema, gastralgia, nausea, dyspepsia, palpitation of the heart, or a feeling of general malaise; if she presents an abnormal appearance, has a rapid pulse, coated tongue, foul breath, or a dry, harsh skin, with a sallow complexion, the total quantity of urine passed in the twenty- four hours should be collected daily and examined for albumin, urea, specific gravity, and casts. Whether the urinary examination is satisfactory or not, the patient presenting symptoms of a gestational toxemia should be put on a diet mainly of milk; meat, eggs, fish, and the stronger nitrogenous vegetables being excluded. A laxative at bedtime, copious draughts of water, and a diuretic should be prescribed. The most valuable indication of the kidney condition is the presence or absence of albumin in the filtered urine. It is true that a small proportion of cases (less than a fifth) develop eclampsia without previous albuminuria, but in more than 80 per cent, albu- min appears in the urine in the early stages of a gestational toxemia and gives timely warning of a threatened breakdown of the excre- tory organs and of an outbreak of eclampsia. Much importance was at one time attached to the excretion of urea. Normally, a pregnant woman should excrete 20 to 24 grams a day, or about 2 per cent. Careful examinations, however, of a number of women in the University Maternity, by Edsall, with control of the diet, showed such irregularity in urea excretion that its estimate gives the clinician little information of value. In the routine examinations in the hospital the urea elimination varies from 3 to 36 grams a day in women on the same diet, under the same conditions and equally well. If, however, there is persistently less than one per cent, of 628 THE PA THOLOGY OF LABOR. urea in the urine, and less than 1200 c.c. a day is passed, especially if, at the same time, there is disturbed digestion and coated tongue, the case should at least be regarded with suspicion and precaution- ary dietetic and medicinal treatment should be ordered. The best test for albumin is Purdey's, with acetic acid, ferrocyan- ide of potassium, and the centrifuge. The most convenient appa- ratus for estimating urea is Doremus'. If, in spite of milk diet, confinement to bed, purgation, diuresis, and diaphoresis, the albu- min increases and the urea decreases, labor should be induced. It must be remembered, however, that the urea percentage is always below normal, and sometimes very low, on a milk diet, and that a woman with a high nitrogenous output may display a rapidly in- creasing toxemia with increasing albuminuria. The treatment of the eclamptic convulsions themselves is best dealt with by considering, first, the different plans of treatment separately, with their results, so that their relative merits may appear plainly. Anesthetization. — Chloroform is the only anesthetic to be em- ployed. When this drug first came into general use it was regarded by many as a specific for eclampsia, and is so regarded by a few to-day. Series of 20, 12, and of 9 cases, treated by chloroform alone, have been reported without a death. Charpentier reports 63 cases treated by chloroform alone with 7 deaths — a mortality of 11 per cent. But, on the other hand, the mortality from this treatment in the Maternite was 50 per cent. The place of chloro- form in the treatment of eclampsia is now settled. No one would rely on it alone; but every one is willing to admit its value as an adjunct to other treatment. Diaphoresis and Catharsis. — Eclampsia is the result of some poisonous matter in the blood, and can not be cured until this poison is eliminated. The only emunctories available for quick and effectual action are those of the skin and bowels. No matter, therefore, what plan of medicinal treatment may be adopted, diaphoresis and catharsis must also be employed. The action of the skin may be excited by a hot wet-pack, by hot air or vapor, or by a hot bath. In private practice the hot wet-pack or the hot-air bath are the most practicable, and are to be recom- mended. A free sweat is conveniently and quickly produced by heating six or eight bricks on the kitchen stove, wrapping them in bath towels, putting them around the patient's lower limbs and trunk, pouring a pint or more of alcohol on them, and then cover- ing bricks and patient with several blankets. The injection of normal salt solution into the subcutaneous cellular tissue or under the breasts is an indispensable aid to free elimination by the skin. It seems literally to wash the blood of its impurities. If, however, DYSTOCIA DUE TO DISEASE. 629 the patient does not sweat or purge freely, the injection of salt solution predisposes to pulmonary edema. Free catharsis is pro- duced best by the use of croton oil, which may be administered in drop doses with a little sweet oil upon the back of the tongue, and can therefore be given to a woman whether she is able to swallow or not. Elaterium in quarter-grain tablets may be administered in the same manner. It is often advisable to wash out the stomach ; if this is done, an ounce or more of castor oil with a couple of drops of croton oil may be put into the stomach through the stomach- pump. If the patient can swallow, a concentrated solution of Epsom salts is administered, in dessertspoonful doses every fifteen minutes, until free catharsis begins. For the stupor that often succeeds convulsions, and in which the patient frequently dies from toxemia, the use of Epsom salts is most suitable. Venesection. — Phlebotomy is at present somewhat in disfavor. The reaction against the indiscriminate use of the lancet has, however, gone too far. While bleeding in every case of eclampsia is unwise, there are many cases in which it rescues women from impending danger of pulmonary edema and apoplexy. Physicians in the country, who have to deal with strong, full-blooded people, are obliged, in the treatment of pneumonia as a routine practice, to use the lancet. In the same class of people blood-letting in eclampsia is equally necessary. In a report of fifteen cases in which bleeding seems to have been the only thing done, there was but one death. In appropriate cases the venesection should be done in time, and not, as sometimes recommended, only when symptoms of pulmonary edema appear. The measure is preven- tive of this accident, not curative. Morphin. — Older statistics of the morphin treatment for eclampsia show a death-rate of 57 per cent. (Winckel), but Veit in more than 60 cases had only 2 deaths — a mortality of 3.3 per cent., the lowest death-rate yet obtained by any plan of treatment. This result is obtained by giving very large doses of the drug. Veit has injected one-half grain in each convulsive seizure, and has ad- ministered as much as three grains in four to seven hours, and four and one-half grains in twenty-four hours. This treatment is per- missible if, as is usually the case in eclampsia, there is parenchy- matous nephritis. In interstitial nephritis it would almost surely kill the patient. 1 It also antagonizes the eliminative treatment. For these reasons the author does not recommend it routinely. Chloral has many advocates. Charpentier prefers it above all others, and presents statistics to justify the preference (114 cases, mortality 3^ per cent.). Winckel recommends it 1 Meyer-Wirz found interstitial nephritis three times in thirty-five autopsies. "Arch. f. Gyn.," Bd. lxxi, H. 1. 63O THE PATHOLOGY OF LABOR. highly, and by its use has saved 85 out of 92 cases. This drug, too, must be given in large doses to be effective. Thirty to sixty grains should be administered by enema at a dose, and as much as three drams may be given in the twenty-four hours, or even more in bad cases. Veratrum Viride. — The use of this drug is the American treatment of eclampsia. For the past thirty-five years it has been extensively employed in different parts of the country. Fearn, in 1 87 1, reported 11 cases of his own and 2 cases from the practice of professional friends treated with very large doses of veratrum viride. None of the women died of the convulsions, but one succumbed later to puerperal sepsis. Rushmore has collected 85 cases of eclampsia treated with veratrum viride, with 20 deaths — a mortality of 23 y 2 per cent. Jewett reported to the American Gynecological Society, in 1887, 22 cases of eclampsia treated with veratrum viride. Four of the women died of the convulsions — a mortality of 18 per cent. In 50 cases of eclampsia collected by Trimble, veratrum gave much the best results. In 26 cases treated by this drug there were 3 deaths, while in the remaining 24 cases there were 6 deaths — a mor- tality, respectively, of 1 1. 5 and 25 per cent. Mangiagalli reports 18 cases treated with veratrum viride with one death, not from the disease. 1 I have used it in more than 100 cases in the last twenty years and believe in its efficiency. The remedial measures detailed above comprise all that should be seriously considered. The treatment of eclampsia by antemortem Cesarean section, proposed first by Halbertsma, has not been successful, and can scarcely be regarded as justifi- able. Caffein, oxygen, and nitrite of amyl have not been used often enough to justify an opinion of their worth, and this judg- ment must be passed also on a number of other drugs recom- mended from time to time. Pilocarpin, as a routine treatment, is simply mentioned to be condemned. There is no other treatment of eclampsia that gives so high a mortality. In the Edinburgh Maternity, where this drug was employed for a time, the mortality was 66.6 per cent. Pilocarpin strongly predisposes to pulmonary edema, which explains the high mortality. Occasionally, however, if wet or dry heat fails to make the patient sweat, a single hypo- dermic injection of a sixth of a grain is of great service. Thyroid extract, recommended by Nicholson as a vasomotor dilator, is receiving a trial, but it is too early to decide as to its value. Among the curiosities of the treatment of eclampsia may be mentioned lumbar puncture, 2 decapsulation of the kidneys, and nephrotomy. 1 "Ann. di Ost. e Gin.," No. 7, I9C0. 2 "Lumbar Puncture for Eclampsia," " Zentralbl. f. Gyn.," No. 45, 1904 ; "Nephrotomie," ibid. DYSTOCIA DUE TO DISEASE. 631 In eclampsia during parturition the obstetrical treatment must receive consideration. As a rule, it is better to avoid inter- ference with the progress of labor, unless the os is fairly well dilated. Should eclampsia come on before labor begins at all, or in its earlier stages, the physician's attention should be confined to combating the convulsions. Having succeeded in subduing them, attention may be directed to the delivery of the patient. It is usual to find that the os has dilated rapidly during the con- Day of Disease 107° 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° M £ M t ~ M E M E M E M E M E \ \ «;. "Si K 2 "fcj V s V 1 \ V i V A \ : ■ Pulse 1 3i 1 Eesp. *s N* Fig. 512. — Temperature-chart of a patient falling in labor in the midst of an attack of typhoid fever (author's case). vulsive attacks or in consequence of vigorous eliminative treat- ment. It has been recommended to resort to forced delivery (accouchement force) in all cases of eclampsia during labor, resorting to deep multiple incisions, if necessary, according to Duhrssen's plan, to vaginal Cesarean section, or to instrumental dilatation by Bossi's or other branched dilators. Zweifel's statistics show, it is claimed, a mortality of only 15 per cent, in 223 cases treated by accouchement force as contrasted with a mortality of 32.6 from the expectant plan. Abdominal Cesarean section has been performed 632 THE PATHOLOGY OF LABOR. in 40 cases with 21 maternal and 18 fetal deaths. 1 Olsnausen in 250 cases of eclampsia has performed three Cesarean sections with one death. 2 It seems logical to evacuate the uterus as the first step in the treatment of eclampsia. The ovum or fetus is the source of the toxemia; many statistics show a less mortality after labor than before and it is quite a frequent experience to witness a cessa- tion of the convulsions as soon as the child is expelled, but the necessary operation for the delivery of the woman distracts one's attention from the treatment of the convulsions, and adds for the time being a violent source of irritation to the already highly wrought nervous system. Eclamptic patients are particularly liable to fatal shock from violent delivery or operative measures of any kind. Moreover, by waiting for a brief period, during which energetic treatment may be directed to the convulsive attacks, sufficient dilatation of the os may be secured naturally to permit the delivery of the woman without excessive violence or without too much loss of time. As soon as the os is dilated beyond the size of a dollar, delivery may be hastened with advan- tage by applying forceps if the head is engaged in the pelvis, or by performing version and extraction by the feet if the head is not yet engaged, or if the breech presents. In eclampsia gravi- darum labor may be induced after the convulsions cease and the toxemic symptoms abate, or the uterus may be emptied if the pa- tient fails to respond to treatment after a reasonable length of time. It may be useful for the student to have a scheme of treatment for the average case of eclampsia that he can put into effect with- out delay or confusion from considering the relative merits of the different plans just detailed. The following plan should be successful in the majority of cases: During the attack itself administer chloroform. As soon as the attack has passed off, inject under the skin fifteen drops of the fluid extract of veratrum viride, and administer by the bowel a dram of chloral in solution. Place upon the back of the tongue two drops of croton oil diluted with a little sweet oil. Or, if practi- cable, wash out the stomach and pour into the stomach-pump 2 ounces of castor oil with 2 drops of croton oil. Wring out three or four blankets in very hot water, and envelop the woman's nude body in them, wrapping one around each limb and covering the trunk with another, and over all piling as many dry blankets and heavy coverings as can be procured. A hot vapor bath by pour- ing alcohol on hot bricks at the woman's feet under blankets, a hot air or steam bath, or immersion of the woman's body in hot water may be substituted for the hot wet pack. Ice should be 1 Hillmann, Sectio Csesarea bei Eklampsie, " Monatschr. f. Geb. u. Gyn.," Bd. x. 2 " Geb. Ges. zu Berlin," Nov. 24, 1899. DYSTOCIA DUE TO DISEASE. 633 applied to the head while heat is applied to the body. Inject by gravity under the breast or breasts a pint or more of normal salt solution, or, if the apparatus for subcutaneous injection is not at hand, inject several quarts of the solution by gravity into the bowel. The sweats and salt solution injections may be repeated every four to six hours. If convulsions recur, repeat the veratrum viride in five-drop doses if the pulse is quick and strong. If the face is con- gested and swollen, and the pulse remains full and bounding', venesection should be resorted to, withdrawing sufficient blood from the veins to reduce the tension of the pulse. Chloral may be repeated in the course of the attack two or three times, if the convulsions persist and are violent. If the face is pale and the pulse rapid and weak, stimulation may be required in the shape of digitalis, strychnin, nitroglycerin, brandy, ether, or ammonia hypodermatically. If the convulsions cease and the patient lies in a stupor, but can be aroused somewhat and is able to swallow, concentrated solution of Epsom salts, in dessertspoonful doses, should be given every fifteen or thirty minutes until free catharsis is established. If pulmonary congestion and edema develop, wet or dry cups should be applied over the chest. If the breathing is stertorous, the face cyanosed and swollen, wet cups or leeches should be applied to the back of the neck and behind the ears. Usually the kidneys recover after eclampsia, but often a true nephritis persists or there is kidney breakdown in subsequent pregnancies. One of my patients had albuminuria and convul- sions in five successive pregnancies, another in six. A woman who recovers from eclampsia should be watched for months and urinary examinations should be made at intervals for years. In subse- quent pregnancies dietetic precautions should be insisted upon. Shock. — The strain of labor in a weak woman, some of the accidents of parturition, or even forcible attempts to expel the placenta, may occasion shock after delivery, with lowered tem- perature, leaking skin, and a running, rapid pulse. Cases of this sort have been reported from compression of the left ovary in attempts to expel the placenta by Crede's method, the womb being turned upon the cervix so that the left side looks forward, and the ovary is grasped between the thumb and the uterine wall, when the hand is placed on the fundus of the womb in the effort of expression. The condition calls for the ordinary treatment of shock — heat externally and stimulants hypo- dermatically. Typhoid fever, pneumonia, and other adynamic diseases may occur in pregnant women, and in the majority of cases occa- sion premature delivery. In typhoid fever this occurs in sixty- five per cent, of the cases, and in pneumonia the proportion is 634 THE PA THOLOG Y OF LABOR. quite as large. The advent of labor in the midst of these diseases is usually disastrous to the patient. Profound shock is often de- veloped ; the temperature falls abnormally low, even to 95 ° F., and the heart-action may be extremely weak. Active stimu- lation should be employed during the first stage of labor, and, as soon as the 6s is sufficiently dilated, the child should be artificially extracted as rapidly as possible without serious injury to the mother, in order to save her the strain of voluntary muscular effort in the second stage. Valvular Disease of the Heart. — Mitral disease is the most serious. Certain statistics show a mortality as high as fifty-three per cent. As pregnancy advances the heart becomes more and more embarrassed, and respiration more labored. The most dan- gerous period, however, is just after the expulsion of the child, when the circulation is much disordered and an extra quantity of blood is thrown back upon the heart. It has been noticed that when the discharge of blood from the vagina is profuse, cardiac failure rarely occurs. This clinical observation points to the most successful treatment in cases of threatened heart-failure, — namely, venesection, — with the removal of from eight to sixteen ounces of blood, if there is not much blood lost from the parturient tract after labor. Nitrite of amyl and nitroglycerin are the most valuable stimulants to employ during labor and directly after its completion. Digitalis should be administered hypodermatically during the first stage in large doses, and as soon as it is possible to insert the forceps through the os, or to grasp the child's feet if the head is not engaged, the infant should be rapidly and, if necessary, forcibly extracted. Deep incisions of the cervix are of the great- est value in cutting short the duration of labor and in lessening the force required in the artificial delivery of the child. With this plan of treatment the mortality of heart disease in labor will be much reduced. It has been my fortune not to lose a case, although charged with the care of a number, some of which were of the most serious character. PART V. PATHOLOGY OF THE PUERPERIUM. CHAPTER I. Abnormalities in the Involution of the Uterus after Child-birth. An abnormal course in the return of the uterus from the post- partum condition to the ordinary dimensions and weight of a non- gravid womb may manifest itself by excess or by deficiency ; there may be superinvolution or subinvolution. Superinvolution is an abnormal prolongation or an exag- geration of the process by which the gravid womb returns, after delivery, to the dimensions of a healthy non-pregnant uterus. It is in consequence reduced to a size much smaller than normal. Sir James Y. Simpson first directed attention to morbid de- ficiency and morbid excess in the involution of the uterus after labor. Since his time many writers have called attention to de- ficient involution ; a smaller number have described the rarer anomaly of the two — excessive involution. Trommel detected superinvolution in 29 out of 3000 cases ; Simpson 1 saw it in 22 out of 1300 cases ; Sinclair, 2 in measuring 108 uteri after child- birth, found in 22 instances a uterine cavity of less than 2*£ in. (5.7 cm.), and Fordyce Barker 3 has declared that he sees from 1 to 3 cases every year, and that in his opinion superinvolution con- stitutes about one per cent, of uterine diseases. Hansen, 4 among 120 nursing women, found 2 with a uterine cavity below 6 cm. 1 A. R. Simpson, " Superinvolution of the Uterus," " Trans. Edinburgh Obstet. Soc," i882-'83, viii, p. 88. 2 "Trans. Amer. Gyn. Soc," vol. iv. This series of measurements, as well as others made later by Sinclair and Richardson ("Trans. Amer. Gyn. Soc," vols, vi and vii), are sharply criticized by Hansen, who declares them to be in great part in- correct. The criticism is apparently merited. 3 "Trans. Amer. Gyn. Soc," viii, 1883; discussion on Dr. Johnson's paper. 4 " Ueber die puerperale Verkleinerung des Uterus," " Zeitschr. f. Geburtsh. u. Gyn.," xiii, S. 16. 635 636 PATHOLOGY OF THE PUERPERIUM. (5.6, 5.4 cm., or 2.2, 2.1 in.) respectively at the eighth and tenth week after delivery. Johnson x gives an account of 3 cases which occurred in his practice, and Simpson 2 refers to those de- scribed by Chiari, Chiarleoni, Jaquet, and Whitehead. A case 3 has been reported after abortion. The etiology of the condition is somewhat obscure. It has been ascribed to wasting diseases, as phthisis, cancer, etc.; to anemia from hemorrhage at a previous birth or miscarriage ; to nervous derangements, as puerperal insanity or chorea ; to over- lactation ; to a rapid succession of labors ; to local inflammations, especially those which attack the ovaries and abrogate their func- tions. The degree to which the superinvolution may occasion- ally progress is surprising. A. R. Simpson reports a case in which the uterine cavity measured but ^ of an inch. Subinvolution may be described as an arrested or a retarded involution of the puerperal uterus. Causes of Subinvolution. — There is a difference of opinion in regard to the exact nature of the changes which occur in the individual muscle-cells during involution of the uterus ; but there can be no doubt as to the cause of these changes, whatever they may be. It is a great reduction of the blood-supply. In a gen- eral way, therefore, it may be asserted that any condition which tends to prevent a rapid diminution of the blood-supply to the puerperal uterus may be a cause of subinvolution. Nature's only method of decreasing the quantity of blood in the puerperal uterus is by the agency of the contracting muscle-fibers ; there- fore, it may again be asserted that any condition which interferes with the contraction of the uterus is a cause of subinvolu- tion. It is necessary to make these two broad divisions in the etiology of subinvolution, for, although frequently interdepend- ent, they are not rarely independent of each other. In point of frequency there should be placed first those causes which pre- vent the normal decrease of blood-supply to the uterus after labor. Prominent among these should stand hyperplasia of the endometrium. Subinvolution by an excess of blood-supply may occasion- ally be traced to the presence of small fibroids, throughout the uterine wall. Other causes of subinvolution are lacerations of the cervix and peri-uterine inflammations ; inflammations of the uterine body and of its lining membrane, usually the result of sepsis ; re- tention within the uterus of placental fragments, shreds of mem- 1 "Superinvolution of the Uterus," "Trans. Amer. Gyn. Soc," viii, 1883. 2 Loc. cit. 3 C. M. Hansen, " Medical Record," Oct. 6, 1888. ABNORMALITIES IN INVOLUTION OF THE UTERUS. 637 branes, placental or fibrinous polypi, and blood-clots ; chronic con- stipation ; displacements of the womb ; premature getting up ; premature resumption of sexual intercourse ; and anything which interferes with the return of the venous blood to the heart, causing a passive congestion of the pelvic organs, as increased intra-abdominal pressure from abdominal tumors, certain diseases of the liver, and valvular disease of the heart. Many examples of subinvolution by the mechanical prevention of perfect uterine contraction may be observed, as large intra- mural and submucous fibroids ; unusually large masses of hyper- trophied decidua that sometimes develop at the placental site ; the retention within the uterus of considerable portions of the placenta, or placentae succenturiatsa ; large blood-clots ; the dis- placement of the uterus by a retroversion or flexion of the organ, or by an overfilled bladder ; peritoneal adhesions from old or recent inflammatory attacks, involving the serous covering of the uterus and adjacent parts. One fact stands out clearly from an observation of such cases : The cause of subinvolution is always some local disturbance, and not a constitutional de- rangement. The puerperal state may be complicated by any of the acute or chronic febrile affections, without the slightest in- fluence upon uterine involution. 1 One exception, however, must be made to this general state- ment : nervous derangements do influence involution. A. R. Simpson rightly assigns to puerperal insanity a prominent role in the causation of superinvolution. On the other hand, a sudden mental shock, some powerful emotion, may temporarily arrest involution. The diagnosis of subinvolution is easy. The fundus uteri should be a finger's breadth above the umbilicus on the first day of the puerperal state, higher than it is directly after birth ; on the second day, at the level of the umbilicus ; the third day, a little below ; the fourth day, about the same ; the fifth and sixth days, two fingers' breadth below the umbilicus ; the seventh, eighth, and ninth days, three or four fingers' breadth above the sym- physis pubis ; the tenth, eleventh, and twelfth days, at the level of or a little below the pubes. 2 Hansen, by measurements of 1 20 nursing women from the tenth day until the third month after delivery, gives the following as the normal course of involution 1 Temesvary and Backer ("Studien auf dem Gebiet des Wochenbettes." "Archiv f. Gyn.," Bd. xxxiii, H. 3, S. 331, 1888) correctly state that fever favors the involution of the uterus. 2 For an extensive bibliography of uterine measurements in the puerperal state see Schroeder's " Lehrbuch," 8th ed., 1884, p. 230, and Hansen, loc. cit. 6 3 8 PATHOLOGY OF THE PUERPERIUM. from the tenth day of the puerperium until the completion of the process : Average Intra-uterine Measurement. Minimum. Maximum Tenth day (114 measurements) . . . 10.6 cm. 8 cm. 13.5 cm. Fifteenth day (1 19 " ) Third week (95 " ) Fourth week (80 " ) 9.9 " 8.8 " 8.0 " 8-3 " 7.5 " 7.0 " II. 5 " 10.5 " 9-3 " Fifth week (64 " ) Sixth week (56 " ) Seventh week (40 " ) 7-5 " 7.1 « 6.9 " 6.5 » 6.2 " 6.0 " 9.0 " 9.1 << 8.5 " Eighth week (31 " ) Tenth week (22 " ) Twelfth week (15 " ) 6.7 » 6.5 " 6.5 « 5-6 " 5-4 " 6.0 " 8.5 " 7.5 « 7-5 " In two-thirds of the cases Hansen found involution completed in six to ten weeks ; in one-sixth, not until the last half of the third month or later ; in again a sixth, within six weeks. The most rapid involution occupied four weeks. Any great deviation from the normal course may easily be detected by abdominal palpation, by combined examination, or by the use of a sound, while along with the arrest or retardation of involution is usually found a profuse lochial discharge. Ahlfeld 1 claims that free per- spiration after labor is a valuable sign of firm uterine contraction in the early part of the puerperal state ; when it fails to appear, he always looks for uterine relaxation. Treatment is directed not to the symptom (subinvolution), but to its cause. Evidently, therefore, it varies greatly. If the sub- involution depends upon the retention of hypertrophied decidua, a curet promotes rapid involution more effectively than anything else. If placental fragments or membranes are retained in utero, they should be removed. If involution is retarded by the presence of fibroids, the administration of ergotin, strychnin, and quinin in pill form, and the application of a faradic current have given good results. The bladder should never be allowed to remain distended with urine nor the rectum with feces. Inflammation in or about the uterus must be combated by appropriate treat- ment. If the heart-valves are imperfect or the heart-muscle weak and the abdominal and pelvic veins are consequently engorged with blood, a heart-tonic, as digitalis or strophanthus, often assists involution. Charpentier has asserted that the routine administration of ergot in the puerperal state hastens involution. This sounds reasonable, but clinical experience has not borne out the statement. 1 " Der Zusammenhang zwischen Schweisseruption postpartum und Uteruscon- tractionen," " Ber. u. Arbeit, a. d. Geburts. Gynak. Klinik zu Marburg," i885-'86, Bd. iii, S. 81. ABNORMALITIES IN INVOLUTION OF THE UTERUS. 639 Herman and Fowler 1 did find, in experimenting on two sets, of patients, — one, 58 in number, receiving an ergot mixture daily for a fortnight after labor ; the other, 68 in number, receiving a single dose of ergot after labor, — that in the first set involution advanced more rapidly, but that there was no difference in the lochial discharge. Boxall 2 also declared him- self in favor of the routine practice of giving ergot during the puerperium, asserting that in two series of cases, comprising each 100, — one treated without, the other with, ergot, — there were fewer blood-clots ; they were more quickly discharged, and the after-pains were less frequent, of shorter duration and diminished intensity in the latter series. Dakin, 3 however, dissented from these views, and claimed, after testing the matter in practice, that the routine administration of ergot re- tarded the involution by at least twenty -four hours. Blanc 4 also declared that the administration of ergotin during the first five or ten days of the puerperal state has not a favorable influence upon involution, but seems to interfere with it to some extent. As it is doubtful, therefore, whether ergot does aid involution, as there are many obvious disadvantages connected with its routine ad- ministration in the puerperal state, the adoption of the practice is unwise, and is not to be recommended. Puerperal anemia might not inaptly be called a subinvolution of the blood. After the first twenty-four hours of the puerperal state there begins a change in the constitution of the blood by which it is converted from the hydremia of pregnancy to the normal proportion of its constituent parts in the non-gravid woman. At the end of two weeks the process is so far complete that the blood is more nearly in a normal condition than it was during preg- nancy. 5 Many causes, however, may disturb the recovery from the hydremia and leukocytosis of pregnancy. Illness of any kind during pregnancy, hemorrhage during labor, 6 nervous affections — as insanity or chorea — during the puerperal state, kidney dis- ease, fevers, etc., may all induce puerperal anemia. The treat- ment of the condition must be governed by the circumstances of the individual case. The cause of the anemia being removed, 1 " On the Effect of Ergot on the Involution of the Uterus," " British Med. Jour.," 1888, i, 299. 2 Ibid. s ibid. i " Ann. de Gynec," March, 1888. 5 Meyer, " Untersuchungen liber die Veranderung des Blutes in der Schwanger- schaft," " Archiv f. Gyn.," Bd. xxxi, S. 145. s It is extraordinary, however, to see how rapid occasionally is the recovery of puerperse, even from severest hemorrhage. A loss of 2000 to 2500 grams (4.4 to 5.5 pounds) of blood is usually fatal to an adult, but Ahlfeld reports two cases in which, respectively, 2000 and 2500 grams of blood were lost without serious anemia after- ward (" Ber. u. Arb. a. d. Geb. Gyn. Klinik zu Marburg"). 640 PATHOLOGY OF THE PUERPERIUM. the blood will improve, and the improvement may be accelerated by tonic drugs and good diet. After hemorrhages, beef-tea, animal soups, milk, and as nutritious a diet as the patient can bear, along with tonic medicines, hasten recovery. By the use of Blaud's pills I have seen the blood-corpuscles rise from less than three to nearly four and a half million per cubic milli- meter, and the hemoglobin increase from forty to seventy -five per cent, in a few weeks. In some cases arsenic alone suc- ceeds where iron fails. Osier 1 has reported an interesting case of the kind. Repair of the Injuries of Child=birth. — Slight cracks in the mucous membrane, small rents in cervix, vaginal wall, and vagi- nal outlet, — unavoidable occurrences in almost every labor, — either unite firmly or else are healed by granulation. Occasionally, very extensive injuries are repaired by natural processes. Per- forations of the vaginal vault, fistulous openings into bladder and rectum, deep tears and perforations of the perineum, transverse rents and perforations of the labia, lacerations about the urethra, — all have been known to unite without interference. Winckel states that perineal tears, when left to themselves, will be found healed in two and a half to five weeks ; by this he means that they are skinned over with mucous membrane. The underlying muscles do not reunite. Extensive injuries should be repaired, wherever practicable, by sutures. Rents in the vaginal mucous membrane not involving subjacent muscles and cervical tears do not always require this treatment, unless there is profuse hemor- rhage. Lacerations of the perineum, of the pelvic floor, and of the vaginal sulci should never be neglected. If the stitches are inserted carefully, primary union is almost invariably secured. In fistulae the result of sloughs after labor, if the opening is not too large, a cure can occasionally be effected by touching the edges of the fistula with a strong caustic, like nitric acid. To do this the diagnosis must be made early in the lying-in period, which, as a rule, is not difficult. The escape of feces and gas from the vagina, and a constant trickling of urine, point respectively to a rectovaginal or a genito-urinary fistula. It is necessary in the latter case to exclude the incontinence of urine due to paresis of the vesical sphincter, and the overflow of retention sometimes seen in the puerperal state. All doubt is cleared away by find- ing the anomalous opening between bladder or ureter and vagina or cervical canal. In abrasions and wounds along the parturient tract it is necessary occasionally to apply lint saturated with car- bolized oil to prevent an acquired atresia of the birth-canal. If 1 "Boston Med. and Surg. Jour.," 1888, p. 454. PUERPERAL HEMORRHAGES. 64 1 the abrasions and wounds are infected and covered with exudate they should be cauterized with nitrate of silver solution, gj- fgj. Edema of the external genitals, the result of injuries, pres- sure, or contusions during labor, gives rise to considerable pain and discomfort, which are best relieved by the application of cloths wrung out in a hot sublimate solution, 1 : 4000. The influence of injuries in the genital tract upon the course of the puerperal state is unfavorable. The danger of septic infection is materially increased, and fever is consequently more common, not only from this cause, but as a direct result of the injury and irritation of tissue. Retention of urine is another consequence of injury to the vagina during labor, according to Winckel 1 , who says that he has seen obstinate cases of retention, lasting from ten to four- teen days, due to this cause. Puerperal hemorrhage denotes profuse bleeding from any point along the genital tract of the female, occurring after the first day of the puerperium until involution of the uterus is com- pleted — a period of about six weeks. The causes of this accident are numerous and should be well considered, for the treatment is governed in most cases by a knowledge of the cause. The causes are placed as far as possible in the order of their frequency. Retained placenta and membranes usually cause hemor- rhage during the puerperal state. The retention of the whole placenta is not now a cause of puerperal hemorrhage, for no practitioner of the present day would allow it to remain within the uterus many hours after delivery. Toward the end of the eighteenth and in the beginning of the nineteenth century, how- ever, it was not rare to find followers of William Hunter, who trusted altogether to nature to deliver the placenta, often with disastrous results. White 2 describes four cases of retained pla- centa, with fatal hemorrhage on the first, second, third, and fourth days. The retention of placental fragments is by no means rare. A careful inspection of the placenta after delivery often shows a defect, and the missing piece must be sought and removed ; but occasionally it is difficult or impossible to tell whether the placenta has come away entire ; and if the retained portion is an accessory growth, there is nothing to indicate its existence in the appearance of the placenta proper. Stadfelt states that, in 70 postmortem examinations of puerperse, placental fragments were 1 " Lehrbuch der Geburtshulfe," p. 741. 2 " A Treatise on the Management of Pregnant or Lying-in Women," Worcester, Mass., 1793, p. 215. 4i 642 PATHOLOGY OF THE PUERPERIUM. found in 7, varying from the size of a hazel-nut to that of an egg. Clinical observation alone makes this complication of the puerperal state appear more rare. Of 2960 births in the Frauen- klinik at Munich, from 1884 to 1887, there were reported 9 cases of retained placental fragments. x It is possible, however, that small portions of placental tissue might escape unnoticed in the lochial discharge, or else by their disintegration form a part of the discharge. The retention of placental tissue does not always cause hemorrhage. I have seen a placenta succenturiata expelled on the second day of the puerperal state without any previous bleeding, the whole placenta left in utero for twenty- four hours without hemorrhage, and a very large piece of the placenta discharged four days after a premature birth, very fetid, but with no bleeding. In the 9 cases reported by Martini there was a prolongation of the bloody lochia in 1, a severe hemor- rhage in 2 ; in 6 there was no excessive loss of blood. The cause of the retention of placental fragments is either some abnormal form of placenta (marginata, multiloba, suc- centuriata, etc.), an abnormal adhesion to the uterine wall, or too forcible or premature efforts at extraction or expression. 2 Retention of the membranes after labor is of frequent occur- rence. Martini reports 71 cases out of 2960 births. 3 Reihlen 4 found a retention of some portion of the chorion in 152 out of 3534 labor cases (4.3 per cent.). Another investigation gave 5.1 percent, from an analysis of 11,381 births. Crede 5 reports 91 cases of retained chorion in 2000 births. Membranes retained in utero may give rise to septic infec- tion ; whether or not they are a cause of puerperal hemorrhage is still a disputed question. Crede 6 believes that retention of the chorion is not at all dangerous. Olshausen declares that the retention of the chorion never justifies interference to extract it. 7 Reihlen 8 says that he never saw hemorrhage as a result of re- tained chorion. Schroeder 9 asserts that retained amnion and chorion practically never cause bleeding, even when retained in 1 Martini, " Ueber das Zuriickbleiben von Eihaut u. Placentarresten bei vor- u. rechtzeit. Geburt," " Miinchen. med. Wochenschr.," 1888, p. 653. 2 Ahlfeld in 996 deliveries saw only 4 cases of puerperal hemorrhage. He attributes the freedom from this accident in his clinic to his conservative manage- ment of the third stage of labor. He insists upon waiting one and a half hours be- fore expressing the placenta (" Ber. u. Arbeiten," Marburg, Bd. iii). 3 Loc. cit. 4 " Zur Frage der Behandlung der Chorion-Retention," "Archiv f. Gyn.," Bd. xxxi, S. 56. s "Archiv f. Gyn., Bd. xvii, S. 278. 6 Loc. cit. 1 « Klin. Beitr. zur Gyn. u. Geburtsh.," 1S84, S. 146. 8 Loc. cit. 9 " Lehrbuch," 10. Aufl., 797. PUERPERAL HEMORRHAGES. 643 toto. On the other hand, Winckel 1 and Hegar 2 have shown that retained membranes could give rise to puerperal hemor- rhage, as well as to septicemia. Martini reports 28 cases of retained chorion in which there was no fever — that is, no patho- logical condition, as uterine inflammation, decomposition of thrombi, etc. — to account for bleeding, and yet among these cases there were two severe hemorrhages, eight of minor grade, and six times a prolongation of the bloody lochia. Fig- 5I3- — Fibrinous polypus (Frankel). Retention of hypertrophied and angiomatous decidua is an etiological factor in puerperal hemorrhage. If the decidua is hypertrophied during pregnancy, the amount of tissue re- tained may be considerable. The mass may act as a foreign body within the uterine cavity, preventing firm contraction, and so predisposing to hemorrhage ; or else, adhering to the uterine wall, it may attract an unnecessary amount of blood to the 1 " Berichte u. Studien," 1874-79 ; "Path. u. Therap. des Wochenbettes." 2 "Path. u. Therap. der Placentar-Retention," 1862. 644 PATHOLOGY OF THE PUERPERIUM. whole organ, with the same result. Even a small portion of deciduous membrane, as well as shreds of adherent chorion and amnion, or placental fragments, may form the foundation of poly- poid tumors reaching occasionally considerable size, composed chiefly of firmly clotted blood or fibrin. The growth of these bodies is like stalactite formations on stone. The same thing occurs in different shape when the placental site is left unusually rough and vascular. The blood oozing from the sinuses may deposit successive layers of fibrin until quite a thick mass is formed. Diagnosis and Treatment. — The fact that a portion of the ovum has been retained in utero is usually easy to discover. A careful examination of the secundines after labor enables one to detect missing parts, which must have remained behind in the genital tract. It is not wise, as a rule, to invade the internal genitalia in order to remove small shreds of amnion and chorion ; if, however, a greater part of these membranes has been retained, it is advisable to remove it. The diagnosis of re- tained placenta is, as a rule, easy. When the whole organ re- mains in utero, the cord dangling from the external genitals points clearly enough to the condition. If one or more cotyledons remain behind, their absence ma}' be noted from the placenta after its deliver}-. Occasionally, the diagnosis is more difficult, even if the whole placenta is retained. I recall a case in which a woman was delivered on her feet ; the child dropped to the floor, the cord was dragged off from the fetal surface of the placenta, and the latter remained behind in the uterus ; it was tightly adherent to the uterine wall, and its discover}-, with no cord to guide one, was by no means an easy matter. It was finally peeled off and extracted, the woman meanwhie bleeding furiously. Cotyledons torn off the periphery of the placenta may easily go undetected, and in certain roughly lobulated placentae it is very difficult to be sure that no placental tissue has remained behind. 1 If the medical attendant suspects the retention of placental masses after labor, he must attempt their removal. This is usually not difficult. The hand, — the only trustworthy instru- ment under the circumstances, — covered by a sterile rubber glove, is inserted into the uterine cavity, the placental substance is felt for, caught by the fingers, and removed; if the placenta is adherent, the tip of the finger must be gently inserted, wherever most practicable, under the edge, and the whole organ gradually peeled off. If the uterine muscle is too firmly contracted to 1 " Zur Frage der Behandlung der Placentar- Retention,'' etc., " Zeitschr. f. Geburtsh.," xvi, pp. 292, 302. PUERPERAL HEMORRHAGES. 645 allow the introduction of the hand, the resistance must be over- come by firm, gradual pressure, first inserting one finger, then two, and so on until dilatation is effected. To accomplish the dilatation it is often necessary to administer an anesthetic. If puerperal hemorrhage occurs, the presence of membranes or placental fragments within the uterus should be suspected, Fig. 5 J 4« — Stratz's section of a primipara, who died from hemorrhage with fatty heart within an hour after delivery : a, a, Contraction-ring ; b, b, os internum ; c, uterovesical reflection of peritoneum ; d, bladder ; e, symphysis pubis; /, urethra; g, promontory of sacrum ; //, pouch of Douglas ; i, posterior fornix ; j, os externum. and their removal should be attempted unless some other con- dition is clearly seen to be the cause of the bleeding. To reach the uterine cavity after involution and retraction have made some progress, it is often necessary to dilate the cervical canal. Hegar's bougies will be found the safest and most convenient instruments for the purpose. Branched dilators, unless used 646 PATHOLOGY OF THE PLERPERIUM. with the greatest care, are dangerous in the puerperal womb. Not rarely, however, the cervical canal remains patulous in con- sequence of a foreign body in utero ; in this case access to the retained mass and its removal are easy. Displacements of the Uterus. — The dislocation of the puer- peral uterus often manifests itself in puerperal hemorrhage. Inversion, prolapse, displacements forward and backward and Fig. 515. — Section of a primipara who died from sepsis five and a half days after delivery (Barbour). upward by a distended bladder, are all likely to be followed by profuse bloody lochia, if not by an active hemorrhage. In- version and prolapse have already been considered ; retroversion, retroflexion, and anteflexion are noticed here. Hemorrhage is likely to occur in these displacements as a result of the passive congestion always associated with them, due to interference with the venous circulation ; or the bleeding PUERPERAL HEMORRHAGES. 647 may be the consequence of the retention of blood within the uterine cavity, due to the mechanical interference with its escape ; in the latter cases clots are formed, increasing gradually in size, often undergoing putrefaction, and acting not only as a foreign body, preventing uterine contraction, and attracting by their irri- tating action an extra amount of blood to the uterus, but consti- tuting as well a favorable nidus for the development of sapro- phytes, which may extend their operations to the thrombi at the placental site, disintegrating them. 1 The causes of uterine displacements in the puerperal state are the increased weight of the puerperal uterus, loss of tonicity and relaxation of the uterine ligaments. They are, therefore, not in- Fig. 516. — Retroflexion of puerperal uterus (Schatz). Fig. 517. — Frozen section of puer- peral uterus in a state of anteflexion (Stratz). frequently associated with subinvolution. Backward displacements of the puerperal womb are most frequently the result of a displace- ment antedating conception. They are frequently due also to a sud- den physical effort soon after leaving the bed, especially if the woman has risen too early, before involution has advanced suffi- ciently far. Another common cause is the fault}' application of a compress under the binder. Many nurses, unless they are properly directed, place a thick compress in direct relation with the anterior uterine wall, thus crowding the whole organ backward, instead of adjusting it over the fundus of the uterus, where it maintains a 1 Five cases of puerperal hemorrhage due to uterine displacement are reported by Grafe in " Zeitschrift f. Geburtsh.," xii, 32S. 648 PATHOLOGY OF THE PUERPERIUM. condition of anteversion, and by constant pressure promotes firm contraction and rapid involution. Retroversion and retroflexion may persist after premature delivery, if these displacements ex- isted during pregnancy. Neglect to empty the bladder at proper intervals may be a cause. The diagnosis is easy if a careful physical exploration is made ; and it should be an invariable rule to make a careful vaginal examination in every case of puerperal hemorrhage. It is not rare to find some portion of the ovum or blood-clots retained within the uterine cavity in consequence of the " steno- sis by angulation " of the cervical canal. 1 It is, therefore, not Fig. 5*8. — Anteflexion. Webster's section from a case of death from eclampsia about thirty-six hours after delivery: a, Fundus; b, bladder; c, symphysis pubis; d, promontory ; e, cervix ; f, pouch of Douglas ; g, vagina. sufficient to rest satisfied with the diagnosis of displacement in puerperal hemorrhage, but it is necessary to be sure that there is nothing retained within the uterus. It should be remembered that there may be no hemorrhage, but, for a time, suppression of the lochia, with displacements of the womb. Occasionally, if the dislocation occurs acutely, it may be associated with grave symptoms, as intense pain, a condition verging on shock, and high fever, these symptoms disappearing immediately upon the reposition of the womb. 1 Fernley, "British Med. Jour.," 1888, ii, 739. PUERPERAL HEMORRHAGES. 649 The treatment of puerperal hemorrhage due to a displaced uterus is the rectification of the displacement, which is occasion- ally followed by the expulsion of blood-clots or remains of the ovum imprisoned within the uterus, and the true causes of the bleeding. 1 The uterus, restored to its natural position, may remain there. The knee-chest posture should be assumed twice a day. Mechanical supports (tampons and pessaries) are contra- indicated before the sixth week. Dislodgment and Disintegration of Clots at the Placental Site. — The thrombus formation in the large sinuses at the pla- cental site plays a subordinate part in the prevention of hemor- rhage after delivery. In consequence of sudden exertion, sitting upright in bed, or actually standing on the floor soon after labor, some of these clots, plugging up important vessels, might be dislodged. It is with this possibility in mind that every pre- caution should be taken to secure quiet and repose for the woman after labor. Disintegration of the clots at the placental site occurs occasionally in consequence of their invasion by micro-organisms. This is, therefore, one of the phenomena of puerperal infection. The bleeding that follows is, of all puer- peral hemorrhages, by far the most dangerous. Diagnosis. — The hemorrhage that follows displacement of thrombi at the placental site is startling in its suddenness, and alarming in the amount of blood lost. There need be nothing in the uterine cavity to account for it ; the uterus may be in good position. The true condition can, of course, only be inferred. Treatment. — The best treatment for this kind of uterine hemorrhage is thus described by its author. 2 He takes with him to every case of labor a strip of twenty per cent, iodoform gauze three yards long, two hands' breadth in width, in four layers. On this is scattered loose iodoform powder. 3 To tampon the uterus the anterior lip of the cervix is seized as high up as possible with two bullet-forceps ; the strip of gauze is then caught by the end in a long pair of forceps and is- introduced within the uterus. As soon as the point of the forceps enters the uterine cavity the left hand grasps the fundus, and only then is the forceps pushed in as far as it will go. The forceps is then loosened, withdrawn a little, a lower portion of the gauze strip is seized, and so the 1 Strachan reports an interesting case of the kind associated with anteflexion. Six weeks after labor there was a severe hemorrhage; the uterus was straightened by upward pressure through the anterior vaginal vault. The following day a cotyledon of the placenta was discharged (" British Med. Jour.," 1886, i, 587). 2 Duhrssen, " Die Uterus-Tamponade mit Iodoform-Gaze bei Atonie des Uterus nach normaler Geburt," " Centralblatt f. Gyn.," 1S87, xi, 553. 3 I prefer sterile gauze. The quantity of iodoform introduced by Diihrssen's method entails some danger of toxic symptoms. 650 PATHOLOGY OF THE PUERPERIUM. uterus is filled with gauze, lying in fan-shaped folds. " It is astonishing," says Duhrssen, "how soon the uterine cavity is filled." The uterus is stimulated to contraction; so one gets the combined advantage of a tampon and a uterine stimulant. When the gauze is removed, it has very few blood-clots in it, and has not a trace of putrid odor. Every one who has ever used the intra-uterine tampon for hemorrhage will indorse the statement that it is of inestimable value. There is no other means so absolutely sure to check uterine bleeding. Emotional Causes. — Sudden emotion of any kind arrests uterine contraction during labor and in the puerperal state. In the latter condition the usual result is a hemorrhage, which may be alarming. Barker x gives an interesting example : A healthy young primipara almost bled to death in the second twenty-four hours after labor in consequence of the brutal con- duct of her husband, who was disgusted that his child was a girl. I have seen a sudden and profuse hemorrhage on the seventh day, the result of fright. The patient's step-son returned home late at night in a violent state of intoxication. Relaxation of the uterus is a rare cause of hemorrhage after the first twenty -four hours. It is scarcely ever seen later than the third day, and when it occurs after the first day it is in women depressed in mind and body, exhausted by prolonged labor, weak from insufficient food or bad hygienic surroundings. It is treated on the same general principles as a primary post- partum hemorrhage from the same cause. Retention of b!ood=clots is usually the result of uterine re- laxation, uterine displacements, or a retention of portions of the ovum, around which the clot is formed. If these conditions are promptly treated, the retention of blood-clots is prevented. The effect of a large clot retained in utero is often a hemorrhage, possibly also septicemia. The mass of clotted blood should be removed as soon as the symptoms point to the presence of a foreign body within the uterus. Fibroids. — If the puerperal state is complicated by intra- mural or submucous fibroids of the uterus, there are certainly a prolongation and an increase in amount of the bloody lochia, pos- sibly a serious hemorrhage. The latter is peculiarly liable to happen if the tumor assumes the shape of an intra-uterine polypus. The diagnosis is only to be made by a careful physical explora- tion. The best treatment is the removal of the growth by tor- sion, by splitting its capsule and enucleation, by cutting the pedicle with scissors after ligation of the base, or with the wire 1 "The Puerperal Diseases," p. 15. PUERPERAL HEMORRHAGES. 65 I ecraseur. In case this treatment can not be carried out, and in other forms of fibroid tumors in the puerperal state, ergotin, with quinin and strychnin, and the daily application of the faradic current, if practicable, do much to secure firm uterine contrac- tion and prevent hemorrhage. Hematomata along the genital tract may burst during the puerperal state, with serious external hemorrhage. The condi- tion is described elsewhere. Pelvic Engorgement. — Congestion of the pelvic blood- vessels may lead to puerperal hemorrhage. The congestion may be due to heart, kidney, or liver disease ; to increased intra- abdominal pressure from any cause ; to the determination of blood toward internal organs during a chill ; 1 to premature sex- ual intercourse ; to the erethism following the return of the hus- band to the wife's bed ; to inflammation about the uterus ; to subinvolution from any cause ; to ovarian irritation, and to con- stipation. Mauriceau 2 describes a case of puerperal hemorrhage that continued quite profusely for five or six days, and which was only checked when "a pretty strong clyster " resulted in the evacuation of " a panful of gross excrements." Wounds in the Genital Tract. — Secondary hemorrhage may occur from wounds in the cervix, vagina, and vulva. Occasion- ally, abnormally large blood-vessels are injured in these regions. On one occasion I saw a hemorrhage from an anomalous artery in the perineum that nearly proved fatal. It is possible that a vessel of considerable size might be wounded during labor, and yet, in consequence of pressure from the child's head or of an unstable plug of clotted blood, would not bleed until, at some time in the puerperal state, the tissues recovering their tone or the clot being dislodged hemorrhage would occur. The diagnosis is easily made if the parts are exposed to view. The bleeding vessel may be detected and should be ligated. Carcinoma of the Corpus Uteri and of the Cervix. — Carci- noma (syncytial) or sarcoma may develop at the placental site during the puerperium. Epithelioma of the cervix, if at all ad- vanced, will surely cause some hemorrhage. The best treatment for the immediate control of hemorrhage from this cause is a uterine or a vaginal tampon. Vaginal hysterectomy should be performed, if possible, without delay. Fritsch has shown that the operation is perfectly practicable immediately after labor. In inoperable cases with uncontrollable hemorrhage ligation of the 1 Winckel (" Path. u. Therap. des Wochenb.") reports 4 cases of this kind out of 1 14 of puerperal hemorrhage. I once observed a striking example during a malarial attack some days after labor. 2 " Diseases of Women with Child and in Child-bed," translated by Hugh Cham- berlen, London, 1752. 652 PA THOL OGY OF THE PUERPERIUM. internal iliac, the ovarian, and the round ligament arteries is in- dicated. Rare causes of puerperal hemorrhage are rupture of the uterine artery, reported by Hewitt, 1 with a fatal result six weeks after labor; the rupture of a distended vein in the cervix, followed by fatal bleeding, described by Hecker. 2 Meschek 3 reports a similar case, with like result, due to an eroding ulcer which opened a large vessel in the cervix. Johnston has re- ported a fatal puerperal hemorrhage due to rupture of a hema- toma of the cervix. 4 Puerperal Hematoma. — A form of hemorrhage in the female genitalia during or after labor, much more rare than the second- ary hemorrhages just described, is an interstitial effusion of blood, with the consequent formation of a blood-tumor, varying in size with the degree of the hemorrhage. Levret seems to have been familiar with the accident, but with this exception a knowledge of the nature of hematoma in puerperae has been acquired in quite recent times. The first systematic treatise on the subject is Deneux's monograph. 5 It was also fully described by Dewees. 6 The accident is rare, but individual experience differs widely as to its frequency. Deneux was able to collect 62 cases, but had himself only seen 3 in a practice of fourteen years. Paul Dubois saw but 1 case in 14,000 labors. Velpeau, 7 writing five years after the appearance of Deneux's article, declared that it would be easy to collect the detailed accounts of 100 cases; that he himself had seen 25. Barker, of New York, reported 22 cases that came under his personal observation. Winckel quotes McClintock's claim that he had observed 25 cases, and places an exclamation mark after the quotation, evidently as a sign of incredulity. 8 The former has only met with 6 well-marked cases in an experience of almost 20,000 confinements. Bossi found hematomata twice among 5660 women in child-bed ; Hugenberger, 1 1 times in 14,000 deliveries; 9 in Vienna it was noted 18 times out of 33,241 births. 10 This would indicate a frequency of 1 to 1600 births. I have seen three cases in fifteen years. 1 " London Obstet. Trans.," vol. ix. 2 " Archiv f. Gyn.," Bd. vii, S. 2. 3 " Zeitschr. d. Ges. d. Wien. Aerzte," 1854, x. 4 Sinclair, " Pract. of Midwifery," 1858, p. 501. 5 " Tumeurs sanguines de la Vulve et du Vagin," Paris, 1830. 6 "Midwifery." 7 " Traite complet de l'Art des Accouchements," Brussels, 1835. 8 " Lehrbuch der Geburtshiilfe," 1889. 9 " Hsematoma Vulvae im Verlauf der Schwangerschaft," "Archiv f. Gyn.," Bd. xxxiv, H. 1. 10 These latter statistics are taken from Winckel's book, where a reference to the original authorities may be found. PLATE 13. Hematoma of the vulva (author's case). PUERPERAL HEMORRHAGES. 653 The situation is most frequently, by far, in one or the other labium majus, rarely in both. The blood-tumor may, however, occupy a position beneath the vaginal wall, on either side, poste- riorly or anteriorly; in the ischio-rectal fossa; in the labia minora; in the carunculse myrtiformes; under the skin of the perineum, be- tween the superficial and median fascia; in the cervix; in the peri- uterine connective tissue; within the broad ligament; in the sub- peritoneal connective tissue, on the posterior and anterior abdomi- nal walls, extending as high as the kidneys and navel (Cazeux,Hu- genberger, Winckel) ; under the skin of the mons veneris or over the inguinal ring (Velpeau). If the effusion occurs above the pelvic fascia, the blood forces its way upward toward the diaphragm ; if below, downward toward the vulva. Size and Form. — Small extravasations of blood are to be met with along the genital tract very frequently after labor ; this form of thrombus is due to the fact that the mucous membrane is pushed in front of the presenting part with a glacier-like move- ment over the underlying tissues, and there thus occurs a lacer- ation of the submucous connective tissue and the small blood- vessels contained in it. A careful examination often reveals numerous hematomata after labor, varying in size from that of a pigeon's egg to that of a walnut. It is the larger tumors that are rare. They may vary in size from that of a hen's egg to that of a child's head; in extreme cases, if the blood is diffused throughout a great part of the subperitoneal connective tissue, the size of the effusion would be very large were the blood contained within a limited, circumscribed tumor. In shape, blood-tumors of the genital tract may be globular; in the cervix they distend the tissues of one or both lips down- ward and outward, giving to the cervix the form of a shark's nose. In the vagina they may hang from the anterior or posterior wall in the form of a polypus (Fleischmann). In the labia the hematoma is sausage-shaped (see Plate 12). Etiology. — The predisposing causes of puerperal hematomata are the engorged condition of the blood-vessels along the genital tract and the strain that is imposed upon them either by the pressure of the fetal body or by the great muscular effort put forth during labor. The more engorged the vessels are, the more likely is the occurrence of hematoma. Winckel says it is self- evident that varicose veins predispose to the accident. Barker, however, denies this emphatically. It is certainly true that many a case of varicose veins may be met with before a hematoma is seen, and in many instances of the latter the veins were in no- wise affected. Halliday Croom 1 attaches great importance to '"On the Etiology of Vaginal Hematoma Occuning During Labor," " Edin- burgh Med. Jour.," vol. xxxi, pt. i', p. 1001. 654 PATHOLOGY OF THE PUERPERIUM. anteversion of the parturient uterus as a predisposing cause of vaginal hematoma, believing that thus an excessive strain is put upon the whole posterior vaginal wall, and a rupture of dis- tended blood-vessels in this region is therefore more probable. This explanation seems reasonable, but it leaves unexplained the hematomata in other situations along the birth-canal. Hypertrophic elongation of the cervix certainly predisposes to the formation of hematomata in that region during and after labor. The determining cause of the accident may occasionally be found in direct injury to the tissues by forceps, and rarely by a fall or a blow, or it might be explained by violent straining efforts during the second stage of labor. In the majority of cases, however (eighty-six per cent., Winckel), the occurrence of hematomata is apparently spontaneous. The immediate cause of the hematoma is the rupture of a blood-vessel and the inter- stitial extravasation of blood ; the vessel injured is commonly a vein, not rarely of large size. Possibly a number of smaller vessels may be ruptured. The injury to the blood-vessels is either a direct and immediate laceration or else, later, a perfora- tion by pressure necrosis. Clinical History and Diagnosis. — The interstitial hemorrhage that results in a hematoma begins, with rare exceptions, during labor. 1 The extravasation of blood may at first be gradual, so that it does not attract attention until some time in the puer- peral state. The distention of the vagina by the presenting part of the fetus may prevent all bleeding until the maternal tissues are relieved of pressure. If the bleeding results from necrosis of tissue, the result of prolonged pressure, the formation of a hematoma may first begin after delivery. In cases in which the accident has seemed to be the result of violent coughing or other exertion during the child-bed period, there had been, no doubt, some injury done the vessels during parturition. The sub- cutaneous or submucous laceration of tissue occurring, as a rule, during the second stage of labor is almost always associated with acute pain of a sharp, lancinating character, quite different from labor-pains. The suffering increases as the hematoma enlarges, and, in addition to the sharp pain of torn tissue, there are exaggerated and painful expulsive efforts excited by the presence of the tumor within or alongside the vagina. This is an almost constant symptom, but Barker reports a painless case. The hemorrhage into the tissues may be profuse enough to occa- sion the most marked signs of acute anemia. Pallor, failure of vision, a thready pulse, air-hunger, loss of consciousness, and, 1 Vinay reports a case in the sixth month of pregnancy after an epileptic fit, " Centralbl.' f. Gyn.," No. 7, 1897. PUERPERAL HEMORRHAGES. 655 finally, death, may all be noted without the slighest external escape of blood. An examination of the patient shows a tumor occupying the situations already described, of varying size, and differing in consistency as the blood contained in it is fluid or clotted. If the hematoma is submucous, it presents a dark, pur- plish color, like clotted blood. If it is covered with skin, it presents a bluish, ecchymotic hue, although in the labium majus the color may be the same as in a submucous hematoma. As a rule, the swelling only appears after labor. It may, however, occur before the expulsion of the child, and it has repeatedly developed between the birth of twins. 1 If the tumor is formed during labor, it may present a formidable obstacle to delivery ; if it appears in the puerperal state, it may dam back the lochia or give rise to dysuria or to retention of feces. With the history of a sharp attack of pain during labor, the subsequent rapid de- velopment of a tumor along the genital tract characteristic in its appearance and situation, the signs of internal hemorrhage, the diagnosis of the true condition ought not to be difficult ; and yet a mistake is quite possible. Puerperal hematoma has been confused with varicose tumors of the labia, inguinal hernia, and inversion of the vagina. Once in Barker's experience a vaginal hematoma was mistaken for a fetal head, and once for placenta prcevia. Auvard 2 says that on first sight he took a hematoma o f the anterior lip of the cervix for a clot of blood lying in the vagina. The Barneses, 3 in describing their case of cervical hematoma, write that they found a fleshy tumor projecting from the vulva which looked like a mass of coagidated blood, or which might have been mistaken for an inverted uterus. The diagnosis is more difficult in cer- vical hematomata than in those of the lower genital canal. The former are rare. Besides the two just mentioned, others are described by Hohl, Braun, Earle (two cases), and Winckel. 4 Hematomata along the genital canal may burst soon after their formation, with appalling and possibly fatal hemorrhage. In cases of labial tumors the point of rupture is likely to be the boundary-line between the greater and lesser labia. A hematoma within the pelvis may open into the peritoneal cavity, with fatal hemorrhage. 5 In one case under my obser- vation a large hematoma formed between the layers of the broad ligament. Four hours later the posterior layer of 1 One case reported by Dewees (" Diseases of Females," "Of Bloody Infiltra- tion in the Labia Pudendi"), and six by Madame SasanofF (" Annales de Gyne- cologie," December, 1884). Four of these latter cases died. - " Trav. Obstet.," Paris, 18S9, t. i, p. 440. 3 " Sys. of Obst. Med. and Surg.," Philadelphia, 1S85. * " Lehrbuch," 1S89. 5 Williams, "Am. Jour, of Olistet.," Oct., 1904. 656 PATHOLOGY OF THE PUERPERIUM. the broad ligament ruptured, the bleeding became intraperi- toneal and unlimited, and the patient died before I reached her. After early rupture or primary incision of the tumor, profuse hemorrhage is likely, and secondary bleeding is apt to occur. This accident is rare when the tumor is opened after bleeding into it has ceased. Winckel has thus summarized the terminations of puerperal hematoma : (1) Death by hemorrhage with or without previous rupture of the tumor ; (2) death following suppuration of the sac and septicemia, most frequently after the sac has been opened ; (3) rupture of the tumor, with recovery ; (4) rupture of the tumor, with a resulting fistula; (5) perfect recovery by absorp- tion of effused blood, without rupture of the sac. In fifty cases collected by Winckel from modern literature the tumor burst spontaneously in the first eight days in twenty-three. A hema- toma may be evacuated not only by escape of the contained blood externally, but by diffusion of its contents under the skin. Dill 1 reports a case of large hematoma of the right labium, which ruptured internally and produced ecchymoses reaching to the nates and to the right knee, to the umbilicus, and even as high as the right axilla. Suppuration may occur in a blood- tumor that has not been ruptured at all, and the effused blood may be converted into a large accumulation of pus. As these abscesses are often in the neighborhood of the rectum, the pus may acquire a fecal odor, without a communication with the bowel. A rectovaginal fistula may result if the hematoma breaks its way into the rectum and also opens anteriorly into the vagina. Suppuration is most to be feared after the blood-tumor is opened and its cavity is exposed to the contamination of the atmosphere and of the lochial discharge. Prognosis. — The formation of a hematoma during or after labor was formerly regarded as a more dangerous complication than it is considered to-day. Of Deneux's 62 cases, 22 died. Fatal cases have been reported by Cazeaux, Lubanski, Broers, Seulen, Josenhans, Hugenberger, Braun, and the author. The causes of death in these cases were hemorrhage (in two instances into the peritoneal cavity), septicemia, and typhoid fever (?). Blot col- lected 19 cases since Deneux's paper was published, with 5 deaths. Perret, in an analysis of 43 cases, found 1 7 deaths. Of II cases observed by Hugenberger, 2 4 died. Girard, 3 in an 1 " Dublin Jour. Med. Sci.," November, 1886. 2 " St. Petersburg med. Zeitung," 1865. 3 "Contribution a 1'etude des Thrombes de la Vulve et du Vagin dans leurs Rapports avec la Grossesse et 1' Accouchement," " These de Paris," 1874. PUERPERAL HEMORRHAGES. 657 analysis of 120 cases, found 24 deaths. Johnston and Sinclair 1 report 7 cases during seven years' service in the Dublin Rotunda, with 2 deaths. Scanzoni met with 1 5 cases, 1 of which died. Winckel, among 50 cases, found only 6 deaths. Of the 6 cases in his personal experience, not one died. Barker reports 22 cases of his own, of which 2 died. Barnes 2 reports 2 cases with a favorable issue ; Auvard, 3 I of cervical hematoma that disap- peared by absorption. Croom's 3 cases all recovered. Death from a puerperal hematoma at present should be rare, especially if the patient's general condition is good and her hygienic sur- roundings are satisfactory. Treatment. — If the hematoma is of moderate size, not larger than one's clenched fist, the main object of treatment is to secure absorption of the effused blood, and thus the disappearance of the tumor. It may, however, be necessary to remove an ob- struction to labor if the tumor develops before delivery ; to con- trol the hemorrhage either before or after rupture of the sac ; to treat the general symptoms of profuse bleeding ; to evacuate the contents of the sac when suppuration has occurred, and to pre- vent septic infection. To secure the disappearance of a hematoma by absorption cleanliness of the parts and rest are necessary. If the tumor is vaginal or cervical, frequent irrigation of the vagina is ad- visable. If the effusion is subcutaneous, cooling lotions and inunctions with carbolized oil often prevent inflammation and rupture of the sac. If the tumor appears before or during labor, and offers an obstacle to the delivery of the child, it must be freely opened ; the contents, whether fluid or clotted blood, evacuated ; pressure exerted by a tampon of iodoform gauze, in order to check the hemorrhage ; while the extraction of the infant by forceps or after-version is hastened as much as pos- sible. To control the hemorrhage into the tissues before exter- nal rupture has occurred, pressure, cold, and the internal admin- istration of ergot may be tried. An ordinary tampon in the vagina is not admissible, for it would dam back the lochial secre- tion, and would become foul. Braun's colpeurynter, or a large Barnes' bag, distended with ice-water, is ihe best appliance, for it can be easily removed at frequent intervals to allow an anti- septic irrigation of the vagina. If it is possible to avoid it, the tumor should not be opened while it is increasing in size, for there may be profuse hemorrhage at the time and a secondary bleeding later. This does not occur, as a rule, when the tumor is incised after the effusion ceases, and yet there are two cases 1 Barker, loc. cit. z Loc. cit. 3 Loc. cit. A2 658 PA THOL OGY OF THE PL ERPERIUM. on record in which hemorrhage occurred from tumors opened one and three weeks after their formation. 1 If the tumors are too large to be absorbed, or if there is threatened gangrene of their coverings, they should be opened. Hematomata may burst within the first few days after their formation, and there may be, in consequence of the rupture, an alarming hemorrhage. In such cases it is best to enlarge the opening ; to turn out the clots within the tumor ; to search for the bleeding vessels, which may be seen spurting from the walls, and to apply a ligature. If this is impossible, and bleeding still continues, the cavity may be firmly packed with iodoform gauze, firm external pressure being exerted by a large pad and a T- bandage. The styptic salts of iron should not be applied, for such a firm, dense clot is thus formed that it takes a long time for it to disintegrate, the woman meanwhile running a risk of septicemia. After the coverings of a hematoma are incised or ruptured, suppuration commonly occurs in the cavity; septicemia must be avoided in such cases by an iodoform -tampon in the ab- scess cavity often renewed, and by frequently repeated irri- gations. Suppuration may occur before the tumor has been opened at all. In such cases the pus must be evacuated. The opening should not be delayed too long, especially in suppu- rating hematomata of the posterior vaginal wall, or fistulae may result. The general treatment for loss of blood is to be con- ducted in the ordinary manner when the indications call for it — hypodermatics of ether, brandy, and other stimulants; hot ani- mal broths internally; "auto-infusion" by bandaging the limbs; and subcutaneous or intravenous injections of a normal salt solution. Noninfectious Fevers. — Fever in the puerperal state not due to infection may arise from emotion, from exposure to cold, from constipation, from reflex irritation of any kind, from cerebral disease, from eclampsia, from insolation, from syphilis, from the exacerbation or persistence of an acute or chronic disease con- tracted during or before pregnancy. Emotional Fever. — In these cases there is simply a nervous stimulation of or a disturbance of balance in the heat-controlling centers of the brain, occasioned by some profound psychical impression — as grief, anger, fear. The normal action of these brain-centers may be disturbed by some powerful emotion which profoundly affects the higher cerebral functions. Another theory of fever after emotions deserves some con- 1 Parvin's "Obstetrics," p. 502. NON- INFE C TIO I T S FE VERS. 659 sideration. It is possible that the profound mental action pro- duces a change in the composition of the blood or of the fluids in glands and muscles, which, it is well known, take a part in heat-production. It is possible that thus a thermogenic toxin is manufactured. There may, again, be an excitation or paralysis of the vasomotor nerves. That fever may appear in consequence of emotions, clin- ical evidence leaves no doubt. The cause of the fever being tran- sient, perhaps momentary, the elevated temperature quickly sinks to normal. It is not in every person that powerful emotions are followed by an elevation of temperature to a noteworthy degree. There must, apparently, be predisposing causes in the nervous system of the individual. Emotional fever is most often met with in children, in hysterical girls, 1 and in women after child-birth. Day of Diseaae ; £ 2 4- 5 t 7 8 9 10 n 12 13 14> tf 16 M £ M £ M £ M £ M £ A/ £. bt £ M £ M £ M £ to EMI I\t£ M £ M £ M ? 105° 104° 103° 102° 101° 100° 99° 08° :; | \ ill 11 V : : ! i : A A h A J _v rr\ ■( ' . V V Y~ : H /■■ T Fig. 519. — Chart of emotional fever from dread of an operation. In child-bed there is a curious irritability of the organism, a lack of control over the mental processes. The petulant child, easily- swayed by and completely yielding to emotions, subject on slight provocation to convulsions, is a familiar picture ; and no one can overlook this same mental and nervous character in pregnancy and in the early part of the puerperal state. It is this condition of the nervous system, apparently, that predisposes to emotional fever. It is, therefore, not at all uncommon in the puerperium. Hunt's 2 records of seventy-five cases, confined to women free from infection and inflammation, in which the temperature was 1 The case reported by Dr. Matomed is a famous example ; the temperature is said to have reached 12S F. ("Lancet," 1S81, vol. ii, p. 790). 2 "Normal Course of Puerperal Temperature," " Practitioner," London, 1S88, p. 81. 66o PATHOLOGY OF THE PUERPERIUM. taken twice a day in the month, gives three apparently typical ex- amples of fever from emotion. I have seen a number of examples of emotional fevers. Failure to receive an expected letter, fear of exposure in illegitimate pregnancy, the expected removal of the woman's infant to an asylum, dread of an operation, and a variety of mental disturbances have given rise in my experience to a high but transitory fever. Figure 519 shows the tempera- ture record of a typical case. There had been an operation for mammary abscess in a hospital ward. It was witnessed by two puerperal patients. One of them, a young girl, shortly after experienced pain in the breast. She at once conceived a morbid dread of an operation in her own case. The beginning elevation of temperature in the chart indicates the commence- Day of Disease /Z IB ;4 IS 16 17 18 19 20 21 105° 104° 103° 102° 101° 100° 99° 98° M £ M E M £ M E to E M £T to E M E to £ M E ■ K ■ ■ d 1: ■ \ ■ l : \ \: : \\ 1 \ : : :, : i : s- i \ ") : \ ■ y v Fig. 520. — Chart of fever case from exposure to cold. The patient left her bed twice against orders, in her bare feet and night-gown. Each time there was a rise of temperature, quickly subsiding. ment of engorgement and pain in the breast. These symptoms continued for a few days, when, after lying awake all night brooding on the subject, the girl's temperature began to rise in the morning, finally reaching the height indicated on the chart. The only antipyretic employed was the emphatic assurance of the resident physician that there was not, and would not be, the slightest excuse for an incision in the breast. The patient's fears being allayed, her temperature quickly sank to normal, where it remained. Fever from Exposure to Cold. — In the sensitive condition of puerperae it is not uncommon to see a febrile reaction follow undue exposure. A careless nurse or attendant may be respon- NON- INFE C TIO US FE I ERS. 66 1 sible for too low a temperature in the lying-in room, or for ill- regulated ventilation, or for insufficient or ill-arranged bed- clothing. A wilful patient may leave her bed too soon and expose herself, thinly clad, to cold (Fig. 520). Fever from Constipation. — Schroeder 1 says that " among the causes, aside from infection and local inflammations, which, with special frequency, produce fever in the puerperal state, overdis- tention of the intestines with fecal masses should be given a fore- most place." This statement is, I think, exaggerated. Every practitioner of obstetrics, however, sees examples of this sort of "puerperal fever" (Fig 521). Day of DiseaBe / 2 3 4 5 6 7 a 9 70 77 72. 73 105° 104° 103° 102° 101° 100° 00° 98° M E M C M E M E M E M E M E M E M E M E M E M E M £ 1 •» A i \ r- / \ i A '■■ h A v f\ w V-, A '■ t (■■' v/ \. \ Fig. 521. — Chart of a woman constipated for six days in the latter part of the puerperal state. There had been one movement of the bowels, five days after labor, and then none for six days. A large dose of castor oil and an enema reduced the temperature to normal in a few hours. The temperature-chart, figure 521, is that of a woman in the Philadelphia Hospital who had had but one evacuation of the bowels — on the fifth day — in the eleven days succeeding delivery. The temperature fell immediately after a large dose of castor oil and the administration of an enema, which produced an enormous fecal evacuation. Fever from Reflex Irritation. — Physical irritation, as well as psychical, may be reflected in general elevation of the body- temperature during the puerperal state. The irritating point is most often in the breast. There may frequently be found, in women of sensitive nervous organism, a well-marked fever, which 1 "Lehrbuch," 8. Aufl., S. 803. 662 PATHOLOGY OF THE PUERPERIUM. can be traced to no other cause than engorgement and distention of the mammary gland. There is usually a history of exposure to cold or drafts of air in nursing the child. For twenty-four hours afterward there may be high fever and every evidence of Day of Disease 1 2 3 4- 5 6 7 8 9 !0 /; 72 13 w 75 M £ M E M E M E M E M EH IE M E M E M E M E M E M E M E M E 105° 104° 103° 102° 101° 100° G9° 98° && * * I I t \ v } '■ \ h V \ I 1 \ \ • i i 'i : V ; !\ • v : ■ tf 4 V \ rr \v <■< r S '?- s V ■ 5 V, 1 : Fig. 522. — Reflex fever from mammary congestion. * Breast incised without finding pus. acute illness. Hot fomentations on the breast, evacuation, sup- port of the gland, and a saline purge dissipate the symptoms in 24 hours. The appended temperature-chart (Fig. 522) illus- trates the influence of mammary congestion upon the temperature. A young primipara developed, on the eighth day of the puerperal Day of Disease 1 Z 3 4- 5 6 7 a 9 JO 11 12. /3 /* /af ;<5 17 18 19 . zo M E M £Wi ' £±E A . I4 ... u s; t--I f ... n — I- ij... \- J- m|.... *■— *— : *■- mi— .- ? .... 0.... idl— ■ pi J.... »— ■ M M a— 1 m-— ?••■■ m|.... -< ^ £ ^-" kt ^- g.... _„ / U- ■ *-■ k,l— ■ ■A / p -t ^ V *■••■ v *;■■•■ Si ■■■ *!•■■■ *■■■■ * -1 1 J.... *■- kll— *■•■■ ■ill"" *■••■ IF ^ ^ — 1 J— ■ »•■•■ . ...I Bw-J- a-- *■•■• §p . ...^ ... J.... *-■ J--/ 1 M)i; jJil *■••• M— ■ > J.... ^ h I § i i s i 3 § 1 1 The fever preserves, during the puerperal state, a perfect periodicity, a characteristic which much facilitates the diagnosis. Spiegelberg and Ritter contradict the last state- ment. In their opinion regu- larity in the occurrence of fever is very rare during the puerperium. In my experi- ence the fever is at first usually continuous. As the patient is brought under the influence of quinin the fever becomes in- termittent and finally disap- pears (Fig. 528). The puer- peral state predisposes to grave forms of malarial in- toxication. The disease may pursue the mildest possible course, with very slight and irregular fever, which is easily con- trolled by quinin in small doses. On the other hand, the worst example of malarial infection which I have ever seen occurred in the last month of pregnancy. Dur- ing the previous eight months the patient had had two at- tacks of malarial fever. With- in a week or two of term, the disease reappeared in a grave form. There were congestive chills, a temperature running above 104 , and finally coma. The fever was almost contin- uous. In the midst of the attack labor came on, and after some difficult)' the child was extracted by the breech. After deliver}- the woman grew worse, and death seemed inevitable, but by the daily INTERCURRENT DISEASES. 679 administration of seventy to eighty grains of quinin for several days, the fever was conquered and the patient made a rapid recovery. Diagnosis. — The diagnosis of malaria in the puerperal state usually presents many difficulties. If it were true, as has been asserted, that the fever is always characterized by distinct periodicity, the difficult}' would in great part disappear, but it is not. The main difficulty is to distinguish the fever of sepsis from that of malaria. In doubtful cases it is a good plan to administer large doses of quinin, and at the same time to disinfect the genital canal thoroughly. If this is fol- lowed by immediate improvement, it is always difficult to say whether there was malaria or infection, or whether the improve- ment was brought about by the disinfection of the parturient tract. The microscopic examination of the blood should clear up many a doubtful case. The whole subject of malarial fever in the puerperal state has been discredited by the tendency to conceal cases of puerperal infection under this name. The prac- titioner should always be upon his guard in this respect. While not so satisfactory to him, it is far safer to his patient to err in the opposite direction — to regard a doubtful case of fever during the puerperium as of septic and not of malarial origin, unless the proof in support of the latter belief is convincing. Treatment. — In the majority of cases larger doses of quinin are required than under other circumstances. Reference has been made to a case in which, on the average, seventy-five grains were administered in the twenty-four hours for several successive days. In another case under my observation, forty- five grains a day were given for a long time, with success in con- trolling the fever and with no ill effect upon the patient. Several times an attempt was made to reduce the dose to thirty grains, but the reduction in the quantity of the drug was always followed by the reappearance of the fever. It was at one time erroneously taught that quinin administered to a nursing woman had a dis- astrous effect upon her milk. Runge states definitely that quinin may be given without hesitation to nursing women. Even in very large doses it does not pass into the milk. My own experi- ence is in accord with this statement. Rheumatism and Arthritis. — Arthritis in the puerperal state is either a manifestation of septic infection, with a localiza- tion of the septic inflammation in a joint, or else, as a rheumatic arthritis, is simply an accidental intercurrent affection. Accord- ing to Celles, 1 Charcot, in his doctorate thesis, published in 'Marcel Georges Celles, " Du Rlmmatisine articulaire pendant l'c-iat puer- peral," " These de Paris," 1885. 68o PATHOLOGY OF THE PUERPERIUM. 1853, was the first to call attention to rheumatism in the child- bearing woman. During the following year, Simpson in Great Britain, and Virchow in Germany, in their works upon the puerperal state, mentioned articular rheumatism as one of its complications. The subject has since been studied by Peter, Loisin, Simon, Vaille, Braunberger, Boillereault, Tison, Quin- quaud, Lacassagne, Hanot, Pinard, Siredey, Charpentier, Alex- andre, 1 Hamill, 2 and others. The diagnosis between septic arthritis and simple acute rheumatism is not always easy. In the latter, during the puerperal state one sees all the character- istic symptoms of the affection, just as under any other ordinary circumstances. Inflammation of the joints following septic infection, on the other hand, presents certain peculiar signs. The joint affected is usually a large one, very often the knee ; the inflammation is not fugacious ; 3 it is exceedingly stubborn Fig. 530. — Temperature-chart of a puerpera with fever and uterine tenderness, with no other symptoms of sepsis. Irrigation and curettage of the uterus had no effect upon the fever, which yielded immediately to the salicylate of sodium. There had been an attack of muscular rheumatism during pregnancy. in its resistance to all treatment ; the duration is usually pro- longed, and in many cases there follows a complete ankylosis of the joint. There may be very? little evidence of general septic infection. The arthritis may make its appearance late in the puerperal state. It may be accompanied by very moderate fever of an irregular type. It is more apt to appear in women who have had gonorrhea. In the worst cases of general septic infection the joints may be the seat of metastatic abscesses as well 1 For extensive bibliography see Celles, loc. cit.; Felix Barral, "Contribution a Etude du Rhumatisme puerperal,'' "These de Paris," i8>5 ; Tarnier et Budin, " Traite de l'Art des Accouchements," t. ii, p. 270. 2 " Amer. Jour, of Obstetrics," 1888, p. 317. 3 There are, however, occasional exceptions to this rule (Barral, loc. cit.). IXTERCURRENT DISEASES. 68 I as other portions of the body ; but in these cases the symptoms pointing to a general septic infection are so plain as to indicate at once the origin of the malady. There is one factor which sometimes adds to the difficulty of diagnosis between acute articular rheumatism and a septic arthritis. A metastasis has been witnessed from the joints to the peritoneum in a case of rheumatism during the puerperal state. 1 Such an occurrence would indicate that the case was septic, and that the peritonitis and the joint disease had a common origin in a grave form of septic infection. Prognosis. — The average duration of the septic arthritis is about three months. Recover}- is the rule, but with an ankylosed joint (sixteen times out of twenty-three (Tison) ). In scrofulous subjects the affected joint may become the seat of a tuber- culous inflammation. Treatment. — General medication is of little use. The salicy- lates are of no value. Local treatment, in the shape of counter- irritation (iodin, blisters, cauterization), may hasten the cure. 2 If the inflammation is acute, soothing lotions must be used. The joint at first should be immobilized, but later a cautious employ- ment of massage and passive motion may prevent ankylosis. Muscular rheumatism may complicate the puerperal state. If the disease affects the uterine muscle and is associated with much fever, the only means, practically, of distinguishing be- tween this affection and puerperal infection with septic inflamma- tion of the uterus is the therapeutic test — the administration of a salicylate. Gonorrhea. — The frequency of gonorrheal infection in the puerperal state depends upon the class of society to which the women belong. In the lower classes, seen in dispensary prac- tice, it is very common. In the upper classes it is decidedly rare. The proportion of cases varies, too, in different localities. Noeggerath and Sanger 3 report that among 1930 gynecologi- cal cases during a single year, in private and polyclinic practice, 230 (twelve per cent.) owed their sufferings to gonorrheal infec- tion. Among 398 pregnant women, 100 had a purulent discharge, presumably from gonorrhea (twenty-six per cent.) ; forty of the children developed blennorrhagia. This estimate is too high to be correct as an average. The differential diagnosis between gonorrheal and other pyo- 1 Alsdorf, " Peritonitis as a Metastasis of Acute Articular Rheumatism in the Puerperal State," " Amer. Jour, of Obstetrics," xx, 1887, 1032. 2 A ring of iodin painted around the joint and equal parts of mercurial and belladonna ointment as a plaster directly over it is a good routine treatment. 3 " Ueber die Beziehung der gonorrhoischen Infection zu Puerperalerkrankun- gen," " Wien. med. Blatter," 1886, S. 902. 682 PA THOL OGY OF THE P UERPERIUM. genie puerperal infections is made, according to Sanger, by the following signs : The progress of gonorrhea is slower. It very rarely breaks out in the early part of the puerperal state, appearing first about six or seven weeks after delivery. The most violent cases observed by Sanger were acquired during the period of uterine involution. It is difficult to draw a sharp distinction in all cases between infection by gonococci and by the other patho- genic micro-organisms causing local inflammation in the genital tract. On the one hand, there are many infectious bacteria which cause a severe inflammation of the mucous membrane along the whole canal; and, on the other hand, gonococci can, without doubt, excite inflammation of the deeper tissues, and are certain, if they escape from the tubes, to light up a sharp attack of peri- tonitis. The diagnosis may be made with approximate certainty if the disease existed during pregnancy, or if a careful examina- tion detects an inflammation of the urethra and of the vulvo- vaginal glands, or if it is possible to detect the gonococcus. The consequences of gonorrhea in the puerperal state may be most serious. There is often a mixed infection, gonococci prepar- ing the way for streptococci or other pathogenic micro-organ- isms. The local inflammation, under any circumstances, may become acute, and may be accompanied by violent peritonitis. There may be a rapid accumulation of pus in the tubes during the puerperium, which, however, can occur just as well in the course of an ordinary septic endometritis after labor, so that a puerperal pyosalpinx is not diagnostic of gonorrhea unless gon- ococci are found in the tube. Usually they can not be found, but they have been in several cases under the author's observa- tion. Skin Diseases. — The diseases of the skin which make their appearance during the puerperal state, and are apparently de- pendent upon that condition for their origin, are often a manifes- tation of septic infection. This is certainly true of erythema. It would appear to be true also of cases of pemphigus, which rarely occur after delivery. This disease x usually breaks out on the third or fourth day of the puerperal state. It may or may not be associated with some rise of temperature. In one case the contents of the blebs had a distinctly fetid odor. The duration of the disease is protracted. It lasts, on the average, ten weeks. It would be well in such cases to thoroughly disin- fect the genital canal, because in all likelihood the endometrium is infected. Any other treatment seems to be of little avail. 1 Croft, "A Case of Pemphigus Recurring after Four Consecutive Labors," "Lancet," London, 1887, ii, 858; Wood, "A Case of Postpartum Pemphigus," ibid., 1888, ii, 468. INTERCURRENT DISEASES. 683 The woman's general condition may require stimulants. The distressing itching or burning of the skin which sometimes ac- companies the disease is relieved by a weak carbolic acid solution. Diastasis of the Abdominal Muscles in the Puerperal State. — If the uterus has been much distended during pregnane}-, and if the abdominal muscles during labor have been called upon to exert an unusual amount of force, there may occur a wide separation of the recti muscles, leaving space between them for a hernia of the abdominal contents. ProchoAvnick 1 has reported two interesting cases of the kind. There was suddenly developed during the puerperium sharp abdominal pain with nausea and vomiting. Careful examination excluded puerperal infection, and detected the protrusion of coils of intestine between the recti muscles. The hernia was easily reduced, and a recurrence was prevented by a compress and adhesive strips. In both instances the symptoms yielded at once to this treatment. The accident is not likely to be a common one among English-speaking people and in countries where the use of the abdominal binder after labor is a universal custom. Permanent diastasis of the muscles with pendulous belly and splanchnoptosis is treated by an ab- dominal binder, massage, electricity, and Swedish exercises. If such treatment fails, Webster's operation (p. 612) is indicated. Flatulent Distention of the Abdomen (Tympanites). — There occurs occasionally in the puerperal state an extreme distention of the abdomen, due to the overdistention of the intestines with gas. The cause of the flatulence is a partial or complete paralysis of the muscular coat of the intestines without peritoneal inflammation. A firm binder, turpentine by the mouth, and asafetida by the bowel suffice in cases of mod- erate degree. I have had a successful result in some very alarming cases by giving a grain of calomel every half hour until six grains were taken ; two hours after the last dose of calomel a quarter of a grain of elaterium, and two hours later an enema of an ounce of glycerin, a half ounce of turpentine, a half ounce of Epsom salts, and two ounces of water. Large doses of strychnin hypodermatically are necessary to the suc- cess of this treatment. In the worst cases the only remedy which affords relief is a puncture of the large intestine with a fine trocar. This procedure appears to be devoid of danger. It has long been applied in the treatment of animals, especially sheep, to relieve flatulent dyspepsia. It has also been adopted with good results in human beings. 2 In one recorded instance 1 " Die Diastase der Bauchmuskeln im Wocheribett," "Archiv f. Gyn.," xxvii, 419. 2 Priestley, " Note on Puncture of the Abdomen for Extreme Flatulent Disten- tion," "Lancet," London, 1887, i, 718. 684 PA TH0L OGY OF THE P UERPERIUM. the bowel was tapped twenty-eight times without bad result. I once saw complete paralysis of the intestinal coats after a twin labor. The abdominal distention was extreme, greater on the second day of the puerperium than it had been before delivery. The distended intestinal coils were plainly outlined through the abdominal walls. The woman's abdomen was opened, and the small intestines punctured with a knife in a number of places. The punctures were carefully closed after giving vent to all the gas and feces that would escape. The relief was only tempo- rary. The woman died on the following day. I have had under my care a case of giant colon in which pregnancy and labor gravely aggravated the condition. The abdominal distention became so extreme that it was necessary to make an artificial anus by inguinal colotomy on the left side to save the woman's life. Twenty-eight pounds of feces were washed out of the colon. The patient recovered. Acute congestion and edema of hemorrhoids in the puerperium causes great distress. Immediate relief is afforded by forcible dilatation of the sphincter under anesthesia. There are many other acute and chronic affections besides those already described which may complicate the puerperal state. They are, however, purely accidental complications, which neither produce a distinctive change in the course of the puerperium nor are themselves modified by the woman's condition. As ex- amples might be mentioned dysentery, intestinal parasites, 1 appen- dicitis, 2 miliary tuberculosis, 3 acute pancreatitis, 4 miliary fever, hepatic colic, 5 and gangrene of the ileum, 6 besides many more, the list of which includes almost all the pathological conditions to which the adult female is subject. Diseases of the Urinary System. — The Urine. — Gassner 7 was the first to point out that the excretion of urine after delivery is very much increased. Winckel comes to the fol- lowing conclusions in regard to the quantity of urine excreted and to the modifications in its constituent parts during the puer- perium : During the first two days the increase in quantity is most marked. The fluid is clear and of a light-yellow color. The specific gravity is very low. The absolute quantity of urea, 1 "Indian Medical Gazette," xxii, 2jo. 2 Dearborn, " Vermiform Appendicitis and General Peritonitis Complicating the Puerperal Period." 3 "Centralbl. f. Gyn.," 18S5, ix, 417. 4 Ibid., 1884, viii, 609. 5 "Ann. Soc. d'Hydrol. med. de Paris," 1887, 169. 6 " Frauen-Arzt," Berlin, 1886, i, 30S. 7 Winckel, "Pathol, u. Therap. des Wochenbettes," p. 11. DISEASES OF THE URINARY SYSTEM. 685 Fig- 53 !• — Edematous hemorrhoids in the puerperium. Fig. 532. — Transverse colon in case of giant colon. 686 PATHOLOGY OF THE PUERPERIUM. phosphates, and sulphates is somewhat diminished, but the amount of sodium chlorid is not altered. The urine during the progress of uterine involution gradually regains its normal quality. The average amount of urine passed in the first six days is 11,160 grams. The average specific gravity is ioio. The quantity passed upon each day averages as follows : The first day, 2025 c.c. (74.4 fl. oz.) ; the second day, 2271 c.c. (76.5 fl. oz.) ; the third day, 1735 c.c. (58.6 fl. oz.) ; the fourth day, 1772 c.c. (59.8 fl. oz.) ; the fifth day, 1832 c.c. (61.9 fl. oz.) ; and the sixth day, 1949 c.c. (65.8 fl. oz.). It is not at all rare to find albumin in the urine l shortly after delivery, but as it is only a temporary phenomenon, disappearing within forty-eight hours, as a rule (Blot, Ingersley, Lantos), and seems to exercise no injurious influence upon the woman's condition, it may be regarded as practically a physiological occurrence. Maguire 2 compares the albuminuria of the puerperal state with the cyclical albuminuria met with under other circumstances, and says that very likely in both these conditions the precipitate with nitric acid and heat is globulin, and not serum albumin. The appearance of sugar in the urine after delivery is also a very common occurrence, which has been attributed to the ab- sorption of lactose from the mammary gland ; indeed, one ob- server declares that the quantity and quality of the milk may be judged by the amount of sugar in the urine. 3 But, as a matter of fact, glycosuria is more common when the milk-secretion fails than when the supply is most abundant. 4 Curiously enough, the amount of urea in the urine does seem to depend on the ex- cretion of milk ; the former increases with the increase of the latter. 5 This statement would also seem to hold good of the phosphates and the sulphates, which increase with the urea and with the excretion of milk. 6 The appearance of peptones in the urine of recently delivered women is quite constant. The following statements in regard to it appear to be justified : 7 1 Examining the urine of 600 puerpera directly after delivery, Lantos found albuminuria in 59-33 per cent. This is a more common occurrence by one-third in primiparae than in multipara; (" Beitrage zur Lehre von der Eklampsie und Albu- minurie," "Archiv f. Gyn.," Bd. xxxii, p. 365). 2 " Pathology of Puerperal Albuminuria," London "Lancet," Sept. 18, 1886. 3 Blot, " Comptes Rendus," xliii, p. 676. * Hofmeister, " Zeitschr. f. phys. Chemie," Bd. i, S. 703; Johannovsky, "Archiv f. Gyn.," Bd. xii, S. 448. A full bibliography on this subject may be found in Schroeder's " Geburtshiilfe," 10. Aufl. , p. 236. 5 Grammatikati, " Ueber die Schwankungen der Stickstoffbestandtheile des Hams in den ersten Tagen des Wochenbettes," " Centralblatt f. Gyn.," 1884, p. 353. 6 Grammatikati, op. cit., p 467. 7 Fischel, "Ueber puerperale Peptonurie," "Archiv f. Gyn.," 1884, xxiv, DISEASES OF THE URINARY SYSTEM. 68 7 1. Peptonuria is constant in the puerperal state. The quan- tity of peptones, however, in individual cases varies consider- ably. 2. The urine contains usually no peptone on the first day, but thereafter until the fourth day the quantity increases steadily, then begins to decrease, and disappears on the twelfth day. 3. The peptonuria is probably the result of the direct con- version of the uterine muscle into peptone. 4. After the delivery of macerated infants, one finds no pep- tone, or only a very small quantity. 5. Occasionally, peptone is found during the latter days of pregnancy. In these cases peptonuria can be demonstrated directly after birth and in the first day of the puerperium, but in lesser quantities than in other puerperse. 6. The difficulty of a labor and its length exercise no in- fluence upon the peptonuria. 7. The peptonuria stands in direct relation to the involution of the puerperal uterus. 8. The specific gravity of the urine is in direct relation with the quantity of peptone in it. 9. The peptones formed in the uterus behave in the blood like the digestion peptones, or like the peptones that are arti- ficially introduced into the circulation. 10. The quantity of the peptones in the urine is in direct ratio to the number of white blood-corpuscles in the blood of the individual puerpera. The lochia may also contain peptones, but independently of the peptonuria, and without influencing the quantity of peptones in the urine. A careful examination of the uterus and its lining membrane after delivery demonstrated that in the uterine muscle considerable quantities of peptones could be discovered, while in the lining membrane this substance could not be found. 1 Fischel declared that he found peptones in one-quarter of all the cases of pregnancy examined. If the urine after labor contains albumin in considerable quantities and persistently, it is evidence of trouble in the kidneys. There are usually associated with per- sistent albuminuria other symptoms indicating kidney disease. One of these is acute pain, most often in the head, but sometimes referred to the epigastrium or to other regions of the body. 2 p. 400, and " Neue Untersuchungen iiber den Peptongehalt der Lochien nebst Be- merkungen iiber die Ursachen der puerperalen Peptonurie," ibid., 1S85, xxvi, 120 ; Biagio, " La Peptonuria puerperale," "Ann. di Ostet.," 1S87, ix, 202. 1 Fischel, loc. cit. 2 Raven, " Note on Puerperal Albuminuria," " Lancet," London, 1888, ii, 715 ; Phillips, "Acute Epigastric Pain in the Puerperal Albuminuria," ibid., 18S7, i, 676. 688 PATHOLOGY OF THE PUERPERIUM. There may be edema. There is found in the urine microscopical evidence of degenerative changes in the renal epithelium. Albu- minuric retinitis is not a very uncommon accompaniment of kidney disease in the puerperium, and may induce complete blindness, but it should be remembered that there may rarely occur a temporary blindness in the puerperal state independent altogether of kidney disease. 1 It usually comes on shortly after delivery, and lasts for a few days. Typical examples have been reported by Brush and by Konigstein. The latter attributes the accident to a spasmodic contraction of the retinal vessels trace- able to a vasomotor disturbance. The loss of vision may follow severe hemorrhage or eclampsia, may be associated with albu- minuria, or may be the result of a septic panophthalmitis. Konigstein suggests, as a treatment for the temporary blindness due to a spasmodic action of the retinal vessels, the inhalation of amyl nitrite. The woman's nervous system exercises a pow- erful influence on the composition of the urine. Cameron 2 has reported an extraordinary case of high temperature and glyco- suria in the puerperal state, the result of nervous influences. The temperature rose during waking hours and fell during sleep, without corresponding variation in pulse. The glycosuria seemed to have direct connection with the nervous phenomena, and lasted only a short time. Hematuria, when seen in the puerperal state, has almost in- variably persisted from pregnancy. In these cases there are usu- ally bleeding hemorrhoids of the bladder, due to the mechanical interference with the pelvic circulation by the presence of the gravid womb. The blood disappears from the urine in a few days after delivery. In bad cases of septic infection of the vesical mucous membrane, as a result of injury with instruments, or as a consequence of vesicovaginal fistulse, the same symptom may appear, but the differential diagnosis is easy. Renal and vesical calculi, malignant tumors of the kidney and bladder and papillo- mata of the latter are possible causes. The Kidneys. — Hervieux divides the diseases of the kidneys in the puerperal state under four heads : First, inflammatory nephritis ; second, metastatic nephritis ; third, evanescent albu- minuric nephritis ; and fourth, subacute albuminuric nephritis. In the first stage of inflammatory nephritis one finds hyperemia and tumefaction of the organ. Often this condition is associ- ated with general septicemia. If the disease develops primarily in the puerperal state, it is probably a manifestation or an 1 Brush, "A Case of Temporary Blindness following Child-birth," " Obstet. Gazette," vii, 1884; Konigstein, " Erblindung nach einer Geburt in Folge von Isch- semia Retinae," " Wiener med. Presse." 1885, xxvi, 585. 2 " High Temperature and Glycosuria in the Puerperal State, the Result of Nervous Influences," "Montreal Med. Jour.," Jan., 1889. DISEASES OF THE URINARY SYSTEM. 689 accompaniment of general septic infection, and is often unde- tected in the midst of other complications presenting more obvi- ous and more alarming symptoms. An intense hyperemia of the kidney associated with septic infection may result in an apoplexy. Metastatic nephritis is, of course, the result of septic infection. In the evanescent albuminuric nephritis the kidney is increased in size. Its surface is smooth ; the fibrous tunic, thickened and injected, is easily stripped off. This increase in size is due principally to the tumefaction of the cortex. In the fourth variety of kidney diseases in the puerperal state the course is more tedious, and it may pass into chronic nephritis. Maguire asserts that the lesion most commonly found in cases of puerperal albuminuria is one of anemia of the kidney with fatty degeneration. Lantos, 1 in the records of 39 postmortem exami- nations of puerperse who had not died from eclampsia or neph- ritis, found in 15 cases the kidney described as "anemic," in 21 "pale," and only in 3 "congested." Among 16 women who had presented symptoms of kidney disease there were found twice acute parenchymatous nephritis, once acute hemorrhagic nephritis, nine times parenchymatous degeneration, and four times albuminoid degeneration. In rare instances, complete suppression of urine after labor is observed, usually with a fatal result. It is explained by an acute exacerbation of an old nephritis. 2 Dislocation of the kidney may occur in the puerperium or during labor. It may be twisted on its pedicle and an acute hydronephrosis may result. The kidney is very much enlarged, there is intense pain and perhaps high fever. Rest in bed and the application of the ice coil give relief. When the obstruction is relieved there is a copious discharge of urine. Incontinence of Urine. — There may be an involuntary escape of urine after labor in consequence of an overfilled bladder, of paresis in the sphincter muscle, and of a perforation communi- cating with the vagina or some portion of the genital tract. The first cause, the overflow of retention, should always be sus- pected and looked for, as it is the most common. The treat- ment varies with the cause of incontinence. The use of a catheter removes the difficulty in cases of the first category. Cases of the second group are more difficult to deal with. The par- tially paralyzed muscle, as a rule, regains its tone in a short time. It may be possible to hasten recovery in a chronic case by the administration of tonics, the use of local astringents, or, perhaps, by the application of electricity. 3 The preventive treatment 1 Loc. cit. 2 Botall, " Jour, of Obst. and Gyn. of the British Empire," 1902, p. 5 1 2. 3 The author has restored continence by Faradism with a bipolar urethral electrode. 44 69O PATHOLOGY OF THE PUERPERIL'M. should never be neglected. These cases almost invariably follow delayed and difficult labors with head presentations. A timely interference, therefore, would save the woman the dis- comfort, and even danger, of a constant dribbling oi urine over the external genitals. 1 The repair of the urogenital trigonum muscle, which acts as a compressor urethrae, often restores conti- nence. It is necessary in some cases after all other treatment has failed to incise the neck of the bladder, shorten the sphincter, join its ends with sutures, and to perform an operation for cysto- cele on the anterior vaginal wall. The author has cured in- tractable cases of long standing in this manner. Cases of the third order should be managed by attempting to obtain a primary closure of the fistulous opening. This can be effected in some cases, if the fistula is not too large, by touch- ing" its edges with a strong caustic — nitric acid. It this treat- ment fails, a secondary operation for vesico-vaginal fistula is in- dicated. Cystitis. — Cystitis is, unfortunately, a common occurrence in the puerperal state. It is due, in the vast majority of cases, to a careless, clumsy, or ignorant use of the catheter. The old plan of introducing a catheter under the bed-sheet is responsible for a large number of these cases. If physicians and nurses would catheterize a patient with an aseptic instrument and aseptic hands, after careful cleansing of the vestibule and by the sense of sight, there would be very little risk indeed of infecting the bladder mucous membrane by a catheter. A transitory inflamma- tion of the bladder may be due to long-continued pressure or to injury during labor, but such cases are rare. The cystitis is almost always septic following infection of the bladder mucous membrane. 2 It is possible that micro-organisms may migrate from the vagina along the mucous membrane of the urethra to the bladder without the intervention of catheterization. In order that the micro-organisms, having gained access to the bladder, may bring about an inflammation of the vesical mucous membrane, it is necessary to have a condition of that tissue favorable to the invasion and to the growth of the bacteria. The invasion is much facilitated by a solution of continuity* in the mucous membrane. It is also favored by a reduction in the vitality of the vesical epithelium, which follows prolonged pressure upon the bladder during labor, or is a consequence of the overdistention of the bladder-walls from prolonged reten- tion of urine. There is a disposition of the inflammation in 1 Bechadergue-Lagreze, " Incontinence d'Urine sans Fistule consecutive a P Accouchement,'' " These de Paris," 18S6. 2 " Die Aetiologie des puerperalen Blasenkatarrhs nacli Beobachtung an Woch- nerinnen und Thierversuchen," " Centralblatt f. Gyn.," 1886,443. DISEASES OF THE URINARY SYSTEM. 69 I many cases to spread rapidly toward the kidneys, so that after the bladder affection is cured the kidney disease remains. There may be an intermission of apparent health between the infection of the bladder and that of the pelvis of the kidney while the inflammation is traveling up the ureters. The termination of cystitis after delivery is favorable in the vast majority of cases. The inflammation may, however, persist for a long time, and may become an inveterate chronic affection. In the worst cases of septic cystitis the disease manifests alarming symptoms and may end fatally. 1 There may be a thick, diphtheric infiltration of the mucous membrane, which is finally exfoliated and discharged through the urethra in thick masses. In other cases the mucous mem- brane becomes gangrenous, and is finally expelled in fragments of varying- size with the urine. Pieces of the infiltrated mucous membrane lying loose within the bladder may obstruct the out- flow of urine. In these extreme cases the urine contains mucus, pus, blood, albumin, and renal tube-casts, and has a horribly fetid odor. Treatment. — Every case of cystitis after labor should be treated energetically and without delay, for fear of a spread of the infection to the kidneys. A daily irrigation of the bladder by a quart or more of boric acid solution (gr. xv-5j), a milk diet, and boric acid by the mouth are usually sufficient, if ordered immediately, to stamp out the disease in its incipiency. Salol (gr. v) and urotropin (gr. viij) may be used internally instead of or with the boric acid. The injection of and retention in the bladder till the next urination of 4 to 6 ounces of a 2 to 5 per cent, solution of protargol or of argyrol, is recommended if the internal medication and the irrigation of the bladder are not entirely successful. Vaginal cystotomy may be required in severe cases for drainage. Pyelonephritis. — An inflammation of the pelvis of the kidney may follow infection of the bladder by an extension of the disease along the ureters. This is true of the vast majority of cases, but in some instances the bladder disease may be of such a transient nature that it passes undetected, and the physician's attention is first attracted by the subsequent pyelonephritis. It is possible that the infection in a case of pyelonephritis may occur in the kidneys from the blood. Pressure on the ureters and nephroptosis predispose the kidneys to infection. The disease may also follow mechanical irritation from renal calculi. I have seen one case of pyelonephritis during the puerperal state which was associated with renal calculi. There was a sudden exacerba 1 Boldt, "Cystitis Suppurativa Exfoliata Puerperali.s," " N. Y. Med. Record," 1885, ii, 4-97- 692 PATHOLOGY OF THE PUERPERIUM. tion of the disease some few days after labor, associated with a high fever and a suppression of urine. The attack passed off in the course of forty-eight hours, however, and the woman finally recovered. Gonorrheal subjects are prone to pyelitis or it may be due to cold. In a majority of my cases in which urine was obtained directly from the kidneys by catheterizing the ureters, a colon bacillus infection was found. The treatment of septic pyelo- nephritis consists of stimulation, support, the administration of bland diuretics, and irrigation of the bladder. Occasionally, it is necessary to incise the pelvis of the kidney by the lumbar route and to drain it for a while. The ureter is washed out from above downward, and finally the urine is allowed to take its natural course. I have seen this plan of treatment carried out twice with success. In two other cases the infection spread from the kidney to the perirenal fat, producing perirenal abscesses, that were opened by lumbar incisions, The outcome of a pyelo- nephritis in the puerperium is dubious. The gonococcus and colon bacillus infections usually terminate favorably. If there has been an ascending infection from a streptococcic cystitis, the mortality is high. The kidney after death is either a large bag of pus or is riddled with innumerable minute abscesses. Diseases of the Nervous System. — For the psychoses and the neuroses, see page 247. Lesions of sacral plexuses, neuritis, and nerve degeneration from pressure during labor are usually seen in a justominor pelvis or in one with a slight projection of the promontory, which affords insufficient protection to the nerve -trunks on either side of it. Puerperal paralysis may result. Both limbs may suffer (paraplegia), or there may be unilateral paralysis, with atrophy and anesthesia. The leg or legs may be the seat of constant pain, and may be very hyperesthetic. Pressure upon the sciatic nerve or movement of the affected limb may cause agonizing pain, or there may be intense and persistent pain in the pelvis, unassociated with disease of the sexual organs. Press- ure with the finger in the rectum upon the sacral plexus causes exquisite suffering. Neuritis of the pelvic nerve-trunks may be the result of pressure from exudates or of their involvement in septic inflammations. Fixation and extension of the limb give the greatest relief at first. Immobilization of the whole body in the orthopedic surgeon's wire cuirass is the most efficient means of securing perfect quiet and comfort. When the acute stage has subsided, massage, electricity, and passive movements hasten the restoration of the limb. The prognosis is fairly good. There may be, after child-birth, neuritis of nerves distant from the genital region (the ulnar, for instance). Multiple neuritis in al- coholic subjects may develop after child-birth or during preg- ANOMALIES OF THE BREAST. 693 nancy. Laury 1 makes three divisions of puerperal neuritis — traumatic, septic inflammatory by extension, and infectious neu- ritis of distant nerves and of the spinal cord. Apoplexies of the Brain and Spinal Cord; Aphasia; Hemiplegia; Paraplegia. — There is a predisposition to apoplexies in the central nervous system during labor, especially in women whose vessels are diseased in consequence of insufficient kidney-excretion. Ascending Myelitis — I have seen an ascending myelitis first manifesting itself some two weeks after labor, the temperature having been previously normal, but becoming elevated as paralysis of the lower limbs appeared. The paralysis was pro- gressive, and the result fatal. At the postmortem examination no starting-point in a septic focus or apoplexy could be discovered. There were simply the signs of inflammation and degeneration. It is an interesting inquiry whether this condition could have come from pressure upon the lumbosacral plexus and an ascending nerve-degeneration. Developmental Anomalies of the Breast. — Absence of Mammas. — Complete absence of both breasts is one of the rarest anomalies of development. Marandel, Lousier, and Froriep 2 each report a case of entire absence of one breast, the other being well developed. Im- perfect development of the mammary glands is common. It is sometimes seen to an extreme degree in cases of infantile or absent sexual organs. Hypertrophy of the mamma? is also rare. Labarraque 3 collect- ed twenty-six cases, of which only five were over twenty-six years of age. The breasts are usually asymmetrical. There is one case on record in which a single mammary gland weighed sixty-four pounds. Lactation has been known to diminish a congenital hypertrophy of the breasts. An overgrown mammary gland, therefore, is not a contraindication to suckling the child. Supernumerary Breasts — Polymastia.— Supernumerary breasts 1 "Archives deTocol.," Nov. I, 1893. 2 "Amer. Sys. of Gyn.," vol. ii, 338. 3 " These de Paris," 1S75. " Bilateral Diffuse Virginal Hypertrophy of the Breasts." G. B. Johnston, "Tr. S. Surg, and Gyn. Soc," 1903. Fig. 533. — Asymmetrical hypertrophy of breasts in a woman recently delivered. University Maternity. 694 PATHOLOGY OF THE PUERPERIUM. and nipples are more common than is generally supposed. 1 Bruce found sixty instances in 3956 persons examined (1.56 per cent.). Leichtenstern places the frequency at 1 in 500. Both observers declare that men present the anomaly about twice as frequently as women. In 400 women examined in one winter in my hos- pital services there was 1 case of polymastia. It is impossible to account for the accessory glands on the theory of rever- sion, as they occur with no regularity in situation, but may develop at odd places on the body. The most frequent position is on the pectoral surface below the true mamma and somewhat nearer the middle line ; but an accessory gland has been observed on the left shoulder over the prominence of the deltoid ; on the abdominal surface below the costal cartilages ; above the umbili- cus ; in the axilla ; in the groin ; on the dorsal surface ; on the labium majus ; on the buttock, and on the outer aspect of the left thigh. In cases reported by Edwards 2 and Handyside, and in some others, including one of the author's, heredity seems to have been a probable explanation for the development of the supernumerary mammas ; but in the vast majority of cases no hereditary influence can be traced. Ahlfeld 3 explains the presence of mammae on odd parts of the body by the theory that portions of the embryonal material Fig. 534. — Polymastia : nine breasts and nipples. (Seen in consultation with Dr. D. E. Kercher. ) entering into the composition of the mammary gland are carried to and implanted upon any portion of the exterior of the body by means of the amnion. The woman represented in figure 534 is remarkable for the ^'Supernumerary Breasts and Nipples." E. B. Young, "Boston Med. and Surg. Journal," March 24, 1904. 2 " Medical News," March 6, 1886 (good bibliography). See also Goldberger (" Archiv f. Gyn.," xlix, H. 2, S. 272), who states that there are 262 cases recorded in literature. 3 " Missbildungen der Menschen." AXOMALIES OF THE BREAST. 695 almost unprecedented number of breasts and nipples that she possesses. 1 She has nine mammae all told, and as many nipples, every one of which secreted milk profusely. The two normal glands are very large. The nipple of the gland in the left axilla is not shown plainly in the illustration on account of its situation, and it is not easy to see it in the woman herself, con- cealed as it is by the axillary hair, but when the corresponding gland in the axilla was compressed, a stream of milk was pro- jected several feet from the woman's body. As may be seen, the glands are arranged with some symme- try. There are five on the left and four on the right side. The woman is a negress, nineteen years old, and a IV-para. Her child was born prematurely. Her mother had an accessory Fig. 535. — Supernumerary nipple and small mammary gland upon left buttock. It was always possible during pregnancy to scjueeze out a drop of milk (author's case). mamma on the abdomen that secreted milk during periods of lactation. Anatomical Anomalies of the Nipple. — The shape of the nipple may unfit it for nursing, predisposing to injury by the child's gums, to fissure and ulcerations (sec Fig. 536), or making it a mechanical impossibility for the child to take hold, as in inverted nipples (Fig. 536). The nipples should always be examined during preg- nancy. If they are inverted, a systematic attempt should be made during the last month to draw them out with a breast- 1 Neugebauer has reported a case of polymastia with ten nipples, blatt f. Gyn.," 1886, No. 45. ; Central- 6 9 6 PATHOLOGY OF THE PUERPERIUM. pump. Should this attempt fail, a nipple-shield might enable the child to nurse. Abnormalities of the Breasts and Anomalies in the Milk Secretion. — Milk secretion begins usually forty-eight hours after delivery. Previous to this time a thin fluid may be squeezed from the breast, containing large cells, within which are many fat-globules. To this substance the name "colostrum" has been given, and the cells are called colostrum corpuscles. It is always difficult to estimate the exact quantity of milk secreted. The best way is to draw the milk with a breast-pump at regular intervals during the twenty -four hours ; but the breast-pump does not excite maternal emotion, and, therefore, it always draws a less quantity than would be furnished a suckling infant, for the breast /oamaL^v. > — /Mushroom. Fig. 536. — Faulty development of the nipple (Dickinson). is in some degree an erectile organ, and even the sight of the child may be sufficient to produce a flow of milk. Allowing for these errors, there is found, at the end of the seventh day, about fourteen ounces in the twenty-four hours. During the five preceding days the quantity is small and variable. By the end of the fourth week the quantity of milk secreted in the twenty- four hours reaches about two pints. From this time it increases gradually until the sixth or seventh month, when about three pints of milk can be drawn from the breast in twenty -four hours. After the eighth month the quantity of milk gradually decreases. A curious anomaly of milk secretion is its occurrence independent A NO MA LIES IN MIL K SE CRE TION. 697 of the puerperal state, as in very old women or very young girls, after operations upon the ovaries, 1 at the menstrual period, 2 or even in the adult male. 3 The most important abnormalities of milk secretion may be grouped under two main headings — quantitative and qualitative. Deficient secretion in its extreme degree is known as "agalac- tia," complete absence of milk, which is exceedingly rare. Win- ckel, in an enormous experience, asserts that he has never seen an example — that there is always some little milk secretion, which may, however, escape notice without close observation. There are a few recorded cases of complete absence of the breasts. Agalac- tia would be a necessary consequence. Deficient milk secretion is by no means uncommon. There are many causes preventing nor- mal activity in the mammary gland. Premature maternity may account for it. Advanced age is another cause assigned for defi- cient lactation. There is either atrophy of the gland or exhaustion by previous activity. The nearest approach to complete agalactia w r hich I ever witnessed was in a woman who had her first living child at the age of forty-three. She had been married at forty, and had had previously two children still-born. There was so little milk secretion that it was scarcely noticeable. Perhaps the most frequent cause of insufficient milk secretion is lack of development in the glandular tissue, which may be hereditary, may depend upon the continuous pressure from the clothing, or may be associated with a defective development of the remainder of the body, especially of the genital organs. Altmann 4 has called attention to the hereditary form of atrophy in the mammary gland. In parts of Bavaria, where it has been the custom for centuries to nourish the children artificially, the mammary glands no longer secrete milk. In Munich, of the women who did not nurse their infants, fifty-eight per cent, were said to be physically unable to do so. Of the women who nursed their children, seventy per cent, had to resort to mixed feeding. In other parts of Germany, on the contrary, notably in Silesia, where the custom of suckling children has been care- fully observed for many generations, it is rare to find mothers with an insufficient supply of milk. The ability of the breast to furnish milk does not necessarily depend upon its size, for a large mammary gland may consist 1 Penrose, "M. and S. Rep.," 1889, 326. 2 Sinety, " Traite de Gynec," p. 955. 3 "John Hunter's Notes," quoted by Barnes; Humboldt, " Reise in die y£qui- noctiale Gegenden des neuen Continents," Bd. ii, S. 40. 4, 'Ueber die Inactivitatsatrophie der weiblichen Brustdriisen," Virchow's "Archiv," Bd. cxi, p. 318. 698 PATHOLOGY OF THE PUERPERIUM. chiefly of connective tissue, while in another apparently ill-devel- oped the gland-tissue is abundant and the milk-supply ample. During pregnancy the glandular structure of the breasts takes Fig. 537. — Mammary gland of a nullipara (from Silesia). X 3 2 °- on an active growth and development, while the connective tissue decreases to a marked degree. If lactation is not practised, there begins at once an involution of the gland, a shrinkage of the epithelial structures, and a regrowth of connective tissue. If 3§§L Fig. 538. — Mammary gland of a nullipara (from Silesia). X S 2 - involution is allowed to occur after the birth of the first child, it is more difficult after subsequent deliveries to awaken the breast to functional activity. ANOMALIES IN MILK SECRETION. 699 The mammary secretion, at first sufficient, may at times be much diminished as the result of hemorrhages or of diarrhea, in consequence of an acute febrile attack during lactation, or of inflammation within the gland itself. Serious organic diseases may also be a cause, and insufficient nourishment must be held accountable in some cases. During the siege of Paris an obser- vation of forty-three nursing women by Decaisne 1 proved that with imperfect nutrition the total quantity of the milk is much decreased. Almost one-third of these women lost their chil- dren by starvation. Emotions exert an extraordinary influence upon lactation. Those which are of gradual development and long continuance, as profound grief, tend to progressively dimin- ish the amount of milk. Emotions of sudden onset and short duration, as fright or anger, either totally stop the formation of Fig- 539 — Mammary gland of a nullipara (from Bavaria). X 5 2 - Fig. 540. — Mammary gland of a nullipara (from Bavaria). X 3 2 °- milk, or else so alter its constitution that it becomes a rank poison to the child. The return of menstruation sometimes af- fects the quantity and quality of a woman's milk, but not nearly so often as is popularly supposed. Zweifel states positively that for the most part the return of the menses is without influence upon lactation. This statement is in accord with the experi- ence of Winckel, Joux, Tilt, Becquerel, Vernois, and my own. There are a few other rarer causes to which deficient mammary secretion has been ascribed. It has been said that the exit of the milk-ducts may be obstructed by an accumulation of epi- thelium recognized by a minute white, projecting, translucent vesicle upon the nipple at the opening of the obstructed duct. 1 " Des Modifications que subit le lait de femme pour suite d'une alimentation insuffisante ; observations recueillies pendant la siege de Paris," " Comptes Rend.," lxxiii, No. 2. 700 PATHOLOGY OF THE PUERPERIUM. Nasal, pharyngeal, or bronchial catarrhs are supposed to dimin- ish the quantity of milk. The mammary gland is described in some cases as torpid. A failure to furnish enough milk is as- cribed occasionally to the fact that the individual approaches the male type. The milk-supply is rarely abundant after premature delivery or the delivery of dead infants. It is an undoubted fact that extreme obesity interferes seriously, if it does not almost entirely prevent, a functional activity of the mammary gland. Treatment. — It is obvious that no single plan of treatment will increase a deficient milk-supply. It is also apparent that in the vast majority of cases the cause of the difficulty is beyond the influence of any treatment. One can not alter the age of the patient nor replace deficient glandular tissue. There are some cases, however, of insufficient secretion that respond promptly to appropriate treatment. A scanty supply of milk dependent upon an insufficient diet is easily corrected. It should never be forgotten that when lactation is interrupted by an acute febrile attack nursing may be successfully resumed after convalescence is established, even though weeks and occasionally months have intervened. I have seen lactation begun and continued success- fully a month after a difficult Cesarean section attended with pro- fuse hemorrhage. In cases of general ill health or constitutional weakness, much may be effected by the administration of tonics and nutritious diet and change of air and scene. If the deficient secretion is dependent upon some emotion, the cause, if possible, should be removed. Electricity has been much vaunted as a remedy for insufficient lactation. It may be applicable in cases of torpidity of the mammary gland or in those cases in which lactation was not practised after the birth of the first infant, and in which, therefore, the mammary gland does not respond readily to the stimulus of subsequent births. This remedy, however, often proves ineffective and disappointing. There is no medicinal galactagogue of any value. If three meals a day of food suitable to the patient's condition, reinforced by four glasses of milk between meals and fluid extract of malt at meals, will not produce a sufficient flow of milk, the child must usually be artificially fed. Quantitative anomalies by excess in the milk secretion may take three forms. In women of a vigorous physique, well nourished, and of a full habit, the supply of milk is likely to be in excess of the infant's needs — polygalactia. Lactation may be continued far beyond the usual time — hyperlactation. In the third variety the milk continues to flow from the breasts in varying quantities and for varying lengths of time after the child has been weaned or when it has not been suckled — galactorrhea. ANOMALIES IN MILK SECRETION. 701 Polygalactia is exceedingly common. The treatment has been referred to on page 362. Its main features are compression and support of the breast by a mammary binder, the administration of laxatives, the regulation of the diet, and the evacuation of the breasts. Hyperlactation is more frequently met with among the poorer classes. Infants are nursed far longer than they should be, either from the fact that it is difficult to provide food for another mouth or because of the prevalent belief that lactation grants immunity from impregnation. Women have been known to nurse their children up to the second or third year. Some women and certain races do it with impunity. Spanish wet- nurses suckle three or four successive children in one family. Japanese women habitually nurse their children for five or six years. Hyperlactation, however, usually leads to serious results. The patient becomes exceedingly weak, pale and thin, and pre- sents all the symptoms of a grave constitutional disease. The quantity of blood is diminished — oligemia. There are loss of appetite, constant headache, pain in the back, languor, and the whole nervous system is more or less seriously deranged. Cramps in the muscles of the neck and upper extremities occur frequently; they appear often during the day and last for vary- ing periods. Suckling the child often originates an attack. There is especial danger of phthisis in women of tuberculous tendency. The treatment of hyperlactation is simple and effective. The child must at once be weaned, and the mother's strength restored by a nutritious diet, tonics, and, if possible, change of air. Galactorrhea means a flow of milk from the breasts not neces- sarily excited by the suckling child, and commonly continued long after the usual term of lactation. The quantity of milk ex- creted may van' from a few grams to seven liters in twenty-four hours. 1 Usually, both breasts are involved; sometimes only one. The cause is unknown. It has been attributed to a relax- ation or paralysis of the circular muscular fibers surrounding the milk-ducts, but this is an effect and not a cause. There is a case recorded of galactorrhea in the left breast, associated with left hemiplegia occurring after child-birth. 2 The duration is long, extending often over years. There is a case reported in which, for thirty years, there was an uninterrupted flow of milk from the breasts of a woman who, at the time of the report, had reached her forty-seventh year. Curiously enough, her health had not suffered. Another anomalous feature in the case was that the 1 Winckel, "Path. u. Therap. des Wochenbettes," p. 440. 2 "Trans. London Obstet. Soc. for 1887,'* xxix. j o 2 PA THOL OGY OF THE PUERPERIUM. return of the catamenia increased the flow of milk. 1 I have seen a woman who had had galactorrhea for eleven years after a miscarriage at the fifth month. Her health remained perfect. The usual effect of a long-continued flow of milk is unfavorable, like any other long-continued discharge. The general debility from this cause is known as "tabes lactea." The same condition may be seen in extreme cases of polygalactia and in hyperlacta- tion. Treatment. — The most prominent feature in these cases is the stubborn resistance that they offer, as a rule, to treatment. There are two measures, however, which can usually be depended upon to give relief — firm compression of the mammary gland and the administration internally of iodid of potassium. It should be remembered, moreover, that in many cases the milk secretion stops spontaneously with the return of menstruation, 2 and that in a certain proportion of cases a treatment adapted to securing a discharge of blood from the uterus has been successful in cur- ing galactorrhea. Routh 3 advocates Simpson's plan of intro- ducing a piece of caustic within the uterus for securing this result. Abegg was successful in two instances in stopping the galactor- rhea by the use of warm douches, which brought about a return of the menses. The intrauterine application of the negative pole of a galvanic current, 15 to 40 milliamperes, is the best treat- ment to bring back the menstrual flow. Electricity has been recommended to secure the proper contraction of the sphincter muscles of the lactiferous ducts. The long-continued adminis- tration of ergot has been successful, and its use is rational. The experiments of Roehrig 4 have demonstrated that drugs causing an increased arterial pressure in the breasts promote milk secre- tion, while those lowering arterial tension tend to diminish or even abolish the function. Chloral was shoAvn to be peculiarly powerful in diminishing the quantity of milk; therefore, this drug is also worthy of a trial. Belladonna internally, or as a local external application, is usually employed as a routine practice, but is of doubtful utility. It has been claimed that antipyrin, in 2^-grain doses, three times a day, diminishes milk secretion. 5 Qualitative Anomalies in the Milk. — The most important factor influencing the constitution of the milk is the diet. A fatty diet diminishes the quantity of milk. A vegetable diet diminishes 1 Green, quoted by Gibbons, "A Case of Galactorrhea (unilateral)," ibid. 2 Gibbons' case; Abegg's cases; in two cases, under the care of Depaul, the galactorrhea was arrested by the recurrence of pregnancy. 3 Discussion on Gibbons' paper, loc. fit. 4 Quoted by Gibbons b '-Bull. gen. de Therap ," ,une. 18SS. ANOMALIES IN MILK SECRETION i"S the casein and fat, and increases the sugar. A diet rich in meat increases the fat and casein, but diminishes the sugar. A scanty- diet diminishes all the solid constituents of the milk except the albumin. The commonest anomaly in the constitution of the milk, in my experience, is a deficiency of fat and an excess of casein. In one of my patients, in each of three confinements there has been a milk of only 0.8 per cent, fat and 3 per cent, albu- minoids. Usually this disordered condition of the milk can not be remedied. In a few instances, however, qualitative anomalies may be corrected by dietetic management. The effect of emotions upon the constitution of the milk has already been referred to. Baranger 1 quotes a good example: A nursing woman saw her husband threatened by a soldier armed with a saber. Directly afterward she gave suck to her child. It seized the nipple at first with avidity, then refused it, became violently convulsed, and died. Every practising physician has seen, at least to some degree, examples of the change produced in the milk by mental impressions. Becquerel and Vernois found that under the influence of emotion the milk of a woman contained more water, very much less fat, and somewhat more casein than was found in the mammary gland of the same individual under ordinary circumstances. Almost all acute febrile affections not only diminish the mammary secretion, but produce some change in its constitution and make it indigestible. This is most marked in the prodromal period. If a chill occurs, the lacteal secretion is suspended almost entirely for from twelve to twenty -four hours. The germs of some diseases pass from the mother's organism into her milk ; this is undoubtedly true of tuberculosis. It is probable that the germs of malaria find an exit from the body in this way. Septic micro-organisms may contaminate the milk from the breast, although the mammary gland itself is free from inflammation. Karlinski 2 has reported a fatal infection of the new-born from the milk of a puerpera with septic fever. Staphy- lococci were found in the milk. Women under the influence of mercurialism or saturnism excrete milk of abnormal quality, dependent, perhaps, as much upon the anemia associated with these conditions as upon the excretion of the drug itself. The influence of syphilis upon the constitution of the milk is not yet known. It has been asserted 1 " Les Contre-indications et Obstacles a l'Allaitement maternal," "These de Paris," 1884. 2 " Zur .Etiologie der Puerperal-Infektion der Neugebofenen," " Wien. med. Wochenschr.," 1888. 704 PATHOLOGY OF THE PUERPERIUM- that there is no change in the milk of syphilitic women. Vernois and Becquerel, on the other hand, affirm that there are well- marked alterations in the relative proportions of the different in- gredients in the milk from syphilitic women. Under ordinary circumstances colostrum-corpuscles may be detected in human milk for the first eight or ten days after de- livery. There are certain conditions in which a return of these corpuscles may be noted. They reappear sometimes upon the return of menstruation, during acute mastitis, or in any other acute affection during lactation. Of twenty-three examinations made by Truman x to investigate this point, colostrum-corpuscles were found present in the following cases : In a primipara for four weeks after the birth of a premature infant ; in a woman who was suckling her four-month-old baby ; in a non-pregnant woman whose infant, born twenty-six months before, had been weaned for ten months ; in a non-pregnant woman who had been married three and a half years ; ever since marriage, for a week before menstruation, the breast filled with milk, in which were colos- trum-corpuscles ; in a nursing woman who had never been able to use her right breast during lactation. Her last child was twelve months old. In the milk which could be squeezed out of the right breast colostrum-corpuscles were discovered. Another case was one of chronic ovaritis. Twenty-three months had elapsed since the last labor, and eleven since weaning. The milk which exuded from the breast contained colostrum-cor- puscles. In the breast of a woman fifty-six years old, which was removed for carcinoma, about a teaspoonful of milk was found, very rich in colostrum-corpuscles. This woman's young- est child was eight years old. In a case of galactorrhea which had persisted for four years these bodies were also discovered. The presence of colostrum-corpuscles in the milk is not a proof, therefore, of a recent delivery. Diseases of the Mammary Glands. — Areola. — The glands of Montgomery may be inflamed, and their infection may lead to mammary abscess. Treatment. — Infection of the areolae should be avoided by cleanliness. Each inflamed and suppurating gland should be opened, curetted, and its interior touched with strong bichlorid solution. Exaggerated pigmentation of the areolae often persists after pregnancy ; it fades away in the course of lactation or after the child has been weaned. } "British Med. Jour.," 1888, ii, p. 947. DISEASES OF THE MAMMARY GLANDS. 705 rs « c as «~™Sa o a i - E h~ 5 I 2£ JZ a- S J V - - u>^ Z = B « ^Z Fig. 541. — Massage of the breasts. 45 706 PATHOLOGY OF THE PUERPERIUM. • Congestion and engorgement of the mamma? occur in almost every case on the third day, when lactation is instituted. Treatment. — Excessive congestion may be avoided by admin- istering a saline purge on the evening of the second day. The breasts must be thoroughly evacuated at regular intervals by the child's mouth, reinforced, if necessary, by massage 1 and a breast- pump. Hot fomentations may give great comfort ; but if the congestion and pain persist, lead-water and alcohol is the best Fig. 54 2 . — Breasts disfigured by exaggerated pigmentation of the areolae. application. A mammary binder is almost always a necessary part of the treatment. The pressure and support which it affords contribute more than any other single item in the management of these cases to prevent excessive congestion and engorgement. From the investigations of Honigmann 2 and Ringel, 3 it appears that human milk contains normally the staphylococcus pyogenes albus, as well as the staphylococcus aureus. These micro-organisms wander in along the milk-ducts from the skin. They produce, usually, no ill results, unless the vitality of the epithelial cells is reduced by engorgement of the gland with milk 1 Bacon claims that mammary massage to empty the breasts is a mistake ; that it should be conducted like massage of a swollen joint to stimulate the blood and lymph circulation. My nurses, however, tell me that the method described and illustrated in the text proves more satisfactory than a breast pump. Massage of the breasts does improve the circulation, but it also empties the breast. See "American Tournal of Obstetrics," vol. xlv, No. 6, 1902. 2 F. Honigmann, " Bakteriologische Untersuchungen ueber Frauenmilch," In- aug.-Diss. , Breslau, 1S93. 3 Ringel, "Ueber den Keimgehalt der Frauenmilch," " Miinchen. med. YVoch- enschr.," 1894, No. 27. DISEASES OF THE MAMMARY GLANDS. 707 and blood, as in the "caked breast." They may then take an active part in the development of a mammary abscess, by attack- ing the epithelial cells of the milk-ducts, destroying them, and invading the surrounding connective tissue. Sore Nipples. — Excoriations and fissures of the nipples are due to the maceration and irritation to which they are subjected by the child's gums and mouth. Mammary abscess not infre- quently results from the entrance of streptococci or of other in- fectious bacteria through these fissures. Prophylactic Treatment. — During the latter months of preg- nancy the nipple should be washed twice a day, and should then be touched with a piece of clean absorbent cotton, saturated with a mixture of glycerol of tannin and water, equal parts. Alco- holic astringents should be avoided. It is necessary to keep the nipple clean during lactation by bathing it after each nurs- ing with boric acid solution (gr. x to fsj), and to keep the skin Fig. 543. — Breast-pump. Fig. 544. — Nipple-shield. in a healthy condition by frequent applications of sweet-oil, until the nipple becomes accustomed to its functions. Curative Treatment. — The nipple should be carefully cleansed after each nursing, and one of the following remedies should be applied to it : An ointment composed of oij each of bismuth subnit. and castor oil ; tinct. benzoin comp., applied directly to the fissure. Iodoform, gr. x, to ung. zinci oxidi, 3ss ; ichthyol, 5J ; lanolin, glycerin, each oiss ; olive oil, siiss. The fissure may be touched with a solution of nitrate of silver (gr. x to the ounce) or with the solid stick. A nipple-shield is almost always neces- sary. It must be perfectly clean, and should be kept immersed in cool water while not in use. In cases of supersensitive nip- ples, without abrasions or cracks, or if the latter are slight in de- 7o8 PATHOLOGY OF THE PUERPERIUM. gree, extract of witch-hazel is an excellent remedy. It is often advisable to protect the nipples between the nursings by lead nipple shields, which guard them against the rubbing of clothing or of the mammary binder. Occasionally the nipples are so exquisitely sensitive that the pressure of a night-gown or of the bed-clothes is unendurable, although there is no fissure, crack, abrasion, or inflammation. In such cases nerve-sedatives in- ternally, lead nipple shields, and cocain as a local application are necessary. Usually, the child must be weaned. Inflammations of the Breasts— Mastitis. — There may be an in- flammation of the subcutaneous connective tissue of the mam- mary gland, of the deeper interstitial tissue, or of the parenchyma. A septic inflammation is rarely confined strictly to one of these localities. There is usually involvement of all the tissues in the gland. As in all puerperal infec- tions, the micro-organisms responsible for the inflam- mation may be of many- pathogenic varieties. The constitutional symptoms of mammary infection are usu- ally slight, but may be very severe, even though the local inflammation appears to be moderate. Causes. — The first two classes, superficial and inter- stitial mastitis, are due to sepsis, the result of direct in- oculation. The sources of infection are unclean fingers, contaminated water, soiled rags to dry the nipple, dirty cloths laid over the breasts, and stomatitis in the infant. Parenchymatous inflammation need not always be ascribed to this cause. Overactivity of the gland, engorgement with blood, and distention with milk (the so-called "caked breast ") may be primarily responsible for the infectious inflammation by weakening the resisting power of the cells against microbic invasion. Treatment. — If the inflammation is parenchymatous and is due to oversecretion, the breast must be emptied with a pump or by Fig. 54$. — Puerperal mastitis forming abscess : a, Group of acini melted to pus (Billroth). DISEASES OF THE MAMMA R Y GLANDS. 709 massage (see Fig. 541), and must be supported by a binder. If the inflammation is confined to the connective tissue and sup- puration is threatened, lead-water and alcohol should be applied with a mammary binder. Suckling had best be intermitted if the inflammation continues and an abscess is threatened, as the irri- tation of nursing may increase the mammary congestion and the milk is apt to disagree with the child. It has rarely given rise to septic infection of the child's intestines by its contained micro- organisms. Mammary Abscess. — The pus may be located superficially, in the gland-substance, or in the submammary connective tissue, as a postmammary abscess. The symptoms of suppuration are uncertain. The reddened skin, the swelling and sensitiveness of the breast, and the fever may be due simply to intense congestion. Fluctuation is rarely detected until late, and should not be awaited. A dusky-red hue of the skin, and edema, with fever, are the most valuable signs of suppuration, and should indicate an immediate incision or incisions. Treatment. — A mammary abscess must be incised as soon as the physician is satisfied that there may be pus within the breast. It is much better to make an unnecessary incision than to allow the pus to burrow through the gland until the operation for the woman's relief becomes quite formidable. If the abscess is opened early, one incision commonly suffices. If the case is neglected, every pocket of pus must be opened and every sinus must be drained to secure a prompt and permanent cure. I have made as many as eighteen incisions in the two breasts, and have had half that number of drainage-tubes through the glands in a woman who had been ill for six weeks or more with mammary abscesses, in spite of a few ineffective and insufficient incisions in the breasts, made from time to time by her medical attendant. In incising a mammary abscess, the incisions, so far as possible, should radiate from the nipple, so that they run parallel with the lacteal ducts. Otherwise, a duct may be cut across and a lacteal fistula may result. The incision should, if possible, avoid the area of pigmentation, or should be confined wholly Fig. 546. — Pigment of the areola following incisions (Rich- ardson). yio PATHOLOGY OF THE PUERPERIUM. within it, as the pigmentation follows the cut, disfiguring the breast (see Fig. 542). The incisions should be made through the skin with a knife, the opening being only large enough to admit a moderate-size drainage-tube. The abscess-cavities should be punctured with a hemostat, inserted closed and withdrawn open. After evacuating the pus and inserting the drainage- tubes, which are pulled through from one opening to another by dressing-forceps, the breast is covered with sterile gauze and is compressed by a firm mammary binder. The drainage-tubes Fig. 547. — Drainage required in a case of mammary abscess. should be irrigated with sterile water daily by a straight-tipped medicine-dropper attached to a fountain syringe and inserted in the end of each tube. In the case of postmammary abscess, the whole breast is lifted off the chest, and there are no signs of suppuration within the gland itself. The systemic symptoms of this kind of mam- mary abscess are usually severe. Treatment. — The incision should be made beyond the per- iphery of the gland at the most dependent part as the woman lies DISEASES OF THE MAMMARY GLANDS. ?1 I on her back, and a counteropening must be made upon the opposite side. A drainage-tube is passed under the gland by a dressing-forceps, and the cavity is irrigated daily. A galactocele is a milk-tumor due to occlusion of one of the lactiferous ducts. It is usually of no pathological importance, unless it should, as rarely happens, reach a large size, when it must be tapped and drained. Other mammary tumors, especially adenomata, may take on a very rapid growth in pregnancy, and may become so engorged and painful when lactation begins that their removal is necessary. In one of my cases an adenoma grew during pregnancy from the size of a walnut to that of a cocoanut, and I was obliged to excise it on the third day of the puerperium. Relaxation of the Pelvic Joints. — The pelvic joints, after labor, may be the seat of inflammation, accompanied by serous exudation, and ending possibly in suppuration. In the case of the symphysis pubis, the abscess can easily be opened and drained. The prognosis, therefore, is good. In the other pelvic joints sup- puration is commonly fatal. The pelvic joints may be ruptured by violence during labor. This accident is considered in connec- tion with the forceps operation and injuries to the woman in labor. Finally, there may be relaxation of the pelvic joints to a marked degree, much exaggerated beyond that seen in almost every pregnant woman, and persisting after delivery. The etiology is obscure. Abnormal motion in the pelvic bones has been seen in justomajor pelves. It has been noted after abortion. It may be traced to a large, hard fetal head which had stretched the joints. It occurs in justominor pelves rather frequently. It has been ascribed to obesity, to a cachectic condition, to sudden and powerful exertion in the latter months of pregnancy, to an unusually great circumference of the preg- nant uterus, 1 and to previous disease or abnormality of the joint. 2 The diagnosis is easy. There is difficult locomotion, unusual mobility in the joints, especially the symphysis pubis, and local- ized pain. The woman may not be able to stand on her feet at all, or to take a step without collapsing. The examination is best made in the erect posture, the physician placing a fore- finger behind and his thumb in front of the symphysis. As the patient takes a step forward and backward the abnormal mobility of the innominate bones is appreciable. If the woman cannot stand, the examination is made in the dorsal position, an assist- ant flexing, extending, abducting, and rotating one thigh. 1 Winckel, " Geburtshiilfe," p. 873. 2 Schauta, in Miiller's " Handbuch," vol. ii. 712 PA THOL OGY OF THE PUERPERIL \M. The treatment is rest in bed with the application of a firm binder about the hips reinforced sometimes by sand-bags. In the course of a few weeks the joints usually become firm. Oc- casionally, the relaxation persists for months. I have not yet seen a case that did not recover under the treatment described : Kelly reports one in which he resected the symphysis and wired the pubic bones together. CHAPTER II. Puerperal Sepsis* Historical. — The history of the acquisition of our knowledge of puerperal infection is distinctly modern. It had its earliest beginning about fifty* years ago, and dates back in reality scarcely thirty years. Indeed, one may say that a true comprehension ol the causes and nature of puerperal sepsis was acquired only at the close of the nineteenth century, and that the past tew years have contributed more information on the subject than all the previous ages of medicine. The history of medical views on the septic fevers of the puerperium prior to the past generation is a long record of error and ignorance. From the earliest beginning of medi- cal literature to the nineteenth century, puerperal sepsis was ascribed to suppression of the lochia. This belief was not ques- tioned until 1670, when Puzos advanced the theory that all puer- peral fevers were due to a metastasis of milk, which flowed in. the blood during pregnancy, and was normally attracted to the breasts after delivery, but which might be drawn to other organs or structures, especially the peritoneum, with disastrous results. This theory found support in the reports of a number of post- mortem examinations, stating that milk had been discovered in the peritoneal cavity after deaths following childbirth. A little later English and German observers explained the puerperal infectious fevers by attributing them to inflammations of the womb and of the peritoneum, without accounting satis- factorily for the occurrence of the inflammation. Occasionally, one finds a reference to putrid fevers in the puerperium, a sug- gestion that putrefying animal matter ma}' occasion disease in PUERPERAL SEPSIS. 71 3 human bodies with which it comes in contact, an intimation of the contagiousness of puerperal fever ; but these were mere glimmerings of light that flickered out at once without illumi- nating the general ignorance. Credit, however, must be given to some of the English writers of the first half of the nineteenth century for insisting upon the contagiousness of puerperal fever. Three events laid the foundation of our present knowledge of puerperal sepsis : The publication of Oliver Wendell Holmes' paper on "The Contagiousness of Puerperal Fever," in 1843; the observations of Semmelweiss in the Vienna Hospital, 1846- '48 ; the publication of Sir James Y. Simpson's paper on " The Analogy between Puerperal and Surgical Fevers," in 1850. The first of these papers must always remain a classic in medical and English literature. It ended with these words : " I have no wish to express any harsh feeling with regard to the painful subject which has come before us. If there are any so far excited by the story of these dreadful events that they ask for some word of indignant remonstrance to show that science does not turn the hearts of its followers into ice or stone, let me remind them that such words have been uttered by those who speak with an authority I could not claim. x It is as a lesson rather than as a reproach that I call up the memory of these irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused ; they have closed the eyes just opened upon a new world of love and happiness ; they have bowed the strength of manhood into the dust ; they have cast the helplessness of infancy into the stranger's arms, or bequeathed it, with less cruelty, the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation, when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly ! " 1 Dr. Blundell and Dr. Rigby, in the works already cited. 714 PATHOLOGY OF THE PUERPERIUM. This unanswerable arraignment of the prevailing views in America in regard to puerperal sepsis fell upon deaf ears. The very men who should have first recognized its truth opposed the new doctrine with all their might, because it contradicted their teaching. At that time, in America, two men were so pre- eminent in obstetrics that they were practically without rivals, and autocratically dictated their views to a large number of un- questioning followers. They were Hodge and Meigs, holding, respectively, the Chairs of Obstetrics in the University of Penn- sylvania and in the Jefferson Medical College. Meigs directed against Holmes' teaching all the satire and ridicule of which his brilliant mind was capable, descending often to undignified abuse ; Hodge inveighed against it with a pon- derous invective. But in spite of this powerful opposition the doctrine of the contagiousness of puerperal fever made rapid headway, and gained from year to year an increasing number of converts in America and in England. Hodge's immediate successor, Dr. Penrose, taught it most impressively. In 1846, Ignaz Philipp Semmelweiss, a young assistant in the Maternity Department of the General Hospital of Vienna, was struck with the frightful mortality in one of the maternity wards, while in a neighboring ward the death-rate was scarcely one -tenth as great. He discovered that in the first ward the women were attended by students who were in the habit of com- ing fresh from postmortem examinations in the Pathological De- partment to the bedside of the parturient patients. In the second the women were attended solely by midwives. Semmelweiss conceived the idea that the students carried on their hands putrid products from the postmortem table to the lying-in women whom they examined, and that these products were responsible for the large number of fatal inflammations and fevers following their work. He consequently ordered that no student should exam- ine a woman until he had washed his hands in chlorin-water. The results were fairly startling, as is shown in the accompany- ing table: Confinements. Deaths. Per Cent. 1846, 40IO 459 1 1.4 1847, 349° !7° 5- 1848, 3556 45 1-27 It should be stated that the rule compelling the students to wash their hands in an antiseptic solution was put into effect in the middle of the year 1 847. Semmelweiss recognized the transcendent importance of his discoverv. He foresaw something of the lives preserved, the PUERPERAL SEPSIS. 7 I 5 homes kept from bereavement, the mothers saved to their chil- dren, the wives to their husbands, in millions of families ; the in- calculable diminution of human suffering which his discovery promised to the world ; but his was not the calm and confident soul of a Harvey, wise enough to know that the truth is mighty and shall prevail : sure that mankind must accept it some day, and content to bide his time. Semmelweiss' nature was not great enough for such patience. He fumed and fretted his life away in vain efforts to obtain recognition for his great princi- ple of chemical disinfection. He preached his new doctrine in season and out of season, endeavoring to impress it upon his immediate colleagues, and upon the medical societies and periodi- cal medical literature of the time in Europe. During the latter days of his professorship in Buda-Pesth he would even stop acquaintances upon the street to importune them with his views. But he got for his pains nothing but ridicule, contumely, opposi- tion, or indifference. He finally lost his mind entirely, from chagrin and disappointment, ending his life in a lunatic asylum in Vienna, where he died, strangely enough, from a septic wound on his finger, received during an operation performed just before his commitment to the asylum. More than twenty years after Semmelweiss' discovery, the mortality of many lying-in hospitals in Europe remained as high as ten per cent. Then came the brilliant work of Pasteur in the field of bacteriology, the acceptance of the germ theory in disease, the application of antisepsis to surgery by Lister, and the adoption of the system almost immediately by obstetricians. From that day to this there has been a steady and increasingly rapid acquisition of knowledge of the etiology of septic infection, and of its most successful preventive and curative treatment. It is to be hoped that the medical world of to-day and of the future can never again be deaf and blind to such an appeal as that of Holmes, or to such a demonstration as that of Semmel- weiss. Etiology. — It has become necessary to study the normal and abnormal microbic flora of the vagina in order to under- stand fully the etiology of puerperal infection, and to comprehend the safeguards that nature affords a woman against infection after labor. The effective study of the subject dates from Doderlein's monograph published in 1892. 1 Before this time the presence of bacilli in vaginal secretions was noted by Hausmann, Gonner, 1 " Das Scheidensekret und seine Bedeutung fiir das Puerperal-Fieber," Albert Doderlein, Leipsic, 1892. 7l6 PATHOLOGY OF THE PUERPERIUM. Bumm, Winter, and Steffeck. Gonner, in 1887, found in vaginal secretions many varieties of micro-organisms, mainly, however, bacilli, which were extremely difficult to cultivate in the ordinary culture media. The cocci in the secretions, many of which could be cultivated with ease, were found to be non-pathogenic. Gonner concluded that the vaginal secretions contained no pathogenic bacteria. Bumm also failed to find pathogenic germs in the vagina. Winter believed that pathogenic germs were present in the vagina in a state of lessened or absent virulence. Doderlein examined the vaginal secretions of 195 pregnant women. In these examinations notice was taken of the macro- Fig. 548. — Vaginal secretion of an infant (Doderlein). Fig. 549. — Vaginal secretion of a virgin (Doderlein). scopical appearance and of the reaction of the secretions, and as the result of this preliminary examination the secretions were declared to be normal or abnormal. In the two conditions the bacteriological find was quite different. In the normal secretion, which was of whitish color, of the consistency of curdled milk, un- mixed with mucus, containing epithelial cells and mucous bodies, moistened by an exudate from the vaginal mucous membrane and of an intensely acid reaction, there was found almost exclu- sively a certain kind of bacillus possessed of distinctive and characteristic qualities. No pathogenic germ was ever found by Doderlein in normal vaginal secretions, except a thrush-fungus which is capable, to a very limited extent, of producing suppura- tion and destruction of tissue when injected under the skin or PUERPERAL SEPSIS. 717 into the eye of an animal. In the pathological abnormal secre- tion, which was yellowish or greenish in color, of the consistency of cream, weakly acid or alkaline in reaction, mixed with mucus, containing often bubbles of gas and secreted usually in very large quantities, the greatest variety of cocci and bacilli could be found. Of the 195 pregnant women, Doderlein found that 55.3 had normal and 44.6 had pathological secretions. Although a number of observers had found bacilli in the vaginal secretions before Doderlein, no one had so carefully studied their characteristics, functions, and cultivation ; so that they are properly called the vaginal bacilli of Doderlein. They are, according to him, anaerobic. They have no motion. They produce by their life -process an acid medium by forming lactic Fig. 550. — Normal secretion of a preg- nant woman ( Doderlein ). Fig. 551. — Pathological secretion of a pregnant woman (Doderlein). acid. They are frequently associated with a yeast-fungus (thirty-six per cent, in normal secretions only), which Doderlein believes to be identical with the thrush-fungus, Saccharomyces albicans. The vaginal bacilli are antagonistic to staphylococci, which within certain limits they have the power to destroy. This was shown by several experiments, among others by infecting the vagina of a virgin with staphylococcus cultures in large quanti- ties. Within four days the staphylococci had disappeared, and no bacteria remained within the vagina except the vaginal bacillus. Doderlein attributes the germicidal action of the normal vaginal secretion to the production of an acid environment by 7 1 8 PA THOLOG Y OF THE PUERPERIUM. the vaginal bacillus. He supports this view by the following facts : i. That all pathological secretions swarming with sapro- phytes and with many pathogenic germs are weakly acid or alkaline. 2. That in a puerpera the vaginal bacillus disappears and in its place are found many kinds of saprophytes, the lochial discharge being alkaline. 3. That when the lochia ceases the saprophytes disappear, the vaginal bacillus reappears, and the vaginal secretion becomes again intensely acid. In only 8 out of the 195 cases examined were streptococci found, and in only 5 of these cases was it possible to demon- strate by inoculation experiments that the streptococci were virulent. In 2 cases the streptococcus possessed no virulence at all. These discoveries of Doderlein have not been universally accepted. His views have not gone unchallenged, and further interesting properties of the vaginal secretions have been pointed out by others, but we may safely acknowledge Doderlein's conclusions to be correct in the main, so far as they go, and that his discoveries constitute the most important advance in the knowledge of this subject achieved by a single individual. Following Doderlein's investigation there have appeared a number of exhaustive studies, the most important conclusions of which may be briefly summarized as follows : In series of examinations conducted by Burgubru, Williams, Stroganoff, and Burkhardt, in 12, 15, 9, and 16 cases respect- ively, streptococci were found in 1, 3, 2, and 5. Taking the sum-total of all these cases with Doderlein's, streptococci were found twenty-seven times in 542 women examined, showing that in only a small proportion of cases are dangerous pathogenic germs to be found in the vaginal secretions of pregnant women ; and accepting Doderlein's results as correct along with those of Winter, in the few cases in which streptococci were found, a considerable proportion of the streptococci were non-virulent. Kronig, 1 in about 200 examinations, found that the vagina in pregnant women, aside from the gonococcus and the thrush- fungus, contained no pathogenic micro-organisms. The strepto- coccus was not found in a single case. Adding these examina- tions to the former series, the proportion of cases in which the streptococcus may be found is, as appears, still further reduced. 1 " Deutsche med. Wochenschr. ," 1894, Oct. 24, p. 819. PUERPERAL SEPSIS. 719 Moreover, Kronig found, after inoculating the vagina with pure cultures of streptococcus, staphylococcus, and bacillus pyocy- aneus, that none of these micro-organisms could be discovered after eleven to twenty hours. Kronig attributes the germicidal properties of the vagina, which are demonstrated by these observations, mainly to the flow out- ward of the vaginal secretions, and not to any special microbe having its normal habitat in the vagina. According to this observer, acid, neutral, and alkaline secretions all have germi- cidal power. Further, Kronig found that if an hour after the infection of the vagina an antiseptic douche of lysol were admin- istered, not only were the infecting micro-organisms not de- stroyed by the douche, but also that it took the vaginal secretions from nineteen to thirty-six hours to destroy microbes that with- out the douche would disappear in from eleven to twenty hours. These results were confirmed by Menge, x in a study of the germicidal power of vaginal secretions in non-pregnant women, except that Menge occasionally did find streptococci in the vagina. From a number of observations and experiments this observer forms the following conclusions as to the causes of the germicidal power of vaginal secretions, putting them down in the order, as he believes, of their importance : The antagonism of the normal microbic flora of the vagina and of the pathogenic micro-organisms which may be deposited there by accident. The products of the life-process of the vaginal bacilli. The acidity of the secretions. The germicidal powers of the anatomical elements of the vagina. The leukocytosis which is provoked by chemotaxic action either of the vaginal discharges or of the infecting micro-organ- ism invading the vagina. The phagocytosis following leukocytosis. The absence of free oxygen in the vagina. Walthard, 2 from the bacteriological study of the vagina in 100 women ante et post partum, concludes that the genital canal of women is divided practically into two parts — one infected, the other sterile. The former comprises the vestibule, the vagina, and lower portion of the cervical canal. The latter, the upper portion of the cervical canal, the uterine cavity, and the tubal canals. The causes of this division of the canals, according to Walthard, are: 1. The plug of mucus stopping up the cervical canal, which, though not in itself germicidal, is deficient in albuminoids and fur- nishes no nutriment for micro-organisms. 1 " Deutsche med. Wochenschr.," 1S94, Oct. 24, p. 819. 2 "Archiv f. (jyn.," vol, xlviii, p. 201. 7 2 O PA THOL OGY OF THE P UERPERIUM. 2. The leukocytes, which are found in great numbers where the cervical secretion mixes with the vaginal secretion at the level of the external os. According to this observer, there are really three divisions of the genital canal : one, the lower, containing leukocytes and bacteria ; the next, containing only leukocytes, and the third, the upper, containing neither leukocytes nor bacteria. It is supposed that the outpour of leukocytes is due to a chemotactic action excited by the mixture of cervical and vaginal discharges, and that the phagocytosis follows naturally the leu- kocytosis. In the vaginal discharges Walthard found, both during preg- nancy and after delivery, pathogenic microbes, streptococci, staphylococci, gonococci, and the colon bacilli. The first named were found in 27 out of the 100 women examined, but these streptococci had lost all virulence and had become veritable saprophytes. Inoculation experiments with them pro- duced no results — that is, if they were inserted in normal tissues ; but if a certain region of the animal's body was reduced in vitality, or if the condition of the animal's system was lowered in any way, the inoculation of the streptococci produced abscesses in which the micro-organisms rapidly regained all their original virulence until they became quite as deadly as the most danger- ous of their kind. From his experiments and observations, Walthard draws the following conclusions : The virulence of vaginal streptococci of a pregnant woman not examined for some time is equal to that of the streptococci that live upon other mucous membranes or in their secretions. In other words, the vaginal streptococci are not virulent, and behave as saprophytes upon healthy tissues ; but as in the case of the intestinal streptococci, the vaginal streptococci can become infectious when the resistance of the tissues with which they are in contact is diminished. The virulence that the vaginal strep- tococci attain under these circumstances is quite equal to that of the streptococci of puerperal infection. Stroganoff, 1 from an examination of eleven pregnant women, supports Doderlein's assertion that the vaginal bacillus pro- duces by its development lactic acid, and shows that, while the vaginal secretions of the new-born are very weakly acid, they become more and more acid as bacteria develop in the vagina. He quotes experiments of Schlutter, showing that an acid medium retards the growth of the staphylococcus and is destructive to the streptococcus of erysipelas. He further shows, by experiments with culture media, that the vaginal bacillus pro- duces not only an acid medium, but also other products of its 1 " Monats. f. Geb. u. Gyn.," Bd. ii, p. 3S1. PUERPERAL SEPSIS. 72 I life -processes that retard or prevent the growth of the staphylo- cocci. In these experiments the vaginal bacillus was cultivated, and the culture then raised to a high temperature, so that the bacilli were destroyed. The culture was then inoculated with the staphylococcus pyogenes albus, with negative result. If the culture, in addition to being treated as described, was made alka- line, the staphylococci grew, but not so vigorously as upon the same culture medium in which the vaginal bacillus had not been grown. Stroganoff explains the sterility of the upper cervical canal and of the uterine cavity by the active germicidal properties of the cervical mucus, by the mechanical action of the flow of men- strual blood, by the same action of the descending placenta and membranes, and by that of the lochial discharge. Perhaps there should be added the germicidal effect of blood itself, which property it has been recently demonstrated that blood possesses, to a certain extent. Stroganoff announces the following conclusions from his study : One finds in the vagina of pregnant women always a quantity of micro-organisms. The prominent form in normal cases is the bacillus, but there are, in addition, usually other forms present. Micro-organisms which liquefy gelatin are met with comparatively seldom in normal cases, and then only in small numbers. A pathological condition of the vaginal mucous mem- brane alters the normal flora. The vaginal secretion of pregnant women is strongly acid in reaction. In addition to micro- organisms, one sees usually under the microscope epithelial cells and isolated white blood-corpuscles. The cervix contains nor- mally no micro-organisms. When they are present in that situ- ation, their number is small. The reaction of the cervical secretion is alkaline. In not a single case were there organisms in the cervix which liquefied gelatin. The external os is usually the boundary between that portion of the genital canal which contains micro-organisms and that portion which does not. Kottmann, 1 with a special apparatus to prevent contamina- tion, finds pathogenic micro-organisms in a considerable pro- portion of the pregnant women examined. Williams, 2 on the contrary, claims that the vagina is free from pathogenic germs. Vahle 3 finds that for the first twenty -four hours the vaginal secretions of new-born infants are sterile. By the third day they always contain micro-organisms, and in a considerable pro- "'Arch. f. Gyn.," Bd. iv. H. 3. 2 " Am. Jour, of Obstet.," vol. xxxviii. 3 ' ; Zeitschr. f. Geb. u. Gyn.," lid. wxii, II. 3, v. 46 722 PA THOL OGY OF THE P UERPERIl T M. portion of cases the staphylococcus pyogenes albus and aureus and a streptococcus. Stroganoff finds that within a few hours of birth the vagina becomes infected, and that in a certain proportion of cases the inoculation occurs in utero, or during the passage of the child's body through the vagina. This is most likely to occur in breech presentations. A great variety of micro-organisms may be found in the vagina of the newly born, including streptococci, diplo- cocci, staphylococci, etc. Stolz 1 finds streptococci, bacilli and cocci in the vagina. Xat- vig 2 finds streptococci in a state of diminished virulence in the vulva, which are easily carried or wander into the vagina. Michiii 3 finds trimethylamin in vaginal secretions and attributes to it de- cided bactericidal properties. From this mass of facts, set down without any special order, confusing in its complexity' and occasionally in its apparent contradictions, the practical physician ma}- draw the following conclusions as to the etiology of puerperal sepsis : The vagina becomes infected almost immediately after birth. In a normal condition it contains no pathogenic bacteria, but occasionally streptococci, staphylococci, and other pathogenic micro-organisms are resident in the vagina before labor. These germs, if present, are usually diminished in virulence, but may regain their full pathogenic power under conditions favorable to their growth and propagation. The vaginal canal has strong germicidal proper- ties which serve to guard a woman against infection. They depend upon the presence of a special bacillus, and upon the products of its life-processes; upon the leukocytosis due to chemotactic action ; upon phagocytosis; upon the germicidal powers, perhaps, of the anatomical elements of the vagina ; oi the cervical mucus, and of the bloody discharge during menstru- ation and the puerperium, and possibly upon the presence of tri- methylamin. During and after labor, mechanical safeguards of the most effective kind are furnished against infection. These are : the discharge of the liquor ammi, washing the vagina out ; the passage of the child's body, scrubbing the vagina out ; the descent of the placenta and membranes, and the bloody dis- charge which follows. Moreover, should the vagina contain pathogenic bacteria, they are likely to be in a condition of diminished or absent viru- lence, in which they will not be productive of disease. Bearing these facts in mind, it is apparent that the common 1 " Studien zur Bakteriologie des genitalkanales in der Schwangerschaft u. im Wochenbette," Graz, 1903; also Hegar's "Beitrage zur Geb. u. Gyn.," Bd. vii, H. 3. 2 " Arch. f. Gyn.," Bd. lxxvi, H. 3. 3 "Jahresbericht," p. 94, vol. xvi. PUERPERAL SEPSIS. 723 practice of relying upon simple vaginal douching for disinfecting the vagina before labor, or before some gynecological manoeuver or operation, is faulty, not to say foolish. It has been clearly demonstrated that the injection of an antiseptic fluid into the vagina does not destroy pathogenic germs there, and robs the woman, to a certain extent, of the safeguards that nature pro- vides for her against infection. If, therefore, under certain cir- cumstances, it is desirable to disinfect the vagina, mere douching should not be depended upon, but the vaginal mucous membrane should be thoroughly scrubbed out as well as douched, just as one would prepare the skin for an important surgical operation. It is clear that these remarkable discoveries in regard to the micro-organisms normally present in the vagina do not, in the slightest degree, lessen the importance of antiseptic precautions on the part of medical or other attendants upon a patient in labor. The presence of the organisms in the vagina might possibly be used as an argument against the necessity for anti- septic precautions. For, it might be said, the vagina being already infected, it is unnecessary to observe such elaborate pre- cautions against infecting it still more. But when one considers that the micro-organisms in the lower genital canal are not pathogenic in the vast majority of cases, and that when they are their virulence is diminished or absent, it is obviously incumbent upon any conscientious man not to insert into the vagina infecting bacteria which may, by their number and virulence, overcome all the safeguards that nature provides, and may, consequently, be the cause of a serious and fatal disease. The Pathogenic Microbes Capable of Producing Local In= flammation and General Systemic Infection when Introduced in the Genital Canal. — Streptococci were first observed in cases of puerperal infection by Mayerhofer in 1865 and were first cultivated from such cases by Pasteur in 1880. 1 Doderlein found the streptococcus pyogenes as the sole infecting agent iri five cases of serious puerperal infection. Czerniewski, in 53 cases of puerperal infection, found strepto- cocci in 49. In a histological and bacteriological examination of 16 cases of puerperal fever, Widal found streptococci in 14, bacilli in 2. Bumm, in an examination of 17 cases of puerperal infection, found streptococci in all — 5 times as pure cultures, 12 times mingled with small numbers of staphylococci and of other germs. Thus, in a total of 91 cases, the streptococcus was found to be the infecting agent in 85, or 94 per cent. 1 See the very instructive article, with full bibliography, by J. W. Williams, on "Puerperal Infection" in "The Practice of Obstetrics by American Authors," Jewett, 1899. 724 PATHOLOGY OF THE PUERPERIUM. Following streptococci, but a long way behind as the cause of puerperal infection, are the pyogenic staphylococci, the colon bacillus, the gonococcus, the tubercle bacillus, the bacillus pyocy- aneus, the bacillus fcetidus, the pneumococcus, the Klebs-Lofiier bacillus of diphtheria, the tetanus bacillus, and possibly any germ at all that, inserted into living tissues or deposited upon weakly re- sisting surfaces, is capable of causing local inflammation or gen- eral disease. In addition to specific septic micro-organisms, the anaerobic saprophytes of decomposition play an important role in the common form of puerperal sepsis, due to the absorption of toxins, or ptomains produced in the decomposition of dead animal matter, such as blood-clots, fragments of placenta, hyper- trophied decidua, within the womb. Dobbin x has reported an interesting case of fatal puerperal infection, in which the bacillus aerogenes capsulatus (gas bacillus) was probably the infecting agent, or, at least, produced the toxins that fatally intoxicated the maternal organism, and, after death, developed the same emphysema in the maternal body which was found in the dead and macerated fetus at the time of delivery. This germ is accountable for cases of physometra, or tympanites uteri. It develops by preference in dead bodies, and may not manifest its presence during life. It finds in the dead fetus within the womb a habitat most suitable for its development ; it gives rise to a hor- ribly fetid inflammable gas, and probably to virulent toxins. 2 Blumer 3 reports a case of mixed puerperal and typhoid infec- tion in which the streptococcus and the typhoid bacillus were isolated both from the blood and the uterine cavity. J. Whitridge Williams, of Baltimore, in an examination of forty patients, the cultures being taken from the ward cases whenever the temperature went to or above ioi° F. and from the out-door cases when it reached 102 °, found — Streptococci in 8 cases Staphylococci in „ . 2 cases Colon bacilli in 6 cases Strictly anaerobic bacteria in 4 cases Unidentified aerobic bacteria in 5 cases Bacteria were found in cover-glass examinations, all cul- tures being sterile, in 4 cases Diphtheria bacilli in I case Bacillus aerogenes capsulatus in I case Typhoid bacilli in . . I case Malarial plasmodia in blood, cultures sterile, in . . . I case No bacteria on cover-glass, cultures sterile and blood negative, in II cases 1 " Puerperal Sepsis due to Infection with the Bacillus Aerogenes Capsulatus," "Johns Hopkins Hospital Bulletin." No. 71, February, 1897. 2 See also studies of five cases by Lindenthal, " Beitrage zur Aetiologie des Tympania Uteri," " Monatschr. f. Geb. u. Gyn.," Bd. vi, p. 269. 3 "Am. Jour, of Obstet.," Jan., 1899. PUERPERAL SEPSIS. 72$ making a total of 44 cases, the difference between that number and the '40 cases actually examined being due to the fact that there were mixed infections in several instances. The Manner in which Pathogenic Organisms Find an Entrance into the Genital Canal. — The majority of puerperal infections are traceable to the insertion of pathogenic germs by the examining finger or hand of the physician, who in the course of his daily work may have touched the dried sputum of diph- theria, the desquamated skin of scarlet fever, suppurating wounds, erysipelatous surfaces, and other virulent, infectious material ; so that at any time his hands may fairly reek with the most dangerous poisons that could possibly be brought in contact with the parturient and puerperal woman. Many hundred cases have been traced directly to the association of the physician with infectious diseases, and there is scarcely a surer way of avoiding puerperal infection than by abstention from vaginal examinations. Epidemics of puerperal fever in hospitals have been quickly stamped out by avoiding all internal examinations, and the best morbidity and mortality records ever known have been obtained recently in institutions in which vaginal examinations were eliminated as much as possible. Even if the examining hand is protected by a sterile glove, pathogenic bacteria may be carried into the vagina from the vulva, if there is a faulty technique in making the examination. The hands of the nurse or other attend- ants may be the agents that deposit bacteria in the vagina or upon the vulvar orifice. The implements used in and about the par- turient canal, an atmosphere laden with dust or vitiated by foul unhygienic conditions, and- the water used to wash and douche the patient may carry disease germs to the parturient woman and may introduce them into the genital canal. The bed-clothing, the personal clothing, the mattress, the vulvar pads, the material used to cleanse the vulva (rags, sponges, cotton, cloths), may each and all be sources of infection. Putrescible material retained within the genital canal (espe- cially within the uterine cavity) attracts the innumerable and ubiquitous saprophytes and their spores, with which the purest atmosphere swarms. The development of these bodies in a situation most favorable to their growth and active propagation may easily result in a toxemia, if not in actual invasion of the body by pathogenic germs. Coitus in the last weeks of pregnancy is said to be a source of infection of the genitalia in exceptional cases, by carrying patho- genic bacteria into the vagina. Finally, a certain proportion of cases may be traced to autoinfection — that is, to pathogenic germs resident in the body, and not introduced from without during or 7' 2-6 PATHOLOGY OF THE PUERPERIUM. after labor. These germs may have had a lodgment in the vagina, as has been demonstrated in the bacteriological studies of that canal; or they may have been contained in a limited area near the genital canal, as in an old pyosalpinx, whence they spread by rupture of the pus-sac during labor, or in which they are incited to new activity by the compression and consequent reduction of vitality of surrounding tissue. There may have been tuberculosis of the genitalia, antedating conception. Or there may be, in the neighborhood of the uterus, tumors of low vitality and highly put- rescible material, which, being reduced in resisting power by com- pression from the descending child, become infected by germs that ordinarily can not influence vigorous body-cells. Dermoid cysts and fibroid tumors are the best examples of these growths. Even highly vitalized tissues like the pelvic muscles, espe- cially the iliopsoas, may be so bruised and injured by the child's head that they slough and become gangrenous. The iliac bone, too, has become carious after the bruising to which it was sub- jected in a prolonged forceps operation. The parturient woman may have had an infectious interstitial endometritis. The micro-organisms being lodged in the interstices of the mucosa, and the woman becoming pregnant, there is con- tained in the uterine cavity, even before conception, a cause of puerperal sepsis. The Behavior of Pathogenic Micro=organisms when Intro= duced into the Genital Canal or Deposited upon its Entrance. 1 — The consequences of microbic invasion of the genital canal by pyogenic germs are variable in the extreme. If the bacteria enter wounds in or near the vaginal outlet, the result may be the same as in the infection of any wound in general surgery — that is to say, local inflammation, suppuration, and perhaps general sys- temic infection ; but the infectious inflammation of a vaginal wound is almost certain to spread upward, for the conditions are more favorable to microbic growth and to systemic invasion in the uterine cavity and in the tubal canals than in the lower portion of the genital tract. Hence it is that the vast majority of serious puerperal infections have their effective starting-point within the womb. For example, it has been found, in a strepto- coccic infection of the whole genital tract, that the micro- organisms were present in the vaginal mucous membrane alone, in the cervical mucous membrane, and in the tissues immedi- ately subjacent ; in the endometrium, and deep within the uterine muscle, showing that they could easily penetrate the deeper tissues within the womb, while they were incapable of invading 1 " Ueber die im weiblichen Genitalcanale vorkommenden Bakterien in ihrer Beziehung zur Endometritis," "Archiv f. Gyn.," Bd. 1, H. 3. PLATE T4- Streptococcic infection of the vagina and vulva, with pseudomembrane. Cured by local irrigation, general stimulation, and support (University Hospital). PUERPERAL SEPSIS. 72J the tissues underlying the vaginal mucous membrane. In other words, the resisting power of the tissues under the mucous mem- brane is less the higher the micro-organisms are found in the genital canal. 1 Septic infection of the genital tract results often in the forma- tion of false membranes. This is true of pure streptococcic infections, of mixed infections (streptococcus, bacillus fcetidus, bacillus pyocyaneus, the pyogenic staphylococci), and especially true, of course, of the rare cases of true diphtheria of the o-enital tract in which the Klebs-Loffier bacillus is found. The apparent false membrane in a septic endometritis is due to a necrosis of the endometrium, clothing the uterine walls with a dirty, greenish-yellow covering. There is much yet to learn of the antagonisms and associations of pathogenic germs in puerperal infections. This much, however, may be asserted with confidence : the streptococcus is frequently associated with the pyogenic staphylococci, the bacillus fcetidus, the bacillus pyocyaneus, and the colon bacillus, though it is said to drive away or to destroy the staphylococci after a time. The gonococcus seems often to prepare the way for the strep- tococcus, which, in its turn, may destroy the gonococcus, con- quering the latter in a struggle for existence and remaining in sole possession of the field. The streptococcus appears often to prepare the way for the colon bacillus, which certainly wanders in frequently in the course of streptococcic infection. Streptococci, staphylococci, and the pyogenic bacilli have preeminently the power to penetrate the tissues of the uterus and to distribute themselves throughout the body. This is particularly true of the streptococci. Gonococci and the colon bacilli confine themselves most often to the endometrium and to the tubal mucosa. The former is the pathogenic agent in a large proportion of the cases of septic endometritis after labor. The latter is often found in cases of physometra. Both of these organisms, however, can pene- trate the uterine muscle, and ma}' be distributed through the system by the lymph-channels or by the blood-vessels. Strep- tococci show a preference for the lymphatic channels in their invasion of the tissues. Hence they usually pass from the endo- metrium to the myometrium, to the parametrium, and to the subperitoneal lymphatics, perhaps affecting the tubes and ova- ries, secondarily, perhaps causing abscesses or general infection of the peritoneal cavity, or of the pelvic connective tissue. The putrefactive micro-organisms (saprophytes) are anaerobic, and confine their activity mainly to the decomposition of putrescible uterine contents, particularly of hypertrophied endometrium, 1 Lahn, '• Inaug. Diss.," Jahresbericht, 1894. 728 PA THOL OGY OF THE P UERPERIUM. which is practically cut off from its blood-supply by the contrac- tion of the womb, and is peculiarly liable to rapid decomposi- tion. During- the process of putrefaction the saprophytes manu- facture soluble and absorbable products (toxins) of a highly pathogenic nature, causing possibly a fatal intoxication without actual microbic invasion of the body. Moreover, saprophytes occasionally attack blood-clots in the uterine sinuses, and may be swept into the general circulation by detachment of a thrombus and deposited as a septic embolus in different portions of the body, causing metastatic abscesses. It is claimed also that the bacteria of putrefaction and their toxins increase the virulence of streptococci. Symptoms and Diagnosis of Puerperal Infection. — The symptoms of puerperal infection are local and general. The latter are : an elevated temperature, preceded perhaps by a chill ; a rapid pulse, and profound physical depression, with the devel- opment in some cases of metastatic inflammations of any of the organs or tissues in the body. The tongue is coated ; the breath is heavy. There is a disinclination to take food. There may be intense thirst ; nausea and vomiting are not uncommon, and a septic diarrhea appears in the worst cases. There may be blotches of a scarlatiniform eruption upon the skin. The local symptoms of septic infection are : a foul discharge, redness of the mucous membrane, spots of ulceration and false membrane formation along the lower genital canal, edema of the vulva, and, possibly, pelvic peritonitis with an exudate. Or there may be other inflammatory affections of the generative organs, such as superficial catarrhal colpitis or ulcerative metritis, the symptoms of which are described in their appropriate places. It is not likely that any case of puerperal sepsis will present all the symptoms just detailed. Elevation of temperature and rapid pulse alone after labor should be regarded as indicative of puer- peral infection if no other cause for them can be demonstrated. It is possible, indeed, to see elevation of temperature alone as a symptom of puerperal infection in the earl}- part of the puer- perium, during which time the influences that normally reduce the pulse-rate are so active as to counteract the disposition to rapidity of pulse usually shown in septic infection. The slow pulse, however, does not continue long. At the end, usually, of thirty-six hours, rapid heart-action appears. It may be difficult to make a differential diagnosis between septic fever and some of the other causes of elevated temperature after labor. In these cases it is wise to treat the patient for puerperal sepsis by a thorough disinfection of the parturient tract, while at the same time the bowels are well evacuated and a full dose of quinin is administered to dispose of a possible intestinal PUERPERAL SEPSIS. 729 toxemia, and to combat a possible malarial infection which in many parts of the country, especially in the spring and fall, is a not improbable event. A microscopic examination of the blood is always advisable in a doubtful case, to discover the leukocytosis of sepsis or the protozoa of malaria. The appearance and number of the blood-corpuscles is of interest in all cases of sepsis and may have distinct diagnostic value. Leukocytosis should be marked at first, unless the Fig. 55 2 - — Doderlein's lochial tube : <7, Lochial tube within its test-tube ; /', tube with syringe attached; r, tube sealed, for transportation to laboratory. The cervix is exposed by a Sims speculum, is pulled down by a tenaculum, and wiped off with bichlorid solution on pledgets of cotton. The implements and operator's hands must be aseptic. system is overwhelmed with septic intoxication. The absence of leukocytosis therefore in a grave case is unfavorable. An ex- acerbation of the leukocytosis usually indicates a fresh focus of 730 PATHOLOGY OF THE PUERPERIUM. infection, an extension of the process, suppuration, or the devel- opment of new generations of micro-organisms. A subsidence of the leukocytosis indicates a spontaneous cure or a localization of the process. If the septic process is strictly limited, there may be no overplus of leukocytes at all. In a large abscess in the para- vesical connective tissue between the uterus and bladder four weeks after labor there was less than the normal number of white blood- corpuscles. It should be remembered that leukocytosis does not necessarily mean suppuration. It may be absent in cases of ab- scess; it may be most marked in streptococcic infection of the lymph-channels without suppuration. In addition to the leukocy- Fig. 553. — Nicholson's modification of the Doderlein tube. tosis, the blood in puerperal sepsis shows degenerative changes in all its corpuscular elements. Any elevation of temperature after delivery calls for the most careful investigation. A vaginal examination should be made, both digitally and with the speculum, to detect the following con- ditions : Redness of the mucous membrane and edema of the vulva ; false membranes and ulceration in the vagina ; arrested involution and fixation of the uterus ; bogginess and extreme tenderness of the uterine walls ; enlargement of the tubes ; en- largement, fixation, or displacement of the ovaries ; edema or exudate in the pelvic connective tissue, and thromboses in the pelvic veins. The abdomen should be carefully palpated for tenderness and exudate ; the character and odor of the lochia PUERPERAL SEPSIS. 73 I must be observed. There are two methods of precision in the diagnosis of puerperal sepsis which ought always to be employed if possible in doubtful cases: intra-uterine and blood cultures. The first is based on the assumption that the uterine cavity is sterile in the normal case; if pathogenic bacteria are discovered in the lochia withdrawn by Doderlein's tube or one of its modifications, the patient is infected; if the cultures from the uterine cavity are sterile, it is assumed that the patient is not infected, though she has fever and other symptoms usually due to sepsis. Unfortunately this method is not invariably reliable. From 30 to 80 per cent, of afebrile cases show a positive result from intra-uterine cultures, the percentage increasing as the puerperium advances, 1 and in a series of 9 cases of streptococcic infection in the University Maternity there was a negative result in 4 cases by cultures from the uterine lochia. The more careful the technique, the more accurate is the diagnosis by this method, but with the very best technique it is often inaccurate and cannot be depended upon. Cultures from the blood- serum are much more reliable. In a series of 35 cases in the University Maternity this method did not fail us once as a means of precision in diagnosis. 2 Although the attempt to study the bacteriology of the blood in cases of infection was begun many years ago it is only in the last three or four years that the method has become satisfactory as a means of precision in diagnosis. At first a drop of blood was taken from the ear and smears made upon solid culture media. Recently the bactericidal property of the blood has been recognized; it is now realized that consid- erable quantities of blood serum must be procured, that it must be well diluted in the culture media and that the technique of the investigation must be as perfect as possi- ble to obtain satisfactory results. Dr. J. S. Evans, of the Pepper Laboratory of the University of Pennsylvania, employs the following method : A glass Luer syringe with a platino-iridium needle, holding 10 c.c, is wrapped in raw cotton, enclosed in filter paper, sealed, and is sterilized by hot air at a temperature of 150 Cent, for one hour. The patient's arm is prepared as for an operation above and below the flex- ure of the elbow ; is washed with tincture of green soap, hot water, and pledgets of sterile cotton; then with alcohol; a wet bichloride of mercury dressing is applied for ten minutes; the skin is then washed off with sterile water and a dry sterile dressing applied until the time for withdrawal of the blood. The operator wears sterile rubber gloves. Pressure is applied above the elbow. The platino-iridium needle attached to the syringe is flamed, and plunged into the most prominent vein. Ten c.c. of blood are withdrawn. The needle is detached from the syringe to lessen the risk of con- tamination. 1 c.c. of blood is injected from the syringe into five flasks of bouillon, each containing 150 c.c. The flasks are thoroughly agitated. Three c.c. of blood are distributed among 6 tubes of litmus milk. The remaining 2 c.c. of blood are discarded, as it is the first quantity withdrawn and the most likely to be contaminated. The lit- mus milk tubes are for anaerobic cultures which are made by the pyrogallic acid and the sodium dioxide method. All the flasks are incubated at37.5°C. At the end of twenty-four hours, the flasks are examined and sub-cultures are made on slanted agar and glycerine agar. At the end of the next twenty-four hours, if the cultures are positive, growth has occurred on the soHdmedia. If no growth has occurred, the flasks are kept at incubator temperature for a week and sub-cultures are made daily. 1 Brownlee, "The Germ Content of the Uterus and Vagina during the Normal Puer- perium," "Journal of Obstet. and Gyn. of the Br. Empire," September, 1905 ; Little, "The Bacteriology of the Puerperal Uterus," "Am. Journ. of Obstet.," Dec, 1905. 2 B. C Hirst, "Some Problems in the Diagnosis and Treatment of Puerperal Infection," "Am. Medicine," Jan. 27, I906. 7 3 2 -PA THOL OGY OF THE PUERPERIUM. Preventive Treatment of Puerperal Sepsis. — It is conveni- ent to deal separately with the several sources of puerperal infection in describing the preventive treatment. Atmosphere. — While the air is not so frequent a source of infection as it was thought to be in the beginning of the anti- septic era, it is undeniable that an atmosphere which is stag- nant, deprived of sunlight, impregnated with dust, tainted with foul odors and mephitic gases, may not only contain disease germs and spores in larger proportion than it should, but also has a most depressing effect upon an individual subjected to its influences, reducing the vitality and resisting power of the body cells until there occurs, perhaps, microbic invasion of the system that would have been successfully resisted had the organism preserved its normal combative power against patho- genic bacteria. The lying-in room, therefore, should be sunny ; should be well ventilated — best by an open fire-place ; and it should not possess a stationary wash-stand or any other connec- tion with the sewer ; nor should it be too near the bath-room and water-closet. If there is a stationary wash-stand in the room, its outlet should be kept stopped, water should be allowed to stand in it, and the overflow holes should be plugged with small corks or putty. If the bath-room immediately adjoins the lying-in room, the door between should be stripped. If the room is heated by a hot-air furnace, the intake for the air and the sanitary condition of the cellar may need investiga- tion. The nurse should be cautioned not to leave trays of food, an unemptied bed-pan, or a commode in the room over night or for any length of time. An antiseptic vulvar pad should be worn durino- the continuance of the lochial discharge, so as to protect the genital orifice from contact with the atmosphere, and the materials of which this pad is composed, or, rather, the anti- septics with which it is impregnated, should be chosen with a view of keeping the bloody discharge from decomposing, should it soak through the pad, and thus be exposed to atmospheric contamination. The best materials for this purpose, in my ex- perience, are salicylated cotton and carbolized gauze. Water. — The water used for douches, if they are employed, or for washing the vulva and perineum, may be the source of fatal infection. All the water used about the puerpera should be boiled beforehand for at least half an hour. It is not suffi- cient to make a germicidal solution — as, for example, of corrosive sublimate — in the belief that all germs in the water are killed by the antiseptic employed. Tetanus bacilli will live for hours in a I : 4000 bichlorid of mercury solution, and the other antiseptics usually employed in obstetric practice — lysol, kresin, creolin — may be perfectly inert against many dangerous pathogenic germs PUERPERAL SEPSIS. 733 during the time that usually intervenes between the preparation of antiseptic solution and its use upon a patient. Three women in the University Maternity contracted tetanus from intra-uterine douches of unboiled water (creolin, two per cent.), during a time when the water of Philadelphia was unusually turbid, in con- sequence of freshets in the Schuylkill Valley. It is possible that the patient's vagina might be infected in the full bath taken before labor begins if she sits or lies in the tub full of water which may be contaminated by the rinsings from her body. A sponge or douche bath in the erect posture is safest. The Patient. — The parturient and puerperal woman may be infected by disease germs carried upon her person, especially in the pubic and anal regions ; by her personal clothing, by the bed-clothing and mattress, by the vulvar pads and the pads upon which the buttocks rest, by the material used to wash the vulva and perineum, and by pathogenic bacteria lodged in the vaginal or uterine mucous membranes before labor or even prior to con- ception. To insure the greatest obtainable degree of personal cleanli- ness, the woman falling in labor should be given a full bath, special attention being paid to scrubbing the genital region most thoroughly with soap, hot water, and a soft, bristle brush or a wash-rag. After the bath, the woman should put on clean clothes throughout. The mattress on her bed should not be soiled by the discharges of previous labors, by urine, feces, or other putrescible matter. It should not have been used in any case of contagious or infectious disease, and it should be pro- tected by a rubber cloth that has been carefully scrubbed clean. The bed-clothing should be clean, the bed being freshly made up for the labor. The pads on which the buttocks rest during labor and afterward should be made of nursery cloth prepared in the way described in the directions to the nurse (boiled and dried). It is scarcely necessary to say that a pad when soiled should be thrown away and not used again. The vulvar pads should be made of carbolized gauze and salicylated cotton — the best materials for disinfecting a bloody discharge. The nurse should make them up with sterile hands as they are required, or if she makes a number at a time they should be wrapped in a clean towel and taken out for use with sterile hands. The material used to wipe off the genital orifice, the mouth of the urethra, and the perineum should be absorbent cotton sterilized by heat or by soaking in a i : iooo solution of sublimate for al least a half hour before use. During the second stage of labor these pledgets of cotton are employed to wipe away feces as it emerges from the anus, always in the direction from before backward. 734 PATHOLOGY OF THE PUERPERIUM. Care must be exercised to remove blood and blood-clots from the vulva before putrefaction sets in. This is best done by placing the woman on a bed-pan, letting a stream of boiled water run over the parts, and, if necessary, using cotton to wipe them off. This should be done about six times in the twenty- four hours for the first four or five days. A careful examination should be made of every woman's vaginal discharges in the beginning of labor. If there is leukor- rhea, or any pathological condition of the vaginal secretions, the vagina should be thoroughly scrubbed with tincture of green soap, hot water, and pledgets of cotton, and should then be douched with a bichlorid of mercury solution, i : 2000, a little clear water being employed at the end of the douche to wash out any residual sublimate solution that might poison the patient or do harm to the infant's eyes in its descent through the birth-canal. It should be borne in mind, in the conduct of the labor, that excessive bruising, long-continued pressure of the maternal tissues, and extensive injuries, all conduce to microbic invasion of the parts by reducing their vitality and by affording, through solu- tions of continuity, a ready entrance into the system. The proper conduct of labor, therefore, is an extremely important item in the preventive treatment of puerperal sepsis. Finally, in the management of the third stage of labor and of the early puerperium, the greatest care should be exercised to evacuate the uterine cavity of all putrescible matter and to secure, as far as possible, firm contraction of the womb, for the presence of putrescible material within the uterine cavity attracts sapro- phytes, and an imperfect involution of the womb favors the direct invasion of the uterine sinuses and blood-channels by micro- organisms and the absorption of the products of microbic activity into the circulation and into the lymph- spaces. The Physician. — The physician should not carry infectious germs upon his person or clothing into the lying-in chamber, and he should be scrupulously careful not to insert pathogenic germs into the woman's vagina in the course of his examinations. If a general practitioner is in attendance upon infectious and conta- gious diseases, he should either give up obstetric practice entirely, or, if he can not do so, he should take a full bath and should change his clothing completely before attending a woman in labor. A long linen gown or duck trousers and a cheviot shirt should be carried in the obstetric bag. The change of clothing should be made in another room before seeing the patient at all, or, at any rate, before making an examination. Furbrino;er's method of hand disinfection is recommended. PUERPERAL SEPSIS. 735 It is a ten minutes' scrub of the hands with a nail-brush, hot water, and tincture of green soap, either with running water or with at least four changes of water in a basin. The water should be boiled and filtered. The preliminary scrub is followed by a two minutes' scrubbing with alcohol, using a fresh nail- brush, then by immersion of the hands in a i : iooo bichlorid of mercury solution for at least two minutes. The routine use of sterile rubber gloves in addition to the hand disinfection just described is an indispensable precaution. If version or any manceuver is attempted involving the deep insertion of the hand into the uterine cavity the long gauntlet glove, reaching to the elbow, should always be worn. The examining finger should be anointed with carbolized vaselin (five per cent.), and in making the examination the vulvar orifice should be exposed by rais- ing the upper buttock as the woman lies upon her side, so that the finger may be inserted directly into the vagina without becom- ing contaminated by being swept over the skin near the anus or pubes while searching for the vulvar orifice. Before inserting the finger, the skin around the vaginal entrance should be wiped off with a pledget of cotton soaked in a i : 2000 sublimate solu- tion. As every examination entails some risk of infection, they should be as limited in number as possible. The best results in morbidity and mortality have been secured by an almost entire elimination of the vaginal examination, which has been replaced, in the practice of some enthusiasts, by abdominal palpation, and even by rectal examinations. It is unnecessary, however, and is, moreover, inadvisable to give up the vaginal examination al- together. Much may be learned by abdominal palpation, so that there is little necessary information to be gained by examin- ing per vaginam, but there are some conditions that can be learned in no other way. A few vaginal examinations in the course of labor are therefore indispensable. No harm is done if their num- ber is restricted, if the examining hand is protected by a sterile glove, and if the examination is conducted in the way just de- scribed. The Nurse. — The nurse should adopt the same precautions in regard to personal cleanliness that have been recommended for the physician. She should not have come from a contagious or infectious case. She should put on fresh clothing throughout for attendance upon the obstetrical patient. She must take a full bath, scrubbing her hair and scalp well with soap and water, and rinsing her hair in a 1 : 1000 sublimate solution. She should cleanse her hands and put on sterile rubber gloves before attempt- ing any manipulation of a patient's genital region or of her breasts. 73$ PATHOLOGY OF THE PUERPERIUM. It is her duty also, in the care of a puerpera, to enforce the sanitary and aseptic regulations already described under their appropriate heads. The Implements. — All implements to be used about the person of the parturient and puerperal woman should be boiled for at Disease 107° 106° 105° 104° 103° 102° 101° 100° 09° 68° M £ M £ /I 1 £ A 4E M £ M £ A /f,£ ^•£ M\£ A f£ Af£ M £ ■ V i|: ip iy ^^ i V 5 k ^ ;|; X '■ h I A \ S V N 1 ; 1 : M ■ 1 i 1 : 1 i= / \ ■ I V ■ v : , i : V S ■/ __ Fig. 554. — Temperature-chart of a case treated in vain by intra uterine irrigation, but cured immediately bv a curetment. least five minutes. A 1 : 1000 sublimate solution should be employed for the disinfection of the few articles that might be injured by boiling water, a full half hour at least being allowed for the immersion, and the bichlorid solution being made up with boiled water. The Curative Treatment of Puerperal Infection. — The treat- ment of puerperal sepsis is both local and general. Locally, a thorough disinfection of the whole genital canal is called for in every case of puerperal infection. It may appear unnecessary, and may prove, on actual experience, to be even harmful, but no one can tell beforehand how necessary this procedure is. In the vast majority of cases it is productive of the greatest good. It is only occasionally useless, and very rarely actually harmful. It should, as already stated, precede all other treatment for puerperal infection. The method of disinfecting the genital canal may be described as follows: A double tenaculum, a large, dull curet, a placental forceps (Emmet's curetment forceps is the best), and an intra-uterine catheter are boiled for fifteen minutes. The operator disinfects his hands and arms and wears sterile gloves. The patient is placed in the dorsal posture across the bed, with her buttocks resting on a rubber pad. The external genitalia and the vagina are scrubbed with tincture of green soap and pledgets of cotton; the vagina is douched with a sublimate PUERPERAL SEPSIS. 737 solution, i : 2000. The operator then seizes the anterior lip of the cervix with the tenaculum. An intra-uterine douche of sterile water or of a weak sublimate solution, at least a quart, is adminis- tered. Then with the placental forceps, and if necessary with dull curet, the uterine walls are gone over thoroughly but lightly in all directions, six to twelve times, until nothing is brought away but bright blood. A second intra-uterine douche concludes the treatment. If sublimate solution is used for this douche, it must be followed by sterile water. If the womb is flabby and large, with a tendency to flexion, so that the drainage of the uterine cavity is not good, it is advisable to pack it with iodoform or sterile gauze. Much discredit has attached to this method of instrumental evacuation of an infected uterus because it has too frequently been carried out like a curettage of a non-puerperal uterus, which would often result in implanting infection in the myometrium or in perforating the uterus. In addition to cleansing the uterine cavity in the manner described, the operator should take the opportunity of carefully inspecting the visible portion of the parturient tract ; and if there are false membranes or areas of inflammation and localized infection on the cervix or in the vagina, they should be carefully treated — best by the application of a strong solution of nitrate of silver, a dram to the ounce. It may be necessary to repeat the intra-uterine douches several times — in fact, several times a day for many days ; in this case plain sterile water only should be used. Nothing is gained by the employment of strong sublimate solutions, which can not always reach and destroy the infecting micro-organisms of the genital tract, but which do have a most depressing action upon the body- cells of the walls of that tract, reducing their resisting power against the invasion of attacking bacteria, and which may fatally poison the patient. The author has employed a one per cent, formalin solution in glycerin and water, tincture of iodin, 1 dr. to a pint each of water and alcohol, and a five per cent, argyrol solution as intra- uterine douches with better results than are obtained by sublimate solutions. It is rarely necessary to repeat the instrumental evacuation of the uterus. It may be advisable to provide drainage from the uterine cavity by the insertion of a strip of gauze to the fundus. This is only necessary, however, in cases of flabby, relaxed wombs which are so sharply anteflexed as to prevent the free exit of the lochial discharge. The general treatment is stimulating. The patient should have as much food of an easily digestible character, chiefly milk, 47 7 $8 PA THOL OGY OF THE P UERPERIUM. as she can assimilate, and as much alcohol as she can consume without showing the physiological effects of it. Digitalis is useful as long as the pulse is above no. Strychnin may be combined with it in suitable cases. To tide the patient over emergencies, carbonate of ammonia in large doses, by the bowel, and nitroglycerin hypodermatically, may be required. Inhala- tions of oxygen may also be of service. Absolute rest and freedom from all disturbances, mental and physical, must be insisted upon, and the patient should be given the best nursing that the family can afford. The Serum =therapy of Puerperal Sepsis. — Stimulated by the success of this treatment in diphtheria and in a few other infec- tious diseases, an effort has been made to procure a serum that is antagonistic to streptococci and antidotal to the products of their activity. Richet and Hericourt x suggested, some years ago, the use of serum taken from animals "vaccinated" with a septic micro- organism, in order to secure immunity in other animals. Mar- morek deserves the credit of introducing this method to the medi- cal world. 2 There are two ways of immunizing animals. One is to take culture media with the microbes destroyed or removed, and containing only the toxins of streptococcic activity. The other is to inject the streptococci themselves into the animal which is to be made immune. The latter is the more reliable method. Marmorek was able to immunize horses, asses, sheep, and mules by injecting exceedingly virulent streptococcic cultures in increasing doses during a period of six to ten months. Taking the serum from animals at least four weeks after the subsidence of all the symptoms in the reaction following the last inoculation, he found that 7 £ part of a guinea-pig's weight in serum was sufficient to protect it against ten times the dose of virulent strep- tococci, which would be fatal in animals unprotected. But he admits that there may be a streptococcic infection so virulent that no antidote is of avail, and also that if the anti- streptococcic serum is employed late after the primary infection, the progress of the septic inflammation can not be arrested. Moreover, the antistreptococcic serum has no antagonistic power over the other micro-organisms of puerperal sepsis ; so that the quite common cases of mixed infection in which the colon bacillus, the bacillus fcetidus, the bacillus pyocyaneus, and the pyogenic staphylococci are active may not be benefited in 1 "Comptes rendus de l'Academie des Sciences," 1888, p. 690. 2 " Le Streptocoque et le serum Antistreptococcique," Alexandre Marmorek, "Annales de l'lnstitut Pasteur," t. ix, July, 1S95, p. 593. PUERPERAL SEPSIS. 739 the least by the antistreptococcic serum. It appears also that there are several varieties of streptococci, so that the serum antidotal to one is inert against the others. The judgment on the serum-therapy of streptococcic infec- tion must at present run as follows : It requires a long time and especially virulent inoculations to obtain a serum with antitoxic and germicidal properties. It should be prepared, therefore, with great care, and should be obtained from a thoroughly reliable source. There is a possibility that this serum may contain danger- ous toxins, and that the treatment may be more dangerous than the disease. There is a streptococcic infection so virulent that the antitoxin will be of no avail, no matter how strong it may be. There is an undeterminable time in streptococcic infections, when the serum will be used too late. The antistreptococcic serum has no antagonistic power over other pathogenic micro-organisms. It is logical to use it only if a blood-culture has shown a general systemic streptococcic infection. Finally, the clinical results of the serum-therapy for puerperal infection have not been at all encouraging. A committee appointed by the American Gynecological Society 1 reported in May, 1899, that 352 cases had been treated by anti- streptococcic serum, with a mortality of 20.74 per cent. After a personal trial of the method extending over three years I discarded it, but have lately resumed its use, as it undeniably is followed occasionally by decided and sometimes by brilliant results. From 20 to 80 c.c. are injected once to four times a day. Further studies of the anti-streptococcic serum, as to its bacteriolytic power, agglutinating activity and as a stimulating agent for the production of opsonins, with improvements in its production suggested by this investigation, promise a remedy in the future of great use. The Treatment of Septic Infection by the Artificial Production of a Hyperleukocytosis. — Phagocytosis has been demonstrated to be par- ticularly effective in destroying streptococci, if the blood serum is rich in opsonins, the mere overplus of leukocytes not being sufficient unless the bacteria are opsonated. It is logical there- fore to stimulate the production of leukocytes if at the same time measures are taken to increase the opsonins of the blood. Antistreptococcic serum does the latter to some extent, it is claimed. 2 Several agents have leukocytotic powers, notably pilocarpin, albu- mose, and nuclein. The last is the best remedy in septic infec- 1 " Am. Jour, of Obstet.," vol. xl, No. 3, 1899. 2 " Phagocytosis and Opsonins," Ludvig Hektoen, "Journ. Am. Med. Ass.," May 12, 1906. 74-0 PATHOLOGY OF THE PUERFERIUM. tion. Ten to sixty minims of nuclein solution should be given hypodermatically three times a day. The first, however, is not advisable in sepsis on account of its depressing action. Hofbauer, 1 from Schauta's clinic in Vienna, reported the results of employing Horbaczewski's nuclein in seven cases of puerperal infection, and in a later report adds twelve more to the list. 2 The cures effected in some of these cases certainly warrant a further trial of the method. For some years I have administered nuclein routinely as part of the treatment of puerperal sepsis, combined with local disinfection, stimulation, and support, and in suitable cases with operative treatment. The Treatment of Sepsis by Washing the Blood ; Hypodermatocly= sis; Intravenous Injections of Saline Solutions, 3 is a modern treat- ment attended with decided success. The best fluid for the purpose is I y 2 gr. CaCl, 1 1 ^ gr. KC1, to 34 oz. normal salt solution. 4 Injections of large amounts — more than two quarts — of this fluid into the bowel seem to give as good results as hypodermatoclysis, and are much more convenient. The use of the modified normal salt solution is a valuable adjuvant to the other measures required in the treatment of puerperal sepsis. The Operative Treatment of Sepsis in the Child=bearing Period. — Since the first performance by Tait of abdominal section for puru- lent peritonitis there has been an extremely important develop- ment, in the scope of pelvic and abdominal surgery for septic in- flammations during the child-bearing period. Regarded at first as a procedure analogous to opening an abscess anywhere on the body, the whole abdominal cavity being looked upon as an abscess-cavity and the abdominal walls as its capsule, abdominal section for puerperal sepsis has become a generic term of wide significance, including hysterectomy, salpingo-oophorectomy, evacuation of abscesses in the peritoneal cavity and in the pelvic connective tissue, removal of gangrenous or infected neoplasms of, or in the neighborhood of the parturient tract, and exploratory incisions. Indications for Abdominal Section in the Treatment of Piter- peral Sepsis. — It is more convenient to deal generically with the indications for abdominal section in the course of puerperal sepsis, 1 "Centralbl. f. Gyn.," No. 17, 1896, p. 441. 2 "Arch. f. Gyn.," Bd. lxvii, H. 2. 3 Bosc, " Presse medicale," No. 49, 1896. 4 See experiments of W. H. Howell, in Boston, on frog's heart ; modified Ringer fluid. "The Use of Intravenous Saline Injections for the Purpose of Washing the Blood," H. A Hare, "Therapeutic Gazette," April 15, 1897. The technic of the injection is the same as for the injections required in the treatment of the acute anemia following severe hemorrhage. PUERPERAL SEPSIS. 74 1 for the operation is usually decided upon in practice without refer- ence to what may be required after the abdomen is opened, the surgeon holding himself in readiness to perform any of the pelvic or abdominal operations detailed above that may be found neces- sary when the abdominal cavity is exposed to view and to touch. In order to decide correctly for or against celiotomy in the course of puerperal septic fever, the medical attendant must be familiar with the different forms of sepsis after labor, and should know which of them are most and which are least amenable to surgical treatment. In a general way, it may be stated that the opera- tion is demanded most frequently for localized suppurative peritonitis ; it may be indicated, and often is, for diffuse suppura- tive peritonitis ; for suppurative salpingitis and ovaritis ; for sup- purative metritis, if the inflammation extends outward toward the peritoneal investment of the womb or into the connective tissue of the broad ligament ; for abscesses in the pelvic con- nective tissue ; for infected abdominal or pelvic tumors. On the contrary, abdominal section is contraindicated or is not required in simple sapremia ; in septic endometritis of all forms — diph- theric, 1 ulcerative, suppurative ; in dissecting metritis, sloughing intra-uterine myomata, which can usually be removed by the enu- cleation or avulsion, but which may require hysterectomy, or in suppurative metritis with the abscess pointing into the uterine cavity; in phlebitis, lymphangitis, and in direct infection of the blood- current. One is most likely to perform an unnecessary operation in diphtheric endometritis. The writer has thus erred several times. By the time that symptoms justify surgical inter- vention in this condition it is almost always too late. It is difficult to formulate rules in a situation involving so much responsibility, and of necessity so dependent upon many circum- stances, as that seeming to require a very serious surgical opera- tion in the midst of an adynamic fever with, very likely, profound depression, rapid pulse, high temperature — in short, with every- thing a surgeon least desires in the face of a major operation. The operative treatment of puerperal sepsis should be avoided if possible, and is not indicated by the cardinal symptoms of septic infection — high temperature, rapid pulse, and general depression. There should be some demonstrable evidence of intrapelvic or abdominal inflammation, necrosis, or suppuration. On the first appearance of symptoms that justify the diagnosis of diffuse suppurative peritonitis, the abdomen must be opened 1 By diphtheric endometritis is meant a dirty, grayish- or greenish-brown exudate on the endometrium, containing mixed micro-organisms, and not necessarily the Klebs-Loffler bacillus. For a report of one and the mention of four cases of true diphtheria of the genitalia see Williams, " Amer. Jour, of Obstet.," August, 1898. 74 2 PATHOLOGY OF THE PUERPERIUM. without more delay than is necessary for an aseptic operation. Even with the utmost promptness the operation is almost always too late, for the inflammation extends so rapidly and at first insid- iously that by the time a diagnosis is possible the progress of the disease can not be stayed. It must be admitted, however, that an occasional success is possible by timely surgical interference. 1 Again, in the presence of exudate, adhesions, or unnatural enlargement of any pelvic structure, suppuration may be sus- pected if the physical signs do not improve and if the tempera- ture, pulse, and general condition indicate a continuance of septic inflammation. It is hardly necessary to state that if pus forms it must be reached and evacuated irrespective of its situation. Just how long to wait, however, is a question requiring experi- ence, good judgment, and a special study of each individual case for its correct answer. Enormous pelvic and abdominal exudates may disappear ; adhesions may melt away ; enlarged and inflamed tubes, ovaries, and uterus may resume their proper size, functions, and condition on the subsidence of the inflammation ; but in these favorable cases distinct signs of improvement manifest themselves in a few days, and the course of the disease is comparatively short. A mere protraction of septic symptoms is in itself suspicious, along with local signs of inflammation. Without the latter, the same general symptoms, sometimes lasting for months, indicate phle- bitis and infection of the blood-current. In this form of sepsis an operation can do no good and may do the greatest harm. In infected tumors in and near the genital tract the indication for operation should be plain and the decision easy. The pres- ence of the tumor should, of course, be known. On the first sign of inflammation in it, or in the event of an elevated temperature for which there is no good explanation, the tumor should be removed. Early operations in these cases have furnished the best results, delayed operations the reverse. 2 In cystic tumors the likelihood of twisted pedicle should be remembered, and in every case of child-birth complicated by a new growth the woman should be watched with extraordinary care to detect the first indication of trouble. An exploratory abdominal incision should be made, as a rule, only when it is desired to determine if a pelvic mass, presumably 1 Hirst, "A Diffuse, Unlimited, Suppurative Peritonitis in a Child-bearing Woman Cured by Abdominal Section," "Medical News," 1894. 2 The most desperate cases, however, need not be despaired of. I have success- fully removed a gangrenous ovarian cyst from a puerpera who was so weak that complete anesthesia was not attempted. The late Dr. Goodell had declined the operation as necessarily fatal. PUERPERAL SEPSIS. 743 containing pus, is situated within or without the peritoneal cavity, and if the abscess had better be evacuated through the abdominal cavity or extraperitoneally. In the early period of experimentation with abdominal section for puerperal sepsis exploratory incisions were made in obscure cases without local symptoms of inflammation in the pelvis or the abdomen. None of these operations yielded information of value, nor did they bene- fit the patients. Consequently, it is a safe rule not to open the abdo'men of a puerpera for sepsis unless there are physical signs of inflammation in the abdomen or the pelvis. The proposition of Bumm and others to ligate or exsect the ovarian veins in thrombophlebitis has not given satisfactory results in practice and does not appeal to the author as reasonable. Following these general statements in regard to abdominal section for puerperal sepsis, it is now more convenient to describe in detail the different kinds of operations required for the various forms of intra-abdominal septic inflammations. Abdominal Section for Litraperitoneal Abscesses and Diffuse Suppurative Peritonitis. — The situation and extent of localized suppuration within the abdominal cavity vary greatly. A quarter of the abdominal cavity may be filled with pus, the huge abscess-cavity being thoroughly walled off by dense exudate from the rest of the abdominal cavity. A smaller accumulation of pus about the orifice of the tube is not uncommon. Occasionally two or three abscesses the size of an orange are found between coils of intestine quite far removed from one another, and with- out apparent connection with the genital tract. Abscesses are found also between the fundus uteri and adjoining structures — the abdominal wall near the umbilicus, the caput coli, and the sigmoid flexure. In these cases infection travels through a sharply-defined area of uterine wall and appears in the same limits on its peritoneal investment. Exudate and adhesions immediately wall off the infected area, with the result of an encapsulated abscess between the uterine wall and the structure nearest to it at the time of inflam- mation. The treatment of these abscesses is evacuation, cleansing, and drainage. The cleansing may be effected by flushing with hot sterilized water, if the rest of the abdominal cavity can be guarded from contamination. In some cases the writer has avoided irrigation and in its place has thoroughly dried the cavi- ties with gauze with good results. For drainage, as a rule, sterile gauze with a glass or rubber tube is best. In certain cases of abscesses near the abdominal walls a rubber tube answers better than the gauze, and in deep-seated abscesses on the base and the back of the broad ligaments vaginal drainage by means of gauze or rubber tube is preferable. If the work during the operation is 744 PATHOLOGY OF THE PUERPERIUM. well done, there may be little or no subsequent discharge, and douching of the abscess-cavities during convalescence is un- called for. Occasionally, however, if the abscess-cavity is very large and well isolated, daily douching with sterile hot water is an advantage. In diffuse suppurative peritonitis the remote chance of success depends greatly upon the earliest possible oper- ation, though there are many virulent cases in which nothing could check the spread of the inflammation and the deadly effect of septic intoxication. This is not the place to discuss the symptoms of diffuse sup- purative peritonitis, but one fact should be insisted upon from the operator's point of view. It is usually supposed that true diffuse suppurative peritonitis appears early after delivery ; it may, however, develop at any time — as late as four weeks after confinement. The technic of the operation is simple: A small incision is made, and the finger is rapidly swept about the pelvis and abdomen to determine the condition of the organs; then the irrigating tube is passed into the cavity at the lowest angle of the wound, and is swept about in all directions, while the return-flow is provided for by two fingers of the left hand distending the sides of the wound, which by the fingers and the irrigating tube is kept gaping as though by a trivalve speculum. The irrigating tube is pressed far over first on one flank and then upon the other, and the tip is cut down upon where it projects through the abdominal wall. Gauze and glass-tube drainage into the pouch of Douglas, a gauze drain in the flanks is provided for, and the wound is left open, or, at most, drawn together by a stitch or two. Puncture of the pos- terior vaginal vault and gauze drainage into the vagina should usu- ally be added. Rapidity of operation and the smallest possible quantity of anesthetic are essential to success. Salpingo-oophorectomy for Puerperal Sepsis. — An acute pyo- salpinx in the puerperium is very rare. It is uncommon for acute septic infection after labor to travel by the tubes alone. Infection usually occurs in the uterine muscle, the veins, the lymphatics, or the connective tissue of the pelvis. When the track of the septic inflammation is confined to the mucous mem- brane of the genital tract, the pelvic peritoneum, in a case serious enough to demand operation during puerperal convalescence, becomes infected, inflamed, and suppuration quickly follows, so that the operation is usually performed for an intra-peritoneal pelvic abscess. The tube may be found somewhat swollen, inflamed, dark red in color, containing a few drops of pus, with flakes of purulent lymph on its external surface, and its removal is required ; but the pyosalpinx is a subordinate feature in the PLATE 15. PUERPERAL SEPSIS. 745 pelvic inflammation. It is the more subacute case, not usually requiring operation in the conventional period of the puerperium, that results later in a typical uncomplicated pus-tube. Ovarian abscess is much more common than pyosalpinx. The infection may travel to the ovary, both by way of the tube and by the connective tissue or lymphatics of the broad ligament. In the latter case the whole ovary may be infiltrated with a thin sero-pus of a particularly virulent character, and, unfortunately, in excising the ovary the exposure of the infected pelvic connective tissue in the stump may lead to infection of the peritoneal cavity and to a diffuse suppurative peritonitis. The commonest indication for salpingo-oophorectomy is fur- nished by a pus-tube antedating conception or by a pre-existing gonorrheal infection of the genital canal. The strain of labor excites a fresh outbreak of inflammation or leads to its spread, and the persistence of septic symptoms with the physical signs of pelvic inflammation justifies operative interference. Occasionally an operation must be performed on a presumptive diagnosis of old pus-tubes, based mainly upon the patient's history and the existence of serious septic symptoms, with tenderness on abdominal palpation over the region of the tube and ovary. The uterus is much too high in the abdominal cavity for a satisfactory pelvic examination of the uterine appendages. There is often nothing peculiar in the technic of these opera- tions. They differ, usually, in no respect from similar operations upon non-puerperal patients. The question of removing the uterus along with the tubes arises, however, rather more fre- quently than in the non-puerperal woman, on account of the infection of the endometrium or of persistent metrorrhagia. But in associated suppurative salpingitis, ovaritis, and infection of the connective tissue of the broad ligament, there is a modifi- cation of the ordinary technic, which is of vital importance. The tubes and ovaries should be excised, the blood-vessels of the broad ligaments tied separately ; the cut edges of the broad ligament should be allowed to gape ; the whole pelvic cavity should be filled with gauze and drained by a glass tube placed just posterior to the uterus. The dressings, sterile gauze and cotton, cover the tube and wound completely. They are not disturbed for twenty-four hours, when the tube is sucked out by a syringe. Twenty-four hours later the gauze is removed, the tube again sucked out and removed, after a rubber drainage- tube is slipped within it, to take its place. Through the rubber tube the pelvis is washed out daily with sterile water. Ap- parently most desperate cases may be saved by this technic. 746 PATHOLOGY OF THE PUERPERIUM. Hysterectomy for Puerperal Sepsis. — Every physician who has seen many cases of puerperal infection during operations or post- mortem is aware that there are some in which the mere removal of infected tubes and ovaries, vaginal section and drainage, or the evacuation of pelvic abscesses through the abdomen can not be expected to save the patient. There remain infected and infil- trated broad ligaments infecting the peritoneal cavity, or there are foci of suppuration or infection in the uterine body that spread to the peritoneum or result in septic metastases. The only hope for the patient in such cases lies in the entire removal of all infected areas, leaving behind in the pelvis a healthy, non-infected stump. To effect this result the excision of the uterus, the broad ligaments, the tubes, and the ovaries is required. In addition to these cases there are others in which, if the tubes and ovaries must be excised, the uterus might be removed with advantage, on account of an infected endometrium or of persistent metrorrhagia. There may also be such wide-spread suppuration and disintegration of the broad ligaments, with tubal inflammation, that it is easier to re- move all the infected area and to control hemorrhage, by a hyster- ectomy. Figure 555 represents such a case. A pyosalpinx ante- dated conception. Labor excited fresh inflammation. The in- fection spread from the tube downward through the connective tissue of the broad ligament, resulting in its partial destruction, in a thick infiltration at its base, and in an abscess between its layers, closely hugging the whole of one side of the uterine body. It was obviously impossible to remove the infected area without removing the womb as well. The operation, though undertaken under the most discouraging circumstances, was successful. There can be no doubt as to the necessity of hysterectomy in the cases represented in figures 556 and 557. There were abscesses in the uterine wall, directly under the perimetrium, about to break into the peritoneal cavity; one, indeed, did rup- ture during the operation. There was a septic ulceration at the placental site in one case so nearly perforating the uterine wall that by a light touch during the operation the forefinger passed into the uterine cavity. There was also a pyosalpinx in these cases that, judging by the history, antedated or was coincident with impregnation. The operations saved the patients. In another successful hysterectomy for puerperal sepsis, the author found the womb completely ruptured at the fundus from tube to tube. The diagnosis of the injury had not been made. The operation was undertaken some weeks after labor, for what was thought to be an intraperitoneal abscess. Areas of suppuration were dis- covered, but the greater bulk of the inflammatory mass was exudate which had shut off the general peritoneal cavity from PUERPERAL SEPSIS. 747 Fig. 555- — Suppurative cellulitis of broad ligament; hysterectomy (author's case) Fig. 556. — Suppurative and ulcerative metritis, salpingitis ; hysterectomy (author's case). Fig- 557- — Suppurating metritis: a, a, a, Abscess cavities. Hysterectomy two week-, after labor. Recovery. 74^ PATHOLOGY OF THE PUERPERIUM. infection through the gaping uterine wound. In cases of strepto- coccic infection the whole uterus may be found so necrotic that its consistence is that of cheese. No ligature holds in it and the uterine wall may be pinched through anywhere by the thumb and forefinger. One might as well expect a woman to live with a gangrenous coil of intestine in her abdomen as with such a gangrenous and necrotic uterus. She can only be saved, if at all, by a hysterectomy. It may also be necessary to remove the uterus in the puerperium to get rid of an infected fibromyoma, as illustrated in figure 558. This uterus was removed on the fourth day of the puerperium, the patient's temperature having been 104 and the pulse 140. Streptococci were found in the interior of the tumor and there was general systemic infection, with phlebitis and septic pneumonia, but the woman recovered. Indications for the Operation. — The indications for hysterec- tomy during puerperal sepsis are furnished by the condition of the pelvic organs when they are exposed to sight and touch after the Fig. 558. — Submucous fibroma removed by hysterectomy in the early puerperium. (Author's case.) abdomen is opened. The conditions described are the types calling for hysterectomy. It is not often possible to determine upon hysterectomy before the abdomen is opened, but it should be remembered that in any abdominal section for puerperal sepsis hysterectomy may be necessary. The surgeon, therefore, should be provided with the implements required for amputation of the womb in every abdominal section for puerperal sepsis, and should be prepared to remove it for any one of the indications described PUERPERAL SEPSIS. 749. above, but should rest content with the least radical measure that promises his patient safety. The operation that is quickest done and shocks the patient least is most successful, provided, of course, that it is adequate. An excision of one or both cornua or of the fundus may suffice instead of a hysterectomy. Technic of the Operation. — There are two points in which the technic of hysterectomy for puerperal sepsis may differ from the technic of the operation performed for other conditions. One is the necessity often of doing pan-hysterectomy; the other is the necessity often of tying the ligatures in a broad ligament much thickened by inflammatory exudate or by ligating the blood-vessels separately so as not to include an infected mass in the ligature. The author prefers amputation of the uterus, leaving as little cervix as possible, unless an examination of the cervix by a spec- ulum shows septic ulceration or exudate upon it or in its canal. The reasons for this preference for amputation of the womb over pan-hysterectomy are that the former can be done more quickly, Fig. 559. — Suppurative ovaritis (rear view). there is not the same anxiety about the cleanliness of the vagina, the suture material is more certainly guarded from infection after- ward, and there is less danger of cutting or ligating the ureters. The thickened broad ligaments are often a source of serious embarrassment in placing and tying the ligatures around the uterine arteries. There is this difficulty to contend with in the majority of the operations. In some cases the inflammatory exu- date within and below the ligature breaks down into pus, but an incision in the posterior vaginal vault evacuates the pus and secures an immediate disappearance of somewhat alarming symptoms. Vaginal hysterectomy is usually unsuitable for cases of puerperal sepsis on account of the danger of clamping or ligating large masses of infiltrated and infected broad ligament, on account of the stiff- ened and adherent broad ligaments, which make downward trac- tion on the uterus difficult or impossible, and because it is imprac- ticable in a vaginal operation to explore the pelvis and abdomen for foci of infection at some distance from the pelvic organs. 750 PATHOLOGY OF THE PUERPERIUM. Exploratory Abdominal Section jor Puerperal Sepsis. — An exploratory incision should be made only in cases of suspected extraperitoneal pelvic abscess, to confirm one's suspicion, to be certain that none of the pelvic organs, especially the tubes, are diseased, and to determine the best situation for the incision to evacuate the abscess-cavity without contaminating the peritoneal cavity. This rule of practice would exclude exploratory abdominal section in cases with no physical signs of pelvic inflammation, but in which there is evident septic infection of a nature difficult to determine. There are possible exceptions to the rule, however, as in suspected pyosalpinx without physical signs, owing to the high position of the recently emptied womb and of its appendages. Figure 560, drawn from life, represents a typical case requiring exploratory abdominal section. The woman had had a miscarriage some weeks before. She had lost over thirty pounds in weight, was bedridden, had night-sweats, high fever, profound prostration, and exacerbations of pain in the pelvis. On examination, the usual symptoms of extra- peritoneal pelvic exudate and suppuration were found on the right side. When the abdomen was opened, it was found that all the pelvic organs and the pelvic peritoneum were per- fectly healthy. There was a large collection of pus between the layers of the right broad ligament, giving to this structure a dome-shape. The tube and ovary running over the top of the distended broad ligament were perfectly healthy and without a trace of adhesion or inflammation of any kind. With the abdo- men opened it was easy to locate the level of the anterior dupli- cation of the peritoneum. A mark was made on the skin an inch below this point, the abdominal wound was closed, an inci- sion was made in the groin, as shown in the drawing, and the pus washed out by douching. Sinuous tracts of suppuration were found by the finger running up the psoas muscle and down into the floor of the pelvis. Two drainage-tubes were inserted, one upward into the psoas muscle, the other downward into the pelvis. In the course of this woman's convalescence it was found advisable to make a counteropening in the right lateral fornix of the vagina, and to pass a drainage-tube through from the opening in the groin to the vagina. In this way perfect drainage was established, and the patient made a good recovery. Cases of true extraperitoneal pelvic abscess due to puerperal infection, and without intraperitoneal inflammation, are rare. There are some gynecologists who deny their existence, but the writer has had eight cases under his charge in which the diagnosis was established by abdominal section. In two cases the suppuration was so evidently extraperitoneal PUERPERAL SEPSIS. 751 Fig. 560. — Exploratory abdominal section ; incision in groin for extraperitoneal abscess (author's case). Fig. 561. — Streptococcus and staphylococcus infection of the endometrium: a, Necrotic layer of the endometrium ; />, zone of inflammatory reaction ; c, gland spaces ; d, blood-vessels ; e, remnants of glandular epithelium (Bumm). 75 2 PATHOLOGY OF THE PUERPERIUM. that an abdominal section was dispensed with. An incision was made in the flank above the crest of the ilium and another in the groin above Poupart's ligament. A pint or more of pus was evacuated. In one case an abdominal incision was made for what was thought to be an intraperitoneal abscess. Before the incision was completed pus welled out of the utero-vesical con- nective tissue. A large extraperitoneal abscess was found be- tween the uterus and bladder. It was counterdrained through the anterior vaginal vault, but in doing so the bladder was punc- tured. Another case exactly similar was deliberately opened by an incision above the symphysis and below the anterior redupli- cation of the peritoneum. All these cases of extraperitoneal sup- puration recovered. Vaginal Section for Pelvic Suppuration or for Infection of the Pelvic Connective Tissue. — If there are physical signs of an ab- scess in Douglas' pouch and no evidence of involvement of the rest of the peritoneal cavity, or if the woman's condition is too bad to admit of an abdominal section, a colpotomy of the poste- rior vaginal vault and an irrigation of the pelvic cavity with sterile water is indicated. After cleansing the vagina with tincture of green soap and a sublimate douche, the mucous membrane of the posterior vaginal vault is incised with a knife, and then with sharp-pointed scissors or one's fingers the opening into the peri- toneal cavity is completed. Adhesions are cautiously separated so as to avoid opening the general peritoneal cavity and the pel- vic organs are carefully palpated to detect isolated foci of sup- puration, which if found are opened. The pelvis is irrigated through a two-way catheter with sterile water and then packed quite firmly with a strip of iodoform gauze. The vagina is also packed. The pelvic packing is removed after two days or more and is replaced by a T-shaped rubber drainage-tube through which the pelvic cavity is irrigated daily with sterile water for ten to fourteen days. Incisions in the lateral fornices and gauze drainage are of service in suppuration of the parametrium or in accumu- lations of infected serum in it. The Morbid Anatomy and Clinical History, the Diagnosis and Treatment of the Different forms of Infection and Septic Inflammation of the Genital Region After Labor. — The mani- festations of puerperal sepsis differ with the various infecting bacteria that are lodged in the genital tract or have invaded the system, but especially with the organs or structures that are involved in the septic inflammation. The terms, therefore, "puerperal infection," "puerperal sepsis," or "puerperal fever," are generic in significance and include a number of distinct dis- eases, widely different in their symptoms, their prognosis, and PUERPERAL SEPSIS. 753 their requirements for treatment. The lesions of puerperal sepsis may be found in the mucous membrane of the genitalia from the vulva to the abdominal orifices of the tubes, in the mucous mem- brane of the bowel, and of the urinary tract, the myometrium, the pelvic connective tissue, the peritoneum, the lymphatics, the veins, and in the parenchyma of the ovaries. Neighboring organs and tissues may be involved secondarily, as the bowels, appendix, ureters, and pelvic nerves, and tumors of the pelvis and abdomen may be the starting-point of septic infection and inflammation. Endocolpitis, Endometritis, and Salpingitis. — These inflamma- tions are most often of the superficial suppurative variety, in which the prognosis is good, except in the case of the tubes, whence the inflammation may extend to the peritoneum, causing diffuse peri- tonitis or a circumscribed abscess near the fimbriated extremities, usually involving the ovary, or a pyosalpinx. The streptococcic inflammation of these membranes with an exudate and necrosis of tissue is much more dangerous. It may be localized in the vagina in the shape of ulcers near the ori- fice or extending up the wall to the cervix. It may be a diffuse, yellowish-green, foul-smelling exudate, occupying the whole inte- rior of the uterus, in which streptococci, the bacillus pyocyaneus, the bacillus fcetidus, and the staphylococcus pyogenes albus or aur- eus are found. Under the necrotic layer of the endometrium there is a layer of granulation-cell infiltration upon which the woman's life depends. If it is well developed, it resists the invasion of the septic micro-organisms. If not, there is a likelihood of systemic in- fection of a grave character. In rare instances the Klebs-Loffler bacillus may be discovered in the pseudomembrane, showing that the case is one of true diphtheria, and the diphtheria of the vagina may be associated with diphtheria in the throat. 1 If the diph- theric inflammation affects the lower portion of the vagina, there is edema of the vulva in at least two-thirds of the cases. Diagnosis. — The diagnosis of these inflammations is made in the case of vaginitis by inspection, in salpingitis by a combined examination, and in endometritis perhaps by the character of the lochia, 2 or by inspection of the cervical canal, which may be lined with the same exudate that covers the endometrium. The diag- nosis between pseudodiphtheric membranes and true diphtheria can only be made by a bacteriological examination. It is most 1 J. W. Williams, five cases, loc. cit., to which should be added one of my own, with diphtheria of the throat in the husband and true diphtheria of the vagina in the wife, demonstrated by bacteriological examination. 2 A foul odor is not distinctive of anything except decomposition. The necrosis of the endometrium usually gives rise to this symptom. But the worst streptococcic infection may be associated with odorless lochia. There is usually, however, a pro- fuse serosanguinolent or purulent discharge, but the lochia may be suppressed. 4« 754 PATHOLOGY OF THE PUERPERIUM. important that this should be done, for cases of true diphtheria should be isolated. The treatment of these inflammations is frequently repeated irrigations of the whole genital tract. Sterile water is best for this purpose. An antiseptic simply diminishes the resisting power of the body-cells without destroying the micro-organisms that are the cause of the inflammation. In cases of septic endometritis the systemic symptoms are grave, and a supporting, stimulating treatment is required in addition to the local treatment. In salpingitis a celiotomy may be demanded. If the inflammation is localized and the in- flamed area accessible, it should be touched with a nitrate of silver solu- tion, 5j-oj. Metritis and Cellulitis of Subcutan= eous and Pelvic Connective Tissue ; Septic Metritis. — As a later stage of septic endometritis all the structures of the womb may be involved — connective tissue, muscles, lymphatics, and often the veins, especially, however, the first. In the process of the inflammation por- tions of the uterine muscle may be undermined by ulceration and may slough off (dissecting metritis). Liep- mann reports a case associated with diabetes mellitus, and another with perforation into the bowel. 1 A limited area of uterine tissue may be involved, not larger in circumference, perhaps, than a dollar. The inflammation ex- tends directly through the uterine wall, still confined within its original limits, until the peritoneal covering is reached. Here the inflammatory process is also strictly limited by the rapid develop- ment of adhesions which bind the womb to those structures in the peritoneal cavity nearest the diseased area. The uterus may be anchored to the caput coli, the anterior abdominal wall, and the sigmoid flexure. In these cases involution goes on imper- fectly, of course, for the womb can not be normally reduced in size, held as it is at a high level in the abdominal cavity by adhesions. There are, however, besides the fixation and ar- rested involution of the womb, no other local evidences of inflam- 1 "Arch. f. Gyn.," Bd. lxx, H. 2. Fig. 562. — Dissecting metritis (Liepmann). PUERPERAL SEPSIS. 755 mation, excepting some tenderness on pressure. It is usually impossible to locate the intraperitoneal abscess, by abdominal palpation or combined examination, on account of its situation. The course of these cases is slow, but they are ultimately almost certain to be fatal, for an abscess commonly develops on the diseased area of uterine surface between the uterus and the structures attached to it, usually the bowel or omen- tum. A bacteriological examination of some of these cases has shown the presence in the uterine wall of pyogenic staphy- lococci. If the pelvic connective tissue is involved, it is at first edema- tous. The serum is then absorbed, leaving a dense infiltrate, if there has been much cell-proliferation, or entirely disappearing if the cell-element is scanty. The infiltrate, if not too extensive, is likewise absorbed in about four-fifths of all cases. Occasionally, however, in about one-fifth of the cases an abscess results, which may be opened above Poupart's ligament, or through the vaginal vault without entering the peritoneal cavity, but which may spontaneously rupture into the abdominal cavity, or may perforate the rectum, bladder, vagina, or uterus. Diagnosis. — The diagnosis of metritis is difficult. The womb is large in size, the walls feel boggy, and the uterus is very sensitive to pressure; but it is almost impossible to be positive that metritis exists unless one can feel an abscess in its walls by an intra-uterine examination, or unless the collection of pus breaks into the uterine cavity. If the abdomen must be opened for the septic infection, the condition of the womb is, of course, easily determined. Ab- scesses may be seen in its walls, and ulceration may so nearly perforate them that when the operator's finger is laid upon the peritoneal covering of the womb, it penetrates at once into the cavity. The diagnosis of pelvic cellulitis is usually easy to establish. The exudate and infiltration can be felt on a vaginal examination. It is often, however, impossible to decide whether the inflam- mation is limited strictly to the pelvic connective tissue, or whether the pelvic peritoneum is also involved. If the exudate is situated only upon one side of the womb and does not involve Douglas' pouch, one has the right to suspect pelvic cellulitis without pelvic peritonitis, but in my experience it has almost always been necessary to open the abdomen before obtaining a positive answer to this question. Treatment. — Occasionally, septic metritis ends in recovery by the discharge of pus-collections into the uterine cavity, or by the resolution of inflammation. But the worst cases demand hys- 756 PATHOLOGY OF THE PUERPERIUM. terectomy. Cellulitis yields in the majority of cases to rest in bed, counterirritation, the ice-water coil or poultices over the lower abdomen, and hot vaginal douches. If it fails to do so, an abdominal section should be performed, in order to be sure that the peritoneum is not involved. If the inflammation is found, after the abdomen is opened, to be confined strictly to the pelvic, connective tissue, the abdominal wound should be closed, and the infected area, if it has suppurated, should be opened by an incision above Poupart's ligament, or through the vaginal vault. Pelvic Peritonitis and Diffuse Peritonitis. — Pelvic peritonitis is the result of the extension of a septic endometritis, either through the tubes or directly through the tissues of the womb, or it fol- lows pelvic cellulitis, the germs penetrating the peritoneum be- tween the endothelial cells or through the lymphatic interspaces. In an extension through the tubes or by the spread of a cellulitis the ovary is likely to be involved, and an ovarian abscess develops. A leakage of lochial or catarrhal discharge through the abdominal orifice of the tubes is by no means uncommon. It is followed by a sharp localized peritonitis, though it is not certain that the discharge is always septic. It may be simply irritating. The infected or irritated region may be surrounded by large areas of peritoneal exudate. A large section of the abdominal cavity, one-fourth or more, may be thus, as it were, solidified. On palpation, the abdominal contents feel hard as stone, with the muscles of the abdominal wall involuntarily fixed over them for protection, on account of great sensitiveness to pressure. Occasionally, the exudate communicates to the fingers a sensation as though snow were being kneaded through a covering of some flexible material. The symptoms are not alarming, and the common termination of this kind of peritonitis is recovery. The exudate is absorbed, the tenderness disappears, the temperature sinks to normal, and no ill-effects are left behind ; but the exu- date may break down and encapsulated abscesses may thus be formed, opening into the bowel, into the bladder, through the abdominal walls at the umbilicus, or possibly undergoing caseous changes. General peritonitis after labor may result from an exten- sion of pelvic peritonitis ; from infection through rents in the vaginal or uterine walls ; from the rupture of old pus-collections in the tubes or elsewhere in the pelvis ; from putrefaction of tumors in the pelvis, as of dermoids and fibroids ; irom the transmission of pathogenic bacteria by the lymphatics, and from the extension of septic inflammation through the bladder- walls. PUERPERAL SEPSIS. 757 If the suppurative peritonitis is not limited, the intestines are lightly glued together; are bathed in a thin pus, which lies in pools between their coils and are covered with a yellow- ish exudate, which can be stripped off, leaving a raw, bleeding surface. There is a form of septic peritonitis so virulent and poisonous that no signs of inflammation accompany it, and the patient dies before pus or exudate can be formed {peritonitis lymphaticd). The abdomen is found, after death, filled with a dirty fluid, composed of serum, some blood, and numberless micrococci. In all forms of septic peritonitis the coats of the intestines are paralyzed and tympanites is marked. Day of Diseaae M £ M E M £ M £ to £ A/ £ M £ 103° 102° 101° 100° 99° ^ ^ Fig- 5^3- — Temperature-chart of diffuse purulent peritonitis. Diagnosis. — The diagnosis of pelvic peritonitis is made by the general symptoms and by the local physical signs. There is fever of varying degree, with accelerated pulse and general depression. There is marked tenderness over the lower ab- domen, and there is tympanitic distention of the abdomen. Aus- cultation shows absent or feeble peristalsis. On making a vaginal examination exudate is found in Douglas' pouch and to the sides of the womb, which is firmly fixed. The exudate is usually ex- quisitely sensitive to pressure. It is sometimes firm and hard, and, again, may be soft and boggy. If the latter condition persists, it is indicative of suppuration. General peritonitis is usually sudden in its onset and very rapid in its course. It occurs ordinarily in the first few days of the pucrperium. There is extreme distention of the abdomen ; a rapid, running, wiry pulse ; an extremely anxious, pinched expression of the face ; the eyeballs arc sunk deep in their sockets and there are dark rings under them ; there is a peculiar grayish color of the skin, and, 758 PATHOLOGY OF THE PUERPERIUM. ' ffek, perhaps, high fever, agonizing pain, and possibly dullness on percussion at certain points in the abdominal cavity; but the latter signs may be entirely absent. There may be absolutely no tender- ness nor pain, no dullness, and very little fever. Malignant cases may end fatally within forty- eight hours from the first appearance of symptoms, with a temperature never exceeding ioo^° by the mouth, though the rectal temperature is often much higher. Treatment. — It is difficult to determine at first whether a pelvic peritonitis will end in suppuration or resolution. As the latter is always possible, the treatment should at first be expectant. Counterirritation and poultices may be used over the lower ab- domen ; an ice-bag or the ice-water coil is often of the greatest service ; the bowels may be thoroughly drained by a strong purgative, so as to diminish intra-abdominal congestion and inflammation, and copious hot vaginal douches may be given. If the symptoms persist much beyond forty-eight hours in their original intensity under this form of treatment, suppuration has prob- ably occurred, or must be expected. In such-a case the abdomen should be opened. Abscesses, if they are found, must be evacuated and the cavities thoroughly cleaned, disinfected, and drained. Dis- tended tubes and ovaries must be removed, and it may be necessary to perform hyster- ectomy. If the abscess is localized in Douglas' pouch, or if the patient's condition is very bad, vaginal section is preferable, followed by drainage through the posterior cul-de-sac. General, diffuse, suppurative peritonitis is almost invariably fatal, let the treatment be what it may. The only possible chance for such a case is in the earliest possible performance of an abdominal section with free irrigation of the abdominal cavity and drainage through the abdominal wall, the flanks, and the posterior vaginal vault; but even though this be done within twelve hours of the onset of symptoms, it will almost invariably be of no avail. Once in a long while, however, a case of true diffuse suppurative peritonitis may be saved by a timely operation. Fowler advocates raising the head of the bed after these opera- Fig. 564- — Clots in sinuses of uterine walls (from specimen in the Army Medical Museum, Washington, D. C). PUERPERAL SEPSTS. 759 tions, so that the patient's body has a downward slant of 30 degrees or more, to facilitate drainage. 1 This proposition appeals to the author's reason and he adopts it. Uterine and Parauterine Phlebitis. — The veins of the uterus and of the surrounding connective tissue are prone to thrombosis by reason of the sluggish circulation, the pressure during preg- Fig. 565. — Section through the placental site of a puerpera who died on the eighth day from embolic pneumonia (thrombotic form of infection) : a, Necrotic de- cidua, with colonies of streptococci and saprophytes ; b, thrombus in a vein opening at the placental site ; c, zone of inflammatory reaction ; , muscular tissue (l!umm). bacillus upon the pharyngeal and upon the vaginal mucous membranes. If a physician can not escape the necessity of at- tending a woman in child-birth while in attendance upon conta- gious diseases, he should take a full bath, should rinse his mouth 774 PATHOLOGY OF THE PUERPERIUM. and brush his teeth with an antiseptic mouth- wash, should change his clothing throughout, and should be as long as possible in the open air afterward before he sees his parturient patient, in addition to ob- serving a careful aseptic technique in his examinations of the patient. Erysipelas. — The connection of erysipelas with puerperal in- fection may be dismissed in a few words. Modern bacteriologi- cal research points to the identity of the streptococcus pyogenes and the streptococcus erysipelatis. The production of pus and internal inflammation or of an efflorescence upon the skin is simply a question of virulence and of situation. It is not surprising, § Fig. 576. — Enlargement of a section of figure 575, showing streptococci. therefore, to hear of such experiences as those of Winckel, who has found germs in abscesses of the pelvis after labor that on inoculation produced erysipelas, and who has seen one of his nurses, after catheterizing a febrile patient, develop erysipelas of the face from a drop of the lochial discharge that splashed upon her nose. Other clinical facts are also easily explicable by the identity of the pyogenic and of the erysipelatous streptococci. In the course of puerperal infection, erysipelas may appear upon the labia and spread thence down the thighs or over the trunk. If the patient, on the contrary, contracts erysipelas in some portion of the body remote from the genitalia, as upon the breast or face, the disease may run its ordinary course without symptoms of infection of the genital tract and without great danger to life ; but if the infection spreads to the genitalia or has its origin there, the danger of death is great. DipJitlicria. — The connection between diphtheria and epi- demics of puerperal infection has been demonstrated beyond a doubt by a vast amount of clinical observation. To select a single example out of many : One of my young friends and former students lost two healthy women in a week from puer- peral sepsis while he was in attendance upon a child with diph- theria. He had never had a serious case of puerperal infection before, and he has not had one since. The Klebs-Loffler bacillus has PUERPERAL SEPSIS. 775 been found in two cases of vaginal exudate under my notice in Philadelphia. As already stated, the mere disinfection of the physician's hands and arms is not enough to protect a woman against this malignant disease. Complete change of clothing, including the shoes ; a thorough soap and hot-water bath, with scrubbing of the hair, face, and exposed portions of the body ; brushing of the teeth, and gargling of the throat with an anti- septic wash, such as listerine, and a purification of the lungs by prolonged exposure in the open air, are precautions none too great or troublesome to clear one's conscience of the dreadful imputation of having destroyed the life that he is charged with preserving, if he must attend a woman in child-birth while he takes care of diphtheric patients. Scarlet Fever. — The connection between scarlet fever and puerperal sepsis is yet in doubt. Contrary to the opinion ex- pressed by some authorities, scarlet fever in the puerperium is rare. The comparatively frequent occurrence of septic erythe- mata has led many observers in the past to believe that scarlet fever is a common cause of septic infection after child-birth. The same rule obtains in the case of scarlet fever in the puer- perium that prevails in other infectious diseases during that period — namely, the woman is more susceptible to contagion, the period of incubation is shorter, and the disease is more dan- gerous than at other times. During pregnancy the woman is particularly resistant against the poison of scarlatina. She may carry it about with her while pregnant, and may only yield to it after child-birth. As evidence that the poison of scarlatina finds an entrance into the body through the mucous membrane of the genital tract, it is interesting to observe that in the puerperium the rash is more marked upon the lower portion of the body, and that the throat symptoms may be entirely absent or very mild. Malaria. — The puerperal state excites almost surely a fresh outbreak of malaria that is latent in the system, even though it has been dormant for years. There is nothing to show that the woman is likely to contract the disease during the period of puerperal convalescence itself, but if she has ever had it in her past life, it is practically certain to break out before she rises from bed. The differential diagnosis of malaria and sepsis may be puz- zling at first, but the past history of the patient, the leukocyte count, the microscopic examination of the blood, blood cultures, cultures of the lochia, and the therapeutic test usually suffice to clear up all doubt in twenty-four hours. To be on the safe side in doubtful cases, it is wise to disinfect the genital tract, as well as to administer antimalarial treatment. PART VI. OBSTETRIC OPERATIONS. Induction of Abortion. — By the induction of abortion is meant the interruption of pregnancy before the viability of the child — that is, prior to the one hundred and eightieth day of pregnancy. Indications. — The induction of abortion should be undertaken as reluctantly as one would commit justifiable homicide. If, in the course of pregnancy, some disease arises as a direct consequence of gestation, or if a woman suffering from dis- ease is made much worse by the existence of pregnancy, and if her life is distinctly endangered in consequence, it is not only justifiable, but it is the physician's duty to terminate gestation, and thus to save one life, and that the more valuable of the two, instead of sacrificing both mother and fetus. The following conditions occasionally furnish a justifiable indication for the induction of abortion : Pathological Vomiting. — When all the remedies for this con- dition have been conscientiously and carefully tried without avail, when rectal alimentation has been continued for a week or ten days without marked improvement in the woman's condition, and it is evident that she is in danger of death if her pregnancy continues, the induction of abortion for uncontrollable vomiting is justifiable. It has been asserted that the amount of ammonia nitrogen in the urine shows the toxemic nature of the vomiting and indicates abortion, but all forms of vomiting, the reflex and neurotic as well as the toxemic, show a high percentage of ammonia nitro- gen and spontaneous recovery is observed with a percentage as high as 30. No dependence therefore can be placed upon this estimate in deciding upon the induction of abortion. Albuminuria and Kidney Breakdown. — If ominous symptoms appear, such as progressive edema, persistent headache, steady or rapid increase in the amount of albumen, sudden diminution in the quantity of urine, casts in great number in the urine, and failing vision, in spite of careful dietetic and medicinal manage- ment, the induction of abortion is called for. Death 0} the Embryo or Fetus. — If it can be demonstrated 776 INDUCTION OF ABORTION. 777 that the embryo or fetus is dead within the uterus, its removal is de- sirable ; but it must be remembered that the signs of fetal death are difficult to elicit, and that a certain diagnosis can be made only after an observation extending over some days or weeks, unless the membranes are ruptured and the fetal body has begun to putrefy. Certain Intra-uterine Diseases. — As pointed out in the section on Intra-uterine Diseases, acute hydramnios and cystic degenera- tion of the chorion villi may call for the induction of abortion. Uterine Hemorrhage. — Uterine hemorrhage, from placenta praevia or from the detachment of an abnormally situated pla- centa, may be so profuse or so long continued as to demand the evacuation of the womb early in pregnancy. Displacement of the Gravid Uterus. — Retroflexion, prolapse, and anteflexion of the gravid womb, resisting other treatment, and threatening to become incarcerated, call for the termination of gestation. Certain Nervous Diseases. — In the course of acute mania and melancholia, or in chorea, and possibly in general pruritus, the question of terminating pregnancy may be considered. Certain Blood Diseases. — If pernicious anemia or leukocy- themia arises in pregnancy or is made much worse by the advent of pregnancy, the question of terminating the woman's condition may arise for consideration. In any of these indications the question is an anxious one, and should not be decided by the attending physician on his own responsibility, no matter what his experience or skill may be. There should invariably be a consultation, so that the responsibility may be shared and the operator may be free from criticism. Methods of Inducing Abortion. — Many plans have been advo- cated, but most of them have been found either too slow, too dangerous, or ineffectual. Such are the administration internally of ergot, rue, sabina, aloes, and of cotton-root ; injections upon the cervix or between the membranes ; the insertion of inflated rubber bags in the vagina or in the uterus ; rapid or gradual dila- tation of the cervix ; perforation of the membranes ; injections of irritating substances, as Monsell's solution, into the womb ; and an electrical current. The method employed by myself with satisfaction in a num- ber of cases may be described as follows : The woman is ether- ized and placed in the dorsal position upon an operating table. The vagina and vulva are disinfected by tincture of green soap and hot water and absorbent cotton, and by a douche of corro- sive sublimate solution, I : iooo. The anterior lip of the cervix is fixed with a double tenaculum, and the cervical canal is dilated to the size of the thumb with Hcgar's dilators or cautiously with 7?8 OBSTETRIC OPERATIONS. branched dilators. An Emmet's curetment forceps is inserted into the womb, opened and shut in several directions so as to crush the ovum, and then withdrawn with whatever portion of the ovum or embryo that comes with it. It is impracticable to remove the whole ovum at once. An iodoform gauze tampon is then packed in the lower uterine segment and in the cervical canal, and a tampon of gauze or antiseptic wool is placed in the vagina. The tampons remain in place twenty-four hours. On their removal, if the remainder of the ovum is not yet discharged from the external os, the cervix, now much softened and easily stretched, is further dilated with larger bougies than were used before, by branched dilators, or by the fingers, and the uterine cavity is emptied of all its contents as after an ordinary abortion by the curet, the finger, and a placental forceps (Emmet's curet- ment forceps). If for any reason, as in the exhaustion of hyper- emesis, the administration of an anesthetic is undesirable, the dilatation of the cervix may be made almost painless by the injec- tion into the cervix at four different points of Barker's fluid, /? eucain, adrenalin chlorid, and normal salt solution. While the interruption of pregnancy before the one hundred and eightieth day is called the induction of abortion, the method just described is only practicable up to the fourth month. After that time abortion is induced in the same manner as premature labor. Induction of Premature Labor In addition to the indications for the induction of abortion there are special indications for the premature interruption of pregnancy after the child has become viable. The most important of these is a contracted pelvis. The next in importance, perhaps, is placenta praevia. It may be necessary, in advanced phthisis, or in grave heart disease, to secure the mother's delivery before term, in order that the child may be born before the fatal termination of her disease, which is evidently close at hand, or to save her the strain of the last month of pregnane}' and to insure her an easy labor. Labor at term, or shortly after, may be induced in a woman showing a disposition to prolongation of pregnane}-. Last of all, in the rare cases of habitual death of the fetus just before term, it is advisable to induce labor before the period at which the child's death may be expected. Methods of Inducing Labor. — The following, founded upon Krause's 1 method, is the best plan for the general practitioner without special training in gynecological manceuvers. The '"Die kiinstliche Friihgeburt, monographisch dargestellt" von Albert Krause, Breslau, 1S55. INDUCTION OF PREMATURE LABOR. 779 parturient tract is made aseptic by tincture of green soap, hot water, and pledgets of cotton, and by an antiseptic douche. An aseptic, stiff, silk or linen bougie (No. iy French), which has been soaked for at least a half hour in a cold corrosive sub- limate solution i : iooo, is thoroughly anointed with carbolized vaselin (5 per cent.). The patient is placed in the dorsal position across the bed, her feet resting on two chairs. The physician cleanses his hands, puts on rubber gloves that have been boiled or soaked in 1 : 1000 sublimate solution, scrubs the patient's vagina with tincture of green soap, pledgets of cotton, and hot water, and administers a sublimate douche, 1 : 4000, followed by sterile water. The operator passes two fingers of his left hand into the vagina, inserting one or, if possible, both finger-tips into the cervical canal, which dilate the cervix and are swept around the lower uterine segment to sever the attach- ment of the membranes. The bougie is then passed along the groove between the two fingers until it enters the cervical canal and passes into the lower uterine segment posteriorly. It is pushed further in until it has entirely disappeared within the uterus, with the exception of an inch or a little more that pro- trudes from the external os. An iodoform gauze tampon is packed lightly in the vagina, to keep the bougie in place. Ac- tive and effective labor-pains begin in from thirty minutes to thirty-six hours. In the majority of cases labor begins within twelve hours. If it has not begun at the end of that time, a Fig. 577. — Champetier de Ribes' bag: A, Inflated; B, folded fur introduction into the uterus. second bougie should be inserted alongside the first. If, after twenty-four hours more, labor has not begun, the cervix should be artificially dilated with Voorhees' bags or Bossi's dilators, and, if necessary, the membranes should be ruptured, forceps may be applied to the head, or version may be performed and the child extracted by the feet. In about one-fifth of the cases the bougie method fails to excite labor pains. Norris proposes the following plan to insure the ap- ?8o OBSTETRIC OPERATIONS. pearance of pains and to shorten the time required for the induc- tion of labor: Dilatation of the cervical canal to a diameter of about 7 cm.; the insertion of one or two bougies and also of a Voorhees bag (medium or large size). The author has adopted this plan with satisfaction, although it fails too in almost as large a proportion of cases as the bougies in exciting effective labor pains. If the mother's condition demands immediate delivery, the best method is as follows: The cervical canal is dilated forcibly by the hand, or by Bossi's dilator, the membranes are ruptured, a forceps is applied, or version is performed and the child is ex- tracted by the feet. The other plans proposed for the induction of labor have not Fig. 578. — Voorhees' bag. been satisfactory. The injection of glycerin between the mem- branes, first proposed by Pelzer, and enthusiastically recom- mended for a time, has proved dangerous, and is, moreover, not to be depended upon. Dilatable bags in the lower uterine seg- ment, while often surer and quicker in their action than bougies, can not be unreservedly recommended, as they are not easy to insert, they have a tendency to displace the presenting part, and they may burst. The inelastic bag of Champetier de Ribes (Fig. 577) for insertion in the lower uterine segment is one of the best of these appliances. Voorhees has modified and improved the de Ribes bags. His models are much to be preferred. The orig- inal implement is clumsy in comparison. The pear-shaped elastic FORCEPS. 7 8l rubber bags shown in figure 579, originally designed for prolapsus pessaries, are easier to introduce into the lower uterine segment than de Ribes' bags, are efficient in exciting labor pains, but are not so good for the dilatation of the cervical canal. Barnes' fiddle- shaped bags are difficult to keep in the cervix. They are liable to slip out into the vagina. All of these bags are inserted collapsed by means of an Emmet curetment forceps and are dilated with water by a Davidson's syringe through the rectal nozle. A hemo- stat is fastened on the tube, which is then knotted, the forceps Fig. 579. — Pear-shaped elastic rubber bags, for the induction of labor; they may- be used as colpeurynters or metreurynters for a number of purposes, a, Deflated ; b, inflated. is removed, and the tube is tucked in the vagina, where it is held by a gauze-tampon, which also prevents the bag slipping out of the cervical canal. If it is desired to hasten the dilation of the cervical canal the tube is pulled upon at regular intervals. FORCEPS. Historical. — Three years before the massacre of St. Barthol- omew, in 1569, William Chamberlen, a Huguenot physician, fled from France to England. He settled in Southampton, and raised a large family of children, two of whom, both named Peter, became physicians, going up to London to practise their profession, where they achieved great success. The younger Peter was in continual conflict, however, with his brother prac- titioners, and was several times summoned for reprimand and pun- ishment before the College of Physicians. On one of these occa- sions he was accused of boasting that "he and his brother and none others excelled in these subjects" (difficult labors). This was in 782 OBSTETRIC OPERATIONS. the beginning of the seventeenth century (16 16), and is the first record of the secret which remained in the Chamberlen family for more than three generations, which was the foundation of their boast that they alone could be regarded as skilled obstetricians, and which enabled them all to grow rich by the practice of their hidden method of dealing with difficult labors. But instead of being honored as the discoverers of one of the most important inventions of medicine, posterity has condemned and must con- demn them for depriving the world of knowledge that might have saved thousands of lives and have prevented untold suffering dur- ing the hundred years that the forceps remained a secret in their family. The younger Dr. Peter Chamberlen had a son, also named Peter, who was a remarkable character : a man of great, but ill-directed talents ; possessing some inventive genius ; an extensive traveler ; an accomplished linguist ; obtaining the favor and friendship of the British royal family, and engaged during the greater part of his mature life in a lucrative prac- tice among the upper classes in London. It is to this man, who made such a mark in his time, that the invention of the forceps was formerly credited ; but there is no doubt, from evidence recently come to light, that he inherited the secret from his father, who, in his turn, obtained it from his elder brother, Peter Chamberlen, senior. 1 The idea that the younger Peter invented the instrument was no doubt fostered by himself, for he was a man of intense egotism. A short time before his death he wrote his own epitaph, which began — " To tell his learning and his life to men Enough is said by, ' here lies Chamberlen.' " This Peter had a son, Hugh, 2 who also studied medicine, and to whom his father disclosed the family secret of the Chamber- lens. Hugh, who was extravagant, determined to make the most of his inheritance, and to part for a consideration with the secret that had remained in his family so long. He accord- ingly went to Paris and offered to acquaint Mauriceau with his secret method of dealing with difficult head presentations, which up to that time had been managed by tearing the child to pieces with sharp hooks. For the disclosure of his secret Chamberlen asked the enormous sum — in those days — of ten thousand dollars (ecus). Mauriceau took the matter under consideration, '"The Cbamberlens," J. H. Aveling, London, 1882. 2 The Hugh Chamberlen whose bust may be seen in Westminster Abbey is the son of this Hugh. He was a man of higher character and much greater repute than his father. FORCEPS. 783 and, happening to have a deformed dwarf in labor, Chamberlen was asked to test his method in the case. He did so and failed completely, the patient dying from a ruptured uterus, unde- livered. This ended the negotiation for the sale of the secret in Paris. On his return to England Chamberlen translated and published Mauriceau's book, with a preface written by himself, in which he says: "My Father, Brothers, and my Self (tho none else in Europe as I know) have by God's Blessing and our Industry, attained to, and long practised a way to deliver Women in this case without any Prejudice to them or their Infants." Hugh Chamberlen is next heard of in Amster- dam, whither he had fled from England on account of some financial difficulties. Here he had better fortune than in Paris, managing to sell his secret to the College of Physicians of Amsterdam. This insti- tution immediately induced the govern- ment to pass a law which forbade any one to practise medicine in the town who had not given satisfactory evidence of possess- ing the secret now owned by the college, and imparted to each aspirant for a medical degree who was able to pay for it. The traffic in the Chamberlen secret continued until the middle of the eighteenth century, when two public-spirited citizens of Amsterdam, thinking it an outrage that a method for which such extravagant claims were made should remain a secret, took a course in medicine, pur- chased the knowledge required of them from the College of Physicians, and published it to the world. It was a single blade of the obstetric forceps ! Whether Chamberlen tricked the college or the college cheated its students is not known. 1 Before this time, however, certainly as early as 1725, the true secret had leaked out in England, and during the middle of the eighteenth century the forceps came to be widely known and quite generaHy used. There was for a long time much Fig. 5S0. — Smellie's straight forceps. An eighteenth century Eng- lish forceps, the blades wrapped with leather, to keep them from slip- ping. 1 Other stories are that Roonhuysen sold the secret to Ruysch and a number of others; that a student of Roonhuysen' s made a surreptitious drawing of the instru- ment and published it; that Jacob de Vischer and Hugo van der Poll obtained the secret from the daughter of a former possessor. ;8 4 OBSTETRIC OPERATIONS. speculation as to the kind of instrument that the Cham- berlens really invented, and there were many, some years ago, Fig. 581. — Palfyn's forceps or '• hands." Fig. 582. — The four forceps found in the Chamberlen chest. Fig. 583. — Chf^mberlen's vectis. who doubted that the invention had been the forceps at all. It was thought at one time to have been a forcing powder or a blunt hook. It was believed for a while that Jean Palfyn (1716) had FORCEPS. 735 first conceived the idea of an instrument which was developed later by others into the forceps. But these doubts have been set at rest. At Woodham, Mortimer Hall, in Essex, owned and occupied by Peter Chamberlen, junior, was discovered, in 1813, a chest in which were found the instruments shown in figure 582. It is obvious that the successive possessors of these instruments received all that were in existence in order to pre- serve the secret. The evolution of the forceps at the hands of the original inventor or of his descendants is plainly seen in the illustrations. The Chamberlens were also the inventors of the vectis, or lever, an instrument no longer made, for a single blade of the obstetric forceps answers the purpose perfectly. The Chamberlen instrument had not been long known and employed before certain defects in it were noticed. It was found difficult to introduce it, especially if the head was high up in the parturient tract. It was also found difficult to lock it, and the necessity of binding the handles together was found to be incon- venient. The first of these disadvan- tages, the difficulty of introduc- tion, was soon discovered to be dependent upon the curve of the pelvic canal, and it was recog- nized that an instrument to be introduced into this curved canal should itself be curved to corre- spond with the direction of the canal. Almost simultaneously, in England and France, about 1 750/ a pelvic curve was added to the forceps — in England by Smellie, in France by Levret. Each of these men, distinguished obstetricians of their time, added other important modifications to the forceps, which are worthy of careful attention, for the two 1 Levret presented his forceps to the Academy of Surgery in 1747- Smellie first published a description of his in 1 75 1, though he had invented the pelvic curve ten years before. 5o Fig. 584. — A, Levret' s forceps with a pelvic curve; B, Smellie's for- ceps with a pelvic curve. 786 OBSTETRIC OPERATIONS. instruments known as the forceps of Levret and the forceps of Smellie are the direct progenitors of the two types of forceps in use at the present time. The English forceps, as may be seen in figure 584, B, is small, short, and light. It has, as may be seen, the English lock ; the pelvic curve is inadequate, and to keep the instrument from slipping it was originally wrapped in leather ; but the instrument had good points about it, which are found modified in the modern English forceps of Simpson. The French forceps (Fig. 584, A) is a heavy, long instrument, with powerful handles and closely approximated blades. The lock is the pin or French lock, which the French forceps carry at the present time. In this instrument, too, the pelvic curve is inadequate, but the forceps has certain advantages, which, modi- fied, may be found in many modern instruments. It was not long before the disadvantage of the inadequate pelvic curve was Fig. 585. — A, French, B, English, C, German locks. appreciated, and soon after the time of Smellie and Levret this feature was improved, and a forceps with a better constructed pelvic curve came into use. It may be noticed that the handles of both the Levret and the Smellie forceps are rather difficult to grasp, if one desires to make a strong traction upon them. This disadvantage was overcome by Busch, a German, who was the first to add the cross-pieces or shoulders to the handles, which enable the operator to take a firm and convenient grip of the in- strument. It is plain that both the French and English locke each possess some advantages and some disadvantages. The English lock is easy of adjustment, but is not very secure. The French lock is difficult to adjust, but when once fastened, is firm and unyielding. Briinnighausen united the advantages of both these locks and did away with their disadvantages in the lock known as that of Briinnighausen, or the German lock (see Fig. 585). FORCEPS. 7 8 7 Almost every eminent practitioner of obstetrics for the last hundred years has added some modification of slight importance to the forceps ; so that the patterns, differing in a slight degree from one another, have been almost innumerable. There are two types of modern forceps, however, that merit description — that of Hodge in this country, and that of Simpson in Edin- Fig. 586. — Hodges forceps. Fig. 587. — Simpson's forceps. Fig. 588. — Davis' forceps. Fig. 589. — Small forceps, modified by the author for use at the vulvar orifice and pelvic outlet. burgh. They embody the best features of the two distinct classes that they represent. Hodge's forceps is the direct descendant of Levret's ; Simpson's, of Smellie's. The Hodge forceps has the advantage of taking an extremely firm grip upon the child's head, and of allowing great power in extraction and compression of the head. Its great disadvantage is that it may 788 OBSTETRIC OPERATIONS. injure the child's head more easily than almost any other instru- ment. Simpson's forceps — the best modern instrument for ordi- nary use — has a cephalic curve so well constructed that it can scarcely injure the child's head, even when great force is used in extraction. The pelvic curve is sufficient, but is not so great as to embarrass the operator when the instrument is applied to Fig. 590.— Showing the direction in which traction must be made by the handles, and the correspondence of the direction in traction upon the traction-handle and the direction in which the head must move. Fig. 591. — Hermann's forceps. the head low down in the pelvic cavity. The blades are of such length that the instrument may be used with equal convenience at the superior strait or at the pelvic outlet. The lock is the English lock, which has the great advantage of easy adjustment; and the handles are provided with shoulders for two fingers, and with depressions along the handle for the remaining fingers and FORCEPS. 789 thumb of the hand, so that a firm and convenient grasp can be taken of the instrument. Another modern instrument deserving description is the Davis forceps, very carefully constructed upon iron models of the fetal head. If this instrument is carefully adjusted to the sides of the normal child's head in the pelvis, it is no doubt provided with a better cephalic curve than any other forceps ; but if it should not be applied accurately to the sides of the head, it is capable of Fig. 59 2 - — Tarnier's axis-traction forceps. To show the details, the hand is repre- sented in an improper position for traction ; helovv is one of the traction rods. Fig. 593- — Poulet's forceps. doing the child's head great damage. A very useful instrument also in the author's experience is a light, short forceps for use at the parturient outlet (Fig. 589). As the mechanism of labor was better appreciated, and the forceps came into more general use in the latter part of the nineteenth century, it was realized that a certain amount of force was lost in the extraction of the child's brad by the necessity of pulling the forceps in great part in the line of their handles. The angle at which this force met the direction it is desired to impose upon the head is shown in figure sgo. This difficulty 790 OBSTETRIC OPERATIONS. has been overcome by the axis-traction principle, first proposed and carried out by Hermann, but popularized a generation later by Tarnier, of Paris. Figure 592 shows the latest and best axis-traction forceps. 1 Figure 590 illustrates the coincidence of the line of traction with the direction in which the head must move. Many modifications of the axis-traction forceps have been made. None of them are commendable that do not allow the oblique application of the blades while traction is made back- ward in the median line. The cheapest and simplest is Poulet's, with strong tapes passed through eyelets in the forceps blades, and fastened to a handle bent at right angles. The best is Tarnier's latest instrument. Uses and Functions of the Forceps. — The main function of the forceps is that of a tractor, which is by far the most impor- tant. Another function sometimes to be remembered is that of a rotator, as, for example, when a straight forceps is applied to the head in face presentation, with the idea of twisting the chin for- ward. In a difficult forceps operation the instrument sometimes has the function of a lever ; the operator, swaying his arms a little from side to side, pulls down first one side of the head and then the other, in this way dislodging it from its impacted posi- tion. Last of all, least frequently to be employed, and most dan- gerous of all functions, the forceps may occasionally be regarded as a compressor ; but the instrument is to be used for this pur- pose only in cases where there is a choice between compressing the head with the forceps and performing craniotomy, by the former action extracting a child that is almost certainly dead, or with a brain injury that makes death preferable, but with one or two chances for life out of a hundred. Indications for the Application of the Forceps. — The for- ceps is an instrument designed mainly to reinforce the vis a tcrgo in labor. The most important indication for the use of the in- strument is found in actual and relative uterine or abdominal inertia. The expulsive force may be relatively too weak if the resistance is greater than normal ; hence the forceps is indicated in contracted pelves, rigidity of the soft parts, and overgrowth of the fetal body. It may be necessary, in any case of head presentation in labor, hastily to terminate the process. This is especially desirable if conditions exist threatening the child's safety, as premature detachment of the placenta, compression or prolapse of the cord, prolonged pressure on the fetal head, feebleness and slow action 1 Tarnier is said to have destroyed ninety-nine models before he accepted the one-hundredth as entirely satisfactory ; for the description of his first models see Tarnier, "Description de deux nouveaux forceps," Pai - is, 1877; and " Gaz. des hop.," Paris, 1877. FORCEPS. 79 l of the fetal heart, or sudden danger to the mother during the second stage of labor, as in eclampsia. There is a valuable indication of fetal condition during labor in the action of the fetal heart. In case of serious disturbance the heart-sounds first increase in rapidity, but soon become slower. If they sink to ioo and remain at that rate for any length of time, it is likely that the child will be born dead, and it is a good practical rule in obstetrics to apply the forceps and to deliver the child rapidly whenever the fetal heart-sounds sink- to ioo and remain at that rate for a minute. It may be desirable to save the mother the muscular exertion necessary in the second stage of labor, especially if labor is complicated by some adynamic disease, as phthisis, typhoid fever, or pneumonia. It is most desirable to avoid all muscular effort in the second stage of labor in valvular disease of the heart. Finally, labor may be obstructed by abnormal positions of the cephalic extremity, or by anomalies in the mechanism of labor, as, for example, in face presentations when the chin does not rotate forward, or in vertex presentations when the head is insufficiently or excessively flexed. A good rule of thumb to govern the obstetrical practitioner is to apply the forceps in head presentations whenever the presenting part remains stationary for two hours in the second stage of labor. It is quite as important to recognize the contraindications to the use of the forceps as it is to understand when the instrument is needed. The contraindications to the use of the forceps, ex- pressed dogmatically as rules of practice, are as follows: The forceps must not be applied unless the os is dilated. There are exceptions to this rule. When the maternal or fetal life is threatened, it may be permissible to apply forceps through a partially dilated os, as, for example, when rupture of the uterus is threatened. It may be necessary, in some cases of rigid cervix, to dilate the os artificially by applying forceps and pulling the head down upon the cervix. It is also necessary, in cases of valvular disease of the heart and in the adynamic fevers, to shorten labor as much as possible by applying forceps to the head through an undilated os and rapidly extracting the child. The forceps must not be applied until the head is engaged in the superior strait. This rule, too, admits of some excep- tions. It is rarely possible to fix the head in a contracted pelvis with forceps, when the powers of nature are insufficient to attain this end. It is also justifiable to apply the forceps to the head loose above the superior strait in cases of placenta praevia with the head presenting, and to bring it down as a tampon in the pelvic canal. The forceps must not be applied until the membranes have been ruptured. This rule admits of no exception. 792 OBSTETRIC OPERATIOXS. The forceps must not be used as tractors in impossible posi- tions and presentations, as, for example, face presentations with the chin posterior. The forceps must not be employed unless the head be of average size. If the fetal head is too large or too small, the instrument is apt to slip and to inflict dangerous injuries upon the maternal soft parts. The forceps must not be used when the disproportion be- tween the head and the pelvic canal is too great. In selecting an instrument, the author would recommend the beginner, if he must restrict himself to a single forceps, to pur- chase Simpson's. As soon as practicable, the Tarnier axis-trac- tion forceps should be added, and it is a great advantage to possess, in addition to these two instruments, a light short forceps for use at the pelvic outlet. Preparation for the Operation. — The patient's consent, or the consent of her husband or nearest relative, should always be first secured. An anesthetic renders the operation less difficult, and is to be recommended to beginners ; but if it is possible to deliver the woman in a short time, — say, half an hour or under, — and if the difficult}- of extraction promises to be slight, the anesthetic may be dispensed with. The woman should be placed in the lithotomy position at the edge of the bed, with her feet resting upon two chairs, her legs supported by assistants or held by an improvised leg-holder made of a twisted sheet. With the small forceps used at the pelvic out- let the lateral position need not be altered. The forceps should be immersed for from ten to fifteen minutes before use, in a pitcher- ful of boiling water, which retains a sterilizing temperature for fifteen minutes after ceasing to boil actively, or should be boiled for the same length of time in a suitable instrument tray. Just before its insertion the whole blade, both outer and inner surfaces, should be smeared with carbolated vaselin or sterile glycerin. ' The Application of the Forceps. — In using the Simpson forceps, or any other with a non-detachable pin-lock, the left-hand blade is always inserted first. The left blade lies upon the left-hand side of the woman's pelvis, and is held in the left hand of the operator. The right-hand blade of the forceps lies upon the right-hand side of the pelvis when introduced in position on the child's head, and is held in the right hand of the operator. Assuming that the diagnosis of the presentation and of the position of the presenting part has been made, and that the vagina is rendered surgically clean, the successive steps in the application of the forceps-blades may be summarized as follows : Having introduced two fingers of the right hand into the FORCEPS. 793 Fig. 594- — Introduction of the left blade: first step. Fig- 595- — Introduction of the left blade: rotation on its long axis. 794 OBSTETRIC OPERATIONS. Fig. ^gg. — Insertion of the right blade, the left wrist being depressed to crowd the handle of the left blade out of the way. Fig. 597. — Both blades inserted, unrotated. FORCEPS. 795 Fig. 598. — Rotation of a blade (the left). Fig. 599. — Both blades joined by the lock after the rotation of the right. 796 OBSTETRIC OPERATIONS. Fig. 600. ■ — The grip on the forceps. Fig. 601. — The direction of the forceps-handles at the inferior strait (Hodge). FORCEPS. 797 vagina, the left blade, grasped at the lock by the left hand as a pen, is held perpendicularly to the woman's body, with the tip of the blade opposite the vulva. The tip of the blade is inserted in the vagina, and is pressed backward along the pelvic floor toward the sacrum. The blade is then rotated outward on its long axis to bring it in apposition with the posterior inclined plane of the pelvis, and to escape the promontory of the sacrum : the handle is depressed and the tip of the blade is thus elevated into the uterine cavity, the fingers of the right hand in the vagina guiding the blade and protecting the soft parts ; finally, the handle is carried to the left side in order to engage the tip of the blade over the curve of the child's head. The right-hand blade is in- troduced in a similar manner, substituting the right for the left, Fig. 602. — The direction of the forceps-handles with the head at the superior strait. of course, in the foregoing description. As the blades lie after their insertion it is impossible to lock them, for both of them have ascended the posterior inclined plane of the pelvis, after being rotated outward on their long axes. It is necessary to bring one of them forward toward the region of the acetabulum, if the head lies in the oblique position, before the blades will lock. ; 9 8 OBSTETRIC OPERATIONS. Obviously, the blade to be rotated forward within the pelvis differs with the different positions of the presenting part. In the left occipito-anterior position of a vertex presentation the right- hand blade must be rotated forward, the left-hand blade lying as it was when first introduced. To rotate the right blade the handle is lightly supported by the fingers of the right hand, while the first two fingers of the left hand are inserted under and to the outer side of the heel of the blade and gently pry it upward, outward, and then inward. If the operator finds it more con- venient, he may reverse the hands. If there is difficulty in locking the blades, a depression of both handles toward the perineum often facilitates their conjunction. Fig. 603. — The grip on the forceps and the direction of traction. The handles being approximated and the blades joined, the operator takes the grip upon the instrument shown in figure 603. The forefinger of the right hand is kept extended against the child's scalp to detect the first inclination on the part of the in- strument to slip. Too great compression of the child's head may be avoided by placing a folded towel between the handles, and by using the slack of this towel to cover the shoulders of the forceps-handles, the operator saves his fingers from excessive fatigue and even bruising. The grip represented in figure 603, with pressure exerted downward, outward, and on the ends of the handles upward, enables the operator to impose upon FORCEPS. 799 Fig. 604 — The extraction of the head from the vulvar orifice : first stage. F'g- 605. — The extraction of the head from the vulvar orifice : second stage. 8oo OBSTETRIC OPERATIONS. \ 1 Fig. 606. — The extraction of the head from the vulvar orifice : third stage. Fig. 607. — The extraction of the head from the vulvar orifice : fourth stage. FORCEPS. 80 1 the head a movement corresponding with the axis of the parturient canal. If traction were made directly outward by pulling straight upon the forceps-handles, much of the force would be lost by dragging the head against the symphysis pubis. In making traction, nature should be imitated as closely as possible, the intervals between one's efforts corresponding to the usual intervals between the pains, and the traction lasting for about a minute. In the intervals of rest the blades should be loosened, or even unlocked, to spare the fetal head from long- continued and uninterrupted compression. The force should be exerted by the muscles of the shoulders and arms. It is inad- visable to throw the weight of the trunk upon the forceps and it is absolutely inexcusable to utilize the muscles of the back and legs, plus the weight of the body, by bracing the feet against the bed while pulling upon the forceps. The tractive force should take a different direction as the head progresses along the par- turient tract. When the forceps is at rest, the direction of the handles is a good indication of the direction in which the next traction should be made ; as the head descends the birth-canal and appears at the vulvar orifice, distending the perineum, care should be exercised to moderate the tractive force, otherwise the head might be violently pulled out through, instead of over, the perineum. When the degree of distention is reached shown in figure 604, the grip on the forceps is changed. The handles are seized in the right hand, as shown in figure 604, the operator standing to one side of the patient. Instead, now, of making traction, the forceps-handles with each pain are lifted and carried up over the woman's abdomen, very little force being employed. The outspread fingers and thumb of the left hand push the head away from the perineum and guide it upward under the pubic arch. When the pain passes off, the forceps-handles are allowed to sink again. Finally, just before the head emerges, the grip on the instrument is again changed so that the handles may be almost laid on the woman's abdomen (Fig. 607). Used in this way there is no better safeguard for the integrity of the perineum than the obstetric forceps. In the description of the application of the forceps it has been assumed that the head is in a normal oblique position of a vertex presentation and that the blades of the instrument are applied to the sides of the fetal head, where they do the least damage, and to the contour of which their cephalic curve has been adjusted. It often happens, however, that the head occu- pies an abnormal position, and the question arises whether the forceps shall be applied at the sides of the maternal pelvis, where the blades are not likely to injure the woman, or whether an 51 802 OBSTETRIC OPERATIONS. attempt must be made to adjust the blades to the sides of the fetal head regardless of the additional risk to the mother. If, for example, the head is transverse, as it usually is when detained at the pelvic inlet in a contracted pelvis, one blade must lie behind the symphysis and the other in front of the promontory if they are to be placed at the sides of the fetal head. It is pos- sible to so adjust them, if one possesses manual dexterity and is skilled in the use of the forceps, but there is always a danger of perforating the posterior uterine wall in the attempt. It is better under these circumstances to place the blades obliquely, the posterior behind the promontory of the occiput, the anterior in front of the chin and mouth. By this adjustment the fetal head is not likely to be so badly damaged as if the forceps were applied directly over the face and the occiput, the anterior rota- tion of the latter is facilitated, and the woman is subjected to no extra risk. It is not infrequently necessary to apply the forceps to the head in a normally oblique position, but with the occiput directed posteriorly. As the head descends, anterior rotation should occur, and it is to be considered whether the grip of the instru- ment will interfere with the rotary movement of the head upon the pelvic floor. As a rule, it does not if the precaution is ob- served to disengage the blades completely from each other by unlocking them after each tractive effort. The author has seen a young practitioner who disregarded this rule astonished to find his forceps turning upside down as the head rotated. As soon as rotation is accomplished, the forceps-blades lie over the occiput and the face ; they must, therefore, be rotated into their appropriate positions over the sides of the head, or, if it is difficult to do this, they should be withdrawn and reinserted. To give a concrete example : In a right occipitoposterior position of a vertex pres- entation the two blades of the forceps are inserted along the posterior walls of the pelvis to either side of the promontory ; the right blade is then rotated forward until it lies under the right acetabulum. As the occiput rotates forward after encoun- tering the resistance of the pelvic floor, the long anteroposterior diameter of the head shifts from the right to the left oblique diameter of the maternal pelvis, bringing the forceps-blades directly over the face and the occipital protuberance. The left blade must, therefore, be rotated forward and the right backward, or, if it is difficult to rotate the blades, they must be withdrawn and reinserted as for a right occipito-anterior position of a vertex presentation. If the occiput rotates into the hollow of the sacrum, the head should be extracted from the vulvar orifice by the following manceuver : The forceps-handles are raised gradually and inter- FORCEPS. 803 Fig. 608.— Overdistention of the perineum in persistent occipito- posterior deliveries ; the nose rests under the pubic arch. The handles at this point should be depressed. mittently until almost the largest diameters of the head have escaped ; then, instead of continuing the elevation, the left hand firmly supports the head through the perineum and the forceps- handles are depressed, turning the fetal face out from behind the symphysis. In this way the perineum and pelvic floor are some- what relieved of the tremendous strain imposed upon them in a persistent posterior position of the occiput. In applying the axis- traction forceps, the bars are closed against the blades, which are in- serted in the ordinary manner. After adjusting the blades to the sides of the child's head if possible, or in an oblique diameter of the pelvis, the blades are locked; the pin-lock of Tarnier's instrument is screwed moderately tight; the con- necting bar between the handles is thrown across, locked, and screwed until the blades take a firm but not too forcible grip on the fetal head. The traction bars are then sprung loose at their lower end and the handle is adjusted to them and locked. Traction should be made in a line as nearly as possible coinciding with the axis of the pelvic inlet — namely, backward and downward. To do this even approximately the woman must be placed upon a bed or table with her buttocks projecting well beyond the edge and the axis-traction handle of the forceps must be pulled downward and backward as far as possible. To pro- tect the perineum from injury by the traction rods a Sims specu- lum should be held in place during the tractive efforts. Between the tractions the bar joining the handles should be unscrewed and thrown out of place and the pin-lock should be unscrewed, thus relieving the fetal head from continued pressure. As soon as the fetal head has descended well into the pelvic cavity the axis-trac- tion principle becomes unnecessary. The handle should, therefore, be removed, the bars fastened in their places by the blades, and the forceps used as an ordinary instrument or else withdrawn and replaced by a Simpson forceps. Statistics as to the frequency of forceps operations have neither interest nor value. They vary enormously in different clinics, in different classes cf society, and in the hands of different operators. The author is an advocate of the frequent use of forceps, believing that more harm arises from inordinate delay in labor to mother and infant than can be traced to the use of the instrument in careful and skilful hands. The mortality of a forceps operation, per se, should be nil. The 8o4 OBSTETRIC OPERATIONS. Fig. 609. — Axis-traction forceps ; head at the superior strait. Fig. 610. — Axis-traction forceps; head in the pelvic cavity. EXTRACTION OF THE BREECH. 805 Fig. 611. — To bring down a foot when it is against the face, the knee may be bent by pressure in the popliteal space (modified from Farabeuf and Varnier). most frightful damage, however, has been inflicted upon both mother and child by the unskilful and careless use of the instru- ment. The pelvic joints have been sprung apart by too forcible traction ; the lower uterine segment with an undilated os has been caught in the grip of the blades and has been cut through into the peritoneal cavity; the posterior wall of the lower uterine segment has been perforated by the tip of one blade; the child's scalp has been cut and a forceps- blade forced between its scalp and the skull; in an attempt to apply forceps to the breech in the mistaken notion that it was the head, the tip of a forceps-blade has torn the perineum of a female infant into the rectum; the vaginal vault has been perforated and the vaginal walls deeply cut, and frequently, indeed, is the perineum torn, often into the rectum, by a failure to elevate the handles sufficiently and to moderate the tractive force as the head is extracted from the vulvar orifice. EXTRACTION OF THE BREECH. Breech labors are normally slow and tedious. The indica- tions for interference are: delay for much more than twenty-four hours, rapid and feeble pulse, signs of exhaustion, elevation of temperature in the mother, and abnormally slow fetal heart- sounds. Methods of Extraction in the Order of their Efficiency. — Manual Method. — Seizing a foot by passing a hand into the uterus, extracting the leg up to the knee, thus decomposing the breech presentation and affording a convenient handle to the fetus by which to control the subsequent progress of labor, is the best of all methods for extracting the breech, if it is practicable. Pinard's suggestion to push one thigh outward and backward, thus flex- ing the leg upon the thigh, occasionally makes it easier to grasp the foot. Another plan of manual extraction is to place the hand on the infant's back, so that the little and fore-fingers hook over the crest of the ilium, while the middle and third fingers are ex- 8o6 OBSTETRIC OPERATIONS. Fig. 612. — Manual extraction of breech. Fig. 613. — Forceps on breech. Fig. 614. — Fillet on breech. Fig. 615. — Fillet carrier. EXTRACTION OF THE BREECH. 807 tended along the spine. This is not so good. For both manoeuvers the patient must be anesthetized. Forceps. — If the breech is low in the pelvic canal, and it is impossible to pass the hand into the uterine cavity to seize a foot, it may be most convenient to apply forceps over the trochanters. By avoiding compression of the handles, and simply making traction by hooking one's fingers over the ^1 7 »« ; t ■■•;' j 1 1 it IIB mi H ■ ft. JL An Fig. 616. — The handle of a long forceps used as a blunt hook. shoulders of the instrument, the breech may be extracted readily, with no danger to the child. Extraction by Fillet. — Each end of a strip of bandage about two inches wide may be passed between the thigh and the abdomen and brought down in front of the external genitalia. If drawn tight, the loop of the bandage is in contact with the child's sacrum. A firm and convenient grip is thus taken upon the breech. The fillet is very difficult to apply with the fingers. A fillet-carrier, 808 OBSTETRIC OPERATIONS. shown in figure 615, makes the application much easier. An anesthetic is required. This plan is excellent if the manual extrac- tion is impossible, or if it is considered inadvisable to use forceps. Blunt Hook. — This instrument is passed between the thigh and the abdomen. It is an extremely dangerous instrument for the infant. It is very likely, indeed, to fracture the thigh or to perforate the groin. Its use, therefore, is not recommended, and is never resorted to by the author unless the child is dead. THE ARTIFICIAL DILATATION OF THE CERVICAL CANAL. It is necessary to dilate the os artificially in cases of rigidity of the cervix, or when it is desired to hasten labor for any purpose. The os may be dilated by Barnes' bags, by graduated bougies, by the fingers, by pulling the head down with forceps, by taking hold upon a foot or leg in a breech presentation, by discission, by multiple incisions, or by branched dilators. Hydrostatic Dilatation. — For this purpose rubber bags of a cone shape (Voorhees) and of graduated sizes are most convenient (see Fig. 578). It is desirable to have the largest bag larger than that ordinarily sold in the shops — that is, four sizes, the largest one made specially. To insert one of these rubber bags, it is rolled upon itself, grasped in an Emmet curetting forceps, well smeared with sterile glycerin, and passed into the cervical canal, so that it enters the lower uterine segment. The tube is then attached to the rectal nozle of a Davidson syringe, and the bag is distended with water. It is well to test the capacity of each bag outside the woman's body, to avoid overdistention and the danger of bursting. When the bag is filled, the rubber tube attached to it is clipped with a hemostat, a knot is tied in the tube below the hemostat, the latter is removed and the tube hangs from the vagina. Each of the progressively larger bags is inserted in the same manner, and allowed to remain in place from fifteen minutes to an hour, accord- ing to the time at one's disposal. The tube may be pulled upon by the nurse or attendant every two to five minutes for about a minute at a time to hasten the dilatation of the cervix. Manual Method. — The best manual methods for the dilata- tion of the os are illustrated in figures 617-626. In Harris' method the fore-finger and thumb, and then the other fingers of the hand, are successively inserted, the thumb and fingers being spread apart as widely as possible. In Edgar's method the dilatation is begun by branched dilators and is completed by the powerful action of the first two fingers of both hands. By this means very rapid dilatation of the os is possible : the manual method, therefore, is recommended in cases of greatest haste, in ARTIFICIAL DILATATION OF THE CERVICAL CANAL. 809 which it is only desired to secure enough dilatation to make the forcible extraction of the child possible. Instrumental Dilatation. — If the os is already about the size of a dollar, and it becomes necessary to deliver the child rapidly, Fig. 617. — Method of performing rapid manual dilatation of the os uteri : I, Posi- tion of fingers in the beginning of manual < r digital dilatation of the cervix uteri, first position; 2, showing limit of dilatation in the first position; 3, second position; 4, showing limit of dilatation in the second position ; 5, third position ; 6, limit of dila- tation in the third position; 7, fourth position; 8, limit of dilatation in the fourth position; 9, fifth position; 10, sixth position (Harris). forceps may be applied to the head and strong traction made. The cervix will cither stretch or tear, and it is thus possible to extract a child in a very few minutes when there is urgent need for rapid delivery. Several two or more bladed instruments have been devised to dilate the cervix of a pregnant or parturient 8io OBSTETRIC OPERATIONS. woman. A good one is the invention of Gau (Fig. 619). Bossi's 1 dilator was first described in 189 1 (Fig. 618), but was not generally adopted till Leopold recommended it ten years later. It is, in the author's judgment, the best instrument for the dilatation of the gravid or parturient cervix. If the blades are gradually dilated up to 7 or 8 cm., on the scale, there is little or no risk of injury. Fig. 618. — Bossi's dilator, closed and opened. The expanded tips are removable, so that the instrument may be inserted in an undilated os. Rapid and complete dilatation with this powerful instrument is sure to be followed by extensive injury. It is best to dilate to 7 or 8 cm. ; then to apply forceps or to perform version. In thirty cases in which the author has used it, there has been no extensive lacera- tion of the cervix. 2 The cervical canal may be dilated by inserting 1 " Sulla Dilatazione rapida della Bocca Uterina col Dilatore Bossi," " Clinica Obstetrica," Anno iv, fasc. vi-vii, 1902. 2 "Instrumental Dilation of the Cervix in the Last Months of Pregnancy." Late, "Am. Gyn.," Sept., 1903, p. 295. ARTIFICIAL DILATATION OF THE CERVICAL CANAL. 8 I I graduated bougies from the size of a small lead-pencil up to the sizes of one' wrist or forearm. This is an effective method, but it requires a number of bougies which are scarcely ever carried about by any obstetrician, and it is, therefore, only available in a well-equipped obstetrical hospital. In fifteen to twenty minutes, Fig. 619. — Gau's dilator for the cervix. ^_ Fig. 620. — Hegar's dilators or bougies. by this plan the os may be almost fully dilated or sufficiently at least to permit the extraction of the child by forceps if the head presents, or by drawing down a leg in a breech presentation. Incisions. — This plan is an old one, but in its modern most effective form, of incisions through the cervix to the vaginal vault, 812 OBSTETRIC OPERATIONS. Fig. 621. — Instrumental dilatation of parturient os, preparatory to further manual dilatation (Edgar). Fig. 622. — Digital dilatation of the parturient os. Os admits one finger. Vaginal and supravaginal portions of the cervix present (Edgar). ARTIFICIAL DILATATION OF THE CERVICAL CANAL. 813 Fig. 623.— Bimanual dilatation of the parturient os. Os admits two fingers. Vaginal and supravaginal portions of the cervix present ; commencing shortening of the cervical canal (Edgar). Fig. 624.— Bimanual dilatation of the parturient os. Os one-half dilated. Lateral position of the hands (Edgar). i 4 OBSTETRIC OPERATIONS. Fig. 625. — Bimanual dilatation of the parturient os. Os two-thirds dilated. Entire effaceraent of internal os (Edgar). Fig. 626. — Bimanual dilatation of the parturient os. External view, showing position of hands (Edgar). VERSION. 815 it was first proposed by Duhrssen. 1 It is to be recommended if there is need for the utmost rapidity in the extraction of the child. If the head presents, it is best to apply forceps to pull it firmly down against the cervix, and then with scissors, or a blunt-pointed bistoury, to cut the cervix in one, two, or as many as four places, until the child can be dragged through the cervical canal. It is necessary afterward to suture the incisions, which bleed profusely for a time, at least. If the patient's condition is serious, it may be sufficient to place one suture in the upper angle of each incision. This checks the hemorrhage sufficiently, and promotes, occasion- ally, the entire repair of the injury. Vaginal Cesarean Section or Anterior Vaginal Hyste= rotomy. — Duhrssen elaborated his original plan of multiple deep incisions in the cervix by proposing the transverse incision of the anterior vault, pulling down the cervix by strong double tenacula, splitting the anterior lip and the lower uterine segment in the middle line till sufficient space is gained to deliver a full-term child. This is the quickest means of delivering a woman, and has in selected cases decided advantages. Duhrssen enthusias- tically recommends it as the first step in the treatment of eclampsia. The author has employed it, but would only recommend it if the quickest delivery possible is essential. Slower dilatation of the cervix by the hands, bags, or Bossi's dilators is safer and less troublesome, if there is no urgent necessity for immediate delivery. The wound in the lower uterine segment and cervix is sutured with a tier suture of durable catgut; the anterior vaginal vault is closed with interrupted sutures and gauze drainage is employed for four days or more. Hemorrhage during the operation is con- trolled by forcibly pulling down the cervix. 2 VERSION. Version maybe defined as an operation or manceuverto change the position of the fetus in utero. The object of version is usually to change a transverse into a longitudinal presentation, or to change the presentation of one pole of the fetal ellipse into a presentation of the opposite pole. The changes in the position of the fetus are effected by tour methods — postural treatment of the mother, external manipu- lation alone, internal manipulation alone, and a combination of internal and external manipulations. As the child is brought to present by the cephalic or pelvic presentation, the operation 1 " Wiener med. Presse," xxxi, 33. 2 Duhrssen, "Ztsclir. f. Geb. u. Gyn.," Bd. xxiii ; "Centralbl. f. Gyn.," No. 7, 1892; "Arch. f. Gyn.," Bd. xlii and xliii ; " Berliner klin. Wochenschr," No. 27, 1892; "Der Vaginale Kaiserschnitt," 1896; "Arch. f. Gyn.," Bd. lxi; " Eklamp- sie," in v. Winckel's " Ilandhuch," Bd. xi 3 , 1905. 8l6 OBSTETRIC OPERATIONS. is called version by the head or version by the breech. If the foot is seized and is extracted in the operation of version, the operation is called podalic version. The operation of version is an old one. Hippocrates speaks of the difficulties encountered when a child lies crosswise in the uterus. He compares it to an olive lying crosswise in a bottle with a narrow neck. But Hippocrates believed that the infant could only be delivered if it presented head first, and therefore, in cross-positions of the fetus, if the effort to turn it with the head toward the maternal pelvis did not succeed, embryotomy was to be performed in the dreadful manner that was practised in those days — tearing the child to pieces with sharp hooks. Among the aboriginal tribes of Mexico a curious custom pre- vailed in cases of difficult labor. A woman was seized by the feet, suspended head downwards, and vigorously shaken. If the dystocia was due to a transverse position of the fetus in ntcro, this rough and unscientific treatment might, in a certain number of cases, be effective, and it was no doubt in consequence of a few successes that the custom had its origin. In Japan, before the country had reached its present high stage of civilization, it was customary to apply massage to the abdomen of pregnant women, in order to straighten out a pos- sibly faulty position of the fetal ellipse. In many primitive races some form of version has been and is in vogue, handed down as a custom of ancient origin. Indications for Version. — The most important and the most frequent indication for version is found in a transverse posi- tion of the fetus in utero. In order to secure delivery, one or the other of the poles of the fetal ellipse must be substituted for the shoulder, which usually presents in a transverse position of the fetus. Contracted pelves are an indication for the performance of version, when it is thought that the child's head can be brought through the contracted pelvic canal more easily with the small end of the wedge coming first than last. If it is necessary to deliver the mother rapidly, in cases of sudden danger, when the head is presenting but not engaged, as in eclampsia, premature detach- ment of the placenta, rupture of the uterus, embolism, and death of the mother, podalic version furnishes the most rapid means of delivery. In malpositions of the head, as presentation of the ear, of one parietal bone, of a brow or face, it may be better to substitute for the unfavorable presentation of the head the more favorable presentation of the breech, which is secured by podalic version, or by version by the breech. In placenta praevia, if the head is presenting, version is indicated, in order to bring down the breech as an intrapelvic tampon upon the bleeding placental VERSION. 817 site. In prolapse of the umbilical cord, version is indicated if the cord can not be returned into the uterine cavity and kept there. Before undertaking the operation of version, it is quite as important to realize the contraindications to the operation as it is to recognize the indications. Version is positively contra- indicated if the presenting part is firmly engaged in the pelvic canal and has passed out of the external os ; also, if the con- traction-ring is so high that a rupture of the lower uterine seg- ment is threatened if version is attempted. While these are the only positive contraindications to the operation, the following conditions may make it difficult, dan- gerous, or quite impossible : An undilated and undilatable vagina ; a similar condition of the cervix. These obstructions may usually be overcome under anesthesia, but they may be insuperable obstacles to the per- formance of version. It may be impossible to effect an entrance into the uterus, as when the liquor amnii has long been drained away and the uterus is firmly contracted, if the uterus is permanently con- tracted in what is called a tetanic spasm, if there is some obstruc- tion on the part of the fetus, as hydrocephalus and spina bifida with a large meningocele, or if the presenting part is pressed firmly upon the superior strait. The last-named difficulties may be obviated by placing the woman in the knee-chest posture. Prolapse of the arm, at one time considered a serious ob- stacle to the performance of version, is no longer so. The phy- sician's hand can readily pass by the arm, and indeed it is some- times an advantage to pull the arm out of the external os before attempting version. It may be impossible to bring the feet down in podalic version after they are grasped. This difficulty may be overcome by applying a fillet to the foot, and, while traction is made upon it, the other hand of the physician in the vagina pushes the shoulder upward and in the direction of the child's head. Certain conditions may interfere, also, with the manipulation of the external hand in combined and in podalic version, as an excessive amount of fat in the abdominal wall, or convulsions in eclampsia, epilepsy, chorea, and hysteria. On the other hand, the conditions most favorable for the operation are : a uterus dis- tended by liquor amnii, a dilated os, a uterine muscle that is not irritable, abdominal muscles that are flexible and thin, and a cervix well dilated or easily dilatable. Postural Version — In this method the woman is put in dif- ferent positions to influence the position of the child in utero by the force of gravity. For example, if the brow should present, 52 OI5 OBSTETRIC OPERATIONS. the woman should be turned on that side toward which the fetal back looks, so that the breech may drop to that side, and thus bring the vertex to the center of the superior strait ; or, if the head should be tightly fixed in the superior strait, the woman may be turned on that side toward which the face looks, in order to promote the flexion of the child's head, and thus favor a con- version of the brow presentation into one of the vertex. This is a simple, safe, and easy means of performing version, Fig. 627. — Diagram of knee-elbow posture for internal version. The lower part of the hollow of the uterus is lifted out of the pelvis (Dickinson). if it is practicable. It is usually, however, unsuccessful, and the physician must be prepared to resort to other plans if it fails. Version by external manipulation may be used before labor to convert a breech presentation into a presentation of the head, or to correct a transverse presentation. When the child has been brought into the position desired, by a series of stroking movements, pads and a binder should be applied to prevent the return of the child to its original position. This method, while successful in a fair proportion of cases, requires often an expert's skill ; a diagnosis of the position before labor has begun ; the preservation of the membranes ; thin, flexible uterine and abdominal walls, and non-irritable muscles. Combined version was first proposed by Busch, D'Outre- pont, and by Dr. Wright, of Cincinnati, and was later advocated by Braxton Hicks, of London. The operation is performed as follows : The patient is placed in the lithotomy position and is anesthetized. Externally, the hand nearest the fetal part to be VERSIOX. 19 acted upon by external manipulation seizes this part through the abdominal walls, the operator being seated facing the vulva. The internal hand pushes the presenting part up and to that side opposite the fetal part acted upon by the external hand. For example, in a shoulder presentation, with the face of the child turned forward and the head in the right iliac fossa, the physician seizes the head with his left hand, inserts the right hand in the vagina, and with two fingers of this hand passed into the uterine cavity pushes the child's right shoul- der upward and toward the mother's left-hand side, while the head by external manipu- lation is pulled downward and toward the median line. In all shoulder presentations, version by the. head should be pre- ferred to version by the breech in the combined method, for this presentation is more favor- able to the child, and the head is more readily brought to present at the superior strait, making the version easier and quicker of performance than if the breech were brought down. Podalic version was known in the time of the Roman Em- pire, but was forgotten in the middle ages until Ambrose Pare and his students revived it in the sixteenth century. The opera- tion is performed as follows: Relaxation of the uterus and of the abdominal muscles is secured by an anesthetic. The lowest possible position of the fetal feet is secured by turning the mother on that side toward which the feet point. The hand which, midway between pronation and supination, as the operator faces the woman's vulva, corresponds with its palmar surface to the abdomen of the child is inserted, in an aseptic condition, into the uterine cavity, until it meets the anterior foot. This foot is grasped by the first two fingers and the thumb, and is then ex- tracted until the knee appears at the vulva. The advantages of resting content with the anterior foot, and of drawing upon it alone without seeking for the other, are these : A further entrance into the uterus is unnecessary. It is easier to hold one foot than two. The other leg is folded up upon the abdomen, and thus secures a more thorough dilatation of the cervical canal. Finally, by pulling upon the anterior foot one Fig. 628. — Version in dorsoposterior posi- tion (Farabeuf and Varnier). !20 OBSTETRIC OPERATIONS. Fig. 629. — D'Outrepont's method of combined version, modified by ScanzonL Fig. 630. — Combined version by the breech. Fig. 631. — Combined version, Wright's method. VERSION. 821 Fig. 632. — Seizing the anterior foot in podalic version (Nagel Fi K . 633. — Version in dorso-anterior position, first stage oi traction on lower limb (Farabeuf and Varnier . 822 OBSTETRIC OPERATIONS. is more likely to secure a sacro-anterior position of the breech. While making traction upon the foot, the version of the child is facilitated by external manipulation of the head (Fig. 635). It is occasionally easier to seize a leg or the knee than the foot (Figs. 636, 637). In such a case time need not be wasted seek- ing for the foot. Combined version by the breech may precede or replace podalic version with great advantage, as first pointed out by Braxton Hicks, obviating the necessity of introducing the X*V \J/« 1 Fig. 634. — The upper buttock is Fig. 635. — Assisting podalic version by moving downward and the lower shoul- external manipulation (Dickinson), der rising (Dickinson). hand into the uterine cavity and enabling the operator easily to seize the knee or foot after it is brought near or into the supe- rior strait. As soon as the knee is born, the operation of podalic version is finished, and, unless there is some indication for immediate VERSION. 823 Fig. 636. — Seizing the leg instead of the foot. Fig. 637. — Seizing a knee instead of the foot. 824 OBSTETRIC OPERATIONS. delivery, the anesthetic should be removed, the patient should be turned upon her back, and should be allowed to expel the child spontaneously until the umbilicus appears in view. The delay secures a more thorough dilatation of the cervical canal, and produces a paretic condition of the circular muscle of the cervix. The advantages of this condition of the cervix are obvious when it comes to the extraction of the after-coming Fig. 638. — Extracting an arm (Xagel|. head. With an undilated cervical canal and a rigid cervical muscle, the neck is likely to be grasped in so firm a hold that all efforts to extract the head are unavailing until the child is asphyxiated. In rare cases rapid extraction ma}" be indicated. If it is, the legs and trunk ate pulled upon forcibly, as shown in figures 639 and 640. The child's body being slippery, should usually be enveloped in a towel. When the child is VERSION. '5 born to the umbilicus the pressure upon the cord is great, and delay in its extraction means an asphyxia so deep that it is unlikely the child can be revived. From this moment, there- fore, the attendant must put forth every effort possible to secure the most rapid delivery of the infant, which is effected by the following methods : The arms, if extended alongside of the child's head, as they usually are after version, must be extracted in the following manner : locate the posterior arm by the position of the trunk and shoulders. To deliver the right arm, grasp the legs with the left hand, the middle finger above the internal malleoli, the index and middle fingers above the ex- Fig. 639. — Method of seizing the breech. Fig. 640. -Method of seizing both feet. ternal malleoli. Raise the child's body upward and outward over the mother's right thigh. This movement should be suffi- ciently forcible to bring the right shoulder well down in the pelvis. The first two fingers of the right hand, entering the vagina in contact with the right scapula, are passed along the posterior surface of the arm beyond the elbow, when the arm and forearm are pushed in front of the child's face as though the elbow-joint did not exist. The fingers are now hooked in the elbow-joint and pulled directly downward until the elbow appears at the vulva, the forearm being flexed by this movement upon the arm. The forearm is then easily delivered by extension. The 826 OBSTETRIC OPERATIONS. left arm is brought down and delivered in the same manner, sub- stituting, of course, right for left. The right hand grasps the child's feet and lifts them over the mother's left thigh, at the same time rotating them on their long axes so as to twist the body and thus bring the anterior arm into the posterior portion of the pelvis. The fingers of the left hand are inserted into the vagina past the elbow-joint. The arm is swept forward over the face, as though it were a single piece without the elbow-joint. The elbow is then flexed, pulled downward, and the forearm extended at the Fig. 641. — Delivery of the after-coming head by flexion through seizure of lower jaw, and extrusion by means of pressure in axis of brim (Dickinson). vulvar orifice. Should the shoulders occupy a transverse posi- tion, either arm may be brought down and delivered first. After delivering the arms, the head may be extracted by one of the following methods, given in the order of their efficiency and safety : Wigand's Method. — In this method the first three fingers of the supinated hand are inserted into the vagina, that hand being employed whose palm corresponds to the abdomen of the child. Over the forearm of this hand the child's body rests astride. VEHSION. 827 The index-finger of the hand in the vagina is inserted in the child's mouth, care being exercised to avoid the eye-sockets. Sufficient traction is exerted upon the lower jaw to secure and Fig. 642. — First step of Mauriceau's method, an assistant making suprapubic pres- sure on the head. maintain flexion of the head. The disengaged hand now locates the head through the abdominal wall above the pubes, anil delivery is accomplished by suprapubic pressure in the axis of 828 OBSTETRIC OPERATIONS. the parturient canal, and by the elevation of the child's body toward the mother's abdomen. Mauriceau's Method. — One hand is inserted in the vagina, as described above, and one finger is placed in the child's mouth. The other hand is passed along the child's back until the middle finger rests upon the occipital protuberance. The index- and Fig. 643. — Second step of Mauriceau's method. ring-fingers are flexed over the clavicles, and traction is made by both hands at once, the force upon the jaw and the pressure upon the occipital protuberance keeping the head well flexed, while the traction upon the shoulders extracts the head in the direction of the parturient canal. As the head descends upon the pelvic floor, the child's body is carried upward toward the mother's abdomen. Properly directed suprapubic pressure by VERSION. 829 an assistant increases the efficiency of this method, and makes it, indeed, the most effective of all methods in extracting the after- coming head. Combined with the Walcher posture in the mother it should be the method of election in cases of contracted pelvis. Prague Method. — The child's ankles are grasped with the right hand pronated, the middle finger being placed between the legs just above the internal malleoli, the index- and ring-fingers above the external malleoli. The index-finger of the left hand is flexed over one clavicle, and the remaining fingers of the same hand over the other clavicle. Traction directly downward is now made with both hands until the perineum is well distended. Fig. 644. — The method of extracting the trunk. Fig. 645. — The Prague method of extracting head. The right hand then loosens its hold upon the ankles, and again grasps them as described above, but approaching them at their anterior surface. The child's feet are now in contact with the back of the right hand. The feet are then raised by a circular movement toward the mother's abdomen, while the left hand as originally placed is used as a fulcrum, around which the head moves until it is finally forced out of the parturient outlet by a lever-like movement on the part of the child's bod)-. Forceps. — An assistant should raise the child's body, sup- porting its arms and legs, and thus keeping them out of the way of the operator, who rapidly applies the blades to tin- sides of the 8 3 o OBSTETRIC OPERATIONS. child's head. Traction is made in the direction of the axis of the parturient canal, and the head is finally delivered by lifting the handles of the forceps, the disengaged hand protecting the perineum as much as possible. De venter's Method. — The child's body is seized as in the Prague method, but the arms are still alongside the child's head Fig. 646. — Deventer's method of extraction of the after-coming head and arms (Dickinson). and need not be extracted first. The body is pulled directly downward toward the ground, until the shoulders descend and press upon the pelvic floor. The child's body is then carried downward and backward under the woman's buttocks, the head being rolled out of the parturient outlet between the arms, which easily follow after. To do this the woman's buttocks must pro- ject well beyond the edge of the bed, and the child must be EMBRYOTOMY. 83 1 carried well under them. The operation is only possible under the most favorable conditions, and is not always to be relied upon. It has, however, the merits of simplicity and rapidity. EMBRYOTOMY. Embryotomy is a mutilating operation upon the fetus. The term is generic, and includes the following operations: Craniotomy, decapitation, evisceration, and amputation of the extremities. Craniotomy — In this operation the child's head is perforated, the contents evacuated, and the head thus diminished in size. The forcible extraction of the evacuated head is often also a part of the operation. The operation may be indicated upon a dead or upon a living child. In the former case the indications for the operation may be comparatively trivial. If the mother can be saved any additional risk or suffering by the rapid delivery of the mutilated child, craniotomy is not only justifiable, but advis- able. In case of prolapse of the umbilical cord, with a con- tracted pelvis, the commonest condition that calls for craniotomy upon a dead infant, it is far better to open the head and to deliver the child easily with a cranioclast, than to apply the forceps to the head at the superior strait and to subject the mother to the delay, pain, and danger of a prolonged forceps operation, when nothing is to be gained by it. Craniotomy upon the living child is only justifiable in excep- tional circumstances. To condemn this operation, however, unreservedly and without exception is a mistake. In cases of difficult labor, if the pelvis is contracted or the child over- grown, and the physician must make a choice between Cesa- rean section, symphysiotomy, or craniotomy, if he has no skill in surgical work and is unable to procure expert assistance, it is better, unquestionably, to sacrifice the child for the mother's sake, rather than to attempt a serious surgical operation, amid un- favorable surroundings, and performed by an unskilful operator whose mortality must be very great. Every attempt must be made to avoid the destruction of a living child, of course ; and if the operator feels himself pos- sessed of sufficient skill to attempt the more serious operations of Cesarean section and symphysiotomy with fair prospect of success, or if he can summon to his aid an expert obstetric or abdominal surgeon, he should not think of performing crani- otomy upon the living child. Hut under certain circumstances craniotomy upon a living infant is a justifiable operation, and one not to be unreservedly condemned. 8 3 2 OBSTETRIC OPERATIONS. The Instruments for the Operation — Embryotomy is the oldest operation of obstetrics and the instruments for performing it would make an interesting historical collection. The sharp hook or crotchet in its numerous forms had a place in the obstet- rician's armamentarium for many centuries. At the present day the operator may need for craniotomy a perforator, a head seizer Fig. 647. — A, Sharp hook or crotchet ; B, Baudelocque's cephalotribe. or cranioclast, and a head crusher in its various forms of cephalo- tribe, basiotribe, or basilyst. Perforators. — The best perforator is Blot's. Smellie's perfora- tor or Hodge's scissors answer the purpose well enough, and in the absence of an instrument specially devised for the purpose, any long, sharp-pointed scissors serves admirably. Head Seizers or Cranioclasts. — This instrument was invented by Sir James Y. Simpson. It has been much improved by Carl EMBRYOTOMY. $33 Fig. 648. — Smellie's perforator. Fig. 649. — Blot's perforator. Fig. 650. — Oldest form of cranioclast. Fig. 651. — Simpson's cranioclast. Fig. 652. — Braun's cranioclast. ]y<^^ .A-->kJ© Fig- 653. — Cranioclast modified by the author. 53 834 OBSTETRIC OPERATIONS. Fig. 654. — Hicks' cephalotribe. Fig. 655. — Tarnier' s basiotribe. Fig. 656. — Tarnier' s basiotribe (separate parts). Fig. 657. — The second blade of the basiotribe has crushed the sinciput. EMBRYOTOMY. §35 Braun and the author has added to the latter instrument a pelvic curve, which facilitates its application at the superior strait. The cranioclast is made with two blades : one for insertion inside, the other outside, the skull. The handles are provided with a screw and nut to bring them close together, so as to give the blades a powerful grip upon the skull. Head Crushers or Cephalotribes. — The cephalotribe is the in- vention of the younger Baudelocque. It is simply a heavy, powerful forceps with the handles screwed together so as forci- bly to compress the skull between the blades. The best cephalo- tribe is Tarnier's basiotribc, which combines a perforator and a powerful head crusher.- Other modern instruments for the extraction of the mutilated Fig. 658. — Perforation of the head begun : the right hand is grasping the handles of the instrument. The tips should not be separated until they have entered the fontanel (Dickinson). head are Simpson's basilyst and Van Huevel's laminator. The latter is designed to saw off the face and the occipital protuber- ance. A wire ecraseur answers the purpose perfectly well, as was shown by Barnes. In addition to these instruments, the operator needs a heavy volsella forceps and a large metal catheter to break up the brain and to wash it out of the skull. The technic of the operation is as follows : The woman should be anesthetized not so much because the operation is painful or prolonged, but to spare her the sight of her mutilated infant. The patient is placed in the lithotomy position, and brought well to the edge of the bed or table on which she lies. 8 3 6 OBSTETRIC OPERATIONS. The vagina is scrubbed with tincture of green soap and hot water on pledgets of cotton. Following this, a douche of bichlorid solution, I : 4000, is given. The child's scalp is then seized by a strong volsella forceps, which is handed to an assistant, who pulls upon the instrument firmly, so as to fix the head at the superior strait. The operator then inserts two fingers of his left hand, made aseptic, and feels for a suture or a fontanel. The perforator is inserted into the vagina, along the palmar surface of the fingers, and is plunged into the skull Fig. 659. — -The head after delivery by the cranioclast. at a point upon which the finger-tips rest — that is, through a fontanel or a suture. When it has entered the skull the per- forator is twisted about in all directions, in order to break up the brain and is also opened in several different directions to enlarge the opening in the skull. The large catheter is next inserted and attached to a Davidson syringe. A column of water is injected into the cranial cavity, to wash out the remaining brain-substance. Next, if it is necessary, the size of the emptied head may be reduced with a cephalotribe. This is only called for in case of EMBRYOTOMY. 837 extreme pelvic contraction, or in the presence of some pelvic tumor seriously diminishing the capacity of the pelvic canal. In the vast majority of cases a cranioclast should be used instead of the cephalotribe. The internal branch of this instrument is inserted within the skull. The outer branch is next introduced in the same manner that one would insert a blade of the forceps. The two branches are then locked, and the handles are screwed firmly together, care being taken that the internal branch isinserted deeply within the cranial cavity, so that it shall get a firm grasp upon the skull. The child is now extracted in the same manner that one would extract the head with the forceps, except that the tractive efforts are made uninterruptedly and with greater Fig. 660. — Craniotomy on the after-coming head: one method of perforating (Dickinson). force. In certain cases it is sufficient simply to perforate the skull. This applies particularly to cases of hydrocephalus. The head being evacuated, the forces of nature are sufficient to in- sure the child's delivery. If it is necessary to perforate the after- coming head, the perforator may be inserted behind the ear, in the lambdoid suture, tinder the chin, through the roof of the mouth, or, possibly, through the foramen magnum. In a case of hydrocephalus with breech presentation, should there be great difficulty in reaching the after-coming head, it is possible to evacuate the fluid by perforating the spinal column and passing a catheter through the spinal canal into the cranium. Decapitation. — The chief indication for decapitation is an impacted shoulder presentation, in which it is impossible to do 8 3 8 OBSTETRIC OPERATIONS. version, either on account of the inability to move the child or because of the risk of ruptured uterus owing to the enormously distended lower uterine segment. The instruments needed for 66l. — Braun's hook. this operation are a Braun hook or a Ramsbotham sharp hook. The former is fastened firmly over the child's neck, when with two or three sharp turns of the wrist the neck is broken, and the soft structures may then be pulled through with the hook alone, or may be severed with scissors. The Ramsbotham knife-edged hook is passed over the neck, and by a rocking motion is made to cut through all the tissues of the neck. In the absence of specially devised instruments for the purpose, a string may be car- ried over the neck and the child decapitated by a sawing movement with the string, the vagina and perineum being pro- tected by a Sims speculum. Amputation and eviscera- tion are very rarely indicated. Some forms of monstrosities may possibly require these operations. A long-handled scissors is the best instrument for the purpose. Cutting or breaking the clavicles (cleidotomy) has been proposed on theoretical grounds Fig. 662.— Decapitation with Braun's to secure delivery of the shoul- hook (Dickinson). ders. SYMPHYSEOTOMY. 839 SYMPHYSEOTOMY. The operation of symphyseotomy is a division of the pubic joint, allowing a diastasis of the bones during labor, the child being extracted through the natural passage. The operation was suggested for the first time in 1598, and was performed for the first time on a living woman in 1777 by Sigault in •Paris. For a time symphyseotomy was in high favor, but the mortality that followed it, and the accidents which frequently marred its success, prejudiced the medical world against it, and it gradually died out. In 1866 the operation was revived in Italy, and from that time to 1886 it was performed 7 1 times with a death- rate of 25 per cent. The success achieved in the latter years of this period attracted the attention of the Parisian school of obstetricians. The operation was revived in its original home, and this revival was followed rapidly by its adoption throughout the civilized world. In the following three years there were 74 operations in the United States, with 10 maternal deaths and 18 infantile deaths. The mortality for America is about 12 per cent., but certain operators abroad have had as many as 20 cases in succession without a fatal result, and in Italy 54 symphy- seotomies have been performed with but 2 deaths. Even the best records for Cesarean section do not quite equal this, and, taking into consideration the statistics of both operations through- out the civilized world, it may be said that Cesarean section has been about twice as dangerous to the mother as symphyseotomy in the hands of a surgeon not specially trained. The expert abdom- inal surgeon, however, with a thoroughly aseptic technic should have a very low, and about an equal, mortality in both operations. An objection long urged against symphyseotomy, and one that retarded its general adoption, was that little space is gained by the separation of the pubic bones. But a careful study of the subject on the living woman and on cadavera has shown that the separa- tion of the symphysis up to 7 cm. (2^ in.) secures an increase in the anteroposterior, the transverse, and the diagonal diameters of the pelvis of 1.4 cm. (0.55 in.), 3.1 cm. (1.22 in.), and 3.5 cm. (1.4 in.), respectively. It is possible to achieve success with a conjugate as low as 6.5 cm. (2.56 in.), but in a pelvis so badly con- tracted symphyseotomy is more dangerous than Cesarean section. and it is possible that after the symphysis is severed it may be found necessary to deliver the child by craniotomy. The Indications for Symphyseotomy. — This operation should be the alternative of version in flat, contracted pelves. The woman with a conjugate diameter over seven centimeters should be al- lowed to remain in active labor twenty-four hours. If at the end of that time the head is not engaged, axis-traction forceps should 840 OBSTETRIC OPERATIONS. be applied and an attempt made with the instrument to engage the head. If after some twenty minutes of intermittent traction with justifiable force the head is not engaged, a choice must be made between version and symphyseotomy. The former is almost always practicable with a conjugate over seven cenL meters, but the mortality of the infants is about thirty-three per cent. The latter practically insures a living child but is distinctly dangerous to the mother, especially if the operation must be performed in a private house, and in an emergency. The case should be laid before the woman or her husband, who should certainly have some voice in the decision. The only situations in practice in which version need not be considered as an alter- native to symphyseotomy are the firm impaction of the present- ing part in the superior strait, and labors obstructed by a gener- ally equally contracted pelvis and by a kyphotic pelvis. The Technic of the Operation. — This differs as one prefers the French or the Italian method. The latter, to my mind, is to be preferred. It is quite as easy as the direct incision, and it has Fig. 663. — GalbiatTs knife for cutting the symphysis. tig. 664. — Author's knife for cutting the subpubic ligament. the great advantages that the wound is more readily kept from infection after delivery and that injuries to the urethra and blad- der are more surely avoided. To perform the operation accord- ing to the Italian plan the technic is as follows : The abdomen and pubic region should be cleansed as though for an abdominal section. An incision is made just above the symphysis, about an inch long, through the skin, fat, and super- ficial fascia. The attachment of the recti muscles to the pubic bones is then severed by a transverse cut just sufficient to admit the fore-finger behind the symphysis. The fore-finger of the left hand is passed behind the symphysis and hooked under it, while an assistant inserts a metal catheter in the woman's urethra, holding it down and a little to one side, usually the woman's right. The curved or sickle-shaped knife S J 'MP /I J 'SE O TOM J *. 841 of Galbiati is then seized firmly in the right hand and passed along the index-finger of the left hand until it glides under the symphysis. With an upward and forward rocking movement of the knife the symphysis is divided. It will almost invariably be found that this incision has failed to divide the subpubic ligament. To cut this, a smaller curved knife is inserted into the wound and passed under the ligament, which is then severed, from below upward, without difficulty. At this point in the operation there is usually a good deal of hemorrhage, which Fig. 665. — Subcutaneous section of the symphysis. occasionally is most alarming. It can be checked at once, how- ever, by packing the wound firmly with a strip of sterile gauze. During this part of the operation two assistants hold the woman's thighs equally flexed and at an equal distance apart from the middle line. Each assistant should also support the pelvis by firm pressure with a hand upon the trochanters. If the child's head is presenting, axis-traction forceps should be applied to it, and the head slowly and interruptedly extracted along the parturient canal, at each tractive effort the assistants being warned to exert firm lateral pressure upon the pelvis to prevent too great separa- tion of the pubic bones, which would endanger tin- integrity of the sacro-iliac joints. As soon as the child is born, the knees of 842 OBSTETRIC OPERATIONS. the woman are brought together and the thighs are somewhat extended. The operator then cleanses his hands again, removes the gauze packing from the suprapubic wound, inserts a finger behind the symphysis to see that the bladder is not nipped between the pubic bones, and then sews together the abdominal wound with three or four silkworm-gut sutures. It is quite unnecessary to suture the pubic bones or the symphysis. A dressing of aseptic gauze, cotton, and adhesive strips is applied Fig. 666. — French method of performing symphyseotomy (direct incision). to the wound. A firm binder is placed about the hips, and the woman is put in bed straight upon her back, upon an even mattress, which should be firm enough not to allow of sagging where the woman lies upon it. It is an advantage to support the sides of the pelvis with sand-bags during the woman's con- valescence. They should be placed directly alongside the hips, extending at least to the knees. The after-care of a symphyseotomy is exceedingly trouble- some. The patient must usually be catheterized, and much care must be exercised to keep the vulva and the surrounding regions clean. This is best done by slipping a bed-pan under the woman's buttocks and rinsing off the external genitalia two or three times a day with a weak solution of bichlorid of mercury. A slip sheet should be placed over the sand-bags and under the woman's buttocks. The knees must be kept bound together, S YMPH\ 'SE O TOM V. 843 Fig. 667. — Author's canvas binder for symphyseotomy. Fig. 668. — IJinder fur u>e after symphyseotomy, applied and fastened. 844 OBSTETRIC OPERATIONS. and the woman must lie quietly upon her back for at least three weeks. If it becomes necessary to disinfect the parturient canal during puerperal convalescence, the legs should be raised straight in the air, without separating them or without bending the knees. A bed-pan is then slipped under the woman's buttocks, and the physician can carry out curetment and intra-uterine douching with comparative convenience. A special bed has been devised for the after-care of a woman subjected to symphyseotomy, which unquestionably makes her convalescence more comfortable to her and easier for her caretakers. In the French method of performing symphyseotomy an incision is made directly over the joint, which is then cut with an ordinary scalpel. Ayers x advocates a subcutaneous section of the joint through a small incision under the clitoris, the joint being cut with a probe- pointed bistoury from above downward and from before backward. It is asserted that synostosis of the symphysis occasionally complicates the operation. I suspect that in the majority of such cases the operator has missed the joint. In view of this possibility, however, a chain or a metacarpal saw should be among the instruments prepared for the operation. 2 HEBOTOMY. Section of the pubic bone in the region of the pubic spine was proposed by Gigli in 1894 as a substitute for symphyseotomy. Doederlein modified the operation by making it subcutaneous. The idea was to escape the injuries to the bladder and the infec- tion which not infrequently followed symphyseotomy. A small opening is made above the pubis in the region of the pubic spine on the side toward which the occiput is directed; the periosteum is incised and pushed back; a ligature carrier is passed behind the pubes and under the periosteum, emerging below through a small incision in the labium majus or at its junction with the labium minus. By this means a Gigli saw is passed upward through the first incision, and the bone is severed. An imme- diate diastasis of 1 to \\ cm. is secured, increasing to 4 cm. as the head passes through the pelvic canal. Considerable hemorrhage from laceration of the crus clitoridis is the rule. After delivery the small wounds are closed with collodion dressing and the pelvis is supported by a firm binder. Some operators prefer 1 " American Journal of Obstetrics," vol. xxxvi, p. I. 2 During the enthusiasm that followed the revival of symphyseotomy I per- formed 7 operations in rapid succession. I have not done it for six or seven years, and think it rather doubtful that I will again. Cesarean section is the preferable operation for an expert, trained in abdominal surgery. CESAREAN SE C TION. 845 passing the saw from above downward, making the primary incision below instead of above the pubis. After the bone is divided the delivery may be spontaneous, by forceps, or by ver- sion. The limitations of the operation are the same as in sym- physeotomy. It is only applicable in pelves with a conjugate diameter of 7 cm. or more. One hundred and forty-six operations are recorded with eight deaths (Kannegieser). In the author's judgment hebotomy will share the fate of svmphyseotomy, becoming obsolete as the results of Cesarean section steadily improve. 1 CESAREAN SECTION. 2 When the escape of the child by the natural passage is impos- sible, it may be delivered by an abdominal and uterine incision. Cesarean section may be performed ante- and postmortem. Postmortem Cesarean Section. — If a pregnant woman near term dies suddenly, the abdomen and uterus may be cut open as quickly as possible, in order to deliver a living infant. It is said that the child has been extracted alive twenty minutes, three- quarters of an hour, and even two hours after the death of the mother, although it is almost inconceivable that this should be so. The child's death usually is synchronous with that of the mother, or follows a few moments afterward. In my opinion rapid version and extraction preceded by forcible dilatation of the cervix is a preferable method of delivery in a woman who has died suddenly during pregnancy, and, if possible, the operation should be completed before death has actually occurred. Thetis- sues of the dying woman offer no resistance to the forcible dilata- tion of the cervix, and the extraction of the child can be effected, as a rule, quite as quickly by version as by Cesarean section. Cesarean Section upon the Living Woman. — The first recorded Cesarean section upon a living subject was performed in Europe in the year 1610 3 ; but the operation is probably a much older one, and was in all likelihood known in certain primitive tribes and nations in remote antiquity. Until quite recent times the mortality of Cesarean section was so high that the operation was avoided at any cost. Among the procedures devised to avoid it was laparo-clytrotoniy, an operation that is no longer justifiable. A few years ago in England the death-rate was more than 99 per cent. Throughout the civilized world the mortality was at least 50 per cent. With the improvement in the technic of abdominal 1 "Zentralbl. f. Gyn.," No. 45, 1904; "Amer. Jour, of Surgery," June, 1906. 2 The name is not derived from Caesar, but from the Latin description of the operation, Ceeso malris utero. 3 By Trautmann in Wittenberg. The patient lived twenty-five days. 846 OBSTETRIC OPERATIONS. surgery, and with the perfection of asepsis in such surgery, the statistics of Cesarean section have steadily improved, until at the present time it has been possible to collect 68 consecutive cases with a mortality of 5.8 per cent., and 27 cases with a mortality of 3.7 per cent. 1 Under favorable circumstances and in the hands of skilful operators, the mortality of Cesarean section may be very low, perhaps below 5 per cent.; but in general practice the mortality of the operation remains high, and will probably continue so. In America the mortality, according to Harris' statistics, ranges from 30 to 40 per cent. Varieties of the Cesarean Section. — In 1 876 Porro 2 modified the operation by successfully performing, in addition to the celio- hysterotomy, a hysterectomy — that is, a removal of the uterus. The stump was fixed in the abdominal wound, and treated extra- peritoneally. The improvement introduced by Porro reduced the mortality one-half by the prevention of leakage through the uterine wound into the abdominal cavity. The next improvement in the technic was introduced by Miiller, who advocated a long abdominal incision through which the womb was delivered before it was incised. This prevented the soiling of the peritoneal cavity by liquor amnii and blood. Miiller also advocated the application of an Esmarch tube around the cervix and broad ligaments to control hemorrhage, but this is a bad plan, as it predisposes to postpartum bleeding from relaxation of the womb, and is never really necessary. No con- striction of the cervix at all is required if the operation is done with sufficient rapidity. The most important modification of Cesarean section in recent times — or, at least, the modification that has attracted the most attention, and has apparently done most to improve the mortality of Cesarean section — was introduced by Sanger, 3 who was the first to propose the careful and accurate closure of the uterine wound by a double layer of sutures. At first it was thought necessary to make a peritoneal flap by exsecting a portion of the uterine muscle below the peritoneum. But it was soon recognized that this was unnecessary, and the present prac- tice is to use simply a deep and superficial layer of sutures, sufficiently large in number to secure the accurate and firm clo- sure of the uterine wound. The superficial layer of sutures may be introduced after the manner of Lembert, but even this is not absolutely necessary; if they are tied tightly and set closely 1 Leopold, " Ueber ioo Sectiones Cesarese," " Archiv f. Gyn.," Bd. lvi. 2 The amputation of the uterus after a Cesarean section was first proposed by Michaelis in 1809, and first carried out with a fatal result by Storer, of Boston, in 186S. 3 "Archiv f. Gyn.," Bd. xix. CESAREAN SECTIOX. 847 enough, a single insertion of the needle on each side of the wound insures the approximation and closure of the peritoneal covering of the wound. Vaginal Cesarean Section. — In 1896 Diihrssen described an operation for the delivery of the child and the immediate vaginal extirpation of the uterus on account of cancer of the cervix. The cancer was curetted, the cervix amputated with a cautery, the bases of the broad ligament were ligated and the cervix was separated from the vagina ; then the anterior and posterior uterine walls were cut upward in the median line sufficiently to allow the extraction of the child, the placenta was extracted, posterior and anterior culs-de-sac were opened, the uterus was split, if necessary, in two, and the broad ligaments were secured with clamps or ligatures, as the uterus was pulled down. Finally the uterine body was cut away and extracted. Thorn proposes, as an improvement of the Diihrssen operation, an incision of the anterior and lateral vaginal vaults, separation of the cervix, opening of the anterior cul-de-sac, and then a median incision of the anterior uterine wall long enough to permit the extraction of the child, the hemorrhage being controlled by forcibly pulling the uterus down. After the uterus is completely emptied, the posterior vaginal vault and cul-de-sac are to be opened, the cervix completely detached, and then the broad ligaments are secured by clamps or ligatures and the uterus is cut away. 1 Indications for Cesarean Section. — The indications for this operation are relative and absolute. By an absolute indication is meant some condition which admits of no other method of delivery. Examples are furnished in extreme degrees of pelvic contraction — in a flat pelvis, for instance, in which the true conjugate is less than 6.5 cm. (2.56 in.). The highest grades of kyphosis, osteomalacia, spondylo- listhesis, and Naegele's pelves also furnish absolute indications for Cesarean section, as do foreign growths obstructing the pelvis, cicatricial contraction of the vagina, and carcinoma of the cervix and of the rectum. By a relative indication for Cesarean section is meant a con- dition that admits of some other method of delivery, — say, by symphyseotomy or by craniotomy, — but in which the question arises whether Cesarean section will not give the best result for mother and child. In a case of this kind the decision is difficult, and should be left, in part at least, to the woman or to her hus- 1 Diihrssen, " Der Vaginale KaUerschnitt, " lierlin, 1S96; also " Ueber die Behan S r - ss - [ )> etc - INDEX Abdomen, appearance of, in pregnancy> 196 changes in size and shape of, in preg- nancy, 194 palpation of, in pregnancy, 201 Abdominal binder, 331 in postpartum hemorrhage, 575 muscles, contraction of, in labor, 323 diastasis of, in labor, 612 in puerperal state, 683 pad after labor, 331 palpation at end of puerperium, 374 diagnosis of position of fetus by, 378 in labor, 377 in pregnancy, 201 pregnancy, 277 clinical history of, 285 death of fetus in, 290 secondary, 277 symptoms of, 295 section, exploratory, for puerperal sepsis, 750 for diffuse suppurative peritonitis, 743 for interstitial pregnancy, 298 for intraperitoneal abscess, 743 for tubal pregnancy, 297 in puerperal sepsis, 740 tumors, pregnancy and, 205 putrefaction of, 770 walls, change in, in pregnancy, 186 Abortion, 259 after-treatment of, 275 appearance of ovum after, 267 causes of, 260 cholemic convulsions in, 262 chorea in, 261 clinical history of, 263 phenomena of, 264 diagnosis of, 268, 270 duration of, 264 eclampsia in, 261 epilepsy in, 262 frequency of, 264 from abnormal positions of the uterus, 263 from accidents to mother, 258 from alterations of the maternal blood, 262 Abortion from anemia, 176 from cholera, 162 from chronic endometritis, 176 metritis, 176 poisoning of mother, 177 from convulsions, 262 from coughing, 262 from diffuse hyperplasia of decidual endometrium, 147 from eclampsia, 261 from heart disease, 249 from injuries of mother, 258 from irritable uterus, 260 from maternal diabetes, 177 from metritis, 223 from overdistention of uterus, 263 from placenta praevia, 565 from prolapse of uterus, 263 from renal calculus, 243 from retroflexion of uterus, 263 from typhoid fever, 162 from vomiting, 262 hemorrhage in, 264 hydramnios in, 263 hysterical convulsions in, 262 in multiple pregnancy, 263 in retrodisplacement of the pregnant uterus, 219 induction of, 776 in pneumonia, 668 indications for, 776 methods of, 777 nephritis in, 241 inevitable, diagnosis of, 269 treatment of, 273 active, 274 expectant, 274 missed, 275 pain in, 264 prognosis of, 271 threatened, diagnosis of, 268 treatment of, 272 treatment of, 271 tubal, 292 \I'M ess, intraperitoneal, abdominal sec- tion for, 743 ischiorectal, 772 in puerperal sepsis, 772 mammary, 709 885 886 INDEX. Abscess, mammary, in pregnancy, 232 of Bartholin's gland, obstruction of labor by, 524 postmammary, 710 suburethral, in pregnancy, 228 Acanthopelys, 486 Accessory corpuscle of spermatozoon, 68 Accidental hemorrhage, 571. See also Hemorrhage. Accouchement force in eclampsia, 631 Acetabulum, fracture of, 490 Acetonuria in pregnancy, 245 Adhesion of placenta, 424 Adipocere, 175 After-birth, 116. See Placenta. After-coming head, delivery of, by for- ceps, 829 Deventer's method, 830 Mauriceau's method, 828 Prague's method, 829 Wigand's method, 825 After-pains, 346 Agalactia, 697 Albuminuria as indication for inducing abortion, 776 from death of fetus, 174 in pregnancy, 240, 246 Alimentary canal, diseases of, in preg- nancy, 232 Allantois, 135 Amnion, abnormalities of, 98 of secretion, 98 adhesive inflammation of, 104 anatomy of, 96 cysts of, 105 development of, 94 dropsy of, 99 Amniotic bands, formation of, 104 fluid, 96. See Liquor amnii. Amniotitis, 101 Amputation of fetal parts to effect de- livery, 838 Amputations, intra-uterine, 167 Amyloid degeneration of placenta, 126 Anasarca, 547 of fetus, 165 Anemia, abortion from, 176 pernicious, in pregnancy, 253 puerperal, 639 Anesthetics in labor, 320 Aneurysm in pregnancy, 252 Ankylosis in fetus, 166 of pelvic joints, 492 Annular placenta, 123 Anteflexion of gravid uterus, 217 treatment of, 218 Antepartum fetometry, 454. See also Fetometry, antepartum. Anteroposterior diameter of pelvic inlet, measurement of, 437 Anteroposterior diameter of pelvic outlet, measurement of, 454 of pelvis, 22 Ante-uterine hematocele, 293 Anus vaginalis, obstruction of labor by, 5 2 3 vestibularis, obstruction of labor by, S23 Aphthae of new-born, 877 Apoplexies in pregnancy, 246 in puerperal state, 693 pulmonary, of new-born, 875 Appendicitis in pregnancy, 238 Appetite in puerperal state, 349 Arbor vitas of uterus, 46 Areola of pregnancy, 195 Armamentarium for labor, 316 Arms, delivery of, after podalic version, 825 Arthritis in puerperal state, 679 Articular rheumatism of fetus, 163 Artificial dilatation of the cervical canal, 808 feeding of infant, 860 food, preparation of, 860 respiration of new-born infant, 871 Schultze's method, 871 Ash of human milk, 860 Asphyxia livida, 870 neonatorum, 870 after-treatement of, 872 causes of, 870 treatment of, 870 of new-born child, 870 pallida, 870 Assimilation pelvis, 472 Asthma in pregnancy, 254 Atelectasis of new-born infant, 872 Atmosphere, puerperal sepsis from, 732 Atresia ani of new-born, treatment of, 876 of vagina, obstruction of labor by, 523 Atrophy of deciduae, 153 Auscultation, diagnosis of position of fetus by, 379 in diagnosis of pregnancy, 203 Auto-infection in puerperal sepsis, 725 Auto-intoxication in pregnancy, 255 Auvard incubator, 858 Avortement instantane, 264 Avulsion of limbs of child in labor, 868 Axis-traction forceps, 789 application of, 803 Baby-clothes, 365 Baby's basket, 366 Baccelli's method of treating tetanus in puerperal sepsis, 771 Bacillus aerogenes capsulatus in puer- peral sepsis, 724 fcetidus in puerperal sepsis, 724 INDEX. 88? Bacillus pyocyaneus in puerperal sepsis, 7 2 3 Bacteria, passage of, from mother to fetus, 158 Bacteriology of blood in puerperal sep- sis, 731 of vagina, 715-726 Bag of waters, 309 Ballottement, 203 Bandl, ring of, 183, 381, 581 Barnes' bag for artificial dilatation of cervical canal, 808 in inertia uteri, 431 in treatment of hematoma, 657 Bartholin's glands, 45 abscess of, obstruction of labor by, 524 Basal decidua, 143 Basiotribe, Tarnier's, 834, 835 Baudelocque's diameter, 437 method of cephalic version, 403 Binder for symphyseotomy, 843 mammary, 363 obstetrical, 331 Bladder, changes in, in pregnancy, 186 diseases of, in pregnancy, 244 irritability of, in pregnancy, 244 Blastomeres, 74 Blindness in pregnancy, 248 Blood, bacteriology of, in puerperal sepsis, 731 changes in, in pregnancy, 186, 253 clots, retention of, puerperal hemor- rhage from, 650 diseases of, in pregnancy, 253 in new-born infant, 856 maternal, alterations in, that are fatal to fetus, 176 Blood-vessels, diseases of, in pregnancy, 251 . of pelvic organs, 32 of uterus, changes in, in pregnancy, 181 Bloody discharge from genitalia of new- born female children, 883 Blot's perforator, 832, 833 Blunt hook, 807 Body of Rosenmiiller, 42 Body-cavity, 75 Boric acid in aphthae of new-born, 877 in cystitis, 691 in thrush of new-born, 877 Bossi's dilator, 810 Bougies, Gau's, 811 graduated, for dilating cervical canal, 811 Hegar's, 811 Bowels in puerperal state, 361 movements of, in new-born infant, 855 of child, injury of, in labor, 869 Brachial palsv from injury during labor, 864 Brain, congestion of, in pregnancy, 246 diseases of, in pregnancy, 246 injury to, during labor, 863 Braun's cranioclast, 833 hook, 838 Breast pump, 707 Breasts, absence of, 692 areola of, in pregnancy, 195 diseases of, 704 hypertrophy of, 692 in pregnancy, 195 in puerperium, 361 inflammation of, 708 management of, in puerperium, 361 sensations in, in pregnancy, 194 stria; of, in pregnancy, 195 structure of, 351 supernumerary, 692 Breech, extraction of, 805 by blunt hook, 808 by fillet, 807 by forceps, 807 manual method of, 805 presentation, 408. See also Presenta- tion, breech. Brim of pelvis, 17 Broad-ligament pregnancy, 279 Bronchial catarrh in pregnancy, 253 Brow presentation, 405. See also Pres- entation. Brown atrophy of myocardium in preg- nancy, 251 Bruit, uterine, 204 Buhl's disease, 881 Bulbs of vestibule, 45 Bylicki's pelvimeter, 449 Caked breast, 707 Calcareous degeneration of placenta, 126 of umbilical cord, 141 Calcification of placenta, 126 Calculi, vesical, complication of labor by, 540 in pregnancy, 244 Calculus, renal, 243 in pregnancy, 243 Canals of Gartner, 41 Cancer of uterus in pregnancy, 224 syncytial, 132 Caput succedaneum, 866 in flat pelvis, 458 in justominor pelvis, 463 Carcinoma of cervix uteri, obstruction of labor by, 532 of uterus a cause of puerperal hemor- rhage, 651 syncytiale, 132 Cardiac nerve-storms, 187, 254 Caries of pelvis, 492 of teeth in pregnancy, 232 888 INDEX. Carunculas myrtiformes, 45, 215 enlarged, obstruction of labor by, 525 Cams, curve of, 24 Casein of milk, 860 Catarrhal endometritis, 150 Catheterization in puerperal state, 360 Celiohysterectomy, 848 and celiohysterotomy, choice of, 850 Celiotomy for ovarian cyst in labor, 538 Cellular hypertrophy of placental villi, 124 Cellulitis in puerperal sepsis, 754 Celom, 75 Centers of ossification as signs of matu- rity of fetus, 88 Cephalhematoma, 866 Cephalic presentation, 379 version. See Version. Cephalotribes, 835 Cervical canal, artificial dilatation of, 808 by anterior vaginal hysterot- omy, 815 by Barnes' bags, 808 by forceps, 809 by graduated bougies, 811 by incisions, 811 by manual method, 808 bv vaginal Cesarean section, '815 by \oorhees' bags, 808 pregnancy of Rokitansky, 153 Cervicitis in pregnancy, 224 Cervix uteri, alterations in, in pregnancy, 185 appearance of, in pregnancv, 200, 202 atresia of, obstruction of labor bv, 5 11 cancer of, in pregnancv, 224 obstruction of labor by, 532 cicatricial contraction of, obstruc- tion of labor by, =520 circular detachment of, in labor, 591 dilatation of, artificial, 808 diseases of, in pregnancy, 224 displacement of, obstruction of labor by, 532 examination of, specular, at end of puerperium, 473 injuries to, in labor, 589 rigidity of, obstruction of labor by, 520 Cesarean section, 845 for placenta prasvia, 570 in labor with contracted pelvis, 517, 5.i8 _ indications for, 847 Porro's method, 846, 848 postmortem, 845 Sanger's method, 846, 849 Cesarean section, vaginal, 847 artificial dilatation of cervical canal by, 815 varieties of, 846 Cessation of menstruation as a sign of pregnancy, 192 without pregnancy, 193 Chamberlen's vectis, 784 Champetier de Ribes' inelastic bag, 781 Child, new-born, 363, 830. See also New-born infant. Chloasmata of pregnancy 195, 258 Chloral in eclampsia, 689 in galactorrhea, 702 in inertia uteri, 431 in rigidity of cervix uteri, 520 Chloroform in eclampsia, 628 in labor, 321 Cholemic convulsions, abortion from, 262 Cholera of fetus, 162 Chorea, abortion from, 261 in pregnancy 247 treatment of, 247 Chorion, chronic inflammation of, 116 description of, 107 development of, 106 diseases of, 107 false, 106 fibro myxomatous degeneration of, 116 frondosum, 107 laeve, 107 myxoma of, no relation of, to syncytial cancer. 112 villi of, 106 Chorionic villi, 106 cystic degeneration of, 107. See also Cystic degeneration. dropsy of, 108 Chronic poisoning of mother, effect of, upon fetus, 177 Chyluria in pregnancv, 245 Circular vein of placenta, 121 Circulation of fetal blood, 84 Circulator}^ apparatus, alterations in, in puerperal state, 347 diseases of, in pregnancy, 249 system, changes in, in pregnane} 7 , 186 Cleft-palate of new-born, 875 Clitoris, 45 Cloaca, 39, 42 Clothing of new-born infant, 859 Cocain for hemorrhoids, 239 in pernicious vomiting, 236 Coccyx, examination of, at end of puer- perium, 378 fracture of, in labor, 612 Coffee-grounds vomit in melena neona- torum, 883 Coitus, time when most likely to result in conception, 72 INDEX. 889 Colic of new-born 877 Colon bacillus in puerperal sepsis, 723, 727 Colostrum, 196, 352, 696 Colpohyperplasia cystica in pregnancy, 227 Combined version, 818 D'Outrepont's method of, 8i3 Wright's method of, 818 visual and touch examination in preg- nancy, 202 Compact layer of uterine decidua, 143 Compound presentation, 551. See also Presentation. Conception, average date of, after mar- riage, 72 time when most likely to occur, 71 Congenital cvstic elephantiasis of fetus, l6 5 .. deformities, treatment of, 875 Congestion of brain in pregnancy, 246 Conglutinatio orificii uteri externi, 519 Conjugate diameter, false, of spondylo- listhetic pelvis, 498 of pelvis, diagonal, measurement of, 441 by manual method, 442 external, measurement of, 437 true, measurements of, 441, 442 Conjunctivitis of new-born, 877 Connective tissue of pelvis, 28 of uterus, alterations in, in preg- nancy, 181 Constipation in pregnancy, 188, 189 treatment of, 237 of new-born, 877 Contracted pelves, version in, 816 pelvis, flat, 463 generally, 461. See also Pelvis, justominor. obliquely, 466 transversely, 470 Contraction-ring, 183, 381, 581 Convulsions, 620. See also Eclampsia. Cord, umbilical, 135. See also Umbili- cal cord. Cords, coiling of, in twin labor, 555 Corpus luteum, 63 of menstruation, 64 of pregnancy, 64 Cotyledons of placenta, 121 Coughing, abortion from, 261 Cows' milk compared to human, 861 composition of, 861 Coxalgic pelvis, 509 Cranioclast, 832, 833 Braun's, 833 Hirst's, 833 Simpson's, 833 Craniopagus, 542 Craniotomy, 831 Craniotomy, instruments for, 832 technic of, 835 Crede's method of expressing placenta, 333^ 4 2 3 Cretinism, fetal, sporadic, 165 Curve of Carus, 24 Cyanosis of new-born, 880 Cystic degeneration of chorionic villi, 107 clinical history and diagnosis of, 112 etiology and frequency of, 114 pathological anatomy of, no treatment of, 115 stenosis associated with, 115 endometritis of deciduae, 151 Cystitis in pregnancy, 244 in puerperal state, 690 septic, in puerperal sepsis, 769 Cystocele, obstruction of labor by, 540 Cysts of amnion, 105 of placenta, 131 of umbilical cord, 141 ovarian, complication of labor by, 536 in pregnancy, 224 Davis forceps, 789 Death of fetus, causes of, in fetus itself, 178 referable to father, 178 detection of, 1 74 diagnosis of, 213 effect of, upon mother, 173 habitual, 175 in utero, 172 of mother, effect of, upon fetus, 171, 616 sudden, in labor, 614 Decapitation, 837 Decidua, basal, 143, diffuse hyperplasia of, 147 epichorial, 143 microbic endometritis of, 153 ovular, 143 placental, 143 polypoid endometritis of, 149 purulent endometritis of, 153 reflexa, 142, 143 serotina, 142 uterine, 143 compact layer of, 143 glandular layer of, 146 spongy layer of, 146 vera, 142, 143 Deciduae, 141 acute inflammation of, 152 atrophy of, 153 catarrhal endometritis of, 150 cystic endometritis of, 151 diseases of, 1 4.7 890 INDEX. Deciduae, Hunterian theory of develop- ment of, 142 Decidual cells of Friedlander, 146 endometritis, exanthematous, 152 hemorrhagic, 152 endometrium, diffuse hyperplasia of, 147 fragments, retention of, after labor, 643 Deciduoma malignum, 131 Deciduo-sarcoma, 131 Deformities of pelvis, 434. See also Pelvis. Degeneration, fibrofatty, of placenta, 124. See also Fibrofatty degeneration. Delirium of fever in pregnant women, 249 temporary, of labor, 249 tremens distinguished from puerperal insanity, 249 Delivery of placenta, 332 postmortem, 617 Descent stage of labor, 310 Determination of sex, 89 Deutoplasm of ovum, 61 Deventer's method of delivering after- coming head, 830 Diabetes, maternal, effect of, upon fetus, 179 mellitus in pregnancy, 245 Diagnosis of life or death of fetus,. 213 of sex of fetus, 215 Diagonal conjugate, measurement of, 441 manual method of, 442 Diameter of pelvis, anteroposterior, of outlet, measurement of, 565 Baudelocque's, 437 diagonal conjugate, measurement of, 441 by manual method, 442 external conjugate, measurement of, 437 transverse, measurement of, 449 of outlet, measurement of, 451 true conjugate, measurement of, 441, 442 Diameters of fetal head, normal, 88 of pelvis, 22 Diarrhea in pregnancy, treatment of, 237 Diastasis of abdominal muscles in labor, 612 in puerperal state, 683 Dicephalus, 534 birth of, 542, 545, 547 Diet in puerperal state, 358 regulation of, in pregnancy, 189 Diffuse peritonitis in puerperal sepsis, 75°. Digestion in new-born infant, 855 Digestive tract, changes in, in pregnancy, Dilatation, instrumental, 809 stage of labor, 310 Dilators, Bossi's, 810 Gau's, 811 Hegar's, 811 Dimensions of fetal head, 88 Diphtheria in puerperal state, 687 relation of, to puerperal sepsis, 774 Diprosopus, craniotomy for, 548 Dipygus, 543 parasiticus, 543 Direction of presenting part, anomalies of, 392 Discus proligerus, 60 Dissecting metritis in puerperal sepsis, 754 Distortion of head during labor, 864 Doderlein, vaginal bacilli of, 717 Doderlein's lochial tube, 729 tube, Nicholson's modification of, 730 Double promontory, 456 D'Outrepont's method of combined ver- sion, 820 Dropsy of amnion, 99 of chorionic villi, 108 Dry labor, 322 Ductus arteriosus, 85 omphalicus, 136 venosus, 84 Diihrssen's method of artificial dilata- tion of cervical canal, 815 Dulness on percussion of abdomen in pregnancy, 204 Duration of pregnancy, estimation of, 212 Dwarf pelvis, 461, 462 Dystocia, 428 due to disease, 620 Dysuria in retroflexion of pregnant uterus, 218 Eclampsia, 621 abortion in, 261 accouchement force in, 631 . anesthetization in, 628 caffein in, 630 catharsis in, 628 causes of, 621 Cesarean section in, 630 chloral in, 628 chloroform in, 628 diaphoresis in, 628 differential diagnosis of, 625 during labor, 631 effect of, on fetus, 171 frequency of, 623 hot-air bath in, 628 morphin in, 629 nitrite of amyl in, 630 obstetrical treatment of, 631 INDEX. 891 Eclampsia, oxygen in, 630 pathology of, 624 pilocarpin in, 630 prognosis of, 625 scheme for treatment of, 632 symptoms of, 623 thyroid extract in, 630 treatment of, 627 urine in, 624 venesection in, 627 veratrum viride in, 630 wet pack in, 6" 8 Ectoderm, 74 Ectopic pregnancy, 276. See also Ex- tra-uterine pregnancy. Eczema of nipples in pregnancy, 232 Edema of genitals after labor, 641 of glottis in pregnancy, 253 of placenta, 123 of vulva in pregnancy, 229 Edgar's method of dilating os uteri, 808 Egg-cords, 60 Ehrenfest-Neumann kliseometer, 452, 453 pelvigraph, 452, 453 Elephantiasis, congenital cystic, 165 Embolism, pulmonary, in labor, 616 in pregnancy, 254 Embryo, development of, 76 in first month, 76 in second month, 80 in third month, 81 Embryonal area, 74 Embryotomy, 831 Emotion as a cause of puerperal hemor- rhage, 650 death from, in labor, 616 Emotional fever in puerperal state, 658 Emotions, maternal, influence of, upon fetus, 170 Emphysema in pregnancy, 253 subcutaneous, in labor, 613 Endocervicitis in pregnancy, 224 Endochorion, 107 Endocolpitis in puerperal sepsis, 753 Endometritis, catarrhal, 150 chronic, as a cause of death of fetus, 176 cystic, 151 decidualis, 127 polyposa or tuberosa, 149 exanthematous decidual, 152 hemorrhagic decidual, 152 in puerperal sepsis, 753 microbic decidual, 153 placentaris, 128 gummosa, 127 polypoid, of decidua, 149 purulent decidual, 153 tuberculous, 153 Endometrium, decidual, diffuse hyper- plasia of, 147 hyperplastic inflammation of, 147 involution of, 342 Entoderm, 75 Epichorial decidua, 143 Epilepsy, abortion from, 262 in pregnancy, 247 Episiotomy, 324 Epistaxis in parturition, 253 in pregnancy, 253 Epoophoron, 42 Erysipelas in puerperal state, 670 of fetus, 161 relation of, to puerperal sepsis, 774 Erythematous rashes in puerperal state, 673 Evisceration, 838 Evolution, spontaneous, 421 Exanthemata of new-born, 875 Exanthematous decidual endometritis, i5 2 Exochorion, 107 Exostoses of pelvis, 486 Expulsion, forces of, 381 excessive power of, 433 of gravid uterus, 219 stage of labor, 310 Extension of fetal head, anomalies of, 392 in face presentations, 399 in labor, 387 External conjugate, measurement of, 437 genitals, development of, 42 Extramedian engagement of head, 460 Extra-uterine pregnancy, 276 advanced, 298 changes in uterus and vagina in, 279 classification of, 277 clinical history of, 278 diagnosis of, 295 etiology of, 277 frequency of, 277 prognosis of, 296 symptoms of, 294 terminations of, 286 treatment of, 297 Eyesight in new-born infant, 856 Eyes, failing of, in pregnancy, 248 Face, appearance of, in pregnancy, 195 of fetus, injuries of, during labor, 867 presentation, 397. See also Presen- tation, face. Fallopian tubes, anatomy of, 50 False corpus luteum, 64 Fat of human milk, 860 892 INDEX. Fatty degeneration of heart in pregnancy, 251 of placenta, 124 Feeding of new-born infant, 860 artificial, 860 Female pronucleus, 72 sexual organs, development of, 39 Femora, luxation of, effect on pelvis, Fertilization of ovum, 71 Fetal body, 383 cretinism, sporadic, 165 head, dimensions of, 88 structure of, 383 heart sounds in pregnancy, 204 mortality, 154 movements, auscultation of, 205 in pregnancy, 194 palpation of, 202 pelvis, 464 syphilis, 154 diagnosis of, 156 manifestations of, 155 prognosis of, 155 treatment of, 157 Wegner's sign of, 156 traumatism, 167 Fetation, multiple, 91 abortion in, 93 acardia in, 92 foetus papyraceus in, 92 frequency of, 91 hydramnios in, 92 placenta in, 92 Fetometry, antepartum, 454 Hirst's method, 454 Muller's method, 454 Perret's method, 454 Stone's method, 454 Fetus, accidents to, 617 alterations in maternal blood that are fatal to, 176 amorphus, 141 anasarca of, 165 ankyloses in, 166 articular rheumatism of, 163 cause of death of, in itself, 178 cholera of, 162 circulation of blood in, 84 conditions of mother which injure, 169 of uterus which interfere with devel- opment of, 176 congenital cystic elephantiasis of, 165 death of, diagnosis of, 213 effect of, upon mother, 171 from causes in itself, 178 referable to father, 1 78 in utero, 172 development of, 76 in eighth month, 83 Fetus, development of, in fifth month, 82 in first month, 76 in fourth month, 81 in ninth month, 83 in second month, 80 in seventh month, 82 in sixth month, 82 in tenth month, 83 in third month, 81 diagnosis of life or death of, 213 of sex of, 215 diseases of, 154 effect of chronic diseases of mother upon, 177 of chronic poisoning of mother upon, 177 of death of mother upon, 171, 616 of eclampsia upon, 171 of excess of urea in maternal blood upon, 177 of maternal diabetes upon, 177 fever upon, 169 nephritis upon, 177 erysipelas of, 161 fractures of the bones of, in utero, 166 habitual death of, 175 diagnosis of cause of, 179 preventive treatment of, 180 infectious diseases of, other than syph- ilis, 158 influence of icterus gravidarum upon, 171 of maternal emotions upon, 170 intestinal invagination in 167 intra -uterine amputations on, 167 luxations in, 166 malaria of, 161 malformations of, obstruction of labor by, 544 mature, 87 general appearance of, 88 length of, 88 weight of, 87 measles of, 160 non-infectious diseases of, 163 overgrowth of, obstruction of labor by, 54i papyraceus, 92 pneumonia of, 163 position of, abdominal palpation to determine, 378 auscultation to determine, 379 rachitis of, 164 recurrent fever of, 163 scarlatina of, 160 septicemia of, 162 sex of, diagnosis of, 215 signs of maturity of, 87 syphilis of, 154 syphilitic infection of, 154 temperature of, in utero, 85 INDEX. 893 Fetus, traumatism of, 167 tuberculosis of, 161 tumors of, obstruction of labor by, 547 typhoid fever of, 162 vaccination of, 160 variola of, 159 yellow fever of, 163 Fever in puerperal state, emotional, 658 from cerebral disease, 663 from constipation, 661 from exposure to cold, 660 from reflex irritation, 661 from sun-stroke, 664 non-infectious, 658 syphilitic, 665 with eclampsia, 664 maternal, influence of, upon fetus, 169 Fibrofatty degeneration of placenta, 124 Fibroid of uterus, obstruction of labor by, 532 Fibroids in puerperal state, 650, 748 Fibromata of uterus in pregnancy, 223 Fibromyoma of uterine muscle in preg- nancy, 223 Fibromyxomatous degeneration of cho- rion, 116 Fibrous degeneration of placenta, 124 Fillet-carrier, 806, 807 extraction of breech by, 807 Fimbria? of oviduct, 53 Finger-nails, loosening of, in pregnancy, 258 Fistulse, genito-urinary, 610 Flat pelvis, non-rachitic, 463 rachitic pelvis, 474 Flexion of fetal head, 386 abnormalities of, 391 Food-yolk of ovum, 61 Foramen ovale, 85 Forceps, 781 application of, 792 axis-traction, application of, 803 Davis', 789 dilatation of cervical canal by, 810, 811 Hirst's, 787 historical sketch of, 781 Hodge's, 787 in after-coming head, 829 in breech presentation, 807 in labor with contracted pelvis, 516 in occipitoposterior position, 802 in transverse positions of head, 802 indications for application of, 790 introduction of, 792 Levret's, 785 locking of, 798 mortality from, 803 Palfyn's, 784 position for, 792 Poulct's axis-traction, 789 Forceps, preparations for application of, 792 Simpson's, 787 Smellie's, 785 sterilization of, 792 Tarnier's axis-traction, 789 traction on, 801 uses and functions of, 790 Forces of expulsion, 381 of labor, anomalies of, 428 of resistance, 381 Fossa navicularis, 44 Fourchet, 44 Fowler's position after operation for dif- fuse suppurative peritonitis, 758 Fracture of limbs of child during labor, 868 of pelvis, 489 of skull during labor, 864 Fractures in utero, 166 Friedlander, decidual cells of, 146 Fritsch's method of treating postpartum hemorrhage, 577 Fundus uteri, height of, as an indication of duration of pregnancy, 213 Funic souffle, 204 Funis, 135. See also Umbilical cord. Funnel-shaped pelvis, 460 Furuncles of new-born, 878 Galactocele, 710 Galactorrhea, 701 Galbiati's knife, 840 Gangrene of vulva, obstruction of labor by, 5 2 5 puerperal, 765 Gartner, canals of, 41 Gastro-intestinal hemorrhage in new- born, 882 Gau's dilators, 811 Gavage of premature infants, 858 Gelatin of Wharton, 136 Generative organs, nerves of, 32 Genital cord, 40 eminence, 42 Genitalia, diseases of, 217 external, development of, 42 internal, development of, 39 Genito-urinary fistula?, 610 Germinal spot of ovum, 61 vesicle of ovum, 61 Germ-yolk of ovum, 61 Gestation, 17. See also Pregnancy. Gingivitis in pregnancy, 232 Glands of clitoris, 45 of Montgomery, 105, 352 Gland-space, 60 Glandular layer of uterine decidua, 146 Glottis, edema of, in pregnancy, 253 in puerperium, 349 8 9 4 INDEX. Goiter in pregnancy, 251 Gonococcus-infection in pregnancy, 227 in puerperal sepsis, 724, 727 Gonorrhea in puerperal state, 671 Gonorrheal stomatitis of new-born, 877 Goodell's rule of pregnancy, 202 Graafian follicles, 55 development of, 60 rupture of, 60 Graduated bougies, dilatation of cer- vical canal by, 810, 811 Graves' disease in pregnancy, 251 Gravid uterus, 183. See also Pregnant uterus. Gum of new-born, 854 Habitual death of fetus, 175 diagnosis of cause of, 179 preventive treatment of, 180 Harelip, treatment of, 875 Harris' method of dilating os uteri, 808 Harris-Dickinson pelvimeter, 438 Head, fetal, effects of flat pelvis on, 458- 460 extramedian engagement of, 460 possible presentations of, 384 structure of, 383 Hearing, disturbances of, in pregnancy, 248 Heart affections of new-born, 880 changes in, in pregnancy, 187 disease in labor, 634 in pregnancy, 249 failure, death from, in labor, 614 muscle, disease of, in pregnancy, 251 of new-born infant, 857 sounds, fetal, in pregnancy, ausculta- tion of, 204 Hebotomy, 844 Hegar's bougies or dilators, 811 sign of pregnancy, 202 Hematocele, ante-uterine, 293 from tubal pregnancy, 293 retro-uterine, 293 Hematoma from ruptured tubal preg- nancy, 293 of cord, 141 of vagina, obstruction of labor by, 522 polypoid, of uterus, 149 puerperal, 651, 652 clinical history of, 654 diagnosis of, 654 etiology of, 653 hemorrhage from, 651 prognosis of, 656 situation of, 653 size and form of, 653 treatment of, 657 rupture of, causing death in labor, 615 Hematuria in pregnancy, 245 in puerperal state, 688 Hemidrosis of new-born infant, 880 Hemophilia of new-born, 880 Hemoptysis in pregnancy, 254 Hemorrhage, accidental, 571 complicating labor, 560 from laceration of cervix, 589 from umbilicus, 882 gastro-intestinal, in new-born, 882 in placenta praevia, 564 in third stage of labor, prevention of, 3 2 9 placental, 129 postpartum, 573 abdominal binder in, 575 auto-infusion in, 580 causes of, 573 compression of uterus in, 576 diagnosis of, 574 electricity in, 577 ergot in, 575 Fritsch's method of treating, 577 intravenous injection of salt solu- tion in, 578 Monsel's solution in, 577 morphin in, 579 rectal injection of salt solution in, 568, 578 symptoms of, 574 tampon in, 576 transfusion of blood in, 580 treatment of, 575 puerperal, 641 from carcinoma of uterus, 651 from dislodgment of thrombi, 649 from displacements of uterus, 646 from emotional causes, 650 from fibroids, 650 from hematomata, 651, 652 from pelvic engorgement, 651 from relaxation of uterus, 650 from retained placenta and mem- * branes, 641 from retention of blood-clots, 650 from wounds of genital tract, 651 unavoidable, 560, 571 Hemorrhagic decidual endometritis, Hemorrhoids in pregnancy, 239 vesical, 244 Hemothorax of child from injury in labor, 870 Heredity- function of, in labor, 304 Hernia of pregnant uterus, obstruction of labor by, 526, 527 umbilical, 140 of new-born, 875 vaginal, obstruction of labor by, 539 Hernial protrusion, pregnant uterus forming part of, 222 Herpes gestationis in pregnancy, 257 Hicks' cephalotribe, 834 INDEX. 895 Hirst's canvas binder for symphyseot- omy, 843 cranioclast, 833 forceps, 787 knife for cutting subpubic ligament, 840 method of antepartum fetometry, 454 operation for inversion, 607 pelvimeter, 446 Hodge's forceps, 787 scissors, 832 Holmes' ut°rine tube and packer, 577 Holoblastic ovum, 61 Hook, blunt, 806 Braun's, 838 Ramsbotham's, 838 Human milk as food, 860 compared with cows' milk, 861 constitution of, 860 Hydatidiform mole, 108 Hydramnios, 99 acute, 99 diagnosis of, 102 differentiation of, from ascites, 103 from ovarian cyst, 103 from twin pregnancy, 103 etiology of, 99 from abnormal pressure in blood- vessels of cord, 100 from both fetal and maternal sources, 101 from deficient absorption of liquor amnii, 102 from excessive secretion of fetal urine, 100 from fetal skin, 101 from the amnion itself, 101 of fetal origin, 99 of maternal origin, 99 symptoms of, 102 treatment of, 103 Hydrencephalocele, 545 obstruction of labor by, 547 Hydroamnion, 99 Hydrocephalus, 548 diagnosis of, 548 treatment of, 549 Hydronephrosis in pregnancy, 243 Hydrops tubee profluens, 300 Hydrorrhcea gravidarum, 300 Hydrostatic dilatation of cervical canal, 808 Hymen, 45 unruptured, obstructionof labor by, 5 2 3 Hyperemesis gravidarum. See Vomit- ing, pernicious. Hyperlactation, 701 Hyperleukocytosis, artificial, in treat- ment of puerperal sepsis, 739 Hyperplasia, diffuse, of decidual en- dometrium, 147 Hypertrophy, cellular, of placenta, 124. See also Cellular hypertrophy. localized, of cord, 141 Hypodermoclysis, 579 Hysterectomy for puerperal sepsis, 746 Hysteria in pregnancy, 247 Hysterical convulsions, abortion in, 262 Hysterotomy, anterior vaginal, for arti- ficial dilatation of cervical canal, 815 Icterus gravidarum, influence of, upon fetus, 171 of new-born, 880 Iliopsoas muscle, 25 Imperforate rectum of child, 876 Impetigo herpetiformis, 256 Impregnation, change in ovum follow- _ ing, 74 time when most likely to occur, 72 Incarceration of pregnant uterus, 218 treatment of, 220 Incontinence of urine in pregnancy, 244 in puerperium, 689 Incubation, 857 Incubator, Kny-Scheerer, 858 Indagation, 370 Indigestion in pregnancy, 237, 23S Induction of abortion, 776 See also Abortion. Inertia uteri, 428 diagnosis of, 430 etiology of, 428 treatment of, 431 Infant, new-born, 363, 830. See also New-born infant. Infarcts, placental, 125 Inflammation, acute, of deciduae, 152 adhesive, in formation of amniotic bands, 104 diffuse hyperplastic, of decidual endo- metrium, 147 Influenza in pregnancy, 255 Infundibulopelvic ligament, 55 Inguinal colotomy for atresia ani of new- born, 876 Injuries of child-birth, repair of, 640 to infant during labor, 863 Inlet of pelvis, 1 7 Insanity in pregnancy, 248 preexisting, 249 Insemination, 66 Insertio velamentosa, 140 Insolation in puerperal state, 664 Instrumental dilatation, Sou Insufflation in asphyxia neonatorum, 871 Internal cell-membrane of ovum, 61 Interstitial placentitis, 124 pregnancy, 297 abdominal section for, 298 896 INDEX. Interstitial pregnancy, clinical history of, 283 symptoms of, 295 terminations of, 291 Intestinal invagination in fetus, 167 Intestines in pregnancy, 237 Intraperitoneal abscess, abdominal sec- tion for, 743 Intra-uterine amputations, 167 Intussusception of new-born, 878 Inversion of uterus in labor, 603. See also Uterus, inversion of. Involution of uterus, 338, 357 abnormalities of, 635 adnexa in, 343 changes in blood-vessels in, 342 in muscle-fibers in, 339, 340 endometrium in, 342 ergot for, 358 Irritable uterus as a cause of abortion, 260 Ischiopagus parasiticus, 542 Ischiopubiotomy in obliquely contracted pelvis, 470 Ischiorectal abscess, 772 in puerperal sepsis, 772 Janiceps,_ 543 Jaundice in pregnancy, 238 of new-born, 880 Johnson's sign of pregnancy, 200, 202 Jorisenne's sign of pregnancy, 187 Justomajor pelvis, 471 Justominor pelvis, 461 . See also Pelvis. Juvenile pelvis, 447 Karyokinesis in ovum, 61 Kidney, dislocation of, in labor, 688 in puerperium, 688 of pregnancy, 239 differential diagnosis of, from neph- ritis, 240 etiology of, 239 frequency and course of, 240 pathology of, 239 symptoms of, 240 treatment of, 240 pelvis of, diseases of, in pregnancy, . 24 3 . Kidneys, diseases of, in pregnancy, 239 in puerperal state, 688 palpation of, at end of puerperium, 376 Klebs-Loffler bacillus in puerperal sep- sis, 724 Kliseometer, Neumann-Ehrenfest, 452 Knots of umbilical cord, 136, 138, 139 Kny-Scheerer incubator, 858 Kyesteinic pellicle, 187 Kyphoscoliosis, pelvis of, 507 Kyphosis, 499 lumbosacral, 500 Kyphotic pelvis, 499. See also Pelvis, kyphotic. Labia majora, 44 varices of, in pregnancy, 228 minora, 44 puncture of, for edema of vulva, 230 Labor, 302 abdominal palpation in, 377 action and appearance of woman in, 308 anesthetics in, 320 armamentarium for, 316 bed in, 319 caput succedaneum in, 866 causes of, 303-305 chloroform in, 321 circular detachment of cervix uteri in, .5? 1 clinical phenomena of, 308 complicated by accidents and dis- eases, 560 by heart disease, 634 by hemorrhage, 560 by pneumonia, 633 by typhoid fever, 633 contraction of uterus after, method of securing, 330 contractions of uterine muscle in, 308 decapitation of fetus during, 867 definition of, 303 delirium tremens during, 249 descent of uterus in, 306 diagnosis of, 305 diastasis of abdominal muscles in, 612 dislocation of kidney in, 688 distorf'on of head during, 864 dry, 322 duration of, 307 eclampsia during, 631 effect of mental impressions during, 616 embolism of pulmonary artery in, 616 ether in, 321 examination of patient in, 316 expulsive forces of, excessive power of, 433 first stage of, 310 anesthetics in, 320 management of, 318 pain in, 319 forces involved in, 381 anomalies of, 428 fracture of coccyx in, 612 of limbs of child during, 868 of pelvic bones in, 611 of skull during, 864 INDEX. 897 Labor, heart failure in, 614 induction of, 778 in placenta praevia, 567 injuries of anterior vaginal wall in, 602 repair of, 640 • to bowel of child during, 869 to brain during, 863 to cervix uteri in, 589 to face during, 867 to infant during, 863 to neck of fetus during, 867 to peripheral nerves during, 863 to scalp during, 866 to trunk of child during. 868 urinary tract in, 610 inversion of uterus in, 603 labia in, 311 lacerations of perineum in, 323, 596 treatment of, 324, 596 of vagina in, 592 of vestibule in, 593 of vulva in, 593 leukocytes after, 347 liquor amnii in, 322 management of, 315 when obstructed by contracted pel- vis, 514 manner in which uterine muscle acts on fetal body in, 382 mechanism of, 377 abnormalities of, 391 expulsion of trunk in, 391 forces involved in, 381 in breech presentation, 408 in brow presentation, 405 in face presentations, 400 in flat pelvis, 456 in funnel-shaped pelvis, 465 in justominor pelvis, 463 in kyphotic pelvis, 502 in obliquely contracted pelvis, 469. in occipitoposterior positions, 393 in osteomalacic pelvis, 486 in rachitic pelvis, 480 in right occipito-anterior position, 393 in shoulder presentation, 420 in third stage, 422 abnormalities of, 423 in vertex presentation, 394 normal, 395 accommodation of fetal head in, 395 anterior rotation of occiput in, 387 descent of head in, 387 dilatation of lower segment and of cervical canal in, 394 external rotation in, 391 57 Labor, mechanism of, normal, propulsion and extension of head in, 388 restitution in, 388 when occiput rotates into hollow of sacrum, 396 missed, 189 obstruction of, by abnormal condition about rectum, 540 by abnormalities of fetal mem- branes, 558 by abscess of Bartholin's gland, 524 by anus vestibularis or vaginalis, by atresia of cervix uteri, 519 of vagina, 523 by calculi in bladder, 540 by carcinoma of cervix uteri, 532 by cicatrices of vagina, 522 by cicatricial contraction of cervix uteri, 520 by closure of vagina, 521 bv congenital anomalies of uterus, 5i8 narrowness of vagina, 525 by cystocele, 540 by displacement of cervix uteri, 532 of uterus, 525 by double uterus, 518 by edema of vulva, 524 by enlarged carunculse myrtiformes, 525 by former fixation of uterus, 527 by gangrene of vulva, 525 by hematomata of vagina, 522 by hernia of pregnant uterus, 526, 5 2 7 by hydrencephalocele, 547 by hydrocephalus, 548 by large fetal head, 544 by malformations of fetus, 544 by ovarian cysts, 536 celiotomy for, 538 by overgrowth of fetus, 541 by pendulous belly, 526 by placenta praevia, 560. See also Placenta pravia. by premature ossification of cra- nium, 544 by prolapse of uterus, 529 bv rectocele, 540 by rigidity of cervix uteri, 520 by sacculation of uterus, 529 by septa of vagina, 522 by short umbilical cord, 558 by tumors of fetus, 547 of vagina and vulva, 523 by twins. 1553 bv unruptured hymen, 523 by uterine displacements, 525 fibroid, 532 polypi, 535 898 INDEX. Labor, obstruction of, by vaginal entero- cele, 539 by vaginismus, 525 by varicose veins, 525 by Wormian bones, 544 pains of, 306 pathology of, 42 S preliminary preparations for, 315 premature, 259 care of child after, 857 induction of, 778 in overgrowth of fetus, 541 preparations for, 315-317 prevention of hemorrhage in third stage of, 329 profound emotion in, 616 pulse in, 347 resistant forces of, excess of, 434 rupture of hematoma in, 615 of respiratory tract in, 613 of sacro-iliac joints in, 611 of symphysis pubis in, 611 of uterus in, 580. See also Uterus, rupture of. second stage of, 310 clinical features of, 313 shock in, 614, 633 signs of, 306 "show," 316 sloughs of scalp from injury during, 867 stage of descent in, 310 of dilatation in, 310 of expulsion in, 310 stages of, 310 subcutaneous emphysema in, 613 sudden death during, 614 syncope in, 616 temperature in, 315 temporary delirium of, 249 third stage of, 310, 331 mechanism of, 422 abnormalities of, 423 thrombosis of pulmonary artery after, 616 twin, 553 coiling of cords in, 555 mechanism of, 555 placenta in, 556 presentations in, 553 prognosis of, 557 uterine contractions in, 308 vulva in, 311, 323 Laceration of perineum in labor, 323 preventive treatment of, 324 Lactalbumin of human milk, 860 Lactose, 860 Langhans' cells, 118 Lanugo, 82 Laparo-elytrotomy, 845 Larynx, diseases of, in pregnancy, 253 Late ligation of cord, 335 Lateral displacement of pregnant uterus, 221 Lateroflexion of pregnant uterus, 221 Lateroposition of pregnant uterus, 221 Lateroversion of pregnant uterus, 221 Length of mature fetus, 88 Leukemia in pregnancy, 253 Leukocytes after labor, 347 Leukorrhea in pregnancy, 194 vaginal, in pregnancy, 225 Levator ani, importance of, 26 Levret's forceps, 785 Ligamentous structures of pelvis, 27 Limbs of fetus, fracture of, during labor, 868 Linea nigra, 200 Lipuria in pregnancy, 244 Liquor amnii, 96 abnormalities of, 104 complicating labor, 558 secretion of, 98 composition of, 97 deficiency of, 98 escape of, in labor, 322 excessive quantity of, 99 origin of, 97 putrefaction of, 104 folliculi, 60 Lithopedion, 175 Liver, degeneration of, in pregnancv, 238 L. O. A. presentation, 380 explanation of frequency of, 380 Lochia, 343 alba, 344 rubra, 344 serosa, 344 Lochial tube, Doderlein's, 729 Lohlein's method of measuring trans- verse diameter of pelvic inlet, 449, 45°. Longings in pregnancy, 188 Loosening of pelvic joints in pregnancy, 231 L. O. P. presentation, 380 Lordosis, pelvis of, 507 Lowenhardt's method of estimating duration of pregnancy, 213 Lumbosacral kyphosis, 500 Lungs in pregnancy, 253 in puerperal state, 349 of new-born infant, diseases of, 872 septic infection of, 873 Luxation of femora, effect of, on pelvis, 5". Luxations of fetus, 166 Lymphangioma of fetus, obstruction of labor by, 547 Lymphatic ducts of pelvic organs, 32 Lymphatics of uterus in pregnancy, 182 INDEX. 8 99 Malaria in puerperal state, 677 of fetus, 161 relation of, to puerperal sepsis, 775 Male pronucleus, 73 Mammae, absence of, 693 congestion and engorgement of, 706 hypertrophy of, 693 supernumerary, 693 Mammary abscess, 709 in pregnancy, 232 binder, 363 changes in puerperal state, 350 glands, 351. See Breasts. in puerperium, 361 tumors, 710 in pregnancy, 232 Manual method of dilating os uteri, 808 of extracting breech, 805 Marginal insertion of cord, 139 Marshall Hall's method of artificial respiration, 871 Martin's pelvimeter, 438 Masculine pelvis, 461 Mastitis, 708 of new-born, 875 Maternal blood, alterations in, that are fatal to fetus, 176 death, effect of, on fetus, 616 emotions, influence of, on fetus, 170 fever, influence of, on fetus, 169 Maturation of ovum, 60 Mature fetus, 87 appearance of, 88 dimensions of head of, 88 length of, 88 weight of, 87 Maturity of ovum, as cause of labor, 3°4 Mauriceau's method of delivering after- coming head, 828 Measles in fetus, 160 in pregnancy, 255 in puerperal state, 674 Mechanism of labor, 377. See also Labor, mechanism of. of various positions, 384 presentations, 384 Melancholia in pregnancy, 188 Alelena of new-born, 882 Mellituria in pregnancy, 245 Membrana decidua vera, 142 granulosa of Graafian follicle, 60 reflexa, 142 serotina, J42 Membranes, fetal, abnormalities of, complication of labor by, 558 retention of, puerperal hemorrhage from, 641 Menstrual flow, character of, 59 duration of, 59 Menstrual flow, quantity of, 59 molimina, 58 Menstruation, 56 and ovulation, connection between, 64 cessation of, 59 as a sign of pregnancy, 192 without pregnancy, 193 in extra-uterine pregnancy, 294 recurrence of, during pregnancy, . 193 time of onset, 58 Mental impressions during labor, effect of, 616 Mesoderm, 74 Mesonephros, 42 Metritis, chronic, as a cause of abor- tion, 176 dissecting, in puerperal sepsis, 754 in pregnancy, 223 treatment of, 223 septic, in puerperal fever, 754 Micro-organisms, behavior of, in gen- ital canal, 726 capable of producing puerperal sep- sis, 723 manner of entrance of, into genital canal, 725 passage of, from mother to fetus, 158, ,. I 59 Miliary tuberculosis in pregnancy, 254 Milk, colostrum-corpuscles in, 704 cows', constitution of, 871 effect of emotions on, 699, 703 fever, 350 human, as food, 860 constitution of, 860 qualitative anomalies in, 702 quantity of, 354 secretion of, 696 defective, treatment of, 700 deficient, 697 excessive, 700 uterine, 1 1 7 Milk-leg in puerperal sepsis, 763 Miscarriage, 259, 275. See also Abor- tion. Missed abortion, 275 labor, 189 Mole, hydatidiform, 108 tubal, 290 vesicular, no Molimina, menstrual, 58 Mons veneris, 43 Montgomery's glands, inflammation of, 704 prominence of. in pregnancy, 195 Morning sickness, 188 Morula, 74 Mother, chronic diseases of, effect of, upon fetus, 177 9