HXOOO 19364 Columbia ©nftiertfttp mtl)fCifpofJlfnjg0rk THE LIBRARIES iHcbical ^ibvavp s'' \, fi^^^'- • vV,^ i;>, ;^;?v^i^A:^- :■ r- :':v. ^ <" .:c,i- r, #f;vi^^;^.i ^vl{|Vi^v: ^:^v,.g.;J v^.. , ^^ ; v ,_, ;; , V-; ; A HANDBOOK MIDWIFERY Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/handbookofmidwifOOdaki A I.OliE OK THE PLACENTA OF THE CALK, SHOWING NON-DECIDUATE MATERNAL PORTION. St. George's Hospital Museum. A HANDBOOK OF MIDWIFERY W. R. DAKIN, M.D, B.S.(Lond.), RR.C.P. OBSTETRIC PHYSICIAN AND LECTURER ON MIDWIFERY AND DISEASES OF WOMEN TO ST GEORGE'S HOSPITAL : PHYSICIAN TO THE GENERAL LYING-IN HOSPITAL LATE EXAMINER IN MIDWIFERY AND DISEASES OF WOMEN ON THE CONJOINT BOARD OF THE ROYAL COLLEGES OF PHYSICIANS AND SURGEONS IN ENGLAND WITH 400 ILLUSTRATIONS (NEARLY ALL OF WHICH ARE ORIGINAL) LONGMANS, GREEN, AND CO. 39 PATERNOSTER ROW, LONDON NEW YORK AND BO^IBAY 1897 All rights reser\ed PREFACE This work is intended for students and junior practitioners. The subject is arranged in two divisions, those of Physiology and Pathology. In each of these the events of Pregnancy, Labour, the Puerperal Period, and those connected with recent birth are dealt with in turn. I have endeavoured to omit nothing that has a practical bearing, and at the same time to avoid the waste of space and the confusion of the reader's mind which would be incurred by inserting all the most recent pathological speculations and the newest details of treatment. With this object it has been my care to read through, or at least examine, all available treatises and monographs dealing with each portion of the subject, to allow the facts, if any appeared, to undergo mental digestion, and then to write the paragraph or chapter dealing with the particular question. The main part of the matter contained and the opinions expressed in the text is, however, derived from the experience I have gained from my own cases, principally in hospital, and from the cases of others either seen by me or described by observers worthy of confidence. I have made all the diagrams to illustrate the text, and not to repre- sent objects or events, drawing them for the most part at the time of writing. I have thus introduced no unnecessary details. In the very few instances where a detailed representation of any object seemed y desirable, I have had it photographed, or have borrowed or copied a \,^ reliable block already published. There is no doubt that students are S. better treated if they are obliged to examine things (even museum ^ specimens) than when they are shown pictures of them, and that they ^ can learn very little of an obstetrical operation from photographs of the ^ .scene, in which the paper is mostly covered with irrelevant detail. viii Preface To the necessarily intermittent method in which Hterary work must be done by a medical man in practice I may be allowed to ascribe at least two omissions. They are an account of Thrombus Vaginae and a description of the attitude known as Walcher's Position. These omissions are sup[)lied in an Appendix. I have taken especial pains with the index, believing this to be a most essential part of a text-book. My thanks are due to many friends (mostly for references to recorded cases), and among them to Dr. Eden for the use of some,^^;^*^ his micro-photographs of the placenta. Especially I must thank Dr. Probvn-\\'II,li.\isis, formerly House Physician to the General Lying-in Hospital, for his generous help during transcription and in the preparation of the index. Erratum In (iL-sciiption of figs. 94 and ^6, for Fig. 97 7-caii Fig. 95 CONTENTS PHYSIOLOGY Physiology of Pregnancy chapter page I. Development of decidua and ovum . . . . . . . i II. Placenta and membranes at term . . . . . . . . 15 III. The ovum at different periods of pregnancy . ..... 29 IV. Attitudes and mechanical relations of the foetus in utero . . . . 32 V. Changes in the maternal organism ....... 35 VI. Diagnosis of pregnancy .......... 58 VII. Diagnosis of pregnancy — continued ....... 65 VIII. Multiple pregnancy ........... 72 IX. Hygiene of pregnancy .......... 76 Physiology of Labour X. Definition of labour ........... 78 XL Anatomy of fcetus .......... 90 XII. Action of the expelling force . . . . . . . • ■ 95 XIII. Action of pains on the uterus and its contents ..... 102 XIV. Progress of labour ........... 109 XV. Progress of labour — continued ........ 120 XVI. General mechanism of labour in vertex positions . .... 128 XVII. Special mechanism of labour in vertex positions 141 XVIII. Diagnosis of lies and positions ......... 149 XIX. Face presentations .......... 153 XX. Brow presentations ........... 165 XXI. Podalic lies 168 Management of Labour XXII. General principles of management ........ 180 XXIII. Management of the first stage of labour 186 XXIV. Management of the second and third stages of labour . . . . 190 XX\'. Details of management of labour in special lies and presentations . 197 XXVI. Labour in multiple pregnancy ......... 203 XX\MI. Anresthetics ............ 205 X Contents Physiology ok thk Puerperal Period CHAPTER PAGE XXVI II. Uterus and other pelvic organs after labour 208 XXIX. Involution 213 XXX. Lochia, afterpains, lactation 216 XXXI. Changes in the general system ........ 219 XXXI I. Diagnosis of the puerperal state ........ 223 XXXIll. Management of puerperal state ........ 225 The Xew-bor.n Child XXXI\'. l^hysiology and management 235 PATHOLOGY XXXV. XXXVI. XXXVII. XXXVIII. XXXIX. XL. XLI. XLII. XLIII. XLIV. XLV. XLVI. XLVII. XLVIII. XLIX. L. LI. Lll. LIII. LIV. LV. LVL LVII. LVIII. LIX. LX. LXl. LXII. LXIII. Pathology of Pregnancy Pathology of pregnancy .......... 246 -Affections of the chorion .......... 252 Affections of the amnion ......... 257 Diseases of the placenta and cord ........ 260 Intra-uterine diseases and death of foetus ...... 263 Affections of the maternal organism directly connected with pregnancy 271 Affections directly connected with pregnane}' — continued. . . . 280 Accidental complications of pregnancy ....... 287 Accidental complications of pregnancy — continued . . . . . 296 Abortion and premature labour ........ 303 Ectopic gestation ........... 315 Hzemorrhages during pregnancy . . . . ■ . . . . 333 Obstetric Oi'ERAtion.s General considerations .......... 352 Obstetric operations — continued ........ 362 Obstetric operations — continued ........ 365 Obstetric operations — continued ........ 371 Obstetric operations — continued ........ 386 Cresarian section, treatment of ruptured uterus, and Porro's operation 394 Symphysiotomy ........... 402 P.\thology ok Labour Precipitate and prolonged labour 406 Abnormalities in the expelling force ....... 410 Abnormalities in the passage ......... 415 Development of the adult pelvis ........ 421 Varieties of deformed pelvis ......... 424 Modifications of the mechanism of labour in the commoner varieties of contracted pelvis 432 Treatment of the common fornis of contracted |)elvis . . . . 438 The rarer kinds of deformed pelvis ....... 443 .Abnormalities in the passage — continued . . . . . . . 454 -Abnormalities in the ovum affecting labour ...... 461 Contents XI CHAPTER LXIV. LXV. LXVI. LXVII. Retention of placenta — Post-partum hasmorrhage — Inversion of the uterus ............. 478 Lacerations of the genital tract ........ 489 Cardiac and pulmonary diseases, albuminuria and eclampsia . . . 503 Accidental complications of labour affecting the life of the child only . 514 Pathology of the Puerperal Period LXVIII. Fevers 525 LXIX. Local specific inflammations ......... 541 LXX. General specific fevers .......... 544 LXXI. Diseases of special systems ; vascular system 548 LXXII. Diseases of the vascular system — contimied ...... 553 LXXIIL Disorders of the nervous system 556 LXXIV. Diseases of special systems — contimied : Urinary-system . . . 566 LXX\'. Affections of breasts and nipples 569 LXXVL Abnormalities of the lochia : Deciduoma malignum .... 576 Pathology of the New-born Child LXXVIL Pathology of the new-born child 579 Appendix A. Thrombus vaginae, hasmatoma of vulva 587 Appendix B. Walcher's position . 588 Index of Authors . . 5^9 Index of Subjects ...... 591 LIST OF ILLUSTRATIONS FIG. PAGE Lobe of placenta of calf ......... Frontispiece I. — Diagram of Graafian follicle .......... 2 2. — To show relation of infundibulum to ovary ....... 2 3. — Ovary a few hours after rupture of a follicle ....... 3 4. — Corpus luteum (i8th day) ........... 3 5. — Corpus luteum at the 6th month of pregnancy . . . . . . 3 6. — Cicatrix of corpus luteum ( I month after delivery) 3 7. — Stages of corpus luteum ........... 4 8. — Diagrammatic section of the uterine mucous membrane ..... 5 9. — Stages in the inclusion of the ovum in the decidua ...... 5 10. — Diagram of decidua ............ 6 II. — Section of decidua vera in situ ......... 6 12. — Uterine wall and membranes at edge of placental site . . . . . 7 13. — Developing ovum ............ 8 14. — Developing ovum ............ 8 15. — Developing ovum ............ 8 16. — Formation of allantois ........... 9 17. — Formation of allantois ........... 9 18. — Developing ovum ............ 9 19. — Developing ovum ............ 10 20. — Developing ovum ............ 10 21. — Diagrammatic section through placenta near centre . . . . .11 22. — Section through a normal placenta of seven months in situ . . . . 12 23. — Section illustrating the structure of the placenta . . . ... -13 24. — Transverse section of a villus from a placenta of seven months . . . . 14 25. — Portion of an injected villus from a placenta of about five months . • . 14 26. — Curling artery .'............ 14 27. — Falciform 'valve '............ 14 28. — Section through edge of placenta ......... 16 29. — Small portion of a four months' placenta ....... 17 30. — Section of membranes . . . . .* . . . . . . 18 31. — A child a few hours old ........... 20 32. — Transverse section of umbilical cord ......... 21 33. — Umbilical artery in fig. 32 .......... 21 34. — Section through wall of umbilical vein 22 35. — Placenta succenturiata ........... 23 36.— Placenta with ' collerette ' . . . . . . . . . . . 24 37. — Section through amnionic fold at edge of placenta of fig. 36 .... 24 38. — Placenta, bilobed, with errant vessel . . . . . . . . . 25 xiv List of Il/ust rations PAGE FIG. 39. — Dilated artery just by insertion of cord 25 40. — Fibrous masses ......■■•••■• 25 41.— Arter)' of a villus in an early stage of endarteritis 26 41A. — Section through the edge of an infarct 27 42. — Central insertion 28 4-3. — Lateral insertion 28 44. — Marginal insertion ......•■•••• 20 45. — N'elamentous insertion 28 46. — 0\-um of about the fifth week 29 46A. — Ovum of seven to eight weeks 3° 47. — Diagram of uterus at three to four months 3^ 48. — Uterus at term 33 49.— Shape of uterus at different months of pregnancy 37 50. — Horizontal section of spinal column and uterus 37 51. — (a) Uterus relaxed ; [b) uterus contracted 3^ 52. — Shape of abdomen in case of arcuate uterus 38 53. — Section of pelvis about third month 39 54.— Opened abdomen of a woman three and a half months pregnant . . . 39 55. — Diagram showing relations of uterus when relaxed, as in fig. 5^, and when contracted ............. 4° 56. — Uterus at six months 4° 57. — Diagram showing increase in size of muscle-cells 41 58. — Part of a placental sinus \ 43 59. — Thrombosis of a spiral arter}', immediately beneath the placenta . . 44 60. — Apparent shortening of cervix in pregnancy 45 61. — Apparent shortening from bulging of anterior uterine wall 45 62. — Varicose veins below urethra 47 63. — Relation of ovar}- and broad ligament at term 48 64. — Right obliquity and dextro-rotation of uterus 48 65.— Section through pelvis (vertical) 49 66. — Bladder during pregnancy (one form) ........ 50 67. — .^ primigravida at term 51 68. — From the same case as fig. 67 52 69. — Colostrum stage S3 70. — Section through edge of old stria from abdomen 53 71. — Areola and secondary areola in a brunette at term 54 71A. — Areola and secondarj' areola in a blonde ....... 55 72. — Method of obtaining Ballottement . . 64 73. — Callipers in position 66 74. — Hymen of virgin 67 75. — Hymen after connection 67 76. — Hymen after parturition 67 77. — Pelvic floor, nuUiparous 68 78. — Pelvic floor, parous 68 79— Twins : I 73 80. — Twins : 2 . . . . . . . . . ■ ■ 73 81. — Twins : 3 • •• 73 82. — Scheme of arterial circulation in the cords and placenta in the formation of an acardiac foetus ............. 74 83. — Acardiac foetus 75 84. — The two ovoids of the foetus 78 85. — Foetus in plan ............. 79 86. — ^Diagram of parturient canal, coronal section . . 80 87. — Diagram of parturient canal, sagittal, showing axis ..... 81 88. — Brim of pelvis 8r 89.— Outlet 8i List of Illustrations xv FIG. I'AGE 90. — Internal surface of pelvis . . . . ■ . . . . . . . 82 91. — Brim .............. 84 92. — Cavity .............. 84 93. — Outlet 84 94. — Pelvic floor (distended) from the side ......... 87 95. — Direction of groups of fibres of levator ani ....... 87 96.— Pelvic floor (distended) from the front . . . . . . . . 88 97. — Pelvic floor from above (part of pubic bones removed) ..... 88 98. — Fascia of pelvic floor ............ 89 99. — Attitude of fle.xion ............ 90 100. — Attitude of extension ............ 90 loi. — Foetal measurements . ........... 91 102. — Dorso-sternal diameter ........... 91 103. — Sagittal section through skull .......... 92 104. — Coronal section of skull through parietal tuberosities . . . . . . 92 105. — Method of overlapping of bones of vault ....... 92 106. — Foetal skull ............. 93 107. — Fcetal skull from above ........... 94 108. — Diagram of pains in the course of labour ........ 96 109. — Relaxed ; and contracted or retracted fibre ....... 97 no. — Upper and lower uterine segments after a few hours' labour after evacuation of liquor amnii ............ 99 III. — Expelling forces and resistances . . . . . . . . loi 112. — General intra-uterine pressure during a pain — membranes intact . . . 102 113. — Direct uterine pressure ........... 104 114. — Direct uterine pressure ........... 104 115. — Effect of bulging membranes .......... 105 116. — Effect of a pain on maternal and foetal pulses respectively ... . . 107 117. — Uterus relaxed ............ in 118. — Uterus contracting ............ m 119. — Primipara, dilation of cervix .......... 112 120. — Primipara, dilation of cervix . . . . . . . . . . 112 121. — Primipara, dilation of cervix .......... 112 122.-— Multipara, dilation of cervix .......... 112 123. — Multipara, dilation of cervix .......... no 124. — In multipara or primipara, dilation of cervix ....... 113 125. — In multipara or primipara, dilation of cervix . . ... . . . 113 126. — Rupture of membranes ........... 113 127. — Formation of a second bag of waters . . . . . . . -114 128. — Formation of a second bag of waters ......... 114 129. — First stage of labour ........... 116 130. — Second stage of labour ........... 117 131. — Showing changes in position during labour of floor of pelvis and pelvic viscera . . . . . . . . . . . . . .118 132. — Opposition of voluntary and involuntary muscles in labour . . . . 120 133. — Uterus in third stage ........... 121 134. — Separation of placenta ........... 122 135. — Separation of placenta ........... 122 136. — Expulsion of placenta (Schultze) . ......... 122 137. — Detachment of placenta ........... 123 138. — Transverse section of uterus .......... 124 139. — Expulsion of placenta ........... 125 140. — Shape of placenta during expulsion ......... 126 141. — Uterus just after end of third stage ......... 126 142. — Flexion, vertex presentation . . . . . . . . . . 129 143. — Extension, face presentation ........ . 129 xvi List of Illustrations Klli. PAGE i^. — Atlitudo bolwcoli flexion and extension, ijiow jjresentation . . . . 129 145. Relation of head to brim (horizontal line) in a priniipara .... 129 146. — Pelvic brim from above 130 147.— Representing the pelvis on its side in the left lateral position and seen from below .........•••• 13^ 148. — Differing inelinations of anterior and posterior planes of head . . . 132 i49._Kffect of inward pressure of walls of birth-canal on moderately flexed head . 132 150. — Diagram of forces causing flexion 132 151.— Effect of obliquity of uterine axis on head at brim 133 152 — Koetal axis-pressure on slightly flexed head 133 153.— Effect of foital axis-pressure, fully fle.xed head 133 i^^. — Relation of head to finger when occiput lies to the left 134 155. — Internal rotation i35 156. — Occiput passing under pubic arch 136 157. — Process of extension i37 158. — Continuation of extension : birth of head 137 159. — External rotation 138 160. — Relations of child to pelvis during delivery of shoulders 138 161. — Mechanism of labour in first vertex 139 162. — Graphic representation of parts felt on abdominal palpation in the case of cephalic lie ............ . 141 163. — First vertex 142 164. — .Second vertex ............. 142 165. — Third vertex 143 166. — Fourth vertex 143 167. — Moulding in first vertex position ' . . . . 144 168. — Moulding in second position of vertex 144 169. — Convexity of promontory causing extension 145 170. — Persistent occipito-posterior, ordinary mechanism ...... 146 171. — Persistent occipito-posterior, ordinary mechanism . . . . . . 146 172. — Persistent occipito-posterior, ordinary mechanism ...... 147 173. — Rarer form of mechanism in persistent occipito-posterior cases . . . . X47 174. — Moulding of head in rarer form of persistent occipito-posterior mechanism . 148 175. — Moulding of head in same case as fig. 174 (seen from above) . . . . 149 176. — Graphic representation of parts felt on abdominal palpation in a case of cephalic lie . . . . . . . . . . . . .150 177. — Graphic representation of parts felt on abdominal palpation in a case of podalic lie ............ . 151 178. — .\bdominal palpation in transverse lie . 152 179. — Relation of head to trunk in face presentation ...... 154 180. — Effect of obliquity of foetal axis-pressure on head at brim . . ... 154 181. — Effect of fa-tal axis-pressure on a partly extended head . .... 154 182. —Effect of cordate uterus on foetal axis-pressure ....... 155 183. — Elliptic pelvis 155 184. — Differing inclinations of mental and frontal planes in face presentations . . 156 185. — Effect of inward pressure of walls of birth-canal on head in face presentations 136 186. — First face presentation ........... 157 187. — Mechanism in first face presentation 158 188. — Mechanism in first face presentation 158 189. — Face presentation after rotation of chin forward 159 190. — Face escaping from vulva . . . . . . . . 159 191. — Face presentation. Birth of head ..;...... 160 192. — Second face presentation ........... 160 193. — Third face presentation ........... 161 194. — Mechanism m third position of the face 16/ 195. — Fourth face presentation 162 List of Illustralions i'k;. iq6.- 197.- ic,8.- 199.— 200.- 201.- 202.- 203.- 204.- 205.- 206.- 207.- 208.- 209.- 2IO.- 211.- 212.- 213.- 214.- 2I5-- 216,- 217.- 218.- 219.- 220.- 221.- 222.-- 223.- 224.- 225.- 226.~ 227.- 228.- 228.\, 229.- 230.- 231.- 232.- 233-- 234-- 235-- 236.- 237-- 238.- 239-- 240.-- 241.- 242.- 243-- 244.- 245-- 246.- 247.- 248.- 249.- 250.- d extension ion in the podalic lie Diagram of elastic rod ..... Persistent mento-posterior mechanism Persistent mento-posterior mechanism Persistent mento-posterior mechanism Action of fcEtal axis-pressure on head between flexion an -Diagrams of cephalic lie in all attitudes . -Relation of head to brim in brow presentation . -Brow presentation from below .... -Relations of head and pelvis in brow mechanisms -Siege d^compl(5te, mode des fesses . -Relation of hydrocephalic foetus to uterus . -Graphic representation of what is felt on abdominal palpat -First position of breech ...... -Mechanism in breech presentation -Mechanism in breech presentation .... -Mechanism in breech presentation. Birth of buttock -Mechanism in breech presentation .... -Birth of shoulders ...... -Birth of head -Second position of breech from below . -Third position of breech . . . . . . -Fourth position of breech ..... -Delivery of head, occipital posterior (i) -Delivery of head, occipital posterior (2) -Head-moulding in a breech case .... -Correct moment for extension of head -Incorrect moment for extension of head . -Child in second position of vertex -Mechanics of delivery in head-last cases . -Height of fundus on first day of puerperium -Height of fundus at about end of first week -Height of fundus (at brim) at end of second week -Uterus and pelvic organs after laljour — Section of uterus shortly after labour -Acini in the colostrum stage ... -Acini in the milk stage ..... -Typical average chart of normal puerperiimi . -Outlines of moulds of the uterine cavity in different states -Budin's catheter . . ... -Foetal circulation ....... -Scheme of right side of heart ..... -Stomach of a newly born infant ..... -Diagrammatic section of a carneous niok' -A carneous mole, opened . . . . . -Villi cut in various planes -Groups of villi from a vesicular mole . . -Dia.gram of affected villus ..... -Amnionic adhesions ....... -Amnionic adhesions compressing umbilical cord -Anencephalus ........ -Anencephalus ........ -Rudimentary development of left arm, foi-earni, and hai -Pendulous belly ....... -P. ndulous belly, showing direction of the pull of the abdominal belt -Retroverted gravid uterus, showing distended bladder -Pelvic ha.='matocele ......... 163 164 164 164 165 166 166 166 167 168 169 170 170 171 171 171 172 172 173 173 174 175 175 175 177 191 191 197 201 208 209 209 210 211 218 218 228 235 236 238 248 249 250 253 254 259 264 264 267 272 276 XVlll List of IllHStratious 251. — Effect of gravity on the rctrovLTted uterus in the knce-e]lx)\v posture 252. — RetroHexed gravid uterus ...... 253. — Kiijroid complicating pregnancy. Uterus relaxed . 254. —Fibroid complicating pregnancy Uterus contracting . 255. — Uterus arcuatus ....... 256. — Effect of cordate uterus on foetal axis-pressure . 257. — Same uterus tending to produce a face presentation 258. — Utenis septus 259. — Uterus bicornutus 260. — Uterus didelphys ....... 261. — Pregnancy in a rudimentary liorn of the uterus 262. — The same uterus as fig. 261, unimpregnated 263. — Complete absence of one horn . .... 264. — Section of a retained piece of placenta 265. — Section of a retained piece of placenta 266. — Sites which ovum is capable of occupying . 267. — Uterus (enlarged, with decidua) and a gravid tube, the left 268. — Rupture of the tube into the peritoneal cavity 269. — Rupture of the tube into the broad ligament . 270. — Ectopic gestation ....... 271. — Ectopic gestation 272. — Sac and placenta in intra-ligamentous gestation (sub-peritoneo-abdominal) 273- — foetal bones in a sac formed by adherent intestines . 274- — l^regnancy in a rudimentary horn of the uterus . 275. — Relations of sac to round ligament in tubal gestation 276. — Parametritis ....... 277. — Accidental hremorrhagc 278. — Placenta praevia, central ..... 279. — Placenta praevia, lateral 280. — Placenta pra;via, marginal 281. — Placenta prajvia ....... 282. — Detachment of placenta praevia .... 283. — Diagram of uterine walls 284. — J'lacenta praevia entirely detached from one side of lower segment, and allowing its membranes to bulge ..... 285. — De Ribes' bag applied to placenta praevia 286. — Wedge formed by child in half-breech attitude . 287. — Laminaria tent ........ 288.— One of a .set of Hegar's dilators 289. — Hydrostatic dilators modified from Barnes's original pattern 290. — Champetier de Ribes' bag ....... 291.— Forceps for de Ribes' bag .... ■ 292. — Infusion of saline fluid ..... 293. — Canula and ligatures in position 294. — Bipolar version ....... 294.\. — Bipolar version ...... 294B. — I-Jipolar version ....... 295. — Bipolar version ...... 296. — C ham berl en's forceps ...... 297. — Simpson's long curved forceps. 298. — Showing disadvantage of long straight forceps in application 299. — .Showing advantage of curve in application of long forceps 300. — Assalini's forceps ........ 301. — Combination fif patterns of .Simpson and Barnes 302. — Axis-traction forceps ........ 303. — .\xis-traction by rods List of Illustrations F!G. 304-- 305- 306.- 307-- 308.- 309-- 310.- 3II-- 312.- 3I3-- 314-- 3I5-- 316.- 317-- 318.- 3I9-- 320.- 321.- 322.- 323-- 324-- 325-- 326. 327-- 328.- 329-- 330.- 331- 332- 333- 334-- 335-- 336-- 337- ■ 338. 339-- 340. 34I-- 342. 343-- 344-- 345-- 346.- 347- 348.- 349- 350.- 35I-- 352.- 353-- 354-- 355-- 356.- 357- 358.- 359-- -Galabin's axis-traction forceps 37^ -Axis-traction by perineal curve in the shanl< 376 -Introduction of lower blade 378 -Introduction of lower blade 379 -Introduction of lower blade .......•■■ 379 -Introduction of lower blade 379 -Introduction of lower blade . . . . • • • • • • 379 -Introduction of lower blade ........■• 379 -Introduction of upper blade 380 -Introduction of upper blade . . . . • ' • • • ■ • 380 -Introduction of upper blade ......••■• 381 -Introduction of upper blade ......•••• 381 -Application of upper blade ......••••• 381 -Action of left hand in producing axis-traction 382 -Extraction over perinagum ....■••■••• 383 -Showing mechanical advantage of oscillation 384 -Ideal application of forceps . ......•■•■ 385 -Usual relation of forceps to head .....•••■ 385 -Oldham's perforator, blades separated 387 -Hicks's cephalotribe 388 -Barnes's craniotomy forceps .....••••• 39° -Oldham's vertebral hook .....•••■•• 39* -Normal abdomen, incision for Caesarean section . . . • • • 39^ -Pendulous belly, incision for Csesarean section ....•• 39^ -Incision, edges grasped by assistant's hands .....•• 397 -Position of deep sutures .....••■•■• 398 -Arrangement of drainage-tube ....■••••■ 4°° -Much thinned lower segment in a case of contracted brim .... 409 -Method of measuring the diagonal conjugate in the normal dried pelvis . . 417 -Method of measuring the diagonal conjugate in a case with contracted brim . 418 -\'arieties of symphysis .....•••••• 4^9 -Development of pelvis (sacrum) .....-•■• 422 -Development of pelvis (sacrum) ......•••• 422 -Development of pelvis (infantile shape) 4^3 -Development of pelvis (adult shape) .....•••• 423 -Flait generally contracted pelvis ....•••■• 429 -Vault of skull moulded by pelvis in last figiu-e 43° -Side ^•iew of same skull as fig. 340 ....••■■• 43° -Abnormal height of uterus post-partum caused by contracted brim . . . 431 -Diagram showing advantage of Xagele obliquity ...-•• 433 -Pioduction of Xagele obliquity .....••■■• 434 -Relation of head to brim in pendulous belly 434 -Elliptic brim .........•••• 435 -Reniform brim .......-•••• 435 -Measurement of foetus in utero by callipers ...■••■ 439 -Development of skoliotic pelvis ....••••• 444 -Skoliotic pelvis .......-••■•■ 444 -Caries of left sacro-iliac joint .....■•■•• 445 -Nagele pelvis (early stage) ......•■•■• 44" -Nagele pelvis (fully developed) .....-••• 44^ -Kyphotic pelvis ........-■•■• 447 -Malacosteon pelvis, seen from above .....-•• 45° -Malacosteon pelvis, from the front .....•■•• 45° -Malacosteon pelvis, from the side and slightly above ..... 451 -Spondylolisthetic pelvis 453 -Back view of a woman with spondylolisthesis ....-•• 453 List of Illustrations 360. — Congenital hypeiiroijhic cloiigaiion of cervix .... 361. — Hisacroinial iliamcler freed fty traclioo applied lo anterior axilla 362. — Hydrocephalic ftrtus in utero ...... 363. — Klevation of brim and child in transverse lie 364. — Plan of brim and child in transverse lie 365. — Diagram of transverse lie ... 366. — Spontaneous version ..... 367. — Spontaneous version ... 368. — Spontaneous version .......... 369. — Spontaneous evolution ...... 370. — Spontaneous evolution ... 371. — Spontaneous expulsion ........ 372. — Graphic representation of parts whicii may Ijc fell in a transverse lie 373. — Impaction of breech 374. — Prolapse of feet with head ....... 375. — Bimanual compression of uterus ....... 376. — Inversion of uterus ......... 377. — Complete inversion, showing relation of ovaries and tubes 378. — Laceration of vagina, cervix, and lower uterine segment into tiu broad ligament and abdominal cavity 379. — Laceration of perintieum ...... 380. — Suture of incomplete perinajal rupture 381. — Method of inserting sutures in complete rupture 382. — Reposition of prolapsed cord by tape and catheter 383. — Isolation of umbilical vessels by finger and thumb . 384. — Case of puerperal septicasmia ending in death 385. — Diagram of parametritis 386. —Remote parametritis ....... 387. — .Vlild case of parametritis (chart) .... 388. — Rise of temperature due to emotion (chart) 389.— Rise of temperature in hysteria (chart I 390. — Lumbo-sacral cord crossing the brim .... 391. — Rise of temperature accompanying constipation (chart) 392. — Paralysis of left side of face 393. — Isolation of umbilical vessels by finger and thumli . I'ACK 456 462 464 467 467 468 469 469 469 470 470 471 472 474 476 484 486 486 490 497 499 500 517 518 529 532 533 536 562 562 563 569 579 58s PREGNANCY PHYSIOLOGY OF PREGNANCY This subject is divided into two sections. The first section deals with the development of the foetus and its appendages, and then with its appearance and characters at term. The account of development is hmited to a short description of the growth of the amnion, chorion, and decidua, and the forma- tion of the placenta and umbilical cord. The size and external appearances of the ovum and foetus at certain stages of pregnancy are mentioned, and the characters special to each of these periods of pregnancy indicated. The description of the child at term applies mainly to the points indi- cating maturity. Its anatomy, as bearing on obstetrics, is descrilDed under ' Labour.' The second section includes a description of the changes in the maternal system which accompany pregnancy; and a consideration of the diagnosis of pregnancy, and the management of the woman during the nine months occupied in the growth of the ovum. CHAPTER I DEVELOPMENT OF DECIDUA AND OVUM The Graafian Follicle. — The mature Graafian follicle is found at the surface of one of the ovaries, partly projecting in the form of a translucent elevation, but having its larger portion imbedded in the substance of the o\ary. This little vesicle has a diameter of about one-third of an inch. Each follicle contains an ovum, and there are computed to be in the ovaries of a child follicles to the number of five or six hundred thousand. Of these not more than about four hundred could under any circumstances ha\c a cliance of maturing, supposing one came to the surface and ruptured once c\ XT) month for thirty years or so. It is believed that a follicle does mature and burst at each menstrual epoch ; it is, howe\er, more tlian pro- bable thai rupture may occur at other moments also, and one of such B r^ 2 Pregnancy occasions is believed to be during coitus. In any case, it is obvious that an overwhelming number of these follicles never reach maturity. The follicle at the stage above mentioned— the earliest stage at which it need be described for our present purpose— is contained in an envelope formed by a condensation of the ovarian tissue around it into an ill-defined outer tunica fibrosa, and a stratum internal to this, the so-called tunica vasculosa. Its cavil)- is lined with a layer of granu- lar cells, two or three deep, tlic tunica granulosa. These cells at one place are heaped up into a thalamus, on which the ovum rests, and the ovum is roofed in on its central aspect by a layer of the cells (fig. i). This thalamus, the discus proligerus {disc, pro/.), lies sometimes on the side of Fig. I. — Diagram of Graafian Follicle. Peril, peritoneum. The other lettering is explained in the text. the follicle towards the surface, sometimes on the deeper side. The ovum is a single cell with a nucleus, the germinal vesicle {gerinl. ves.), and a nucleolus, the germinal spot. Its cell-wall is called the zona pelhtcida, and is a firm translucent membrane faintly striated in a radial pattern. Its main contents, in which the nucleus lies, consist of a granular fluid, the yelk. The o\ um at this stage has a diameter of j.V- of an inch. Rupture of Follicle. Formation of Corpus Kuteum. ^W'hen the Graafian follicle bu;-:-. its contents are discharged among the fimbriio of the Fallopian tube lying underneath it (fig. 2), and the ovum is guided into the opening of the tube by the cilice cover- ing the inner aspect of the fimbri;t. It is in all probability fertilised at some time during its passage through the tul)e. It travels along towards the internal ostium, and passes through this into the uterine cavity, being pro- pelled by the action of the cili:e and possibly by the peristaltic contractions of the muscular wall of the tube. Coipus Luteuin.-- .Xhftv the follicle has burst, its cavity becomes more or less distended with the blood effused in the process of rupture. The follicle is thus converted into a blood-cyst, with its walls lined by the remains of the tunica granulosa. This cyst is rather a larger object than the fully- developed follicle, and indeed occupies nearly half the bulk of the ovary (fig. 3). The blood is slowly absorbed, and during this process the cells of the tunica granulosa undergo a hyperplasia, and it bulges into the cavitN- of the follicle. The now somewhat stellate piece of partially de- Fig. 2. — To show relati'ii. r f infundibuhini to ovary. Jt, uterus ; p^', ovary ; _/7, tube ; or. y; ovarian fimbria ; inf, infundibulo-pelvic ligament ; /, pelvic wall. The uterus and inner end of the tube are raised to make the diagram clearer. Corpus Luteinn 3 rolorised clot (fig. 7) is inclosed by the thickened granular wall of the cyst. This wall is of a dull yellowish colour, and the structure is in consequence named the cotpiis liiteum. If the ovum becomes fertilised the corpus lutcum de\cl()|)s foral^out three Fig. ■:;. — Ovary a few hours after rupture of a follic Fig. 4. — Corpus luteuni iSth day. The clot, here pj-riforni, surrounded Ijy the thickened tunica granulosa, is at the right-hand end of tlie figure. C\C, Fig. 5. — Corpus hUdum (//, newly- developing follicle. months. By this time it has a bulk much larger than that of the original tolliclf, and almost as large as the original b!oo:l-clot first effused. It measures about two-thirds of an inch in diameter and it is impossible to overlook it in a section of the ovary. It remains in the same condition 4 Pregnancy during the rest of ])rcgnanc\-, shrinkinj^ sliglitly to a diameter of aljoiit lialf an inch (fig. 5). The bulged and coinoluled granular walls become welded together into a mass which now obliterates the former ca\ity, except for a thin stellate figure, the remains of the original clot, in the centre (fig. 7, 3). Capillaries also develop in the walls. After delivery the corpus luteum shrinks rapidly. Fig. 7. — Stages of corpus luteum. since the Ijlood supply is very considerabK diminished, and it becomes converted into a small mass of connective tissue and e\entually into a cicatrix (fig. 6). If impregnation does not occur, the follicle undergoes similar changes, but the corpus luteum in this case does not reach the same degree of cle\elopmcnt as in the case of pregnancy. The yellow body is formed and continues to grow up to the third week, instead of to the third month, and then it shrinks, being converted into a small cicatrix, just as happens after impregnation. The corpus luteum of pregnancy has been called the true corpus luteum, while that oi menstruation had the name of false corpus luteum. There is, however, no meaning in these names. Constancy of ocairre)ice in cases of pregnancy. — Supposing it has to be settled whether a dead woman, of whom only the o\aries are a\ailable for examination, has been pregnant at the time of death, or supposing the signs in other parts are doubtful, then the presence or absence of a well-developed corpus luteum in one of the ovaries has no absolute value as a medico-legal proof. This body has been ftumd in the cases of uteri affected with myomata, aixl in the ovaries of prostitutes who were not, and never had been, pregnant.' The corpus luteum has, moreover, been absent in one or two cases of pregnancy. Formation ot Secidua. If the lining membrane of the body of the uterus -' is examined at the time at which the ovum reaches it, it will be found to be modified in structure. Its thickness is much increased, and its glands become enlarged in all dimensions (fig. 8). This growth continues to about the fifth month, by which time the decidua, as the endometrium is now called, measures about half an inch in thickness, and the glands are more dilated and very tortuous. Its more detailed changes will be alluded to later on. ' Fopow, (.list. Trans, vol. x.xiv, where otlu-r authors are referred to. - Tlie C'-Tvix uteri takes no part in the changes here described. Forinatio}i of Decidua 5 Tlie ()\um on its arri\al in tlic uterine cavity finds itself lying on the somewhat irrcguhir surface of this decidual membrane, in a depression of which, being still a minute body, it soon settles, and becomes adherent. It is assisted in fixing itself to the surface by certain projec- tions like the pseudopodia of an amoeba, which have ap- peared on its surface, and which are called villi. The 7t^/. Fig. 8. - IJiagiaminatic sections of the- uterine mucous memljrane, showing the changes which the glands undergo with the supervention of pregnancy (from Kundrat and Engelmann). A, Diagram of the glands of the non-pregnant uterus ; tit, muscular layer. 1), Condition of the [glands at the beginning of pregnancy ; c, compact layer near free surface of decidua : the glands are here somewhat enlarged but not very tortuous, and the mucous membrane is rendered compact by hypertrophy of the interglandu- lar tissue ; s^, spongy layer, containing the middle portion of the glands greatly enlarged and tortuous, producing a spongy condition in the mucous mem- i)rane ; i/, deepest portion of the glands, elongated and tortuous, but not much enlarged. it and burv it. It is thus shut off from the Fig. g. -Stages in the inclusion of the ovum in the decidua. zona pellucida forms the most external layer of the outer membrane of the ovum. This membrane is called the c/io- rion (see p. 8, ' Chorion '), and from it the villi spring. When the ovum is fixed in its place, the two folds of decidua between which it is embedded grow together over cavity of the uterus (fig. 9). cL.y. 6 Pregnancy The ckcidua which is in contact with tlie ovum is now specially named. The part co\ ering in the o\ um is called the accidua rcflcxa > see fig. 46^/); that lying imderneath the ovum, between it and the uterine wall, is called liecidna serotina ' (fig. 10). As the ovum grows the decidua refle.xa is bulged more and more into the cavity of the uterus, until about the end of the fourth month it comes into contact with the decidua covering the rest of the uterine surface, which is called the liccidua 7'era. Decidiuil Cells. — The interglandular part of the decidua hypertrophies as well as the glands, and there are developed in it the large epithelioid cells known as dcciduid cells. These are characteristic of this struc- ture, and are conspicuous in microscopic sections which happen to contain decidual tissue, whether taken from the placenta or from the membranes (figs. 1 1 and 23 I »). Layers of the Decidua. — The dilation of the glands already spoken of is most marked at their middle and near their deeper ends. The effect of the dilation in the former position is that the membrane at this level has a reticulated appearance on section (fig. 8) ; the cavities in its sub- stance are lined with the epithelium of the glands. There is a compacter Fig. 10. — dv, decidua vera ; i/k ana, embryonic area; r/, zona Fig. 14. — />'/rtj/, .somatopleure . c//, outer layer of pellucida ; I'lasi, somatopleure ; ys, yelk-sac in- chorion ; {blast and c/i ^chorion) : ys, yelk-sac ; closed by splanchnopleure {blast and c /> = cu-l. ccelom ; am, amnion ; a c, future amnionic chorion). cavity. The mesoblast splits into two layers, one of which is united to the epiblast, the combination forming the somatopleure, and the other to the hypoblast, forming the splanchnopleure (figs. 13 and 14). Round the cells which are to form the embryo a groo\e appears on the surface of the membranes, beginning -'^^i- at the head end, and the embryo is thus defined from the general surface. The embryo now sinks towards the centre of the o\um, and the walls of tlie groo\c in which it thus comes to ' /. , lie consist of somatopleure only, the splanchnopleure sinking with the embryo (fig. 14). These somatopleuric walls grow up o\cr the back of the embryo, rising from the head end, the tail end, and the sides. They meet over the back, abut against one another, and coalesce so as to form two distinct membranes. Of tiiese, the inner — that Fig. 15— /r;, placental villi ; all, allantois ; cocl, ne.\t the embryo — forms a complete cotlom ; blast, somatopleure ; ch, outer layer of , • i \ chorion; am, amnion; ac, amnionic cavity; saC, the aUiniOU \aill.) /r fore-gut;/:^, hind-gut ;r J, yelk-sac. NB. The outer becomes united to the — 1 he embr\-o now hangs with Its dorsal surface . r r i n • i away from the allantoic attachment. Uincr SUrfaCC of the ZOIia pcUuClda, and in combination with this forms the c.k- ternal membrane of the o\um, the chorion {^■g's,. 14, 15, 18, \c), 20. b/asf. ami ch.) Between the amnion and the layer of blastoderm which has thus joined in forming the chorion, there is a space, the ccelom, or pleuro-peritoneal space, which is continuous with the caxitics of .the peritoneum and pleura now in process of formation. ch TJic Allantois 9 The surface of the amnion lookin<;' inwards toward the back of the cnil)ryo is the one which is formed of the epiblastic layer of the somatopleure, and is continuous with the epitheHum covering the body of the embryo. As the body of the embryo begins to close on its ventral aspect by the yrowing" together of the anterior abdominal and thoracic walls round what will s/ic- -f~sp.c. Fig. i6. — Formation of allantois. .Section through head and tail of an embryo lying on its side. (Adapted from Lockwood, ' Phil. Trans.,' vol. 179, B, p. 365.) ac, amnionic cavity ; V, villi ; ch, chorion ; uv, umbilical vessels ; spc, spinal column ; h g, hind-gut. (About the stage of fig. 14.) be the umbilicus, the edges of the abdominal and thoracic walls from which the amnion springs (see fig. 18) are carried in towards the central point too, and by their approximation form one end of a tube which will enclose the structures forming the umbilical cord. While these changes are going on, the splanchnopleure, which sank into the interior of the ovum with the embryo, has assumed the appearance of a sac with a pedicle, named the umbilical -vesicle, or jelk-sac{y.s.) It contains the remainder of the yelk, and its pedicle is the umbilical duct {it.d. fig. 20). This pedicle lies in the tube formed by the amnion. ic.y: aXL Kig. 17. — Formation of allantois (after Lock- Fig. \%.—pv, placental villi; all, allantois; cccl, wood). _ c/i, chorion; 2^1.', umbilical veins ; a//, coslom : blast, somatopleure; ch, outer layer of allantois ; /«^, hind gut ; a f, amnionic cavity : chorion; am, amnion;,/^, fore-gut; kg, hind- .fi#c, spinal cord. (About the stage of lig. 15.) gut ; j'.f, yelk-sac. Allantois. — When the embryo sinks into the o\um it remains attached at the tail-end to the chorion (fig. 14). Its attachment, the allantflis, consists of tissue continuous with that forming the hind part of the body, and sur- rounding the hind-gut. In its substance are vessels, the innbilical vessels {u.v. figs. 16 and 17), which veiy early become extended into the chorion, and convert the villi into vascular processes. This vascularisation of the villi is lO Pregnancy cA. Fig. ig.^T', placental villi; /'/ast, somatopleure ; c/i, outer layer of chorion ; aw, amnion ; a c, amnionic cavity ; /g, fore-gut ; /ig; hind-gut ; j's, yelk-sac. said in the first instance to extend over the whole siiperhi ies of tlie o\ iini, Ijut it soon becomes limited to a comparati\ely small area, the site of the future placenta. The place of attachment, which was at first at the tail-end of the em- Ijryo, becomes shifted round to the front (figs. 14 and 15) by growth of the hind-end of the embryo to form the con- tinuation (tail) of the embry- onic axis. The allantois will be seen to be another of the structures lying in the tube of amnion, and it becomes elongated as the embryo re- -^^0,5^ treats more into the middle of the ovum. 77/ 1' uDibilical duct is lengthened by the same pro- cess, and the contents of the vesicle being absorbed by the embryo, the duct and vesicle both atrophy. At full term the remains of the vesicle can occasionally be found on the fcctal surface of the placenta, l\ing under the amnion. .Sometimes the intra-abdominal part of the duct persists after the umbilical cica- trix has closed, in the shape of Meckel's diver- ticulum. The allantois soon atrophies, and is lost in the tissues com- _g/^5^ posing the umbilical cord. C/zw/o;/.— The first villi of the chorion, before the somatopleure became united to the zona pellucida, were sim- ple, becoming branched after this union took place. They extended over the whole super- ficial area of the ovum, and became fixed to the decidua (serotina and reflexa) with which they were in contact. They then, as has just been seen, recei\ed a vascular equipment from the allantois. Soon after this all those over the surface which is not about to take part in the formation of Fig. 20. — p-,\ placental villi of chorion ; am, amnion hg, hind-gut; j/j-, yelk-sac show the further changes in the ovum.) blast, sonialopleure ; ch, outer layer a c, amnionic cavity : fg, fore-gut ; 11 d, umbilical duct. (Figs. i8, 19, 20 Development of Placenta — Mater tial Part 1 1 the placenta are found to be atrophied, but those over the placental area de\eIop further, and eventually form the villi of the placenta. Bevelopment of the Placenta. — The placenta consists of a maternal and a foetal part ; the maternal portion is formed of the modified decidua serotina, of which the layer superficial, or rather internal, to the ampullary layer alone takes part in its construction ; and the latter is constituted by the fully developed chorionic villi. . Maternal part. — The whole of the superficial layer, except a narrow film of membrane lying immediately on the ampullary layer, takes part in the change. This consists in its conversion into a series of communicating sinuses, which form an irregular space, the inter\illous space, containing maternal blood. amnion __ latinous layer ... nbilical vessel "" chorion ... ipullary layer Fig. 21. — Diagrammatic section through placenta near centre. The villous tufts are only intlicated at one place for the sake of clearness, tt. art, uterine artery. is intersected by bands and imperfect septa, the remains of the solid decidua which has been, so to speak, excavated ; and the fcetal villi float freely in the maternal blood contained in the space. The sinuses, which b\- their union form this space, have been considered as enormously dilated decidual capil- laries ; they may, however, turn out to be developed from chorionic elements.' The \illous tufts number from twenty to fort}", and each tuft, as it lies in contact with the decidua, becomes enclosed in a wall of decidual tissue, which rises up around it (fig. 21). A villus thus clothed is recognised as a ' For a clear exposition of our )jresent knowledge of the development of the placenta in man, see a jjaper by Eden, Journal of Pathology and Bacteriology, 1895, in whicli the origin of the intervillous space is discussed. Fig. 22 (for (Jcscrii.ti.'ii see foot of p. 13). Development of Placenta — Fcvtal Part 13 lobitli' OY lo/ylcdo/i oi ihc fully cle\ eloped placenta, and the wall of decidiia which rises around it is named a decidual process. Into the bases at least of the decidual processes, and in some cases higher, there is carried up a pro- longation of the anipullary layer (fig. 21). Some of the decidual proce^.ses grow up to the surface of the chorion, and become attached to it in tlic spaces between the villi, as shown in the same diagram ; and on section of Fig. 23. — Sections illustrating the structurt; of the placenta (Minot). A, vertical section through the margin of a placenta at full term ; Z?, Z), deep layer of decidua ; /7, chorionic villi variously cut, their blood-vessels injected ; Si, marginal space of the placenta, nearly free from villi ; rv", aljorted villi beyond the placenta ; Fib, canalised fibrine of Langhans, produced, according to Minot, by transformation of the superficial layer of the chorionic epiblast. K, decidual tissue from a placenta at full term ; v, a blood-vessel ; li, li' , decidual cells the latter with several nuclei. the placenta smaller processes branching off from the main processes arc seen, and form the imperfect bands and septa alluded to above. Fatal pari. — The greater number of the villi forming this part of the tig. 22. — Section through a normal placenta of seven months in situ (Minot). . /w, amnion : Cho, chorion ; \'i, root of a villus ; vi, sections of the ramifications of villi in the intervillous spaces, the larger blood-vessels Vi-ithin them are represented black ; D, deep layer of the decidua, showing flattened remnants of enlarged glands in spongy stratum ; Vc, uterine vein (V artery) opening out of placental sinus ; .l/r, muscular wall of uterus. 1 4 Pregnancy placenta float frcily in tlie maternal blood-stream (figs. 22 and 23) ; but the ends of some of thcni are firmly united to the film of decidua (basal layer) lying on the ampullary layer, and some are attached to the decidual processes and their brandies, while some few extend into the uterine sinuses themselves Fig. 24. —Transverse section of a villus from a placenta of seven moinhs (ilinot). Three blood-vessels are seen within the villus, im- bedded in a jelly-like connective tissue con- taining cells and fibres ; a, a, cell-layer covering villus (epiblast according to Minot ; according to others of decidual origin) ; /\ a thickened portion of this cell -layer, which has undergone a fibrinous transformation (canalised fibrin). Fig. 25. — Portion of an injected villus from a placenta of alxiut five months (Minot). (fig. 21). The mass of villi fills up the sinus cavity, and gi\es to the placenta, on section, the appearance of a fairly firm fibrous structure. Each villus (figs. 24 and 25) consists of a process of connective tissue of an embrj'onic tjpe, carrying a loop of \essels— namely, an artery and vein, and covered with two layers of epithelium, one of which belongs to the \illus Fig. 26. — Curling artery. Fig. 27. Falciform ' valve. originally, and the other, the more superficial one, may be the layer of cells lining the sinuses, if the older theory of their decidual origin is still held, which the villus has carried before it as it grew into the cavity of the sinus; or it may be a special la\er, the trophoblast, from which many of the sinuses are in all probability formed. Placenta at Term 15 Effe7-eiit and Afferent Vessels. — The sinuses are supplied witli maternal blood by arteries derived from the uterine artery, which run in a corkscrew (figs. 2 1 and 26) form through the ampullary layer ; and the blood is returned by \ eins which traverse the same layer, and are directed obliquely towards the peritoneal surface of the uterus, many of them having an elbow in some point of their length. This spiral and oblique method of arrangement of the vessels is most useful when the placenta has to be detached during labour from the surface of the uterus ; for b\- the contraction of the uterine muscle (as shown by the arrows) the limbs of the angles can be eftectually compressed against one another, and the haemorrhage which would occur without some mechanism of this kind entirely arrested. The bend in the veins has been called a falci- form 'valve' (figs. 21 and 27). The placenta begins to develop during the second month, and is com- pleted during the third. It continues to grow in proportion to the size of the fcetus until full, or nearly full, term ; but before that time is reached, a certntn amount of degeneration has begun to show itself in its vessels and tissues. CHAPTER II PLACENTA AND MEMBRANES AT TERM Placenta at Term. Situation oj tite Placeiita in Utero. — The placenta is attached almost altogether in the upper part of the uterus. Its site usually occupies part of the anterior or posterior wall, perhaps a little more often the posterior than the anterior. It is usually more or less to one side, and extends some short distance on to the fundus. It is \ery rarely situated on the fundus. Under normal circumstances its lower edge does not approach to within about four inches of the internal os (see Placefiia Prcevia, p. 341).. It is never inserted on the cervix, for the nmcous membrane of this part ne\ er undergoes decidual changes. Description of Placenta. — The placenta, when deli\ered, is found to be a discoid body seven or eight inches in diameter. Its thickness is about an inch to an inch and a half in the centre, and diminishes towards the edge, where it somewhat abruptly merges into the membranes. The amnion co\ering its foetal surface is continuous with that lining the rest of the chorionic cavitv, and is continued to form the sheath of the umbilical cord (fig. 20). The chorion entering into the formation of the placenta is continuous with the chorion forming the sac which surrounds the ovum (figs. 20 and 28). The decidua serotina, whose superficial layer is now interlocked and compacted with the villi, is traceable at the placental edge into the decidua \-era ; the two deeper layers, the compact, and the ampullary undergoing no change at this edge, and the superficial laj^er which forms the maternal part of the placenta being altered in structure as already described. The placenta has two surfaces to be described, a maternal and a foetal one. i6 Pregnancy The maternal surface is of a dark reddish-brown colour, coated over with a thin film of greyish membrane. This membrane is very friable, and is seen to be missing in many spots. It consists of the part of the ampullary layer still adherent to that layer of dccidua which has come to form the maternal part of the placenta. The placental surface is divided into twenty or thirty lobules or cotyledons by sulci, which dip to a varying depth into the substance of the placenta. Into each sulcus, which corresponds to a main decidual process, there is continued a prolongation of the ampullary layer, and the cotyledons can be separated from one another without tearing the tissue, to as far as this layer extends towards the chorion. It is very rarely that the openings of the spiral arteries and the veins can be found. In a normal placenta there is no spot where the tissue has been torn, and so no \ illi arc exposed. At the edge of the organ the greyish film, if carefully uterine muscle J and sinuse; Fig. 28. -Section through edge of placenta. DP, decidual process; cor. sin, coronary sinus. The decidua at the edge merges into decidua vera. traced, is found to be continuous with a similarly friable layer covering the membranes. The foetal surface is different in character. It is smooth, owing to its covering of amnion. Beneath this membrane the large vessels may be seen running tortuously on the chorion, and dividing into branches for the supply of the villi in the cotyledons, into which these branches dip at a right angle. In a deeper stratum than the vessels the dark granular placental chorion can be seen through the transparent amnion. In a small percentage of cases (about two per cent, in a large number of placentie examined by the author) the remains of the yelk-sac or umbilical vesicle may be found, usually a few inches from the insertion of the cord, and looking like a well-defined bit of yellow putty about the size of S split pea. On section the thickness of the placenta is seen to be made up of a dark reddish-brown fibro-granular material, with some lighter-coloured fibrous bands of tissue intersecting it in various directions. Embedded in the granular material, which is the villous part of the placenta, is a certain amount of blood-clot, finely divided for the most part, but here and there. Placenta at Term ly especially at the edge of the organ, forming distinct clots. In many placentic a sinus is cut across at the margin, the so-called coronary sinus (Tig. 28) ; but this is not continuous all round the placental margin, and in f ict can rarely be traced for as much as an inch as a definite tube. On teasing out a portion of the villous part in water, it is at once seen to resohe itself into the characteristic seaweedlike structure already familiar in the chorionic villi of the early ovum (fig. 29). On microscopic examination of a slightly magnified section of the pla- centa (figs. 22 and 23), it is seen to be composed mostly of villi of different l''ig. 29. — Small portion of a four months' placenta, showing root and ultimate twigs of one villus distinctly and one indistinctly. sizes cut across in the section in various directions (■?'/). In each villus (fig. 24) there will be seen the vessels which it supports, and the coxering of epithe- lium, of which it is in most places impossible to make out more than one layer. .Scattered about as islets of different sizes are the decidual processes, and these are at once recognisable on account of the larger size and somewhat indefinite outline of their cells. At the maternal surface the decidua, if the section is made of a placenta in situ (fig. 22), is formed into a definite layer, through which the vessels may be observed to pass ; and in the middle stratum of this are the characteristic meshes of the ampullary layer. At the foetal surface of the section the well-defined boundary of the amnion is seen to overlie the chorion, which is continued into the villi. In some places, lyingmostly on the decidual processes bounding the sinuses, there are masses C 1 8 Pirii'i/diii]' and layers of niuhimicloatcd ^iant-cclls (Jib, tij^. 23 A and fig. 58), embedded in a structureless translucent material. Some of this material is found in the vessels in the decidual layer, and partially or completely obstructs their lumen. The formation of this element begins during the fifth month of preg- nancy, according to Friedlander. It is probably a condition which facilitates the more complete obliteration of the vessels by thrombosis that occurs after deli\ery of the placenta. This material is also found in the sinuses of the uterine wall at the same period. After labour the cells and fibrinous matter in the uterine sinuses become converted into connective tissue, and the site of a former sinus can be recognised in the walls of the uterus for many months after a pregnancy by the presence of this connective tissue, whose fibres are arranged in a more or less concentric manner. This will be again alluded to on p. 42, and under the heading of Evidence of Parity (p. 223). On catching up a piece of amnion at the edge of the placenta, it will be found that this membrane can be readily stripped ofif the chorion, and a gelatinous layer (fig. 21) will be exposed, separating the amnion and chorion, and enveloping the upper surface of the large vessels which are here ramifying. This is the remains of the space (ccelom, pleuro-peritoneal space) between the true and false amnion (see figs. 14 to 20). At the base of the umbilical cord, however, the amnion is no longer further detachable, and is firmly adherent to \Vharton"s jelly, which is to be described. Membranes at Term. — The amnion and chorion, with the shreddy remains of the decidua, are seen, when they are examined after delivery, to form a sac. This sac has been ruptured at one spot, the situation of the internal os ; and if the hole made is not a larger one than is necessary for the passage of the child, the shape and general characters of the membranes and their relation to the placenta while in utero can be made out. If the membranes ha\e been badly torn, this may be impossible. ' "-^"*^*-^J^*^^i^S^-'^,'^^«.\*C«f. ^ .-;:-^ } Chor.cn ^'^f^^wi^^:'£^ r"'' Fig. 30. — Section of meml>r;ines. The section does not include the ampullary layer of the decidua. The placenta and membranes will be found to be turned inside out, so that the amnionic surface is on the outside, and the surface which was applied to the uterine wall looks towards the interior of the bag. The inversion is due to the mechanism of delivery of the placenta (see p. 125). Decidtia. — This consists of the layer superficial (nearer the uterine cavity) to the ampullary layer. It is somewhat thicker than the decidual layer found on the maternal aspect of the placenta, since it is not fused with the chorionic \illi, and remains a distinct layer, which moreover is composed of jMcinbraitcs — IJquor Aini/ii 19 the fused dccidua \eraand decidua reflexa. It is \cry friable, and if a small piece is pinclicd up by forceps or between the fingers, it is found that a long .stri|3 cannot be taken off the other membranes, but that it breaks at once. Its continuity with the decidua on the maternal surface of the placenta will orobably not be directly traceable. If the edge of the hole in the membranes be now examined, it will be found that the amnion and the chorion can be easily separated, and that they form two distinct layers of membrane as far as the edge of the placenta. Here tlic chorion merges into the foetal substance of the placenta, and its identity with the membrane from which the villi spring can be made out. It is a translucent fairly firm membrane, but not so strong as the amnion. On separating it from the amnion, thin fibrous threads are often to 1)c seen, uniting the apposed surfaces. Amnion. — This is the membrane which confers the toughness on the sac which contains the foetus and liquor amnii, a toughness sufficient to enable the bag of membranes during labour to withstand a considerable pressure. The amnion is a transparent membrane, which forms a complete lining to the sac above mentioned, and is not interrupted or modified anywhere o\er this surface. Its relations to the substance of the umbilical cord will be presently described. It is as easily detached from the placental surface up to the insertion of the cord as it is from the chorion over the general surface of the sac. Over the placenta it is separated from the underlying chorionic structure by a gelatinous layer already mentioned, but under normal condi- tions it is elsewhere closely applied to the chorion. The microscopic structure of the three layers, amnion, chorion, and decidua, is seen \\\ the diagram (fig. 30). Iiiquor Amnii. — This fluid fills the amnionic sac. Its quantity varies within one and two pints in the normal state. It is a light-coloured, usually turbid fluid, watery, and of a specific gra\ity of about loio at term, though in the earlier months this is as high as 1020. In the earlier months, too, it has a greater bulk in proportion to the foetus than it has at term. In solution there are found small quantities of chlorides and phosphates, a trace of albumin, and, in the later months, a variable quantit)' of urea. -Suspended in it are flakes of verni.x caseosa, lanugo, and epithelial scales. Its source is not definitely agreed upon. It has been believed to be secreted by the maternal \essels in the uterine walls, and to exude through the membranes ; but in all probability it is a foetal product. Liquor amnii is found in the o\-a of birds, and in that case it must be produced quite independently of direct maternal sources.^ That some of it comes from the kidneys of the child is probable, on account of the urea it contains ; though the small percentage of urea (not more than -3 or -4) may be imagined to be within the capacity of the skin to excrete. It is very likely that the fcetal kidneys do secrete urine, for in cases of occluded urethra the urinary passages are almost always found distended with fluid having most of the characters of urine, though of low specific gra\ it\'. It nnist in any case require ' Jungbluth has described a system of vessels ramifying in the amnion, in the neigh- bourhood of the placenta, which he believes supply the liquor amnii, and which atrophy before the later months are reached. 20 PregiuDicy a considerable muscular efilort on the part of the abdomen to get rid of its contents completely, since the viscus is deprived of the action of gravity as an aid to evacuation, and it is a common experience that a distinct effort is needed even by an adult to micturate while immersed in water up to the neck.' All that can be said, therefore, as to the origin of the licjuor amnii is tliat it is probably foetal. Its uses are numerous. During pregnancy it forms a medium in which the embryo or foetus can develop in any direction without restraint, since no one part is pressed on more than another ; the free mo\ements which appear necessary to the growth of the child are not restricted ; shocks due to falls of the mother, or to blows on her abdomen, are only transmitted gently to the child ; the circulation in the cord and placenta is not interfered with if the uterus contracts. During labour it forms, by virtue of its fluidity, the most perfect dilator possible of the cervix, as will be explained : it protects Fig. 31. — K child a few hours old. The junction of amnion and skin is easily seen at aliout three-quarters of an inch above the general surface of the abdomen. the child from the great pressure which is brought to bear on the uterine contents during the dilating stage. The albumin contained in it has been supposed to help to nourish the- child, for some of the substances found in the fluid are occasionally seen in the alimentary canal of the child ; but there is not enough albumin to be of any service innutrition, so that if any of it is swallowed it is most likely an accidental occurrence. TTxnbllical Cord. — The umbilical cord springs from the fojtal surface of the placenta, except in a few cases where it comes off the amnionic surface beyond the edge of the organ. It is inserted into the umbilicus of the child, where its vessels enter the abdomen. Its sheath of amnion becomes ' The bladder is often found to be full after delivery, especially in cases where the breech is born first, and possibly the escape of urinr dining intra-utcrine life is an over- flow from an over-distended bladder. Umbilical Cord 21 Fig. 32. — Tra^^iverse section of umbili- cal cord, showing the two arteries and the vein. The walls of the vessels have shrunk slightly. continuous with the skin of the abdomen, which projects for from half an inch to one inch from the surface (fig. 31), and the mucoid tissue known as Wharton's jelly abuts on the subcutaneous connecti\e tissue. It is usually about twenty inches long, and varies in thick- ness from three-quarters of an inch to, in places where the jelly which makes up the greater part of its bulk is absent, merely the thickness of the vessels which it contains. Its surface is marked by spiral lines and grooves, indicating the twisting which has occurred during pregnancy. This twist is, in a large majority of cases, from right to left, or in the opposite direction to that of a corkscrew. In the earlier weeks the cord is straight, and the twisting which takes place is due to foetal revolutions during the earlier and middle months of intra-uterine life.' If a section is made across the cord (fig. 32), it is seen to consist of a sheath of amnion containing two arteries and a vein, which are embedded in a supporting medium of mucoid tissue. This (the jelly of Wharton) is a product of the deeper layer (next the chorion) of the amnion (see figs. 18, 19, 20). It is, therefore, really a part ^^*55^ of the amnion itself, and that is the reason why the amnion cannot be stripped off the cord as it can off the placen- tal surface. The jelly ends abruptly at the chorionic surface, as is seen in fig. 21. The vessels of the cord arc three in number, two arteries and a vein. The latter is, when empty, more or less collapsed, but the former retain their tubular appearance, owing^ to their thicker walls. The arteries are branches of the internal iliac, and in the abdomen arc named the hypogastric arteries. The vein is formed by the fusion of the original pair of umbilical veins. This fusion occurs in the very early days of the de\elopment of the embryo as far as that part of the veins which lies in the cord is concerned ; but the ' Or it mav be causL-d 1>\- mure rapid growth of one or iiiorL' of tlio vessels, e.^^. the arteries, than the rest. Fig. 33.-U 2 2 Pregnancy two \csscls remain distinct in the abdomen till much later, and then the\ do not fuse, but the right one is obliterated. There are no valves in the vein. In the arteries there are numerous dilatations, which can be seen externally, giving rise to bluish knots, to be found in every cord. There is thickening of the walls of the arteries at these points, and the condition is no doubt connected with the twisting of the cord, and is produced by local damage. The arteries have very thick muscular walls 'fig. 33), but have no elastic layer. The vein has no \al\es. It is dilated at in- tervals in its length. The remains of the allantois arc not distin- guishable in the cord ; but in the abdomen this organ is represented b\' the urachus and the bladder. In the earlier months a loop of intestine is found in the sheath of the cord, extending for half an inch or so into the tube. This is the part of the small intestine to which the umbilical duct is attached. It is with- drawn into the abdomen about the beginning of the third month, when the umbilicus closes. Fig. 34. — Section tlirough wall of umbilical vein. Pbysiologry of the Placenta. — The placenta forms the means by which the blood of the foetus is brought into apposition with that of the mother. The anatomy of the foetal and maternal parts of this organ has been suffi- ciently described for it to be seen how close the apposition is. Between the maternal blood, fresh from the lungs, and fully ox\genated, and that of the child, which is carbonised, there is a very thin layer of tissue. This layer is composed of, {ci) the epithelium covering the surface of the villi, {b) a varying amount of the tissue of the villus itself, and (<) the vessel-wall of the terminal twig of the artery belonging to the \illus. Through this diaphragm the two currents interchange their gases and soluble substances by diffusion and osmosis. The placenta is at once the lung, the alimentary apparatus, and the kidney of the foetus. The child parts with its carbonic acid gas, wliicii is taken up b) the maternal blood, and receives in return the small amount of oxygen necessary for its chemistry ; it passes over its waste-products and receives the materials for its nutrition. Experiments have been made showing that there is a certain amount of selective power in the partition between the two bloods, and this power lies, most probably, in the epithelial layers. X'AkiKTii.s 01 SHAri:, Structure, &c., in thk Xokm.m, Piack.nt.x, COKD, .VNU MKMBRANES Placenta. {(i\^ Shape. — The placenta is usually composed of one lobe ' only ; but it may be divided more or less completely into two or more lobes. ' A lobe is a term of convenience, and has no meaning in the sense that ' cotyledon ' has. Varieties of Normal I'lacenta 23 The main \ariations in the sha|)c of the sin;_;le-Iobed placenta are that its outhne may be roui^hly circuhir ; it ma\' be oval ; or it may be of irregular shape. The existence of two or more lobes is less common. These may be of ncarl)- equal size, or one may be larger than the other, or others. They may l)e united by placental tissue ; or may be quite separate, and the lobes are then united by a bridge of the three membranes of the ovum, in which the chorion is de\oid of fully-developed villi. The placenta of this last class is of obstetric importance when one lobe forms the main mass of the organ, and is large enough to be regarded on superficial examination as the whole placenta ; for during the process of its detachment from the uterus during labour, the small lobe, or lobes, if more than one exist, may be left attached to the uterine wall, and may not be 4i«^- Fig. 35- — Placenta siiccenturiata. /'/, placenta ; a. c/i. d, amnion, chorion, decidua ; ?■, \essels ; //. sklc", placenta succenturiata. missed by the physician. Such retention of a part of the placenta will, in all jMobability, lead to dangerous results later. The small lobes, separate from the main mass of the placenta, are named Placentic succenturiatje (fig. 35). On examining a placenta in connection with which a placenta succenturiata has existed, but is torn off, it will be seen that at some part of the edge of tlic main mass there arc two \esscls torn through, which have supplied the small lobe with blood. If the membranes have been delivered entire, it will be found that at the spot where the small lobe existed there is only a layer of amnion, the chorion and decidua being absent, or there may be some traces of the villi still adherent to the surface. If the membranes are torn away from the edge of the main mass, there will be no evidence of the succenturiate placenta but the torn vessels. Placenta with 'collerette' (fig.'36l This consists of a doubling back of the amnion at the edge of the placenta, so as to form a kind of pouch. The 24 PrciTuaucv collerettc may extend all round the circumference of the placenta, or it may, as in the specimen figured, only exist on about two-thirds of its circumference. It is not \ery uncommon, and the amount of freedom of the double layer of amnion varies considerably in different cases. It is probably due to a more rapid growth of the \ illous part of the chorion than the membranous part Fig. 36. — Placeiit.i with ' collcrette.' and the amnion can keep up with ; the two layers arc in consequence over- lapped by the villi, and are inverted, as will be readily understood from the diagram of a section of the same placenta.' The vessels on the surface of the placenta are seen in the figure to disappear beneath the free edge (fig. 36). {b) Striuiiire. — The varieties in structure occur almost entirely in connection with the vessels. These may be erratic in their course ; they may be thrombosed (the smaller ones) ; they may present local dilata- tions, or they may be the seat of calcareous deposit. J' 'g- 37- — Section through amnionic fold at edge of placenta of fig. 36. Other irregularities in structure found in placent;e which come from per- fectly normal ova are the presence of cysts, of extravasations, of fibrous masses Erratic Vessels. — A vessel is sometimes found to run over the edge of the placenta on to the membranes, form a loop on the surface of the chorion, ' This condition is well described by Anvarcl ( Traxaux d'Obstclriqiic, t. 2><-"'"«"). Varieties of Normal Placenta 25 Ijeneath the amnion, and then to return to the placental surface and distribute itself in the usual way. This may occur in a placenta whose outline is of the circular or oval type, when the errant vessel describes a curve aroimd the edge of the placenta at a variable dis- tance "from its edge ; or the vessel may bridge across some notch in, for instance, a bi-lobed placenta (fig. 38). The condition is not in itself of any im- portance, but it may lead to undesirable consequences in two ways. If the vessel happen to lie in that part of the membranes covering the internal os during dilation of the cervix, it may be ruptured at the time of ruptuie of the membranes, and bleeding dangerous or fatal to the child result ; or if the torn end of such a vessel is found at the margin of the placenta when this is ex- amined after labour, it might give the impression that a placenta succen- turiata had existed, and, failing to find this attached anywhere on the mem- Fig. 38.- -Placenta, bilobed, with errant vessel. Fig. 39. — Dilated artery just by insertion of cord. Fig. 40 — Fibrous masses, represented by shaded areas, in a normal placenta. branes, the medical man might explore and unnecessarily manipulate the interior of the uterus. The wav to avoid this unnecessarv disturbance of 26 Pregnancy the woman is to notice whether there are two vessels torn across or only one. If there is only one, that is either an artery or a vein alone, the vessel is an erratic one, and the edge of the placenta, if followed round, will show the other end of the errant part of the vessel. If, however, there has been a succentiiriate placenta at the end of the torn vessel, there will be an artery and a vein. Dilatations of Vessels. — The \essels, either arteries or \ein, may be found considerably dilated into aneurysmal-looking sacs 'fig. 39). Fibrous Masses. — On the foetal surface of almost every placenta are found plaques, or lumps, of tissue of areas varying from that of a threepenny bit or Fig. 4j. — Arteiy of a \ ilkis, in an early stage of endaileriti^, showing also tliickeiiing of the muscular coat (Kden), less to such as arc of sufficient size in rarer cases to occupy a third or so of the surface, as in fig. 40. These lumps lie immediately beneath the amnion, to which they are nearly always inseparably united, and are of a lighter colour and a much denser texture than the placental tissue proper. They dip down into the placental substance to a depth \ ar\ing from one-eighth of an inch or so to one involving the whole thickness of the placenta. They have been called by various names by those who have seen them for the first time — gummata, organised blood-clot, patches of placentitis, fibromata, sarcomata. They arc infarcts due to thrombosis of villous arteries (fig. 41). Many of these in the later months become thick b\- proliferation of their intima, which may occlude the channel. Microscopically the masses consist of compressed and necrosing villi (fig. 41. v).' ' See a paper by Eden ' On the Structure of the Ripe I'l;»centa, &c..' OM. Tnins. vol. xxxviii. J^drn'elii'S of Xoniial P/ncruta 27 They arc found in tlie course of a xessel, and sometimes contain cysts, with thin walls as a rule, and holding a pale, turbid, watery fluid. Occasionally the cysts are found to contain a portion of partially or totally decolourised clot in addition to the serous fluid. Even when of large size, they are perfectly consistent with an entirely healthy placenta and foetus. Calcification of Decidua. — If the maternal surface of any placenta at term, or even a few weeks before term, be examined, there \\ill be seen to Fig. 41 A. — Section through the edge of an infarct. The villi on the left of the section are seen to be compressed and atrophied. On the right there is no trace of villi, and tlie dense white fibrinou.s material aione is present. be thinly scattered over it superficial dendritic deposits of white, hard material. These are small portions of calcified decidua. Cysts. — The formation of cysts in connection with fibrous masses has iicen alluded to, and in all probabilit)' this is the commonest way in which the\- are produced. C)sts have been described which were considered of a my.Komatous nature ; but this opinion was probably founded on an imperfect acc[uaintancc with the normal histolog\- of the placenta. Cord, {(x) Insertion (see figs. 42-45). — The cord may be inserted into the placenta at the centre, or somewhere near it — the usual place ; or it may be near one edge, and the insertion is then a lateral one. It may join the placenta at its edge, marginal insertion, 'battledore placenta ;' or it may end on the membranes at a distance of one, two, three, or more inches from 28 Pregnaiicy the edge of ihc placenta. This last is called an 'insertio velamcntosa.' In the case of velamentous insertion, the vessels may remain together and unbranched till they reach the surface of the placenta, or they may begin to divide on the membranes and reach the edge by numerous branches. In this case, as in that where there is an erratic vessel, there might be some danger of rupture of vessels during labour if the branches crossed the internal os. {b) Structure. Knots. — During the free mo\ ements of the fojtus in utero in the earlier months the fcetus may float through a loop of the cord, and thus form a knot in it. If this is drawn tight in labour, the \essels may I^e occluded. Nodosities. — These are to be seen in most cords, and the lumps are Fig. 42. — Central insertion, a, amnion //, placenta. Fig. 43. — Lateral insertion, a, amnion //, placenta. Fig. 44.— Marginal insertion. /», amnion ; //, placenta ; ck. d, chorion and decidua. Fig. 45. — Velamentous insertion, a, .nmnion ; pi, placenta; ch.d, chorion and decidua; 7", vessels. sometimes twice, or more than twice, the diameter of the cord elsewhere. The thickening is mostly composed of a collection of Wharton's jelly at that spot, but on e.xamination of the vessels they will also be found to 'ie thickened as to their coats, and this change in all the specimens e,xamined by the author has affected the arteries and not the vein. It is very likely caused by a kink in the cord from o\er-twisting, which has damaged the vessels but has not occluded them. Cysts. — These have been recorded. They ma\" be owing to persistence of the cavity of the allantois at one spot, and in that case are developmental errors ; or they may be local softenings of the jelly, caused by twisting and damage. This subject has not been worked out. ivxembranes. — Fibrous masses are found occasionally in the membranes at \ ariable distances from the edge of the placenta. They have no doubt The Ovum at Different Ages 29 the same origin as those on the ])lacenta, for islands of undeveloped and unatrophied vilH are sometimes found. There is sometimes a space containing fluid between the amnion and the chorion. On looking at the diagrams of the development of the ovum, it will be seen that this fluid lies in the space between the 'true' and 'false' amnion (the pleuro-peritoneal space, coelom). It is thus due to the persist- ence of a space that should have disappeared. It may cause some confusion by the appearance of a double bag of membranes during labour (p. i 14). Iiiquor Amnii. — The only normal variation in this, apart from variation in the quantity (see p. 19), is its occasional discolouration. It is then of a dark olixe tint, more or less muddy. This may be due to evacuation of meconium by the child during pregnancy. Evacuation of meconium during labour often means that the child is in danger from asphyxia, but not always, and it has been found to occur in a large number of instances in perfectly normal cases. CHAPTER III THE OVUM .'^T DIFFERENfT PERIOl^S OF PREGNANCY rirst month. — There are a number of ova figured and described which are belie\ ed to be something under a month in age ; but, as far as any practical importance exists in recognising the age of embr)'oes so early as this, it will be served by a general description of the ()\um alDout the end of the month. The o\-um measures roughl)' one mch in diameter, and the embryo when straight- ened out about half an inch. The chorion is covered with villi, and has the appear- ance of fine seaweed when the ovum is floated in water (fig. 46). The amnion does not quite fill the ca\ity of the chorion, and is separated from that membrane by a space containing clear fluid. Second month. — At the end of this month the n\um is nearly two inches in diameter, and the embryo rather o\er three- Fi-. 46.-0\ um of about ih^- ilftii week. quarters of an inch in length. The amnion fills the chorion ; the umbilical \esicle has shri\cllccl down to little more than the size of a pea, and has a long pedicle : the villi are ;;o PregiuDuy clisappc;iiinj4 otf the yrtatcr part of the chorionic surface ; tlie uniljihcal cord is not yet twisted, and contains a loop of intestine in its base (fij,^ 46A). Third month. — At the twelfth week the ovum is about four inches in its long diameter, and the fcEtus or embryo (as it may be indifferently called at this moment) is about four inches long also, and may be compared in point of size to a mouse. The placenta is quite distinct, and the rest of the chorion is practically clear of villi. The cord has begun to twist, and the coil of intestine is about now withdrawn from its base. Ch JfJi C/t Fig. 46 A. —Ovum of seven to eight weeks. /> /', decidua vera; V K, decidii.i leflexa C/i, chorion ; Am, amnion. Through the amnion the embryo can be indistinctly seen. Fourth month. — The foetus is now five to si.\ inches long or more, and its body is about the size of a moderately grown rat. The head is pro- portionately \cry large. The sexes can be distinguished. Seventh month.— The length of the foetus is now about 15 inches, and its weight about 3 lb. A child born at the end of this month may li\e if it is strong and carefully tended. The large majority of children born at this time, however, die. The nails do not reach the finger-tips. At the end of the ninth calendar month, or full term, the child is, on an average, 20 inches long and weighs 7 lb. The Mature Fa'tns 31 Other points indicating maturity are : the iDody is pUimp, and of a colour a little redder than that of the parts of an adult's skin which are usually covered ; the lanugo, a fine down which covers the body of the foetus of the earlier months, has almost disappeared ; the nails project beyond the tips of the fingers, and those of the toes just reach their ends ; both testes can be felt in the scrotum, which has its normal corrugated ap- pearance. The head is large in proportion to the body still, but this is not so marked as in the earlier months ; the edges of the sutures are close together and the bones are firm. The head is usually covered with hair an Fig. 47. — Diagram of uterus at three to four months, icw, uterine wall; dv, decidua vera ; d r, decidua refle.va ; ds, decidua serotina ; am, amnion ; ch, chorion ; ac, amnionic cavity ; 11 s, uterine sinus ;/'', falciform valve ; c a, curling artery. inch or so in length. The body is smeared o\cr with a sebaceous material, the Ve?-mx caseosa. The child cries loudly after birth, and within a few hours passes urine and meconium. (For composition of meconium, see p. 238.) Sucking move- ments are made if the finger is introduced into the child's mouth. Varieties in IVciglit. — The children of large parents are often large, but this rule is not by any means unixersal. Two important factors go\erning small variations in the size of the child are the age of the woman and the sex of the child. The practical bearing of these will be discussed later (p. 440), but it may be remembered that male children have, as a rule, more fully ossified and therefore less compressible heads, and that if the woman has borne children before the age of twenty-fi\e, those children which succeed them and are born between the ages of twenty-five and thirty-five are larger ; whereas those born after thirty-fi\e are, as a rule. 32 Pregnancy again of al)out the same wciglu and size as the earlier ones. A woman, in fact, has tiie best developed children between twenty-five and thirty-five. The proportion of male to female children born in the (General Lying-in Hospital during two years was 547 males to 545 females in 1,092 births. Children are sometimes born which exceed the average weight and size to a remarkable degree. Foetuses of 18 lb., 16^ lb., and so forth are recorded.' The measurements and anatomy of the fcjetus, and especially of its head, as far as these subjects are of importance in labour, are described at p. 90. The circulation peculiar to the foetus is also dealt with in a later section, as it will be more convenient to describe this and the changes in it which occur at birth together. CHAPTER IV ATTITUDKS AXD MECHANICAL RKI.ATIOXS OF THE F(ETUS IX UTEKO lie, Attitude, and Position of the Poetus in TTtero. — To prevent tlie confusion \\hich often arises in the use of the terms '//>,' '•altitude^ '■position^ and ^ pi-esentaiion^ these will now be defined. Lie. — By this is meant the relation of the long axis of the child to that of the mother. The child may lie with its long axis approximately in that of the mother, or its long axis may be at right angles, or something near it, to hers. In the former- case the lie is said to be a longitudinal one, and in the latter a tf-ansveise one. Further, the head or the pelvis of the child may be below in the case of a longitudinal lie : then, if the head is downward, the child is in the cephalic lie ; if the breech is downward, the lie is said to be pelvic (see figs. 56 and 48.). Attitude. — This refers to the relations which the trunk, head, and limbs of the child have to one another, cjuite independently of the relations of any part of the fcctus to any part of the mother. Thus the child may be in a yf^.iv'^ attitude, with the head flexed on the trunk, the thighs flexed on the abdomen, and the legs on the thighs ; or it may be extended, \vith the occiput in contact with the back, possibly with the thighs extended on the trunk, and the legs on the thighs ; or the head, or trunk, or both may be bent to one side (lateriflexion), or one or more limbs may be extended (see figs. 142, 143): Position. — This, in obstetrics, is used to indicate the relation of a given surface of the fcetus, usually the back, to the anterior, posterior, or lateral aspects of the mother. The antero-posterior diameter of that part of the child which is under consideration, say the head, may be considered as the needle of a compass, and the peh is of the mother the compass card. The head may be in such a position that this diameter lies with its posterior pole ' \\'olff, Bcrl. Klin. \\\>ihi:)i. 1878, p. 620, and //'/(/. p. 648; quoted by Spiegelberg. Lie^ Attitude, Position, Presentation IZ looking to the front (occipito-anterior), to the side (head transverse), or to the back (occipito-posterior), of the pelvis, or to some other point on the circle of the pelvic circumference (see figs. 146 and 147). In fact, the position of the head might be called its orientation.' The term presentation is often used as synonymous with lie, Ijut this is a mistake. The presentation means that part which is first touched by an examining finger at any time while the head is descending through the parturient canal. Now the foetus may be in the cephalic lie, and may then present by the vertex, or by the face, or by an intermediate part of the head ; 1st lumliar utero-vesica pouch Douglas' pouch vaginal and urethral orifices Fig. 4S. — Uterus at term. that is, the vertex, face, or other part may be the one wliich descends first through the parturient canal, and would be first felt of any part of the chikl b) a finger entering the vagina. So, too, in the case of a pelvic lie the presenting part, or presentation, may be the breech or may be the feet, and in a trans\erse lie the shoulder or the elbow may be the presenting part. ' .\ tcriit used by some French obstetric authors, in analogy with the term indicating the direction of a line on a. map or chart. 34 Pregnancy The word presentation should be restricted to nicun tliat pan (jf tlic f(Ctal liead (or breccli or Umbs, as the case may be) which is ' felt most prominently within the circle of the os uteri, the vagina, and the ostium vayina\ in the successive stages of labour' (Tyler Smith), or ' that point on the surface of the child's head through which the axis of the fully developed pelvic canal passes' (Matthews Duncan). The description of the lie, attitude, &c., in which the child is most often found at term (see First Cranial Position, p. 141) (fig. 48) would be : Lie, cephalic ; Attitude, that of flexion ; Position, left occipito-anterior ; Presen- tation, vertex. Causes of the Prevalence of certain ]«ies and Positions at Term. — The most common position for the child to assume is the first vertex — the one just described. Cephalic lies are found in about 96 per cent, of all cases, and of these about 75 per cent, are in the first, or occipito-anterior, position, with the occiput to the left. The reason for this preponderance is not absolutely settled. It is no doubt a complex one, and comprises more than one factor. There are three conditions each of which has some influence. They are : (i) the position of the centre of gravity of the foetus; (2) the relative shapes of the uterus and of the foetus ; (3) movements of the foetus. (i) Matthews Duncan found that the center of gravity of tJic J\vtus at term lay somewhere about the level of the shoulders, nearer the right shoulder than the left owing to the presence of the liver on the right side, and nearer the posterior surface than the anterior. Consequent!}', if a foetus were immersed in a saline fluid of nearly the same specific gravity as its own, it sank into a position with the back of its right shoulder looking downwards. The head became, therefore, the lowest part of the body. Now, if the position of the uterus in the abdomen is considered, it will be seen that, if the foetus were unrestrained in its movements, the first vertex position is nearly the one which it would assume at term. The uterus is inclined forwards to an angle of about 60° with the horizon when the woman is in an upright attitude, and, in addition to this, its anterior surface is rotated somewhat to the right (see figs. 51 and 64). The result of these two obliquities is that the anterior surface and the left border of the lower uterine segment form the lowest part of the uterus, and so the head-end of the child tends to fall into this part with its back to the left and forwards. Flexion is the natural attitude of the embryo at the beginning of its development, and extension is always due to some abnormal condition. The vertex is thus the lowest part of the head. (2) Shape of the Uterus and the Fa-tal (^tvvV/.— The uterine ca\ ily forms an ovoid with its wider end at the fundus, and the fcetal ovoid is widest at the breech (see figs. 48 and 102) ; the breech therefore tends to lie in the fundal end of the uterus. This is well demonstrated by the fact that in the case of a hydrocephalic foetus, in which the head-end of the child is the larger, the podalic lie is much commoner than is the case, of normal fa-tuses i^sec fig. 206}. Causes of Prevalence of certain ]Jes and Positions at 'Per in 35 In addition to the actual sliapc of the uterus when undisturbed by external pressure, it must be remembered that while it is relaxed, and when the woman is lying on her back especially — though the same effect is produced in a lesser degree by the backward pressure of the anterior muscular abdominal walls — the posterior uterine wall is convex inwards, owing to the projection forwards of the lumbar spine (see fig. 51). The child, which, owing to its flexed attitude, has a bent axis, with the concavity on its anterior aspect, fits best to the shape of the uterine ca\ity when it has its back to the mother's front. It assumes a position under these circum- stances with its back to the left (specific gravity) and forwards (lumbar spine). (3) Mcn'ciiicftts of the Fcvti/s in Utcro. — The child is often felt by the mother and by the hand of the medical man to move its limbs ; and the legs, acting at the end of the body-lever, will have great effect in bringing about changes of lie and position. They also are actually more vigorous in their movements than the arms. Supposing the child to lie with its feet down- wards, it will have the resisting pelvic brim, or some part of the pelvis, to kick against, and every kick will tend to displace the legs upwards. When the child has kicked itself into a transverse lie, the shape of the uterus will then tend to convert the lie into a longitudinal one, either cephalic or back again into the podalic. The lie will not long remain podalic on account of the movements of the legs, which again convert it into a transverse one. If, however, the foetus is forced by the uterus into the cephalic lie, there is no reason why it should not remain in it, for there is now no resisting object against which the legs can take effect, as the fundus yields readily. In addition, the action of specific gravity and the shape of the uterus tend to keep the child in the cephalic lie. In further support of the above considerations, it may be mentioned that in the case of premature children, w-here not only does the child not fit the uterus at all closely (fig. 56, p. 40), but in which it is found also that the specific gravity is not greater towards the cephalic end of the foetus, the podalic lie is much more common in pi'oportion than in children which have reached term. The podalic lie is commoner than usual where the child is dead, even when it is at or near term ; and in this case it is most likely due to the absence of movements on the part of the child. CHAPTER V CHANGES IN THK M.\TKRNAL ORGANISM The changes in the maternal organism which take place during pregnancy may be divided into two sections : {a) those which occur in the generative organs and their immediate neighbourhood : and {b) those which occur in the general physiology and anatomy of the w onian. I) 'J 36 Pregnancy (n) Changes in the Generative Organs and in thkir Neighbourhood, including the Brp:asts The alteration in function of the generative organs, whicli consists in the suppression of menstruation, will be best dealt with in the chapter on the Diagnosis of Pregnancy (p. 58) ; those about to be considered are mainly anatomical ones. Vterus The most obvious change in the uterus is that which takes place in its size and shape. The increase in size takes place in the bod)- of the uterus ; the cer\i\ is not much, if at all, enlarged. The cavity of the body increases in length from i^ inch — its length in the unimpregnated state — to about 12 inches ; in width from \\ inch to about 9 inches ; and in depth from practically nothing to about 8 or 9 inches. Its cubic capacity is enlarged from one of theoretically none to about 500 cubic inches, and its weight (of the entire uterus), instead of being about i ounce, increases to about 24 ounces. Fane and Tanner t^ixe the followin<;' figures : — End of 3rd month Length 4i to 5 Width 4 Depth 3 4tli 5th 6th 5^- to 6 6 to 7 8 to 9 5 6.1r 4 5 6 7th 10 to II 1\ 6^ 8th II to 12 8 7 9th 12 to 14 9^ 8 to 9 There is a certain amount of variation possible in these measurements, due to the varying size of the foetus and amount of liquor amnii in different cases. The uterus is larger also in the case of multiple pregnancy at any given date than the abovb measurements indicate. This increase in all dimensions is a growth, and is not a result of mere distension. In the early months the uterine ca\ity grows rather faster than the ovum, and at the same time the walls grow thicker. Later on the cavity is filled by the ovum, but there is little tension exercised on its contents as long as the organ remains relaxed, for the outlines of the child can readily be felt in a relaxed uterus up to the last moment of pregnancy. The walls are then somewhat thinner than they are in the earlier months, but this can hardly, for the reason mentioned, be due to forcible distension. In certain cases, too, the ovum becomes implanted elsewhere than in the cavity of the uterus— namely, in the tube (see ' Ectopic Gestation,' p. 313) ; and in such circumstances the uterus is found to go on growing up to the fourth month, or longer, of gestation, and to attain an equal degree of development with that of the uterus of normal pregnancy at this period. The changes in shape in pregnancy are very characteristic. — In the early months — up to about the fourth, that is — the uterus modifies its outlines from those of the unimpregnated pyriform shape, flattened antero-posteriorh', to C/iir!i. vide end u])i)crmost. The cervix attached to this bf)dy looks dispropor- tionately small. The shape of the uterus on transverse section is pretty circular during the earlier months, but later on it is modified while the organ is relaxed, by the projection forwards of the lumbar spine. (See chapter on Labour, ' In a section of Webster's, from whom the accompanx ing diagrams aie copied, this Mas found to be the shape, though there may have been some moditication due to the presence of a dermoid cyst of the ovary in Douglas's pouch. On measuring the relative width of the upper and lower parts of the caxity, he found that the latter was the w itler. 38 Preer)ia)icv p. 97). The uterus is kept in close contact with the posterior wall of the abdomen by the tone of the anterior abdominal wall both while the woman is in the erect position and when she lies on her back. In the latter position there is also the eftcct of gravit\- in the same direction. When the uterus is Fig. 51. — (I, Uterus relaxed : /', uterus contracted. in a state of contraction, however, the tension produced on its contents is enough to cause the organ to resume its uniform ovoid shape, and to obliterate the depression caused h\ the projection forwards of the lumbar spine. This has the result that the uterus as a whole comes forwards in the abdomen, and then lies nearly in the axis of the pelvic inlet, and it can be felt by abdominal e.xamination to so project during a contraction. CFigs. 50 and 51.) Uterine Contrnctionscitiriiigprcgnaiuy. — During the whole of pregnancy the uterus is in a state of alternate contraction and relaxation. In the later months this can be easily made out by alxlominal examination, and, in fact, it may be felt to harden occasionally as soon as the fundus is accessible to examination from the abdominal surface. This contraction is not always caused by the stimulus of the examination, for the uterus may be found contracted when the hand is first laid on the abdomen, and will after a few moments be felt to relax. This character of the pregnant uterus is a most important one, and was first described by Braxton Hicks. It will be again alluded to in the chapter on Diagnosis of Pregnancy. The inter- mittent contractions are of some use during pregnane)-, for by them the circulation in the placental sinuses is much assisted, and were it not for them it is possible that the hearts impulse would be unable to keep up a sufficient supply of fresh blood for the needs of the foetus. The ;. 52. — Shape of abdomen in case of arcuate uterus. Positw?i (Did Relations of Uterus during Pregnancy 39 uterus during' a contraction is most common!}- felt to have an outline of a fairly uniform ovoid ; but in a certain proportion of cases the fundus is found to be divided into two lobes by a more or less ob\ious sulcus. The uterus then approaches the arcuate or cor- date type (fig. 52, and see p. 293^ and this modification of the curve of the fundus has been considered by some to be of im- portance in the production of certain presentations. Position of tJic Uterus in tlic Pelvis ajid Abdomen dicring pregnancy. — During the first two or three months the uterus, though larger and more globu- lar, does not greatly change its le\ el in the pelvis. Its increased weight may cause it to lie a little lower, but this effect is to a great e.xtent counterbalanced by an increase of the normal antetlexion, also Fig. 53. — Section of pelvis about third month. (From a frozen section of Pinard and Varnier.) DP, Douglas' pouch ; A', rectum : C, cervi.K uteri ; V, vagina ; U}-, urethra ; Bl, bladder ; Synt, symphysis ; L 5, fifth lumbar vertebra; .Si, .S"2, sacral vertebra;. The fine dotted line divides the decidua from the uterine muscle ; the thick dotted line outlines the bladder. ovarian vein Fig. 54. — Opened .-tbdomen of a woman three and a half months pregnant. The intestines have been removed. The case died of chorea in St. George's Hospital. (Se also fig. 55). 40 Pregnancy due to the j^rowih in Ijulk of the body re) ax. -I tion Fig- 55- — Diagram showing relations of uterus when relaxed, as in'ifig. 54, and when contracted. is up to the lower ribs (fig. 48). The cer\ix is thus carried somewhat further backwards in reference / to the vaginal outlet. When the end of the ////W/ month is reached the fundus is level with the pelvic brim (fig. 53), and may be felt on moderately deep pressure rather above the top of the symphysis. At the end of ihc/ourt/i month the fundus is in contact with the an- terior abdominal wall just above the pubes, and can be readily felt on abdominal examination. The fundus reaches the level of the umbilicus at five and a half months. At the seventh month it is about half-way be- tween the navel and the xiphoid cartilage, and during the iiinth it In the last week or two the fundus falls ist lumbar -- Douglas" pouch Fig. 56. — Uterus at six months. rather forward, and the level of the whole uterus is said to be lower on account of its sinking slightly into the pelvis. Muscular Wall of Uterus 41 Tlic icl;ui\c positions of the uterus and the abdominal \iscera at term are indicated in the diagram (fig. 48, p. '^'^. The pregnant uterus retains the usual sHght aniouni of dextro-rotation of the non-gravid state — that is to say, its anterior surface looks sHghtly tf) the right (figs. 63 and 64). It has also comrnonly some oblicjuity, which is most marked at term, and it leans to the right as a rule, rarely to the left. In 89 cases examined at the General Lying-in Hospital, the fundus was found to be inclined to the right in 53 (59 per cent.), and in 36 (41 per cent.) it was in the middle line. None of the cases in this series leaned to the left. (See fig. 67.) The changes in the e/idoiiie/riin/i, resulting in the formation of the decidua, have been already described (p. 4). C/iangLS in the Uteri?tc Muscle. — The changes are practically confined to the body of the uterus ; those which occur in the cervix will be noted later. The uterine wall increases in bulk during pregnancy mainly by increase in its muscle. This enlargement has till recently been considered to be due to a combination of the hypertrophy of existing individual muscle-cells with the formation of new ones, on the strength of Kollikers observations.^ He said that the increase oc- curred in this way up to the fifth month, and that after that date the process was limited to hypertrophy of those fibres already formed. In a large number of observations on the uteri of rabbits, it was found by Helme - that there was no e\idence in support of the theory of the formation of iie-w fibres ; there was no division of nuclei. The existing cells enlarge, become striated longitudinally, and show some transverse rings. This hypertrophy of the cells is a very remarkable one, each cell becoming about ten times greater in length and thickness (fig. 57). The connective tissue was found by Helme to increase in proportion to the muscle, the increase beginning near the \essels and between the muscle-layers and bundles. Here there really does occur a multiplication of elements or hyperplasia. Some of the newly-formed cells develop into connective-tissue fibres, others remain cellular. The new fibi'es being formerly supposed to be dc\clopcd from embryonic cells, the exhaustion of these was imagined ' to be a possible cause of interference with the proper develop- showin" increase ment of the uterus during pregnane)', when man}- pregnancies i" size of muscle- had already occurred. The arrangement of these muscular fil^rcs in the wall of the pregnant uterus was found l^y Helie, who made most careful dissections,-' to consist ' KiJUiker, Mikroskop. Aiiatoinic, 1854. - Helme, ' Muscular Fibre and Connective 'lissuc of the L'Iitu.s in Pregnancy and the Puerperium,' Trans. Roy. Sec. Edin. \o\. 35, pt. 2. ■'' H(51ie, Kcchcrclus sur la disposition dcs fibres musculaires dc tutCrus d&L'elappCcs par la grosscssc. Paris, 1864. 42 Preg7iancy in the superposition of three layers. The main layer, which is the most important of the three, lies between the other two. It consists of a close network of fibres, running in various directions and forming bundles which surround the \essels, and contain spaces which on section are of fusi- form shape, and enclose the sinuses. This layer extends over the whole uterine body, and ends at the internal os. Its fibres at the placental site are described by Hunter as interlacing very closely, so as to form a liowerful compressing agent to the torn vessels after detachment of the placenta. External to this layer, and lying immediately under the peritoneum, is a sheet of fibres which lie mostly longitudinally, forming a series of loops arising from just abo\e the level of the internal os before and behind, and arching over the fundus. A few transverse fibres are also described. The innermost set is mainly composed of a series of rings of fibres, which surround the orifices of the Fallopian tubes, the bod\' of the uterus, and the internal os. To the latter they stand in something of the relation of a sphincter. It has been found in the examination of uteri at various stages of preg- nancy that there is to be made out, immediately above the level of the internal os, a zone of the uterine wall which \aries in width, distinctly thinner than the rest of the body (see fig. no). This part has been called the lower uterine segrment, or ist/iiiius, and is more fully de\elopcd as the uterus becomes modified in shape by the process of labour (see p. 98). It is marked out more or less distinctly by the fact that over its surface the peritoneum is less firmly attached than it is over the rest of the uterus abo\ e this level. It is the part which, duiing labour, is dilated to allow of the passage of the foetus, as this is being expelled by contractions of the thicker upper segment. Its muscular fibres are arranged mostly in rings, and few of the longitudinal fibres or those belonging to the middle la\-cr are found in it. Changes in the Vessels. — Tlie trunks of the uterine and o\ai-ian arteries become enlarged to supply the increased needs of the organ. They increase in length as well as in calibre. The smaller branches are much enlarged, and are very tortuous ; and those in the uterine wall have the corkscrew form already alluded to. The veins become correspondingly increased in size, and the sinuses in the uterine wall are especially developed at the placental site. There is no special muscular coat to these sinuses, and their occlusion depends on the contraction of the uterine muscle. They are also destitute of valves ; but their shape and relation to the muscle surrounding them cause their lumen to be at once obliterated on any alteration, caused by contraction, in the planes of the tissues around them. The above description of the muscle and the vessels in the uterine wall applies to these structures up to about the sixth month. After this, certain changes of a more or less retrogressive kind are found to occur. They C/uvi^ij^i's ill Sinuses and Lymphatics 43 ])re])are tlic \csscls for the thrombosis which mu-st take |)lace immediately after labour, but the change in the muscle-fibres cannot be definitely said to be any change known to produce increased activit)-. The muscle-cells were found by Helme to undergo a certain degree of hyaline change ; they l)ecome glass)', and occasionally vacuolated. In the connective tissue among the fibres there appear epitheHoid cells, especially around the vessels, and also some larger, multinucleated cells (plasmodia). The vessels undergo important changes. The endothelium of the vessels proliferates and the cells of the muscular coat of the arteries swell and become hyaline (fig. 41). The swelling and proliferation in the sinuses were described by Friedlander,' and again b)- John Williams.- The lumen of the arteries and sinuses is thus narrowed in a degree corresponding to the amount of change. (See also p. 27.) Further, there is found, especially at the seat of tliesc changes, but also in sinuses which have remained unaltered, Fig. 53. —Part of a placental sinus, showing the hyaline thickening of the endothelium (semi- diagramtnatic). j, sinus wall ; v, villus, with a, a vessel, and <■', corpuscles (fretal) ; c, blood- space, with corpuscles (maternal) ; d. decidual cells ; c, proliferated endothelium of sinus. This figure of :i placental sinus may stand for a uterine sinus, as the changes are similar. a \arying amount of thrombosis. The sinuses are compressed too, from the outside, by the collection of cells in the connecti\ e tissue around them. Some of the arteries also become thrombosed (fig. 59;. The changes in the sinuses and their surroundings will be again men- tioned in the chapter on the Puerperium. Arcii.f. Cyn. h^. i.v. p. 22. 2 Obsf. Trans, vol. x.\. p. 172. 44 PrariuDicx Ly)iiphatks. — There can be no doubt tliat these are enlarged in pro- portion to the other elements of the uterus. There appears to be in the uninipregnated uterus a deep and a superficial layer of channels in relation with the endometrium. The deep layer lies beneath the attached surface of the mucosa, and sends up smaller vessels which come to lie immediately under the epithelium, and surround the mouths of the glands, there being no tissue iDctwecn the gland and the lymphatic walls.' There seems to be no well-defined subserous layer of lymphatic channels, such as had been pre- viously described, but the muscular bundles are surrounded by such channels. Seeing how close the lymphatic \essels lie to the epithelial surface of the uterus, it is easily understood that septic absorption would not lie difficult, Fig. 59. Tluombosis of a spiral aiti:ry, iiiiniccliultly heiicalli the placcnla. The villi are seen in the upper part of the figure. (Eden). and that this wmikl be favoured l)y imperfect uterine retraction, which would allow man\- of the lymphatic \essels, as well as the sinuses, to remain patent. Nei'ves. — The ncr\es take \yAvl in the general growth, and llie incli\ idual fibres also become thicker, but rather, it is found, from increase of the primitive sheath than of the actual nerve-substance. Cervix. — In addition to i)arlicipating to a slight degree in the enlarge- ment of the uterus, there are some special changes which occur in the cervix. ' ]ioggan, Ol'.- also increase in length. The o\aries are raised to slightly above the level of the ])el\ ic brim. They are brought close to the side of the uterine body, o\\ ing to the growth of the uterus between the layers of the broad ligament. 77^1;' connective tissue throughout the pehis becomes much more succu- lent and distensible, and this serous infiltration affects adhesions resulting from previous peritoneal inflammation, i-endering them more easily stretched bv the growing organ. Changres in the Articulations of the Pelvis. — The mobility of the separate bones on one another bee omes mueh increased during pregnane)'. There is an increased de\ elopment of the existing synovial pouches in the sacro-iliac and the pubic joints ; and this condition may go on in extreme cases to a degree which makes it almost impossible for the woman to walk with comfort. The eliect at the symphysis pubis is that the ends of the apposed bones ' Barbour; Webster; Polk, N. Y. Med. J. vol. x.xxv. p. 560. Changes in Structures adjacent to the Uterus 49 can j^lidc on one another niucli more freely; and there is also some, but not much, power of separation. In the sacro-ihac joints this relaxation allows of an extended swing of the sacrum in an antero-posterior plane; and also some capability of bending" back of the innominate bones on the sacrum — such a movement as is caused when the symphj'sis is divided in the operation of symphysiotomy and the ends of the pubic bones are pulled apart. The state of things at term is now seen to be one which gives great advantage in the process of expulsion of the ovum. Those parts which, as will be seen later, assist in expulsion have become hypertrophied — namely, the main portion (upper segment) of the uterine body, the broad ligament muscle and the round ligaments ; and those parts which have to be stretched to allow the ovum to pass are relaxed — the cervix is softened, the lower Fig. 65. — Section through pelvis (vertical), showing the sacro-iliac ligaments and the synovial cavities. segment is thin, and the vagina and vulva are now more easy of dilatation. The relation of surrounding tissues is found to be most advantageous— the body of the uterus is surrounded by a strong, elastic, firmly attached peritoneal covering, except over its lower segment, where the attachment is loose and allows of rapid expansion ; and, further, the peritoneum does not form a complete sheath round the lower segment or the cervix, but only co\-ers the back of these, the sides being supported by the loose connective tissue in the base of the broad ligaments, and the front by that between the uterus and the bladder. The lower part of the cervix is surrounded Ijy the easily stretched vagina. Cbangres in adjacent structures caused by Pressure of the growing: Uterus. Prcssi/?-c on ihc Bliiddcr. — In the early months the anteversion of the heavy fundus causes this to jjress on the bladder and so to produce some 50 Pregnancy increased frequency of micturition. In the unimpregnated condition the uterus accommodates itself in position to the varying modifications in size of the bladder ; but during pregnancy the bladder has to adapt itself to the space available for it, and this in\ erted relation jjecomes more marked as pregnancy advances. It is during the first three months, during which time the uterus is not too large to be contained the pelvis, that the bladder is most pressed upon ; for after this time the increasing size of the uterus makes it necessary that it should rise more and more above the brim, and there comes in consequence to be more room in the pelvis for the bladder. In the last months, and especially in primiparii;, the lower end of the uterus occupies most of the space in the brim and cavity of the pelvis, and the bladder has to again accommodate itself to circumstances ; and it does this to an extent which in some measure depends on the laxity of its connective-tissue attach- ments. Thus the bladder, if much distended in the last months, is, as a rule, fcnind to rise above the pubes, and to lie between the anterior abdominal wall and the uterus, being rather flattened. It has been found in some cases on passing a catheter that there was a pouch of bladder filling the angular space formed by the pubes, the uterine wall, and the anterior wall of the \agina — the space usually occupied by the empty bladder in the non-pregnant condition — as well as the pouch rising abo\e the pubes. In yet other cases ' the bladder has been found altogether in the pelvis, lying below the lower end of the uterus and forming a cradle, in which this part of the uterus lay. Here the base of the bladder must have been very firmly united by connective tissue to the \ agina and the supra-vaginal cervix. The ureters have never been shown to be affected by the pressure of the gravid uterus, though it has frequently been asserted that they are. This assertion has been made to account for certain affections of the renal func- tions which occasionally occur in pregnancy (p. 504,'. Rectum and Intestines. — The action of the rectum is interfered with to some degree during pregnancy owing to pressure, and constipation is one of the most constant troubles. The rest of the intestines seem rather sluggish, but the rectum is no doubt the part most affected. The pressure on the pelvic veins and some of its results have been mentioned ; piles very often appear for the first time during pregnancy, and any previously existing ones are rendered much more troublesome. The veins of the thighs and legs are enlarged as a rule, and may become slightly \aricose. The \aricosity is sometimes, howe\er, \ery considerable, even in primiparie : while in multipara;, especially in those who have had this condition in earlier pregnancies, the cases may be among the most severe examples of this disease (see p. 283). The abdominal walls, though they no doubt to some extent undergo a hypertrophy in connection with pregnancy, do not seem to de\elop much as regards their muscle. They rather passively stretch than actively grow. 1 .\uvar(l, Trav- nia\- occasionallv be seen on the thighs of men who have grown very rapidh- Fig. 68.— From the same case as fig. 67. Stria are seen over the lower riljs, a somewhat unusual position. within a short period. They are found on the breasts of women apart from pregnancy where there has been a rapid increase in the size of these organs by fatty deposit, such as often takes place at puberty. Changes In the Breasts.— These consist in a gradual preparation for the function of lacialion which will have to be performed after the birth of the foetus, and of some small incidental alurations in the framework and coverings of the glands. The glands attain complete development at the first pregnane) . I he lobules then enlarge and become more distinct from one another ; the epithelium lining the acini becomes active, and desquamation into the cavity of the acini occurs. The epithelial cells thus set free are in a state of fatty degeneration, and constitute the Colostrum corpuscles. Serum is secreted early in prcgnancv, and may be squeezed from' the nipple in the second or Chanzcs in Breasts 53 lliird nionlh. Later on the colostrum cells are found in the secretion, and their presence causes the fluid to have a streaky yellou' appearance. The secretion exudes imperceptibly from the breast as soon as it begins to be secreted, and in most cases forms a thin incrustation on the nipple which can be seen at any time during the last six months of pregnancy. The acini, on being examined microscopic- alh, are found to be lined with a layer of cubical or cylindrical epithelium, and to have their cavities filled with granular cells during all the time the secretion remains in the colostrum stage — in fact until the third day after labour, when the character of the secretion changes to that of milk, as will be described. While the development of the breast tissue is connectixe tissue which forms the framework of the gland increases in quantity, and the whole organ becomes enlarged and full. The skin over the breasts is stretched, and often develops skin-cracks which have a radial distribution and direction. Numerous blue veins may be seen beneath the skin. The most characteristic changes occur in the areolae and nipples. The former become in all cases but those of the very blonde type pigmented in a \arying degree. In dark women the colour becomes of a very dark Fig. 69. — Colostrum stage. going on, the fat in the Notmal 'Skin SCr/a --=,v 'i^ . Cor i urn Fig. 70.— Section through edge of old stria from abdomen. The unaltered skin is seen on the right, the stria on the left. Note the absence of papillw, the thinness of the Malpighian layer and the con- densation of the fibrous tissue of the corium. brown, in negresses jet-black. On the surface of the areola the sebaceous follicles, from ten to twenty in number, are found enlarged. The colour of these is rather lighter than the rest of the surface, and they are easily seen. At the edge of the areola the pigmentation assumes a somewhat irregular out- line, owing to its extension over the adjoining surface beyond the original edge. As the area of pigmentation extends it surrounds the sebaceous glands immediately adjoining the areola, and leaves them uncoloured. This gives rise to an appearance more or less peculiar to pregnancy — namely, that 54 Pregnancy of a number of paler spots on an extension of the pigmented surface — the secondary areola of Montgomery, who, in describing it, compared it to a stained surface from which the colour had been discharged when drops of water had fallen on it. The secondary areola is to be seen first about the fourth month in most cases, and begins at the upper and outer edge of the original areola (figs. 71 and 71 a). The nipples become moister in texture, and readily undergo erection on stimulation. The dried secretion mentioned is visible on their summits, and serum can usually be squeezed through them any time after the beginning of the third month Previous preg- nancies may modify the history of this development. If the woman becomes pregnant while she is suckling a child, there is, of course, milk in the breasts at the beginning. This, however, as a rule, soon disappears, the energy of the system being directed to the uterus. The pigmentation of for- mer pregnancies, though these may be remote, does not entirely disappear, and the edge of the areola nearly always remains somewhat irregular. {b) Changes in other than the Generative Organs The local changes just described are accompanied by alterations of function or of structure in the other systems of the body ; and these \\ill now be described. Wervous System. — In the case of the nervous system the changes are, as far as is known at present, entirely functional. The pregnant woman, especially if she is pregnant for the first time, is usually the subject of a certain instability in the discharge of her nervous functions, as evidenced by the prevalence of mental aficctions during this period, and also of chorea, and other disorders showing loss of regulating power. Short of such serious disturbances as these, the instability shows itself not uncommonly in a change in the woman's disposition, which may be for the better, but is oftener for the worse. She may become irritable or morose, or may be the victim of unfounded prejudices of diftcrcnt kinds ; the 71. — Areola and secondary areola in a brunette at term. I \iniitiug of Pregnancy 55 'longings' of pregnancy arc an instance, for here tlie woman has or imagines she has desires for \arious articles of food, or for substances which are not usually emploj'ed as food, such as pickles or other sour things, or starch or raw rice. These longings are explained by Giles ^ as being the desire for something to check the feeling of nausea in pregnancy, and in this case sour things would naturally be thought of ; or the expression of an instinctive want for some class of food in the altered condition of pregnancy ; or, in many cases, a kind of auto-suggestion prompted b)' a popular tradition. They are most often met with in primiparai. Vomiting of prcg- iiancy. — This affection, from which about two- thirds of all pregnant women suffer at some time or another of their pregnancy, seems to come under the head- ing of affections of the nervous system. There is no physical change in the stomach to account for it in the early months, and in the later ones it may or may not be due to the mechanical compres- sion of the stomach by the fundus uteri. It is probably not. Sickness begins in a very large majorit)' of cases early during the second month of pregnancy ; - it commonly persists during the second and third months and ends in the fourth. In some cases it lasts throughout pregnancy. It may begin in the later months, the seventh, eighth, and ninth. Giles finds that vomiting is commoner in women who suffer much pain and lose much blood at menstruation. The disturbance may be either mild or severe when it is present. It is sufificiently frec[uent in occurrence to be looked upon as one of the suggestive 1 Obst. Trans, vol. xxxv. p. 242. - According to Giles [Obst. Trans, vol. xxxv. p. 303, 'Observations on the /Etiology of the Sickness of Pregnancy ') vomiting most frequently begins in the first month. 1 hese facts are founded on the observation of 300 cases in the General Lying-in Hosi:iitaI. The subject is one which it is obviously rather ditiicult to accurately investigate. b"ig. 71 A. — Areola and secondary areola in a Ijlonde, 56 Pregnancy symptoms of pregnancy when it is concurrent with amenorilKL-a, but it is of course not diagnostic (see p. 59). \'omiting from definite physical changes in the stomach or from cerebral tumour for instance, occurring during pregnancy, must be distinguished from the vomiting of pregnancy affecting a healthy woman. The woman is usually attacked by nausea and vomiting, or only nausea, when she first rises in the morning. This may only happen occasionally, or may take place every morning, and it may or may not recur during the day. The transition in degree from w hat may be considered almost physiological to a severity which is undoubtedly pathological is imperceptible. As regards the causation of the vomiting little is known beyond what has been said above. Numerous hypotheses have in consequence been invented. The unstable nenous condition of the woman during pregnancy is, according to the most acceptable of them, an important element in the matter, and the state of things is believed to be somewhat similar to that supposed to be present in eclampsia, chorea, or insanity (see pp. 509, 280, 556). The nc7-ve-endi77gs are affected \ery frequently. Alterations of vision, of smell, and hearing ; of sensation, and sometimes of motion ; and very frequently of vaso-motor nerve-endings, resulting in pruritus, neuralgia, anaesthesia, and other perversions of function, are not rare. Circulatory System. — There is a distinct increase in the quantity of the blood, which is no doubt caused by the addition of the large uterine circulation. There is also a change in the quality. More fibrin and white corpuscles and less red corpuscles and albumin are found to be present. There is thus produced a physiological chlorosis, which is accompanied, as in the pathological Aariety, by 2,dilatation of the heart. Dilatation must necessarily take place ; for as the quantity of the blood-mass is increased, either the pulse must become more rapid or the cavity of the heart must enlarge to maintain the same rate of circulation as before. The pulse is not more rapid in pregnancy, and the heart's apex is found to be displaced a trifle outside its ordinary position. The dilatation is combined with a perfectly compensatory hypeffj'ofhy, and instead of the blood-pressure being diminished, as would be the case if only dilatation of the heart were present, it is on the contrary found to be increased. These changes in circulation and in the cjuality of the blood vary in degree according to the original soundness of the woman, and according to the state of nutrition maintained during the pregnancy. In some cases there is marked increase in the size of the thyroid gland., especially in women mIio ha\e already a tendency to goitre ; and where there is any exophthalmos before pregnancy the protrusion becomes more marked. The spleen is found to be somewhat enlarged (by aljout an ounce or so). The blood-changes may go on to a dangerous state of anaemia, and the gradations are infinite ; on the other hand, pregnancy often benefits a diseased heart for the time by causing its walls to hypertrophy. Respiratory System.^.Xs the uterus ascends in the abdominal cavity, it Changes in various Systems of the Body 57 diminishes the range of moxemcnt of the diaphragm according to the amount of encroachment on the available space. The thorax\\iO\\^\'^r^ to compensate for this, widens to a slight extent at its base, though it diminishes slightly in its antero-posterior measurement at this level, owing probably, as Dohrn suggests, to the upward pressure of the uterus on the diaphragm dragging on the attachments of the muscle, which yield at the weakest point, tlie anterior part of the thorax. ^ The vital capacity of the chest is little if at all diminished. Owing, no doubt, to the increased oxidation-processes going on, the amount of expired carbonic acid is somewhat increased. Alimentary System, including^ Nutrition. — In healthy women there is probably little change in the assimilation and chemical changes of the food during pregnancy. There is, however, as a rule, increase of fat in the system, and the body- weight is greater, apart from the weight of the uterus and ovum. Certain diseases seem to have a close connection with pregnancy ; osteomalacia is one of these, also acute atrophy of the liver, and Garrod finds that gout is rather more common in women who are pregnant than in others (see also Diabetes, p. 298). The digestive troubles consist in the characteristic vomiting of pregnancy (see p. 55) ; in constipation, and in salivation, which is occasionally present. The gums are found to be thickened and reddened at their edges in a large number of cases, most frecjuently in the class of hospital patients. Urinary System.— It is said by Tarnier and Chantreuil that the total solids in the urine are diminished, with the exception of the chlorides, though this is denied by Winckel.'- ^/(^z/;//z;/.— Hypolitte and other observers have found traces of albumin in about one-eighth of all cases, but traces only. This may have to do with the changes described later as occurring in parenchymatous organs during pregnancy. Sugar is occasionally found during the last few days. Osseous System. — In addition to the modifications in the nutrition of bone mentioned as osteomalacia, irregular deposits of calcareous matter, called Puerperal Osteophytes, are found on the inner "surface of the skull. These are not peculiar to pregnane}-, but ha\ e been found in other conditions. They were first described by Rokitansky. Cutaneous System.— (For a description of Lineti; albicantes, see p. 51). — The skin in pregnancy increases in acti\it). There is a deepening in colour of parts ordinarily more or less pigmented. Thus the areola become darker, as already described, and there is an increased deposit of pigment over the linea alba on the abdomen ; and this in dark women forms a well-marked line reaching from the pubes to the umbilicus. The skin i-ound the eyes is also darkened in varying degrees, and sometimes irregular deposits of pigment appear on the face, and resemble those patches which are often found in connection \\ith osteo-arthritis. • Dohrn, ' Die Form der Thorax-bnsis,' &c., Monafs. f. Gch. vol. xxiv. p. 414, vol. xxviii. p. 457 ; and Herman, Ohst. Trans, vol. xxxii. p. 108. - As regards m-ea excretion, see Herman, Ol>st. Trans, vol. xxix. p. 530 and sqq. 5 8 Pregnancy There is greater activity of tlie sebaceous glands, especially in those near the genitals and the breasts. In a certain number of cases, lumps appear in the skin of the axilla, mostly at the end of pregnancy. They were first described by Champneys, who observed them in 27 women out of yj"] who were confined in the General Lying-in Hospital. There was no opportunity until lately of examining them microscopically, and from the secretion which could be squeezed from them they were looked upon as a specialised form of sebaceous gland. They are now found ' to be composed of modified sweat-glands, and the neighbouring sebaceous glands are not altered. The lumps are situated in the skin of the axilla, and this cannot be pinched up over them ; but they can be raised from the deeper structures, and do not resemble lymphatic glands in any of their connections. They vary in size from ' the smallest perceptible to that of an ^%^,^ or perhaps larger.' They are in their most characteristic state during the lying-in period, when their course of development coincides with that of the breasts. They are present sometimes at the beginning of pregnancy, especially if they have existed in a previous pregnancy. No secretion flows spontaneously from them, and they thus differ from axillar}' mammas ; but when they are squeezed at or soon after the time of labour, granular debris, like the secretion of sebaceous follicles, then colostrum, and then milk, successively appear. The secretion, however, varies in uniformity over the surface of the lump at any one time ; aind the secretion is produced over the whole surface. They are often painful, and are found in a few cases to be so during subsequent menstruations. CHAPTER VI DIAC.XOSIS OF PREGNAN'CY The subject of the diagnosis of pregnancy will be considered in this and the ensuing chapters under the following headings : Diagnosis of the Existence of Pregnancy ; Diagnosis of the Date of Pregnancy ; Diagnosis as to Parity or Nulliparity : Differential Diagnosis. DiA(;xosis OK THK ExisTKXCE OK Pkegxancv The method adopted will be to enumerate the symptoms and signs in turn, and consider the fallacies in each case. Symptoms. I. Si/ppfcssto/i of Menstruation. — The failure to appear of an expected menstruation is the first event which suggests to a woman that she is pregnant. 1 ' On the Development of Mammary Functions by the Skin of Lying-in Women,' Med. and Chi. Tnitis. vol. Ixix. ; and Cham, neys and Bovvlby; Med. and Chi. Tnitis. vol. bcxviii. Dmgnosis of Pregnancy 59 Such cessation may occur in several modes. Usually it is quite sudden ; that is to say, the woman has menstruated regularly and according to her own type up to a certain month, and then the expected flow fails to arrive. There is complete absence of any sign or symptom of the monthly process. The amenorrhoea lasts during the pregnancy. In another class there is one, more rarely there are two, and still more rarely three attempts, more or less complete, at menstruation after conception has occurred. The question of menstruation during pregnancy will be more fully discussed under the heading of Haemorrhages (p. 335). Suppression due to pregnancy may take place in a woman who is always irregular in her menstrual rhythm, and then the condition may easily be overlooked, the omission of menstruation being regarded at first as a longer than usual interval. Pregnancy may occur during the amenorrhoia of lactation, and then there will have been no menstruation since the time before the last pregnancy ; or during the amenorrhea of chlorosis or other debilitating disease ; or before the first menstruation has appeared at puberty ; or possibly after the meno- pause is supposed to have arrived. In these cases some confusion might arise if the possibility of impregnation taking place under such conditions were forgotten. It must be remembered, too, that the occasion may be one on which the statements of the patient should not be- too implicitly believed, for she may- be anxious to conceal the fact of her pregnancy ; and in the case of her state- ments not agreeing with physical signs, there can be no hesitation in relying on the latter evidence in preference to the former. 2. Vojiiiting. — The date of commencement of this and its characters ha\e been described. It is a sign of moderate value. It may be entirely absent throughout. Care should be taken that it is not due to any of the following states : {(i) Chlorosis with gastric ulcer, in which combination, a not very uncommon one, there will be found to be sickness, and most likely amenorrhoea. ib) Hysteria, combined with chlorosis and flatulence. The woman may ^"omit, have a distended abdomen, and there may be amenorrhoea. (t) Ascites from hepatic disease. Here there may be vomiting, together with the abdominal enlargement. There are other conditions which may lead to a combination of symptoms more or less resembling those of pregnancy, but the above-mentioned will Idc enough to illustrate some of the possible ones. 3. (liiickcniiig. — The existence of this symptom must be accepted on the woman's own statement. It consists in a sensation of something stirring inside her, and it was believed, when the term was invented, that at this time the child first became a living creature. Quickening usually appears about the middle of pregnancy, and no more exact statement can be made about the date than this. It is of very little \alue, therefore, in calculating the probable date of delivery. The \ariations in the date of its first ap- pearance are due to the difference in quantity of liquor amnii in different cases, and also in the sensitiveness of different women. Primipariv are said to feel it on an a^•erage about a week later than women who ha\e previously 6o Pregnancy borne children, and this may be due to tlie fact that it is not so soon re- cognised and carefully noted as it is by women who have felt it before. Sensations like those of quickening are sometimes caused by the move- ments of flatus in the intestines, and are sometimes imaginary. They are especially frequent about the time of the menopause, and not seldom occur in women who have been childless, and are hoping even now to become mothers. Any statements on this subject must be received with much caution, and only be considered as suggesting the possibility of pregnancy. (See Pseudocycsis, p. 71.) The pbysical signs of pregnancy arc much more important, as from some of them it can be said positively that the woman is pregnant, and also that the child is alive or is dead. 1. Inspection. — The standing attitude of the woman is altered according as the growing uterus throws the centre of gravity of the body further in front of the spinal column, for this necessitates the throwing back of the upper part of the chest and shoulders to bring the weight backwards again. The amount of deviation depends to a great extent on the height and figure of the woman ; a tall woman does not show the change of attitude so markedly as a short one, and sometimes women go to term without any suspicion being excited by their appearance. Other tumours, such as o\arians, ha\e exactly the same effect when they are the same size as the enlarged uterus. The shape of the abdomen differs at different periods of pregnanc\'. There is no projection of the abdominal wall forward until after the uterus has come into contact with it at about the end of the fourth month ; and any enlargement spoken of by a woman as existing before this must be due to flatulence. The abdomen of pregnancy is in the earlier months rather pointed, for there is not a uniform distension as in ascites, but a local ])rojection. The abdomen becomes increased in width too, and this change can be well observed from behind in an increase of girth, and thickening of the figure above the hips. Pigmentation and striae will be found according to circumstances already defined (pp. 51 and 57). The navel is very frequently, though not always, pushed out in the later months until its pit is obliterated or until there is a protrusion in its situation. This takes place in other ab- dominal tumours if they are large enough. 2, Palpation. — The position of the uterine tumour in the abdomen can be made out without the least difficulty if the uterus is contracting at the time of examination, and if the abdominal walls allow of satisfactory examination. If, however, there is relaxation of the uterus, the outlines may be very in- definite, and this character of the uterus of being hard at one time and soft at another is one of the most valuable signs we have that an abdominal tumour is the pregnant uterus (see p. 38). The alternations are most readily felt after the uterus has risen above the brim, but they ma\' be recognised much earlier by bimanual examination. Observations that the height of the fundus corresponds with the date of pregnancy calculated from the duration of amenorrhoea, and that, if time enough be allowed, the womb can be made out to enlarge in agreement with the rate normal to pregnancy, are most valuable as evidence. There may in some cases be felt a thrill over certain parts of the uterus, Diagnosis of Pregnancy 6i usually on the left side, where the uterine bruit, to be immediately described, is most commonly heard. The thrill is, in fact, a ' palpable uterine bruit,' and is synchronous with the woman's pulse. Palpation of the Fa'tus. — When the uterus is relaxed the outlines of the child can usually be felt, unless there is excess of licjuor amnii, and the lie, position, and attitude can be made out after a little practice. When con- traction occurs, the outlines of the child all disappear, and the surface of the uterus becomes part of a tense smooth ovoid. Fibroid tumours in the uterine wall must not be mistaken for parts of the foetus ; they do not dis- appear completely on contraction, and are often rendered more prominent. If the head happens to be at the fundus, it may be played between the hands, or felt by 'dipping' through the layer of liquor amnii intervening. The small parts (limbs) are felt on the opposite side to the broad, smooth surface of the back. Movements. — These may sometimes, if the child is vigorous, and the abdominal walls thin, be seen, and this sign might have been included in the evidence obtained from inspection. They may readily, under these circum- stances, be felt, and the spot where they are most distinct is almost sure to be that under which the legs and feet lie. This sign, if clearly made out, is absolute evidence of the presence of a living child in the uterus. 3. Ausciiltatio7i.—T\-YeYe are certain sounds to be heard over the uterus of a pregnant woman which are of much importance in the diagnosis of pregnancy. Uterine Souffle. Uterine Bruit. — This is a blowing noise, synchronous with the mother's pulse. It may be heard over any part of the uterus in a few cases, but is most constantly found in the flanks, particularly in the left one. It is rnore or less musical, and at times is composed of several notes, which form a sort of chord. If it is listened to during relaxation of the uterus, and contraction then takes place, the pitch of the bruit gradually be- comes higher as the contraction reaches its acme, when it becomes almost in- audible, and then, as the uterus again relaxes, the pitch lowers and the bruit returns to its original characters. This peculiarity is best observed, however, during labour. It is first heard alDout the sixteenth to the eighteenth week, and continues during the rest of the pregnancy, and for some days into the puerperium. Its cause is not clearly ascertained, but it is in all probabilit)' produced by the entrance of the blood from the arteries supplying the uterus into the sinuses in its wall. The sudden change in the shape and volume of the blood-containing passages produces a \ibration, which is heard (and some- times felt) as a bruit. The sudden curves in the uterine and ovarian arteries may also have something to do with the vibration, and the altered quality of the blood during pregnancy is considered by many, and probably with truth, to be an important factor ; at all events, it may intensify a bruit produced by the first-mentioned means. The bruit can occasionally be arrested by compressing per \aginam the strongly pulsating artery or arteries usually felt in the lateral fornix. A dicrotic bruit has been heard in cases where there was great anaemia. The aeason why it is loudest on the left side is no doubt that the left side of the 62 Pregnancy uterus is usually nearer than the rij^in to the front 'dcxtro rotation) (see figs. 63 and 64). The name of 'placental bruit' was given to the sound in past times because it was believed to be produced by the circulation in the placenta. This is, however, not the case, for the bruit can be heard in a certain proportion of cases after the expulsion of the placenta, and is not by any means heard exclusively over the placental site. Thus the uterine bruit is no guide whatever to the situation of the organ, and any attempts to thus localise it in cases where Cjesarian section is to be performed, or where an ectopic gesta tion is to be operated upon, are cjuite useless and misleading. A similar bruit is heard in some cases over fibroid tumours of the uterus, and ver}' rarely in some o\arian tumours. In these cases, however, although in the former disease there is some slight variation of pitch occasionally, there is not the characteristic change above described. Fivtal Heart Sounds. — After about the eighteenth week the heart of the foetus can be heard in a large majority of cases over some point or points on the uterine surface. Mayor of (iene\ a was the first obsei'ver who described this. The character of the sounds, when once they have been heard and their peculiarities noted, is unmistakable. The sound is, of course, a double one, but the second sound is very rareh- heard. No better description of it can be given than the old one which likens it to a loud watch heard ticking beneath a pillow. It is independent of the mothei-'s pulse, and during examination the finger may Ije kept on the radial arter\- of the woman to note this fact. Its rate is about 150, varying in different cases between 140 and 160 as a rule, though it may be slightly faster or slower than these figures. Its rate does not depend as far as has been obser\-ed on the intra- uterine age of the child, nor in any definite manner on its sex, though it is true that in a fairly large proportion of cases the rapidity is less in male children than in female. Its rate is influenced by uterine contractions (see p. 106), during which it diminishes : this is probably from pressure, which may act by increasing the arterial tension in the foetus by compressing the placenta, or by direct compression of the nervous centres in the medulla. It is found to be more rapid when the mother's temperature is higher than normal, and after vigorous movements of the foetus. The spot where it is best heard depends on the lie and position of the child. In the commonest relation of the child to the mother — that where the head is downwards, the attitude one of flexion, and the back to the mother's left — the heart is best heard about the middle of a straight line joining the navel to the anterior superior spine of the ilium. The different situation of the spot under different circumstances will be mentioned in the chapters on Labour. The quantity of liquor amnii has much influence in deciding whether the iieart sound is audible or not. If the fcEtus does not touch the uterine wall with the anterior shoulder or some part of the bod\- not far removed from the heart, the sound will probably not be heard at all, for a very thin layer t)f fluid is enough to pre\ ent the \ibrations from reaching the stethoscope. This sound is an absolute proof of the presence of a living foetus, but its absence at any moment is no proof that there is no foetus, or that the child is dead. Many pregnancies ha\ e been watched through, and frequent attempts made to hear the heart without success, and vet the woman has been Diagnosis of Pregnancy ^t^ delivered of a livirii^- child in the end. At the same time, in any pregnancy, if after a large number of attempts the sound has not been heard, it is, in the absence of other proof that the child is ali\c, a fair assum]nion that the child is \ery likely dead. Uinlnlical Souffle. — This is another sound produced b\- the foetus. It is s\nchronous with the fcetal heart, and is heard over the cord. It is without much doubt produced in the cord by compression, either by the stethoscope, or by some position of the cord in relation to the child which leads to stretching. .The cord may not infrequenth' be felt if it lies over the back of the child, and may e\-en be rolled under the finger, and in such a case this sound can be heard. The sound is of a blowing" character. It is not of very great value as a sign of pregnancy, since if it can be heard there is other e\"idence necessarily present of a more unmistakable kind. It occurs in about ten per cent, of all cases. There are other sounds heard over the abdomen of a pregnant woman — namel}-, the mo\ements of flatus in the intestines, which may, by the beginner, be mistaken for foetal heart sounds ; and the sounds of the aorta, faintly transmitted through the uterus to the abdominal wall, though it is in most cases the aortic impulse that is felt rather than the sounds that are heard. It is said that the pulse in the epigastric arteries may sometimes be heard, but this must be very seldom. The abo\e sounds are quite independent of pregnancy, though they are heard in the abdomen of a pregnant woman. A foetal sound, that of the limbs striking the uterine wall, is pretty frequently heard. It is a faint tap, with which there may probably be felt an impulse through the uterine wall. This is, of course, characteristic of pregnancy. Under certain circumstances there exist sounds having a pathological origin. The vesicular respiratory murmur has been heard in cases of |:)neumonia, and is conducted by the uterine wall to the surface from the diaphragm and ribs. Friction sounds between the uterine surface and apposed peritoneal surfaces are described, and must be caused by local peritonitis. Also when air finds its way into the uterus or is developed there by decomposition, it may be heard to move about if the uterus contracts (see p. 502). 4. Vaginal cxavnnation. — On inspection the colouration and venous congestion already alluded to w ill be noted at the proper period, and the vaginal walls may be seen to be in folds, protruding slightly in man\- cases, e\en in primigra\idae, from the \aginal orifice. On digital e.xploration this laxity is very obvious after the sixth month, and the amount of mucus is found to be considerably increased. The amount of softening and apparent shortening of the cervix in primi- gra\idce and parous women respecti\eh- will be found according to the date (see p. 45). The amount of enlargement of the uterus belonging to the period of pregnancy will be readily made out bimanually, and bimanual examination will show the presence of contractions before it is possible to observe these by abdominal examination alone. The globular shape of the pregnant uterus in the early months must be 64 Pregnancy remembered, and the characteristic way in which the forniccs are occupied owing to this change of shape. The uterus is very mobile considering its size, up to the time at which it fills the pelvis completely, and by this mobility it is distinguished from many other enlargements of the uterus or of the organs in its immediate neighbourhood. The laxity of the lower uterine wall is as a rule well marked in the Cjuite early months. Ballottement. — A kind of ballottement was spoken of when the abdominal signs were being enumerated, but a more complete example of this can be obtained per vaginam. This sign is produced when the foetus is tossed up towards the fundus by a movement of the finger in the vagina, and is then felt to fall back on to the anterior uterine and vaginal wall by the same finger. The woman should lie in a semi-recumbent attitude, as then the uterus will be nearly vertical. The finger is introduced to just in front of the cervix, where there should be something solid felt, the child's head. A smart push upwards is given to this surface, and the finger allowed to remain in the same position. In one or two, or perhaps three, seconds after the impulse, a sensation of something lightly falling on the finger will be felt, or if the fall cannot be actually felt, it \\\\\ be found that the body which retreated before the finger is again l)ack in the same place. In the case of podalic lie this sign is obscure. The head can be distinctly felt bimanually also. The date of the first appearance of this sign is dependent on the size of the child compared with the size of the uterine cavity, and also on the weight of the foetus. The foetus is too light and too small to give an unmistakable tap on the finger before the fourth month, and it fills the uterine cavity too completely after the seventh month to be displaced far enough. So that the sign is obtainable only from the fourth to the seventh month. Before the foetal heart can be heard this evidence is most valuable, since it is absolute proof of pregnancy ; for the fact of a solid body of the size of the fcetus lying in a fluid-containing cavity of the size of the uterus is unique. The fallacies which have been mentioned as possible, of a large calculus in a full bladder, or of an anteverted uterus which can be displaced by the finger, are not likely to be misleading. The disappearance of this sign after the seventh month is of no consequence, as more certain signs, such as the foetal heart, are then to be readily made out. Method of obtainiiis liallottement. Diagnosis of Date of Pregnancy 65 CHAPTER VII DIAGNOSIS OF PREGNANCY — COJttinued Diagnosis of the Date of Pregnancy and probable Date of Deliyery It is impossible to fix the date of fertilisation of an ovum, though the date of fruitful coitus may, in a certain number of cases where there is no doubt that only a single act of copulation has occurred, be determined. The reason for this uncertainty is obvious when it is remembered that the moment of rupture of a Graafian follicle cannot be ascertained ; that the place at which fertilisation takes place has not as yet been accurately determined ; that the rate at which the ovum travels down the tube is not known, nor the rate at which the spermatozoa penetrate the internal genital passages. The spermatozoa may remain in the uterus or tubes of a woman for many days or even weeks in an active condition after insemination, and their contact and fusion with the ovum is possible at any moment after they have obtained entrance. In conseciuence of the wide margin of error thus existing, the calculation of the duration of pregnancy can only be approximate. Many observers have tried to find an average period, basing this on the time of delivery after a single act of intercourse. Duncan makes the a\erage 275 days, Ahlfeld 271, Hecker 273-5, ^^^'^ 276, Lowenhardt 272, and Stadtfeldt 272 also. Since it is not unlikely that the ovum escaping at the last menstruation is the one fertilised (though this is almost certainly not invariably the case), and as labour probably most often, if not always, occurs normally at what would have been a menstrual act, the best and most practicable way to determine the date of delivery is to add ten menstrual intervals of one lunar month (twenty-eight days) each — that is, 280 days — to the date of the first day of the last-occurring menstruation. It can onl)' be said that the pregnancy is more likely to terminate on the day thus calculated than on the one before or after, and on these rather than on days more remote in a backward or forward direction. The method usually employed is to add nine calendar months to (or, what is the same, subtract three calendar months from) the date of the first day of the last menstruation, and to the date thus found to add se\en days, so as to make up the 280. Thus if the last menstruation began on April 5, the day nine calendar months ahead would be January 5, and if seven days be added, the probable tlute of delivery will be January 12. In leap year, if February be one of the months included, the numbers are al)out equalised, but if the year is not leap year, two days must be added for the shortness of February. This calculation will be seen to be a rough one, but it is quite as accurate as the most elaborate, for emotions or other disturbing causes may pre- F 66 Pregnancy cipitate labour by several days, and in few women is the menstrual interval exactly the same for ten months consecutively. Further, cases have no doubt occurred where the foetus was retained for some days, or possibly even weeks, beyond the 280 da)'s. This calculation holds good supposing that the last menstruation is normal, and that it coincides with the beginning of pregnancy. But con- ception may take place during a period of amenorrhcca, or menstruation may occur during pregnancy (see p. 335), or haemorrhages, which arc mistaken for menstruation, may arise after impregnation, so that the histor)' of this function may be in some cases valueless as a basis on which to calculate. Another symptom on which women often rely is that of quickening. Its value in this connection has been already discussed (p. 59). There remain two other ways which are very much more reliable — namely, the determination (1) of the size of the uterus, a method available through- out pregnancy ; and (2) of the length of the fcetal ovoid during the later months of pregnancy. The calculation of how far pregnancy is advanced can be made from these data, and the date of delivery approximately determined. Size of Uterus. — This can be judged bimanually, and to a moderately experienced observer will give a very close approximation to the truth in the early months before the uterus has risen above the level of the brim. After this has happened, the height of the fundus can be defined per abdomen. Instead of referring the height to the navel and the lower borders of the ribs, both of w-hich points are more or less variable, it is better to measure the height of the fundus above the pubes with a pair of callipers if these instruments are handy. The following table is gi\en by Sutugin and (ialabin : Weeks . . .16 Inches above pubes 4 Care must be taken in using this method that the child is in a cephalic lie, and that the head is in the pelvis to the normal depth (see Contracted Pelvis, p. 427). The urine should be passed or drawn off previous to the measurements being made. The presence of a tumour raising the uterus or displacing it, or the existence of hydramnios or of twins, will of course make this method useless. Length of Fa'tal Ovoid. — This gives the most reliable datum. The foetus is first to be made out to be in its normal attitude of flexion. One arm of a pair of callipers is introduced into the vagina, and the end placed on the lowest point of the child's head felt through the anterior vaginal wall. The other end is 18 20 22 24 26 28 30 y- 34 36 38 40 47 5-4 6 6-6 Tl 7-S S-3 87 9 9-3 9-6 10 Fig. 73. — Callipers in position. Diagnosis of l^'arity or Nulliparity adjusted to the highest point of the breech on the abdominal wall (fi< riie method is equally applicable if the lie be a podalic one. The following numbers will then Ije a guide : Weeks . . . 26 28 30 32 34 36 38 40 Length in inches . 7-2 7-6 7-9 8-3 8-8 9-2 9-5 97 67 Diagnosis of Parity or Nulliparity The determination whether a woman has previously borne children or not rests on the fact that the foetus produces by its size certain mechanical effects on the walls of the abdomen and of the canal through which it passes in the act of birth. If the ovaim of a woman who has been delivered has not been large enough to cause these mechanical changes, it is impossible to be certain as to her parity ; that is to say, it would be impossible in most cases to say for certain that a woman was parous if she had not gone longer in pregnancy than the fifth month or thereabouts. The signs consist in : changes in the hymen, vagina, and perinteum ; changes in the cervix ; abdominal strife. Cbangres in the Hymen, Vag'ina, and Perinaeum.^The base of the JiyDien is usually accepted as the lower limit of the vagina, and it is in this part of the membrane that the most characteristic alterations occur. Fig. 74. Hymen of virgin. Fig. 75. — Hymen after connection. Fig. 76. — Hymen after parturition. The membrane itself is usually lacerated at the first intercourse, but this is by no means invariably the case, and a quite appreciable proportion of women who ha\e arri\-ed at the full term of pregnancy are found to have an entire hymen. ^ The tears found under these circumstances merely affect the membrane itself, and do not involve the base at all. The flaps formed b\' the tearing can be arranged in their proper position, and the membrane thus reconstructed and shown to be complete, though torn (fig. 75). After parturition the base of the membrane is found to be torn to a varying depth, and the portions of the membrane remaining are seen to be separated by considerable intervals at their attachments, the tissue covering tlicse intervals being cicatricial. The fragments themselves are of irregular ' Budin has found an intact hymen 13 times proportion than has been found by the writer. 75 priniipara-, but this is a far higher 68 Pregnancy shape and are also more or less cicatrised, and constitute the carunciihc niyrtifprmcs (fig. 76). The vnf^nal walls are lax, their rtigte ]ia\e almost disappeared, and cicatrices may be present in their substance. Even after delivery of a full-time child, however, cases are occasionally seen where the hymen remains untorn and the vagina has its rugje almost as marked as ever. The perincEinn is nearly always found to be torn to the e.xtent of the fourchette, though this is not nearly so constant as the laceration of the vaginal orifice. The result of the tear through the fourchette is that the fossa navicularis is obliterated, and there is a more or less plane surface leading out from the vagina on to the perinaeum (fig. 78). Hyrnen: Fig. 77. — Pelvic floor, nulliparous. Vac). orij. Fig. 78.— Pelvic floor, parous. (The whole pelvic floor is usually lower than this. The laceration of the perinaeum is sometimes more extensive than this, and very frequently its anterior edge is constituted by cicatricial tissue. Chang-es in the Cervix. — This is almost inevitably torn in the passage of the head, and its oval external os is converted into a transverse slit, which varies in extent from a slight widening of the nulliparous os to a gaping mouth reaching from one vaginal fornix to the other. In \-ery rare cases the cervix is not torn, and then it cannot be distinguished from that of a woman who has not borne a child. The split is most commonly unilateral, or at all events is more marked on one side than on the other. The side affected in a very large majority of cases is the left. The prevalence of tears on the left side is usually ascribed to the frequency of the first or left occipito-anterior position of the head. As the occiput descends first into the stretched ring of the external os, that side against which it lies will be first torn, for the opposite pole of the head, the frontal, is stretching the canal of the cervix at a somewhat higher level than the extreme margin, and thus does not tear the tissues so readily, for they are thicker, and there is no thinned edge in which the tear can begin (fig. 1 27). This is a probable explanation, but is not true of all cases, as the author has often found a split in the left side only of the cervix when the head has descended in the second position ; and, conversely, a split in the right side only after a labour with the occiput to the left. If the split is an extensive one, reaching to or nearly to the vagina on each side, the two lips may be found to be everted, in a state of ectropion. This deformity is due partly to glandular overgrowth on the inner aspect of Di^erciitial Diagnosis of Pregnancy 69 the lips owing' to chronic cervical catarrh, and partly to the action of the muscular fibres on the outer aspect of the lips (see p. 42). The cervix is also sometimes torn in a radial manner, some of the intervals between the segments being deep and some shallow ; the lobes thus produced sometimes hypertrophy, and con\'ert the \aginal portion into a somewhat irregular mass. Abdominal Striae. — These are almost invariably found to follow a pregnancy which has advanced to the later months. They may be pro- duced, however, by any condition which pretty rapidly stretches the abdo- minal walls, such as quickly developing ascites or rapidly gro\\'ing ovarian tumours ; and, as has been mentioned, they are found on the breasts in cases where these organs have developed at puberty with some rapidity, and over the hips when these have widened at the same epoch. The difference in appearance between old and new stride has been alluded to. Attention may be directed to the general condition of laxity of the abdominal walls and the mammae in women who have borne and nursed a child, though these changes are by no means constant. Some increase in the size and weight of the uterus on the vaginal and bimanual examination can nearly always be made out by an experienced observer. Differential Diagnosis The symptoms and signs of pregnancy have been fully discussed and the fallacies to which they are liable. It will have been learned that the symptoms are only suggestive, and by themselves are not enough to form an opinion upon. Taken together, however, especially where there are no psychical or social circumstances likely to distort the view presented to the medical man, they are of considerable value. The absolute signs of pregnancy need not, of course, be discussed. If the pregnancy is a normal one, there should not be much doubt as to the diagnosis by the time the uterus has reached the level of the navel ; but before this, and particularly while the uterus is still a pelvic organ, mistakes are very frequently made. The subject may be divided into — {a) The diagnosis of pregnancy in the first three months, and {b) its diagnosis during" the last six months. In this latter group pregnancy may have to be distinguished from a general abdominal enlargement, or from an intra-abdominal mass which resembles the pregnant uterus. The rate of growth of the pregnant organ must Idc remembered always, and any tumour which increases at the same speed is more likely to be the gravid uterus than anything else. If there is no urgency about the case, this sign can always be obtained by a few weeks' waiting. First three montbs. — The symptoms of pregnane)- may be marked ; or may be absent or modified in various ways. Enlargements of the Uterus. — Fibro-myomata. These may occasionally •JO Preg7iancy resemble the gravid uterus, in their shape and sometimes in their consistency. There is sometimes a souffle, and there is often softening of the cervix (p. 46). It is well to mention here that there are occasionally lumps found on examination of the pregnant uterus, which may be mistaken for fibroids in its walls, but which are only temporary local contractions. These may lead to mistakes if the)- are not remembered. The distinction lies in the usually irregular shape of the uterus affected with fibroids ; the surface irregularities ; the absence of contractions in anything like the degree natural to the pregnant organ ; and in the rate of enlargement of a uterus, which is very much slower than in pregnancy. If the ordinary symptoms of fibroids, menorrhagia and discharge, are present, they will be of much value. 2. Ha:mato-metra, due to retained menses. The resemlDlance lies in the amenorrhoea, accompanied with an abdominal tumour of the shape of the enlarged uterus. The distinction lies in the fact that the patient has ne\er menstruated, although she may be well o\er twenty years old, and has no general ill- ness to account for the amenorrhoea ; that the tumour increases ver\- slowly, and that there are, as a rule, at monthly intervals, signs and symptoms that menstruation is going on, although there is no external show. 3. Subinvolution. — The uterus is large, and the woman ma\- ha\e amenorrhoea from ansemia, or she may be nursing. The uterus does not increase in size ; its texture is not that of the pregnant uterus, but inelastic. Its shape is not at all globular, but merely that of the unimpregnated uterus enlarged ; and there are no contractions to be felt under any circumstances. Tiniiours outside the Uterus. — Among the tumours which may be con- fused with pregnancy are small ovarian cysts ; distended tubes, especially if they are adherent to the uterus and move with the cervix ; ectopic gestations ; encysted peritonitis. It must not be forgotten that intra-uterine pregnancy may co-exist with ectopic gestation and with ovarian tumours, and that in the case of intra-uterine pregnancy, the uterus may be retro\erted or flexed or both, and appear as a tumour in the pourii of Douglas. Kast six months. — During this period the diagnosis will be easier, as there will be some of the absolute signs of pregnancy to be found. The con- ditions from which pregnancy may have to be distinguished include fibroids ; ovarian tumours ; distension of the bladder ; and possibly renal, splenic, or other masses. If contractions are felt in any tumour, it is quite certain that it is the jjregnant uterus. Collections of fat in the omentum and abdominal wall have sometimes given rise to mistakes, and flatus and masses of fa.>ces might do so. .Such mistakes are most likely to happen towards the end of menstrual life, and especially in women who have had no children, and are anxiously noting every ap- pearance which might suggest pregnancy. If, at the same time, menstrua- tion is omitted occasionally, as happens frequently about the menopause, their suspicions are strengthened. About this time, the phenomena known as Phantom Tumours are not uncommonly found in women who are watching Diagnosis of Life or Death of Child Ji with such anxiety. 'l"hesc consist of ineguhir muscular contractions in the abdominal walls, or collections of gas in sections of intestine, and either of these conditions may give the impression of a definite tumour. Little or no difiRculty is, however, likely to arise in connection with a phantom tumour ; for on applying the usual tests of percussion, auscultation, and so on, its nature will become evident ; and, in any case, an examination under an an;i;sthetic will clear up the doubt. Spi/rioi/s Pregnancy. Psetido-cyesis. — It is occasionall)' found that women imagine themselves pregnant when they are not so ; and in some cases certain of the symptoms characteristic of pregnancy are present, and may be accompanied by physical conditions which appear on a superficial examina- tion to confirm this idea. Such a state of things is most common about the time of menopause, especially in childless women who are anxious to become mothers, but the mistake is not confined to such women. It is rather a delusion than a mistake. A careful examination, under an anaesthetic if necessary, will at once make the matter clear ; and it may be easy, or the reverse, to persuade a patient she is not pregnant. Women have been known to persist in this idea for several months beyond the time at which, according to their own calculations, delivery should have occurred, and in a few cases have gone through a spurious labour.^ In one class of case there are no symptoms present, except those of imaginary foetal movements, due, of course, to flatus ; in another class, as pointed out by Matthews Duncan, vomiting, mammary changes, and other symptoms may be present. In neither class do supposed foetal movements fail to appear. Diagnosis of Life or Death of the Child In a case in which the fact of pregnancy has been established, the ques- tion may arise as to whether the child is alive or dead. The woman may suspect the death of the child on account of certain feelings of weight or coldness over the pubic region, as these sensations are considered b)' those well informed to be signs of death of the o^■um ; or she may cease to feel the movements of the foetus ; or her breasts may become flabb)'. It is not always eas)' to settle that the child is dead. If it is felt to move by the medical man, or he hears the foetal heart, he can give a certain negative answer ; but his not hearing the foetal heart at one or two examina- tions, nor feeling movements, are not sufficient grounds upon which to make a diagnosis. The matter can only, as a rule, be settled after se\eral examinations ha\e been made, and after some weeks have elapsed. If the heart and move- ments of the child cannot be perceived on several occasions at intervals of a week or so, if the uterus ceases to grow and the breasts become flabby, and the congestion of the lower end of the vagina, though this is a sign of no great value, diminishes or disappears, it may fairly be inferred that the child 1 A case of spurious lal)our is well described in tlie Ohstctrical Transactions, vol. x.wii. p. 326, by H. Roxburgh Fuller, M.A., M.B. In the discussions on this paper a case was mentioned by Galabin. 72 Pregnmicy is dead. If decomposing parts of the child come a\\a\- from the uterus, or are felt through the cervix, there is, of course, no doubt. (For the diagnosis of molar pregnancy, see p. 248.) Schoiic for the routine Exainitiniton of Cases 7i.'here Pregnancy is supposed to exist History. — Individual type of menstruation. Whether the patient menstruated irregpalarly before cessation ; whether in previous pregnancies she menstruated once or more after impregnation. Any peculiarities in previous pregnancies or labours. Symptoms. — Date of occurrence of vomiting ; quickening. Pbyslcal Sigrns. — i. .Size and shape oi abdomen ; Stria:. 2. Height of fundus above pubes ; shape and position of tumour ; surface and consis- tence of tumour; contractions in tumour; foetal parts, and lie, attitude and position of foetus in utero if they can be made out ; external ballottemcnt ; percussion ; tlirill (palpable uterine bruit). Breasts, size ; areolae ; nipples ; secondary areolae ; secretion. Skin generally ; pigmentation. 3. Auscultation. — Bruits ; foetal heart ; intestinal and other sounds. 4. Cervix. — Position in pelvis ; relation of a.xis to that of pelvis ; mobility ; softening ; lacerations ; erosions ; patency. 5. Vaginal lualls ; — secretion. 6. Fornices ; — resistance, tumours ; lateral bulging of uterus. 7. Body of Uterus, e.-!i2cmms.(\. bimanually ; — mobility; size; connection of tumour felt per abdomen with cervix ; contractions ; regularity of shape ; position in pelvis and abdomen (versions, flexions, lateral displacements, rotations) ; /(;«r/; of Douglas, resis- tance ; contents. 8. Inspection of Vulva ; — blueness or discolouration ; varicose veins ; discharge. 9. Perinaeum ; fourchette ; hymen. 10. Bladder (catheter if necessary). CHAPTER \'I11 MULTIPLE PREGN.WCV Under this heading cases of multiple pregnancy /;; utero only will be considered. Two or even more ova may develop simultaneously, one or perhaps two in the uterus, and the other in the Fallopian tube ; but ectopic pregnancies, as those occurring outside the cavity of the uterus arc named, will be treated of elsewhere. The occurrence of twins or triplets is nothing abnormal, and must be looked upon as merely a variation. Prequency. — Multiple pregnancy occurs mostly among races which are more than usually fertile. For instance, in Ireland twins are found to be born once in sixty labours, whereas in France the average is once in eighty or thereabouts. Taking all statistics together, triplets appear once in six or seven thousand, and the birth of four or more children is an event of great rarity. Multiple Pregnancy 7Z Heredity seems to be a powerful factor in the causation of multiple pregnancy, and shows itself on the mother's side more especially. More twins are born at a first pregnancy than at any other, especially in elderly primiparae ; but in after-occurring pregnancies the tendency increases with the number of oL.s ^'■^:::;^^^^^^^?^::r^~^ y'^s. pregnancies. Mode of Origin. — Twins may arise in three ways ; they may be de\eloped from — 1. Two ova, from the same or different Graafian vesicles and from the same or opposite ovaries. 2. One ovum with two )'elks (see figs. 13 and 14, p. 8). 3. One yelk with two embryoes. The accompanying diagrams (figs. 79, 80, Si) show how the membranes and placenta; arc arranged under each of these methods. As the pregnancy advances, the decidua and the chorion between the embryoes in many cases fuse or are partially absorbed ; thus, where there were originally two separate decidual sacs, these become converted into one, and the same result may occur in the case of the chorion. The amnionic partition is probably much less frequently absorbed : this, however, must occasionally happen, though it is difficult of proof. The fertilisation of the two ova or embryonic cells does not necessarily take place at the same coitus, and twins have been born, one of which was ^■rr Fig. 79. — Twins: i. d s, decidua sero- tina ; rfz', decidua vera ; dr, decidua refle.xa ; «;«, amnion; at, amnionic cavity. The heavy black area = chorion. d^. Fig. 81. — Twins : 3. ds, decidua serotina : dv, decidua vera ; dr, decidua reflexa ; a»i, amnion ; a c, amnionic cavity. The heavy black area = chorion. black and the other mulatto, and so on. This non-simultaneous _/tV-////jra- /I'on is called superfecundation. Here the two ova develop simultaneously, and unless there have been two fathers of differing colour, superfecundation cannot be proved. In the condition known as superfcctation, where the foetuses arc not of the same 74 Pregnane)' degree of development, it is sometimes more easy to show that the fertihsa- tion of one ovum must have occurred before that of the other (see p. 76). Triplets seem to be developed from two o\a, one of which was double- yelked. Cbaracters of Individual Cblldren. — The case of twins only is con- sidered ; but the same laws hold good in the case of larger numbers. Sex. — There is not much departure from the ordinary relative numbers of each sex born ; it is found according to some statistics that the children are oftener of the same sex than of different sexes, and according to others that they are oftener of different sexes.' Double monsters are always of the same sex. Development. — -Twins are almost always smaller when born than single children, and this is to a great extent because labour is so often premature ; though it is true e\en when the pregnancy goes to term. In triplets this under-development is still more common, and it seldom happens that all three children survive. Twins are unequally developed as a rule. This may be due to the more favourable implantation of the placenta of one of the children or to original superiority. If one foetus is much stronger than the other and grows faster, the weaker one is sometimes compressed to such an extent that it finally dies, and becomes converted into a Fcetiis papyraceiis, being flattened out between the growing child and the uterine wall, and dried up into a mummy. Putrefaction does not occur, for no air is admitted. If one embryo dies early from some damage to the ovum or decidua sero- tina (see p. 24§), the ovum to which it belongs may be converted into a mole. Such a dead ovum or a foetus papyraceus may by acting as a foreign body set uterine contractions going, and then it alone, if the membranes of the two o\a are separate, may be expelled, the healthy ovum being retained ; or both foetuses may be aborted (see remarks on Double Uterus). Acardiac fivtiis. — If, in cases where the vessels of the two placentjc inter- communicate, or where there is a common placenta, one foetus is much stronger than the other, the heart of the stronger child raises the blood pressure higher in its own vessels than that found in the vessels of the weaker child. In consequence the blood is forced towards the heart of the weaker one through the incommunicating vessels. After a time the heart of the weaker child, being over-distended by this means, gives out, and its muscle atrophies. The heart of the stronger child then carries on the circulation 1 Galabin gi\es as the result of an examination of the statistics of the Guy's Lying-in Charity, that in 38 per cent, both were males, in 34 per cent, the sexes were different, and in 28 per cent, both were females. Pl^xA Fig. 82. — Scheme of arterial circulation in the cords and placenta in the formation of an acardiac foitus. Fl, placenta ; S, stronger foetus: \Vy.A, weaker and acardiac fcetus. iMiiltiplc Pregnancy. Donble U terns 75 of both fcetuscs (fig. 82). Naturally the weak fcjetus gets a very imperfect l)loocl-suppl)', and those parts which are supplied b\' the vessel nearest the point of entrance of the umbilical arteries into its body (the current in the umbilical arteries being here reversed) ha\e the best supply. So that the lower limbs, supplied by the iliac arteries, into which the reversed current is first poured, are the best de\eloped part of the weak child's body, the head and upper jjart of the body being ^"ery im- perfectly nourished. This state of affairs exists in varying degrees in different cases, and varying de- grees of deformity are produced, for a description of which the reader must consult works on teratology (fig. 83). The imperfectly formed foetus \ is named a Foetus acardiacus. Symptoms. Diagnosis. — The only syinpio/ns noticed are that the abdomen is larger than usual at a given date of pregnancy, and that pressure symptoms arise sooner and are more se\ere than in single pregnancy. Labour is, as has been said, often premature ^ig. Ss.-Acardiac fetus. (St. George's Hospital ' i^ Museum.; (in about 20 to 30 per cent.). The diagnosis of twin pregnancy is made by palpation and auscultation. Two heads may be recognised, and this will be usually the easiest way, or the w hole outlines of two bodies maj' be felt. The two heads may both be in the pelvis, or one may be in the pelvis and the other at the fundus. Tw^o foetal hearts, not beating synchronously, may be heard. The t\\ o hearts may be made out by two observers listening at different points of the uterus, each stethoscope being over a different child. One obser\er lays his hand down and the other taps upon it in time with the pulsations of the iicart to which he is listening, and the first named notices whether the beats coincide or not with those of his side. Or a double binaural stethoscope may be used, one chest-piece being applied to one part of the uterus and the other to another part. The two conditions most likely to be mistaken for twins are H\dramnios (sec p. 257) and a large single foetus. Double Uterus. — Twins or triplets may be developed in the two halves of a double uterus (see p. 294). In such cases it is not unlikch' that one child may be born before the other or others, this interval occasionally extending to several weeks. In such circumstances the last-born child will be of larger size and fuller development than the earlier one. J 6 Pregnancy Superfoetation. — This has been defined in mentioning superfecundation (p. T^. In cases where the simultaneous birth of two children of different degrees of development, or the birth of two children of the same degree of development at different times, cannot be accounted for by one foetus having obtained all the nutriment, it is probably explained by the pre- sence of a double uterus. Spiegelberg says that the possibility of super- foetation rests on an exploded hypothesis, namely that of fertilisation of a second ovum after pregnancy has already commenced. It has been supposed to be possible because, as will be remembered, up to the fourth month of pregnancy there is a space between the decidua vera and decidua reflexa, through which spermatozoa miglit pass to the Fallopian tube. A case in support of the hypothesis is recorded ; namely, one where a five-months' ectopic foetus has been found with a three-months' intra- uterine pregnancy. Here the worse-placed foetus is the better developed. This case, however, would only prove that ovulation during pregnancy, a possibility denied by most, may occur under pathological conditions. The question is not as yet settled. CHAPTER IX HYGIENE OF PREGNANCY Since pregnancy is a purely physiological state, there would seem to be little to be said on this head. But as few women are without some weak point in their constitution, care should be taken to keep every pregnant woman up to as high a pitch of health as possible, so as to enable her to bear the strain of parturition and lactation. Serious deviations from health will be considered in the chapters on the Pathology of Pregnancy. The general rules to be observed are as follows : — Exercise. — This should be continued during the later months of pregnancy, though anything like over-fatigue should be avoided, and exertion in the way of lifting weights or making prolonged efforts must be forbidden. Although the woman may prefer not to show herself much in public, a short walk every day must be obtained, unless there is any contra- indication. The various functions of the bod)- must be kept in order, especially the action of the botue/s, which is the one most liable to cause trouble. In most cases a gentle laxative, where the usual tendency to constipation exists, is enough, and strong purgatives must always be avoided. Tight clothing of any kind is most undesirable, and this especially refers to corsets. Some women wear these as tight as possible so as to conceal the enlarg^ement of the abdomen, but the movements of the thorax are then interfered with, and the venous congestion found in all pregnant women to some degree is much Hygiene of Pregnancy 77 increased. This may cause damage to the pelvic organs, and to the tissues of the decidua and ovum. Tlie nipples, especiall)- in primigravida^, must be attended to during the last months of pregnancy. Pressure on them should be avoided, and they ma)' with great advantage have their epithelium rendered tougher by bathing them with a weak alcoholic solution, such as eau-de-Cologne and water, daily. They should be kept scrupulously clean, and the dried secretion which collects on their summits softened and wiped away, as there is a great likelihood of the epithelium beneath these crusts becoming atrophied, and a sore will then readily form if they are at all hardly used by the child during the first days after its birth, before the flow of milk is fully established. Excitement in women who are ready to abort on small provocation is to be especially shunned. If a woman becomes pregnant while she is nursing she should wean her child, since the irritation of the nipples may lead to sufficiently energetic uterine contractions to start labour. Coitus must be indulged in to a very restricted degree, especially in the later months. It is well for the medical man to examine the woman's abdomen at least once towards the end of pregnancy, as he can thus detect any abnormality in lie or position, and, if necessary, correct this by external manipulation before labour begins. It will, of course, be borne in mind that the foetus is constantly changing its lie during the middle months, and not infrequently does so even after the seventh month. In the last week or two the lie and attitude remain constant as a rule, and it is then that observations are of the most use. 78 LABOUR Before considering CHAPTER X DEFINITION OF LABOUR ' Labour is the process by which the ovum and decidua arc detached and expelled from the body of the mother. Three factors combine in this process — namely, A. The expelling force ; B. The passage through which expulsion is effected ; C. The body to be expelled. The mechanism of labour consists in the results of mutual reactions of A, B, and C. these factors and their relations to one another in detail, the following propositions may be stated ; they briefly epitomise the more important processes of labour : 1. The expelling force is made up of several components ; the resultant of these at any given moment, however, must act in the direction of the axis of the passage. 2. The passage through which expulsion pro- ceeds is a short irregular tube with a bent axis (see fig. 87). The walls of this tube \-ary in rigidity at different cross-sections, and the shape of its cross-section varies at different points along its length m a definite manner (see figs. 91, 92, 93). 3. The body to be expelled (considering^ here the foetus alone) consists of two ovoids, as shown in the diagram — the trunk, and the head, con- nected by a joint which allows of almost ' universal ' movement. Of these two o\oids the former is very plastic, the latter comparati\eIy rigid. On this account the relations of the head to the passage are more important than those of the trunk to the passage. 4. The foetus can only pass through the tube with a squeeze, fitting it very closely under the most favourable condition ; that is, when the longest axis ' When the term 'labour' is used without any qualifying adjective, it is understood that ' labour ' at or near full time is meant. Fig. 84. — The two ovoids of the foetus. Partiirioit Canal 79 of cither of the two ovoids of the foetus coincide as nearly as possible with the axis of that part of the tube which either ovoid is occupying. 5. The long axes of the two ovoids respec- tively are almost at right angles to one another when unrestrained. This holds g'ood whether the foetus be looked at in elevation (fig. 84) or in plan (fig. 85). 6. As these ovoids pass through the tube they each tend to place their longest axes where there is most room for them. The axes seen on looking at the fcetus in elevation tend to coincide with the axis of the tube, and the longest axes as seen in plan (these are nearly in the plane of that cross-section of the tube in which they happen to lie) tend to move into the longest diameter of that cross- F'g- s?.— Fcetus in plan. section. 7. Bearing the irregularity of the tube in mind, it will be seen that the position of some of the axes of the ovoids with reference to the walls of the tube must be constantly changing during the progress of the former through the tube. Now these movements constitute the mechanism of labour. The expulsion of the placenta and membranes is really part of the mechanism of labour. It is, however, a comparatively simple matter. Anatomy of A, B, C A. Expelling' Force. — The anatomy of the main expelling agent, the uterus, has already been considered under Pregnancy, together with those modifications in the vagina and round and broad ligaments which occur in the gravid woman. The auxiliary muscles of labour, those which act by diminishing the size of the abdominal cavity — namely, the diaphragm and the muscles of the abdominal wall — need not be described here in detail as regards their anatomy ; their action will be treated of later. The muscles and fasciae of the pelvic floor act in two ways ; at one period they form part of the pelvic resistances, and at a later moment they act as components of the expelling force. They will immediately be described as forming part of the parturient passage. B. The passage through which expulsion is effected is formed of the bones and soft parts of the true pelvis. General Description of the Parturient Canal The maternal passages in the parturient condition have already been alluded to as forming a short tube. This tube has unequal sides ; posteriorly its length corresponds to that of the \-ertical measurement of the sacrum plus the length of the coccyx and the stretched pelvic floor,' while anteriorly the tube is only as long as the symphysis is deep. The upper part of this tube is bony and therefore rigid. The lower part ' For definition and description of the pelvic t^oor see p. 86. 8o Labour is yielding as to its posterior wall, owing to this being made up of muscle and other soft structures. The transition between these two parts does not occur at a definite line, but extends over a short length where there is an external sheath of bone and an internal one of muscle and fascia (fig. 86). The upper entrance of the tube corresponds with what is known as the brim of the pelvis, to be presently described. Below this, as far as the origin of the levator ani muscle, the tube is rigid. Below this again, the lateral extensibility is limited by the tubera ischiorum which form the lowest continuation of the bony canal, and provide the bony outer sheath spoken of. Except for this transition space the tube below the ' white line ' above described is distensible posteriorly and laterally to any required extent, both on account of its elasticity and its capability of being torn. The coccyx may Fig. 86. — Diagram of parturient canal, coronal section. B, brim ; O, outlet, corresponding to the ' white line ; ' /'i^, pelvic floor. be neglected as a bone affecting parturition as long as it is not rendered immovable by anchylosis of its joint ; it forms merely an ossified intersection between the posterior parts of the levatores ani. Axis of the Tube (a, fig. 87). — The axis of the tube has been spoken of as a bent one. In defining the term 'axis,' as applied to the female pelvis, it is of no use attempting to do so in a way which will satisfy mathematical requirements, for the walls of the canal are so irregular that they by no means enclose a cylinder. The most practical definition of the axis in this case is as a line describing the path of the centre of a spheroidal body, such as the foetal head, in its passage through the genital canal, it being under- stood that such spheroidal body fits fairly tightly the tube at every part. This line will join the centres of a series of planes, each of which lies within a line marking the girdle of contact between the body and the tube at any stage of the formei-'s progress. From the brim down to the ' white line ' of the pelvic fascia the path of Bony Part of Parturient Canal 8i such a body would be nearly a straight line, but here the direction would change to one lying at about a right angle to the former one, since the anterior wall terminates at this level, and the forward pressure of the pelvic floor on such a body as the foetal head is then unopposed. ^ ^' ^^^ ( \ q \ ^^ A The shape of the walls of the tube, both bony and elastic, which bring about the particular character of its axis is seen in the dia- gram (fig. 87). Bony part of the Canal. This consists of the true pel- vis only, as the part above the brim has nothing to do with labour. No description will be given here of the de- tailed anatomy of the several bones, but those parts alone will be mentioned which have a direct bearing on the present subject. The bi-iiii of the pelvis, already alluded to as the upper entrance of the tube, corresponds to a line which, starting from the promontory of the sacrum, is continued forwards by the upper and anterior border of the ala of the sacrum and the ileo-pectineal line, and ends at the upper border of the symphysis by joining a corresponding line on the opposite side. Fig. S7. — A A, axis of parturient canal ; B, brim ; O, out- let (tip of sacrum to lower edge of symphysis) ; the coccyx is shaded somewhat lighter ; P', vulvar orifice expanded. Fig. -Brim of pelvis. .—Outlet. The brim has an elliptoid shape, as is seen in fig. 88 ; its antero-posterior flattening being accentuated posteriorly by a very slight con\exity forwards caused by the projection of the promontory of the sacrum. G 82 Labour The outlet, or lower end of the bony lube actually concerned in laljour (figs. 86, 87, and 89), and corresponding to the ' white line,' has an elliptoid shape too, but the flattening is in the transverse diameter. The line bounding it begins posteriorly at the lower end of the sacrum, runs along the lesser sciatic ligament to the spine of the ischium, and is continued forwards, cutting the obturator foramen, to the lower border of the symphysis (see fig. 87). The plane lying within this line is known as the ' middle strait,' the brim forming the 'upper strait.' The 'lower strait' is sometimes called the outlet of the pehis, and lies between the tuberosities of the ischium laterally, but has the same antero-posterior boundaries as the ' middle strait.' With the ' lower strait' normal labour has nothing to do, and it has to be con- sidered only when labour in deformed pelvis is in question. The cavity of the pelvis is the pait of the tube which lies between the plane of the brim and that of the outlet, or middle strait. Its walls are formed as follows : — Posteriorly, by the sacrum. This bone has a moderate conca\ity forwards, and its curve is subtended by a chord of about 4 in., the curve being deepest at the junction of the second and third sacral vertebrae. Down to the junction of these vertebrte the general curve of the sacrum is very flat, and this has the effect of making the pelvic axis of the part of the tube above this level straight also. Below this level the surface begins to curve forwards, and the axis then tends slightly in the same direction (see fig. 87). Laterally (fig. 90), by that part of the ischium and pubic bone lying behind the obturator foramen and by the sacro-sciatic ligaments. On this wall there exists a ridge of bone formed by the inclination to one another of two bony planes. This ridge, often diflicult to define, runs from just below the pectineal eminence downwards and back- wards to the spine of the ischium. The planes, one on each side of this ridge, face respectively, the posterior one upwards, inwards, and backwards ; the anterior or lower one downwards, inwards, and forwards. The posterior slopes into the sciatic notch, the anterior into the obturator foramen. These 'inclined planes of the pelvis,' as they have been called, have been thought by some authors to have great influence in the rotations of the f(JLta! head. We shall see immediately that when the pelvis is clothed with muscles these planes are buried under the muscles, and cannot therefore influence the head, unless the pressure on the covering muscles is so great that their padding action is destroyed and the bony surfaces beneath assert Fig. 90. — Internal surface of pelvis. The line divides the anterior from the lateral wall. The so-called ' inclined planes ' are indicated. Pelvic Measurements 83 themselves. The occasions on which this close fit may arise will be mentioned later (p. 145). We shall see also what is a far more striking proof of their non-effect in causing rotation — namely, that rotation frequently occurs in an opposite direction to that which the action of the planes would produce. What is expected of them by those who still believe in their importance is that, as the head lies obliquely in the cavity, and one of its poles is resting on, say, the posterior plane of the right side, and the opposite pole on the anterior plane of the left side, that the left-hand pole will glide along its plane into the sciatic notch, and the right-hand one along its plane into the obturator foramen. Anteriorly (fig. 90) the wall is formed by the pubic bones and obturator membranes. Pelvic Measurements. — The pelvis has certain measurements of great importance in their relation to the foetal head, and these are for practical purposes the same in all normal specimens. The more important of the measurements are those of different diameters of the planes already referred to — namely, the brim, and the middle strait or outlet. A third plane is added, that of the cavity, and certain external and other internal measurements are also of value. Brim. — Three diameters are taken in the plane of the brim : an antero- posterior or conjugate (the smallest diameter of the elliptoid of this plane), a transverse, and an oblique diameter. The conjugate is the line joining the middle of the promontory of the sacrum to the upper edge of the symphysis pubis. The upper edge, how- ever, is somewhat everted, and does not come into relation with the head in labour. The point that is taken in practice as the anterior end of this line is a little below the edge, and is really the nearest point on the symphysis to the promontory, and the diameter thus obtained is called the obstetrical conjugate, or conjugata vera. The first described one is the anatomical conjugate. The Conjugata Vera (fig. 91) measures 4:^ in., taking the average of a very large number of pelves. It will be found con\enient, for the sake of getting a whole number to deal with, to call it 4 in. There is another measurement taken from the promontory which is of great importance, as it can be taken during life, and is a means, when ob- tained, of arriving at a sufficiently accurate conclusion as to the measurement of the conjugata vera. This is the Diagonal Conjugate ; it lies between the promontory and the lower edge of the symphysis pubis. Its length is about \ in. more than that of the conjugata vera ; and so when the conjugata diagonalis has been made out in the manner to be described later, the conjugata vera can be deduced from it by subtracting f in. The Oblique diameter is taken from the point on the line of the brim marked by the sacro-iliac synchondrosis, to the pectineal eminence of the opposite side. There are of course two, and they are named right and left respectively, according to the sacro-iliac synchondrosis from which they start. They measure 4^ in. The Transverse diameter lies between the middle points of the two ileo-pectineal lines, and is the widest diameter of the brim, measuring 5 in. G 2 84 Labour Cavity. — A certain plane is usually taken to represent the cavity for the purposes of measurement. This plane cuts the junction of the second and third sacral vertebra?, the middle of the sciatic notch, the upper edge of the obturator foramen ; it ends at the centre of the back of the symphysis pubis. The diameters in this plane are (fig. 92) : Antero-posterior, 4^ in. This diameter lies between the junction of the second and third sacral vertebrae posteriorly and the middle of the back of the symphysis. Oblique. This diameter of 5 in. extends from the sciatic notch to the posterior edge of the obturator foramen. The oblique diameter is slightly extensible. The transverse, 4^ in., lies between points on the ridge which divides the 'inclined planes,' where this ridge is cut by the plane of the cavity. The outlet, or middle strait, already defined, has the following dia- meters (fig. 93) :— Antero-posterior ; from the lower end of the sacrum to the lower edge of the symphysis, \\ to 5 in. Oblique ; from the middle of the lesser sciatic ligament to the middle of the obturator membrane of the opposite side, 4^ in. (extensible). Transverse ; from the tip of one ischial spine to that of the other : this measures 4 in. 45- 5 Fig. 92. — Ca 'ity. Fig. 93. — Outlet Ant.-pwst. 4 in. 4i „ 5 ,> Oblique 4^ in. 5 „ 4i „ Transverse 5 in. 4i „ 4 „ 4 Fig. 91. — Brim. Tabulating these numbers. Brim .... Cavity Outlet it will be seen at once that there are three measurements of 5 in., corre- sponding from abo\e downwards to the transverse, the oblique, and the antero-posterior diameters of their respective planes. It will be noticed also that the antero-posterior diameters increase from above downwards, while the transverse ones diminish (see figs. 86 and 87), and that, taking the tube as a whole, two screw-like surfaces exist ; so that an ovoid body l)ing with its longer diameter in the trans\erse diameter of the brim must, as it descends, rotate either in the direction of the spiral of a corkscrew or in the reverse direction. To illustrate this, let us imagine the head lying with the occiput to the left and forehead to the right. This will Pelvic Measiirenients 85 Ijriny a diameter of 4|- in. (occipito-frontal diameter of head) into relation w itli the Brim. As the head descends, this 4^ in., so as to be in the most favourable position, must come into the oblique diameter in the Cavity. It can do this by turning either occiput or forehead forwards. If the occiput turn forwards, the head turns in the direction of a corkscrew ; if backwards, in the reverse direction. So there maybe said to be two screws, one a right- handed one and one a left-handed one, in the same tube, either of which can act, if not impeded, on a head-diameter large enough to come into relation with it. One is made up of the left anterior part of the tube-wall, acting in combination with the right posterior part, the other of the left posterior and right anterior parts. The result of this arrangement is that the longest head-diameter engaged — that is, in relation with the tube- walls -will be found to be in the Transverse at the brim ; Oblicj[ue in the cavity ; Antero-posterior at the outlet (in thick lines in figs. 91, 92, 93). We may now consider the remaining measurements of the pelvis. In gi\ing numbers for these, the average is the only number in each case which is of use, for no two pelves measure exactly alike. Further, the nearest whole number or large fraction to the average is always taken. This is done because, in addition to the variety in the bony measurements, the differing thicknesses of muscle in different women make exact figures useless ; and because it is impossible to make a greater approximation to exactness than within \ in. or so when measuring a pelvis during life. The method of obtaining the measurements which are to be got on the li\ ing woman will be best dealt with under Pelvimetry, in the chapters on Deformed Pelves. Between ischial tuberosities, 4 in. (the same as the transverse diameter of the Outlet). Depth of walls : inches Posteriorly (sacrum) 4^ Anteriorly (symphysis) i^ Laterally (pectineal eminence to tuber ischii) . . 4 External measurements (including tissues covering bones) : External conjugate, ' diameter of Baudelocque,' from tip of last lumbar spine to middle of front of sym- physis 7i (about) Between iliac spines ....... 10 Between iliac crests .11 Between posterior superior spines (showing width of sacrum) ......... 5 Width o\er trochanters 12 (about) In addition to these measurements there is the Diagonal Conjugate, already mentioned. This measures 4^ in. Note. — The value of such seemingly remote measurements as those of the distances between the spines and between the crests, which are of 86 Labour course measurements of a part of the pelvis not concerned in lal)our, lies in the fact that an idea, often a very close one, can be obtained from them of the diameters and general sha])e of the true pelvis. Pelvic A,rtlculatlons. — The articulations are of interest, as by their presence they prevent the pelvic tube from being an absolutely rigid one. The flexibility the\- confer is, however, very slight. The joint with the greatest mobility is the sacro-coccygeal. It has been alread>' pointed out that, from an obstetrical point of view, the coccyx is only a part of the muscular pelvic floor. It shares in the freedom of movement belonging to this, hinging, of course, on its upper end. The sacro-iliac articulations allow of very little movement, or at least not much is required of them, owing to the union of the front ends of the in- nominate bones at the pubes. The only movement of any importance in normal lal^our is a gliding one, which occurs as the sacrum swings on an axis passing transversely through its upper vertebra, advancing or retreating its lower end. By this movement some further room is obtained in the antero-posterior diameter at the pelvic outlet. The symphysis pubis in the pregnant woman obtains, in common with the other joints, increased mobility. Its synovial space enlarges, and allows of a small amount of gliding movement. There is practically no separation ot surfaces ; in fact, only a very considerable separation could increase the antero- posterior diameters to an appreciable extent (see Symphysiotomy, p. 402). Soft Parts of tbe Canal. — The lower and more flexible part of the birth- canal has now to be described. Before doing this it is necessary to mention the soft parts which at some places cover the interior of the pelvis and act as padding. These consist of the following muscles : the psoas and iliacus muscles at the brim ; the obturator internus over the lateral and a little of the anterior walls and small sciatic notch ; the pyriformis, lying over the edge of the sacrum, and filling the great sciatic notch. These muscles diminish the diameter in which they lie to the extent of their thickness, the psoas and iliacus bringing the transverse measurement at the brim down to about the size of the oblique diameter. It may also be noted here that the obturator internus lies on the 'anterior inclined plane,' filling up the declivity and making the inclination disappear. Thus one of the 'inclined planes' only exists in the dried pelvis, and has probably no special effect on the movements of the foetal head under ordinary circumstances. The anterior pelvic wall is least covered with soft parts of any, and the back of the pubis has no thickness of muscle to act as a pad, and so save from injurious pressure the parts which lie between the bony wall and the bones of the fcttal skull. The importance is that, greatly owing to this arrangement, the base of the bladder is in some cases of obstructed labour so damaged that it sloughs, producing a vesico-vaginal fistula. The muscles just described do not modify the funnel shape of a coronal section of tlic pelvis. Pelvic IPloor. — Below the 'white line' corresponding to the outlet, the parturient canal is mainly composed of muscle and fascia. The only bony Pelvic Floor 87 structures are the coccyx, which is of no importance as a bone, and the lower margin of the pubic bones ; the tubcra ischiorum ha\ e no relation to the mechanism of normal labour. The canal here consists of a lateral and a posterior wall only, as the anterior wall ends at the lower margin of the symphysis ; and this edge of bone, the angle being rounded off by the subpubic ligament, opposes the whole length of the posterior part of the pelvic floor. The pelvic floor (posterior segment), when stretched by the foetus, measures from the tip of the sacrum to the anterior border of the perinaeum about five inches. Its upper anterior surface is concave on antero-posterior section, and also on transverse section (figs. 94, 96, 97). It is composed of muscles and fascia mainly. Muscles. — These consist of the Levator Ani, which corresponds to nearly the whole extent of the floor ; and, forming a second muscular layer on its superficial surface, the Sphincter Ani, the Transverse muscles of the Peri- ni^um and the Sphincter \'agin£e. -->.^ Levator aiti. — This is a thin muscle whose fibres are in many subjects not sufficient to form a continuous layer of Fig. 94. — -Pelvic floor (distended) from the side. The markings on the inner surf;ice of the pelvic floor do not represent the direction of the muscular fibres (see fig. 97 for this). Fig. 95. — Direction of groups of fibres of levator ani. a, anus ; r', vagina ; n, urethra. muscle, but in places leave intervals be- tween thebundles. By itself, therefore, this muscle cannot be considered the strongest part of the floor. It is by some anato- mists separated from the Coccygeus, a bundle of fibres whose independence is This bundle will be here described with the rest not always well marked of the muscle. Origin. — From the back of the pubcs, then running along the ' white-line ' 88 Lnbour to the spine of the ischium ami on to the lesser sacro-sciatic ligament on each side. Those fibres arising from the ])ubes pass backwards to be inserted into the last two pieces of the coccyx, and on their way send fibres to the urethra, Fig. g6. — Pelvic floor (distended) from the front. The markings do not represent the muscular fibres (see fig. 97). P"ig. 97. — Pelvic floor from above (part of pubic bones removed). vagina, and internal sphincter ani, and a few to unite with those of the opposite side behind the anus (fig. 95). The action of this part of the muscle is to draw the coccy.x upwards and forwards, and to form a sphincter for the vagina and to some extent for the anus. It is this part of the muscle which Fascia of Pelvic Floor 89 can sometimes be felt per vaginam to be spasmodically contracted in cases of vaginismus, or more rarely as causing obstruction in labour. This division of the muscle has been called the pubo-coccygeus by Savage. The greater extent of the muscle, that part arising from the 'white line' and the rest of the line of origin, runs from here backwards, downwards and inwards, to the side of the coccyx and of the lower end of the sacrum. This muscle, corresponding as it does to the form of the pelvic floor, forms a diaphragm with the concavity upwards. The second layer of muscles is a still thinner one. They all meet at the ' central point ' of the perin;eum, which is the lowest point in the curve formed by their union, and they raise this point when they contract. Between the two halves of the sphincter vagina the fcetus has to pass, and in this process the muscle is extraordinarily stretched. Fascia of the Pelvic Floor.— This element of the pelvic floor has been more particularly studied of late, and it is found to be of considerable importance. It forms a very tough and unyielding sheet of tissue, from which all the pelvic viscera receive their sup- port, most of them directly, being woven into the texture of the fascia at their points of support, and some indirectly, by resting on its surface, as the uterus. It may be described in two portions, a parietal and a visceral one (fig. 98). The less important parietal layer covers the muscles described as padding muscles at the sides ; in front it forms the posterior layer of the tri- angular ligament, and is perforated by the urethra and vagina ; at the back it helps to cover the sciatic notches. The visceral layer is continuous with the fascia covering the sides of the pelvis ; and it and the lower part of the parietal layer just described are produced by the splitting of the fascia which descends over the brim. The splitting takes place at the 'white Une.' From this line of origin the visceral layer extends downwards and inwards to the middle line, where its fibres fuse with the connective tissue of the base of the bladder, the vagina and the rectum. It thus slings these structures in the pelvis. On its lower surface is the levator ani, which is covered in- feriorly by a thin layer of fascia, the anal fascia. The deep layer of the superficial fascia of this region is very tough and aponeurotic, and gives material aid in strengthening the pelvic floor. Looking now at the pelvis, including bones and soft parts as one tube, its general construction is readily seen see (figs. 86 and 87). Abo\e, the tube is a rigid one ; below, it is elastic. The rigid part is straight or nearly so ; the elastic part is strongly curved, and curved in such a way that the change of direction of the foetal path is managed with the least possible abruptness. This change is from a course in the axis of Fig. 98. — Fascia of pelvic floor and its rela- tions to the levator ani and obturator internus and to the bony peU'is. 90 Labour its entrance, the pelvic brim, to one in the axis of its exit, the vulvar orifice. The part of the fcttus which descends first will be the first acted on by the surface on which it impinges ; and as all the surfaces of the pelvic floor converge to the vulva, the part in advance will always be turned forwards if there is nothing to prevent such rotation. The impact of the foetus on the pelvic floor takes place at the angle which marks the change of direction of the a.\is of the tube (see fig. 87). CHAPTER XI AX.VTOMV OF FfKTU.S C. The Body to be expelled. (The 'Poetus.) — The anatomy of the placenta and membranes has been already described, and this section will be concerned with the foetus only. This body is best considered as being composed of two irregular o\oids, the head and the trunk. The two ovoids tend before or during- normal labour to so place them- selves that together they form a single roughlj- ovoid mass whether \iewed Fig. 99. — Attitude of flexion. Fig. 100. — .Vttiludc uf exlension. from the side or the front. This holds good in the case of fle.xion or of extension, but the former (figs. 99 and 100) makes the more compact ovoid and is the natural attitude of the foetus. So long as the long axes of the two ovoids are as nearly parallel as the neck will allow, and the main axis of the ovoid formed by their combination coincides as nearly as possible with the axis of the parturient canal, the Measurements of Foetus 91 inechanisin is a normal one. This holds good by whichever extremity, head or hrt'cch, the fcctus presents (cephalic or podalic lie). Fig. loi. — Fcetal measurements Fia;. 102. — Dorso-sternal diameter. Trunk. — The diameters of the trunk of the fcetus are very compressible, and those which are of importance are few. They are (figs. loi and 102) : — inches Bis-acromial (A A) . . . . . . . -4$ Bi-trochanteric, Bis-iliac (7" 2") ...... 4 Dorso-sternal {B S) -ok Vertex to breech (vertico-podalic), ( F/") . . . . 9^ to 10 Bead. — The importance of the fcetal head in the mechanism of labour is due to its large size and comparative want of plasticity in proportion to that of the rest of the body. It will, however, be seen to be plastic within a limited range, though some of its diameters, those of the base, are incom- pressible. If a section be made parallel with the coronal suture and a little behind it through the parietal eminences and the mastoid processes (fig. 104), the rela- tions of the compressible vault and the incompressible base will be seen. The fiase is formed of solid, firmly anchylosed bones ; the vault of thin semi- cartilaginous plates, flexible in themselves and, with the exception of the frontal bone, united to the base and to each other by membrane only. The base, from an obstetric point of view, consists of a mass of bone including the face and inferior maxilla, and the vault is attached behind and aljove it. The attachment is made along a line drawn through the junction of the orbital and squamous parts of the frontal bone, continued backward 92 Labour by the squamous suture and downwards iDy the hinge-like junction of the tabular part of the occipital bone to the basilar and condylar portion (fig. 103). Sutures luid Fotitanellcs. — In addition to the sutures of the adult skull, the foetal head has a frontal suture allowing of movement between the two halves of that bone ; and there is also the joint just mentioned across the occipital bone. At the crossing of the two lines of suture formed by the coronal on the one part and the sagittal continued into the frontal on the other, there is a Fig. 103.— Sagittal section through skull showing base and vault. Black line shows line of section in fig. 104. Fig. 104. — Coronal section of skull through parietal tuberosities. large membranous area, the Anterior Fontaiielle or Bregma (see fig. 107). This fontanelle is rhomboidal in shape and has opening into each of its four angles a suture. The greater part of its area lies between the two halves of the frontal bone, and it reaches anteriorly about half way from the line of the coronal suture to the glabella, a space at the root of the nose just abo\e the fronto-nasal suture. Posteriorly, this fontanelle forms a blunt indenta- tion between the parietal bones. It measures roughly li in. in length by i^ in. across. The Posterior Fontaiielle has only three sutures opening into it, and by this means is distinguished on vaginal examination during labour from the anterior. It is formed by the union of the sagittal with the apex of the lamboidal suture, and has no dimensions. Temporal Fontanelles. — The only ones to be felt are the posterior ones (see fig. 106) lying at the junction of the lambdoidal, parieto-mas- toid, and occipito-mastoid sutures. These fontanelles are triradiate, and may on this account be mistaken for the posterior fontanelle (see Diagnosis of Positions). Plasticity of Vault. — At the fontanelles and sutures of the vault considerable overlapping of the bones occurs under pressure ; the sutures are not mere lines of membranous union, but are of sufficient width to allow of considerable movement and over-riding of the bones on one another. This o\erlapping takes place in a definite way Fig. 105. — Method of overlapping of bones of vault. Measurements of Fcetal Skull 93 in all cases ; the parietal bones always o\er-ride the frontal and the occipital bones (fig. 105), and of the two parietals, the one most pressed upon — namely, the one which is posterior in the pelvis — always goes under the anterior. The two halves of the frontal bone obey the same rule as the parietal bones. The bones themselves are capable of very considerable bending owing to their thinness and membranous condition, and their flexi- bility plays an important part in the adaptation of the head to the pelvic diameters. In addition to the flexibility of the bones and their overlapping at the sutures, the head can be slightly reduced in total volume by {a) the flow of cerebro-spinal fluid into the spinal cavity ; {b) by the emptying of the cerebral vessels, both of which events occur when the head is compressed in labour. The brain of an infant will bear much more compression and alteration in shape than that of the adult, at all events as regards the hemispheres ; the ganglia at the base are protected by the solidity of the bones there. SM Fig. 106. — Foetal skull. Diameters of the Fcetal Skull.- — The diameters of importance in labour are taken between certain points which can be made out during life. Those most important in cases of deformities of the pelvis are the diameters of the base, as they are incompressible ; but those which come into relation with the pelvis in ordinary cases of labour are the diameters of which one end at least lies on the vault, and which are therefore reducible. inches Fronto-ocdpital {F O) (fig. 106), between root of nose (glabella) and posterior fontanelle 4^ Mcnto-occipital {M 0), point of chin and posterior fontanelle 5 Siiboccipito-breginatic (S-0 B), angle at nape of neck and centre of bregma y\ 94 Lalwur inches Suboccipito-fronial^ nape of neck and anterior angle of bregma 4 Mento-7'ertical {M V), point of chin and highest point on crown, about middle of sagittal suture .... Ca-vico-bregmatic, angle formed b\' neck and chin, and centre of bregma ......... Cervico-vertical {S-M V\ angle formed by neck and chin, and vertex ......... Bi-parictal {P P) (fig. 107), parietal eminences (greatest trans- verse) 3'? The following are incompressible : — Bi-mastoid, mastoid bones 3 Bi-malar {M M), malar tuberosities 3 i)'/-/^?///*?;??/ (7^ 7), anterior ends of coronal sutures . . 3 Fig. 107. — K(xtal skull from above. It will be readily understood that single diameters would be of little use unless they were an indication of the circumference of the plane of the skull in which they are taken. As the head is roughly spheroidal, the diameters i'ive a pretty fair idea of the bulk of the mass to be transmitted. In the tase of the diameters lying around the long mento-vertical axis of the head (suboccipito-frontal, suboccipito-bregmatic), they are about one-third of their 95 figures approaching the inches 14 II 12 13 Expelling Junre corresponding circumferences, as is the case in al circular. Those of importance are : — Circumference uf the fronto-occiijital plane Circumference of the mento-occipital ]ilane Mento-vertical circumference . Suboccipito-bregmatic .... Suboccipito-frontal ..... Cervico- or submento-vertical . The circumference at the shoulders in the liis-acromial plane is . . . . . . -13 No mento-frontal diameter is given, as there is no fixed point on the frontal bone to which a line can be drawn from the chin. Roughly speaking this diameter may be considered as about 3 in., of which the part between the glabella and chin measures about i^ in. This last is of great im- portance ; it is the one which is usually brought into relation with the conjugate when a face-presentation is induced after removal of the vault by cranioclasm (p. 390). If now we consider together all the ways in which the head can adapt itself to the birth-passage we have the following : — It can bring its smallest available diameters into relation with the largest diameters of the cross-section of the birth-canal in which it happens to lie, by lateral movements on the trunk, antero-posterior movements on the trunk (nutation), rotary movements on the axis of the trunk continued upwards. It can be compressed in any diameter which includes the vault, by overlapping of bones at the sutures ; flexibility of the bones themselves ; reduction of its total volume. The former group of methods is by far the more important, since it occurs in all cases ; the alteration in shape and volume is a means called into play only to a limited extent in the ordinary mechanism of labour, and takes place to a marked degree in those cases alone where sufficient adaptation hy the \arious movements above described is prevented by some abnormality of the parturient canal, or some faulty position of the head. It then compensates in a considerable degree for the want of normal movement. CH-VPTER XII ACTION OF THE EXPP:LLING FORCE The forces which expel the ovum comprise the action of three groups of muscles ; 1. The uterus. 2. The vagina and pelvic muscles. 3. The auxiliary muscles of labour (abdominal muscles). 96 Labour I. Vterlne Contractions. — The contractions of the uterus are by far the most im|)ortant factor in the process of expelling the ovum. Before describing their mode of action in detail three important characters belonging to them must be mentioned : They are involuntary, intermittent, painful. As they are involuiihiry the beginning of labour and that of each contrac- tion during labour are independent of the woman's will. The contractions may be rendered weaker or inhibited entirely for a time by various agents ; for instance, emotion, such as dread of the pain which contractions produce ; or the nervousness which the entrance of a stranger, such as the medical man, causes. They are liable to reflex inhibition, from a loaded rectum or bladder. The contractions ara pcristal/ic. In those animals, rabbits for instance, which have a long tubal uterus, this character can be easily seen, and the organ can be perceived to behave exactly like a length of intestine. The contractions which take place in the human uterus are in all pro- bability of the same character, although in the short, round uterus of a woman this is impossible to demonstrate clinically. They are intermittent. Each contraction begins gradualh- and reaches its acme more or less rapidly, according to the stage of labour, disappearing in the same, but in an inverted manner. In all the stages of labour the uterus may be felt to harden under the hand laid upon the abdomen ; in the earlier ones slowl)-, in the later ones more rapidly. During the intervals between the contractions the uterus may be felt to be completely relaxed. The average duration of each pain is al^out one minute ; but there is some difference in this particular between the beginning and the end of labour, as the pains occupy onh- a few seconds at first, but come to last longer and to be much stronger as the final stages of expulsion of the foetus approach. The pains, as the uterine contractions are called, are rhythmical in their intermission ; that is, there is a certain regularity in their appearance and disappearance. This rhythm varies in rapidity in the same ratio as the duration of separate pains, the greater the I'apidity the longer the pain ; in the beginning there are long intervals, say, of a quarter of an hour, towards the end the intervals become very short, and often last only a few seconds. So that looking at the process of expulsion of the foetus as a whole, the uterus, just as in the individual pain, begins quietly, and gradually attains its maximum degree of activity ; thus Kig. 108. — Diagram of pains in the course of labour. 'J'o be read from left 10 riglit. Tli contractions indicated by the last two thickenings in the line belong to the third st.igc. There are great ad\ antages in the intermission of contraction. As will be seen later, the circulation in the uterine sinuses and the placenta comes to a standstill during a pain, and the fcetus, in common with the other contents of the uterus, is powerfully compressed. This state of things could not be borne for many consecutive minutes, for the foetus suffers from compression of its nervous centres ; its blood is cut off from the oxygen sup]5h- : and the uterine muscle itself is not nourished and loses its irritabilitv. Definitions of 'fcvn/s licsciibing Uterine Action 97 The contractions ^rc pelo-w the Iiowest Point of the Foetus has escaped. — The head, if this is the presenting part of the foetus, now takes the place of the membranes which enclosed the ' fore-waters,' and fills up the internal os. The remaining liquor amnii is retained above the head, and transmits effective intra-uterine pressure to the base of the skull, or rather on to an area of it corresponcHng to the size of the aperture of the os at this moment. The direction of the force is pretty accurately in the axis of the uterus. C. Direct Uterine Pressure on the Foetus. — After the liquor amnii retained by the ball-vahe action of the foetal head has drained away so as to allow the uterus to come into contact with the body of the foetus, the uterine contractions act on the foetus in a new manner. If we consider the uterus as composed of two sets of fibres, one a longitudinal set and the other a circular set, it will be seen that if these two sets of fibres contract in an equal degree, the uterine cavity, while growing smaller, will still retain the shape it had before chminution. It is found, however, that the circular set contracts much more strongly than the longitudinal, and the uterus, while undergoing diminution in its cross-section, during a pain is actually lengthened. The foetus is straightened, and therefore lengthened, during the pain too ; and its breech is in direct contact with, and being firmly pressed on by, the fundus. This downward pressure of the fundus tends to resist the distorting action of the powerful circular fibres and to restore the uterus to its usual shape, and has received the name of ' form-restitution force.' Its importance in the process of labour lies in the fact that it is a direct onward pressure, forcing the foetal mass, of which the long axis is made rigid by the circular fibres, down in the axis of whatever part of the birth-canal may be occupied at the moment. (Figs. 1 13 and 1 14). The action of the fundal onward pressure— /on/i-frstz'tutiofi force, or fvtal-axis pressure, as it is also called — is strongly reinforced by the muscles of the abdominal wall and by the diaphragm, which come into play at this period. I04 LdlhVU- As labour proceeds, retraction of tlie uterus is steadily j^oing on, and, as already described, causes the contracting part of the walls to lie, on the whole, on a rather higher level as regards the ovum. This thickening of the fundal end (upper segment) and thinning of the lower, in addition to accumulating the uterine energy at the back of the object to be mo\ed onwards, also diminish the circular g^rip, and therefore the friction of the sides of the uterus on the foetus. (Fig. 114. Kig. 113. — A A, action of circular fibres of uterus, stiffening and lengthening fcctus ; Ji, fuetal-axis pressure. Fij;. 114. — Ji 11 B, direct onward pressure of fundus (fictal-axis pressure) ; A A, lateral pressure, stiffening the fivtus. The direction of the expulsive force of the uterus, being that of the uterine axis, is practically that of the pelvic inlet. Dilation of Cervix.- — In the following description of tlie c\ents which occur in labour, it will be convenient to take as a type the case where the foetus is in the cephalic lie with the vertex presenting, as the mechanism here is the most frecjuently occurring one. The membranes, consisting of amnion (internal) and chorion (external), and containing the amnionic fluid, arc the agents which, when dilatation has once begun, complete the process. Their action is at once the simplest and most perfect imaginable. Leaving the fcetus out of the question for a moment, the arrangement is that of a bag filling completely the uterine cavity, and containing fluid of a density little greater than that of water. The pressure in this bag of fluid is raised on contraction of the uterus. Directly the yielding of the internal os begins, to the smallest degree possible, it allows a certain amount of projection of the sac in this direction. (Fig. 1 12.) Dilalioii (if Cervix 105 The following points in the anatomy of the lower cncl of the utcius; \\ ill be remembered. First, the cervix consists almost entirely of circular fibres, since the longitudinal and oblique fibres which form the main mass of the muscle of the body end abruptly above this in the lower segment (p. 42). Second, the cervix and lower uterine segment have the peritoneum very loosely attached where there is an\', and are therefore surrounded by comparatively loose connective tissue. Given, then, the relative states of body and cervix called polarity, any contraction of the former implies relaxation of the latter. We have during a pain, therefore, the longitudinal and oblique fibres pulling apart the edges of a loosely supported and actively relaxed ring on the one hand, and on the other a raised intra-uterine pressure ready to force some of the uterine contents into the smallest opening. Under these conditions the internal os begins to dilate. The sac of the ovum, being not too firmly attached to the uterine wall at the lower pole, tends to bulge through the opening ; and since the pressure in a closed bag of fluid is equal on any two or more equal areas of its surface, there is, in addition to an onward pressure acting towards further projection, a radial stretching action produced on the inner sur- face of the ring of the internal os, tending to enlarge the diameter of the latter. The cervix is thus both further invaded by the projecting process of the membranes and at the same time widened. As the area of the inner surface of the internal os increases, the dilating effect in- creases in proportion with the additional area pressed upon, so that the wider the os the greater the dilating effect of the intra- uterine pressure during each pain. While the membranes are bulging, the lower pole of the uterus is being withdrawn to a small extent off the lower pole of the ovum, thus aiding in the separa- tion of the membranes. Retraction, as already explained, maintains some of the ground gained at each contraction, so that the bag of membranes (as the projection is called), although it retreats and becomes flaccid in the intervals of the pains, does not after each pain retreat entirely to its position before the pain. The force of gravity also helps the intra-uterine pressui-e. In the stage of dilation of the cervix the woman is usually more or less in an upright position, and the pressure of a column of fluid roughly eight or ten inches high is added to the effect of the uterine contraction. It is acting, too, during the intervals of rest between the pains. The head takes no share in dilating the cervix, and, in fact, during a pain it seems to recede from the opening. This recession is, however, not a real backward mo\ement, but is produced b)' the projection of the bag of mem- branes. The head retains its relation to the internal os, and is acted on by an upward pressure of the same force as that exercised on each equal area Fig. 115. — Effect of bulging membranes. (Uterine wall black ; membranes a double thin line.) io6 Labour in the interior of the uterus as long as the membranes remain entire and there is free communication between the liquor amnii in the bag I'fore-water^) and that in the body of the uterus (see fig. 1 15). Should the communication be shut off by the head being forced down during a pain so as to exactly plug the lower segment, the bag will be found not to vary in tension during the pains and the intervals respectively. This isolation of the fore-waters is a great disadvantage ; the dilating force is destroyed by removal of the intra-uterine pressure on the circle of cervix surrounding the bag, and at each contraction the pressure forces the head and lower segment tog^ether down into the pelvis, and dilatation has to be effected by the head acting as a solid wedge, with the disadvantage of the great friction produced by the blunt shape of the wedge. In this case a caput succedaneum (see p. 108) may be formed before the membranes rupture, since the intra-uterine pressure is greater than the pressure of the fore-waters on the part of the vertex occupying the opening of the cervix. In addition to the radial stretching of the lower uterine segment, there is also some longitudinal stretching, and therefore further thinning. The thinning is limited above by the retraction ring, and below by the attach- ment of the cervix to the vagina, this attachment being fortified in front by the firm union of the supra-vaginal cervix with the base of the bladder, arid laterally by the tissues forming the base of the broad ligament and by the utero-sacral ligaments. Posteriorly there is nothing but vaginal wall, and consequently the posterior wall of the lower segment is more stretched and thinned than the anterior and lateral walls. The contrast between the stretched lower segment and the now thickening upper segment becomes more and more marked as labour proceeds. Effects of Contractions on tbe Circulation in the TTterus and Placenta. — If the uterine bruit be listened to during a pain, it is found to gradually get higher and higher in pitch, and then to become inaudible for a short space, reappearing and gradually lowering in pitch until it again has the character of the sound when the uterus is at rest. During this series of events the sinuses are being slowly obliterated and emptied by the muscular contraction, and on relaxation they gradually refill and the circulation is re-established. The nutrition of the uterus is thi:s temporarily interfered with, a.-^ has already been mentioned. The maternal part of the placenta suffers in the same way, but the fcetal part of the organ is not emptied, as the fcrtus itself and the cord are under the same pressure as the villi. Effects of Pains on Foetal Beart. —The compression causes slowing of the fcetal heart, for it raises the general fcetal blood pressure. This effect is the same practically as the result in the adult of forced expiration with the glottis closed. The slowing may be due, too, to some extent to the pressure on the medullary centres. Effect of Pains on the Mother generally. — A. Before the Memlmines are ruptured. — There is no marked disturbance of function at this stage. The pulse rises ten to twenty per minute gradually during a pain, and J.ocal Effects of Pains i^n luvlns — Caput Succedaiicuin \0J sul)siclcs gradually as it passes ofl'. 'I'liis rise of pulse rate (M) (fig. Il6), it will be noticed, contrasts witli the fail which happens in the case of the fcetus. If much pain is felt, as sometimes occurs, the woman may become liysterical now, supposing she is inclined that way, but hysterical attacks during the first stage are rare. M Fig. ii6. — Effect of a pain on maternal and ffrtal pulses respectively. 21, maternal pul.se ; /", fcetal pulse; y, normal line of both. Vomiting is an occasional event at this stage, and rigors sometimes occur, as they are Hable to do in many instances when sphincters are dilating. B. After rupture of tJic nieinbraiies. — Towards the end of the first stage the pains have caused rather more excitement than at the beginning, but now their effect is a marked one. This will be fully described in the chapter on the Progress of Labour. The pulse rises in a greater degree in this stage owing to the increased muscular exertion involved by the action of the \oluntary muscles. At the acme of a pain, when violent expiratory efforts are being made with a closed glottis, the pulse may cease for the space of a beat or two. The temperature sometimes rises, but only a degree at the most. When the head approaches the \ulva the excitement becomes the greater as the suffering becomes more severe, and it reaches a climax as the head stretches or tears the sensitive perinaeum. There may be now complete loss of self-control, and the woman in her frenzy may do violence to the child. Such acts, if fatal in their results, are considered with leniency in courts of justice (see chapter on Puerperal Insanity, p. 556). The skin acts \"ery freely during and after labour, as it does after any other considerable exertion. Iiocal Effects of the Pressures on the Foetus. — The pressure on the fcftal surface during expulsion has been seen to be considerable. Before the membranes rupture this is equal on all areas ; after rupture, certain parts arc pressed upon more than ethers, the effect of the pressure and its situation depending on the amount of resistance offered to the advancing child ; the length of time during which the pressure is exercised ; and the relative positions of the foital and maternal parts. The pressure-effects after ruptuie are mainly visible on the head ; for aUhough the body of the foetus is much more compressible than the head,. it at once resumes its shape on remo\al of the distorting force. The 1 08 Labour tliamcters of the soft body, too, are all, except the bis-acroniial, so small as not to fit the pelvic diameters tightly. The pressure-effects on the body are therefore only momentary, and of no importance. With the head it is different. It fits the pelvis tiyhlly, and will undergo some change of shape in its passage through this if labour is at all prolonged ; but the soft parts squeeze it tightly enough to distort it in nearly every instance. In each separate lie and presentation a different shape is found at the end of labour, as will be described later. In addition to changes in the shape of the bones of the head, the different distribution of local pressures brings about local inequalities in the vascular tension, and the most marked result of these inequalities is the production of the caput siiccedaneunt. Caput Succcdanciim. — When ever)' part of the bod>' but a small area is exposed to a considerable pressure, the increased blood pressure will be able to squeeze out some of the contents of the vessels into the unsupported tissues, and to prevent the reabsorption of the fluid e.xtra\asated. According to the disproportion of the tension inside and outside the vessels of such an unsupported area, the extravasation may consist of serum only, or of blood ; and the longer the time this disproportion lasts the more marked will be the results. The unsupported part in the present case is the area of surface occupying the ring of birth canal most recently opened up at any moment, whether it be cervix, vagina, or vuha. In normal labour this ring is always bounded by soft parts. For instance, after the membranes have ruptured at an os dilated to a diameter of three inches, the unsupported area of the foetus during each uterine contraction (the time in which the disproportion in pressure exists) will measure three inches in diameter. The tissues underlying this area will become oedematous to a degree \-ar)ing with the amount of pressure and the length of time during which it lasts. The depth to which the tissues are affected depends on the thickness of tissue superficial to the bone underlying. The term ' caput succedaneum ' is sometimes applied also to the swellings which are produced in the same manner on other parts of the body, such as the breech. In the latter case, the scrotum, if the child be a male, and to a lesser degree the external genital organs in the case of a female, become very considerably swollen. In face presentations, the lip or e\-clid is often niarkedh aftected. The instances in which actual extravasation of blood occurs under the skin, the occipito-frontalis tendon, or under the periosteum, or even within the cranial cavity, and the after-history of these swellings, will be considered under Diseases of the New-born Child. (Cephalha-matoma, p. 581). The caput is liable to be formed at several periods during labour ; and as would be expected, its situation depends on the presentation existing at the moment at which this tumour is being formed. Hconorrhacres iitto other parts of the body of the Fatus. — It has lately been shown by Spencer ' that haemorrhages into internal organs are very ' Obit. Trans vol. xxxii. Labour — J^rcmojiiloy Stage 109 common in dcad-boi-n children, including- those cases in which labour is normal. It is \cry like!)- that hiumorrhages are much more frequent than is usually supposed in children which survive ; and these extra\asa- tions may have an important relation to certain diseases which arise in infancy. (See Diseases of the New-born Child.) CHAPTER XIV PROGRESS OF LABOUR It is convenient to divide the processes of labour into several 'stages' for purposes of reference. These divisions naturally fall into the following : — Premonitory Stage. Labour proper : — First Stage, Dilatation of tJie Cervix. Second Stage, Expulsion of the Fa'tiis. Third Stage, Separation and Expulsion of Placenta and Membranes. To explain this briefly : there are first certain preparatory events which occupy any time from a few minutes to several days. The first stage begins the process in earnest, and ends on complete dilation of the cervix. Usually rupture of the membranes happens when this is complete. The second stage is now able to begin, and during this stage the foetus passes through the parturient canal. Directly the child is born the third stage begins, and this in its turn ends with complete expulsion of the after-birth and efficient retraction of the uterus. Premonitory Stagre. — The events which occur before labour really sets in are variable as regards their duration. They also vary in their character, mainly according- to the parity of the woman. It may be mentioned here that a woman pregnant for the first time is called 3. primigravida ; one in labour or in the puerperium for the first time, a primipara ; if she has had children or miscarriages, one or more, previously', she is a multipara. When the exact number of the labour is to be indicated she is spoken of as a i-para (primipara), 2-para, 3-para, 4-para, and so on. The change of position of the uterus which takes place (p. 40) during the last weeks of pregnancy is by some considered a premonitory sign ; but it is rather a i-emote one in point of time, and as often as not it is unnoticed by the mother. Patients are frequently warned that labour is imminent by pains of a more or less regular character, usually felt in the abdomen. Attacks of these pains may occur several days before the actual onset of dilation of the ccr\ix. They are often due to disorders of tlie stomach and bowels, and especially often to constipation. They are sometimes severe and cause much suftering to nervous and sensitixc women. They are always very irregular in rh\ thni. I lO Labour More regular and less painful are contractions which recur at, as a rule, very long intervals for a day or two before labour, which are simply intensifications of tlie normal contractions of pregnancy. Effects on the Cervix. — I'ains of the latter class are sometimes accom- jjanied in i-para; by, some yielding of the internal os, but this is exceptional ; and, as a rule, any real shortening of the cervix (see p. iii) is a sign that labour has begun. In connection with them, however, there is often an increase in cervical secretion, and on examination the vagina is found to be well lubricated with mucus from this source. In the case of the former kind of pains there is not any such increase in secretion. Probably they do not raise the intra-uterine pressure, and thus do not stimulate the cervix to secrete. This is owing to their being contractions of parts onl)' of the uterine wall and not of the entire organ — colicky contractions in fact. In either case the uterus may sometimes Ijc felt to harden under the hand laid on the abdomen ; and the pain is referred to the abdomen as a rule entirely, and not to the sacral region. Pains felt in the sacral or lower lumbar area are always suggestive of changes of some kind going on in the cervix. Frequency of micturition and, less often, of defiecation are found during the last few da)S before labour. The)' may be due to the change in position of the uterus, but are much more probably caused by the increase of ner\ous excitabilit)' present in the pehic organs just now. This premonitory stage is sometimes absent in multipanu, and the first stage then begins without any warning. First Stage The uterine contractions during this stage arc occupied solely in dilating tlie cervix, and little or no propulsion of the o\um takes place. (The slight advance of the bag of membranes through the internal os in the act of dilating it is the whole amount of forward movement.) The characteristic events at the beginning of this stage are : — 'l\\& pains are fairly regular, though possibly separated by long inter\-als. The intervals shorten steadih' as labour advances. The pains are nearly always referred to the sacral region. The vagina is found to be freely luljricated with mucus. This mucus is, as a rule, blood-stained, and is colloquially termed ' the show.' The blood comes from the separated surfaces of the membranes and uterine wall just above the internal os. The vagindl portion of tlic cei-7'ix is undergoing real shortening as the canal is progressively invaded by the membranes. These three events are diagnostic of the beginning of labour. Seeing that all or nearly all of them may accompany the regular contractions observed in the premonitory stage, it may not be easy to fix the exact moment at which labour begins, but these signs are sufficiently characteristic for all practical purposes. Clinical Events. — The duration of a pain at the beginning of labour varies from two or three seconds to eight or ten, and the intervals occupy First Stai^e of Labour I 1 li;ilf an liour or more. As labour achances tlie duration of the pains becomes steadily longer, and the intervals shorter. (Fig. io8.) There is, as a rule, though not always, a 'show,' and this proves that the cervix is yielding satisfactorily, as it indicates a fair amount of softening and secretion, as well as some separation of the membranes round the internal OS and therefore dilation. The 'show' is not always present in favourable labours ; but it is nearly always absent in abnormal conditions of the cervix, such as spasm, or rigidit)' from fibroid degeneration or new growth, or in the case of irregular and useless pains like those which occur sometimes in the premonitory stage. In the intervals of the pains the woman is calm and is able to walk a'jout and take food for usual. The pains themselves are not as a rule dis- tressing, for the cervix is a comparatively insensitive structure. The abdominal muscles and diaphragm are not yet called into action, and there is in con- sequence no need to hold the breath and strain. The pulsa and respiration are not considerably affected just now, but in the later pains of this stage they do become quicker, and their general character comes to resemble that of second-stage pains, to be shortly described. On abdominal examination the uterus is felt to distinctly harden during a pain, and in doing so to come forward in the abdomen. This projec- Fit;. 117. — Uterus relaxed. Fig. 118.- Uterus contracli tion of the Uterus is due to its assumption of a more circular shape on cross-section, b)' which change in shape from that of the flaccid condition it is caused to move forwards by the resistance of the vertebral column Ij'ing behind it (fig. 117 and 118). Vag-lnal Examination. — If the membranes have not reached the ex- ternal OS, the cervix during a pain is found to be notably diminished in length, and the remaining undilated part feels like a soft appendage to the spherical surface of the distended lower pole of the uterus (fig. 120). 1 12 Labour If they have reached the external os, and this is yielding, the smooth niemliranes, chorion and amnion welded into one, will be found to stretch Fig. 119. — Primipara. X = internal os. level of Ext. Fig. 122. —Multipara, Fig. 120. — Primipara. X = internal os. during a pain across the aperture ; having while the dilation is slight a small curvature, but later on becoming a segment of a larger sphere (fig. 121). In primiparje the circle of the os consists at first of a thin and sharpish edge, which becomes thicker and oedematous as labour proceeds. In multiparje, in whom as a rule the cervix has been lacerated and has thus become irregularly thick at its lower end, this sharpness is not to be felt. In them, too, the external os is usually patulous to start with, and therefore does not elongate and thin to any marked extent as the bag of membranes descends (figs. 122 and 123). Ext lig. 123. — Multipar.-- X = internal os. The bag of membranes when tense prevents the head or other presenting part from being felt ; but in the intervals it is completely relaxed and is Rupture of Membranes 1 I more or less closely applied to the head, and if a suture lies over the uterine orifice it may now be felt. The anatomy of the head can also be recognised 124. — In multipara or priinipara. X = internal os. Y\%. -In multipara or primipara. X = internal os. through the anterior uterine wall, and the sutures often made out, if the vagina is sufficiently relaxed to allow the finger to explore freely the lower end of the uterus. Rupture of Membranes. — When the membranes have done their work of dilatation they are useless, and their persistence is even harmful, and under the most favourable conditions they rupture at this time. The os is sufficiently dilated when it has reached a diameter of. three to three and a half inches, for then the occipital end of the head can enter and easily com- plete dilatation. If the membranes are thin they rupture before this, if too tough they remain intact longer. The disadvantages of too early or too late rupture to the normal progress of the third stage of labour will be made clear further on. Modes of Rupture of Membranes. — The usual place for rupture to occur is somewhere on the free surface, most commonly, no doubt, about the centre (i), as this is the least supported point. The tear may be made, hovve\er, just inside the ring of the os (2), or even higher still (3), (fig. 126). In the first case the fore- waters escape, and the occipital end of the head comes down and takes the place of the bag of membranes at the os. In the last two cases the head comes down, but in the higher position of rupture (3), certainly, and in that just within the os (2), possibly, it covers the rent, and a second collection of liciuor amnii takes place (fig. 127). As the head moves down during labour, the rent is carried with it below the level of the 1 ig. 126. -Rupture of membranes, i, usual situation ; 2, just inside the os ; 3, some way up in the cervix. 114 Labour OS, and tlic second collection of fore-waters escapes. Two successive bags of membranes are thus produced, and this nii^ht, if the condition be not recognised, give rise to confusion. Two successive discharges of fluid may be brought about in other wa>s ; in one, the two layers of membranes, the amnion and chorion, are separated \\^ from one another by a layer of fluid (see Vm diagrams of Development of the Mem- Wf branes), and this amnio-chorionic fluid M {C/t. A, fig. 128) may bulge the chorion ^ ' ^'" away from the amnion o\cr the area of the OS. If the chorion now ruptures alone, there will still remain the bag formed by the general amniotic sac as usual. In another, there is a collection of fluid in connection with the decidua (fig. 128;, between the decidua vera and decidua reflexa, and if this collec- tion is near enough to the internal os, the advance of the ovum and the \vlthdrawal of the lower uterine segmentiwill bring the fluid into the area of Fig. 127. — F"ormation of a second liag of waters. D.cTi Fig. 128. — C/i. A, fluid between chorion and amnion ; D.ch, between chorion and decidua. the expanding os, when it may l)e discharged and expose the true bag of membranes. Prot7'U5io/! of Amnion throiigJi CItorion. — In some instances, c\cn where there is no intermembranous fluid, the chorion sometimes ruptures alone and the amnion protrudes through it (prolapse of amnion). This involves some considerable separation between the two membranes, which must increase as the amnion advances, for the chorion remains attached to the decidua. This separation will, in all probabilit)-. lead to some retention of chorion. Too early and too late Rupture of Membranes. — If rupture happens before the cervix is nearly dilated, the head, or whatever part presents, has to do the work of dilatation, and for this it is a clumsy instrument compared to the normal one. Instead of the force of hydrostatic pressure, which insinuates itself into the smallest orifice and then works without friction and radially Anatomy of Parts at end of First Stage 115 oil the circle to be dilated, we ha\c an obtuse wedge, with the drawbacks of friction and of decomposition of forces. This disadvantage is removed to a very slight degree by the formation of caput succedaneum on the area of the head in the ring of the cervix. Owing to its consistence, the caput may be considered to have a slight hydrostatic character, and it certainly makes the wedge of the head somewhat more acute. The child in this case runs some risk from longer continued compression of its head. The cervix, too, suffers from this anomaly ; it becomes lengthened to an abnormal degree, and the anterior lip is frequently carried down in front of the head for some distance, and then becoming oedematous, causes delay in labour, and is possibly injured by being torn or so much compressed between the head and the pubes that it afterwards sloughs. Late rupture is a disadvantage. The foetus and the whole amniotic sac have to pass through the birth-canal together until the membranes do give way. This means detachment of a considerable area of membranes (if not the whole, including the placenta) from the uterine wall. If the placenta is detached to any measurable degree now, there will be considerable bleeding behind the ovum, and the condition of Accidental Heemorrhage will be developed (see p. 336). Complete separation of the ovum is very rare, but it may happen in the case of premature children ; and in these cases the whole ovum is occasionally expelled entire. Up to the sixth month or so this is not extremely rare, and even at term, or very near it, the child has been expelled in the still entire amniotic sac. When the bag of membranes presents at the vulva the condition has been called 'prolapse of the bag.' In this case the membranes give way as the head clears the vulva, and the child is often expelled with a segment of the membranes over its head : it is then said to be born with a ' caul.' The uterus is by too late rupture deprived of the stimulus which it normally gets from the contact of its walls with the foetal parts. Too early or too late rupture has also an unfa\ourable influence on the third stage of labour, as we shall see later (p. 124). After rupture and escape of the fore-waters, the head, no longer kept back by the pressure of this fluid, comes down well into the os. As it does so, a variable amount of the liquor amnii behind it escapes, but the whole quantity is prevented from running away by the head filling the ring of the cervix, which it fits especially tightly during a pain. The uterus, as the liquor amnii runs off, is able to contract and retract on to the body of the foetus ; and the fresh stimulus produced by this contact with an irregular more or less hard body converts the pains of dilation into those of expulsion. There is often an interval of quiescence immediateb' after the rupture, during which the uterus is retracting on to the child. Anatomy of Soft Parts during: and at the end of the First Stagre. — There is but little alteration in the relative positions of the pelvic viscera during this stage, but at the end of it the bladder is found to be drawn by the rising cervix, and pushed by the descending lower pole of the ovum, upwards and forwards : and the vagina is beginning to expand at its upper end (fig. 129). I 2 ii6 Labour The upper uterine segment has retracted to a varying extent and is now gripping the foetus, closely or not according to the amount of liquor amnii liq. amnii rectum i Douglas' - pouch urethra anus '> fourchette Fig. 129. — First stage of labour : no change in position of bladder. drained away ; and the head of the child, now meeting for the first time the resistance of the brim, becomes more flexed. Second St.vgk During this stage of labour the foetus is expelled. The typical second-stage pains develop when the head reaches the pelvic floor. It then meets the resistance of voluntary muscle, and the voluntar>' expulsive muscles — namely, the diaphragm and those of the abdomen (see fig. 1 11)— come into play. This type of pain is, however, appearing at the beginning of this stage, and the woman is conscious of something occupying her pelvis which has to be expelled. The head can be felt on vaginal examination to be descending at each contraction, and to retire when the force is removed, owing to the elastic pelvic resistances. The amount of retreat is of course less than that of advance, and some progress is made at each pain. When the pelvic floor is reached the head meets with an elastic barrier lying nearly across its path. Under pressure this barrier is ready to alter its position of nearly a right angle to the present path of the head into one of a more obtuse angle, the head changing its dii-ection at the same time to one more forwards than before. It can do this, for now it has got its anterior pole below the pubic arch (see fig. 130), and the head is becoming free to move forwards as far as bony resistances are concerned. So that the down- ward and backward path of the centre of the head is changed in direction by this obliquely acting force, which is a constant one, and the head now moves more and more directly forwards. Auatoiity of Paris zvlicn Vulva begijis to dilate Wj If this part of the pelvic canal be divided in imagination int(; a series of zones, the greatest circumference of the head is seen to pass through each of them in succession. As the circumference approaches anyone of these zones, the latter forms a resistance to the head's progress, and after the circumference has passed the zone, this contracts behind it, and helps to push it onwards in the axis of the birth-canal in a peristaltic manner. The pains are now of the typical expulsive character. The woman has an almost irresistible impulse to bear down with all her might at each contraction of the uterus, feeling there is a mass to be expelled. She fixes her diaphragm after a deep inspiration by closing the glottis, and then contracts her abdominal muscles. If she cried before, she is silent now, at all events at the height of a pain, and she concentrates her attention on the one object of expelling the child, occasionally taking breath during a long pain and making a fresh effort. The pains now follow each other more rapidly and last longer. When the perinteum is being distended the agony at times is so great that the woman interrupts her now almost involuntary bearing-down efforts to cry out. This cry necessitates the opening of the glottis, and the pressure is thus at once taken off the abdominal contents, and therefore off the perineeum. Tearing" of this part is thus for the moment avoided. The glottis, as was pointed out by Tyler Smith, acts in this way as a safety valve for the perinaeum. We left the head impinging on the floor. In accordance with what has been already said, the occiput, being the first-coming part of the head, glides along the sloping pelvic floor to the vulva, and is forced under the pubic arch. It is the first part to distend the vulva, and it now presents at the vaginal orifice. bladder Fig. 130. — Second stage, showing tht ali<.f>jd position of the bladder, and the thickening in the uterine wall just above the bladder. Anatomy of labour wben the Vulva Is begrlnnlng- to dilate. — By this time the shoulders arc just abo\c the level of the cervix. The uterus ii8 Labour has retracted on to tliat part of the foutus remaining inside it, and the cUffercntiation between its upper and lower segments has become marked, unless the second stage has so far been a very easy one. If it is well marked, llie line of division may be felt above the pubes through the abdominal wall as a depressed line running across the uterus, often very obliquely. The longer this stage has lasted, the more easily felt will this King of Bandl be. The bladder is now wholly above the pubes, and the urethra is elongated mainly from this cause, but also because the tissues below and behind the pubic arch are pushed down somewhat by the descending head, and the lower end of the urethra with them. It is also compressed and its direction rendered more vertical, as it lies parallel to, and tightly jammed against, the symphysis. Catheterism is thus made somewhat difficult, and micturition practically impossible (see fig. 130). The structures attached to the sacrum and coccyx, consisting of the rectum, posterior vaginal wall, and perirtasum (fig. 131), are pushed downwards and backwards by the descending head, and form the posterior half of an arrangement like a pair of folding-doors, one of which opens inwards and the other outwards, the in- ward-opening one being the liladder and anterior vaginal wall as described by Berry Hart.' As the head sweeps down past the posterior valve it compresses the rectum, and completely empties it of any fcEces there may be in it. In the process of leng-thening which the perina^um under- goes, the anterior and pos- terior walls of the rectum Fig. 131.- Showing ch.-iiige in position during labour of Hoor glide One OVCr the Other, the of pelvis and pelvic viscera. .-V dotted line indicates the . • r i i position of the parts in the uniaipregnated woman. anlCnor mOVlUg further dowil than the posterior. This is most obvious at the anus, where the anterior wall is considerably exposed, and comes to form, when distension is getting marked, a part of the perinaeum (fig. 131;. The perinaeum bulges and thins in both a longitudinal and a transverse direction under the pressure of the head, and the sutures may often be felt through it. The edges of the vulva are forced apart by the occiput at each pain, coming together again as the head retreats in the intervals ; and as the skin of the hairy occiput appears, it is seen to be wrinkled from compression of the underlying bones. of Rectum ' Atlas of Female Pek'ic Anatomy, pp. 56-67. Fonitation of Caput Siiccedaneiuii 119 (".ladually laiycr and larger diameters occupy the vulva, which is corre- spondingly stretched, and when the sub-occipito-frontal — the largest dis- tending diameter — begins to engage, the pcrinitum in primiparie usually shows signs of beginning to tear at its anterior edge, if it has not done so before. The head is sometimes fixed at this stage for a {&\\ moments, and does not retreat when the pain goes off. This is called by the old nurses the 'crowning,' and it shows that the perinttum is elastic and will probably not tear. Occasionally the fourchette even is found after\\ards not to have been torn, but this is very rare. The stress of labour is now at its height, and the safety-valve action of the glottis is most valuable. The greatest diameter clears itself, and extension of the head occurs with almost a jerk to an extent which sometimes clears the chin, and sometimes only carries the perinii2um as far as the glabella or the mouth. The occiput now lies in front of the symphysis, the sub-occipital angle being tightly pressed against the lower edge of the pubic arch (fig. 158). The next pain frees the head if it has not yet escaped, and after the neck has been gripped by the \'ulva for a short time, usually for a pain or two, the shoulders come down and distend the opening. With the head the most resistant part has been born, and there is no difficulty with the shoulders, except that occasionally the cord is found round the child's neck, and if it is not freed by pulling down a little more of it and passing the loop over the child's head or over the shoulders, sometimes gives rise to danger of strangulation of the neck, or rupture of the cord, or detachment of the placenta. The body follows at once on the shoulders, and is accompanied by a gush of the remaining liquor amnii, and some blood, as a rule, from laceration of the cervix, and perhaps also from partial detachment of the placenta. The contracting uterus follows the last portion of the child down. Felt through the abdominal wall, it is found to rapidly diminish in size to about that of a five-months' pregnancy — that is, just below the navel. It is now closely retracted on the placenta and the small amount of blood- clot often lying behind that (figs. 133 and 137). Its shape during a contraction is flattened, and the edge of the fundus is plainly felt ; in the intervals it becomes a rather indefinite mass, which has about the same size. This ends the second stage of labour. Formation of Caput. — As the foetal head descends in this stage the scalp is much wrinkled, and the bones of the vault overlap at the sutures. In addition, a caput succedaneum is found to develop more or less in all cases. This swelling is formed on the leading part of the head (p. 108). In the mechanism of the first vertex, if produced mainly in the vagina, it lies over the right parietal bone, rather nearer the posterior than the anterior upper angle, and close to the sagittal suture. As the head descends through the vagina and rotates, the occipital end tends to come into the presenting area, and the (edematous lump moves towards and partly on to this bone. As the resist- ances are greatest at the pelvic floor, the caput formed at this stage is more marked than that caused in the higher parts of the canal -for instance, at the cervix. The stages at which a caput may form are, to recapitulate : I20 Labour In the Jirsl singe — {a) Before'mcmbranes have ruptured by close fitting of head (p. io6). {b) After rupture, owing to resistance of ring of cervix. In the second stage — {a) In the upper and middle parts of the vagina. {b) At, or nearly at, the vulva. The exact situation of the caput, which varies according to the position of the head, will be mentioned as the mechanism of each position is de- scribed. It is interesting to notice how during the first stage of labour, while the resistance to be overcome is that of involuntary muscular fibres— namely, the lower segment and cervix — the expelling force is that of in\ oluntary muscle ; A]V- Fig. 132. — Opposition of voluntary and involuntary muscle- in labour. D, diaphragm ; A /K, abdominal wall; US, upper segment: LS, lower segment of uterus; I' F, pelvic floor. The continuous lines represent the forces, the thin lines of involuntarj- muscle, the thick ones of voluntary. The dotted lines represent the resistances, the fine dots (as at L S) the involuntary, the heavier dots the voluntary (levator ani). when, however, the pelvic floor containing voluntary muscles (levator ani, &c.) has to be dilated, the expelling force has added to it the action of the voluntary muscles — namely, the abdominal muscles and diaphragm (see fig. 132). CHAI''I'P:R X\' I'ROC.RESS or \.\v.ov\<—conttnifcd Third St.vgk Thk third stage of labour is occupied in the exjjulsion of the placenta and membranes. After the child is born the uterus ceases to contract with vigour for a variable time, usually for a quarter of an hour, or in many cases for somewhat Separation of Placenta 121 longer. All hour, or even more, cannot l^e rej^arded as abnormal, as long as there is no bleeding going on. Retraction is in progress all the time, and there are occasional slight contractions, resembling those which take place during pregnancy. The woman is able to recover somewhat from her past exhaustion. Events are now going on in the uterus which involve the separation and expulsion of the after-birth. Separation of Placenta and IVIembranes. — It will be remembered that the decidua \era and scrotina are divided into three layers at the end of pregnancy ; the middle layer is the one concerned in the process of separation (see p. 6, and figs. 8 B and 12). On the uterine aspect of this layer is the deeper part of the decidua, which remains attached after the uterine contents have been expelled ; and on the foetal aspect, between the middle layer and the modified (pla- cental) or unmodified chorion is the superficial part of the decidua, which is cast off ^\•ith the chorion and amnion — in one part as unchanged decidual structure, and in another as the maternal part of the placenta. Recently the mechanism of detachment and expulsion has been more perfectly studied. Separation of Placenta There are three modes of separation described — namel)^, by : 1. Reduction of the placental site by uterine contraction and retraction. 2. Detrusion. 3. Extravasation of an appreciable amount of blood between the placenta and the uterine wall. We will consider them in turn. I. Reduction of the Placental Site. — The placenta is comparatively inelastic, and cannot follow its diminishing site. It has been shown in certain cases ^ that the placental site may be diminished to an area 4 in. by 4 in. without separation (the initial diameter being 7 to 8 in.). The detachment, according to this method, would begin at the edges of the area and advance to the centre, supposing the edge of the placenta be not dis- turbed (fig. 134). If, however, one edge of the placenta were carried along with the edge of the site (fig. 135) — the upper edge pushed down by the descending fundus, ' Barbour [Rdin. Med Jour. No. CDLXXXiv. October 1895, p. 301) believes that often the placenta does not begin to separate until the commencement of the third stage of labour ; that its texture is such that it can accommodate itself to the shrinking of its site until the uterus contains nothing but placenta without separation taking ]5lace ; that there is no eni]3ty space in the uterus into which the placenta can bulge ; and that there is not sufficient evidence to support the view of Baudelocque and Schultze that retro-placental ha-inorrhage is a factor in its sepa- ration. See also Pestalozza, Aiiatomia deli Utero Umaiio, Milan. 'ig. 133 — Uterus in third stage, showing non-de- tachment. The figure also shows the thinness of uterine wall at placen- tal site. /'/, pl.acenta. (.\fter Barbour.) 122 Labour for instance— the detachment would begin at the lower edge (fig. 135), and would take place by detrusion. Fig. 134. Separation of placenta. Site shrinks from ab 10 a' b'. Detrusion would not occur till the fundus reached the position shown by the dotttd lines. Fig. 135. — Separation of placenta. Detrusion as site shrinks from a b to a' b'. By the move- ment of a to a' the whole placenta is pushed down, p moves to/'. 2. Detrusion. — It is considered by some observers that detrusion is the sole factor in detachment. Barbour believes that detachment does not begin till the uterus has contracted down so as to contain nothing but placenta. He is supported in this view by a number of frozen sections. 3. Sub-placental Hccviatoina. — This extravasa- tion is said to be effected by the uterine muscle during contraction squeezing all the blood in its walls into the least contractile (fig. 133) (and already more vascular) part of it— namely, the placental site. The haematoma has been accounted for in another way — namely, by the aspiration of blood from the sinuses by the vacuum formed in the folding placenta. If this were the principal cause of detachment, as believed by Schultzc. whose diagram illustrating the process has become classical and is here re- produced in outline, the placenta would be always Fig.i36.-Expuisionofpl.Tcenta completely inverted during its expulsion into the (accordmg to .Schultze). F L,. . . , i vagina. This is by no means the case. We have thus three methods of placental separation, each of which is advocated in turn as being /Ae mode, but all of which agree in assigning as the fundamental cause the processes of retraction and contraction. Separation of Placenta 123 Matthews Duncan believed that complete absence of hicmorrhage is the natural state, and that this is due to the fact that in retracting and con- tracting the uterine muscle separates the placenta by causing the placental site to shrink, and by the consequent compression of the torn blood-vessels prevents the bleeding which would occur. Now absolutely bloodless labours are never found, and Champneys ' believes that hci^morrhage caused by rupture of vessels does pla\- a certain part in the detachment of the placenta. To summarise. The placenta is separated lay contraction and retraction of the uterus in the following way. Shrinkage of the placental site separates the placenta, beginning at the edge and ad\ancing to the centre, if the surface of the uterine wall around internal os- placenta ■^'^'liH— /- haematoma retraction-ring bladder Fig. 137. — Detachment of placenta, x x at internal os. the site has no abrupt curve preventing it from gliding underneath the edge. If, however, the fundal angle fits closely against the upper edge, detachment will begin at the lower edge, and detrusion will play an important part. Detrusion must, in any case, complete the process of detachment. If any part of the placenta has become abnormally adherent, this part will form the centre towards which separation by shrinkage will advance. Vessels will necessarily be torn across at the earliest moment of separation, and some h;i?morrhage will occur. ' Reference on p. 125, footnote. 124 Lnbonr Antecedent to, or at the same time as, commencing separation, blood is being extravasated into the trabecular spaces at the plane of utero-placental union, owing to the squeezing of blood into the subjacent vascular area, and this helps separation to some extent, and renders easier the shrinking of the placental site awa)- from the placenta. It should be mentioned that complete separation has been found at the end of the second stage (Lemser), though this, according to recent obser- vations, is quite exceptional. Separation of Mkmjjranks The production of a ' bag of membranes ' descending into and below the cervix necessitates some separation of the lower pole of the ovum from the lower segment of the uterus (figs. 1 19 to 125), which is drawn up off the bag. This process goes on until tlie membranes rupture. placent.i -membranes Fig. 138. — Transverse section of uterus. Detachment of placenta. When rupture occurs and the uterine surface shi'inks, the comparatively non-elastic membranes are thrown into folds and wrinkles (fig. 138), and thus partially detached, or at all events considerably loosened, in places. While the placenta is in process of expulsion it peels the membranes, as it descends, completely off the uterine walls. The amnion has already been described as the layer which confers toughness on the membranes. It is therefore of the gi-eatest importance that the chorion remain firmly united to it throughout this process. Failure to adhere is liable to result in some of the chorion being left behind in the uterus — a most dangerous state of things, as will be seen later. Apart from morbid conditions of the chorion or of the decidua, leading to separation of these structures from the amnion as the latter follows the placenta out of the uterus, separation may be caused by too early or too late rupture of the membranes in the first stage of labour. Too early rupture prevents the separation of the lower pole of the o\ um, since then there is no bag of waters formed, and the membranes adhere to Expulsion of Placenta and Membranes 125 the uterine wall too closely. Tliis interferes with that part of the normal mechanism of the detachment of the membranes which takes place before rupture. Too late rui)ture means that the bag of memlaranes is prolonged far down into the vagina. The chorion is almost bound to give way, and the amnion will advance alone. The chorion will then lose the advantage of adhesion to the amnion, and some may be left behind.' ExpuL.siOiN OF Placenta and Membranes The mechanism of expulsion varies slightly in different cases, but the differences are only matters of degree, and the main plan is as follows. The sub-placental extravasation causes a slight inversion of the placenta (fig. i yj)^ and as this body is pushed down by the diminution in cubic capacity of the uterus, or earlier by detrusion, it has to detach the membranes from the segment of uterus below- the site as it descends. This delays the membranes retraction-rmg external os placenta bladder etraction-rins Fig. 139. — Expulsion of placenta. The lower x in front marks the internal os. ad\ ance of the lower edge ; and the higher the implantation of the placenta on the uterine wall, the more membrane it has to detach, and so much the later the lower edge lags behind the point on the amniotic surface which presents at the os. The placenta never, unless its lower edge was originally close to the internal os, presents by its edge, but by some spot on its foetal surface from \ to ^\ in. above its lower edge, in most cases about 2 in. It is in a form of slight inversion at its lower edge (fig. 139), but is of 1 See Champneys, Mechanism of the Third Stage of Labour. ' Some Clauses of Retention of the Membranes,' Obst. Trans, vol. xx'ix. 1887, p. 317 126 Labour course bent backwards on a vertical axis witli its foutal surface inwards following the cur\c of the internal uterine surface (fig. 140). Very complete inversion is probably due, as .■'"^ ~^ Duncan believed, to traction on the cord.' The uterus is to some extent detaching the placenta by retracting during the interval of rest, but expulsion into the vagina does not happen until the pains reappear. Two or three pains are usually enough to effect this. Abdominal contractions are now required to force the placenta out of the vagina, for the vaginal muscle has been too much stretched to carry out this unaided. The membranes, as they are dragged out after the placenta, are seen to be inverted (fig. rjg shows the commencing inversion), the amnion being outer- most ; and the whole mass is accompanied by a variable amount of clotted and fluid blood from the placental site. This blood comes partly from the sub-placental h^ematoma, and partly, especially the fluid portion, from the site after separation. When the after-birth has been expelled, the uterus is found contracted and retracted down to about the size of a foetal head, though \-arying in size in different women, according to the amount of retraction, and often according to the size of the child. nm h. Fig. 140. - Shape of placenta during expulsion. Pig 141. — Uterus just after end of third stage. Z. n, /. \, lumbar vertebrae \pl.s, placental site; DP, Douglas' pouch; 01, os internum: O E, os externum; A" A", retraction ring ; i/ K/', ulero-vesical pouch ; i/r, urethra ; «;///', umbilicus. (After Webster.) ' These views pnitake more of the character of Schultze's ideas than of Duncans. Schultze thought that the normal way for the placenta to be expelled was in an inverted form (see fig. 136) ; Duncan maintained that the normal mechanism was for the edge to Amount of Blood lost. Duration of Labour 127 Some of this diminution in size is due to contraction alone, as witliin a few hours of the completion of labour relaxation occurs and the uterus is found to have again increased in Ijulk. In tlie meantime slight relaxations take place now and then, lasting for a minute or more ; and during their presence the uterus loses its definite outline, and sometimes a little care is required to find it. No blood is lost, however, in these intervals of relaxation, as a certain amount of tone remains, sufficient to keep those vessels closed which are not thrombosed. (It cannot be said that the uterus has retracted down to this size, as it increases afterwards, and it is probable that contraction is in some degree continuous at this stage.) Labour is now over, and the puerperal period has begun. Amount of Blood lost at labour. — The average amount of blood, taking clots and fluid blood together, is four ounces before the placenta is delivered and six ounces - with the placenta and membranes. The blood is mixed with liquor amnii, and it is not easy to fix its exact amount. The total quantity varies within wide limits which may be considered normal. It is found that those women who habitually menstruate profusely also lose more than others during labour ; and they have been found to behave in the same way as regards the lochial discharge afterwards. Duration of several Stag-es of Xiabour. — The time taken up in each stage varies principally according as the woman is a primipara or a multipara. The relation of the first stage to the second is fairly constant— namely, about six to one. In multiparte the average length of the expulsive stage is one to two hours out of a total nine or ten. In primiparas the expulsive stage lasts about three or four hours out of twenty : in some elderly primiparas, where- the cervix and perinaeum are less easily dilated, four to five hours out of twenty-four. The following are about the average figures : --- isi stage 2iid stage Total MultiparcC 8 1-2 .... 10 Primipara^ 16 3-4 . . . .20 Elderly 20 4-5 . . . .24 It happens almost as a rule that in the absence of al^normality the relative length of the first and the second stage vary inversely as one another, a long first stage being succeeded by a proportionately short second, and the converse. If the first stage has been prolonged, the parts below have had time to become more softened and easy of dilatation. The increased length of laliour in elderly i-para; depends to a slight come first. A series of" observations recorded by Champneys are the basis on which the statements in the text are made (see Obsf. Trans, vol. xxix.) The membranes follow the placenta down, and the mechanism of their detachment is also that of their expulsion. - Average of loo cases observed in the General I^ying-in Hospital. These figures pretty well agree with those of Chamjineys {Obsf. Trans, vol. xxix. p. i66), who says six ounces before, and six with. I2rECHANlS.M OF LAl'.OUK IN Vl'.RTEX POSITIONS The fcetus has been described as an o\oid body made up of two lesser ovoids ; a larger, the body-ovoid, and a smaller, the head. We have now to study the various lies in which the composite fnjtal ovoid may be found. The ovoid may lie above the brim with its long axis coincident or nearly so with the axis of the brim. All normal lies, whether cephalic (head lowest) or pelvic, are in this class, and all lies in this class are normal e.xcept certain rare attitudes of the foetus in the cephalic lie — namely, brow presentations. The fuetal ovoid may also lie with its long axis at something near a right angle to the axis of the brim, constituting a transverse lie. .All transverse lies are abnormal. ' Spiegelberg, Text-book of Midwifery (Eng. Trans. New Sydenham .Soc. ), vol. i. p. 172. V^ertex Presentations 129 Cephalic Lies With the head downwards the attitude of tlie foetus may be one of flexion, of extension, or of a posture midway between the two. In the case of flexion, the larger end of the head-o\oid forms the end of tlic whole foetal ovoid (fig. 142). This is a vertex presentation. Fig. 142.— Flexion, vertex presentation. Fig. 143. — Extension, face presentation. Fig. 144. — Attitude between fle.xion and extension, brow presentation. If the head is extended, the smaller end of the head-ovoid forms the end of the general foetal ovoid. This is a face presentation (fig. 143). The long diameter of the head-ovoid may lie at right angles to the body- ovoid, and the attitude is one between flexion and extension. This is the abnormal presenta- tion just alluded to, brow presentation (fig. 144). Vertex Presentations Flexion is the usual condition of all the joints of the fcetus, and so vertex presentations are by far the most common of all. They occur in 95 to 96 per cent, of all cases of labour. (Face presentations (extension) occur in about -4 per cent.) With the vertex presenting and the head moderately flexed on the trunk, a diameter near the occipito-frontal diameter is seen to be the longest diameter of the head in the plane of the pelvic brim (fig. 145). According" to the relation of this diameter with the diameters of the pelvic brim in the plane of which it lies, the vertex, as will immediately be seen, may be in one of four positions. Fig. 145. — Relation of head to brim (horizontal line) in a primipara. I30 Labour The above diameter cannot lie in the conjugate, since this measures only four inches. The one in which it might be expected to lie according to relative measurements is the transverse (five inches),' and approxi- mately this is so ; the long diameter of the head always lies nearer to the transverse than to any other diameter of the brim when the head is once engaged.- Before the head enters the brim at all, however, the fcetus is acted on by the other forces already described (p. 34), which tend to place it in a definite position with regard to the walls of the genital canal. Owing to these causes the long diameter of the head in the plane of the brim de\iates somewhat from the exact transverse in nearly all cases even before the cavity, where the shape of the pelvis forces it into the oblique, is reached. It does not deviate as a rule, however, into an oblique diameter, as defined in Anatomy of Pelvis (p. 83;, at the brim, but lies in the transverse with a slight inclination towards one or other oblique diameter.' Fig. 146. — Pelvic brim from above. The figures represent the situation of the occiput in the four positions of the vertex. This de\iation from the transverse may be towards either oblique diameter, right or left, and in either case may lie with the occiput forwards or backwards. Thus four positions are possible (fig. 146) : — First, occiput forwards and to left (head in right oblique). Second, occiput forwards and to the right iTiead with long diameter in left oblique). Third, occiput backwards and to the right (head in right oblique). 1 The shonening of the transverse diameter by the psoas muscles tends to cause the occipito-frontal diameter to lie originally out of the e.\act transverse. * ' Engaged ' means that the presenting part has entered the brim far enough to be influenced in its movements in the plane of the brim by the shape of that bony ring. 3 In a small number of cases, estimated at 20 per cent., of all vertex presentations, by Spiegelberg, the head enters the brim actually in an oblique diameter, Solayres' Obliquity. Positions of Vertex 131 Fig. 147. — This figure represents the pelvis on its side in the left lateral position and seen from below. The numbers indicate the position of the occiput. Fourth, occiput backwards and to the left (head in left oblique;.' It will be seen that the positions follow one another round the brim in the direction from left to right, like the hands of a watch, if the pelvis is looked at from above ; in the reverse direction if looked at from below (fig. 147). It will be noticed also that if the long dia- meter of the head is in the right obUque, the position must be the first or third ; if in the left, the second or fourth, the direction of the occiput forwards or back- wards deciding the point. The occiput is towards the left in first and fourth positions, and towards the right in second and third positions. In all positions the head in the beginning of labour lies deeply enough in the pelvis to be engaged at a level, a little nearer the vertex than the level of the occipito-frontal diameter (see fig. 145). The plane of the head coinciding with the brim may, however, be slightly above or slightly below this, according to the laxity of the lower uterine segment, the tone of the abdominal muscles, &c. In primigravidae the head is usually lower than in multipara?. ' On the Continent, the positions of the head have a different nomenclature in France and Germany respectively. In France, the occiput being, as with us, the part of the head taken as the point of reference, the positions are named as follows : Occipito-iliaque gauche-anterieure, O. I.G.A. Occipito-iliaque droite-ant^rieure, O.I.D.A. Occipito-iliaque droite-post^rieure, O.I.D.P. Occipito-iliaque gauche-postdrieure, O.I.G.P. corresponding to our first, second, third, and foiu-th positions. The transverse positions are named also : Occipito-iliaque gauche-transversale, O.I.G.T. Occipito-iliaque droite-transversale, O.I.D.T. when the occiput p)oints to the left and right respectively. It may be mentioned that the meaning of the terms right and left oblique diameters of the pelvis are the inverse of ours, the right oblique diameter indicating that which ends at the right ileo-pectineal eminence, and the left that which ends at the left eminence. In Germany the child is said to be in the first vertex position {Schiidellagc) when the occiput lies to the left side of the pelvis, and in the second when it lies to the right. The Germans consider our third and fourth vertex positions to be varieties of the usual vertex mechanism ( Vordcrschiitelstellungy. In America the Continental method cf naming the oblique diameters is followed, and this must be remembered in reading American works on obstetrics. 132 Laboi We may now follow llic head t)irough llu- pels is, starling from llic first position (left occipilo-anterior). Mectaanism in left Occipito-anterlor Position. — As the head descends under the influence of the uterine contractions, it becomes more flexed than it was to start witli. Flexion is due to several causes. I. In the first moments of descent, while the head is being pushed down by the action of the uterine contractions on the liquor amnii remaining in the 148. — Differing inclinations of interior and posterior planes of head. Fig. 149. — Effect of inward pressure of walls of l)irth-canal on moderately flexed head. Uterus after rupture of the membranes (p. 103), the pressure acts on the whole base of the skull, and flexion will be caused by the different angle at which the anterior and posterior slopes of the vertex meet the resistance of the walls of the passage to be dilated. It will be seen by the diagram that the resistance acts on the anterior slope of the vertex more nearly at a right angle than on the posterior slope, and therefore more power- fully. In other w^ords, friction at this sur- face will be much greater, and this end of the head will be more impeded in its de- scent than the posterior end, which thus descends in front of it (fig. 148).' ' The mechanics of this an.' (tig. 150) : II' II' are the walls of the parturient canal. U T \s, the line of the general intra-uterine pressure acting on the head, in the axis of the part of the canal occupied by the head. A B, CD lepresent the surfaces of the vertex at the anterior and pos- terior ends of the head respectively, acted on ijy the walls, IV IV. The lines r' and ;-- are drawn at right angles to these surfaces, starting from points on them equidistant from the axis of the canal ; r ' and r- meet at c, and their resultant is /C, which must — since the head must move in the axis of the canal— be parallel to C/ T. It is now seen that [/ T and R form a couple, which will cause the forehead to be detained until the line R coincides with U T. Cfiuscs of Flexion 133 2. This cause is reinforced by the tendency any ovoid body has, in passinj^- through an elastic tube, to place its long axis in coincidence with that of the tube. A couple is produced as long as this result is delayed, as is seen in the diagram (fig. 149). 3. Another reason for flexion in the case where the occiput lies to the left is the obliquity of the uterus. The uterus is usually in- clined to the right, so that the axis runs downwards from right to left. It will be readil)' seen by the dia- gram that this state of things will tend to cause the head so to rotate on a horizontal axis at right angles to the plane of the paper that the occiput descends. All these causes of flexion begin to act before the fundus comes into contact with the breech, and the form-restitution-force, or foetal-axis- pressure (p.. 103), comes into play. 4. When this happens, there is another cause of flexion produced. In the case of a somewhat flexed head, the force transmitted through the vertebral column acts on the head along a line running nearer the occipital than the frontal end of the head (fig. 152). If the head, represented by its occipito-frontal diameter, be considered as a lever, it will Ije understood that the longer arm (frontal) is more acted on b)' Fig. 151.— Effect of obliquity of uterine axis on liead at brim. O, occipital ; F, frontal end. Fig, 152 -Fffital axis-pressure on slightly flexed head. Fig. 153. — Eflfect official axis-pressure, fully flexed head. the resistance of the walls of the canal at the girdle of contact than the shorter (occipital) arm, and the occiput is allowed to descend faster, producing flexion, and maintaining it (fig. 153).' 1 This inclination of the head to the horizontal, produced by He.xion, is known as Koederer'.s Obliquity. 134 Labour The effect of flexion is to lower the posterior fontancUe, and to bring it within easier reach of the examining finger than the anterior funtanelle (see fig. 154). When the head has descended to the pelvic floor, the attitude of flexion causes the occipital end of the head to be the first part which comes into relation with that resistance. This fact will be immediately seen to be one of integral importance in the further movements of the head. When a vaginal examination is made after the bi-parietal diameter has passed the brim, and before the head has come under the influence of the pelvic floor, the examining finger, which enters in the axis of the outlet, Fig. 154. — Rehuion of hend to finger when occiput lies to the left. touches one of the parietal bones first (in the position of the head now being considei-ed, the right parietal bone), and not a point in the line of the sagittal suture. This suture lies nearer to the posterior wall of the pelvis than to the anterior ; in fact, it seems to be lying close to the sacrum. The reason for this is easily seen in the diagram (fig. 154). This obliquity of the Internal Rotatio 35 horizontal plane of the head with reference to the planes of the cavity, toj^ether with the situation of the caput succedaneum on the right parietal bone, ga\e Naegele the impression that the head passed the brii)i with the sagittal suture nearer to the promontory than to the pubes, and therefore with the relative obliquity just alluded to. He described this obliquity as existing at the brim, and as being a normal movement of the head in labour. It has been called Naegele's obliqidty since his description. Another name for the want of coincidence between the horizontal plane of the head and that of the brim is Asynclitism. Asynclitism, or Naegele's obliquity, occurs in the case of passage of the head through the brim in a particular kind of deformed pelvis (see p. 433), but not in normal labour. Internal Rotation. — As descent goes on, the head, with an inclination towards the right oblique diameter to start with, comes to lie, owmg to the shape of the pelvis, quite in the right oblique diameter of the cavity, the occiput therefore coming more forwards. This movement in a plane at right angles to the axis of the pelvis at this part, and like that of a screw as 155. — Internal rotation. it enters a piece of wood, is called rotation. It is mainly a rotation of the head on the shoulders, but the shoulders are carried round with the head to a small and variable extent. To distinguish it from another rotation which takes place after the head has passed the vulva, the movement at this stage is named Internal Rotation. When this movement has been begun by the tendency of the long axis ' of the head to coincide with the longest diameter of the pelvic plane occupied, it is, when the occiput encounters the oblique resistance of that side of the pelvic floor, on which it impinges, carried further, so that the long axis of the head at the end of the rotation lies almost in the antero-posterior diameter of the pelvic outlet, with the occiput directed under the pubic arch. The head has rotated through nearly a cjuarter of a circle. In this particular ' In iliis plane. 1 36 Labour nieclianism (occipito-antcrior) the pelvic floor continues the movement already begun by the shape of the bony pelvis (fig. 1 56). The shape of the bony tube and that of the sloping floor do not, however, under all circumstances tend to rotate the head in the same direction as one another ; for, supposing the occiput at the brim to be slightly behind the end of the transverse diameter, in the fourth position, the shape of the pelvis would rotate it, as descent went on, into the nearest oblique diameter of the cavity — namely, into the left oblique ; and supposing the influence of the bony canal, owing to the very close fit of the head, continued to rotate the head in the same direction, the occiput would, at the end of rotation, look backwards instead of forwards (see fig. 1 70). Owing to flexion, however, the fit of the head and the bony canal in the cavity is not an absolutely tight one ; for the longest diameter of the head in this plane is now not the occipito-frontal, but the sub-occipito-frontal, or one near it, measuring about 4 in. This diameter being in the left oblique is able to rotate, if caused to do so by the pelvic floor, across the transverse diameter of the cavity (4^ in.), and to gain the right oblique. The pelvic floor is thus the most important agent in causing the normal anterior rotation of the occiput ; and, as we see, it is able to do this in cases where the occiput is originally inclined to go backwards, as well as in occipito-anterior positions. It thus differs in its action from the bony canal, whose shape, if allowed to act on unfavourable positions of the vertex, ends by increasing the backward rotation of the occiput. Returning now- to the head descending in the first vertex position. The resultant of the force (uterus and abdominal muscles) acting downwards in ■ l^^^A I'ig. 156. Occij.ut p;tssiiig uiiJer pubic arch. the pelvic brim axis and the forces acting forwards and upwards (pelvic floor) is one which is mainly forwards. The head moves bodily forwards in obedience to this, the \ertex gliding along the gutter formed by the con\erging halves of the pelvic floor. By means of this movement, which is part of descent, though with the direction somewhat changed, the occiput is pushed under the pubic arch, and separates the edges of the vulva to some degree (fig. 156). Extension ^37 extension. — Since the nape of the neck is firmly applied to the back of the s}mph)si.s, the centre of the head can only ol)e)' the general forward pres- sure just mentioned by means of the chin leaving- the chest and extension of the head occurring (fig. 157). Fig. 157. — Process of extension. The separation of the chin from the chest is exaggerated. This forward movement of the head has been just described as if it happened only after the occiput had rotated to the front as completely as it will do while in the maternal passages. As a matter of fact, however, the head is pushed forward by the pelvic floor before complete rotation of the Fig. 158. — Conunuaii.Hi i.if extension : birth of head. occiput has occurred, and while the right parietal bone is still looking to the front. The consequence of this is that some lateral flexion of the head toward the child's right shoulder takes place. 138 Labour It is when rotation is complete that extension of the head occurs. The vertex being, now that the neck is fixed, the most mo\able part of the head, revolves round the point of fixation — namely, the lower edge of the symphysis ; and the vertex, anterior fontanclle, forehead, nose and chin, successively glide o\cr the perinanmi and the head is born. On account of the extension, the occiput moves upwards and forwards in front of the symphysis, so that on the emergence of the head the face is looking backwards and downwards in reference to the mother (if she were standing upright) (figs. 157 and 158). Rotation of tbe Shoulders. — During the passage of the head through the cavity of the pelvis, the shoulders become engaged in the brim. Their long diameter (bis-acromial) is at right angles to the long diameter of the head, and they consequently come down in the pelvic diameter at right angles to that in which the head descends. In the first position, therefore, Fig. 159. — External roiation. The head is re- moved and the direction of rotation of the shoulders is shown by the arrow. Fig. 160. — Relations of child to pelvis during deliverj- of shoulders. (From Winckel's frozen section.) they come down in the left oblique, with the right shoulder in front and close to the right foramen ovale. As they continue to descend they rotate so that their bis-acromial diameter approximates to the antero-postcrior, the posterior shoulder gliding to the bottom of the gutter of the pelvic floor (figs. 159 and 160). When the head is born they come into the antero-posterior diameter (fig. 161). Restitution; External Rotation. — Directly the head is born and free to move as it pleases, it recovers its usual relation to the shoulders — namely, (;nc with its long diameter, occipito-mental, at right angles to the bis-acromial, which last is nearly in the antero-posterior. It does this immediately the chin clears the vulva, as a rule with almost a jerk. Then, as the bis-acromial diameter turns completely into the antero- posterior at the outlet of the vagina, the right shoulder being in front, the Delivery of the SJioiilders 1 39 head retains its relation to the shoulders and rotates too, thus turning com- pletely facing to the right (fig. i6i). The occiput is therefore to the left, the position of the head becoming the same as that in which it entered the pelvis ; and hence the name of restitution. The direction of this rotation is the opposite of that of internal rotation. External rotation occurs in all mechanisms in which the head is born first and it is only necessary to remember that the back of the foetus ah\ays Fig. i6i. — ^lechanism of labour in first vertex. looks to the same side of the mother at the end of this rotation as it did when the head entered the pelvis at the beginning of labour. There will then be no difficult)' in describing the external rotation proper to the particular mechanism under consideration ; this rule holds good whether the presenta- tion be vertex with the occiput anterior or posterior, or whether it be a face or a brow presentation. Belivery of the Shoulders. — The shoulders are deli\ered both together in the antero-posterior diameter of the vulvar aperture. While they are passing through the lower end of the birth-canal, they lie with the bis-acromial diameter in coincidence with the plane of the outlet, whereas the pelvic end of the child's tnmk is passing the brim with the bis- iliac diameter in the plane of the brim. There is, in consequence, a lateral flexion of the trunk (see fig. i6o), which is most accentuated just as the shoulders escape ; for the anterior shoulder, in somewhat the same manner as the nape of the neck in the delivery of the head, is made for a moment the centre of rotation round which the posterior shoulder revolves. The arms are usually arranged with the hands up under the chin, and in this attitude have no influence on the mechanism. The hips have undergone the same rotation as the shoulders and in the same diameters of the pelvis if the head has been all along in the first posi- tion. They emerge with the bis-iliac diameter in the antero-posterior of the pelvis.' ' If the head began in the fourth position (see p. 143), the shoulders will have rotated into the left oblique before the hips engage, and the latter will not need to rotate across the antero-posterior as the former have done during the long rotation of the head occurring in the mechanism of a fourth vertex. 1 40 Labour Moulding, of the Hkad It will be noticed that the rij^ht parietal bone has been the anterior one during the whole process of expulsion. It is anterior at the beginning when the head is in the transverse or nearly so ; it is anterior in the cavity when the occipito-frontal diameter is in the oblique (right or left oblique according as the head is in the first or fourth position) ; it is so at the outlet when the head does not completeh' rotate into the antero-posterior. It is thus less pressed upon than the left parietal bone (sec fig. 155J, and therefore tends to become more convex. The left parietal bone, on the contrar)-, is exposed to pressure througliout the second stage of labour, and is so especially when the head has reached the pelvic floor, since it is on the posterior aspect of the skull that the pelvic floor then presses. In consecjuence the left bone, especially in its anterior part, becomes flattened. The head thus may, if the resistances to its onward passage are at all considerable, become much distorted. In addition to this change of shape, the head is compressed along certain of its diameters in its journey through the birth-canal, and the diameters at right angles to these are in a more or less corresponding degree lengthened. In the brim and cavity the pressure compresses the circumference corre- sponding to the sub-occipito-frontal and sub-occipito-bregmatic diameters ; and at the outlet of the vagina the same diameters are still compressed together with a series of circumferences of imaginary planes on a common a.\is, the mento-vertical. The bi-parietal is a diameter of one of the cir- cumferences thus reduced, and the bosses at the ends of this diameter are flattened. The head is by this pressure shortened as to its short diameters, and lengthened in its long ones (mento-vertical, mento-occipital) (sec figs. 156, 157, and 158;. The shape which the head assumes in each mode of delivery will be described in the account given of the mechanism of each. Summary of Movements of Head Summarising the movements of the head, we find— The centre of the head .VDV.VNCKS in the axis of the parturient canal throughout. ROT.ATIOX is going on throughout ; in the canal (internal rotation) in one direction, outside the pelvis (external rotation or restitution) in the opposite. Flkxion exists from the beginning of the second stage of labour to the moment at which the nape of the neck hitches under the pul^ic arch. EXTKXSION then ensues and persists until the head is born. 'ihe following table may help the student to remember the relations of the movements. Those movements placed on the same line take place at the same time. Advance . Rotation . . . Flexion Advance Rotation . . Extension Advance . Rotation (reversed) j\TccJianis)ii in First Vertex Position 141 CHAPTER XVH SPECIAL MKCHANISM OF LABOUR IN VKRTKX POSITIONS First Vertex. — The long diameter of the head (occipito-frontalj is in tlie right obhque diameter of the pelvis, with the occiput anterior.' The back of the foetus is to the left, the limbs to the right of the mother's abdomen, and the foetal heart is heard best to the left of, and below the navel, on the side opposite to that on which the limbs are felt. Per vaginam, if the os is sufficiently dilated the sagittal suture may be felt, running, the woman being in the usual left lateral position, downwards Fig. 162. — {'ir:i|il in tlic . L-ntation of parts ftlt on aljdoniinal palpation uphalic lie. (ist vertex position.) and forwards, and ending anteriorly in the tri-radiate posterior fontanellc ; with further dilatation of the os than is necessary for the last observation, the anterior fontanelle may be felt (fig. 163) ; and later, the right ear, if sought, with ' It will be remembered here, and in other positions of the head, that the long diamettr is not in the actual oblique at the brim, but in the transverse, with an inclination to one or other oblique. 142 Labour Fi^. 163.— First \erte\. Pelvis of woman lying on "hei left side, seen from below. The dotted ring indicates the position of the os before much flexion has taken place. tlic pinna directed downwards and forwards, will be a guide to the position. At this stage the posterior fontancUc will have descended so as to form part of the presenting area, and the anterior one will have turned upwards out of reach owing to flexion of the head. The right parietal bone is anterior (see also figs. 129 and 130). beginning at the brim, the liead passes this flexed, and reaches the ca\ity with its flexion increased. It there ro- tates completely into the right oblique, with the occiput close to the left foramen ovale. The occiput is then directed by the pelvic floor towards the middle line, and the sub-occipito-frontal diameter comes almost into the antero-posterior diameter of the outlet. The head is delivered by extension. The shoulders descend in the left oblique, the right shoulder being to the front, the back of the child to the left, as at the beginning. When the head is free the face turns towards the mother's right thigh, and the occiput towards the left at once ; and on the shoulders rotating into the antero-posterior, the external rotation is completed by the occipito- frontal diameter coming to lie squarely right and left, the oc- ciput being to the left as at the iDrim. Second Vertex.— The long diameter lies in the left oblique diameter, with the occiput an- terior. The back of the foetus is to the mothei''s right, the limbs to the left. The foetal heart is to the right of the middle line, away from the limbs. Per vaginam, the sagittal suture runs upwards and for- wards. The left parietal bone is anterior, and, substituting left for right, the process of labour is identical with that which takes place when the head engages in the first position. The occiput on birth of the head turns to the mother's right thigh. Fig. 164 — Second vertex. Pelvis as in last figure. Mechanism ill Third and Fourth Vertex Posiiiotis 143 The foetal Third Vertex. — 'I"he lony diameter of the head lies in the rigiit oblique with the occiput posterior. The back of the foetus is to the right, the limbs to the left. heart is heard to the right of the middle line. The sagittal suture runs downwards and forwards (as in the first position), but the pos- terior fontanelle is found at the posterior (with reference to the mother) end of the suture. The left parietal bone is anterior (the back being to the right). The head descends well flexed, and as the occiput reaches the pelvic floor, it is directed forwards under the pubic arch, rotating through three-eighths of a circle. The shoulders are at first in the left oblique, the left shoulder forwards. As the occiput comes to the front the shoulders rotate into the antero-posterior and then beyond this into the right oblique. The third position has now been converted (or ' reduced ') into a position identical with that which an originally second vertex would have at this stage of advance, and the mechanism becomes now that of a second vertex. Fig. 165. — Third vertex, feh in last fieure. Fourth Vertex. — The long diameter is in the left oblique, with the occiput posterior. The back of the foetus is to the left, the limbs to the right. The foetal heart is heard on the left side. The sagittal suture runs up- wards and forwards, the small fontanelle being posterior. The right parietal bone is in front, as in first position. The head de- scends well flexed, and the occiput is rotated to the front. The head behaves from now to the end as if the position had been originally a first vertex, the shoulders having rotated so as to accommodate themselves to the new oblique diameter occu- pied by the head. It will be noticed that the mechanism of the first and fourth positions are practically the same thing, as are those of the second and third 166. — Fourth vertex. Pelvis as in last fisrure. The onlv difter- 144 Labour cncc is thai in ilie third and fourtli the occiput impinges on the pelvic floor behind the transverse diameter, and consequently has a larger segment of a circle to rotate through tlian in the first and second, since in the two latter the impact takes place in front of the transverse. If the direction of the back of the foetus be remembered — to the right in the second and third, to the loft in the first and fourth — there is no difficulty in remembering which parietal bone or which shoulder is anterior in any case, or to which side the face turns in the movement of restitution. IMCoulding: of Bead This group of mechanisms ending with rotation of the occiput forwards have in common a characteristic head moulding. As already mentioned, the diameters of the head compressed throughout are mainly the smaller ones — viz. suboccipito-bregmatic and suboccipito-frontal, the occipito-frontal being only slightly compressed. The head therefore elongates in a line joining the chin, which is the last point of the advancing head-ovoid, to the \ertex (slightly to one side or other of the middle linci. Fig. 167.— ^Moulding in first vertex position Fig. 168.— Moulding in second position (right occipito-anterior). of vertex (left occipito-anterior). In the first and fourth positions the elongation is along a line joining the chin to the posterior upper angle of the right parietal bone, and produces a head shaped as in the diagram (fig. 167). In the second and third positions the head is correspondingly altered (fig. 168). The deformity of the head is accentuated by the caput succe- daneum, which is situated on the apex of the asymmetrically conical vertex. It is therefore in the first and fourth positions on the posterior upper angle of the right parietal bone ; in the second and third on the corresponding angle of the left bone. Unreduced Occipito-posterior Positions of the \'ertex In some cases where the head lies at the brim in the third or fourth position, the usual movement of flexion does not happen, or is deficient, and there results some modification of the mechanism of these positions. The failure of the head to flex and so to get into such an attitude that its longest diameter coincides as nearly as possible with the pelvic axis at the level to \vhich the head has reached, is caused in some cases by a lesser degree of action of those forces (slight contraction of the conjugate, tilting of the uterus to the side towards which the back of the child lies ; see p. 154), Mechanism in Unreduced Occipito-posterior Positions 145 wliich, when they act more fully, produce face and brow presentations. These presentations will be described in their place. Spiegelberg says that the head passes out with the occiput directed backwards when there is not sufficient resistance to cause it to be strongK' flexed ; and that birth in the third and fourth positions occurs chiefly with small heads and large pelves. If the causes of flexion as described on |). 1 32 be accepted, it is obvious that an abnormally large pelvis can have no effect in diminishing flexion, because this movement is brought about by the reaction of the soft parts alone. The convexity of the promontory and lumbar spine will tend to cause extension when the child's occiput is backwards at the brim (fig. 169). Herman ^ points out that in a normal pelvis, if the occiput is directed backwards, lying in one or the other oblique, the bi-parietal diameter of the skull lies in the sacro-cotyloid diameter (or one near it) of the pelvis. If, on the other hand, the occiput is directed for- wards, the bi-parietal lies in the full length of the obHque (compare figs. 163 and 164 with figs. 165 and 166). The bi-parietal is thus, if the occiput is backwards, some- what more retarded by friction than when the occiput is forwards. Flexion is by this means interfered with, and (i) the occipital end of the head does 7iot reach the pelvic floor imich^ if any^ sooner tJian tiie frontal end. It is therefore not directed forwards under the pubic arch as it is in the normal mechan- ism of vertex presentations. The absence of flexion also (2) causes the occipito-frontal diameter of tJie Jiead to lie across the pelvis, instead of tJie suboccipito-frontal, which should by the time the head has reached the cavity have replaced the longer diameter. These 4^ in. (occipito- frontal) lie in a 5-in. diameter of the cavity — namely, the oblique ; but to rotate into the oblique at right angles to .the one it now occupies (as would happen if the head were flexed) it would have to occupy the transverse for a moment. The transverse diameter of the cavity is 4^ in., even in the dried pelvis, and so when the soft parts are present the fit is too tight to be possible. As the long axis of the head must, before it reaches the pelvic strait, be rotated into the antero-posterior diameter of the pelvis, the occiput turns into the nearest space — namely, the hollow of the sacrum. Tlie anterior fontanellc is now to be felt without difliculty. This fontanellc has been lower than usual all through, owing to the horizontal le\ellingof the head. Its presence in the presenting area should at once suggest the state of aftairs. Fi . — Convexity of promontory, causing extension. (After Pinard and Varnier's photograph of a frozen section.) IVIeclianism Of labour. — After rotation of the occiput backwards, the whole head is pressed against the pubic arch by the pchic floor, and the ' Difficult Labour, p. 5. L 146 Labour forehead becomes fixed there for a short space of time (fig. 170). The head revolves round the forehead to a variable extent, producing flexion (fig. 171), Fig. 170. — Persistent occipito-posterior. a slight gliding mo\ement upwards of the forehead behind the symphysis as a rule taking some share in the mechanism. The \ertex is in this way finally 1' ig. 171. — Persistent occipito-posterior. brought most in advance, and, by further descent of the head, it and the occiput pass over the perinaum. Directly this happens, and the occipital Mechanism in Unreduced Occipito-posterior Positions lA^j end of the head is free from the forward pressure of the pehic floor, it moves back with almost a jerk over the inferior surface of tlie pcrinaeum until the anterior border of the latter presses on the nape of the neck. The forehead, y Fig. 172. — Persistent occipito-posterior. face, and chin by extension now successively glide under the pubic arch (fig. 1 72). The shoulders behave as in the ordinary third position. To take an example : in the third position the shoulders are at first descending in the left oblique, and the back is to the right. The left shoulder is opposite the right foramen ovale. This shoulder rotates slightly backwards, almost into the transverse, as the occiput turns backwards ; but, when the head is free, this shoulder comes to the front again, and the face will look to the left thigh of the mother, as in a normally behaved third position ; in fact, the back of the child, as in all cases, looks to the same side of the mother throughout. Another and a less common method of delivery in unreduced occipito-posterior cases is by exaggerated flexion occurring while the head is on the perineum, or before it reaches the pelvic floor. The forehead must in the former case move up when it is behind the pubes, since flexion has been described as taking place at a late stage ; but in the latter case the forehead remains hitched on the upper edge of the symphysis, as shown in the diagram (fig. 173), which was made from a case in the writer's own practice. Here the head had remained fixed at the level of the cavity, but with the forehead high, and the supra-orbital ridge above the brim. The vertex had descended low into the pelvis, and was slightly distending the perin;eum. Attempts at delivery with L 2 Fig. 173. — Rarer form of mechanism in persistent occipito-posterior cases. 1 48 Labour the forceps which had been made had not succeeded, because the blades shpped off the head each time traction was made, since they could be applied to the hinder end only. The forceps were effectually put on by pressing the forehead backwards through the abdominal wall abo\e the pubes, and bring- ing the handles very far back so as to get the tips of the blades well on the bulk of the head. IVIouldingr of the Head The alteration in shape which the head undergoes in passing through the pelvis with the occiput backwards is, in the first-described and commoner mechanism, almost in an opposite direction to the moulding in occipito- anterior positions. So, instead of finding the suboccipito-frontal diameter diminished and the mento-vertical increased, we have, in face to pubes cases, the suboccipito-frontal and suboccipito-bregmatic diameters increased, and the mento-vertical, if anything, diminished, as is seen in the diagram (fig. 171) showing the mechanism. Fig 174. — Moulding of head in rarer form of persistent occipito-posterior mechanism. (Case of fig. 173.) In the rarer mec/ianisiii, howe\er, the head comes to resemble that of a \cry exaggerated occipito-anterior position. The way this is brought about will be readily seen from the diagram (fig. 173) representing one stage of the mechanism of labour, and the result is shown in the outlines of the head of the same child after delivery. In both methods of delivery the perina;um runs more risk of laceration tlian is the case in occipito-anterior mechanisms, for the diameter distending tlie vulva in the latter is the suboccipito-frontal (4 in.), whereas in the face to pubes cases the full diameter of the head is represented by the fronto- occipital diameter of 4^ in. (fig. 171). Diagnosis of Lies and Positions \A^yj AsymmctiN' of he \ault is not so marked in unreduced occipito-posterior cases as in those which end with the occiput forwards, because the fore part Fig. 175. — Moulding of head in same case as fig. 174 (seen from above). of the vault, being partly formed by the frontal bones, is not so plastic as the rear. The presenting (anterior) side of the vertex is, however, in prolonged labours, rendered more convex than the posterior. CHAPTER XVIII DIAGNOSIS OF LIES AND POSITIONS It is of the utmost importance to ascertain exactly the relation of the foetus to the maternal passage at the earliest possible moment of labour, so as to be able to render intelligent assistance if aid becomes necessary. To make quite certain of the relation, a routine method of examination must be adopted in each instance, and the following means of investigation are at our disposal : Abdominal Examination. — {a) Inspection. {b) Palpation. {c) Aus- cultation. Vag^inal f Examination. — {a) Before rupture of membranes, {b) After rupture. We will here consider the question of abdominal examination especially; the results of vaginal examination are sufficiently detailed under the de- scription of each position. ISO Labour Abdominal Examination The same arrangements should be made for ins]jccting and palpating the abdomen as those described under the heading of Diagnosis of Preg- nancy, especially bearing in mind that the bladder must be empty. The long axis of the foetus can, as a rule, be easily made out, and in the group of cases now under consideration it will be more or less coincident with that of the mother. In all cases it will be found that the best time for observing the general uterine contour is when the organ is contracted ; Fig. 176. — Graphic representation of parts felt on abdominal palpation in a case of cephalic lie. while the position of the fcetal parts, both as regards lie and attitude, can only be ascertained during relaxation. Deviations of the axis of the uterus, when present, can readily be seen and felt under favourable circumstances. These deviations, as will by this time be understood (see p. 133), are of some importance in the mechanism of labour, and the less favourable presentations may be impro\ed by taking steps to diminish or change the side of any obliquity which may exist, before or during the engagement of the head. When the uterus is relaxed, the situation and attitude of the trunk and limbs of the child can with care be absolutely determined in the great majority of pregnant women. To do this it is best to stand at the right side of the woman, so that the Abdominal Examination 151 observei-'s face looks towards her head. The hands should then be j)laced on the abdomen, the palms lying flat on the surface. The left hand will lie on the patient's right side, and the right hand on her left. The uterus and its contents can now be examined with a hand on each side, the one ready to make counter-pressure while the other explores the surface. The limbs are the easiest parts to recognise, owing to their greater irregularity and their projection from the general mass ; and very often, where the foetal movements are vigorous and the abdominal walls are thin, they may be seen at once. If in a longitudinal lie the limbs are felt or seen at the fundus when the presence or absence of the liead there is as yet / / Fig. 177. — Graphic representation of parts felt on abdominal palpation in a case of podalic lie. doubtful, it is thereby pro\ed that the breech is uppermost, and that the foetus is presenting by the head (fig. 176). On the opposite side of the uterus to the limbs can be felt the broad, smooth surface of the back. This surface usually looks pretty square!)- to one side or the other, and it is thus not easy to make out whether the position is an occipito-anterior or posterior one. This may, however, be done in a fair proportion of cases if the head does actually, as is not, however, the rule, lie in one of the oblique diameters of the brim. The he and the direction of the back of the fcetus can be made out in this way far more certainly and fully than b)- vaginal examination. In cases of vertex presentation the heart can, as a rule, be best heard on the 152 Labour side opposite to that on which the hmbs are felt or seen ; and it may be here said that in face presentations (which we have yet to consider) the heart, owing to the extension of the foetal body, and consequent projection of the chest against the uterine wall, is best heard on the same side as the liiii1)s. So that if the heart is plainly heard on the dorsal side of the child, it ma\- be fairly concluded that the presentation is a vertex one. The arrangement of the hands should now be changed, and the observer should stand so that he looks towards the woman's feet. The tips of the fingers will be directed to the pubes. Making out the anterior shoulder, he Fig. 178. — ,4bdominal palpation in transverse lie. N.B. The fcetal head is at a higher level than usual. will be able by firm pressure with the pulp of the fingers, one hand being on each side of the child, to find the base of the skull, and after some little practice will distinguish the occiput, which runs down into the brim in a plane almost continuous with that of the back, from the more projecting forehead (see fig. 176), and thus absolutely determine that the presentation is a vertex, and not a face or a brow ; for in the two latter cases, and more markedly in brow presentation, there will be a prominence on both aspects of the child, the chin in the brow cases being often very readily recognisable. In making these observations, it is enough in many patients to simply Face Presentatio7is i 5 3 place the hands in the various positions mentioned, and press gently on and ihrouLjh the surface. In some women, where the abdominal walls are thick or there is sonic muscular rigidity, or where there is a larger quantity than usual of liquor aninii, far better and more certain results are got by ' dipping,' a method well known in connection with palpation of the liver in a dropsical abdomen. It is surprising how easy it is to make out foetal parts in this way, when b\- simple pressure a confused notion only can be obtained. To perform it, the pulps of the fingers, not the tips, are laid on the surface, and then by a sudden downward movement, which depresses the abdominal and uterine walls, the liquor amnii is displaced, and the solid foetus beneath is felt as a momentary but remarkably distinct impres- sion ; and, by a succession of these dips, the fingers travelling over the surface of the uterus as rapidly as recognition of the parts allows, a very clear composite impression is produced of the surface of the child which is being examined. The importance of abdominal examination as a means of diagnosis can hardly be overestimated, and the student is most strongly recommended to practise it at every available opportunity.^ Long series of cases occurring in lying-in institutions have been published lately, in which, with a view of avoiding septic infection, all necessary information as to the position and lie of the child has been obtained without any vaginal examination, and by abdominal palpation only. It jis, however, not for a moment recom- mended that any attempt should be made to perform this feat by the student or physician, since vaginal examination is absolutely necessary for the purpose of recog'nising many abnormal conditions which would give no evidence of their existence per abdomen. Presentation of the cord (p. 514) is an example. Abdominal and vaginal examination may be combined with the greatest advantage. Many somewhat obscure cases — in fat subjects, for instance — are readily cleared up by a bimanual examination of the part of the child which lies in the pelvis or at the brim. Bimanual examination in this way should conclude every vaginal examination. CHAPTER XIX FACE PRESENTATIONS We have to deal now with presentations of the opposite end of the head- ovoid. These presentations will be found to obey the same general laws as those which hold in vertex cases, the difference being that other diameters of the head go\-ern the movements of this part of the fcetus, owing to the head being extended vistcad of a.e-x.eA. There are two dlsadvantagres which exist in face presentations as com- pared with those of the vertex — namely, that a blunter end of the head-ovoid ' The subject is treated very completely in a most useful pamphlet by Cred^ and Leopold, translated by Dr. W. H. Wilson, A Short Guide fo the Examination of Lying- in Women (Kingston, 1894). 154 Labour has to dilate the genital passages fcompare figs. 142 and 143, p. 129), and that tlie transmission of the axis-pressure of the uterus through the frjutal trunk to tlie head takes place at a less favourable angle. For the force exerted on the base of the skull is seen by the diagram to act almost at a tangent on the spheroid of the head, and is thus not so perfectly transmitted as when it is applied at a more direct angle to the sur- face, as in vertex positions (fig. 179). Frequency. — Face presentations occur in about the proportion of rather over one to three hundred of all cases. Mode of Production. — They are produced from the usual semi-flexed attitude of the foetal head in pregnancy by several causes. I. Obliquity of the Uterus. — The usual inclination of the uterine axis is to the right side. Consequently, the line of the foetal axis-pressure is directed somewhat to the left, as well as downward and backward (fig. 180). The point of application of this force to the head is at the occipito-atloid joint, a point on the upper sur- face (in this lie) of the head. The resistance of the peh'ic brim acts at a point at or below the horizontal equator of the head, according to the amount of engagement at the time the axis-pressure comes to be exerted (see p. 103). The force and the resistance form a 'couple,' which causes the head to rotate on an antero-posterior axis in the direction of the cuned arrow. This rotation in the case of a foetus lying with its I'ig. 179. — Relation of head to trunk in face presentation. ■ig. 180. — Effect of obliquity of ftctal axis-pressure on head at brim. O, occipital ; F, frontal end. iSi. — Effect of fujtal axis-pressure on a partly-extended head. occiput to the left would be in the direction of increased flexion (fig. 151). In cases where the back is to the right, however — that is, in the second or third position of the vertex— the action of this couple is towards extension C< ruses of Face Presentations 155 of the head (fiy. 180), lending to produce first a brow presentation, and then a face. It will ])e seen, on referring to fig. 200 (p. 165), that in a brow presentation the point of attachment of the spinal column to the base of the skull lies over the middle of the long diameter of the head-ovoid, and that a slight degree of fle.xion (fig. 152) shortens the occipital portion of the lever. In the same way a slight degree of extension beyond that present in a brow presen- tation shortens the frontal portion of the lever, and produces further exten- sion (fig. 181) into a complete face presentation. The proof that obliquity of the uterine axis does produce this result is shown by the following considerations. The uterus is nearly always inclined to the right, and on the present hypothesis it would have a greater tendency to convert cases in which the back looks to the right into face presentations than those in which the back looks to the left. It is actually found to be the case that left dorsal positions predominate over right dorsal positions in vertex presentations in the proportion of about three to one ; while in face presentations, left dorsal positions have the lesser predominance of only four Fig. 182. — Effect of cordate uterus on fcetal axis-pressure. Fig. 183. — Elliptic pelvis. F, frontal ; O, occipital end of head ; x = situation of condyles. to three. This shows that there is a greater tendency for left dorsal than there is for right dorsal positions to remain as vertex presentations ; or in other words, there is a greater tendency for right dorsal positions to become face presentations than there is for left dorsal positions to do so. It is said that the cordate uterus may have the same effect, the result depending on whether the breech of the child lies in the lobe to the abdominal or dorsal side of the child (fig. 182). 2. Abnormal relation of Pelvic Brim to tJie Bi-parietal Diameter. — In the flat pelvis, with a brim of the elliptical type (see p. 435), the bi-parietal diameter is caught at the brim, and arrests the head. Pressure exerted through the vertebral column acts now in a line falling in front of this diameter (fig. 183), and the forehead descends, the head rotating round the bi-parietal diameter as an axis into a face presentation. It is possible that an analogous process takes place in some cases in a normal pelvis with a disproportionately large head. 3. Dead childroi ^xQ's&viXhy \\\Q. face in a larger proportion than living ones. They may approach the brim in almost any attitude of the head, as 156 Labour there is an entire absence of muscular tone. Under these circumstances, slight obliquity of the uterus (if towards the side of the back of the fcetus) readily converts the attitude of unstable equilibrium into a face presentation. 4. In the rare instances where 'a goitre is large enough to cause extension of the head by its bulk, the face necessarily presents. 5. In addition to these undoubted causes, it has been said ' that dolicho- cephalic children are very liable to present by the face. To be an inde- pendent cause of the production of extension from previous flexion, the dolicho-cephaly, it will be seen, would have to be very marked indeed, and this has not been shown to be the case in anv child so born. Mecbanism of Face Cases in General After what has been said of the forces which govern the mechanisms of vertex presentations, there is no need to make a statement of the general principles of the process, for face cases differ from vertex cases in the details only. (Figs. 184 and 185 may be compared with figs. 148 and 149.) Fig. 184. — Differing inclinations of mental and frontal planes in face presentations. Fig. 185. — Effect of inwarJ pressure of walls of birth-canal on head in face presentations. The points of difference are : — 1. The chin takes the place of the occiput in being the leading part of the head in descent, and the occiput comes last. The head-ovoid is thus inverted. 2. The submento-vertical (cervico-vcrtical 1 diameter (4^ in.) takes the place throughout labour of the sub-occipito-frontal (4 in.) The passage of this larger diameter is proportionately delayed. 3. The chin in face presentations does not come so far in advance of the rest of the head as the occiput in vertex presentations, so that rotation of the chin forwards (in the case of its being directed Ixickwards as the head enters the pelvis) occurs rather later than rotation forwards of the occiput in occipito-posterior positions. ' Hecker, Uch. d. Schiidclform bei Gesichtslage. Mechanisjii in Face Presoitations 157 4, Moulding takes place with more difficulty than in vertex cases, for the whole hind-head has to be bent downwards and compressed against the neck (figs. 185 and 190). 5. The head is delayed longer at the brim, as the change from flexion or semi-flexion has to be accomplished before advance can be made. It is of importance to remember also that the thickness of the upper part of the neck has to be added to the diameters of the posterior part of the head. On account of the conditions mentioned in 2, 3, 4, and 5, laljour in face cases is as a rule more protracted than in presentations of the vertex. The positions in face presentations are four, as in vertex cases, and they are named according to the direction of the chin. In numbering them (which is scarcely a necessary comphcation) they are made to correspond to the vertex positions from which they have been, or might have been, evolved. First. Right Mento-posterio7\ — Long diameter of the face in the right oblic[uc diameter of the pelvis. The head, by extension, lies so that its forehead occupies the place where the occiput lies in first vertex positions. Second. Left Mento-posterior. — Long diameter of face in left oblique. The forehead occupies the place of the occiput in the corresponding vertex. Third. Left Mento-anterior. — Long diameter of face in right oblique. The same remarks apply as to forehead and occiput. Fourth. Right Mento-attterior. — Long diameter of face in left oblique. Forehead and occiput as in the other cases. There is little or no object in remembering the numbers, but it can easily be done by keeping in mind the fact that the forehead takes in face cases the place of the occiput in vertex cases, and that the back of the fcetus has in each position the same direction as in the vertex position with the corresponding number ; in first and fourth face presentation the back is to the left, and in second and third to the right. Special Mechanisms First Face. Rig'ht IWento- posterior. — This is the com- monest of the face presentations. Face in right obliciue, forehead anterior. The back of the foetus is to the left, and by further ab- do/iiifial exaiiiinatio/i the angle Ijetween the occiput and the back of the neck is found on the left side of the abdomen ; the limbs are to the right ; the foetal heart is best heard, if heard at all, to the right (compare first vertex), on the same side as the limbs. Per vagi nam., if the os is sufficienth- dilaicd, 1)c felt, probably the orbital and glabellar region Fisr. 36. — First face presentation, left side, seen from below. Pelvis ill some pan t)f the face may and the iM'idgc of the nose 158 Labour traced backwards and upwards (in the ordinary ol)stetric position), as seen in fig. 1 86, to the mouth, where the alveolar ridges are to be recognised. Beyond 187. — Mechanism in first face presentation. this the chin may be felt if the head is already ])retty well extended. Down- wards and forwards the smooth forehead extends, being more or less with- in reach, according to the ;• amount of extension. The right cheek is an- terior. Movements. — i'he head becomes more extended and reaches the pelvic cavity, through which it passes in the right oblique (figs. 187, 188). On reaching the pelvic floor, the chin is directed by the slope of this round the right side of the pelvis towards the pubic arch. The chin is not so far in front of the rest of the head as the occiput is in \ertex cases, and so rota- tion forwards is often some- what delayed. There is less tendency than in occipito-posterior positions of the vertex for the posterior pole (the chin in this presentation) to turn into the sacral hollow, for the long diameter of the face is shorter than the Fig. ib£. — Mechani-m ni wt>\. iace prL-si;iuation. Thecurved arrow shows the direction of the chin-rotation. MecJianisiii in Face Presentations 159 occipito-frontal diameter of the vertex, and the shape of the bony pelvis has thus less power of opposing the action of the pelvic floor. (See Unreduced Occipito-posterior Positions of the Vertex, p. 145.) • Fig. iSg. — Face presentation after rotation of chin forward. The chin rotates almost invariably through three-eighths of a circle round the right side of the pelvis to the pubic arch, and the face lies in the antero- posterior diameter (nearly) of the outlet (fig. 189). Face. Then the head is pressed forwards by the pelvic floor, the chin appears at the vulva, and the angle between the neck and chin hitches beneath the pubic arch (fig. 190). I Go Labour The head now moves forward by flexion, and the face, forclicad, vertex, and occiput successively clear the pcrina?um (fiJ,^ 191). Fig. 191. — Face presentation. Birth of head. The head, being now free to move, assumes its usual position on the shoulders, which have by this time rotated into the right oblique diameter, the right shoulder being to the front as at the beginning. The face therefore looks to the mother's right thigh, and rather forwards. On the right shoulder coming under the pubic arch, the rotation of "the bis-acromial diameter into the conjugate causes the face to I'otate so as to look directly to the right. This is the same restitution as occurs in vertex cases, and obeys the same rules, finally bringing the face to look in the same direction as the one in which it looked when engaging at the brim. ' i '^ ^^ I \?^ Second Face. IieftMento- ^■- ' ' posterior. — The face in the left oblique, the forehead anterior. The back of child to the right, and the limbs to the left. The angle between the occiput and the back looks to the right ; the heart is best heard, if at all, to the left. The left cheek is anterior. The head descends, rotating in iJie opposite direction to that which is followed in right mento-posterior positions, and restitution takes place with tlic face towards the left. Second face preRentation. Mcc/iaiiisi/i ill Face Presoitatioiis i6i In both these presentations, which resemble in mechanism the two occipito-posterior positions (3 and 4) of the vertex, the chin has to rotate round three-eighths of a circle to reach the pubic arch. Third Face. Xeft Mento- anterior. — The face lies in the right oblique diameter of the brim, the forehead backward. The back of the foetus is to the right and the limbs to the left ; the fcetal heart is best heard to the left. The left cheek looks forward. As the face descends, with extension becoming more marked, the chin is directed under the pubic arch, turning through one- eighth of a circle. The head is born by flexion, as in the previously described face mechanisms, and when it is free it rotates so that the face looks to the left and forward. The shoulders are in the left oblique, with the left shoulder in front. As the shoulders rotate into the conjugate, the face moves round to look directly to the left. Fig. 193. — Third face presentation. Fig. 194. — .\lL'L-h;iniMii in thinl positi.in of the face. Fourth Face. Right IVIento -anterior. — The face lies in the left oblique diameter of the brim, with the forehead backwards. The back of l62 Labour Fig. 195. — Fourth face presentation. tlie fu-tus is to the left, the limbs to the right, and the fojtal heart is heard to the right. The right cheek looks forward. The rotations and restitution are the reverse of those described in the last position. The mechanisms of the various face presentations, espe- cially the direction of external rotation, are best remembered by keeping in mind the back of the foetus. This has at the be- ginning of labour the same as- pect as in the correspondingly numbered vertex position. The forehead in face cases has the same aspect as the back, and the chin as the abdomen. The chin is the salient point on the presenting surface, and, like the occiput in vertex cases, governs the rotations. Contrasting face and \ertex mechanisms : In vertex there is flexion ; the fourth position rotates into the first ; the third rotates into the second. Head delivered by extension. In face there is extension ; the first rotates into the fourth ; the second rotates into the third. Head delivered by flexion. And in mento-posterior positions reduction occurs later than in occipito- posterior positions. ivxouldinir in Face Presentations. — In face presentations the diameter most compressed is the cervico-vertical, or one between this and the cer\ico- bregmatic, along with the other diameters of the section at this plane, and the diameters of other planes parallel to this and behind it. Each succeed- ing plane, following the series towards the occiput, has below it a greater thickness of neck than the one in front of it (fig. 189). The head is diminished in the diameters of these planes, and assumes the shape shown in the diagrams (figs. 190, 191). It will be seen that in most cases there is an, at first sight, unaccountable prominence of the forehead. This has been explained by supposing that the head was for some time in a brow presentation in its transition from a vertex to a face at the brim. It is more simply accounted for by remember- ing that the horizontal part of the frontal bone is rigidly united with the base of the skull, and its vertical part only gradually thins oflf to the anterior fontanelle. The vault of the skull here does not obey the compressing force so readily, and so remains somewhat prominent. (It would be almost impossible for a sufficient amount of moulding to take place above the brim while the head was in a brow presentation Unreduced Mcnto-posterior Positions J 63 without some impaction, and in any case there would be but h'ttle chance of the presentation being readily converted after such moulding into a face presentation. The prominence of the forehead is as frequently found when there has been no delay at the brim as it is in cases where the brow moulding might possibly have occurred.) The diameters lengthened are the occipito-frontal and the occipito- mental. Those shortened are the submento- (cervico-) bregmatic, the suboccipito-bregmatic, with the transverse diameters corresponding to these (fig. 191). The vessels of the neck and the thyroid gland are much exposed to pres- sure during the passage of the head through the pelvis, as will be seen from the diagrams. The caput succedaneum, if one is formed while the face is at the brim, is around the e}'e which lies anterior — in first or fourth positions the right, in second and third the left. If, as is usual, the caput is formed in the lower part of the vagina, it is near the angle of the mouth, right or left as above. Owing to the laxity of the tissues of the face, and to the slower progress of labour, the swelling is often very great, and covers a large area, and subconjunctival haemorrhages are pretty frecjuent. ram. Unreduced Mento-posterior Positions Mento-posterior positions sometimes remain unreduced just as do occipito-posterior positions. This is, however, an extremely rare event, and fortunately so ; for with a normal pelvis and a full-sized head delivery cannot be completed with the chift back- wards. It is rare, because the mento-frontal measure- ment (about 2)\ in.) is much shorter than the occipito- frontal (4^ in.), and the bony canal cannot exercise its influence over the head. This is left, if extension is pretty complete, entireh- under the influence of the pel\-ic floor, which, as we have seen, invariably directs the part of the head which first impinges on it towards the sub-pubic space. In addition, when a face presents the head is over- extended, and its muscles and soft parts are in a state of great tension, those on the anterior aspect — the flexors — being much overstretched. There is, in consequence, a very strong tendency' towards flexion, and resistance to further extension. The fcetus is then like an elastic rod, whose nor- Jr'eri mal shape is a bent one, lying in a curved tube so F'g-i96.--Diagrani of elastic , . .' . . . \ °. , , . rod. Black side is concave that It IS in a strained attitude and has its curve (flexor side) when rod free ; reversed. If the rod can move in the tube without 'Jght.^ide is convex (exten- sor side). Front, promon- friction, or rather with very little, it will when it is tory; Syvt, symphysis; pushed down the tube almost immediately rotate on "', pennreum, its long axis, so that its normal curve is restored, and it comes to lie with its curve corresponding to that of the tube. M 2 164 Labour If the dark side of the rod (fig. 196) is considered to represent the flexor (front) aspect of the neck, it is easily seen that this side will tend to turn towards the symphysis if the foetus is free to rotate. .Supposing, however, extension is not good, and a diameter approaching the mento-vertical lies in the pelvic planes throughout which the head is Fig. 107. Persistent mento-posterior mechanism lig. passing. The head would be nearly in the attitude of a brow presentation, and the diameter engaged would measure about 5 in. It is clear that the shape of the pelvis will prevent forward rotation, and the chin will turn into the nearest space — namely, backwards into the hollow of the sacrum. There is a great difference between the state of things here and that in the corresponding unreduced occipito-posterior position. In the latter the head flexes a little more, and the occiput clears the perinreum, thus freeing the head ; but here the anterior fontanelle is jammed against the back of the pubes (fig. 197), and, to enable the chin to clear the perinieum, extension to a degree impossible in a living full-sized child must take place. The head, neck, and upper part of the thorax thus form a wedge, which advances into the pelvis to a distance depend- ing on the smallness of the child, and which is, unless the child is very small or is dead and flaccid, arrested and impacted. For delivery to be accom- plished with a full-time child, tb.c head has to be reduced in size by perforation (see p. 387), unless the chin can be rotated forwards before it is too late. In the cases where deli\ery has occurred with a small and dead child, the chin has slipped over the perinasum, and the head has been born by flexion (figs. 198, 199). -Persistent mento-posterior mechanism. Hrozv Presentatio7is 165 nzouldlngr and Caput Succedanenm. — The moulding is the same as in other foce presentations. The caput would be situated over the eye and adjacent parts, on that side of the face which lies anterior in the pelvis. CHAPTER XX BROW PRESENTATIONS Presentation of the forehead is a very rare occurrence when once the head has engaged in the pelvis, and the natural termination of labour in this attitude is almost impossible, at least in the case of a living child at term. It is an interesting presentation, for it throws some light on two mechanisms already described — namely, those of persis- tent occipito-posterior and persistent mento- posterior. The head is in the attitude shown in the diagram (fig. 200), midway between extension and flexion, and the arms of the head-lever are of equal length. The head is consequently in an attitude of unstable equilibrium. No doubt very nearly all face cases ha\e to pass through this stage on their transition from vertex presentations, and until the head is eng'aged this attitude has no special in- terest. When the head engages without flexion or extension having taken place, it must be con- siderably moulded at the brim, and the pre- sentation may then remain a brow to the end. Fig. 200. — Action of fcetal axis-pres- sure on head between flexion and extension. nZode of Production. — In numerous experiments with a fcetusand man- nikin, Auvard found that he could by directing the expelling force applied to the breech of the child in an oblique downward direction, or in a quite down- ward direction, with the head in an intermediate state between flexion and extension, produce a vertex, face, or brow pi-esentation at will. If he inclined the axis of the foetus to the side towards which its back was turned, and pressed downwards, he got a face presentation ; if he pressed directly down- wards, a brow presentation. This happened with the head cither at the brim or in the cavit}-. Probably in nature the head lies slighth' flexed before labour has begun, and there is a slight obliquity of the uterus (or at all e\-ents of the foetus) towards the side to which the child's back is directed, which produces some extension, but not enough to bring about a face presentation.' ' The other causes of face presentation (see p. 155) may also produce a brow presenta- 1 66 Labour Cases of vertex and face presentation, where insufficient flexion and extension respectively take place to allow of the normal mechanism in occipito-posterior and mento-posterior cases, might therefore be included, one on each side of brow presentations, in a classification of cephalic lies. Thus ; vertex proper, bregma, brow, malar region, face proper. Face Meclianisiu. — The head lies with its longest axis, the mento-vertical (5^ in.) across the brim. The bregma is at one end of the presenting area, the glabella near the other (figs. 202 and 203). The orbital arches may be felt, and will indicate the anterior aspect of the child. The mento-vertical diameter may lie in either oblique diameter of the pelvis. An abdominal examination will show to which side the Hmbs look, and if the ^.^^^Sji^^^- woman be a favourable subject, ^^I^^^^^HHfi^^^ the of the chin ^H^^^^^^^^^^^^ Fig. 202. — Relation of head to brim \ \ .- ' ^^K^K in brow presentation. (The dotted y^^^^V line corresponds to the mento-verti- ^^^^m cal diameter.) 3^^r occiput can be made out in this • ._-__" - ■ -7^ way above the brim. - 'iiiJ^^S^ The head descends, having Fig. 203. -Brow presentation from below. remained arrested at the brim for a long time while the mento-vertical diameter is being reduced by lateral pressure. Descent probably occurs by means of an advance of chin and occiput alternately, neither advancing sufficiently at any moment to produce a vertex or a face presentation. The rotations are, in all probability, controlled almost entirely by the diameters of the bony pelvis, as the fit is an extremely close one. Since the part of the presentation most in advance is in the centre of the presenting area, there is no marked tendency for the chin or the occiput to Mechanism in Broiv Presentations 167 come to the front. Whichever of the two is the lower, howc\'cr, docs so eventually, usually the chin. The descent of the chin is due to a continuance of the obliquity which caused the presentation in the first instance. The frontal eminence descends to the vulva, and presents there. The face is arrested at the lower margin of the pubic arch, and the head flexes, rotating round the point where arrest occurs, which is usually at the level of the malar bones, as a centre (fig. 204). The vertex and occiput pass over the perinaeum. When the latter is born, the mento-vertical diameter is free, and the head slightly extending again, the face passes under the pubic arch and the chin is born last. If the chin rotates backwards instead of forwards, arrest occurs when a point near the vertex has arrived at the pubic arch. The chin descends by extension and is born over the perinseum ; and the mento-vertical diameter being freed, the vertex passes under the pubic arch by flexion. Delivery in the first case (chin in front) is practically impossible without assistance ; and in the second in almost any case. With small or dead foetuses it is different. The diameters distending the vulva are, in the first case, a diameter which may be called the occipito-malar (about 4f in.) ; in the second the mento-vertical (over 5 in.) These diameters are, of course, reduced by moulding. Restitution in delivery of the shoulders will take place according to the same rules as those which govern the mechanisms of presentations already described. Fia -Relations of head and pelvis in brow mechanisms. IVIouldin^ and Caput Succedaneum. — The distortion of the head in brow presentations is very great owing to the slow progress of labour ; this in its turn is due to the relation of the head and pelvis. The frontal bone is rendered extraordinarily convex and prominent (fig. 204), and has on it the caput. The slope down to the occipital region is very steep. The diameters lengthened are the occipito-frontal and the sub-occipito- frontal ; those shortened are the cervico-bregmatic and the mento-vertical. The most posterior part of the head is, as in face presentations, compressed somewhat between the back of the neck and the pelvis. 1 68 LaboiiJ- CHAPTER XXI PODALIC LIES Undkk this heading arc included all kinds of presentation of the podalic end of the foetus, whether of the breech, of one or both feet, or of the knees. Presentation of the breech is by far the commonest, since the child during expulsion remains in the same attitude as that which it has main- tained during pregnancy. The podalic end may present in the following attitudes : Full Breech. — The thighs are flexed on the abdomen, and the legs on the thighs ; the legs are as a rule crossed so as to be closely applied to the general mass of the body. Incomplete Breech. (' Siege decomplete, mode des fesses ' of French authors.) -The legs are extended on the thighs, so that the feet are on a level with the shoulders (fig. 205). This attitude is some- times reproduced after birth, the legs, which ha\e been brought down for the purpose of aiding labour, at once flying back to their former place along the front of the child's trunk ; and in these cases it is probable that the child has lain in this attitude in the womb for some long period before birth. In other cases of incomplete breech the legs remain in their natural attitude after the child is free of the genital tract, and then it is clear that the malposition was an event of labour and not of development. Knee Prescnf(itio?t. Footling Presentation. — One or both feet may ,.-• . present. If only one, the half-breech remains on the 1* v^. 205. 1 J y side of the flexed thigh to dilate the maternal parts. This half-brccch attitude is artificially produced in most cases where version is performed, as it has the advantage of not leaving the main part of the dilatation of the passages to the head. As will be immediately seen, this is a matter of supreme importance for the life of the child. Frequency. — The proportion of podalic lies is about i in 40 of all cases. The full breech presents in about 60 per cent. (3 in 5) of podalic lies. Causes of Podalic liie. — The causes of the cephalic lie ha\e been entered into at length, and it may be said that the absence of such causes, or rather their inversion, will favour the podalic lie. Thus, where the fct-tus is the subject of hydrocephalus, its cephalic end is the larger one, and so occupies the larger end of the uterus — namely, the fundus (fig. 206). In the case oi premature children, the specific gravity of the head is found to be not higher than that of the trunk, so the presentation is, as far as this cause is McchiDiisni in lircccli Prcsciitations 169 concerned, indifferent, and the free mobilit)- of the child in tlic uterus, owing to the comparatively small size of the former, prevents the usual action of the shape of the uterus on the foetal lie. Breech presentations are for the last reason relatively commoner in cases A\here there is excess of liquor ainnii ; and laxity of tJie i/fcfine walls, a condition sometimes found in multiparie, may perhaps have a similar tendency. In the conditions existing in I'lui/! pregnancy, where the two fcKtuses form an ovoid with equal ends, there is no intluencc capable of being exerted b)' the uterine shape, and on looking at the statistics of presentations in twin labours it will be seen that, although head lies are commoner than others, the others are in greater proportion than in single preg- nancies. Podalic lies are commoner in contracted pelvis than in the normal one, for the head cannot in them rest in the brim to any extent, and is therefore readily dis- placed off it ; and moreover, the whole uterus is higher in the abdomen, and therefore more inconstant in its Fig. 206. position, being often very oblique. In placenta prcevia, the cephalic lie is less constant than in normal cases owing to the occupa- tion of the lower uterine segment by the placenta. Among podalic lies, footlings and knee presentations are in all pro- bability due to the want of close fitting between the pelvis and the head ; thus, footling cases occur oftener when the child is pi-emature than when it has reached term ; and oftener in a hydramnionic pregnancy than in one with the normal quantity of liquor amnii. Positions. — The long diameter of the breech, the bi-trochanteric, may lie in either of the two oblique diameters of the pelvis, ha\ing in each the back either to the left or to the right. The positions are named according to the direction in which the sacruna looks, and as this corresponds to the aspect of the occiput, it is easy to remember the breech positions if those of the \ertex are thought of. The numbers of one correspond to those of the other. The positions which have the back looking forward are the commoner for the same reason as that which causes this preponderance in cephalic lies — namely, the convexity of the lumbar spine ; and the sacrum more often lies to the left because of the dextro-rotation of the uterus (see fig. 64, p. 48). IMCechanisms First Breech. — Xieft sacro-anterior. This is the commonest. The bi-trochanteric diameter lies in the left oblique (in the oblique crossing that occupied b)' the antero-posterior or sagittal diameter of the child). On abdominal examination the back is found to the left, and the limbs to the right ; the globular mass of the head is at the fundus (rig. 207). The foetal heart is best heard as a rule to the left of the navel, and at its le\el or above it. I/O Labour Per vaginam the cleft between the buttocks (which corresponds to the sagittal suture) lies in the right oblique diameter, and the sacral spines of Fig. 207. — Graphic representation of what is felt on abdominal palpation in the podalic lie. Fig. 208. — First position of breech. the child's pelvis, corresponding to the posterior fontanelle, aie felt to lie near the left foramen ovale (fig. 208). Mcch(X7iisi)i in lirccch Prcsciitatunis 171 Meiliaiiisiii. — W'lien tlie l^rccch descends, the left trochanter comes to the front, owini;- to the sha|)c of the ])cl\ is, as the pelvic floor is reached ; thus Fig. 209. — Mechanism in breech presentation. Fig. 210. — Mechanism in breech presentation. bringing the bi-trochanteric diameter (4 in. nearly) into the antero-posterior diameter of the outlet (fig. 210). When the lower end of the body is pushed forward bj' the pelvic floor the trunk has to undergo a lateral flexion, to accommodate itself to the pelvic curve. The presenting part is now the left buttock, which is first felt on vaginal examination for the same reason that the anterior parietal bone is first felt in vertex presentations (fig. 210). The lateri-flexion of the trunk is combined with slight extension, because the child does not turn completely sideways to the mother ; just as in vertex cases, where the head does not rotate com- pletely into the antero-posterior of the pelvis at the outlet, but only nearly so (P- 137)- The anterior buttock appears under the pubic arch, hitches about the tro- chanter until the posterior buttock has revolved round it for a small segment of a circle, and then both buttocks are born together (fig. 211). Fig. 211. — Mechanism in Ijreecb presentation. Birth of buttocks. 172 Labour The part played by the pelvic floor in rotating the bi-trochanteric diameter into, and retaining it in, the nearly antero-posterior diameter of the pelvis is the same as its mode of action in the case of the shoulders in head presentation (see fig. 159). Immediately the hips are born, which happens at once, the position of the shoulders in the left oblique diameter of the brim (fig. 211) causes the hips to rotate back somewhat, so as to relieve the twist of the trunk. The left trochanter thus apjjroaches the mother's right thigh. This external rotation Fig. 213. — Birth of shoulJers. The child's Ixjdy has Ijeen carried forwards, producing apparent extension. The head, however, retains its Hexed relation to the pelvic walls. corresponds to the first slight movement Pig_ 2,2. of restitution immediately after delivery of the head in cephalic lies. The abdomen, and then the arms folded across the chest, in turn make their e.\it. The shoulders descend in the same diameter (fig. 212) and undergo the same rotation as the hips have just done, and the bis-acromial diameter turns almost into the antero-posterior diameter of the outlet of the vagina. The head comes down into the pelvis flexed (fig. 212). The occipito- frontal diameter lies in the transverse, tending to the right oblique, the occiput being to the left and forwards. This long diameter is rotated into the antero-posterior pelvic diameter, the forehead going into the hollow of the sacrum (fig. 213). The whole head is pushed against the lower edge of the symphysis by MccJianism in BreecJi Presentations ^73 the pelvic floor ; the nape of the neck hitches against this edge, and the face revolves round this point chin first and is delivered flexed (fig. 214), that isthemento-vcrtical diameter corresponds to the axis of the pelvis. Delivery is often delayed at the stage when the head should pass the vulva ; for the head is the part of the f(Etus which suffers most resistance from the passages, and the uterus is now contracted almost to its furthest limit, and is of very little use in expelling any part of the foetus. The vagina and the abdominal muscles have in consequence to complete the delivery. This stage is always a critical one for the child, and is often an occasion requiring assistance. As the head rotates into the antero- posterior diameter of the outlet, it causes the trunk to rotate further in the same direction as the one in which it started, and the left thigh and shoulder of the child lie in close relation with the right thigh of the mother (fig. 214). Second Breecb : Rigrht Sacro-anterior. — The bi-trochanteric diameter lies in the right oblique. Per abdomen, the back is found to the right, and the limljs to the left, the head is at the fundus. The fcetal heart is heard to the right of and above the navel. Fig. 214. — Birth of head. Fig. 215. — Second position of breech from below. Pelvis on left side. Per vaginam, the cleft between the buttocks lies in the left oljlique diameter, and the sacral spines lie near the right foramen ovale. 174 Labour J/rt7/(W/jv//.— Substituting right for left and left for right, the mechanism is exactly similar to that of the first ])osition. Third Breech : Rlg^ht Sacro-posterior. — The bi-trochanteric diameter is in the left oblique. The back is to the right and somewhat backwards, and the limbs to the left and forwards. If the heart is heard, it is on the right side. The cleft between the buttocks lies in the right oblique diameter, the sacral spines lie towards the right sacro-iliac sj'nchondrosis. Mechanism. — The breech de- scends and the riglit hip rotates forward towards the pubic arch. There is lateri-flexion and some forward flexion of the pelvis to correspond to the curve of the genital canal. The hips are born in the same manner as in sacro-anterior cases, and the child's abdomen faces the mother's left thigh. The mechanism may be con- tinued from this stage in one of two ways : (l). The -internal rotation ot the bod\- already begun by rota- tion forward of the right trochanter may go on until the shoulders come to lie in the right oblique, thus bringing the occiput forwards, and the head into the left oblique. The labour then terminates as a second breech. (2). The shoulders may come down in the same diameter of the pelvis as that in which the hips engaged, and the head will then lie in the right oblique, with the occiput backwards. If this happens, the occiput is rotated forw-ards by the pelvic floor, for two reasons. First, the head is flexed on the trunk, and for the upper part of the trunk to move forwards under the pubic arch, in obedience to the curve of the genital canal, the cun'e forwards of the foetal axis, which has already become one of some tension, would have to be much increased, if the occiput remain posterior. But the foetal axis is ready to bend backwards by extension of the head, so the foetus rotates on its axis and comes to lie in the relation to the pelvic curve where it is in the condition of least tension— that is, where its curve corresponds to that of the passage ; that is, with the back forwards. (See fig. 196.) Secondly, of the two poles of the suboccipito-frontal diameter (or one very near it) in contact with the pelvic floor, the sub-occipital is the lower. It is thei-efore guided round by the pelvic floor to the sub-pubic angle, and delivery proceeds as if the presentation were originally a second breech. The two varieties of mechanism thus depend on the moment at which Fig. 216. — Third p> if iircech. Abnormal jllcchanisms in rodallc Lies 175 rotation forwards of the back 01 the foetus occurs. In the first method it lakes place when the hips occupy the cavity, and in the second when the head comes into rehition with the pelvic floor. Rotation has been described as taking place at the time when the shoulders are in the cavity, and this would be at an intermediate stage. Fourth Breecb : ILeft Sacro- posterior. — The bi-trochanteric diameter is in the right oblique. The back is to the left and some- what backwards, and the limbs to the right and forwards. The heart, if heard, is on the left side of the navel of the mother. The sacral spines look towards the left sacro-iliac synchondrosis, and the cleft between the buttocks is in the left oblique. Mechanism. — The movements are similar, substituting left for right and the converse, to that of the third breech. Abnormal IVTechanisins In tbe Sacro-posterior Positions. If, in cases where the head descends into the pelvis with the occiput still backward, there is not good flexion, the occipito-frontal diameter which now lies across the pelvis causes a tight enough fit to bring" the bony pehis Fig. 217. — Fourth position of breech. Fig. 218. -Delivery of head, occipital posterior (i). Fig. 219. — Deliverj- of head, occipital posterior (2). underlying the muscles and fascia of the pelvic floor into play, and the head is rotated into the nearest long diameter ; that is, the occiput rotates into I j(i Labour the hollow of the sacrum. The head descends, and the occiput hitches on the edge of the perin;tuni, which lies in the nape of the neck. The head then flexes further on the chest, and the chin, nose, and forehead successively pass under the pubic arch (fig. 218). Failure of complete flexion as a cause of non-rotation forwards, and delivery of the head by exaggerated flexion, are strictly comparable to the state of affairs in unreduced occipito-posterior positions of the vertex. A rarer way of delivery of the head than by the process just described is by extension of the head at the perinteum. The chin hitches behind the symphysis, and the head revolves round this as a centre, the occiput, vertex, and forehead successively passing over the perina^um (fig. 219). This mechanism can happen with a small head only, and is no doubt caused by flexion being even more deficient than in the case of the other manner ot delivery in unreduced sacro-posterior positions. It is, in fact, an inverted face mechanism. Footling-. — In this case one or both feet may be found in the \agina or at the OS. The most characteristic part of the foot is the heel, and this, on being recognised (see diagnosis of transverse lies, p. 471), will show the direction of the occiput. If both feet come down, labour is more easy than in a full breech case until the head reaches the pelvis and meets with the resistances, at present only sufficient dilatation having been produced to allow the hips alone {i.e. without the legs doubled on them) and the shoulders to pass. The head has therefore to dilate the passages under very unfavourable circumstances, and help is almost bound to be necessary. Except for this, the mechanism is that of ordinary breech cases. If one foot only presents there is a slight difference. The foot which is down is guided by the pelvic floor to the front, turning the trunk round with it, so that the side to which it belongs comes to the front. If, for instance, the child is in the right sacro-posterior (third) position and the left leg is extended, this leg, which is at first behind, rotates to the front, and the child is born as if it had been originally in the first or fourth position. Similarly, a left sacro-posterior position is converted by the descent of the right leg into a case with the sacrum to the right. This fact is of some importance to remember in choosing the leg to be seized in turning in the case of contracted pelvis (see p. 442). The movements of the child will be easily remembered, if it be borne in mind that the back of the child turns to that side of the mother which has the same name, left or right, as the leg that is brought down. The half-breech dilates the cervix in this case, and is a better dilator than the hips alone, though not so good as the full breech. Knee Presentations.- — The mechanism in these cases is the same as that in footlings, as soon as the knees have been born and extended. IVXoulding of the Head in the Podalic Ziies. Formation of'' Caput: The 'caput'" is formed on that buttock which is anterior throughout, or Prognosis in Longitudinal Lies 177 during the passage of the breech through the vagina. The tissues of the scrotum arc often much distended with serum, and sometimes extravasation of blood occurs. The vulva in female children is affected, but to a less degree. The head passes through the pelvis in the same relative (but in- verted) positions as in vertex cases ; but the vault is not pressed on by the uterus in breech cases to the same extent as it is by the pelvic floor in vertex presentations, and so the suboccipito-frontal and suboccipito- bregmatic diameters are not reduced to any extent. The latter is, indeed, occasionally somewhat lengthened. ^//"\ The fronto-occipital diameter is ^^ ,^,^--— ^ shortened conspicuously, and the ''^^^'^^^^^^^^-^^S^'^ head becomes somewhat dome- '"'' shaped (fig. 220). Fig. 220. — Head-moulding in a breech case. , 1 -11 , !• .1 1 The dotted Hne shows the natural shape of In children born alive there can be the head, but little moulding. All that occurs must take place in the pelvis, for the child cannot remain with the shoulders born and the head on the perinaeum for more than a very short time, or asphyxia will be produced by pressure of the vulvar ring on the umbilical cord. Prognosis in Cases of Longitudinal Lie To make a standard with which the prognosis in each of the presentations we have now considered may be compared, the prognosis of the first vertex (left occipito-anterior) may be taken as absolutely good so far as mechanism alone is concerned. The second vertex and normally ending ttaird and fourth positions may practically be put on the same footing. The other presentations have in their mechanism elements, some inti^nsic, others adventitious, which modify the prognosis, either for mother or foetus or for both. Vertex, Third and Fourth, unreduced. — The head passes more slowly through the pelvis, owing to the greater resistance it offers to moulding in the diameters involved ; and, if the absence of flexion is due to slight contraction of the conjugate, this will also retard its progress while the brim is being passed. The soft parts of the pelvic canal are thus pressed upon for longer than usual, and their vitality is endangered. The fronto-occipital diameter distends the perin;tHim, and makes rupture probable in multipane, and certain in primipara\ In consequence of damage to the soft parts of the pelvis and the perinaeum, there is increased risk of septic absorption, and this may be N i/S Labour favoured also by the greater amount of nianijjulation of tlic genital tract necessitated by the malposition (see p. 197). The prognosis for the child is but little affected, unless the failure to rotate causes a very long detention and long pressure on the head. Face Presentations. — In a face presentation of any position although it may end with the chin forwards the prognosis is not so good as in vertex cases. Labour is longer (see p. 156), and, being carried on with more difllculty, small abnormalities, such as uterine inertia or muscular weakness, readily bring about a stoppage of labour, and render help — which means, in most cases, internal manipulation of some kind — necessary. The child has its neck much extended, and the vessels and other structures in front of the spine stretched and possibly damaged. This effect is most marked, however, when the chin does hot rotate forwards, and the front of the neck and the chin have to accommodate themselves to the concavity of the sacrum (see fig. 198, p. 164). In the unreduced cases the mother runs risks from the arrest of labour \\hich must occur, and all the results of prolonged labour, constitutional and local, may ensue (p. 408). Here again the necessary introduction of the hand or instruments adds to the danger. Prolapse of the cord (see p. 514) may endanger the foetus in any position of the face. Brow Presentations. — The prognosis is distinctly bad here ; that is, of course, in those cases where conversion into a face or a vertex does not take place. The woman is open to all the results of prolonged labour, and the effects of manipulation and the use of instruments needed to reduce the size of the head (craniotomy). If delivery occurs without any help, as it may rarely do with a small child and vigorous uterus, the perinieum is certain to be freely lacerated. The foetal head must be considerably compressed during its descent, and the nervous centres may be permanently damaged e\en if delivery be possible without perforation. Brow cases with the chin backwards arc the most unfaxourable of this group. Pelvic Presentations. — Tlie mother's chances arc not affected on account of the podalic lie, except that in primipara\ if the trunk has passed through the canal too rapidly, the latter may not be sufficiently dilated to allow the head to pass without some laceration. The child is, however, in considerable danger if all does not go \ery well as the head reaches the perina:;um. For then the uterus is empty of all but the placenta and a section of the head, and is contracting strongly on this, and cutting off the supply of oxygenated blood to the foetus. The placenta may even be detached by this time, partial!)- or entirely. The cord is being compressed between the head and the parturient canal. Asphyxia is thus produced ; and as the cold air is stimulating the surface of the child's Prognosis in Podalic Lies 179 body, the chances are that attempts at respiration will be made, and the child in its gasps will suck mucus, liquor amnii, and blood into its trachea and lungs, and speedily suffocate unless the head is rapidly extracted. In breech cases, too, prolapse of the cord (see p. 514) is more common than in vertex presentations, owing to the imperfect fit between the breech and the lower uterine segment. In third and fourth unreduced breech mechanisms, the delay in delivery of the head is necessarily greater, and the prognosis for the child pro- portionately worse. The stcrno-mastoid muscle of the child is occasionally iiamagcd and a hi'ematoma is produced (see p. 581). i8o MANAGEMENT OF LABOUR CHAPTER XXH c;knkral principles of maxagemf.nt In the management of all cases of labour there are two essential functions which the medical man has to discharge — namely, that of assisting the woman where necessar)- during the actual processes of labour, and that of protecting her from any infection which might be imported from without. He will assist to prevent — 1. Undue prolongation or complete arrest of labour from any cause, maternal or foetal. 2. Accidents during labour, such as hcemorrhages and lacerations. 3. Retention of any part of the ovum. 4. The spread of septic or specific [e.g. gonorrhoealj inflammations intO' the deeper parts of the genital tract. 5. Accidents to the child. He will protect the woman from — 1. Septic diseases. All sepsis is imported from without, either by air — as in hospitals where there are suppurating wounds, by the hands of the doctor or nurse, or by instruments. 2. Specific fevers, such as scarlatina, and others. In performing these duties there is another matter to be attended to, namely, the accomplishment of the labour with as little pain and discomfort as possible : this will include the use of anaesthetics, and the care of a number of small details, which often in the patient's eyes constitute the most important part of the matter. It may be said with perfect truth that the course of events, as far as the ultimate result to the woman is concerned, is, in an o\erwhclming number of cases, in the hands of her medical attendant and her nurse. Sanitary iirrang^ements of the House. — The house in which a woman is about to be confined should be ascertained to be as free from defects as regards drains and the arrangement of water-supply as can be managed at the present day. The possibility of sewer-gas finding its way into the lying-in room by means of water-closets or sinks must be carefully inves- tigated. That contamination of the air by this gas is a real source of illness there is no doubt whatever, and this is well shown by a series of Antiseptic Measures l8i cases published Ijy Plu)fair. It has not, however, been sliown to produce septicaemia, though opinions on this point differ. It certainly may depress a patient and make her ill, and should therefore be strictly guarded against. The bedroom in which the labour is to take place, and in which the patient will remain during the greater part of the lying-in period, should be as large and airy as pocsible, as a large room is more easily ventilated without ■draughts than a small one. It should also be well lighted, and not have its windows looking on to a blank wall, both for the sake of the patient and the ■doctor ; for patients undoubtedly convalesce better in the light than in the depressing influence of a dim, semi-obscure room, and the medical man wants as much light as can be had, so as to observe his patient accurately. The temperature should be kept at 60° to 65° Fah., and free ventilation should be insured. If the woman is nervous and sleeps badly, a quiet room is essential. If it can be obtained, another room in communication with the lying- in room is useful, as the baby may be washed and attended to in it, and the many necessary preparations made of douches, food, and so on. The nurse can sleep there for a few nights, and the medical man, if he is •obliged to stay in the house for many hours, can be within call, and yet not be too much in evidence when he is not actually wanted. The patient can after some days be removed into this room occasionally for a change. The bed should be hard enough not to form a pit where the patient lies, and really the harder it is during labour the better. A feather bed is out ■of the question. A rather narrow bed is desirable, so that both sides of the patient can be easily got at, and anaesthetics, if needed, can be more ■easily given. A wide bed is perhaps more comfortable after labour, for the patient can change her position sometimes, and move from one side of the bed to the other before she is able to be moved off it altogether. A mackintosh sheet, over which a draw-sheet is arranged, must be placed under the woman, and it is a great advantage to have over this a square cushion made of absorbent wool, which can be burnt after it is soiled with discharges.' It will be found useful to have two such squares, or ■even more, in case the second stage is a prolonged one. Antiseptic Measures The principles of asepsis in the case of midwifery are identical with those :governing the practice of surgery. We owe the beginnings of our present knowledge of their paramount importance in midwifery to Semmelweis of Vienna. In 1847, while he was in charge of one of the lying-in wards of the General Hospital at A'ienna, he found a terrific mortality— namely, one of about 12 per cent. — among the women treated there. The death of a colleague from a poisoned dissection wound suggested to him the probability that students coming straight from the dissecting-room, with hands only hastily washed in soap and water, were the carriers of poison of a similar kind, and that they probably inoculated the patients when they made \aginal examinations. ' Such squares of tissue, nieasuiing 32 in. by 32 in., are to be obtained from the Sanitary Wood Wool Company. i82 Manngeuie)it of Lab our He issued orders that any person about to examine a patient should, after washing his hands, rinse them thoroughly in chlorine water, or in chloride of lime solution. The mortality of 12-24 'n the May of this year went down to 304 per cent, in the months following to December. A case of cancer of the uterus in a parturient woman was admitted during this period, and of twelve patients examined immediately after she had been examined, all died of septicaemia but one ; and a case of caries of the knee caused eight fatal cases. Semmelweis came to the conclusion that 'not particles from dead bodies alone, but any material in a state of decomposition proceeding from living organisms ; even air, contaminated from such sources, may generate symptoms of puerperal fever. Scrupulous attention to the use of dis- infectants, combined with separation of patients affected with the disease,' brought the death-rate down to r27 per cent.' The mortality in lying-in hospitals has until recently been far in excess of that in private cases, and the most marked triumph of the use of antiseptic measures has occurred in such institutions. In the history of the General Lying-in Hospital there are accounts of epidemics of ' puerperal fever in which the death-rate was an awful one ; 19 out of 71 in the year 1838, 9 out of 63 in 1887, and cases of septicaemia were nearly always occurring.' "^ Cullingworth finds the total mortality of the hospital from 1838 to i860 to have been 3'o85 per cent., declining to i-6 per cent, in the period 1861 to 1877, and to o-6i8 percent, in the years 1880 to 1887 inclusive. Antiseptic measures are to be credited with the saving of very nearly all the lives indicated by the differences in this series of percentages. If the principles of aseptic midwifery could be perfectly carried out, there should be no deaths from septicaemia, and, what is more, no illness. The unavoidable deaths in childlDed, which are caused by other abnormalities than septicEemia, may be taken as about -2 per cent., and this at present is the ideal death-rate.* Stress is to be laid on viorbility as distinct from mortaliiy. That a patient may be very- ill from septicaemia, and yet not die, is obvious, and such cases would not be included in a death-rate. The women who survive such illnesses are infinitely more numerous than those which succumb, and hence the importance of this group. Many of them are rendered invalids for long periods, or possibly for the whole of their lives, by the disease which occurs at the time of child-birth. It is, therefore, satisfactory to know that the morbility has diminished to 1 Duka. - Cullingworth. ^ Septicasmia is shown to be practically controllable by the following facts. For five, years there has been no case of septic disease in the General Lying-in Hospital unless the patient has come in already infected. In consequence of, and proving this, only 3*3 per cent, of the patients were obliged to be kept in the hospital longer than fourteen days after labour. During the year 1895 only one case died of 535 admitted, and this fatal case was moribund from ruptured vagina and exhaustion on admission. The 535 cases included 25 cases of contracted pelvis admitted for induction of labour, and other abnormal labours in a far larger proportion than would have occurred in any 535 cases taken from general sources. A titiseptic Method 183 ;i greater extent even than the mortality, and tliat this is entirely owing to the antiseptic treatment of labour. The influence of the antiseptic method is not confined, however, to the prevention of septic processes alone ; but, taking it in its broadest sense, it is equally applicable to other infectious diseases which are liable to attack the lying-in woman. This part of the subject will be more fully dealt with in the chapters dealing with the puerperal fevers (p. 525). Antiseptic Method. — The medical man, in deciding, as he must do in bare justice to his patient, to conduct labour on antiseptic principles, should determine exactly his line of action. There are two very important points to bear in mind. First, the dciails III it si be as simple as possible, for they will have to be carried out mainly by the nurse, and complicated directions may possibly lead to the neglect of all principles and details together. Second, as antiseptic materials (including soap) will have to be used, only those should be employed on the same case as are compatible with one another, for it is found that some of those in more common use cause mutual decomposition, and both are thus rendered useless. Impromptu combinations are therefore undesirable, unless the user is well acquainted with the chemical characters of his materials. Soap decomposes perchloride of mercury, iodine, and permanganate of potash ; but, of course, excess of a solution of any of these drugs will prevent any appi'eciable interference with their action. Carbolic acid and per- manganate of potash are incompatible. Carbolic acid can be used with soap without decomposition occurring. The following table, copied from BoxalV shows these characters - : — .0 ■0-3 6'' 4) c '■3 1^ > > J 1 a § Perchloride of mercury . X _ _ _ _ X Carbolic acid sol. . X — X X ■ Iodine sol. (in iodide of X X X potassium) Salicylic acid sol. . X X Potassium permanganate — X — X — X X X The absolutely necessary part of aseptic midwifery is cleanliness. Without this the use of antiseptic drugs is of little or no advantage, and an)- good that may accrue from their employment apart from cleanliness is more than neutralised by the false security produced in the mind of those in charge of a case. In the majority of laljours cleanliness is probably all that is needed ; but the possibility of the existence of infective material on the hands of the Fever in Childbed,' Obstct. Trans, vol. 32, p. 270. - An X shows inconipatibihiy. 1 84 Management of Labour medical man or nurse which cannot be entirely removed by simple washing makes it advisable to use some antiseptic to destroy such matter. The following directions may be considered to include what is essential in the greatest number of cases. Essentials.— The first and most important point to be observed is that the hands shall be germ-free. This holds good of the medical man and the nurse equally ; and while compelling the nurse to adopt stringent rules on this point, the doctor must not think that he is exempt, and can without danger employ an un'washed finger to examine his patient. The hands and especially the nails should be carefully brushed with hot soap and water and then placed for a quarter of a minute in some antiseptic solution, the best being a i-iooo solution of corrosive sublimate, in all cases before the genitals are touched. This process must be repeated each time an examination or manipulation has to be made. A basin containing enough sublimate solution to completely cover the hands when immersed must always be kept ready for use. This solution is to be kept at the bedside and renewed occasionally during labour, and once a day during the lying-in period. The external genitals and their neighbourhood must be washed well with soap and water before labour, and then swabbed over with a i-iooo subli- mate or 1-40 carbolic solution. This washing of the external parts is most important, and must be repeated daily during the puerperium. It is ad- visable not to use an ordinary sponge for this purpose, but a piece of absorbent wool or an artificial sponge, which must be burnt after use. All catheters and vaginal tubes must be washed before and after use, and then placed in an antiseptic solution for a few minutes ; it is better to keep them in such a solution at all times when they are not in use. Mackintosh sheets and bed-pans must be washed and rinsed with the solution before and after each time of use. Everything absorbent that becomes contaminated with blood or secre- tions must be at once removed from the room, and if of wool or wood-wool, burnt. For lubricating the fingers before an examination per vaginam, a solution of sublimate (i-iooo) or carbolic acid (1-40) in glycerine is the best material. \'aseline is not good, although it may be convenient, since it is impossible to make it aseptic, and it is difficult to wash it off. Animal fats and oils are dangerous. The sublimate solution cannot be used for lubricating metal instruments, as mercury is deposited on them, so that where forceps are employed, carbolised glycerine is the more useful of the two ; or a combination of pure soft soap and carbolic acid (5 per cent.) is convenient and safe. When antiseptic solutions are prepared for use by diluting stronger stock solutions, or by dissolving solid substances, no guessing at quantities is to be permitted ; everything must be measured. It is safer and much more convenient in private work to use as far as possible solid tabloids made to contain enough of the drug, say of sublimate, to make a solution of a given strength by dissolving one or more in a certain quantity of water. The nurse should be instructed to arrange three basins on the table in DoucJiing. List of Special Requisites 185 the lying-in room : one in which the hands are washed with soap and water ; a second containing the i-iooo sokition in which they are dipped ; and a third containing a similar solution, in which the catheter and douche-tube are constantly kept. If it is considered advisable to use vaginal douches, the occasions for which will be mentioned as they arise, an irrigator is better than a Higgenson's syringe. Irrigators are now in almost universal use, for they save the trouble of pumping, they can be easily used by the woman her- self in almost any attitude, and, as they act merely by gravity, they supply a constant stream instead of the intermittent one of the syringe. There is in the use of the irrigator much less chance of forcing air into the genital pas- sages, and a source of danger is thus avoided. The syringe also, when it is in ' diastole,' draws fluid back through its nozzle as well as from the vessel containing the solution, and small clots and other debris get sucked back into the vaginal tube ; these may decompose, and be subsequently injected into the vagina, or, at any rate, they block up the holes in the end of the nozzle. Two quarts is a suitable quantity of solution for a douche. The douche- tin should be hung about three feet above the level of the patient. The strength must vary in different cases. If there is no special indi- cation for an extra strong solution, about 1-5000 sublimate or 1-60 carbolic acid is quite enough. (See p. 526, Septicaemia, &c.) The whole question of the necessity for systematic douching is discussed in the chapter on the Management of the Puerperal Period. Some weeks before the expected labour the mother or the nurse should be supplied by the physician with a list of the articles and drugs which he Avill require, and they must be kept in readiness. The list found at the bottom of this page will be found to contain all necessaries, and it may be modified according to the tastes of the individual medical man. The fii'st summons to the case must always be obeyed- at once, for, in addition to affording mental relief to the woman by his presence, the medical man can make an approximate, or possibly an exact, diagnosis of the kind of labour likely to take place. If there is any malpresentation or other abnormahty, he will be in the best position to rectify it at an early stage of labour, or he can at all events prepare to encounter it. He may, by delaying, allow a transverse presentation to become impacted, for instance ; or the patient and her uterus to become tired out in a case of contracted pelvis ; or he may lose his patient from haemorrhage. List of Spcciat Requisites Four dozen wood-wool ' towelettes,' large size. Two or three wood-wool sheets, 32 x 32 in. The wood-wool may, with advantage, be impregnated with sublimate. Four binders, made of huckaback towelling, 36 in. wide and I5 yard long. Large pins for securing the binder. Gum-elastic (male) catheter. No. 8. A i-iooo solution of hydrarg. perchlor. in glycerine ; 4 oz. in wide-mouthed, glass- stoppered bottle. Tabloids of hydrarg. perchlor. or ' iodic hydrarg.' to make solutions. Chloroform, 4 oz. A douche-tin, 2-quart size. 1 86 Management of Labour CHAPTER XXIII MAXAGKMKNT OF THK FIRST STACK OF I.Ar.OUK On the arrival of the medical man he has to make out whether the woman is in labour or not, and if the labour is so far normal. The diagnosis of the commencement of labour has been dealt with in the chapters on the Progress of Labour, and the possible fallacies pointed out. If the pains which suggest to the woman the need of assistance are due to irregularity of the bowels a dose of some purgative must be given, unless the bowels have been recently quite satisfactorily opened. In this case a sedative, such as 5 to 6 drops of Tr. Opii, is likely to be of most service. If it is clear that labour has net begun, the lie of the foetus should be made out by abdominal examination, and if it is one of the normal lies, the patient may be left. If on the other hand, labour has set i/i seriously^ it will ha\e to be decided whether it is safe to leave the patient, and if so, for how long. The points to take into consideration are : whether the woman is a primipara or a multipara ; the amount of shortening or of dilation of tlie cervix already attained, and the dilatability of the cervix ; the history of pre- vious labours, if there have been any ; regularity of the pains. The axerage durations of labour in different classes of parturient women ha\c been already compared ; they may be here recapitulated. First Second Total Multiparse 8 1-2 10 hours Primipane . . . . .16 3-4 20 ,, Elderly primiparac (over twenty-six) 20 4-5 24 ,, To avoid discussing in full c\cry possible combination of conditions, two crfses may be taken. Suppose a young primipara has begun the first stage and her cervix is nearly obliterated ; the pains are regular, say every ten minutes or so ; she may, as a rule, be left for three or four hours with safety, if all is going on normally. A multipara with a history of rapid labours, and with easily dilatable passages, with the membranes, bulging through the internal os, and with regular pains, should not be left at all. Between these two extremes each case must be judged on its merits and by the light of personal experience, remembering always that it is better to stay too long and come too often than to be out of the way at the critical moment. After making out as completely as possible by abdominal examination the lie and position of the child, the physician must ascertain the state of the genital passages, and especially that of the cervix, by vaginal examination. The womaii is to be made to lie on her left side quite at the edge of the bed, and to draw up her knees. This attitude is almost universal in Great IMnnagemcjit of First Stage 1 87 r>rit;iiii, and is known abroad as the 'English position.' 'I'lie advantages o\ei" the dorsal one, which is used on the Continent, are that all necessary manipulations can be carried on at the edge of the bed within convenient reach, without disturbing'' the woman more than is necessary ; she does not see what is happening, or how much she is exposed. A disadvantage is that the uterus is deprived of the assistance of gravity in expelling" the child. In case of there being marked anteversion of the uterus, the lateral position does not correct this, and the dorsal one does. These objections are, however, comparatively unimportant, and are more than counterbalanced in ordinary cases by the advantages of the left lateral position. (During the stage of dilation the patient need not remain in this position longer than is necessary for examination.) The first examination should be made during a pain, for the woman is not at that time so much alive to the discomfort that may be caused, being- otherwise occupied. The bladder should be empty ; at this stage the woman is able as a rule to pass water without the aid of a catheter. The rectum must also be cleared by an enema, if necessary. At the beginning of his experience the student will find some difficulty in remembering the altered, relation of the various diameters to the horizon brought about by the lateral position of the patient ; but the difficulty will soon be got over, and the diagrams illustrating the various positions will help in this particular. The right forefinger, made aseptic and lubricated, is passed into the vagina and up to the cer\ix. The cervix is not always easy for a beginner to find, it is sometimes so very soft, especially in primiparte, and so slippery. The foetal head is often bulging the anterior vaginal wall forwards and downwards, thus concealing the cervix above and behind it (see fig. 61) ; and the anterior uterine and vaginal walls may be very thin, and closely resemble the bag of membranes. The parts should be handled very gently so as to a\oid rupturing the membranes, if these are protruding, or abrading the surfaces of the cervix and vagina. The vagina is found to be well lubricated with mucus from the cervix if labour is proceeding normally, and the freedom of the genital tract from cicatrices or other obstructions (e.g. pelvic deformities) should be noted. If a pain is present when the cervix is touched, the exact amount of dilation can be made out, since the membranes bulge through the opening and define it completely. In a primipara, if the membranes ha\'e not yet reached the external os, the amount of real shortening will be estimated, (see p. no). The edge of the distended os in i-panc and in multiparje respectively has been described. A soft thick edge in a primipara means, as a rule, rapid and safe dilation. The edge is often thin at first, and may thicken afterwards to a \ariable degree. If any difficulty arise in reaching the cerxix on account of bulging of the anterior uterine wall, the patient should be put on her back and the cer\ix brought forward by pushing the fundus backwards with the other hand laid on the abdomen. 1 88 Management of Labour If no effect is produced on the membranes by pains, and no dilatation of the OS occurs at the moment of one, the pains are of no use, and are either * false pains ' — that is, merely a colic of the uterus — or their failure to advance labour is due to one of the causes described in the section treating of abnormalities of labour. If slight dilation has taken place, the failure to bulge on the part of the membranes during a pain may be due to adhesions of the membranes round the internal os, and this can be remedied by detaching them from the uterine wall by passing the finger round the circumference of the os. The presentation should now be completely made out ; and if a vertex, face, or breech is found at the os, one cause of delay in labour — namely, a transverse lie — is excluded. This will, however, have been done in almost ever}- case by the previous abdominal examination. If a pain be present, or comes on while the diagnosis is being made, and the membranes bulge and become tense, the examining finger should remain in contact with the cervix, but quite still, for fear of rupturing the membranes. WTien the pain goes off the presenting part can be identified. If any doubt as to the roominess of the pelvis is now suggested by the woman's stature or appearance, or by the history of pre\ious labours, an estimate of the conjugate measurement, and of other measurements if necessar}-, must, if the pelvis has not been already measured, be made at this time. (For indications and method of examination, see p. 415.) All the above data — namely, the presentation, the formation of the bag of membranes, the amount of dilation, the permeability of the parturient canal, and the condition of the rectum — should be obtained at one examination if possible, and the patient left alone until the membranes rupture, if this occurs within a reasonable time. Frequent examinations afford no fresh information, and they irritate the patient. They tend in some cases, too, to cause spasm of the cer\-ix, and thus to actually retard labour. The woman should not lie do\\Ti until nearly the end of this stage of labour, but she should rest when necessary- in a chair. Her uterus thus con- tinues to be assisted by the action of gravity. There is no need for the medical man to remain constantly in the room during the dilation of the cervix, if this is going on normally ; and the pains will go on all the better for his absence. A careful examination should be made to see if there is any purulent vaginal discharge. If this is present, a douche of 1-2000 solution of corrosive sublimate should be given, both to prevent the secretion from being carried within the internal os by the finger, and thus causing infection of the interior of the uterus, tubes, and peritoneum, or the inoculation of abrasions ; and to prevent infection of the eyes of the child as it descends through the vagina. This douche must be repeated if the first stage is unusually long. Instead of corrosive sublimate, which has been found at the General Lying-in Hospital to tend in primipane to cause rigidity of the perinicum and a greater tendency to rupture, a solution of carbolic acid may be used. .•\s the pains usually increase in frequency just before the end of the first stage, this sign will suggest the necessity of the patients lying on the bed at short intervals, so as to be prepared for rupture of the membranes. She should lie on her back, jMid have an absorbent sheet and a mackintosh beneath her. Condition of Bladder —Artificial Rupture of Membranes 189 The condition of the bladder must receive attention ; a full bladder is a frequent cause of delay in the expansion of the cervix. If there is any retention of urine on account of an already low position of the head in the pelvis, causing pressure on the urethra, a catheter should be passed. A No. 8 male gum-elastic one is the best. Passage of a catheter. — In passing a catheter at this stage, and at all times in future, care must be taken that there is no vaginal discharge at the urethral orifice to be carried into the bladder by the instrument, for the septic organisms thus imported frequently cause cystitis. The vulva, which has already been well washed with soap and water, should be swabbed with a 1-2000 solution of sublimate or its equivalent in carbolic acid or other antiseptic immediately before catheterism ; the catheter and the hands will of course have been made aseptic previously. The altered direction of the urethra at this stage must be remembered (pp. 1 16 and 1 17). When, taking the average length of the first stage, the time has arrived at which the os may be expected to be fully dilated ; or if the pains have become very frequent, and yet no gush of liquor amnii has shown that the waters have broken, an examination should be made, and if the os is found fully dilated (see p. 113), the membranes should be artificially ruptured. The disadvantages of delayed rupture have been explained (p. 115). Care must be taken not to rupture them before full, or nearly full, dilation has taken place, for reasons gi\en at the same place. Rupture should be accomplished by scratching through the membranes with the nail while a pain is rendering them tense. If they are too tough for this, a sound, or the stilet (aseptic) of a catheter, may be used with great care. As on rupture the fore-waters will be at once discharged, a vulcanite or porcelain tray should be placed to catch them. Any abnormality, such as the presence of meconium or discolouration, can then be noticed (see p. 29), and the bed is kept dry. The quantity, too, is of importance ; an unusually large quantity, say over half a pint, suggests that the presenting part is not filling the os, and that it may be a breech, or a shoulder, or there may be some contraction of the brim. The child's heart is now to be listened for per abdomen at inter\-als, to ascertain if it is alive and vigorous, or if there is need for rapid delivery. Immediately after the membranes have iniptured, an examination must be made per vaginam, so as to accurately diagnose the presentation, if this has not been already accomplished, and to be ready to deal with any abnormality that may be found. 100 Managcinoit of Laboii'y CHAPTER XX I \' 'management of the second and TlIlkD STAGES OF LAHOUR Second Stace The woman should now lie down all the time : not necessarily on her left side, except when an examination is to Ijc made or when the head is on the perinaeum. An arrangement for helping the jjatient in her bearing- down efforts can be made by letting her lie so that her feet are flat against the foot of the bed, and giving her a towel fastened to the foot-rails to pull upon. The pains are probably by this time causing enough suflering, especially in a primipara, to make a little chloroform welcome, and this will by- diminishing the suffering induce the patient to bear down more freely (see chapter on Anaesthetics). The anfesthetic is only to be given when a pain is beginning, and to a very slight degree. Note is being taken of the steady advance of the presenting part at each examination, and of the particular mechanism in action. If the anterior lip is pushed down in front of the head, it should be reduced by gentle pressure upwards during a pain as soon as diagnosed ; for if allowecl to remain it soon becomes ocdematous, and may cause delay ; besides this it is liable to be damaged itself, and becomes a cultivation- ground for septic organisms. As long as labour is found to be progressing, although it may seem slowly, there must be no interference ; and further examination must not be made until the head reaches the perinjeum, unless another douche is needed on account of the accumulation of more purulent discharge in the vagina. W/ien the perinceiim is distended -Awi^ the anus dilates, the effect of each pain on the perinjeum must be carefully observed, and the physician, rcmem- iDeringthe change of direction now occurring in the path of the head (p. 1 16), must be ready to assist the floor of the pelvis in effecting this change, if the occiput does not seem to be taking full advantage of the space under the pubic arch. He may therefore during each pain la\- his left hand with its palm flat on the perina^um, making it in fact a second layer of pelvic floor, and tending to push the head forward under the pubic arch. Great care must be taken in doing this not to begin to .push too soon, as by doing so the head is not allowed to protrude sufficiently to place the angle at the nape of the neck in relation to the under surface of the symphysis. If this does not take place, the vulvar orifice is stretched by a diameter near the occipito- frontal, rather than by the smaller suboccipito-frontal (see figs. 221 and 222), and more harm is done than good. So that the perinieum had better be left to take its chance than be interfered with unskilfully. There was formerly great difference of opinion as to whether the periniuum should be supported or whether it should not, and each side was able to bring forward statistics to show that their view was the correct one. Some solution of the difficulty Alanagcnient of Perinceuni 191 ^vill probaljly be found in the above explanation of the disadvanta^^c of pre- mature and the advantage of timely support. The left hand is to be laid over the perinaeum with the thumb extended, and the radial border corresponding roughly to about where the coronal suture is judged to lie — that is, a little behind the anus. The head should be allowed to bulge the perina^um freely as long as there is only slight dilation of the vulva, for the gradual stretching and relaxation thus obtained tend to avert laceration. When the posterior part of the pelvic floor becomes an active agent in expulsion — that is, when the bi-parietal diameter is through the posterior ring's of the contractile tube — the head, according to the principle just mentioned of allowing the nape of the neck to reach the edge of the symphysis, should be gently pushed forwai'd. As more and more of the head is extruded and the critical circumference, the subocci pi to-frontal (which, it will be remembered, nearly cuts the Fig. 221. Correct. Fig. 222. Incorrect. SbO F, suboccipito-frontal diameter; FO., fronto-occipital diameter. parietal tuberosities), comes to occupy the vulva, the woman, if not under an anaesthetic, must be told not to bear down more than she can help during the pains, but to cry out and thus relieve the perinasum. The too rapid advance of the head can be regulated by the right hand, the fingers of which are to be laid for this purpose over the occiput. In the intervals of pains an attempt should now be made to squeeze the forehead over the periiKTum edge. This passage will be made during an interval with less chance of laceration than during a pain, for the muscles of the pelvic floor are relaxed. When the head seems to be completely born, it should be made out that the chin has cleared the perinasum, and if it has not, it should be extricated by gently pushing the edge of the latter backward on to the neck. In primiparte laceration of the vaginal orifice (the base of the h^mcn) practically always occurs, and the laceration may vary in depth and in super- ficial extent. Usually the tear is continued on across the fossa navicularis to 192 Management of Labour the fourchcttc, and tlicn makes itself evident on the surface. In slight cases of laceration the bottom of the fossa may escape, and the laceration may involve the base of the hymen and the fourchette only. It is quite exceptional for the latter to escape. The tearing, if slight, is done by the suboccipito-frontal diameter only, l3ut it may be begun by earlier diameters, and will then be extended by the passage of the largest distending diameter. Severer lacerations will be considered later. The object of assisting the pelvic floor in the way just described is to minimise the tears which are liable to occur. When the patient is anaesthetised the physician has more control over the movements of the head, since the abdominal muscles do not contract so violently during the pains, and in the intervals the perinjeal structures are relaxed. It is therefore advisable, in all cases where the perinaium is likely to be inelastic as in elderly primiparas, or when the perina^um is rigid from cicatrices, or unusually long, or where the patient is unable to exercise a moderate amount of self-control, to give chloroform to remedy more or less completely these drawbacks. Local applications to the perinaeum are probably ot little value, but hot fomentations and inunction of grease or oil of some kind have been recommended and are practised by man)'. Stretching the perineum digitally while the head is still abo\e the level of the pelvic floor may possibly be of some service ; but it is not easy to satisfy one's self that much advantage has been gained. If, however, it is thought well to try it, it is done during a pain by hooking the forefinger o\er the perinteal edge and stretching it towards the sacrum occasionally. If it be not too roughly done no harm accrues. There is one procedure which, however, may be mentioned as a thing to be avoided. It is the operation known as cpisiotomy. It consists in anticipating a tear by making an incision or two incisions through the perinaeal edge for about three-quarters of an inch. It is said by those who advocate it that this clean incision heals better than the expected laceration. The cut is to be made backwards and outwards from one side of the fourchette towards the tuber ischii of the same side, and one cut may be made ; or two, one on each side. This will possibly enable the head to pass the vulva more rapidly, but this is all that can be said for it. On the other hand, it is in the first place never certain that laceration will occur at all, and the cuts may be useless, and, what is more, afford an entrance to septic matter. In the second place, laceration may occur, even when episiotomy has been done. In the third place, a tear made by the head, if properly sutured, heals most satisfactorily, even when it extends into the rectum, and in these severer cases episiotomy would be useless. It is therefore not to be recommended under any circumstances, unless a dense cicatricial condition of the perinieum is found, when possibly some harm might be averted by a central incision carried as far as the sphincter, if necessar)' Such a cut ensures the greater part of the tear being made through the middle line, where there are fewest vessels. When the head is bo?-/! the neck should be examined to see if there is a loop of cord round it. If one is found, or there maj- sometimes be two turns, a little more cord may be pulled down and the loop slipped over the head. Managcmc7it of Third Stage. Tying the Cord 193 If the cord is too tight to be pulled down, the loop may be passed over the shoulders as they emerge, and if this is impossible, it must be divided and tied, or a clip put on each divided end until the child is delivered. If labour be allowed to go on with the cord round the neck, the child may be strangled by the loop, or the placenta ma)- be detached, and in any case the delivery of the shoulders is delayed. The right knee may now be raised by the nurse, so as to afford more room for the occiput to travel up in front of the symphysis. As the shoulders emerge the perinreum must be watched, and the uterus should be followed down by the left hand on the abdomen ver)' carefully, if there seems to be any tendency to relaxation. Occasionally there is a little delay in the passage of the shoulders owing to the resilience of the perinseum, and the child gets blue in the face. In this case the head should not be forcibly pulled upon to the danger of the neck, but the neck should be pushed against the perinasum to allow the anterior shoulder to come down. The shoulders can then be extracted by passing a finger under the posterior axilla (see fig. 361). As a rule, however, it is better to express the foetus by the hand laid on the abdomen, unless there is need for hurry. There is no great danger in congestion of the head if this is not allowed to continue for more than one or two pains. The child is now partly lifted, partly guided on to the bed, where we may leave it for the present, having seen that it begins to cry and to breathe satisfactorily. Its eyes should receive attention at this moment (see p. 240). Third Stage The third stage should receive the most careful attention. On its proper management depends to a great extent the welfare of the woman in the lying-in period. The uterus must now be carefully looked after, and light but steady pressure must be kept up until some time after the expulsion of the placenta and membranes. The nurse can relieve the medical man if his attention is needed for the child. Tying- the Cord. — It was formerly the practice to tie and divide the umbilical cord immediately after delivery, but it has been shown that by doing this the child is deprived of about three ounces of blood, which is the equivalent of about three pints in an adult. If the cord is left untied for five or six minutes, these three ounces of blood are allowed to flow in from the placenta. The forces bringing this about are the aspiration caused by the filling of the child's lungs, and the new pulmonary circulation (see p. 236) ; the slight compression of the placenta as the uterus retracts and contracts ; and the gravitation of the blood towards the child as it lies on the level of the bed. The time to tie the cord is when the umbilical \ein collapses, or a rougher test is by observing when the pulsations in the cord have nearly ceased. If complete cessation of pulsation is awaited, there will be no harm done ; but it is unnecessary to do this, for the arteries can be felt beating for some time after all the blood which the child will gain has passed into its body. O 194 Management of Labour Children who obtain the amoimt of blood above mentioned are found to be more vigorous during the first few days than children whose cords have been tied at once. The process resembles what would happen if the woman were to be unassisted, as she might be in a state of nature, for then the placenta would l)e expelled still attached to the child. It has been said that jaundice follows late tying of the cord in a larger ])crcentagc of cases than occurs in those children whose cords are tied at once. That this is an a priori argument, founded on the idea that the excess of blood corpuscles thus finding their way into the circulation must dis- integrate and by the colouring matter set free cause staining of the tissues, is shown by the observations of Schmidt,' who found that when the navel-string was tied at once 72 per cent, of the childien were jaundiced, while in those children where ten minutes were allowed to elapse before tying only 42 per cent, were jaundiced. He also found that the most intense cases occurred where the cord was at once tied. As regards the weight of the child after a fortnight, those children whose cord was at once tied gained on an a\erage 12-3 grammes, while those whose cord had not been tied for fifteen minutes gained 489 grammes. It is better not to compress the uterus while the placenta is still attached to the foetus, nor to raise the placenta above the child if it has been expelled before ligaturing, as this might conceivably lead to the entry of undesirable material into the child's circulation. The cord is usually tied in two places, one at about two inches from the umbilicus so as to allow of re-tying if the ligature slips, the other an inch or so nearer the placenta, and is divided between the ligatures. The second ligature is of no use except to prevent a mess, and if pulsation has ceased there will be little or no blood to run from the cut end (placental). If, however, there is a second child in the uterus the matter is different, since its vessels may communicate in the placenta with those of the first, or the two cords might be joined near the placenta. In the case of twins, then, the cord must be tied twice. In other cases it is a matter of indifference. After the cord is divided the child is given to the nurse, who has had her hand on the uterus during this process. If the child is not crying and breathing properly after its entire body has been born, its mouth and fauces should be carefully wiped free of all secre- tions, and external stimuli, such as sprinkling the chest with cold water and slapping the buttocks, should be applied. If these measures are insufficient, treatTTient according to the rules for reviving stillborn children must be adopted (p. 5:20). In cases where the mother has had a good deal of chloroform during the labour, the child is often slow in responding to the stimulus of the external air, and often requires considerable encouragement before it cries freely. Supposing all is going on well \\ ilh the child, it may be laid aside in a flannel receiver, and attention paid to the uterus. The management of the uterus must now be conducted according to the following rules : — (i) The expulsion of the placenta and membranes from the uterus is to be effected as far as possible by uterine contractions alone. Therefore the ' Airhiv.f. CiY't. vol. xlv. 1894. Maiiagcmciit of T/n'n/ S/a^qc 195 ]ilaccnta must under ordinary circumstances be neither forciljly e\|)resscd nor pulled out. 'I'his tends to ensure (2) and (3). (2) The expulsion must be complete. To ascertain this, very careful examination of the placenta and membranes after expulsion must l)e made, with a view to find out if any portion has been left behind. (3) Retraction is to be encouraged by attending to i and 2, and by carefully watching that no increase in size of the uterus takes place while it is uncontractcd. This pix-xents post-partum haemorrhage. 'I'here is no need to explain in detail the rationale of these principles. The reader will at once be able to understand it if he has carefully read the •chapter on Separation and Expulsion of the Placenta and Membranes, and if he understands the nature of retraction. The uterus is to be taken in hand, as mentioned already. The palm of the left hand should support the fundus, which is now about the le\el of the umbilicus, and should press gently on it. The ulnar side of the hand will l)c abo\e the fundus, and the thumb in front. When the uterus is felt to contract, slight pressure must be made in the axis of the brim for as long as the pain lasts, and no longer. If more than fifteen minutes elapse before a pain appears after the end of the second stage, the uterus may be stimulated by gentle friction o\er that part of the abdominal wall under which it is felt, until a contraction is brought about. In case of moderately free bleeding before the first con- traction occurs, this interval should be made shorter, the hand should make firm pressure in the axis of the brim, and stimulation should be repeated soon. If, however, there is little or no bleeding, the next pain must be awaited, and the gentle pressure on the fundus repeated when it occurs. After several pains, or sometimes during the first, a pretty sudden diminution in bulk of the uterus will be evident to the hand. This means that the placenta has been expelled into the vagina. By a little extra pressure in the same direction as before, it may be expelled almost entirely through the \ulva. The afterbirth may be re- moved from the vagina, however, with the right hand, care being taken to get a good grip of it, and not to tear it. Simultaneous downward pressure made by the left hand will help this. As the placenta is drawn from the \-agina it should be twisted round several times, to con\-ert the membranes into a rope, and render them less easily torn. The left hand is on the uterus all the time, and this organ will often be felt to relax to some extent. This relaxation need cause no alarm if there is no marked enlargement of the uterus, and no bleeding, w^hen it happens. When it is well contracted the uterus feels about the sire of a fretal head, but its size varies in different subjects within fairly wide limits. It lies with its middle about the level of the brim, and its fundus two finger-breadths or so below the umbilicus. After a few minutes' supervision the utrms may be again given into the nurse's charge, and the placenta and membranes must lae now carefully examined. o 2 iq6 Management of Labour Examination of Placenta and Membranes. — To do this it is best to float thcni in a lar-e basin of \\alcr. The placental edge and maternal surface should be first examined to see if any part of its tissue is missing. A lobe, or part of one, may be left behind, and the amnion to which this part was attached may come away entire.' Traces of placental tissue should be soutfht for on the maternal surface of the amnion, and it will be remembered that the presence of a pair of vessels torn through at the placental edge denotes the existence of a placenta succenturiata somewhere. If this is not found outside, it must still be in the uterus. If the membranes have not been badly torn, the position of the hole for the passage of the foetus will be found. The sac of the amnion and chorion can then be roughly reconstructed, and any deficiency noted. If the membranes have been badly torn, their entirety can be only approximately- judged of ; but if the third stage of labour has been conducted in the way- just described, and if no internal manipulations have been necessary, they should be complete. Attention must be paid to the state of the chorion, as portions of this are likely to be left behind if the cohesion between this membrane and the amnion has been in any way destroyed. The presence of a layer of membrane of fair strength (the chorion;, overlying the amnion beyond the placenta, can be proved by splitting the membranes into their two layers at various spots. The decidua is found as a softish layer on the surface of the chorion, and is easily separated by gentle scraping with the nail. Small islets of this are frequently detached, but are not likely to cause any trouble, as they dis- integrate and come away with the lochia. If, however, any decidual endo- metritis has existed, signs of it may be discovered in the shape of thickenings and of a shreddy condition of this membrane (see p. 246). Hiemorrhages into the chorion or decidua may be found too, and these may be recent or remote ; but unless they have occurred in connection with inflammation they are of no importance. If it is judged that everything has not come away, the vagina first, and then if necessary the uterus, must be explored with the hand. The explora- tion should be preceded by a hot douche of 1-5000 or so at a temperature of 1 10 to 115°. This will wash away any loose clots or shreds, which can be examined for the missing pieces of. tissue; and it will also, by its heat, cause strong uterine contraction, and thus favour evacuation. If the placenta, or any large part of it, is retained, the case must be investigated and treated as described on p. 478. Tlie Vaginal Orifice and the Perinseum should now be e.xamined for lacerations. The vaginal canal should also be explored if the head has lain for long in the passage, or if labour has been difficult, or if instruments have been used. The parts should be visually inspected, and for this the woman must be placed on her side in the semi-prone posture. The cervix may be e.xamined by the finger for any extensive rents'; but it is almost impossible to judge of moderate ones now, for after involution, tears which were an inch • The absence of a cotyledon, or part of one, is roughly shown when the placenta is held in the hand, with its maternal surface upwards and concave. The cotyledons should then have a continuous surface, owing to the obliteration of the normal sulci. Maiiageuicut of Occipito posterior Positions 197 or more long, and involving great thickness of tissue at the time of labour, shrink to insignificant fissures. Tears of the periniieum invohingmore than the fourchettc, and lacerations of the \agina if accessible, should be at once sewn up ''see Lacerations of Cicnital Tract, p. 496). This is necessary, not only on account of the more remote results of such lacerations, but also because of the immediate danger of septic absorption from the raw surfaces. It is therefore ctn essential part of antiseptic niidwifejy. The proper conduct of the third stage of labour is thus seen — and this cannot be too strongly insisted on — to be of vital importance ; and septicaemia and haemorrhage, the two great, and practically only, dangers after a normal labour, are really under the control of the medical attendant. CHAPTER XXV DETAILS OF MAXAGEMEXT OF LABOUR IX PRESEXTATIOXS SPECIAL LIES AXD The above instructions require to be somewhat modified if the presentation be that of the face or the brow ; if the occiput tend to remain posterior in vertex cases of the third or fourth positions : or if the child be in the podalic lie. In Oceipito-posterior Positions. — It must be remembered that no reduction of this position occurs until the first-coming" part of the head reaches the pehic floor ; and that indeed, with a normally sized head and pelvis, it is almost impossible for reduction to happen before this. Con- sequently no attempts should be made to actively rotate the head until that level is reached. Indirect means, which imitate nature, are, however, most useful, and should never be omitted in cases where flexion is not already marked. These consist in attempts at causing flexion — that is, in restraining the forehead from advancing during a pain by upward pressure on the frontal pole of the head. Such delay of the forehead is all that is necessary : it is sometimes recommended to attempt to push the forehead backwards towards the sacrum at the same time, but this is of no use until the moment comes at which rotation should normally occur. If flexion is good, reduction will probably occur spontaneously, and artificial help is not wanted. Advantage should be taken of the fact that obliquity of the uterus has a good deal to do with flexion or extension of the head, and the woman ought to be placed on the side to which the front of the child looks. In the Fig. 223. — Child in second position of vertex. Fle.xion is promoted by the fundus beinff moved from A to B. 198 Management of Labour diagram, A represents the fKJsition of the uterus. The tendency to extension is remedied by placing the woman on her left side, when the uterus falls over to B. If all efforts to induce rotation forwards of the occiput have proved useless, care must be taken not to hurr)- the head over the perina^um, but time must be allowed for it to mould, so that the occipito-frontal diameter, the one which will in this case distend the vulva, may be diminished. The use of the vectis is recommended in these cases, and it will no doubt be found seniceable in bringing down the occipital pole of the head, and thus causing flexion (see Vectis, p. 386). It is an instrument not often carried by the medical man. In some cases forceps are necessar\- for the deliver)' of the head, and their use ^\"ill be governed by the ordinarj- principles (see p. 371). The perini^um should be carefully inspected for lacerations. race Presentations.— Many ways have been devised for the conversion of face presentations into those of the venex, seeing that a face presentation does not offer quite so good a prognosis as a vertex. Manoeuvres to this end must be employed before the membranes i-upture, for after the uterus has retracted down on the child they are useless. If a face is felt to present before the membranes rupture, or if the diagnosis be made by abdominal palpation and auscultation, Schatz re- commends that an attempt be made to convert the extension into flexion. This can only be done when the chest is lying against the anterior or lateral wall of the uterus. The shoulder in front is used to raise the head out of the pelvis, being" grasped by the hand through the anterior abdominal wall. The chest is then pushed by the other hand dorsalwards as regards the child, so as to flex the trunk. The head is free of the pehis, and will also flex if the occiput be pressed downwards and forwards. When flexion of the child is accomplished, the body is pushed downwards into the axis of the brim, so as to engage the head in a flexed attitude. This manoeuvre requires a lax uterus and lax abdominal walls. Another way, recommended by Herman, is to trj- to flex the head bimanually, by placing two fingers in the vagina, and the hand on the abdomen, and then pressing the jaws towards the chin end of the presenting part, and the occiput downwards. Care must be taken not to rupture the membranes. Before making any attempt of this kind it is absolutely necessary to obtain a correct diagnosis of the presentation and position, since if this is not done such attempts will be useless. Supposing it is found impossible to convert the presentation into one of the vertex, the following rules are to be observed. The tiienibrancs must be preserved until full dilation^ if possible ; for ( i ) the face is a blunt and therefore bad dilator ; and (i) delicate parts such as the eyes are liable to injury if they are unsupported by the counter-pressure of the fore-waters in the bag of membranes. No attempt whatever should be made to induce a vertex presentation after the membranes have burst. Such attempt would cause the risk of the head being flexed enough to lie in the attitude of a brow presentation, but not enough to be a \ ertex ; there Maiiagi'inciit of Brozv and BrcccJi Presentations 199 would l)e considerable danger of injuring- the eyes, and the possibility of introducing septic organisms into the uterus. \'ersion in uncomplicated cases of face presentation is quite inadmissible. It has been made clear that the prognosis of labour is not so very much uorse in face cases than in vertex, so that as a matter of fact the best way for those who are not sufficiently skilled to be quite certain as to the need for interference is to leave things alone. It is possible in some chin-backward cases that the head may not rotate into a mento-anterior position. In all mento-posterior cases, if extension seem to be deficient, as shown by the anterior fontanelle approaching near to the axis of the pelvis, and being too readily felt on vaginal examination, extension should be favoured by retarding the forehead during the pains, and by, if possible, pulling down the chin with the fingers in the intervals. A vectis may be used for this purpose. The rule that such cases are reduced comparatively late is to be remembered, and premature attempts at pushing the forehead into the hollow of the sacrum avoided. Postural treatment is most valuable here in causing extension. The woman must be placed on the same side as that to which the foetal back is turned, thus producing an obliquity of the uterus which brings the direct intra-uterine pressure into a line impinging in front of the centre of the head (see fig. 180}. If the head persists in the mento-posterior position, an endeavour may be made to rotate it by introducing the whole hand into the vagina and grasping the face with the thumb opposing the four fingers. The external hand is used to push the anterior shoulder in the same direction as that in which the effort to turn the face is made. If this endeavour fail, the head will probably have to be perforated. As face presentations are frequently caused by contraction of the conjugate, a careful \\atch must be kept on the rate of its advance as compared with the estimated force of the pains. If after two or three hours no advance of the head occurs into the brim, and if the uterus is acting well, version (see p. 365) is the best treatment, unless the brim is found on measurement to be too small for deli\eiy to be practicable without craniotomy, or there is any other contra-indication to version. A look-out must also be kept for presentation and prolapse of the cord (see p. 514), which is another not uncommon accompaniment of face pre- sentation, especially in contracted brim. Bro-w Presentations. — In these cases the same manoeuvres should be resorted to as in mento-posterior face presentations. Postural treatment, and attempts at increasing extension of the head, manually or by the vectis, are the only methods available after the membranes have ruptured. Schatz's method should however be employed during the first stage. The presenta- tion will usually be found to be converted into a face case eventually. If progress is completely arrested and forceps fail, craniotomy (p. 386) must be performed. Breech Presentations; Podalie He. — It has been alreadv said that presentations of the pehic end of the child in\ oh e little or no increased risk 200 Management of Lahonr to the mother ; and therefore nothing should be done which will prejudice her fcuourable chances of reco\ery. It may be stated broadly that any interference whatever until the pelvis is passing the vulva is bad practice. When a breech presentation has been diagnosed, and this may be done with certainty without a vaginal examination, through the abdominal walls, the fewer vaginal examinations made the better. The Dienibranes must not be endangered. They form a mucli better dilator than the breech, and it will be remembered that the head is the part on the passage of which the attention has to be concentrated. The more slowly the body passes through the parturient canal the better is the canal dilated, and the less delay will there be in the emergence of the head, which is the critical part of the case in a breech presentation. The legs viiist be left alone. Pulling on them to expedite labour will in ordinary cases have just the opposite efifect, for one or both of two things may happen. First, the head may become extended, if flexion is not very good, owing to the fact that the traction acts on a point of the head behind the centre. Second, the body may come down and leave the arms to slip up by the side of the head, thus very considerably increasing the already tight fit of the head. When the pelvis is born, hoA\e\er, help is almost always necessary. The cord runs much risk of being compressed by the head, which is now entering the pelvis (see fig. 212). The indication is to protect the cord as much as possible, and to be prepared to deliver rapidly, if necessary. A loop of the cord is pulled down — it can be traced from the umbilicus — and placed as near as possible to that sacro-iHac synchondrosis which is not occupied by the long diameter of the child's head. If the head is in the right oblique diameter, the cord Avill be placed in the left posterior quarter of the pelvis ; if it is in the left oblique, in the right posterior quarter. By observing the pulse in the loop which has been pulled down, the vitality of the child is readily ascertained. The slack of the cord prevents the sti-etching which might arise, after the child is born to the level of the navel, by the body becoming suddenly extended. When the navel is outside the vulva, the arms must be attended to. They must be brought down one by one before the head has reached the pelvic floor. If they are in their normal position, with the elbows down about the level of the epigastrium, this will be easy, if care be taken to move them along the anterior surface of the body, and to keep their inner surface in contact with it. If either or both happen to be above the head, the attendant should pass a finger up to and over the shoulder corresponding to the arm which is to be brought down, and thence along the upper arm to the elbow. The arm may now be swept down in front of and in close contact with the face and chest. It is important to reach the elbow before the arm is pulled down, so as to avoid fracturing the humeiois. After the birth of the pelvis, firm but gentle pressure over the fundus is of the greatest assistance, for it keeps the head flexed and the arms down. This pressure can be carried out by the nurse. Delivery of Head in Breech Presentations ?0I Durin,^ all the second staj^c of labour the fcutal pulse must be carefully Avatched, so that the labour may be hastened at any moment if necessary. As the body is born it must be carried up between the mother's thighs. The perinjEum is to be attended to as in head-first cases, and assisted in expelling the head of the child. When the head has arrived at the vulva it must be delivered as quickly as possible, for the reasons already given. The simplest and best plan is that of forward traction of the body. In considering the advantage of traction now, it must be remembered that the relation of the head to the pelvis is different at this stage from that ■which held while the head was higher ; for at one end ^there is now a firm bony resistance, the pubes, and behind at the other, the distensible perineum. When forward traction is applied to the condyles, a lever of the third order is formed, the fulcrum being at the pubes, the power at the condyles, and the weight at the centre of the head, which lies further back in the pelvis (fig. 224). It will be readily seen in the diagram that the force P will bring the chin downwards, the occiput remaining be- hind the pubes. Consequently flexion, or rather what would be flexion if the body were in the line of the lower pelvic axis still, is brought about, and the smallest possible diameter, the sub- occipito-frontal, passes through the vulva. To apply this principle, the body of the child, MTapped in a soft cloth, must be grasped in the right hand which carries it forwards to about a right angle to the mothers tnmk. No greater angle than this is advisable, as it would cause too great a strain for safety on the front of the child's neck, and the forces act at a less mechanical advantage. The traction is; much assisted by pressure from above. This will occupy the left hand until the forehead reaches the perinaeum, and then this hand will take charge of the head in its few remaining movements in the genital jcanal. It is well to prevent the head from coming out with too forcible a jerk, and traction may be almost discontinued when the head is delivered as far as the mouth. There are other ways of producing increased head-flexion at the perinatal stage of breech cases, and they may be had recourse to if the just described method fail. By passing the first two fingers into the patulous rectum the chin and forehead may be gently pressed forward. This mode is often useful in combination with the first described procedure. By jaiu-tracfw/j, also in combination with the first method. The fore- finger is passed into the vagina and over the chin on to the lower gum, and it can then exert firm pressure on the lower maxilla. Fig. 224.^ — Mechanics of deliverj' in head-last cases. F, fulcrum ; /-", power ; W, weight. 202 Management of Labour These last two methods are to be had recourse to successively should there be any delay at the critical moment, and fear of the possibility of rupturing the perinieum should cause no hesitation in speedy delivery of the head. Another way of deliver}- of the after-coming head has been recommended — namely, that of pushing up the occiput with the fingers of one hand and exercising jaw-traction with the other ; it is, howe\ er, far inferior to those described, for pushing up the occiput gives no great advantage, while the drawing down of the chin is not so completely accomplished. Jaw-traction has certain dangers for the child : fracture and dislocation are not unknown, and difficult}' in taking the breast for several weeks after birth is occasionally caused, if forcible traction has been made. Matthews Duncan ^ found in experiments on the dead foetus that there was only injur\- when great force was used. He found that a force of 28 lbs. caused a slight crack to be heard ; but 56 lbs. produced no injur)-, as shown externally or found on dissection. It appears, therefore, that very considerable power can be used in this way, no doubt enough to deliver the head in all ordinary' cases without running any risk. In the course of his experiments Duncan found, however, that jaw-traction had \er\- little influence in causing flexion of the head, and that its main and almost exclusive use lay in the power of direct extraction. By the forceps applied to the aftercoming head. There is no very- great difficulty in applying this instrument Tsee p. 383) if the body of the child is drawn well forward, and by their aid the head can be rapidly delivered. They should be at hand in head-last cases, so as to be applied if necessary ; that is, on the failure of the means just described. In sacro-posterior {X)sitions of the breech, the normal mechanism is rotation forwards of the sacrum at an early or late stage see p. 1 74^. If rotation has not occurred by the time the head is on the pelvic floor, increased care should be taken to prevent extension by pressing on the ftindus during the pains, and by avoiding traction on the legs. No ver%- forcible pressure should be applied to the top of the head when it has once engaged in the pelvis, however, for unless flexion is ver)- good, and in this case a persistent face to pubes position is ver\- rare, the occiput may be forced down and extension favoured. In the case of extended head, where the mechanism is somewhat that of an inverted face, deliver}- is often imf)ossible without extensi\"e lacerations of the pelvic floor, as the diameter which has to pass the vulva is the cer\-ico- vertical of 4^ in. An attempt may be made to get the head past the brim, where delay may occur, by passing the hand behind the neck into the hollow of the sacrum and tr}ing to glide it round by the side of the head to the mouth. This will tend to turn the head into the transverse diameter of the pelvis, where there is most room for its long diameter to pass. ' Ol'st. Trail;, vol. xx. Labour i)i Multiple PregncDuy 20j CHAPTER XXM LABOUR IX MULTIPLE PRE(;XAXCV It has been mentioned (p. 74) that twin and other mukiple pregnancies often end prematurely (in about a quarter of all cases), the degree of pre- maturity depending on the amount of over-distension of the uterus. Other abnormalities liable to occur in the uterine contents will be remem- bered — namely, the death of one foetus, the production of a mole, and of a foetus papyraceus. \\'hen labour does occur, the \ariations from the normal process are due to— 1. Impairment of the contractile power of the uterus from over-distension. 2. The presence of two or more foetuses, which descend in various relations to one another. 3. The occasional fusion, more or less complete, of the placentae, or of their vascular arrangements. The first two render the conditions rather less favourable for the mother than in single pregnancies. There exists, however, a more marked difference in the prognosis for the children, owing, in addition to the above, to the occasional anomalies of presentation (breech or transverse) and to pre- maturity. The usual course is as follows : — The first child presents as usual and is delivered, the uteiiis being more liable to inertia than in noiTnal labour. The mode of deliveiy of this child is practically that which belongs to single pregnancy. If it is not discovered before, the existence of t\\ in-pregnancy is now made evident by the still large size of the utenis, and the evidence by palpation of its containing" a second fanus. In a vaiying period, usually under half an hour, the uterus, which has been retracting on its remaining contents, forces the membranes of the second foetus through the cer\ix. These rupture, and the child is born, as a rule, rapidh", owing to the previous dilatation of the passage. There now remain the two placenta; and two sets of membranes, which may be separate or more or less united. These are expelled — those of the first child usually first — after an interval which, owing to the inertia, is usually longer than in single cases. The order is — - Formation of the bag of membranes of the first child. Birth of first child. Formation of the bag of membranes of the second child. Birth of second child. Placenta and membranes of first child. Placenta and membranes of second child. The commonest combination is for both children to present by the head 204 Management of Labour Next in frequency is for one to present by the head, and tlie other by the breech. Transverse presentations are commoner than in single pregnancies, owing partly to the uterus being roomy, so that the remaining ftt;tus is liable, from its loose fitting, to be disturbed and to move into anomalous lies and attitudes during the expulsion of the first. According to Spiegelberg, the percentage of the respective combinations is as follows, in 1,114 pairs of twins : — Two heads, 49* i ; one head and one breech, 317; two breeches, 8-6 ; one head and one transverse, 618; one breech and one transverse, 4-04 ; two transverse, "35. In the individual foetuses, numbering 2,228, there were presentations of the head in 68 per cent. ; presentations of the breech in 26-48 per cent. ; transverse presentations in 5-46 per cent. In some cases the placenta of the first child is born immediately after the child. For this to happen complete independence of the two placenta is necessary, and under such circumstances the second child, although it usually soon follows the first, may be retained for an indefinite period after the birth of the first. The interval hardly ever exceeds a day or two, but has been extended to some weeks. In the latter case there was probably a double uterus (see P- 75)- Management. — Care must be taken, by following the uterus down and exerting firm pressure on it, to prevent the uterine inertia which is liable to occur. If a diagnosis of twins is made before the birth of the first child, the cord must be tied on both sides of the section, since the two sets of vessels often intercommunicate. So long as the woman is not losing much, she may rest for half an hour or so, the uterus being supported during that time. The cervix should then be examined, and if pains have not come on, the second bag of membranes should be ruptured and the uterus encouraged by friction and gentle pressure to expel the second child. The ordinar)' precautions against post-partum h;emorrhage will be taken, the physician remembering the tendency of the previously over-distended uterus to relax ; and if forceps are needed for the second child, this point should be specially attended to, and the uterus carefully followed down by the hand. In places where the first placenta at once follows the fcEtus to which it belongs, and the uterus becomes inactive, there is no reason for hurrying on the labour of the second child. The prolongation of intra-uterine life may be of advantage to a weaker child, especially if labour has occurred pre- maturely. The same mles govern the conduct of labour in the case of triplets and other multiple births. As in these cases prematurity is pretty constant, the children require special precautions in their management. (See Induction of Labour.) Chloroforui tii Labour 205 CHAPTER XXVII AN.t:STHETICS One of the not least important uses of anccsthetics is in labour. They act not only by preventing" the acute suffering which almost always accompanies parturition, but also — a matter of greater importance — they are of actual assistance in the progress of a very large number of cases. They have the power of relaxing spastic muscle, e.g. of the cer\i.\, and of enabling the physician, on account of this effect, if they are carried to a sufficient degree, on the body of the uterus, to carry out any operation, such as turning, with far greater ease than in their absence. Chloroform is the most useful drug of this kind in midwifery \\ork, and, in the absence of any marked contra-indications, it should always be chosen in preference to other ansesthetics. The reasons for this are as follows : 1. It exercises its effects in some degree in almost any depth of the anaesthesia which it brings about. This is not the case with, for instance, ether, which has to be pretty fully g•i^•en before relaxation is obtained. 2. It is very easily given, and, short of narcosis to the surgical degree, does not require that undivided attention of the administrator which ether needs. 3. It is not unpleasant to take. 4. Fatalities under its use in cases where it is not pushed to the full degree are unknown in labour, and so there is no reason on this ground for adopting" the less easily manageable and less useful ether. A \ery few cases have been recorded of death during labour where chloroform has been given to its full surgical degree.^ It is only necessary to proceed with its administration to this extent when some obstetrical operation has to be performed, and under these circumstances ether may be used if the operator prefers, and if the apparatus is handy and an assistant can be obtained. Judging" from the statistics a\"ailable, ho\\e\er, there is practically no danger in the use of chloroform to e\"en this degree in the parturient woman, and it is therefore to be recommended under all circumstances where ansesthesia is required. The reason of this peculiar immunity of women in laljour is unknown. It has been put down to the phj'siological hypertrophy of the heart which occurs during pregnancy, and \\hich tends to prevent syncope. There are various degrees of anaesthesia obtainable by the administration of chloroform : one, a slight degree, \\hich, while not depri\"ing the patient of consciousness, does relieve her of pain, and is absolutely safe ; and another, the full degree, which is practically safe. We will here confine our attention to chloroform. Probably the best way of g"i\ing it is by means of Junker's inhaler, though many prefer to give it sprinkled on a towel or lint. If a Junker is chosen, the bottle containing" the chloroform may be fixed to the rail of the bed out of the patient's way, ' Charpcntier, Bulletin de la Soc. Ohstet. de Paris, Xo. 5, 1889. 206 Mauai^t'incnt of Labour and she may be entrusted with the face-piece after she has been shown how to apply it durinj( one or two pains. When the suffering at each pain becomes acute — as, for instance, when the head distends the vulva — if the patient loses her self-control the nurse must take charge of the face-piece. If deep anaesthesia is necessary in case of an obstetric operation, an assistant is very desirable, and in some cases essential, for the physician can then devote his whole attention to the operation. The administration of chloroform is an important treatment in cases of eclampsia and chorea. We may now consider its use in the three several stages of labour. First Stagre. — Chloroform should not be used, as a rule, before rupture of the membranes. There is little need of it on the ground of suffering, and cases of rigid os will usually yield to simpler remedies. It is, however, a fairly sure remedy in certain cases of rigid cervix (see p. i88). Some patients may be the better for it if they suffer severe pain at the end of this stage. It should, however, be avoided if possible. Second Sta§re. — It is now that anaesthesia, or analgesia rather, is most useful. The patient, relieved to a great extent from suftering, will use her abdominal muscles more freely ; and, by giving a little more of the drug, the physician can restrain her otherwise sometimes uncontrolled action more effectually. This latter advantage is most conspicuous as the head is just about to be delivered and the perinrcum is in danger, for it renders more easy any attempts to squeeze the head out between the pains. In cases where full anaesthesia is produced, care must be taken that no vomited food is sucked into the larynx. Vomiting is hardly more likely to occur under the present conditions than when the patient has been prepared for the anicsthesia of a surgical operation, since the woman has probably taken no solid food for several hours. Third Stagre. — .Since chloroform is considered by many to predispose to post-partum hccmorrhage, the uterus should be carefully watched during this stage in cases where the drug has been administered during the second stage, though in all probability there is little or no danger added. It is never desirable to give it in the third stage of normal labour, even to insert stitches, unless the laceration of the perinaeum has involved the sphincter ani ; for the perinaeum is usually rendered fairly insensitive by the stretching which it has underg'one. Effects on the Child. — No prejudicial effects on the child have been established. The writer has seen one or two new-born children in which there has seemed to be delay in the establishment of full respiration, and where the delay could not be accounted for in any other way than by assigming it to the chloroform, which in each case had been administered for longer than the usual period. Chloroform has been found in the placenta after expulsion, and in the urine of the new-born child.' ' Porak, Bull, et Mint, dc la Hoc. Obsl. ct Gyn. dr P.uis, No. r, 1390. ?07 PUERPERAL PERIOD TiiK puerpenil period commences after the birth of the phicenta. and meni- Ijrancs. The uterus has now done its duty and sinks into the background ; and the lareasts come to be the important organs. In the transference of prime function from the uterine system to the milk- secreting one there should be no constitutional disturbance. Preparation has been made for this transference during the later months and weeks of pregnancy, by the functional development of the breasts and by the changes in the circulation and mucous membrane of the uterus (sinuses and decidua) already described ; and thus under normal circumstances there is no evidence of strain of any kind when the breasts take on their full duty. The 'milk- fever' or ' weed' described as normally occurring on the third day is proved to be due in almost every case to septic absorption, by the fact that in aseptic cases no constant rise of temperature occurs about that period. The most important modification existing during the puerperal period is the fact that the woman has at least one large fresh absorbent surface, the recently denuded placental site, and in nearly every case many other smaller ones due to laceration and bruising of the cervix, vagina and perin;tum, and other tissues. It is almost entirely on account of the existence of these places of weak resistance that the puerperal woman is in a state of less stable equilibrium as regards health than her non-parous sister. Her nervous equilibrium is easily disturbed, however, and, as will be seen, such disturbances ma)- at times cause some unnecessary alarm if the proper cause is not recognised. The essential phenomena of the period are then — (i) the return of the enlarged and otherwise modified genital apparatus to its nearly original condition, and the effects of this process on the secretions and excre- tions ; (2) the estalolishmcnt and process of lactation and its accompany- ing phenomena. The natural history of the puerpcrium will he considered main]\- as falling under one or other of these two heads. The alterations in the general functions of the body will be dealt with briefly. They are mostly the result of the bodily exertion during labour ; of some of the local effects of labour ; and of the diversion of the energies of the economy towards the production of milk. 208 Puerperal Period CHAPTER XXVIII UTERUS AXD OTHER PELVIC ORGANS AFTER LABOUR Clinical phenomena. — During the first hour or so after deliver)- the uterus is alternately contracting pretty vigorously and relaxing slightly, and is of about the size of a foetal head. It is felt four or five inches above the pubes as a distinct, somewhat flattened mass. If only the extreme fundus is felt, the comparison anciently made to a cricket-ball might be justified ; but if care be taken to palpate all the uterus which lies above the brim of the pelxis the organ will be found to be much larger, and certainly not spherical. Within the next few hours, however, it relaxes considerably, and at the end of twelve hours or so is foimd to reach on an average about six inches above the pubes ' (fig. 225). There is, of course, no haemorrhage during this relaxation owing to the retraction present. The height of the uterus above the pubes a few hours after delivery is considerably understated in most text-books.- In some cases, when the woman has been Ivnng on one side the fundus is found displaced to that side, and then the measurement above the pubes may amount to ten or eleven inches. Knovinng this, the medical man will not be alarmed if he finds such a mass within the abdomen when he makes an examination of this region. The uterus is, as a rule, ante- flexed to a greater or less extent, and remains so during its involution. Though in height it reaches to about the same level as it attained at the sixth month of pregnancy, its width is less than that of a six months' uterus, and it is in width and depth from before backwards that its main dimi- nution has occurred. It is often very tender to the touch for some days after deliver)-. Contractions, which in multiparae are often painftil (see After-pains, p. 216), are occurring at intervals during the first few days. They are accompanied by regularly advancing retraction. > This is the average of a large number of cases (several hundred) investigated at the General Lying-in Hospital. The patients were as nearly as possible under the same conditions of bladder, rectum, &c. * Lusk, 4^ inches, Charpentier 4I ; Webster also says 4I in the cadaver. 225. — Height of fbndns «m fiist day of puerperium. Involution of Uterus 209 Day by day the uteru5 decreases in size, and this decrease is fairly shown by external measurements. It must be remembered in making these that the uterus may be more anteflexed than usual or may be retroverted or retroflexed, and in some cases may be lateriflexed ; and that fulness of the bladder or rectum or both may make a difference of several inches in the height of the fundus. Allowing for these causes of error, the diminution in size will be found to average about three-quarters of an inch in a day for the first five or six days ; and at the end of ten to twelve days the highest part of the uterus is level with the brim, i.e. about two inches above the pubes figs. 226 and 227. Fig. 226. — Height of fundus at ; end of first week. Fig. 227. — Height of fundus (at brim) at end of second week. Involution appears to be more rapid during the first few days ; but this im- pression is not borne out by frozen sections. In about eight weeks the uterus has diminished to the size at which it will remain unless disturbed by a fresh pregnancy — that is, to the size of a normal parous uterus (see p. 224). Cervix. — The cer\ix will be found, if examined, to be a flaccid tube applied loosely to the lax vaginal walls. As the finger is passed into its ca\-it\- and reaches the level of the internal os, this latter may be found to be contracting, and of a firmer texture. In nearly all cases, but especially if labour has been prolonged and there has been much thinning of the Lcrn'er uterine segment, the retraction-ring may be felt at a height varying from a fingers breadth to an inch or more ' above the internal os as a ven,- firm ridge. This ridge has by many obseners been considered wTongly to be the internal os. Above this ridge again is the thick fleshy uterine wall, Avith the placental site projecting from some part of its surface, and feeling like a raised and roughened portion of the mucous membrane which is elsewhere quite smooth (figs. 228 and 228 a). During the first fony-eight hours the lower segment which has hitherto been stretched undergoes retraction. As the cersix gets firmer during the first fourteen days, any lacerations which may have occurred are to be more distinctly made out. ' Three inches in a specimen described by Barbour and Webster. lO Puerperal Period The anatomy of the generative organs during the puerperium has now to be considered, and the variations in shape and size of each organ in the pelvis noted ; namely, of the uterus, vagina, bladder, and uterine ap- pendages. Fig. 228. — Uterus and other pelvic organs immediately after labour. L iv, L v, lumbar verte- LrsE ; umb. umbilicus : R. retraction-ring ; U VP, utero-vesical pouch ; (7 /, os internum ; O E, OS externum ; Ur. urethra ; D P, Douglas' pouch ;//. s. placental site. (From Webster's frozen Section.) For most of the facts at present known as to the anatomy of this period we are indebted to the studies of frozen sections made by Webster, Barbour, Pinard, \'amier, Winckel, and others, which on almost all points are quite reliable for this purpose. Anatomy of the parts immediately after labour. — The uterus lies with its fundus in contact with the anterior abdominal wall and the upper part of the back of the symphysis pubis. It fills up the pelvis, and lies in an anteverted and anteflexed state, usually rotated to the right. Its shape is not constant, but is usually an irregular ovoid. On transverse section at about its middle in length it has been found to be pretty nearly cylindrical. The walls of the body are pale and bloodless on section owing to the tight contraction and retraction. (This condition of emptiness of vessels is maintained for two or three days.) A distinction is easily made between the upper thick and the lower thin uterine segments, and between the latter and the cenix. T/ie Upper Uterine Segment is thick-walled (about li in.), pale pink on section, has a cavity of greater or less capacity, according to the amount of clot contained in it, and shows on some part of its surface the placental site which is darker in colour. This segment constitutes the greater part of the uterus.. Pelvic Organs inunediately after Labour 21 I Lower Segment [or Isthmus .. — This is separated from the retracted upper segment by a well-marked line (see figs. 228 and 228 a). It is shorter than it was during the second stage of labour, for some of it has retracted into the upper segment. It is thrown into folds (see fig. 228) owing to the weight of the upper segment. The Cervix is thicker than the last-described portion of the body and the Placental ?ite R. Ring Int. OS E.\t. OS ^. Rina Int. OS Ext. OS Fig. 22S .\. — Section of uterus shortlj" after labour. R. Ring, retraction-ring ; int. os, internal os ; ext. os, external os. (St. George's Hospital Museum.) internal 05 can be rough!)- made out. ^^'hat has usually been described as the tight ring of the internal os was really the retraction-ring. The length of the cer\ix is about 2 in., though the external ^os is not well marked ; and the lips are everted to a variable degree. They rest on the posterior vaginal wall, and are flattened from above down by the weight of the uteiTJS. 2 1 2 Pjicrperal Period The lower part of the cervix is much congested, and thus contrasts with the bloodless body. Infer/ml Surface of ike Uterus. — Tliis surface consists of two main parts, the placental site and the rest. The placental site has a ragged surface, showing the openings of torn sinuses, and forms a convex elevation above the plane of the rest of the surface. The uterine wall beneath now appears rather thicker than that of the rest of the body, and this area often bulges inward somewhat (compare its thinness before detachment of the placenta, fig. 133). This thickness is not muscular, for if muscle alone is considered the wall is thinner here. The increased bulk is due to thrombosed sinuses. The site measures about 4x3 in., and is thus roughly the size of the palm of the hand. This area is usually on the antero-lateral or postcro-lateral wall ; quite exceptionally on the fundus. The area of the attachment of the membranes occupies the rest of the inner surface. It is much smoother than the placental site, and has small shreds of decidua adherent here and there. A part of it corresponding to the lower segment is still smoother than the rest, and on microscopic examination is found to have scantier glands and smaller decidual cells. The internal surface is found to be smooth also over a small area at the entrance of the Fallopian tubes. The inner surface of the upper part of the cervix is continuous with the inferior segment of the body, and no very definite boundary (internal os) is, as a rule, to be found between them. The lower half, however, is much congested, not being contracted and retracted like the rest of the uterus. The Vagina has roughly its usual shape on longitudinal section. It is much stretched and its walls thick and bulging inwards in \arious directions, the anterior vaginal wall especially bulging downwards. Hyuien and Lacerations of the Vulva. — The hymeneal orifice is found to be stretched and torn to a variable degree. The tissues are very soft, and, in case of any unsutured perineal tear, the granular raw surface of this can be felt partly covered with clot. Tears, usually superficial, may be found running on to the vestibule, or affecting the attachments of the urethral orifice or the labia minora. The pelvic floor and perineal body are lower compared with the plane of the pelvic outlet by about an inch or so than in the nulliparous state. Tubes and Ovaries. — These lie just above the brim, packed in between the uterus and the pelvic wall. The ovaries are \ery close to the uterus, owing to some lateral expansion of that body during retraction. The ovarian ligaments are spread out on the uterine wall. Bladder. — This is seen l)y the diagram (fig. 228) to lie in its usual position, and to ha\e ag'ain become a pchic organ, h naturally sinks down Jnvohitiou of Uterus 213 w itli the lower uterine segment, to wliich it will be remembered it is closely attached. It lies usually out of the middle line, this depending on the position and rotation of the uterus, and under the uterus ; so that any dis- tension which occurs will raise, and, if continued, i-etrovert, the womb. The urethra and urethral orifice are now nearly in their usual position, lia\ing, as a rule, descended somewhat. Peritoneum and Broad Ligaments. — The peritoneum on the lateral portion of the uterus and in Douglas' pouch is wrinkled owing to its not lia\ing completel)' followed the shrinkage of surface undergone by the uterus itself (see p. 100, Elasticity). The upper edges of the broad ligaments are free to lie as the)' please. The part below the edge is occupied almost completely by the thickened uterus, and the part unoccupied is compressed between the uterus and the pelvic wall. Since this compressed part contains the arteries, ovarian and uterine, on which the uterus depends for its blood suppl)-, its compression must have a very marked influence in keeping the uterus anaemic. CHAPTER XXIX IXVOI.UTION Size of the Vterus. — This does not seem, according to the evidence of frozen sections, to decrease much for the first few days. It has already been mentioned that within the first twelve hours the uterus, when it relaxes immediately after labour, increases in size, as far as the evidence of measurement through the abdominal walls can demonstrate this, and that according to these measurements reduction is most rapid during" the first days. According" to the evidence of frozen sections, it lies at or below the level of the brim by the sixth da)- ; it can, of course, be felt above the pubes for many days after, unless it is retroverted. Anteflexion is the rule throughout, though there is nothing abnormal in retroflexion. In nearly 300 cases in which careful measurements were taken at the General Lying-in Hospital, the fundus was found to be level with the brim in 20 on the seventh day, 40 on the eighth day, 20 on the ninth, 70 on the tenth, 60 on the ele\"enth, J2i on the twelfth, and in the remainder on some da\" after the twelfth. The wrinkling of the peritoneum gradually disappears, and the broad ligaments assume their normal relations as the uterus diminishes. The area of the placental site diminishes with the uterus, and the uterine wall over this area remains somewhat more projecting than in the rest of the uterus. The distinction in thickness between the upper and lower segments 214 Pucrf>cral Period disappears soon after the first day, owing to the retraction of the lower segment. The internal os for a few days remains difficult to define. The cer\i.K gradually shortens ; but its diminution has been said, from clinical obser\ation supported by the evidence of frozen sections, not to begin until about the fourth day. Cbangres in Muscle and Vessels. Mi/scular Layer. — Owing to the continuous squeezing of the sinuses by the contractions of the uterus after labour, these channels are almost bloodless, e.\cept where thrombosis has occurred. Gradually, howe\ er, this anaemic condition becomes less marked, and about the sixth day the circulation in the uterus becomes freer. Fatty degeneration of the muscle has been described as the process by which absorption of the now useless muscle fibres takes place, but no obser\ er of late has found any fat globules in the cells. Fatty degeneration is usual during the absorption of many inflammatory products, and may occur in the uterus if the tissue has been damaged ; but there is no reason to expect it apart from pathological processes, and absorption occurs most likely by some process of solution.' New muscle fibres were belie\ed to be developed from the embryonic cells in the connective tissue, and their production was said to occur earliest (fourth week, Spiegelberg) in the subperitoneal layer. This is "contradicted by Helme ;see foot-note J. Cbanges in Vessels. Arteries. — The enlarged arteries have shrunk to correspond with the marked diminution of blood-flow through them, and their channels in the uterine wall are almost obliterated (see fig. 59, p. 44). The walls of those remaining are, however, not absorbed in proportion with the rest of the tissues. They indeed never undergo complete in\olution, but always remain as evidence of the occurrence of pregnancy, standing out as thick stumps of tubes on a section being made of a parous uterus. The ovarian and uterine arteries remain more tortuous than before pregnancy. The changes in the sinieses during the last month or so of pregnancy have been described and figurfed (p. 43). The thrombosis then begun is now completed, and the sinuses are obliterated by connective tissue forming in the clot and proliferated endo- 1 Helme ( Trans. Royal Soc. Edin. vol. xxxv. pt. 2) has investigated this subject very fully in the c;ise of rabbits. He finds that there is no fatt>- change in the muscle, and that the process is an atrophy rather than a degeneration ; for if it were the latter there would be an increase in the connective-tissue corpuscles, which always occurs during degeneration, and this does not exist here. There is merely a diminution in volume, probably by a process of solution (? peptonisation). He believes that there is no pro- duction of new fibres to take the place of the old ones, since there is no karyokinesis. In the connective tissue he finds that the fibres and cells become granular. .Some of the fibres swell up, become hyaline, and break down into granules, and in the subperitoneal connective tissue some fat-cells are produced. In places the destruction is complete. Epithelioid cells lie around the blocked capillaries, and Ijecome filled with granules from disintegrating red blood-corpuscles. He also finds that the arteries disappear in large proportion in the same way as the sinuses do — by endothelial proliferation and conversion into connective tissue. Mucous Membrane, Vagina, ajtd Abdoiuinal Walls 215 llielium. Tlie results of this change are very obvious on section at and after four weeks, and are most numerous at the placental site ; they can be dis- tinguished for a year or perhaps more (J. Williams). Mucous Membrane. — After separation, through the ampullary layer, of the stratum of the decidua which is expelled with the amnion and chorion, the deeper layer, consisting of the fundi of the uterine glands and the cells filling up their interstices, is the only representative of mucous membrane remaining. The surface of endometrium covering the placental site differs slightly from that of the area which has been covered with decidua vera in being thinner and much more irregular, and being interrupted by the mouths of many torn sinuses. The regeneration of mucous membrane proceeds b)- a growth of new glands which start from the unshed fundi, and by increase of the inter- glandular tissue. During this process a free discharge takes place from the inner surface of the uterus, constituting the greater proportion of what is known as the lochia. At first blood oozes from the torn sinuses of the placental site. This soon gives place to serum, which is blood-stained, and contains many leucocytes and epithelial cells. When the remaining clots have disintegrated, the serum from the newly forming surface, together with the cervical mucus, constitute the fluid part of the lochia ; and the leucocytes increase in number, for during the regeneration the greater part of the surface is in a condition something, but perhaps not strictly, comparable to granulation. This reconstruction is complete by the fourth or fifth week, the placental site being the last to return to its former state. When the mucous membrane has been physiologically restored there are found submucous spots of pigment, especially over the placental site, which remain as indications of a previous pregnancy. Pigmentation may, however, be the result of inflammation, so it is not sufficiently characteristic of pregnancy to be ground for an absolute diagnosis. Vagrina. — The increase in all dimensions existing after labour gradually subsides, and the tissues become firmer and lacerations heal. The perineal body, if not torn beyond the usual amount, very nearly regains its usual shape and texture, the fourchette and vaginal orifice being- altered as described. The pelvic floor is found to be lowered permanently in a very large majority of cases. The ovaries and tubes return to their ordinary situation in the pelvis as the uterine fundus descends, and the broad ligaments recover their relations as the uterus shrinks towards the middle line. Abdominal "Walls. — The elements composing these structures have undergone stretching and some hypertrophy during pregnancy (p. 51)^ and have now to return to their former condition, just as do the org^ans of generation properly so called. The skin, which is often, especially in multipareu, thrown into loose wrinkles after labour, regains its elasticity to a varying degree ; the stri;u 2l6 ]^iicrpci-al Period gradually lose their pinkish or purplish colour and become white, often, however, remaining pigmented ; the recti in normal cases become approxi- mated if they ha\c not been much separated by \ iclding of the aponeurosis at the linea alba. Sometimes they do remain separated to a ^■ariablc extent, and this can be rendered ver\- ob\ious if the woman is told to raise her head as she lies on her back, for an elliptical projection filled with intestines or omentum then appears between the recti. This separation, diastema reciorum, is some- times in subsequent pregnancies combined with anteversion of the gravid uterus, constituting the condition known as pendulous belly fsce p. 271). Joints of the Pelvis.— IMicse soon become firmly knitted again. The relaxed ligaments shorten, and do not permit the increased movements ot one bone on another which pre\"ailed during pregnancy. The involution of these structures docs, however, fail sometimes, and trouble is caused l^y the want of firmness when walking is attempted (see p. 5681. Tborax. — The widening of the base of the thorax found to occur during the later months of pregnancy now diminishes to some extent, but does not entirely disappear. The diaphragm has a greater range of movement. The position of the heart's apex, which moves outwards somewhat tow ards the end of pregnancy, now gradualh" I'eturns to the ordinary. CHAPTER XXX LOCHI.\, .\FTI-:RPAINS, l.ACJATION locbia.— This is a discharge from the vagina of the lying-in woman. It is a result of the changes which arc taking place at the inner surface of the uterine body and cervix, and in lacerations and abrasions. It begins to flow when the placenta has been expelled, and persists on an a\ crage for about twehe days to a fortnight. It consists at first of the oozing from the torn sinuses and \essels, and is almost pure blood, mixed with some cervical mucus. As a rule, there are small clots in the discharge ; but large ones, the size of the palm of the hand, are sometimes expelled in quite normal cases. After three or four days the blood begins to diminish in quantity, and the discharge becomes chocolate-coloured and then paler. Leucocytes are now more abundant, and with them arc found shreds of decidua, and epithelial cells from the cervix and \agina, mucus corpuscles, and granular cells. The red corpuscles become fewer, and on the ninth day or so entirely disappear, the discharge now being of a creamy colour and consistence. Aflcrpcxiiis — Secretion of Milk 217 Cholcsterin crystals are found for a short time about now, and the epithehal elements almost disappear. The discharge then gradually merges into slight excess of the ordinary mucous secretion of the cervix, and finally vanishes. The quantity has been found b)' recent careful measurements in a large number of cases to be about lo^oz. in all, and not about 50, as was stated b)- Gassner on the strength of only a few observations. It \-aries slightly according to the size of the child and placenta and the temperament of the indi\idual, dark women losing more than fair ones. Women who habi- uially menstruate profusely lose more than those who usually sec little at menstruation.' Afterpains. — The uterine contractions occurring at inter\als of varying length ha\e been already alluded to. They are usually attended with more or less pain, though this symptom varies greatly in different cases. A moderate amount of pain seems in multiparas to be normal, but most primipar^E go through their lying-in period ^\■ithout any suffering worth speaking of. Afterpains, if severe, are no doubt clue to irregular, and therefore in- complete, contractions, caused by the irritation of something, usually a clot, of which the uterus is trying to rid itself The pains are therefore more liable to occur in the case of uteri which allow clots to form, and are not in perfect expulsive order. These conditions are found in multiparous uteri which have been stretched and weakened by previous pregnancies, and which may have not completely retracted during the shortened labour which is connected with multi parity. Twin pregnancy and Indramnios, both of them causes of over-distension of the uterus, are also frequently associated with se\ere afterpains. The pains, when they occur, do so as a rule only during the first two or tlu'ee days. Their frequency varies from eight or ten times in the day to four or five or more an hour. During their presence the uteixis may be felt through the abdominal walls to very distinctly harden. They are occasionally severe enough in sensitive women to exhaust the patient considerably, and to interfere with convalescence. It may be difficult in some cases to discriminate between the effects of the pains on the nervous system in causing slight rises of temperature and the absorption of some septic products of matters retained in the uterus. Breasts. Secretion of Milk Tlie mammary glands (see p. 52) have dui'ing pregnane)' been preparing for tlieir complete function, and at the time of labour, and often for some w eeks before, a good amount of secretion can be squeezed from the nipple. The fluid thus obtained is thinly mucoid, with streaks of creamy-looking matter running through it. This character is preserved for the first two days, during which time there is a slight increase in the quantity obtainable. The condition of the acini of the glands is that already described, and llie streaks are due to the admixture of tlie colostrum corpuscles (altered • Giles, Obslcl. Trans. \o\. xxw. 2l8 Puerperal Period epithelial cells) with the almost clear fluid. These products of cell degenera- tion contain a certain amount of albumin, which may be separated as a precipitate on boiling. Casein is not yet secreted in appreciable quantities, though a few milk globules are visible on microscopic examination. Fig. 229. — Acini in the colostrum stage. Fig. 230. -.\cini in the milk stage. The colostrum, about the third day, merges into the fully developed secretion of the gland — namely, milk, The acini, on being examined now, are found to have a more regular lining of epithelial cells than they had in the colostrum stage. There are no loose granular cells in the cavity (see figs. 229 and 230), and the fat globules characteristic of milk are produced by changes in the cell contents, the cells remaining attached to the basement membrane and allowing the globules to escape through their walls. During this development the breasts become large and congested, being slightly lumpy in feel, and having distended veins on their usually sensitive surface ; sometimes there is considerable throbbing pain in cases where for some reason, probably that of over-secretion, the lobules are over- distended. There is normally no rise in tonpcrattirc zuhaievcr, and an)' fever which occurs now must be put down to septic absorption, unless it be one of the very transient rises characteristic of the puerperal state (see p. 220), possibly in this case due to the pain caused by the tension existing in the glands. Composition. — Human milk is an opaque, bluish-white fluid, composed of serum holding in solution milk-sugar and traces of salts (chlorides and phosphates of potassium and calcium) and casein, and in suspension (emul- sion) particles of fat (butter) measuring from '001 in. in diameter downwards. Analysis. — Rotch gives the following as the proportion of the diftcrent constituents : Fat ...... 4 per cent. Proteids i — 2 ,, „ Lactose 7 » » Ash 0-2 „ „ Total solids Water 12—13,, 88-87 „ Under certain circumstances milk may contain, in addition to its normal constituents, foreign soluble substances which have passed through the Changes in the General System 2 1 9 mother's blood, such as sulphate of magnesia, salicylate of soda, potassium iodide, atropine, and the purgative principles of castor oil. Substances that do not appear to pass into the milk are mercury, opium, acids. Specimens of milk from different women show much variety on analysis. The most important point is the quantity of fat and of proteids present per volume. Milk is of bad quality if there is much proteid and little fatty matter. The quality of the milk depends very much on the health of the woman. It may even be suppressed by emotion ; menstruation occurring during suckling has been found to alter the milk, but not in any definite manner as. regards the proportions of its constituents. As the months of suckling go on, the milk becomes of a poorer quality as a rule, containing more sugar and less proteids in relative proportion. This change may, however, be due to the woman's general condition ha\ing deteriorated in the later months. CHAPTER XXXI CHANGES IN THE GENERAL SYSTEM Skin. — The skin acts freely during the first week or so of the puerperium, and this is found to take place in the absence of any increased warmth of surface. This condition exists with, and is analogous to, the activity of the breasts. In connection with this increased function of cutaneous structures, it has been mentioned (p. 58) that lumps which are of purely cutaneous origin occasionally appear during pregnancy and lying-in in the axillte and in their neighbourhood. Some of these lumps, on being squeezed, now exude a milky fluid ; others have no orifice. During this period the pigmentation of the skin which develops during pregnancy gradually fades ; but where it has been of marked degree it never entirely disappears. The striae, if unpigmented, become whiter and more opaque as time goes on. Circulatory System. Heart — The displacement and hypertrophy of this organ Mhich ha\e occurred during pregnancy now disappear. This process may be considered as somewhat analogous to the diminution in sixe of the uterus, and is partly of the nature of retraction. The apex, if sufficient displacement has occurred to be noticed, is found to gradually return to its normal position, partly by the thorax to some extent resuming its former width of base, and partly by the subsidence of the cardiac hypertrophy. The heart sounds too are modified during the first few days of lying-in, in that a bruit of a soft blowing character, first described by Angel Money, 2 20 Puerperal Period c;in be dcloclcd at the apex. In loo cases specially observed recently at the (General Lymg-in Hospital, this was found in 57. Pulse. — The pulse has hitherto been described as being exceptionally slow during the puerperium, and is stated by some authors to go down as low as 40 beats per minute. Such slowness as this must be very exceptional. In a series of consecutive normal cases in which the pulse was carefully taken at the same hospital, it was found that the average rate was not lower than 72 (see Chart (fig.231), and Probyn- Williams' ' and Cutler's paper). The pulse rate was faster in the morning than in the evening throughout this series. The same observers have examined the pulse tension in a large number of normal cases. They find that in a few instances the tension is diminished by delivery ; but in the majority it is increased, and that this increased tension may persist throughout the puerperium. The uterine bruit can frequently be heard for from twenty-four to forty- eight hours after the expulsion of the placenta. This fact shows that no possible diagnosis of the position of that organ can be made by auscultation. Blood. — By some obseners the amount of haemoglobin and of red corpuscles has been found to be diminished, by others to be increased. The varicose veins and oedema which ha\e been described as often accompanying pregnancy rapidly diminish. The latter disappears, but not always the \aricose veins. Respiration and Temperature. — Respiration is somewhat slower during the puerperium than it is during labour (the rate being taken in the intervals between the pains). The Tcinperattire is that of a healthy person, as is seen from the accompanying chart, constructed from the average temperatures of 100 normal cases. It will be seen to be a temperature with a mean of 98*4°, with the highest and lowest temperatures of the day somewhat exaggerated. Thus the temperature taken about 8 A.M. is on an average 98°, that in the evening at 6 P.M. averages about 98-8° the temperature on the e\ ening of the first day being the highest and averaging 99°. The chart shows also that the pulse and temperature have the peculiarity of moving during each day in an opposite direction, for the pulse is higher in the morning and lower in the evening. The respiration tends to follow the pulse in its daily movement, and is therefore also contrary in this respect to the temperature. It is possibly in agreement with its increased daily excursion that the temperature of the lying-in woman is easily disturbed. Emotion and cxeitcment., •i>MQ\\ ■A.% that as caused by visits from friends, and constipation and tension of the breasts, may each cause a considerable rise (see chart, figs. 388, 389 and 391, pp. 562 and 569). This is, however, as a rule extremely transitory, though often alarming enough for the moment. Sometimes 105° is reached in cases due to the first-named cause ; but if the temperature be taken an hour or two later, it will nearly alwajs be found to have regained the normal. In the last two kinds of disturbance the elevation disappears when the bowels are well opened, or when the breasts are relieved of their engorgement. There is thus no such thing as a normal rise of tem- ' 'Some Observations on the Tempcrntuie, &c.,' Probyn-W'illiani.- and Cutler, Obsl . Trans, vol. xxxvi. Respiration and Temperature 221 perature on the third day. This phenomenon has been described as an event which is cjuite to be expected, but in the light of our present knowledge it must be considered as a matter requiring investigation in all cases. It o CO vO tJ- cyj o CO K K N K K CVJ •». . ^ *.^ — < 1 { ^^ — •c >< »• y 1 •u - — " '' > > < ( o •< •^ ^ 1 < "*1 > i 4 ( ON i§ C \ > 1 <' ^ >• r 00 ,^ < ' 1 < > ^^ N •< :C ]> < **,. > ( ( vO < «= ;5 ) 1 1 < >- { ^ iO •c S' y •c, r"" >" ( ( ^ •< :>i N 1 < •^ ^ o me. ?S \ 1 « k- ^--1 ^ N ( h^ ^ )> » . c^ T > < < — < < > 1 N \ t 1 / > a. < ^ Vco^OTt(\l'bO (\J — o en • • • • ctn c\j c\i og 222 Puerperal Period was formerly due no doubt to the slight septic absorption which almost in\ariably occurred in cases where the genital tract, especially at or near the vulvar outlet, had been lacerated during labour. This is well shown by com- paring the results of observations made at the General Lying-in Hospital in 1882,' before antiseptic measures were carried out with the perfection now reached, with the records compiled during 1893 ^n*^ 1894.- In the former list of cases there was a constant rise on the third day, which was most marked in cases where lacerations of the perinicum had occurred ; whereas in the latter cases such lacerations caused practically no difference in the temperature chart. Bowels. — -The intestines are always sluggish in their action after labour. This is due in great part to the want of support the\' suddenly experience from the relaxed conditions of the abdominal walls, and the consequent diminution of abdominal tension. Urinary System.- — ^There is not seldom retention of urine for twenty-four hours or more after labour. This is brought about by se\eral causes, which may act alone or in combination, (i) A bruised and swollen condition of the urethra, which, according to Spiegelberg, affects especially its upper end. This causes pain on attempts to pass water, and, in consequence, inhibition, which may be partly voluntary, partly reflex. (2) Diminution of the intra-abdominal pressure, which has been seen abo\e to influence the intestines. The abdominal muscles constitute the most important agent (Matthews Duncan) in emptying the bladder, and at this period they are temporarily useless owing to their previous stretching. (3) The patient is deprived of the assistance of gra\ity by reason of her hing in the horizontal position. If in the case of retention relief is not given by the catheter, the urine after the bladder has become full will trickle awa)-. This incontinence is hardly likel)' to be confused with that due to the presence of vesico- vaginal fistulte, for on a very superficial examination the bladder would be found reaching to the umbilicus or its neighbourhood, and dribbling from this cause belongs to an earlier date of the lying-in than that due to fistuht (see p 567). The urine during the lying-in period contains a great excess of urates, and this is always a very conspicuous feature when the urine has stood for a time. The average specific gravity is unaltered. The quantity is also about the same as usual, being, however, considerably increased if the diet contain an excess of proteids. The chlorides are also found to be increased in a marked degree.-' .A. new substance is often found in the urine of the lying-in woman — namely, sugar. This is milk-sugar, and is no doubt due to resorption from breasts. It is present at some time or other in nearly all cases. Its quan- tity has been found ' to vary pretty evenly with the amount of milk secreted. ' E. S. Tail, ' Some Observations on Puerjjeral Temperatures,' Otst. Trans, vol. xxvi. p. 8. ^ Probyn-Williams and Cutler, i/'id. '• W'inckel, Lchrbnch der Gebiirlshulfc, 2. .\ufiage, p. 195. * McCann and Turner, ' On the Occurrence of .Sugar in the Urine during the Puerperal State," Obst. Tratis. vol. xxxiv. p. 473. Diagnosis of the Puerperal State 223 Tlie quantity is stated by different authorities to \ary between 3-5 per cent. (McCann and Turner) and i per cent. (Winckel). The normal urine may also contain small quantities of acetone, and F"ischel describes peptonuria as a constant feature. This last fact possibly has some relation w ith the involution of the uterus. CHAPTER XXXII DI.\GNOSIS OF THE PUERPERAL STATE The signs that labour has recently occurred are well marked immediately after a deli\ery at term. The evidence of abortion in the earlier months is far less characteristic, and is not after two or three days to be relied upon as proving previous pregnancy. After delivery at or near term the clinical signs are good evidence for about a fortnight in any woman ; in primiparse this period may be somewhat extended, owing to the usually greater amount of laceration. For the diagnosis of parity or nulliparit)', see p. 67. General Condition. — The woman is in most cases evidently convalescing, and this condition is naturally the more marked the sooner after deli\'ery an examination is made. External Examination. — On examining the abdomen the uterus is found enlarged, and the measurements given on p. 209 will be a guide to the date to which the puerperium has advanced ; and, if observations are made of the height of the fundus on consecutive days, it will be found to diminish as there described. This is characteristic, for nothing but preg- nancy causes the uterus to undergo an enlargement which after remo\al of the cause disappears so uniformly and steadily. The size of the uterus may be estimated through the abdominal walls readily for the first week ; afterw^ards not so certainly ; for, ow ing to e.vaggerated anteflexion or to retro\-ersion, the fundus of the uterus ma)- be below the brim at an earlier period than normal. The abdominal walls are very relaxed, and are easilv pinched up into folds. The pigmentation in some cases is very marked, more so than at the end of pregnancy, since the lines and spots of pigmentation lie closer together now that the abdominal walls are no longer distended. The striae are usually red or purple, and often in multiparas the stri;v belonging to the last pregnancy can be distinguished from the dead white ones of gestations previous to the last. The breasts will be found knotty or full, according to the stage of lactation reached ; and either colostrum or milk can be squeezed from the nipple, flowing very freeh' as a rule. New stride also ma)- be seen radiating 224 Puerperal Period from the nipples. It is only in exceptional cases that the milk is scanty during the lying-in period, whatever it may become afterwards. The external genitals may show signs of laceration in varying degrees ; the orifice of the vagina is gaping to an extent corresponding to the rccent- ness of delivery, and is much pigmented ; and the lochia proper to the period are present. Internal Examination. — The vagina is extremely lax and inelastic. In a primipara the lacerations in the hymen, and especially its base, are recent, and granulations in a more or less advanced condition are found. The cen'ix is very broad and soft, and for the first day or two the tip ot the finger can be passed through the internal os. After then the finger can pass as far as the internal os for ten days or so, and then, if there is not much laceration, may only just be able to enter the external os. Bimanually, the body of the ute?-us, though enlarged, is fairly freely movable in the pelvis, its mobility becoming more marked as it grows smaller. It may in the earlier days contract on examination, and it lies in an anteverted position, as already described. The most reliable signs are found in the uterus, the vaginal orifice, and the breasts. The regular diminution of an enlarged uterus occurs in this state alone. When a large fibroid or polypus has been removed, and this is the only condition which could cause error, contraction and retraction are often very rapid, owing probably to the fact that the uterine enlargement caused by them does not affect the whole of the tissues in the same way as pregnancy does. The vagmal orifice may have been stretched and lacerated by the recent removal of such a tumour, but as a rule the hypertrophy of the tissues characteristic of pregnancy will not have occurred in this region — the parts will be merely stretched and torn. If delivery has been effected by Caesarean section or by embryotomy (in the last case especially in a multi- para), there will be no characteristic lacerative signs of recent delivery found at the vaginal orifice. Secretion is found in the breasts occasionally in cases of fibroids, ovarian tumours, and spurious pregnancies. It is in these cases a thin, serous fluid, and is very scanty, and thus differs from that which is present in the puer- peral state. Post-mortem Sk.ns of Dklivery, kkcknt or remote To make the diagnosis of parit\- complete, these signs may be added here. They consist only of additional points to be noted in the uterus, and affisct (i) the shape ; (2) its vessels and sinuses. The characters of these last have been already alluded to (p. 213). I. Shape. — The uterus ne\er returns after labour at or near term to its former size. In the case of super-involution of the uterus the organ is smaller than normal, but ordinarily the parous uterus has a cavity measuring nearer 3 in. than the 2A in. of the healthy nulliparous one. The alteration in shape is the more characteristic sign. Managemettt of Puerperal State 225 Comparing the outlines of the cavity in a nulHparous (A and I>, fig. 232) with those in that of a parous uterus (C, fig. 232), it is seen that the convexity of the lateral wall and of the fundus towards the cavity in a coronal section is much diminished in the latter, and in such a section the cavity is now more broad in outline, and has not the narrow triangular one existing before pregnancy. Seen in antcro-postcrior section there is no marked difference. Fig. 232. -Outlines of moulds of the uterine cavity in different states (after F. Guyon). Natural size. A, in a virgin of 17 years of age ; B, in a woman of 42 years who had not borne children ; C, in a woman of 35 years who had borne children, b, cavity of the body ; c, th.'it of the cer\-ix ; z, the isthmus or os internum ; 0, os externum ; t, passage of the upper angle into the Fallopian tube. The A\eight of the uterus is increased on an average by a few grains. The lacerations of the cervix and its other modifications have already been mentioned. 2. Vessels and Si?7i(ses. — The permanent changes in the arteries and the structure of a sinus-remains (which are characteristic for at least twelve months) have been described (p. 214). CH.VPTER XXXI II MANAGEMENT OF PUERPERAL STATE It will be seen from the foregoing description of the physiology of the lying-in period that the management of it must be simple in its principles ; and that, in the absence of interference from ^vithout or of previous organic disease, hereditary or other tendency to insanity, this period runs a satisfactory and uneventful course. Q 2 26 Puerperal Period Already partially or wliolly developed diseases of \arioiis organs, such as cardiac disease, or gonorrhcea, or a hereditary tendency to insanity, are conditions whose results can only be guarded against with more or less success ; but diseases due to fresh contamination from external sources can be practically abolished. These consist of septic processes and specific fevers, and the safeguards against them are found in antiseptic measures conscientiously carried out through all the stages of labour. These include both the two principles laid down (p. 1 80)— namely, (i) care that no material remains in the genital passages in which septic organisms can flourish ; and (2) care that no organisms are imported. (i) has been carried out by obtaining complete evacuation and retraction of the uterus; (2) so far by the observance of the laws laid down on p. 184 as essential. Aseptic cleanliness is the first and most important thing to aim at. The increased weight of the uterus and the relaxation of its supports now existing, the bruised condition of parts of the genital tract, the exhaustion of the muscular, and especially of the nervous system, all suggest complete rest till the several organs have returned to their condition before impregnation. Complete rest is then the second aim. The breasts and the 7mrsing of the child are the remain'ng subjects for attention. Cleanliness (aseptic). — The same precautions with regard to personal cleanliness in doctor, nurse, patient, and instruments are to be observed as in the conduct of labour. Douching' after labour. — In addition, in certain cases antiseptic douches must be given. These cases are : — (i) Where any manipulation above the le\cl of the internal os has been necessary, or where instruments ha\'e been used during the labour. (2) Where the ovum or other uterine contents have been diseased, and where the patient has had a purulent \aginal discharge before or during labour. (3) Where there are other lying-in women in the same room or ward. Under any one or more of these circumstances it is necessary for the patient's safety that a vaginal douche of some reliable antiseptic solution should be used at regular inter\ als for a few da\-s after labour. The best solution is, unless mercury is contra-indicated, one of perchloride of mercury of a strength depending upon circumstances, this being usually from i in 4,000 to I in 8,000.' Two quarts of this solution should be used morning and evening, a douche-tin always being employed where obtainable. Administration of the douche. — To administer the douche the patient should be made to lie on her back with her shoulders raised. The bed slipper is then arranged beneath her, and the tin is suspended about three ^ Mercury is contra-indicated in cases where renal albuminuria is present ; where the patient on other occasions has shown herself specially susceptible to mercurialism ; usually where diarrhoea is present ; and of course mercurial douches must at once be discontinued on the appearance of any symptoms of poisoning. These are : spongy gums, foul breath, diarrhoea, and abdominal pains. Vaginal and Tntra-iitcrine Douches 227 feet above the level of the bed. A small quantity of the fluid should be allowed to run off before the nozzle is introduced into the vagina, so as to ■expel any air that may be in the tube, and any solution which has become cold in the tube. The temperature of the douche should be from 108^ to 1 10°. The nozzle is passed for about two inches into the \'ayina and the ta]3 turned. The left hand of the person giving the douche must be laid over the uterus on the abdominal wall, so as to guard against distension by the solution, for some of the fluid often finds, its way into the uterus even when the patient is in the semi-recumbent position, and if it is retained there for several hours may be a cause of symptoms due to the absorption of mercury. Further, in some cases, the solution has found its way through the tubes into the abdominal cavity and has caused rapidly fatal results. Retention is more likely to occur in the vagina, especially if the perinaeum is still intact, or, at all events, has still sufficient tone to more or less completely close the vaginal orifice. Retention is prevented by pressing firmly down on the fundus at the end of the douche in the axis of the brim and by at the same time depressing the perineeum with the nozzle or with the finger. There are several kinds of nozzle, the one in most general use being the red gum-elastic tube usually supplied with a Higginson's syringe. A glass nozzle is a much better instrument in the lying-in room, for it can be kept absolutely clean and aseptic, whereas there is no such cer- tainty about the other. There should be no central perforation at the extreme end of the nozzle, whichever kind be used, since a powerful stream may find its way through this hole to the uterine cavity. There is no need to use any modification which allows of a return current either through, or by the side of, the nozzle when merely vaginal douching is employed, because the nozzle is not gripped by the vaginal orifice in the wax it may be by the cervix after the first few days. Carbolic acid (i in 60), or a saturated solution of boracic acid, may be used, instead of corrosive sublimate. Condy's fluid is not so reliable. If vaginal injections are made at all, it is certainly safer to use some form of antiseptic in the douche, as there is always a possibility of carrying infectious matter from the parts about the vaginal orifice into its deeper recesses or even into the uterus, either on the nozzle itself or by the stream of fluid. This will not occur if the rules already laid down as to cleansing the vul\a are adhered to ; but no safeguard should be neglected, and a i-eliable antiseptic will destroy such infectious matter. In some of the cases above mentioned (especially in (i)ancl(2)) it is often desirable to give an intra-iiterine douche after the delivery of the placenta and membi-anes, so as to wash away or destroy any septic matter which may have entered the uterus during labour. If given hot, at a temperature of 1 1 5° to 118° it acts also as a powerful stimulant to the uterus, and thus aids asepsis in two ways. The douche should be administered in the same manner as that abo\'e described for the vagina. A different nozzle, however, may be emplo)ed, the best one being Budin's uterine catheter made of celluloid or glass, though the cervix is at this time sufficiently lax to allow the fluid to escape if an ordinary long tube is used. Budin's is practically a flat, wide tube, folded in its length so as to form a semicircle on cross-section (fig. 233). The fluid returns under the arch made by the folding, and this channel cannot be Q)2 228 Puerperal Period occluded, (ilass has the advantage of ensuring greater cleanliness, but is^ of course, more easily broken. A short length of india-rubber tubing should be fitted to the butt end of the nozzle, and this can then be slipped over the bone or vulcanite end of the tube attached to the douche-tin. Supposing the labour has been perfectly normal, and that only one or two \aginal e.\aminations have been made, it is a question whether douches^ should be given at all. The results in some hospitals abroad, even with many women lying in one ward, have been as good as possible without any douching whatever. The outcome depends very much on how far strict asepsis- has been observed in the conduct of labour ; and in the above-named cases the success has been attained in the absence of vaginal examinations of any kind, the whole labour having been superintended per abdomen. In view of these results in lying-in hospitals, it is obvious that in private practice douches can be safely omitted after normal labours, and in the absence of the conditions already detailed. It is also perfectly true, however, that most patients feel far more comfortable and refreshed after each douche,, and that often clots are washed away by the fluid which might have remained in the vagina for some time and possibly ha\e done harm. It may be said, then, that a weak antiseptic douche, though not essential, may with advantage be given once a day, if not twice. A good solution is i -lo.ooo perchloride of mercun.-, or boracic acid 5j to a pint, or tr. or liq. iodi 5ss to a pint, or carbolic 1-60 may be used. If the nurse is inexperienced, it is safer to omit the douche and be satisfied with external cleanliness. The external genitals are to be washed twice daily, before the douche if this is given, with soap and water, and careful attention is to be given to the pubic hair, for it is liable ta entangle small clots and particles of mucus. .All soiled linen must be at once removed from the room, according to rules already laid down. A draw-sheet should be used for the first two or three days, and a fresh surface should be placed beneath the patient after each washing, or a fresh wood-wool sheet may be used each day. During the washing and the douching, in addition to the bed-slipper, a thick absorbent towel should be placed beneath the patient, and if soiled should not be used again. The patient will need to wear an absorbent pad of some kind over the vulva as long as any lochial discharge persists. The best material for this is wood-wool impregnated with a small percentage of corrosive sublimate. These pads can be obtained ready for use. The pad will have to be changed frequently during the first day, the number soiled each day becoming less and less. They are burnt at once after use. The total number will var>- much in each patient, an average for the w hole fortnight being three to four dozen. Fig. 233. — Btidin catheter. The Binder 229 Other materials may be used for the pads. Some patients find the wood- -wool pads uncomfortable, and in that case ' flannelette ' folded into two or three layers is ^•ery satisfactory. The lying-in woman should try to manage without a pillow for the first twenty-four to forty-eight hours, unless its absence causes her discomfort. Otherwise the tendency is for the pchis to lie considerably below the level of the rest of the body, and congestion of the lax and possibly lacerated parts is thus promoted. Binder. — \t is always better to use some sort of a binder, though in the opinion of many it is not essential. The binder affords some support to the abdominal walls in their relaxed state, giving them rest and promoting their involution, and it makes the woman more comfortable. It is certainly not such a vital part of the management of the lying-in as some women suppose, and accusations of incompetence made against the nurse on the ground of her failure in retaining the patient's previous figure because she had not applied the binder properly are not to be listened to. At the General Lying-in Hospital the method of application of the binder is as follows : — The binder should consist of huckaback towelling, 36 in. wide, and a yard and a cjuarter long, doubled lengthways. Its lower edge should reach four inches below the top of the thigh-bone (great trochanter). The free end of the binder should be uppermost on the right side. Starting from the left flank, the binder should pass over the abdomen, round the back, and again ■over the abdomen, ending on the right flank, where, after it has been tightened, and all creases smoothed out, it should be securely fastened by four strong pins. The patient's skin should be guarded by the left hand "beneath, and the pins inserted in the following- order, beginning from below — ■one at the lower end of the binder, three inches below the top of the thigh- bone, and a second a similar distance below the top of the hip-bone, both fastening the binder tightly, serving to keep it in position and preventing it from riding up. The third should hold the binder still more firmly on a level with the top of the womb ; and a fourth near the upper edge of the binder, not too tightly applied, completes the series. This will be worn until the woman is considered fit to get up. It will have, of course, to be changed occasionally, and at once on its lower edge being in the least soiled. The ventilation and lighting of the room have been already alluded to (see p. 180). The patient should be allowed to sleep as long as she will after labour. No excitement of any kind must be permitted ; and the lying-in woman must not interview friends ; the husband e\"en should only see her once for a few minutes on the first day. On the second, if all is well, two ^"isits may bs allowed, but should not exceed ten minutes each. The patient should have no household affairs to think about for the first few days. There need be no restriction placed on the woman's mo\ements in bed. She is not likely to want to move much, and changes of position are useful rather than otherwise, as they help the circulation in the pelvis, and add to her comfort. Rest in bed. — The woman should if possible remain in bed for a fortnight at least ; and if she has been lacerated, until all the tears are healed ; 230 Puerperal Period though she still nuist not be confinccl to one position, but mo\c about in bed. After this she can lie outside the bed for a day or two, and then be carried on to a couch, where she must pass a good deal of her time for the next fortnight or so. Of course ditierenl lengths of time are required to be spent in lying-in by different patients ; and each must be judged on its merits. The patient should ne\er be allowed to become tired ; and if this happens more time sliould be spent in lying down. If the lochia become red the first time she gets up, she must go to bed again for a da)- or two in an)' case, and must staj- there until the discharge becomes again free from blood. Greater care than usual should be exercised afterwards in deciding when she can move about more freely. Diet. — The patient will, as a rule, do Aery well on milk, a cup of tea, and a basin of soup for the first day. The milk can be taken plain, or made into- a custard or otherwise cooked. On the second day she may ha\e fish or chicken; and if all goes well, anything she likes on the third da\-. No attempt at a low diet should be made at any time ; the only reason light food is given on the first day is that the most easily assimilated nourishment should be used. Milk should always form a large proportion of the lying-in woman's diet ;. though if she does not nurse the baby for an)- reason (see below ) this rule may be neglected, and the diet then should not be too nutritious. Bowels. — The sluggishness of the bowels is a reason for administering a purge on the second or third day ; usually this is left until the third. Any aperient the patient prefers, provided it be not too strong, ma\- be used, or an enema may be gi\-en. Micturition.- — If the patient has retention of urine (sec p. 567) a catheter must be used w ith the strictest antiseptic precautions, since no doubt catheterism is a frequent cause of cystitis. This complication need never occur if no infective material is carried into the bladder by the instrument. The catheter should be passed every six hours, the patient in the meantime making attempts to pass water without it. She should, directh' the uterus has pro\'ed itself safely retracted by relaxing without hiumorrhage, begin to pass water kneeling in bed, and the nurse must help her into this position. A lying-in woman should never be allowed to have a full bladder, for it causes the uterus to rctrovert, and this retro\ersion may in some degree hinder involution. Fiilsc and Teiiipera/inr. — The muse will keep a careful morning and CAening record of the pulse and temperature ; preferably on a chart. The possible causes of any sudden rise of temperature will be borne in mind (sec pp. 562 and 569). If the rise is due to confined bowels a purge should be administered ; if to excitement, a dose of bromide may be given if considered necessary ; if to tension of tlie breasts, this nuist be relie\ed. and a purge is here also most useful treatment. If the rise of temperature is due to septicitmia or sapnvmia (see p. 527) ; this will be mainly shown by its persisting over twenty-four hours, and by the general condition of the patient. Suckling 231 Afterpalns. — If these are moderate in seveiit)', and only last for the first t\\ent)-f()Ui- or forty-eight hours, and the uterus diminishes in size in the usual manner, the patient should be encouraged to bear them, and should be informed of their value in expelling clots and favouring involution. If they are very frequent or severe, and seem to be wearing her out, some anodyne may be used, provided there is no reason, such as profuse lochia or a per- sistently large uterus, to suggest retention of any part of the placenta or membranes. The afterpains are usually severe where the uterus has been over-distended ]))• twins, or by hydramnios ; and in the case of women who ha\e had large families and have an enfeebled uterus. If treatment is required, hot fomentations or equal parts of glycerine and extract of belladonna spread on lint may be applied to the abdomen. Opiates internally are to be avoided, as they tend to prevent the uterus from con- tracting ; and if the afterpains are caused by clots, the expulsion of the latter is interfered with. In many cases two or three full doses of ergot (5ss of the ammoniated tincture) at short intervals, say of four hours, will be found a good form of treatment. However, if there is no question of retention of clots or other solid matter, and no considerable tenderness on palpation of the uterus per abdomen, and the pain is due merely to a colicky and irregular uterine contraction, 5ss doses of tr. hyoscyami in liquor ammonias acetatis or some mixture of the kind may be given, and the bowels made to act. Antipyrin and phenacetin have been found useful in a very large number of such cases ; and a trial should always be made of them before any sedative is given. The systematic administration of ergot during the whole of the puerperium has been advocated by some authorities as tending to promote involution and diminish the retention of clots, and thus the afterpains caused by them. There is, however, insufficient evidence of any such advantage ; and ergot steadily administered rather tends to produce tonic contraction of the uterus than to promote the physiological state of alternate contraction and relaxation. Iiactation. — The child should be nursed by the mother, at all events for the first three months, in all cases where there is no pathological reason to the contrary. Phthisis, recently acquired syphilis, or depression of health from any cause, and certain conditions of the breasts, are contra-indications to nursing. It would naturally be expected, and it is true, that its own mothers milk is the best food for a child. In the mother's interest it is probably also better, for the application of the child to the breast stimulates the uterus to rhythmical contraction and thus it may be expected to more rapid involution. ( )bscrvalions made on the rate of involution in cases where the woman has or has not nursed her child do not, howe\er, prove any such influence. Time and frequency of Suckling. — During the first day and until the milk- secretion is established the child should be put to the breast for a few minutes tliree or four times only in the twenty-four hours. The child obtains some slight nourishment from the colostrum and this also acts as a natural aperient for it. It is better for the breasts too, for they are stimulated, and the ducts are cleared ; and this tends to prevent the painful distension of the lobules which 232 Puerperal Period is often due to blockijiy. The nipples, too, are drawn out. After the milk has be^mn to flow freely the child should be suckled every two or three hours for ten minutes during the day. The baby must not be awakened for this purpose, but must wait until the next regular time. It will soon acquire the habit of being hungry at the proper time. In the night the mother should sleep from 1 1 P.M. till 5 a.m. As the child gets older and its stomach larger, the intervals between the times of nursing should be increased, so that at the end of a month they should be of four hours' duration. The breasts should be used alternately during the day. After each meal the bab^s mouth must be wiped out with a clean linen rag moistened with a solution of borax (5j to a pint of water) ; and the nipples should be treated with the same lotion, and carefully wiped dry. During suckling the mother should depress the part of the breast around the nipple with the fore and middle fingers, so as to enable the child to breathe with ease. If it cannot breathe easily, it has continually to drop the nipple to take a breath, and this tends to rub off the epithelium and lead to sore nipples. The child should under no circumstances be allowed to remain in its mother's bed during the night, or when she is likely to sleep, for it may then be 'overlaid' — that is, smothered. It will also be constantly sucking at irregular times, both spoiling its own digestion and giving the mammary glands no rest ; for it will be remembered that the breasts normally secrete only when they are stimulated by suckling ; and in the absence of this stimu- lation are at rest. The cases in which the mother should not suckle her child fall into two groups, (i) For reasons relating to her own health, nursing is contra-indi- cated by Sc7)crely cracked /tipples. Ma/ninary abscess. Depressed nipples^ which cannot be sufficiently drawn out after repeated attempts. Marked anannia Phthisis in any stage. Acute fevers., septic or specific. (2) for reasons relating to the child. Very scanty milk. Recently acquired Syphilis of the Mother. — Old syphilis of the mother acquired before pregnancy has already infected the child, and the latter can take no harm if there are no lesions about the nipple. If, how- ever, the infection is recent, the child may have escaped while in utcro, and no risks should be run of infection by the milk or by sore nipples. Cases where the child cannot suck owing to weakness or malfomiation will be dealt with later. If the breasts yield only a small quantity of milk at first, it is well for the mother still to try to nurse the child, for the quantity often increases to the Management of Breasts 233 full amount necessary, especially if licr strength is well supported by a generous diet, including much milk and a moderate quantity of alcohol, and possibly a full amount of protcids. Scantiness of milk occurs rather more frequently in \cry large breasts (the bulk of which is made up of fat) than in smaller ones ; the external appearance being no criterion of the amount of gland substance. It may here be stated that local applications are absolutely useless, and that, other things being equal, the amount of milk secreted depends on the general health. Care should be taken to keep the breasts and nipples in the best possible order. Any cracks or excoriations should be attended to ot once, for in most cases where mammary abscess develops they are the channel through which the organisms find entrance. They will rarely occur if the precautions detailed above are obser\"ed. If they do make their appearance, the nipple should be carefully washed with carbolic lotion 1-60 after each nursing, and an application of equal parts of glyc. ac. tannic, and a 1-20 solution of ac. carbolic, made on a small piece' of absorbent wool until the next time for suckling. This must be washed off before the child takes the nipple into its mouth. If the cracks become very severe and painful, nursing must be given up. For fuller details on this subject, see p. 570. A nipple-shield will in slight cases be found a useful protection, and will prevent much pain and some bleeding. The shield should be kept in a solution of equal parts of sulphurous acid and water when not in use, and washed in plain boiled water before it is applied. In the case of cracks which bleed readily the child may swallow some of the blood and subsequently vomit it. This is a possibility which should be remembered, as if it were forgotten it might suggest serious disease on the part of the child. Cracks are important not only on account of their immediate effect, but also, as just stated, on account of their becoming a channel for the admission of septic organisms to the tissues. Engorgoiietii of Breasts.— ^\i about the third day the breasts become painful and lumpy, all dried secretion which might cause blockage of the orifices of the ducts should be carefully removed from the nipples. Hot fomentations either of water or of olive oil may then be applied ; and very gentle stroking of the lumps towards the nipple with a lubricated finger should be practised. Some of the milk should be evacuated, either by the child, or, if it is not strong enough, by a breast-pump. The breasts should be supported by a bandage if they are at all heavy and pendulous. A napkin arranged under the breast and across the opposite shoulder answers very well. A saline aperient should be given. In cases where owing to the child's death or from maternal causes (see above) it is desirable that the secretion of milk should cease, the woman should be put on a lower diet than that described above, and no attempt made to draw off the milk. Tlie bowels should be freely opened with a saline purge, a pretty firm pressure should be applied by bandages uniformly adjusted over the breast, avoiding the nipple ; and the breast should be previously covered by a piece of lint smeared with glycerine and belladonna, 234 Puerperal Period a liolc being left for the nip|jlc. The nipple is covered with a pad of ab- sorbent wool, which is renewed as it becomes soaked with milk. The child must never have the breast again, nor must the breast-pump be used when once this treatment has been begun ; for the latter procedure rouses the gland to activity, and the child if nursed runs the risk of being poisoned by the belladonna. -^03 THE XEW-BORN CHILD CHAPTER XXXIV physiology and management Physiology The changes from the fcutal to the aduk type of circulation which occur at birth may be here described. The course of the blood in the foetus differs from that in the adult, mainly in the absence of the pulmonary circulation. Starting- from the abdominal aorta, its course is as follows : (fig. 234). It passes through the hypogastric arteries, which arise from the internal iliacs, and are continued as the umbilical arteries {U A) into the placenta {P). It is there aerated, and returns through the umbilical vein [U V) \.o the abdomen of the child. The umbilical vein divides on the under surface of the liver into two branches ; one, the ductus venosus {D V), joins the inferior cava, while the other unites with the portal \e'm {Port) and sends its stream through the liver, the blood afterwards joining that in the vena cava by means of the hepatic veins (// V). More blood goes through the li\er than through the ductus venosus, and in the diagram the latter is drawn too large. The inferior cava opens into the right auricle {RA), and its blood is directed across the auricle by the Eustachian vah'e, shown in fig. 235, to the foramen ovale, through which it passes into the left auricle, as shown by the arrow. It thus escapes the pulmonary circulation, and finds its way immediately into the left ventricle, passing on into the aorta, and being dis- tril)uted to the head and arms. Returning to the right auricle ; the superior cava con\eys the blood coming from the head and neck and upper extremities, which is entirely venous blood, into this cavity at its upper and outer angle. The stream then passes in front of the Eustachian valve into the right \entricle. This venous stream crosses the aerated one of the inferior cava (sec fig. 235). On reaching the right auricle, the blood is forced into the pulmonarx" artery, PA (figs. 234 and 235). A very small quantity, /"yi (fig. 234), merely enough to nourish the as yet unexpanded lung, is diverted from the main current, which latter passes on through the ductus arteriosus to join the aorta below where the left subclavian artery is gi\en off. It there mingles with the blood, originally from the inferior cava, which has passed through the left \cntricle. The 2^6 The Neiu-bor)i Child supply of aerated blood to llie head and arms is thus given off before this venous blood joins the aortic stream. The mixed blood is then supplied to the trunk and lower limbs, but the greater part of it goes to be fully aerated in the placenta. On looking at the scheme of the circulation (fig. 234) it will be seen that there is fully aerated blood in the umbilical \ein only, and fully deoxygenated blood in the vena cava superior, in the part of the vena cava inferior below where the ductus venosus joins it, and in the veins from the viscera. The rest of the blood in the main trunks is mixed blood. In the later months of preg- nancy there is less marked separa- tion between the two currents in Fig. 234. — Foc-tal circulation. C, carotids ; y, supe- rior cava ; /'.-!, pulmonary artery ; P K, pulmo- narj- vein; R A, right auri.Ie; A'/', right ventricle; LI'-, left ventricle; DA, ductus arteriosus; Ao, aorta; HA, hepatic artery; // V, hepatic vein ; Port, portal vein ; D I', duc- tus venosus; UA, umbilical artery; U l^, um- bilical vein ; /', placenta. The branch from the y? /'should join the portal vein before entering the liver. Fig. 235. — Scheme of right side of heart. I'CJ, vena cava inferior; I'CS, vena cava superior; /'.J, pulmonary artery; ventricles and auricles marked right and left, A'. I, /. .), A r, L i: the right auricle, and the blood passing through from the upper ca\a and on into the pulmonary artery, ductus arteriosus and aorta is better aerated. The lower limbs are consequently better nourished, and grow more rapidly than at first. 'Wlien the cbild is born and ihe placenta is dct;u:hed, the child's system feels an immediate want of oxygen, and by the reflex action of the respiratory centre the first breath is taken. The stimulation of the skin by the cold air helps to make the child give its first gasp, and ma\-, unfortunately, do this occasionally before the respiratory passages arc free ; as, for instance, in a Functions of Nezv-boni CJiild 237 breech delivery before llic head is born (see Asphyxia Neonatorum, p. 518). When tlic first inspiration is made the lungs expand, and with them their capillaries. This causes at once a large quantity of blood to pass through the pulmonary artery direct to the lungs, and very much less through the ductus arteriosus, in which the pressure is correspondingly lowered. The huge quantity of blood is returned to the lieart through the now expanded pulmonary veins (/'. K), and the pressure in the left auricle is increased to one at least equal to that in the right auricle, which on its side is diminished by the withholding of the placental blood, for the now detached placenta has its circulation very greatly diminished. The stream through the fora- men ovale thus ceases, and the valve begins to close. The ductus arteriosus gradually closes owing to the diminished pressure in it. The pressure in the aorta is consequently lowered, since it has the force of only one ventricle behind it ; and now that the placental circula- tion is abolished, the hypogastric arteries diminish down to the size at which they are found in the adult. The temperature at birth is a little higher than the maternal one — namely, about 100^ F. It becomes slightly lowered soon afterwards, averaging about 97-5'^ in healthy children, and then again in a few hours rises to the adult normal temperature. A fall of 3° or 4° F. may sometimes occur, but if this is not soon recovered from, it is of bad augury for the life of the child and shows deficient vitality. The daily range amounts to about 2°, the highest point reached being at 5 to 6 P.M. Pulse. — This is about the same as in utero ; the respirations are at about 44 per minute. Urine. — This secretion is of low specific gravity, about 1012 at the ver)- first ; afterwards about 1004 for the first few weeks. It contains less urea than that of the adult, but a large proportion of uric acid. It is cloudy at first, but becomes pale and clear after the first few da)s. It is passed ten or twelve times daily and amounts to about 10 oz. in the 24 hours, a considerable quantity in proportion to the child's size. Exact investigations are, however, extremely difficult to make, as the urine requires special arrangements for its collection. Traces of albumin are not infrequently found for the first six days or so Albumin is considered by some (Dohrn and \'irchow) to be a post-mortem phenomenon ; but Martin and Ruge are of opinion that it is normal in most cases, and that the kidneys of the newly-born are always in a hyperjemic state, sharing this peculiarity with the lining membrane of the large serous cavities, the bronchi, and the endometrium. The urine contains at first some epithelial cells from the bladder and the rest of the urinary tract, including the pelvis of the kidneys ; uric acid in rhombic plates; urates, uric acid infarcts; and occasionally hyaline casts. All these points of difference from adult urine (except the low specific gravity disappear after the first week or so. Alimentary System. — The stomach is ready to deal with food long before full term, and pepsin has been found in it as early as the third or 2:i8 The Nciv-boni Child lourlli nionlh. Soon after it Ijccomcs active it assumes tlie adult position, i.e. one nearer tlie \ertical than that in which it lies before this. It holds only one to two fluid ounces at birth ffig. 236), but soon increases in capacity. The salivary j,dands have not attained their full development in the power of starch-conversion, and do not attain it for the first three or four months ■of independent life. The pancreas is able to dij^est fats and albumin. Fig. 236. Stomach of a newly-born infant (natural size). (.Ashby and Wright.) For the first two days the bowel expels only meconium, a dark Ljreen substance which consists of mucus, bilc-piyments, cholesterin, and epithelium. This is in three or four days gradually replaced by the characteristic yellow semi-liquid ficccs of the infant. M()tif)ns are frequent, occurring every few hours. Iioss of "Weight. — Owing to the free secretion of urine and discharge of meconium in the absence of renewal of supply, the child loses weight for the first three or four days. This loss is only a few (2-3) ounces, if the cord has been Hgatured late, as advised, but after immediate ligature it may be as much as half a pound. When the food-supply is established, it picks up what it has lost by the end of the week, and thence onwards gains rapidly in weight, and makes roughly about an ounce a day.' Skin. — The redness of the skin of new-born children passes on to a desquamation, which begins about the third or fourth day and proceeds for about a week. The change from red to )ellow which the skin imdcrgoes during this period may, as Spicgclberg has pointed out, be mistaken for slight jaundice. It begins on the trunk and lower limbs, and ends on the face and arms. A real yellow staining of the skin does occur in about 25 per cent, of all newly-born children. It is called icicnis uconataniin (see p. 5i. Both these distortions disappear completely as a rule by the third or fourth day, so that in measurements taken on the fourth day the original shape of the head in utero is reproduced ; and with these the measurements taken immediately after birth may be compared, and the amount of distortion estimated. There remain to be noticed two slight abnormalities, wliich occasionally arise in the first few days of new-born life. One is a sTvelling of the 7-udinicntary mammary glands. In children of either sex indifferently, these organs may become swollen and tender, and may secrete a little serous fluid, which is sometimes almost as opaque as colostrum. This condition subsides, if the breasts are left alone, in a couple of days or so. It occurs within the first few days of life, and is, no doubt, connected with the increased activity shown by the skin at this time. The other abnormality occurs in female children only, and consists in a discharge of blood from the vagina. This probably occurs without any lesion of uterine or other surface, and is merely part of the general congestion described by Martin and Ruge and mentioned abo\e. It happens in about one in 40 or 50 cases, and lasts one or two da vs. 240 The Ncw-boni Child This symptom aj^ain ma\' Ije part of a serious disease ; it may be comliinccl with mehcna and (jthcr li;Liiiorrhages (sec |). 582). ]\Tana(;i:mknt When the mother has been left in a satisfactory condition after the end of labour the nurse must turn her attention to the child, which has been left wrapped uj) in flannel in a safe place, breathing normally. Its various organs, orifices, and limbs should be first carefully examined. The cycs^ if not attended to before, should be \ery carefully washed w ith clean warm water, to guard against ophthalmia, and if there is a suspicion of any purulent vaginal discharge in the mother, a solution of perchloride of mercury (1-2000) should be dropped into their outer canthi. Crede, who was the first to ad\ocate and to prove the \alue of this practice, used a 2 per cent, solution of nitrate of silver in every case. It must now be washed in water of the temperature of 96° F'., never hotter, and the washing should be done in front of a fire. The \ernix caseosa, if very plentiful, may be remo\ed w ith a little oil, and then soap (which should be free from excess of alkali) ajjijlied wiili a piece of soft flannel. The friction must not be too vigorous. When the surface is quite clear and all the creases attended to, it must be well powdered \vith starch and oxide of zinc powder, or pure boracic acid ('Sanitary Rose Powder'). The ctvd should be passed tlirough a hole in a square of some antiseptic gauze, and after it is clear that no bleeding is occurring from it, coxcred with the powder, one or two teaspoonfuls being dusted on to it. The gauze is then folded o\-er so that the cord turns upwards on the abdomen, and a flannel binder fix'c inches wide is firmly, but not too tightly, adjusted over all. The clpihing should co\er the limbs and not be too tight, and no pins should be used. The buttocks should be smeared with cold cream or vaseline each time before the napkin is put on. In the after manage inait, care should be taken after the dail\- washing to dr)- it thoroughly, and to powder all the flexures and wrinkles carefulh-. The cord must be examined every day and its dressings renewed. After it falls off, its site should be carefully protected until it is quite healed. Care must be taken to renew the napkin frequently. Soiled naiikins must be immediately remo\ed from the room. If there is any difficulty in micturition, a warm bath often removes this ; and a careful examination should be madeforan\- abnormality of the external gcni to-urinary organs. Feeding-. The frecpicncy and other details of suckling have been already dealt \\ itli, and also the strict necessity for the child's not remaining in the mother's bed, but sleeping in a bassinette. If, unfortunately, the mother is unable to suckle her child for the reasons given above (p. 232), a wcl-iuirse is the best possible substitute for her, and no artificiallv-made food is for a moment to be compared in value with the milk of a hcaitln- woman. Selection of Wet- Nurse 241 The 'Wet-NTurse. — There are some ])oints of importance in sclcctinj^ such a person. (i) She must be healthy. She must be carefully examined for every sign of syphilis at any stage. Her obstetric history, especially as regards mis- carriages, must be particularly incjuired into. The existence of tubercle in any form, or a strong family history of it, at once disqualifies a woman from acting as wet-nurse ; antemia, if marked, is a disqualification, for the milk is usually of a poor quality, and the woman may ha\e to give up suckling after a week or two, thus necessitating a fresh nurse, and disturbance to the baby. The best age is from 22 or 23 to 32 or 2,2,-, and it is better that she should have had a child before the present one, so as to ha\e learned how to manage the nursing. (2) Her own child must be healthy. This is a very important matter, for if her baby is unhealthy it probably has either some hereditary taint, or its mother's milk must have disagreed with it ; that is, if it has been fed on nothing else. Signs of s)-philis are to be looked for in the shape of eruptions on the buttocks. Ophthalmia, convulsions, diseases of the umbilicus, haemorrhages from \arious mucous tracts, aphthae of mouth, jaundice, rickets, all need a most careful inquiry into their causes, and a consideration of the possibility of injury to the foster-child. (3) Age of her child. This should correspond fairly closely to that of the baby to be substituted for it, since the composition of the milk alters slightly, as has been mentioned, as the lactation period advances. If there is any difference, it is found best for her child to be a little older, for then greater opportunity has been given for syphilitic rashes to appear, and the nurse has acc[uired some experience. (4) Her breasts and nipples must be well formed. Both sides should be examined carefully, and the nipples should be capable of being easily seized and not tender or retracted. The breasts must not be too fat, as such organs do not as a rule yield so much milk as those only comfortably padded ; and the excess of fat may prevent the child from breathing comfortably during its meals. (5) The milk should flow freely on squeezing the breasts, but should not run away continuously. If it is thought well to analyse it, the normal standard is given on p. 242. It will be seen in a week or so whether the baby is thrumg on its wet- nurse's milk. Children often do not take to a strange breast at once, so a fresh nurse must not be procured until the existing one has had a week's trial. If after that time there is any digestive disturbance, such as vomiting, diarrhoea, or restlessness, the nurse should be changed. If the wet-nurse has been accustomed to hard work and poor food, she should not be encouraged or allowed to eat large rich meals, drink quantities of stout, and do absolutely nothing all day ; but should be fed very sparingly at first, with no alcohol as a rule, and should take enough exercise to prevent her from suffering from over-eating. R 242 The Nciv-born CJiild Artificial roods.— If a wet-nurse is not to be employed on account of tlic expense, or of objections on the mother's part ; or if tlie mother is able to suckle to a moderate extent, but not sufficiently for the child's wants ; or if the child is syphilitic, in which case it would be criminal to allow a wet- nurse to risk being infected ; then some more or less artificial food has to be contrived for the baby. It stands to reason that the more nearly the substituted food resembles the mother's milk, the better it is likely to agree with the child. Cow's milk is nearly always the raw material out of which such a sub- stitute will be made. Before deciding how this is best done, it may be mentioned that the ass, mare, and goat yield milk that has a nearer com- position to human milk than that of the cow, and any one of these may be used if it is easily obtainable ; but practically, cow's milk can be made quite as suitable. For a healthy child, milk is the only diet admissible for the tirst six to eight months ; and it is in exceptional cases alone that any other food, even ' malted' food, should be used until the end of that period. Ignorance, or non-obser\ance, of this rule is the cause of more than halt the alimentary diseases of children. The child during the first weeks of life has little or no power of con- \ erting starch into sugar ; and foods such as arrowroot, boiled bread, rusks, and so on, which consist almost entirely of starch, are cjuite inadmissible, since they either pass through the alimentary canal unchanged, or undergo acid fermentation, acting in either case as irritants to the mucous membrane. If we compare the composition of cow's milk with that of human milk we see by the table that cow's milk contains more proteids in an equal bulk than human milk does. Proteids Fat Sugar Salts Human 1-2 4 7 -2 per cent. Cow's 3-4 4 5 -6 „ „ We see also, however, that dilution alone will not eftect what is wanted, for the sugar will then, being already below the required percentage, be reduced further, and if enough water be added to bring the proteids down to the human standard the fat will be too much reduced. In addition to the difference in composition as shown In- the abo\e table there are other important points to be mentioned. The proteids of either milk are of two kinds : one, caseinogen, which coagulates into curd on the addition of 'rennet,' and in the stomach ; and the other, lactalbumin, which coagulates on boiling. Cow's milk contains much caseinogen and little lactalbumin ; in human milk (and in ass's) this relation is reversed. The curd formed in cow's milk is much more solid than that of human milk. The latter curd is quite soft, and easily disintegrated ; the former is tough. This tough curd cannot be digested by the majority of infants, and the lumps pass through the alimentary canal almost unaltered, except that they ha\e fermented and are giving oft" ptomaines and gases. Such decomposing lum|)s will set up enteritis, w ith diarrhaa and convulsions. Cow's milk, as usually obtained, is acid and contains already many bacilli ; human milk is sterile and alkaline. Preparation of Covus Milk 243 Cow's milk, tlicrcforc, to be made at all fit foi" infaiUb' food must be subjected to some mode of preparation. It may be used diluted with water holding various substances in solution ; diluted, with added cream ; deprived of most of its casein (whey) ; sterilised, diluted or not ; pcptonised and diluted ; condensed ; in manufactured 'foods.' nU II ted with Water holding various substances in solution.— T\\\'?, is the commonest way in which infants' food is prepared. Water is added in the propoition of three parts to two of milk, and then sugar, one moderate- sized lump to 2 oz. or so of the mixture. It is better to be more exact, and add in the above proportion water containing 5 per cent, of milk-sugar. Sufficient lime-water to make the mixture alkaline is advisable. After the first month or so milk and water may be used in equal quantities. Instead of water, barley-water, or a solution of makose or dextrin, may be used. This is belie\-ed to render the curd less tough ; and whether it does this or not, it has been proved by experience to be more easily digested. Diluted, with added cream ('Humanised milk' of the dairies'). — Cream is added to make up the loss of fat in the milk after dilution. The cream when supplied by the dairies is not by any means free from micro-organisms, and unless it is obtained from fresh milk specially treated, it may be dangerous from this cause. The cream should be produced by a 'separator,' which does its work by centrifugal force in a few minutes without any need for the milk to stand. All the cream so obtained may be mixed with half the separated milk, and the- mixture diluted and treated as before. Deprived of its Casein (w/z^j/).— This must be quite fresh, and may be used with or without cream. If cream is added it should be in the proportion of 1-6 or 8. Sterilised. — Sterilisation removes the A-arious micro-organisms which multiply rapidly in milk that is kept, and produce ptomaines and turn the milk sour. Milk may contain also the organisms of tubercle, or other specific diseases, including the exanthems. It is found that, if the milk is fresh to start with, a temperature of 160° F. is enough for all purposes, and does not alter the flavour or coagulate the lactalbumin.- After milk has been kept at a temperature of 212° F. for over an hour, the casein produced on coagulation is found to clot less firmly, and to more nearly resemble that of human milk than if the milk had not been so treated. Ikidin and Chavane use this milk undiluted, and ha\-e found it extremel)' suitable and successful. The milk after this process is, however, found to have lost some of its emulsion, and large drops of butter which arc not easily digested are separated out. Pepto/iised.—Xhar cow's milk has been peptonised the curd is found to be softer. It will often agree with children whom ordinary diluted milk does not suit. Peptonisation must not be carried to the full degree, for the milk is then rendered bitter. Ashby and Wright recommend that the cream mixture described above be used, and that the process of peptonisation be carried out in the sterilising apparatus. They advise that 'a reliable peptonising powder containing pancreatin and soda be added to the 1 This is usually sterilised. '^ Hawkslcy, of 357 Oxford Street, supplies a steriliser for this purpose. 244 The Neiv-horn Child mixture when nicely warm (iio'^ F.), and the temperature raised during the next ten minutes or quarter of an hour to i6o° F., when the process is complete. Or the temperature may be raised to the boiling point.' As Co7idenscd Milk. — TJiis is often \ery useful for a short period, and may agree with the child when diluted fresh milk will not. It should be diluted to about I in 12 for infants. Care must be taken to get a reliable brand ; the 'Milkmaid' brand has been found so ; it contains about 12 per cent, of fiit, so that it is desirable to add cream to bring up the i per cent., when the condensed milk has been diluted twelve times, to the normal 4 per cent. In Maiiufactwrd Foods. — These consist of desiccated milk, with milk- sugar and dextrin. They are sterile, and are con\'enient where reliable milk cannot be obtained. They may be tried with advantage when the child is unable to digest the proteids in other preparations, and where the difficulties of peptonising the milk as advised cannot be overcome. The directions for use supplied with the food must be carefully observed. From the above methods of preparing the child's food, one has to be selected ; and if it is wished to give the child the best possible chance on an artificial diet, it will be wisest to choose the method of sterilisation and peptonisation described. Many children, howe^•er, thrive on the milk simply diluted, or with added cream. It is not advisable to keejj the child on condensed milk for more than a few weeks, as it is, in the opinion of many, a cause of rickets and infantile scur\y. The food should be taken by a healthy child from a bottle. The only kind of baby's bottle that is admissible is one that can be perfectly cleaned without difficulty. Thus all indiarubber and glass tubes, and corks, must be abolished, and the apparatus reduced to a smooth bottle, with, as recommended by the above authors, no raised or indented letters on the glass, with a large teat of indiarubber fitting over its mouth. This may with advantage be large enough to be turned inside out and so completely cleaned, and it may be kept in a solution of boracic or sulphurous acid when not in use. The bottle should be given to the child about e\'ery two hours during the day, and should contain about two ounces of whatever mixture is emplojed,. at about the temperature of the body. The child should be taught to sleep- for five or six hours during the night. It should never be allowed to ha\e the bottle in its cot while it is unwatched ; and it is a good rule never to give the child the bottle in the cot at all, but alwa)-s to take the baby up during its meals. The greatest care must be gi\cn to the cleansing of the child's mouth after its meals ; this is done with a soft clotli or handkerchief, and a little glycerine of borax and water. PATHOLOGY Thk pathological part of this work is arranged in the same order as that dealing with physiology, and the Pathology of Pregnancy, of Labour, of Lying-in, and of the New-born Child are in turn considered. In the Pathology of Labour, a section on Obstetric Operations is included. To this section a reference may be made by the student in the case of his meeting with allusions to operative procedures in chapters earlier than those dealing with this subject. The organs and the tissues which are affected by disease, or are abnormal, are, in each of the above divisions, arranged as nearly as possible in the same manner and secj[uence as in the physiological part. 246 Pathology CHAPTER XXXV PATHOLOGY OF PREGXANCY In this dixision the abnormahties and diseases of the pregnant woman and the o\um are considered in the order of description adhered to in the accoimt of N^ormal Pregnancy, as follows : — Ovum and dccidiia. The diseases and abnormalities of the decidua are grouped for convenience with those of the en\elopes of foetal origin (see Chapters I. and II.) Maternal Organism : — 1. Affections, directly connected with pregnancy, of {a) the generative, and ib) other organs. 2. Affections of independent origin, which only accidentally complicate pregnancy, of {a) generative, and {p) other organs. Abortion and Prcmatii7'c Labour. Ectopic Gestation. Hcrmorrhages during Pregnancy. Affectioxs OF Oyum axd Decidua Secidua. — The aftections of the decidua not essentially in\olving the placenta are alone treated of under this heading. The)- comprise inflammation and its results, hivmorrhages into and under the decidua, anomalies in development. Injliimmatinn {Endometritis decidi/alis) This may be acute or chronic, but as during pregnancy the former probably only occurs in connection with acute fevers or traumatism, it comes under the description of acute fevers or abortion. Chionic decidual endometritis is usually described as being of two kinds, one of which results in thickening, or fibrosis, of the endometrium affected (E. d. tuberosa s. pol)'posa), and one in which the only sign or symptom is a watery discharge which occurs during the later months of pregnancy, and in wliich no special pathological changes have been described. Endometritis decidualis tuberosa s. polyposa consists in a chronic inflammatory change in the decidua, which may be general or local, and results in abnormal adhesions of the affected tissue to the uterine wall, and in thickening of a more or less irregular character. Causation. — The causes, as far as is known, are : — Endometritis existing before conception ; irritation due to a diseased, or a retained dead, o\um ;. HydrorrJuva Gravidarum 247 injuries from, for instance, blows on the abdomen, or conceivably from the passage of instruments. SyphiHs is not by any means estabHshed as a cause, but most aftections of the membranes of the ovum are, for want of a better explanation, accredited to syphiHs. Morbid Anatomy. — The decidua is found to be changed from its friable easily detached condition, to one of tougher consistence. It has undergone a cirrhosis, the interglandular cellular tissue becoming fibrous, and the glands atrophied. In some cases, as shown by the names given to this affection, the free surface is elevated into tuberosities, or even polypoid excrescences. Often there are extravasations of blood into, or under, the altered decidua, and the condition merges into that of a carneous mole (p. 24S). The de- \elopment of the ampullary layer (see p. 7) is interfered with, and the membranes are in consequence more adherent than normal to the uterine wall. Syinptojiis and Signs. — There are no definite S)'mptoms, unless the disease ends in abortion. This sometimes occurs in severe cases, \\here much extra^•asation ensues, e\en when the decidua \-era alone is aftected. When the serotina also is diseased, the danger to the ovum is much increased. If the embryo dies from failure of nutrition, the ovum may be expelled, or retained for some time as a bHghted ovum (p. 250). In certain cases where the haemorrhage into the decidua is considerable, the result is a 'mole' (see p. 248). Trcatinc/if. — No cui^ative treatment can be adopted, for the disease cannot l^e diagnosed ; but in the case of abortion, threatening or actually occurring, this affection may be borne in mind as being likely to produce abnormal adhesions of the membranes. Endometritis Decidualis Catarrhalis (Hydrorrhoca graxidarum). — This condition is recognisable clinically. It has been defined already. Its morbid anatomy is not known. The fluid, howe\-er, comes from the space between the decidua vera and decidua reflexa, and this space, or some part of it, must be persistent very late when the discharge occurs, as it usually does, during the latter months of pregnancy. The fluid is thin, resembling" liquor amnii, and occasionally contains blood. Symptoms and Progress. — If there is a free outlet for the fluid, it runs away as it is produced, and possibly is not noticed unless the quantity is considerable. More commonly, however, it collects and is discharged at intervals in gushes. In such cases the uterus has been noticed after the gush of fluid to become smaller, and contractions have been felt by the woman. Such a sudden change in the shape and size of the uterus sometimes causes labour to begin ; and, in fact, labour in cases of this aflection is usually premature. Hydrorrhoea occurs most commonly in the latter months of pregnancy, but may begin in the third or fourth month. Diagnosis. — This disorder has to be distinguished from rupture of the membranes (anmion and chorion) and discharge of liquor amnii, and from rupture of the chorion alone and discharge of the amnio-chorionic fluid occasionally present (p. 114). 248 Pathology The fluid is as a rule shown to be not h'quor amnii, first, by the pregnancy pursuing its ordinary' course in other respects, and second, by the repetition of the discharge. The latter character also distinguishes hydrorrhoea from the discharge of amnio-chorionic fluid. In exceptional cases, however, labour does not come on immediately after the discharge of the liquor amnii. Matthews Duncan ^ describes such cases — one where forty-five days elapsed after the discharge of some of the waters ; and such instances are within the experience of most. He mentions also other discharges of fluid which may occur during pregnancy — namely, discharge of urine from the bladder during coughing, and discharge of the liquor amnii of one ovum in a case of plural pregnancy. There is no evidence that the fluid, if collected, could be distinguished from liquor amnii, or from amnio-chorionic fluid ; but the presence of urea (p. 19) would certainly be strongly suggestive of liquor amnii. Treatment. — Rest in bed, with sedatives, is the only treatment. The physician should always be prepared for a summons to attend the labour, whether he is certain of his diagnosis or not. Hcemorrhage Formation of a Blood-IMoIe or Carneous IWole (' False conception '). — Haemorrhage into the substance of the decidua or beneath the chorion may be due to, or combined with, chronic endometritis, as already mentioned. It is also caused by violence or injury to the utenis, such as blows on the abdomen ; by incarceration of the retroverted gravid uterus ; by the uterine contractions in the actual detachment of the ovum during abortion from any cause ; and may possibly occur in cases of severe obstructive heart disease. £mbryo--f Arnn ? Cdv. Fig. 237. — Diagrammatic section of a carneous mole. Morbid Anatomy. — The bleeding may take place into the decidua vera or the serotina. The membrane is destroyed and broken up to a greater or less extent, and the blood frequently forces its way into the space between vera and reflexa, or it may reach the amnio-chorionic space, or e^•en the amnionic cavity. The chorionic villi, whether the hsemorrhage occurs, as it usually does, before these structures become limited to the placental area, or after the 1 Obst. Trans, vol. xiv. p. 216, ' Missed Miscarriage or Labour.' Carneoiis Mole 249 placenta is formed, are rendered useless by the compressing action of the extravasated blood, which soon clots firmly. If the ovum is still retained in the uterus, the villi occasionally become irregularly swollen (fig. 239). Either by failure in its nutrition owing to this destruction of the decidua, or by the direct pressure of the extravasated blood on the ovum, the embryo dies. Frequently the direct pressure ruptures the ovum, and the liquor amnii and the embryo escape ; but if this does not happen the embryo usually disintegrates, and is more or less completely lost. Fig. 238. — A carneous mole, opened. The external surface is to the right ; the bosses, b, b, are seen on the inner surface ; e, embryo, with short, thick untwisted cord. (The specimen was photographed in a bottle, and this accounts for the appearance of the left-hand edge.) The result of these changes is the formation of a blood-mole. This con- sists of a thick-walled cyst, lined with amnion, which is bulged up into irregular bosses (fig. 238) by the blood. The blood is clotted among the villi of the chorion and in the tissue of the decidua, and to a great extent decolourised. The blood-infiltrated tissues form the cyst-wall (fig. 237), which often attains the thickness of an inch, and may enclose a cavity of about the same measurement in diameter. A mole may be expelled soon after the death of the embryo, or may be 250 Pathology retained, probalily owing to the abnormal adhesion of tlic dccidua to tlio uterine wall, for some weeks, or even months (Missed Abortion). (See also Inira-Uterine Diseases of P'cetus, p. 269.) Expulsion usually occurs before the fifth or sixth month, but is sometimes found to be delayed indefinitely. In the latter case the blood underjjoes further changes, and the mass shrinks, and may even become calcified.' The irregularities of the amniotic surface abo\e mentioned ma)' become con- \'crted into cysts, which project into the cavity of the amnion, and contain a sero-sanguineous fluid. If organisms of decomposition obtain entrance to the uterus, the ovum will putrefy and break up. In the examination of a doubtful mass of the kind described, sure evidence is found of its nature in the presence of villi. Fig. 239. — \'illi cui ill \.iiicu> pUinus. The .spaco btUvecu llicm urc lilltU with blood, more or less changed. This specimen shows some fatty degeneration (osmic acid). (Eden.) CJiorionic Villi. — These will be embedded in the mass of coagulated blood in almost all cases, and if present they may be demonstrated by teasing a small piece of the mass out under a low power, or by making sections of it (figs. 239, 264 and 265). If the mole be passed entire, it forms a mass often ot the size and shape of an orange, and it will be seen on section to enclose a more or less well- marked cavity, lined with the smooth or slightly altered amnion (fig. 238). If the disease has arisen after the beginning of the third month, there maybe traces of an umbilical cord attached to the inner surface. It is not very usual to find anv trace of an embrvo. Carucoiis Mole 251 Ifllic mass is passed in ijiecc-s, one side of a pircc nia\- Ijc found snioutli, the oilui- idugh ; and \illi should be looked for in the suljstancc of tlie mass. A mok' passed entire lias to be distinguished from a ntyoiiin which has I)een expelled from the uterine cavity. The presence of \illi in the mole will readily enable the physician to distinguish between the two. It must be borne in mind that either may be calcified, though calcification of a mole is \cry rare. The presence of \illi and the thickness of the wall will also prevent a mole being confounded with the membrane passed in cases of membranous dysmenorrhoea, and with the decidua in the case of ectopic gestation. Sv/iif>foi>is. — The indications of the formation of a carneous mole arc not well marked, and in cases where the death of the o\um has occurred in this way, the diagnosis of the existence of pregnancy is not ahva)s clear. What may be expected is this : the \\oman has considered herself pregnant, and has had the rational signs — vomiting and suppression of menstruation — of early pregnane)-. Then, after a month or so, she finds the vomiting cease ; her breasts, which may ha^•e been enlarging, become flaccid, and her abdomen, if the pregnane)- has reached the stage at \\\\\c\\ enlargement of the abdomen can be appreciated, does not increase. The latter sign will usually be wanting, since carneous moles are formed for the most part before the third month, and abdominal enlargement due to pregnancy is not obser\cd before the fourth. The uterus does not grow, but freciuently becomes smaller and nearly always harder. This can be made out by bimanual examination. Menstrua- tion docs not take place, and there is often a brownish discharge due to irrita- tion of the uterus by the mole and tingeing of the discharge by some of the colouring-matter of the effused blood. The condition of retained dead o\'um has been called 'missed abortion,' a term of which the application is obvious. A woman so affected may suiier no further unpleasant s)-mptoms than those described until the mass is expelled. Sometimes she shows the effect of septic absorption, the o\um having begun to decompose, and she ma)- ha\eafoul discharge ; or attacks of hiemorrhage due to partial separation of the mass from the uterus. Cliniidl Diagnosis. — I'hc conditions most likely to be coniiised on account of their ph)sical signs with a carneous mole are (i) a normal pregnancy \\here conception has occurred after one, two, or more months of amenorrhoea due to some other cause. The uterus will here be smaller than the date of the last menstruation would lead one to expect ; (2) a fibroid tumour of the sub-mucous variety in process of spontaneous expulsion (in these cases, however, there is usually a history of previous menorrhagia) ; (3) cancer ot the body of the uterus. This is extremely unlikely to be confused with carneous mole, as it always occurs, at the earliest, c[uite at the end of the child-bearing period. It would resemble it by increasing the size of the uterus, and gi\ing rise to a foul discharge. If pregnancy is observed to de\elo|i, and the uterus to grow normally, the matter is easily settled. In an\- of these cases, dilatation and exploration of the uterus are indicated when the woman is suffering from uterine h;vMiiorrhagcs or discharges, especialh- if the discharge is foul, and there arc septic symptoms. 252 Pathology Tn-(it)iicnt. — The uterus should be emptied as soon as the existence of a missed abortion is diag^nosed ; for although patients often suffer no harm from retention of a dead o\um, they are ahvays liable to do so, and in any case the endometrium must be the worse for its presence. A laminaria tent should be inserted into the cervix, dilatation completed if necessary with some form of rapid dilator such as Hegai-'s, and the uterus emptied in the method described under 'Abortion.' It is most important that rigid antiseptic measures should be adopted in these cases, since any breach of surface caused during the evacuation may become infected by the possibly decomposing con- tents of the uterus. If there is a foul discharge, showing that the uterine contents are de- composing, it is better at once to rapidly dilate with Hegars dilators without first employing tents ; and, after evacuation, to well wash out the uterus with a I- 2000 solution of corrosive sublimate, and leave an iodoform pessary ' in the uterine cavity. Imperfect Dcvelop))ieni of the Decidua I'cra and Reflexa These are rare conditions ; in such cases the reflexa is more commonly absent to a greater or less extent. The result is abortion ; the o\um is attached to the uterus by only the serotina, which is gradually drawn out into a kind of stalk, and finally severed by the uterine contractions. CHAPTER XXX\ I AFFECTIONS OF THE CHORION* These are two in number: iij myxomatous degeneration of the villi, resulting usually in the formation of a vesicular or hydatidiform mole ; and (2) diffuse myxoma, which is only a pathological curiosity. Vesicular MCole. — The disease may be limited to that part which fiirms the ffx'tal placenta, or may affect the whole extent of the chorion, according to the date of pregnancy at which the disease becomes established. This will be understood when it is said that the villi alone are attacked. Defi/iition. — The process consists in a myxomatous degeneration at intervals in the length of the several villi, resulting in the formation of cysts by liquefaction of the degeneration products. Causation. — Since this is a disease of the ovum, pathological conditions in the mother can have only an indirect influence in its production. It has been supposed to be due to uterine diseases of various kinds — endometritis, fibroids, and others— acting immediately on the chorion. Tending to show that this h; not true, however, cases of twin pregnancy have occurred in which one ovum was perfectly healthy, and the other partially or wholly ' Containing about 15 gr. of iodoform with glycerine, gum, and starch. Vesicular Mole 253 affected by the degeneration. In addition to this, it has only very rarely been found to recur in the same woman, and no uterine abnormality has been seen constantly associated with it. The death of the fa^tus is not the cause, since lixingfcttuses are sometimes observed to have partially degenerated placentie. The mothers health, however, must have some influence on that of the ovum she produces, and whose connection with her is so intimate ; and it has been found that vesicular moles occur oftener in pregnancies when the mother has reached middle age. A certain number of cases have been recorded, too (i) where this disease accompanied dropsy in the foetus and mother ; (2) (though the instances are extremely rare, as already said) where a woman has borne several vesicular moles in succession. Fig. 240. — Groups of villi from a vesicular mole. Natural size. Morbid Anatomy. — The myxomatous degeneration begins most com- monly during the first two months, a period at which the whole chorion is clothed with villi, and the morbid change has the opportunity of becoming- general. It occasionally begins later, after all the ^•ilH but those forming the fretal placenta have atrophied ; and in this case it may affect either the whole placenta, or only isolated cotyledons. The affected villi are swollen at intervals in their length owing' to' the o\ergrowth and breaking down of their cells and inter-cellular substance. At each of the spots where the degeneration has occurred, the cells have 254 Pathology liquefied and formed a vesicle. The result is a moniliform appearance of each branch of \ illus affected. The structure of such a vesicle is as follows : the fluid, of a consistence \arying between that of water and that of glycerine, and containing mucin and albumin, is enclosed by a layer of connective tissue cells, degenerated but not liquefied. More externally the cells merge into the connective tissue cells forming the ground substance of the \ illus ; and enclosing these again is the epithelial sheath. The \essels of the villus are atrophied. The effect of this change is to produce a mass of vesicles '^fig. 240), which either in\olves the whole ovum, and may reach to the size of the foetal head, or affects only the placenta, wholly or in part. The vesicles vary in size from that of a pin's head to that of a filbert, and the fluid in the larger-sized vesicles is thinner than that in the smaHcr. Their relative position in regard to one another will be understood from the de- scription just given of their formation and from the diagram (fig. 241), and it will be seen that they are not arranged on separate stalks like the berries in a bunch of grapes, but resemble rather the beads on a necklace. The mole, or so much of the placenta as is degenerated, is .utached to the dccidua ; which is much thickened, and may become abnorn.ally adherent to the uterine wall, and pie\ent complete separation of the o\um The degenerated villi occasionally extend deeper than this, and perforate the muscular wall of the uterus. (This is not infrequently done to a \ ery slight extent by the normal villi .p. 14).) .\ few cases of the kind ha\e been recorded both where the placenta only was affected, and also with general disease of the chorion ; and death has occurred from hai-morrhage or peritonitis, owing to the uterine sinuses becoming freely invaded by the growth, and to rupture of the thus weakened uterine wall at some place where the muscle has been eroded. A search in a complete mole for the embryo may be unsuccessful, or \ cry rarely an atrophied one may be found. The amniotic cavity is often \ ery small in such cases, and may be difificult to identify. In cases where the placental villi only are affected, the foetus may be normal or diseased, or un- developed in varying degrees, according to the amount of placenta involved in degeneration ; the amniotic cavity will be e\ident ; and there may be a fair Cjuantity, and sometimes even an excess, of liquor amnii. Sometimes isolated vesicles may be found in the non-placental part of the chorion. Symptotiis (Hid Course. — Owing to the swelling of the degenerated \ illi, the ovum becomes rapidly larger, out of all proportion to normal growth. The result of this in cases of complete mole is as follows : during the first month or two there is probably nothing abnormal about the pregnancy. Veiy likely nothing is noticed until the rapidly increasing size of the ovum causes Fig. 2+1. -Diagram of aficcted villus. Vesicular Alole 255 the uterus to resent the too hurried stretching and to contract, partially detaching its contents, and causing some pain and hiemorrhage. In many cases the usual sympathetic aflcctions of normal pregnancy are intensified, notably 'morning sickness.' The disproportion between the size of the uterus and the calculated duration of pregnancy may, about the third month, be sufficiently striking to attract attention. The absence of foetal signs is mentioned under ' Diagnosis.' The haemorrhage becomes more profuse as more ovum is separated, and rarely some of the \csicles are said to be detached and appear whole in the discharge, which is composed of blood and the fluid from the ruptured Aesicles. Expulsion of the uterine contents usually ensues. The date at which this occurs varies, depending on the irritability of the uterus, the rapid gro\\th of the o\um, and the extent of chorion involved. The commonest time, if the whole chorion is degenerated, is perhaps about the fourth month, and by this time the fundus uteri may ha\e reached the navel or abo\e it. Expulsion may occur without any very great haemorrhage if unassisted ; but, on the other hand, the bleeding may possibly be dangerous, if not fatal, in the absence of help. The ovum is sometimes expelled pretty nearly entire, l3ut usually comes awa\- in pieces, which are detached either by uterine contractions, or by the fingers of the medical man. Some of the growth niav be left behind, being adherent, and then may give rise to septic trouble. If there be another and a healthy ovum in the uterus, it may be retained, or may be expelled with the mole. In addition to the danger from hjemorrhage, and the remote possibility of rupture of the uteiais, the patient runs the risk of septicccmic infection during the manipulation required to clear out the uterus ; and also the loss of blood renders the patient less able to resist septic infection.^ Otherwise the prognosis is fairly good. Diag7iosis. — This is, as a rule, not made till the mass begins to be ex- pelled. In the cases where the disease is suspected, and the appearance of vesicles in the discharge is awaited to confirm the diagnosis, it will usually remain unconfirmed. The points most strongly suggesting a vesicular mole are the disproportionate enlargement of the uterus in a case of pregnancy, and the absence of any sign of the presence of the foetus. The foetal heart cannot be heard, nor can the foetal parts be felt, nor ballottement obtained, although the uterus may be of the size of a 5i months pregnancy. The addition of a blood-stained discharge to these physical signs renders the diagnosis more certain, and the discovery of vesicles in the discharge would make it completely so. It will be remembered, however, in examining such a case that it is possible that a living foetus may coexist with a mole, and therefore that frctal outlines and sounds do not absolutely exclude this condition. Treatment. — If a pregnant woman is bleeding dangerously, the uterus must be emptied in any case as soon as possible, whether a diagnosis be made or not. If the diagnosis of hydatid mole is certain (from the discovery of vesi- cles) the cervix if closed must be dilated for this purpose, unless foetal parts are discovered in utero by external examination. In such a case, if the bleeding' 1 Menge mentions (Z. f. G. u. G. vol. xxx. pt. 2, 1894) malignimt degeneration as sometimes occurring in portions of the endometrium some months after the expulsion of a hydatid mole. (See p. 578.) 256 PatJiology be only slij^lit, it may be as well to wait awhile and see if the uterus will expel the mole without the healthy ovum. Or, supposing the degeneration has occurred in a single ovum and is only partial, the pregnancy may go on to term if allowed. As long as the diagnosis is onl\- probable, the amount of bleeding is the best guide. If this is not dangerous the case should be treated like a threatened abortion (p. 310.), and on the same principles. If the bleeding is free the uterus must be emptied. The cervix will, in nearly all such cases, be found open, or very easily dilatable ; but if it will not admit two or three fingers, it must be dilated with hydrostatic bags, which will in the meantime act as efficient plugs. In cases where vesicles have been expelled and evacuation determined on, with a still closed cervix, a laminaria tent must be introduced, and then Hegar's dilators used to complete the dilatation if necessary. Before the evacuation a dose of ergot (ext. ergot, liq. 3J-3ij) or mv-x of inj. ergot (B.P.) should be administered ; the bladder and, if there is time, the rectum emptied ; and the patient anaesthetised. The uterus is then com- pressed by the left hand outside the abdomen, and masses which present at the OS coaxed out by the fingers of the right hand passed through the cervix. All through the process of evacuation more should be done by expression than by traction. When the uterus is nearh- empt}-. and has contracted down, the fingers \\\\\ be able to explore its ca\ity and bring away any still adherent pieces, if it is pressed firmly down by the left hand on to the internal fingers. Care must be taken to use no force with the fingers inside, for the occasional erosion of the muscle by the villi is to be remembered, and the consequent possibility of rupture in such cases by rough handling or by the use of the nails. All these manipulations must be conducted under the most strict anti- septic rules, and a hot intra-uterine douche of sublimate (l in 5,000) or carbolic acid (i in 60) should be given when the operation is finished. The patient will then be treated as a case of miscarriage, and be kept in bed for a week or more. Regular antiseptic vaginal douches are ad\isable in such cases — one douche a day of sublimate (1 in 5,000) being gi\en. Myxoma of the Chorion may occur in the layer of this membrane which lies next the amnion ; but a few cases only have been described. The degeneration may be diffuse, as it was in the first case ever described ; or partial, forming isolated masses. Its cause is as unknown as that of myxoma of the villi. It apparently has no effect on pregnancy. The chorion in the diftuse variety is thickened ' and nodular. The histology is that of mucoid tissue. The isolated masses have the same minute structure. ' In Breslau and Eberth's case, the first described, to 5 mm. or 2 in. (Virchow's Anhiv. vol. xxxix. p. 191, quoted in .Spiegelberg ; Text-book of Midwifery, New Sydenham Societv.) Hydramnios 257 CHAPTER XXXVII AFFECTIONS OF THE AMNION Excess and scantiness in the quantity of the amniotic fluid arc the only diseases to be described. Certain other incidental pathological conditions may be found at the same time in the ovum. Although not a disease, the condition of dark-coloured liciuor amnii not due to the presence of meconium as far as is known, may be mentioned here. It is occasionally observed, and has no symptoms or results. Hydramnios. Hydrops Amnii. Definition. — This is a condition in which the liquor amnii is in marked excess. Its results and symptoms are, as far as is known, all due to the mechanical action of the excessive bulk of fluid. Cmisation. — It is not proved whether the mother or the foetus is princi- pally concerned in producing this disease ; but it is most probably a foetal disorder, for it rarely shows itself before the last three or four months of pregnancy are reached ; and, whatever may be the possible sources of the liquor amnii in the earlier months, the foetus is generally considered to secrete it at this period. Hydramnios, moreover, often occurs in healthy women ; and in cases of twin pregnancy only one amniotic sac as a rule is over-distended ; and in one case of extra-uterine pregnancy the sac contained seven litres of liquor amnii. (Teufel.) At the same time the fact that malformed foetuses are common in this condition cannot be considered a reason for assigning its production to the child, since, owing to the intra-uterine tension, arrest of growth in delicate parts might easily be produced. Diabetes in the mother has been found A'ery frequently to concur ^\ ith hydramnios ; and in one case certainh', and in another probably, the liquor amnii has contained sugar.^ This suggests a maternal influence, but it does not prove at all that the excess of fluid had its origin directly from the maternal vessels. In all probability, remembering \\q\\' often the life of the child is sacrificed in a diabetic pregnancy," the hydramnios in these cases is a symptom of foetal disease, and the sugar may ha\c diffused through the maternal placental vessels. Diabetes insipidus appears to have no effect on the ovum.* There is no evidence that syphilis has anything to do with hydramnios. It has been noticed that the child is nearly always a female, and that the o\a of multiparce are more liable to the disease than those of primigravida?. Morbid Anatomy. — The quantity of liquor amnii is increased beyond the normal one or two pints to five or six pints, or considerably more than even ' M. Duncan, Obstet. Trans, vol. x.xiw - Ibid. '" Ibid. vol. x.xix. .S 258 Pathology of Pregnancy this. Its composition has not been found altered, except in the cases just mentioned ; and no histological changes in the amniotic membrane have been noticed beyond Assuring of the epithelium, no doubt from stretching. (Ahlfeld.) The fcetus is in a large proportion of cases malformed or already dead when delivery takes place ; and death is not always due to the usual prematurity of labour, for in a fair proportion of Duncan's cases the child died after reaching a viable age. It is sometimes dropsical, occasionally markedly so, and sometimes hydrocephalic ; and the placenta under these cir- cumstances has been large and flabby. Symptoms and Cottrse. — There is nothing, e\en in a subsequently well- marked case, to call attention in the earher months to this affection. It may begin to be noticed by the fifth month. Thence onwards the uterus rapidly increases in size and tension. Its shape becomes more rounded than normal. Owing to the increased size and weight it tends to fall forwards ; and, by resting on the anterior abdominal wall, to cause separation of the recti, and Pendulous Belly. From the same cause the circulation in the pelvis is more obstructed than usual in pregnancy, and there is abnormal oedema and congestion of the lower pelvic viscera. When the uterus is large enough, especially if the abdominal muscles are strong, the diaphragm is pre\ented from descending and some dyspnoea results ; the stomach also is much limited in capacity, and vomiting is occasionally rendered severe and protracted. Albuminuria has been found in some cases of great distension. When these mechanical disturbances become very se\'ere, the uterus usually empties itself ; and labour in hydramnios is nearly always premature. Besides this result as regards the ovum, it has been mentioned that the foetus is rarely healthy and is sometimes malformed. In consequence of the spacious uterine cavity the movements of the child are not restrained, so that it may assume any lie ; and thus malpresentations are common. A further consequence occurs during: labour. The o\-er-distended uterus is sluggish in its action. It becomes stronger when the liquor amnii has been expelled, but inertia is common at all stages, the worst results occurring post-partum, when haemorrhage is particular!)- to be feared and guarded against. Rupture of the uterus has happened.' Involution is said to be tardy, and is so, no doubt, on account of the previous distension of the uterus. It is almost a rule to find the uterus large during the puerperium after large children or twins ha\"e been born. Diagnosis. — Mistakes have arisen in many cases of this disease, owing to the abnormal size, shape and consistence of the uterus ; and they have often been confirmed by the impossibility of making out any foetal parts, or hearing the foetal heart. Careful examination will nearly always lead to a correct diagnosis, and the foetal heart will be heard or limbs will be felt if frequent examinations are made. The confusion in some cases arises from the similarity of all the physical signs to those of a thinnish-walled ovarian cyst. The abo\ e signs if they can be obtained, the uterine bruit, and occasional uterine contractions, together with the breast changes, and the history (which is usualh- normal) of the earlier months of pregnancy, combined with the rapid growth, which may be verified by repeated examinations, will generally make the case evident. ' McClintock : Clinical Memoirs. ' Dropsy of Ovum." Scantiness of Liquor Amnii 259 Greater difficulty may arise if early pregnancy exist with an ovarian cyst ; but the recognition of uterine contractions in one part only of the abdominal mass will solve the difficulty (see p. 392). Carelessness is nearly always the cause of mistakes in these cases. Fi-om twin pregnancy, with which it may also be confused, hydramnios is distinguished by the readiness with which in the case of twins the observer is able to come into relation with the children, stethoscopically or by palpation. It will be remembered that hydramnios may be combined with twins. Treatment. — During pregnancy, if -the uterus is only moderately o\er- distended, it may be enough to support its weight by a belt, keeping the patient at rest as much as possible. In severe cases, where respiration and nutrition are dangerously interfered with, premature labour should be induced by puncturing the membranes. If the uterus can be emptied gradually, the danger of shock from sudden removal of abdominal pressure is avoided. To this end the puncture should be made between the pains if labour has begun ; and as far as possible above the ring of the external os. This precaution may help to prevent the production during labour of malpresentations and prolapse of the cord. During labour, the uterus must be carefully supervised and well supported from the abdominal side. Forceps, if found necessary, should be used with caution, and expression should always accompany traction. A plain hot douche ( 1 1 5-1 20° F.) should be used immediately after the third stage is over, and full doses of ergot given. Fig. 243. — Amnionic adhesions compressing umbilical cord. (After Pinard and Varnier.) The result as regards the mother is favourable if no concurrent affec- tion, such as diabetes, exists. For the foetus the prospect is not so bright. Fig. 242.— Amnionic adliesions. (After Pinard and Varnier.) In this case a meningo-encephalocele was produced. Scantiness of Iilquor Amnll. This condition is somewhat rare. It has been observed in connection with occlusion of the foetal urinary tract, or absence of foetal kidneys, but it sometimes occurs with a normal child. The degrees between a scantiness sufficient to be of importance and the natural quantity are of course infinite. Symptoms. — In a few cases the foetal parts are remarkably easy to map out by the abdomen, and this seeming closeness to the surface has been known to give rise to a diagnosis of ectopic ('abdominal') gestation. The uterus 26o Pathology of Pregnancy is smaller than normal, and natiually less elastic. Thefcctal movements are sometimes very painful to the mother. Results. — The main interest of the condition lies in the possibility of the formation of adhesions between the amnionic surface and the fcjutus, or between one amnionic surface and another. If such adhesions form early in pregnancy, and the amount of fluid later on increases, the adhesions become converted into bands. In this form they may compress parts of the child, a limb for instance, and cause its atrophy or prevent its development. Thus are produced some of the cases of intra-uterine 'amputations;' and other deformities (retroflexion of foetus, (Sec.) may arise (see figs. 242 and 243). During labour, since there is not enough licjuor amnii to form a sufficient bag of waters, the first stage is much delayed. No treatment is possible of the anomaly during pregnancy. During labour, the process of dilation may, if necessary, be assisted by hydrostatic ba- great inconvenience may be caused by erythema intertrigo in the folds of skin above thepubes ; and oedema of the abdominal wall is described as occurring in some cases. Results. — The most important effect, because it is the commonest, and results from slighter degrees of the displacement, is prolongation of labour (see p. 407). Pendulous belly is also a cause of abnormal presentation. The head during labour does not enter the brim, but glides over it ; and the side of the head presents. Of course, any contraction of the pelvis aids materially Retroversion of the Gravid Uterus 273 in producing this result. Rupture of the \agina or uterus may occur if the head is made in this way to distend the vagina or to grind the posterior wall of the lower uterine segment against the promontory (see fig. 247). Treatment. — No pessary or internal support is of the least use in cases of anteversion. As already mentioned, anteflexion is normal in early preg- nancy, and later on it is obvious that no instrument acting from the \aginal walls could ha\e any effect. A carefully fitted abdominal belt is the only treatment. This should give support to the hypogastrium from both below and above the crest of the ilium (fig. 248) and pull upwards and backwards in the plane of the brim. Retroversion and Flexion This abnormality consists in displacement of the fundus of the gra\'id uterus backwards, and as the two conditions of version and flexion are nearly always combined, they may be considered together. In a few rare cases the flexion seems the more prominent symptom. Causation. — In nearly all cases the displacement of the uterus has existed before impregnation, but has given rise to no symptoms if the organ has been healthy and not enlarged. It may also, but more rarely, be due to a fall on the sacrum when the uteixis is already retro- verted — so far retroverted at all events as to lie in the axis of the woman's trunk. A normally situated uterus probably cannot be retroverted or flexed more than momentarily by any fall. A bladder habitually allowed to become over-full may have some influence in producing some degree of retroversion ; but again, a full bladder alone cannot cause the malposition. Anato/ny and Mode of Production. — As long as the uterus does not measure more than four inches or so in length, there is room for it to lie across the axis of the pehis. When, howe\er, its length exceeds that of the pelvic dia- meter in which it lies, and there is a corresponding increase in bulk, it be- comes too large for the pelvis, and begins to cause pressure symptoms of a marked character. When upward mo\ement is pre\ented b)' the projecting promontory the uterus is said to be incarcerated. Incarceration usually occurs about the end of the third or beginning of the fourth month. The position of affairs is as shown in the diagram. The fundus occupies the hollow of the sacrum, and distends Douglas' Pouch and the posterior fornix, so as to make the latter bulge forwards towards the Auha ; and if a Fig. 240. — Retroverted gravid uterus, show- ing distended bladder. A, anus; DP, Douglas' pouch ; l-'ag; vagina ; Ur, ure- thral orifice (which is more drawn upwards than is shown in the diagram). 274 Pathology of Pregnancy \a;,nnal examination be made in a well-marked case, the posterior wall, with its surface made ver)' convex forward, is the first thing the finger touches after passing the vulva. The cervix is, under these circumstances, not felt until the finger is passed up behind the symphysis. There is produced in this way a great distortion of the anterior vaginal wall, which is dragged up by the displaced cervix and assumes a vertical position. This in itself is of no importance, but it will be remembered that the urethra and base of the l^ladder are so much a part of the anterior vaginal wall that they follow it in all its displacements. Consequently the upper end of the urethra and the Ijase of the bladder are dragged up too, the walls of the former being stretched and distorted to a variable extent, and its canal considerably narrowed or even occluded. In addition to this the fundus, being prevented from grow- ing backwards by the resisting sacrum, causes the cer\ix to press against the back of the symphysis or against the stretched pubo-vesical ligaments ; the urethra thus suffers a direct transverse pressure, and e\entually becomes entirely blocked. Retention of urine is now produced. Owing to the incarceration of the uterus, the veins returning the blood from it and lying in the broad ligament (ovarian plexus, pampiniform plexus) are compressed, and the fundus may become cedematous. There is of course no fundus to be found in the situation proper to it in the fourth month, but often its place is taken by the distended bladder, and this is very important to remember. The cervix is often not in a line with the axis of the uterine body, but is flexed somewhat downwards. It practically never has its normal direction, however. In a case of displacement backwards, which exists at a time when the uterus is not large enough to cause any marked symptoms, events may follow one of two alternative courses ; the commoner alternative being that the uterus as it develops regains its normal position, no doubt by growing in the direc- tion of least resistance, up into the abdomen' ; or it remains retroverted and becomes incarcerated. The natural restoration occurs, as will be understood, , gradually ; though this is not always the case, and a patient who had, on a given day, a retroverted gravid uterus may be examined a few days later and found to be free from the displacement. Incarceration is most liable to occur in flat pelves (see p. 428). Symptoms. — During the early weeks of pregnane)- the retro\ersion causes much the same symptoms as are produced by a subinvoluted and retroverted utertis ; namely, sensations of weight and bearing-down pains in the pelvis, and frequency of micturition. These go on increasing in severity until restoration, if it is to take place, is accomplished. When incarceration has occurred the uterus, if it has not previously relieved itself by abortion, as sometimes happens, may do so now, and put an end to the trouble alto- gether ; or, less frequently, may even at this stage right itself spontaneously. Abortion is no doubt caused by the growth of the ovum and increase of liquor 1 The method of restoration in this case resembles the mode in which a half-filled bladder may be passed through a key-hole. A small portion of empty bladder can first be passed through, and some of the fluid squeezed through into this part, and then the rest coaxed through in the same way. Retroversion of the Gravid Uterus 275 amnii. Since the increase in bulk cannot occur in the normal direction by expansion of the uterus, the ovum is forced against and through the internal OS and cervix, and contractions are started in this way. The mode of pro- duction of the symptoms is sufficiently obvious to need no explanation. Supposing- that the uterus continues to grow, however, no relief comes to the symptoms, but they steadily, and in some cases rapidly, become alarm- ing ; the woman finds herself unable to pass water, often quite suddenly, but perhaps after having succeeded once or twice with great difficulty. The bladder fills ; then becomes over-full, and the urine begins to dribble away. After a \-arying time cystitis develops, and the inflammation and the diminished blood-supply due to over-distension cause sloughing of the mucous membrane, which becomes detached in larger or smaller flakes ; or possibly gangrene of some of the muscular coat may take place. The bladder changes may spread in the usual way to the renal pelvis and cause 'surgical kidney,' and the patient may thus die of septicaemia or in the urccmic state. The urinary symptoms have been pursued to their termination at once, so as to lay stress on their importance ; and it must never be forgotten that the effects on the bladder are by far the most characteristic phenomena in cases of incarceration of the gravid uterus. In addition, the bearing-down pains increase and radiate in all directions, rectal tenesmus is severe in many cases, and the bowels are unable to act. Vomiting often occurs in bad cases, and the abdomen becomes distended and painful, from the condition of the bladder. The body of the uterus gets lower and lower, from the fre- quent bearing-down efforts, and may bulge the posterior vaginal wall through the vulva and even cause the anterior wall of the rectum to project through the anus. In consequence the cervix mounts higher and becomes more inaccessible. Qidema of the \ulva is freciuent, and occasionally the thighs suffer in the same way. Diagnosis. — The nature of the case is readily cleared up, in the majority of instances of retroversion of the gravid uterus, when symptoms of incar- ceration have appeared, and an examination is made. The history of retention and dribbling of urine in a woman who has had the symptoms and signs of pregnancy for three or perhaps four months ; the round, elastic, and very likely rather doughy-feeling mass occupying the vagina ; the position of the cervix and, most important, its upward direction,, are practically conclusive ; and as the distended bladder will be expected it will not cause any uncertainty. In the cases of retroflexion (to be described), it is true the cervix may point downwards, but a careful examination after emptying the bladder with a catheter will, in these rare cases, clear up the doubt, and bimanual examination is here most useful. This latter method will serve, by defining the position and size of the uterus, and especially by making out uterine contractions, to distinguish cases of displacement of the gravid uterus from instances of tulDal gestation, of an intra-ligamentous cyst pushing the uterus upwards and forwards, or from large intra-peritoneal httmatoceles, which have the same effect. In all these cases, except that of tubal gestation, there are no signs of pregnancy ; in all T 2 2/6 Pathology of Pregnancy OP Vac.'U(^. Fig 250. — ^,anus; Z)/", floor of Douglas' pouch ; Vag, vaginal orifice ; Ur, urethral orifice. the cervix points downwards, although it may be jammed against the symphysis, and the unimprcgnated uterus can be made out immediately over it (fig. 250J ; and in the last-mentioned kind of tumour the mass will be hard, inelastic, and quite fixed. In the diagnosis from tubal gestation uterine contractions, if felt in the tumour behind the cervi.x, are most valuable evidence, since in ectopic gestation signs of preg- nancy may be present. The uterus, enlarged by a fibroid to the size of a four months' pregnancy and retroverted, will be readily distinguished by its long and characteristic history and by its hardness, and by the absence of contraction and relaxation ; though in some cases of this disease there may have been no haemorrhage, and the oedema of a fibrous uterus so displaced may cause extreme softening, or the fibroid itself may be very soft and make the diagnosis by means of local signs somewhat uncertain. Earlier stages of retroversion of the gravid uterus may be confused with, among other things, retroverted sub-in\oluted uterus, a peri- metritic mass adherent to the back of a retroverted uterus, a fibroid in the posterior uterine wall with retro%"ersion and adhesions. In these last cases of small tumours, since no urgent danger is to be apprehended for a week or so the patient may be kept in bed ; and she may then be examined again, if necessary, under an anaesthetic. TreatDient. — If bearing'-down pains and frequent micturition direct attention to the uterus of a pregnant woman, and it is found to be retroverted, tlie uterus should be restored, and a ring^-pessary or a Hodge's pessary inserted until the gravid uterus is too large (four to four and a half months) to retrovert again. Any threatening of abortion will, of course, be attended to. If incarceration has occurred, no violent means must be used to reduce the displacement. The sooner it is done, however, the better. The urine should be first drawn off with a catheter. In doing this the direction of the urethra must be remembered (fig. 249), and care be taken to use no force, especially if the course of the urethral passage is not easily found. A gum-elastic catheter is the best. If it be found impossible to pass the instrument, even after putting the patient on her hands and knees so as to try to raise the fundus uteri and take the pressure of the cervix ofif the urethra, or by pressing the cer\ix backwards with a finger on each side of it, an attempt may be made to reduce the uterus while the bladder is still full. This is hardly likely to be entirely successful, but even if partially so, it may enable the catheter to pass. If neither the catheter will pass, nor the uterus move, the bladder must be aspirated about two inches above the pubes. An anaesthetic is of great advantage, though not absolutely necessarj' at once, as there may eventually turn out to be little or no difficulty in restoration. It must be understood that all operative measures are to be Retroversion of the Gravid Vterjis 77 Fig. 251. -Effect of gravity on the retroverted uterus in the knee-elbow posture. conducted under strict antiseptic precautions. To reduce the uterus the patient may be placed in the semi-prone position, and the first two fingers of the riglit hand (well pronated, so that the palmar surface presses against the mass) introduced into the vagina, the perinajum being retracted so as to admit air. Firm pressure may now cause a sensation of yielding, though the surface of the mass often indents considerably without any real movement. If the mass is felt to mo\e more readily towards one sacro-iliac diameter than upwards in the middle line, this movement should be favoured. If success is not attained in this position the patient should now get, or if anaesthetised, be lifted, into the genu-pectoral position. The perineum should be freely stretched backwards as before to allow air to enter the vagina, and to enable gravity to act on the uterus, pressure again being made in the direction of the brim. This failing, the whole hand may be passed into the vagina to make the pressure. If still there is no success, two fingers in the rectum will have the advantage of increased leverage on the mass, and a volsella may be fixed in the cervi.-v to pull this part backwards and downwards. No great force must be used for fear of damaging the ovum, and because, although it is a rare condition, there may be adhesions binding the uterus down. Supposing now that all these methods have failed, the next step depends on the patient's condition. If it is very urgent, and the bladder is inflamed, the uterus must be emptied. If not, the patient may be put back to bed and regularly catheterised, lying on the abdomen or in the semi-prone position as much as possible, for a few days, in the hope that, as not rarely happens, the uterus will right itself. This event may be assisted considerably by the use of hydrostatic elastic bags in the vagina, or if it can be borne, in the rectum, during this period. After a week, supposing no indications for immediate interference ha\e arisen in the meantime, the methods described above for attempting reduc- tion should be again resorted to. If they still fail (or in case the s)Tnptoms are urgent at first) a bougie should be introduced through the cervix (see Induction of Labour). This proceeding is often difficult on account of the angle the \agina and cer\ix make ^\•ith one another. The latter must be caught with a volsella and pulled down as far as possible, and then the bougie can be introduced with a little manipulation. If the membranes are ruptured in the process it cannot be helped, and as a matter of fact this is recommended by many authors. In cases where the cervix is impermeable it is necessary to aspirate the uterus through the posterior vaginal wall, the needle being passed into the most prominent part per vaginam. In either case, when pains begin and 78 Patliology of Pregnancy the liquor amnii has to some extent run away, tlie uterus should be restored at the earliest opportunity. The cases consistin The uterus is here dou tlie incarcerated organ as j A OP. vaq.""- Fig. 252. — Retroflexed gravid uterus. Note the direction of the cervix. A, anus ; D F, Dou- glas' pouch ; / 'ag, vagina ; Ur. urethra! orifice. that of the brim must take be pushed up l^y tlic physi linly in Flexion backwards are \er)' rare. bled up so that the fundus attains the position of ust described ; but the cervix, although occupying a situation immediately behind the upper part of the pubes, has a fairly normal direction. The anterior uterine .wall is bulged upwards and occupies the lower part of the abdomen, and contains most of the fcetus. The condition is probably due to an incomplete restoration of the retroflexed and retro\erted organ. The most frequent result in these cases is for the uterus to right itself eventually. It may, how- ever, give rise to symptoms of incarceration, and premature labour may follow. Considerable difficulties occur in labour (if the case, as has happened, goes to term) as well as in abortion. The cervix is out of the axis both of the uterus and of the pelvis, and dilatation is almost impossible. Restoration has been known to take place even at full term. If labour is to be completed at all, some sort of accommodation of the axis of the uterus to place, and probably in most cases the fundus will cian durinjj' dcliverv. Sacciform Dilatation of the lower Segrment. — This is not very un- common in the case of the anterior wall, and is merely an exaggeration of the normal condition (see fig. 61, p. 45). The importance of dilata- tion of the posterior \\all is not great, and there is need for treatment during labour only if the fcetus happens to be forced into the dilated part rather than through the cer\ix. When the anterior wall is dilated, the os is further back than normal, and lies against the sacrum, sometimes \ery high up and in an almost inaccessible situation. This condition is found in connection with descent of the foetus into the pehis before the pains begin (Spiegelberg). The difficulty of finding the cervix has caused the mistake to be made of incising the anterior uterine wall per vaginam under the impres- sion that occlusion of the cervix existed. (For treatment, see I'athology of Labour, p. 454.) Prolapse of the Pregrnant Uterus. — This can only take place in the quite early months while the uterine body is small enough to slip between the two edges of the le\ator ani. Such an escape can only occur in the case of an organ already retro\crted, and with lax ligaments ; in fact, in a uterus which has been prolapsed for some time before. Pregnancy may occur in a uterus which is already partially or completely prolapsed. In the former case its increasing size presently causes it to rise Prolapse of tlie Vagina 279 in the pelvis and assume its normal position. If there is much retroversion the symptoms may dc\clop into those of retrovcrted gravid uterus. If reduction does not spontaneously occur, or is not artificially produced, the pregnancy may go on for a few months — three or four (in one case it went to the sixth month) ' ; but the bladder and urethra become too much displaced for further growth of the uterus, and the vaginal walls will prolDabh- not undergo dilatation to the necessary extent without sloughing, since they are inverted and their circulation is much interfered with. If the body of the uterus remains in the pelvic cavity after the first two or three months it may grow for a month or two longer, but then becomes incarcerated. This failure to rise is, however, almost unknown. Hypertrophies of the cervix are most likely to lead to the idea that the body is lower than it really is. There may be congenital elongation of the portio vaginalis (fig. 456) ; or an elongation of the supra-vaginal portion such as occurs in old cases of prolapse of the vagina. The cervix in these cases may project to even beyond the vulva, this body being at the normal level, and in the case of supra-vaginal elongation the inverted vagina will conceal the real position of the body. Treatment. — If the case is seen in the earl)- weeks the prolapse must iDe reduced and the uterus retained in position by tampons and a perineal bandage ; or more conveniently by a ring pessary. This will not be needed longer than the fourth month. The uterus should be carefully watched during this time lest retroversion and incarceration occur. The bowels should be kept freely open, and all bearing-down or straining efforts avoided. If the patient is not seen till later, and some wedging has occurred, the uterus must be elevated, under an anfesthetic if necessary, and care must be taken that at the end of the operation the fundus is abo^•e the pelvic brim and looking forwards. Where I'eduction is impossible at the first attempt, a further one may be made, if the uterus has not spontaneously risen, after a few days' rest in bed. In case of failure now, or before now if pressing symptoms have arisen, abortion should be induced. Prolapse of the Vag-ina. — This is fairly common in patients who have suffered from the same condition in the unimpregnated state. It affects the anterior wall alone in a very large majority of cases. The trouble here is the effect on the bladder, which is bulged downwards so as to form a cystocele ; and difficulty and frequency of micturition are caused. The veins on the under surface of the urethra (see fig. 62) are often much distended and sometimes cause great discomfort and irritation. The best treatment is the insertion of a small \aginal tampon soaked in glycerin, acid, tannici, renewed twice daily. This is supported by a perineal bandage. A ring pessary is not of much use here, but a trial may be given to it, as it causes less discomfort than the tampons. Care must be taken that the tampons do not induce abortion, and an)- tendency on the part of the woman to easily abort is a contra-indication to their employment : for effect on labour, see p. 457. ' Tarnier. Also in n case seen bv the author. 28o Pathology of Pregnancy Hernia of the Pregnant Uterus This condition is so rare that it hardly needs more than simple mention. Separation of the recti muscles, as shown under the heading of Anteversion of the Gravid Uterus in the present chapter, sometimes allows the uterus to fall into what is almost a hernial sac. The uterus has been found, when yravid, to have its fundus in an umbilical hernia, or protruding into the pouch of a yielded cicatrix, such as sometimes occurs after abdominal section The gravid uterus has been found also in an inguinal and even, according to old writers, in a femoral hernial sac. In the last two classes of case, in which pregnancy never goes to term, some operation on the inguinal or femoral canal may be necessary after exacuation of the uterus, either through the Aagina or by hysterotomy ; in the others the support of an abdominal belt is all that is necessary. Pregnancy in a Maldeveloped Utei-iis. — The effects of malde\elopments of the uterus and \agina are more marked in labour than in pregnancy ; the most important abnormalities are described at p. 293. Pregnancy in a Rudimentary Horn is dealt with under Ectopic Gestation. CHAPTER XLI AFFECTIONS DIRECTLY CONNECTED WITH PREGNANCY — continued B. — Other than Generative Organs Nervous System Insanity. — The subject of insanity in connection with pregnancy, labour and lying-in is discussed under *;hc Pathology of the Puerperium (p. 556). Cborea. — Chorea occasionally occurs during pregnancy, and is often then continued into the lying-in period. It is a veiy interesting fact that the existence of pregnancy makes it possible for a woman to have a disease which is otherwise almost exclusively one affecting little girls. A woman, if pregnant, may ha\e chorea at any time up to the age of even twenty-six or twenty-seven. Also, contrary to its habit in children, the disease is frequently severe in its manifestations and results. It leads in many cases to abortion or premature labour, and although a woman after one pregnancy complicated \\ith chorea will be free in the non- gravid intervals, she may suffer during the next pregnancy from a recurrence of the chsorder. This last fact illustrates, and its existence is rendered possible by, the impressionable nervous condition already described as normally existing during pregnancy. Chorea during pregnancy has until comparatively lately been regarded as a rare and fatal disorder. Spiegelbery, in his \ery large experience, says' CI 10 re a in Pregnancy 281 he has only seen three cases. But in a recent paper' its author records four cases observed during a period of six months. This discrepancy is due, no doubt, to the absence of former record of any but severe cases, and possibly to mistakes in diagnosis. From the author's personal experience, a greater frecfuency than was formerly held to occur can be affirmed. - Causation a?id Mode of Origin. — Omitting t\\Q discussion of the various theories of the pathology of chorea, the following statements may be made. Chorea alone is found to have occurred previously in rather more than one- third of the cases, rheumatic fever with or without chorea in about the same proportion, and the attack has been preceded by fright alone or mental disturbance in a very few.-' Malnutrition has great influence in impairing the nervous function, and so the hydrasmia of pregnancy partially accounts for the prevalence of chorea at that period. Syinptonis and Course. — Chorea, like the commoner disorder, albuminuric eclampsia, almost invariably occurs for the first time during a first pregnancy. If an attack of rheumatic fever has intervened between a first pregnancy which has been healthy and a second, chorea may occur for the first time in the second. It may or may not recur in successive pregnancies. The first symptoms usually appear from about the third to the fifth month — very few towards the end of pregnancy. Quickening has been observed to coincide in a few cases with the commencement of an attack, and probably the increased irritation of the nervous centres caused by the foetal movements is the reason ; at this period, too, the chorea if already existing is often intensified. The clonic spasms are as a rule severer than in children, and if they are severe and continuous they soon lead to exhaustion of the patient ; and in such cases abortion often occurs. The choreic movements almost invariably persist until after delivery, when gradually, and not at once as usually happens in eclampsia, they cease in moderately mild cases. If the attack is not a mild one, the woman may die of exhaustion before or after delivery ; or from abortion ; or she may become maniacal. Death is probably due in a majority of cases to complications. In the two fatal cases alluded to as happening in St. George's, there was acute endocarditis, and the temperature ran up to 106° to 108° before death. If the foetus is not prematurely expelled, it seems as a rule to be none the worse for its mother's condition. Chorea very rarely, if ever, arises anew after deliver}', and many of the cases so described are probably best accounted for as reappearances of a chorea which existed unnoticed before labour began. The reflex excitement of the system by suckling may in some cases 1 McCann. ' Chorea in Pregnancy,' Obst. Trans, vol. xxxiii.' 91. - Three cases in two years. Two fatal, in ,St. George's Hospital, one mild, in the General Lying-in Hospital. •' McCann. Ibid. 282 Pathology of Pregmmcy accentuate spasms already existing, or may be a cause of the reappearance just referred to. Treatment. In mild cases the patient's strength must be maintained by nourishing food, stimulants, and iron and arsenic. In severe cases, especially where the woman does not sleep, premature labour should be induced at once. This is very necessary, for such patients go to pieces rapidly when the disorder is severe ; and when a mild attack shows signs of getting worse, hesitation should not be for long. Another reason for not hesitating is that the disease goes on for some lime after delivery, so that the birth of the child does not make the mother safe ; and, further, mania is not very uncommon in these cases ; and probably the earlier labour is induced, the less chance there is of this complication. Mania ma\-, howe\er, be a quite early addition to the symptoms, and will increase the urgency of the case, and the necessity for immediate induction of labour. (See Insanit\-, p. 556.) Eclampsia. — See Patholog)' of Labour (p. 508). Tetany. — Tetan\' occurs very rarely during pregnane)'. It is commoner in the lying-in and nursing periods, and is discussed in the Pathology of the Puerperium. Pruritus.— Itching of the vulva in varying degrees is not uncommon during pregnancy, especially in women who lead indolent li\es, or in those who are neurotic in disposition. In the latter the pruritus may affect other parts of the surface of the bod)-. It is not always a neurosis, and care must be taken to eliminate eczema and pediculi as causes, and to see that there is not some redness due to irritation of the vaginal orifice by leucorrhctal discharge. The treatment is to keep the bowels regularly and fairly freely acting, and to apply some astringent anodyne locally. The patient must not scratch or rub the part. A very useful application is a 1-2000 or 1-4000 solution of corrosive sublimate, and this will be found more effectual if used hot. A 1-40 solution of carbolic acid is sometimes successful. Other astringents in common use may be employed, and absorbent wool or lint wetted with them worn constantly applied to the vaginal orifice. If no relief is obtained from astringents, a solution of cocain hydrochlorate, 4 gr. to the oz., may be used when the irritation, which is usually intermittent, occurs. Circulatoiy System Anaemia. — In some cases this is simply an exaggeration of the hydr;t'mia which prevails in nearly all pregnancies. It is then treated in the ordinary way with saline aperients and continuous doses of iron, or iron and arsenic. There is another form of ana:mia, that named Pernicious, or Progressive, which, common to both sexes, is rather inclined to affect pregnant women. It is, in this country at all events, a rare disease. The blood-changes (poikilo-cytosis) and hitmorrhages into the retina and other parts, occur as in the ordinary type of the disease ; and the fatality may be as great as in cases independent of pregnane)-. ]'an'cosc J'cius 283 It causes abortion or, more commonly, prcmatin-e labour in about half the women affected by it,' and the blood lost at labour may be enough to precipitate death. In all cases of an;emia during pregnancy which do not )ield fairly rapidly to treatment, or which get worse, a microscopic examination of the blood should on no account be omitted, and if the forms of corpuscles characteristic of Pernicious Antemia are found, and especially if there are any retinal haemorrhages, labour should be induced after a consultation. Obstruction to Venous Return. — Owing to pressure by the growing uterus on the larger \enous trunks of the peb'is, varicose veins are frequently developed in pregnant women. They present varying degrees of severity, and affect the upper part of the thighs and the lower part of the buttocks to a much greater extent than in cases apart from pregnancy. Occasionally thrombi form in the dilated vessels ; and rupture sometimes takes place. The labia majora and vagina are often the seat of this affection ; and in rare instances rupture of the veins of the lower part of the vagina during labour takes place, forming the ' vaginal thrombus ' of the older writers. The small knot of \-aricose veins 'which so often forms just under the urethra has been already mentioned. Treatment. — The ordinary treatment of this condition — keeping the limbs raised as much as possible, and where necessary using elastic stockings or Martin's bandages— will be enough in nearly all cases. Excision of the \eins is not an operation to be undertaken during pregnane}', for after delivery the veins recover themselves, sometimes almost completely ; and operations during pregnancy, though cjuite justifiable where real need exists, always involve the risk of abortion. The patient should be instructed what to do in case rupture does occur ; that is, to lie on her back at once and elevate the limb, if a vein of the leg has ruptured ; and to have a pad and pressure applied to the bleeding point \\herever it is. If the dilated veins are in the vulvar region, a pad of some fairly elastic material, such as cotton-wool, should be made to support the part by means of a perineal band. (For ' Thrombus of the \"agina,' see Labour.) Attention to the action of the bowels is of great importance. Piles are also a common accompaniment of pregnancy, and in some cases cause much discomfort. Their causation is the same as that of \-aricose veins in the legs, combined with the constipation usual in gra\id women. They must be treated on the ordinary palliatix e principles : more radical measures are practically never called for. CEdema has been mentioned as occurring in normal pregnancy. It is never, except in cases of renal disease or intense anaemia, a matter calling for special treatment. 1 Graefe, Halle, 1880. 284 PatJiology of Pregnaucv Digestive System Vomiting-. Pernicious Vomiting- of Pregnancy. — It is impossible to draw any well-marked line between what may be considered a physiological and what a morbid degree of this disturbance, though the extreme instances of each are well contrasted. Xormally, about fifty per cent, of pregnant women are sick occasionally during the second, third, and perhaps fourth months of pregnancy. In cases which may be called pathological the vomiting may occur during this time, and be so urgent that the stomach retains nothing ; or it may persist with severity when it should, under normal conditions, cease. Caifsation. — In a iew cases vomiting is due to a complication already existing, such as gastric ulcer, new growths affecting the gastric mucous membrane, renal disease, cerebral afifections, and so on ; but in the majority of cases no such cause can be assigned. The affection is commoner in first or second pregnancies than in later ones. Formerly the various flexions which may affect the cervix ; or displacements of the uterus ; or circum-uterine inflammation have each been assigned as a cause, and treatment has been actively applied in accordance with such views. No proof, however, exists that these conditions have anything to do with the vomiting*-, pernicious or otherwise, since they arc present in a large proportion of cases where no vomiting exists ; and, as just mentioned, in the majority of instances there is no physical cause at all to be found. Constipation is a frequent accompaniment, however, and possibly an important one. Acute atrophy of the liver, a very rare disease, has been found in connection with vomiting. SyiiipioDis and Progress. — If the vomiting is not excessively severe, and it ceases at the usual time or soon after it, the pregnancy will go on uninterruptedly ; and the woman will recover her strength, which may have been considerably lessened, in a very short time. If, however, the disorder is extremely severe, so that little or nothing is retained by the stomach, and attacks of retching and vomiting come on independently of food, exhausting an already enfeebled patient ; or if the disorder goes on for more than the usual two or three months, even moderately severely, the patient in the former case soon, in the latter eventually, arrives at a dangerous point. In her progress to this she becomes wasted and hollow-eyed, possibly slightly jaundiced, her breath gets foul, and her tongue drj- and raw-looking. The urine, owing to the small amount of liquid absorbed, is scanty and high- coloured (in the cases where acute atrophy is present it contains leucin and tyrosin), and for the same reason, the woman has a most distressing thirst. There is often some fever. She may continue in this condition for an unexpectedly long time, without further deterioration : she may suddenly recover, the vomiting ceasing completely ; or she may rapidly fall into a moribund state, death being due to exhaustion, to some intercurrent disease such as phthisis, or to the sudden increased strain on the nervous system and the loss of blood caused by abortion, which often takes place at the end. Abortion may occasionally occur earlier, and in time to save the Pciiiiciuus Voiiiiling of Pregiiajicy 285 patient's life, for it is a constantly observed fact that the death of the foetus in utcro, or the delivery of tlic mother, puts an end to the vomiting. In cases of vomiting late in pregnancy, the possibility of its being due tX) renal disease should al\\a\s be borne in mind. Treatiiieiit. — Since there is no evidence that local pehic conditions have anything to do with pernicious vomiting, no treatment will be directed to these parts as a matter of routine. It will be well, howe\er, to make an examination of the pelvic organs, so as to eliminate the possibility of disease there, for no doubt acute attacks of vomiting maybe caused by incarceration (not merely retroversion) of the gravid uterus, or, as another instance, by the pressure of tumours on the gut or the ureters. As a rule, the treatment must be directed to dieting the patient, attending to the bowels, and keeping her at rest lying down. She should have all her food cold, at short intervals, and in very readily digested form. The best way in severe cases is to give milk, iced or not, meat-broths, or meat-juices (extracts are of no use for nutritive purposes) in small quantities every quarter of an hour or so. Some patients retain very hot liquids well. Some or all of the food may be peptonised, partially or completely, if the patient seems to retain little or nothing, in the hope that anything that does pass the pylorus may the more rapidly undergo complete digestion and be absorbed. Nutrient suppositories or enemata should be used early. Care should be taken that she has enough sleep, and the ordinary' sedatives (excepting opium, because of its effect on the bowels) may be given for this. The bowels must be carefully regulated, and saline purges are probably the best for this purpose. The intense thirst may be relieved by large enemata of warm water. If the patient gains ground under the treatment, she may probably tide o\'er the tendency to vomiting. Other therapeutic measures are sedatives such as bismuth, ice, or hydrocyanic acid ; but it may be said at once that they are of ^-ery little good. One-minim doses of tr. iodi in a little water every half-hour ha\e occasionally a very marked effect, as they ha\e in some other cases of constant sickness. Ice to the epigastrium, or a blister there, may be tried. If there is no other cause but pregnancy, and in spite of every attempt to stop the sickness and improve the strength, the patient is losing ground, the uterus should be emptied. This should never, of course, be done too soon : but the tendency in most cases will be to leave this resource until too late. If leucin and tyrosin are in the urine, with other suggestions of acute atrophy, there should be no hesitation. It is verj- rarely indeed that recourse will have to be had to this extreme measure. Remembering the fact that vomiting sometimes disappears spontaneously at the fourth month, or soon after, the patient, in cases of early severe vomiting, should, if going on moderately well, be kept up in health till that time by the means above mentioned. If no cessation occurs and her condition is becoming worse, abortion should be induced at once. If this operation is left too long, it may be impossible by it to save the patient's life, and its peiformance may, indeed, accelerate her death. Nothing has yet been said about treatment applied to the cervix. Cope- 286 Pathology of Pregnancy man's treatment by dilating the internal os with the finger or by bougies has been recommended. It is, however, better to induce abortion at once if radical interference is necessary. Other kinds of treatment applied to the ccrvi.x, such as painting it with various substances, are waste of time. It will be noticed that the instances in which cessation of vomiting has followed such treatment have always been about the fourth month, when no doubt cessation would have occurred spontaneous!)-. It should be mentioned that before abortion is induced in these cases — or in any others — a consultation should be held. Dyspepsia is not very unusual in pregnancy ; and often causes much flatulence. It may occur at any period of the nine months, and is treated on ordinary principles. la cases of flatulence alone, some drug which checks fermentation, such as sulpho-carbolate of soda, taken about three-quarters of an hour to an hour after meals, is very often useful. The action of the bowels should always be carefully looked after, and any constipation treated. Salivation is an uncommon disorder. It is sometimes associated with swelling and tenderness of the parotid and submaxillary glands ; and in a very large proportion of cases, with vomiting. It often appears at the time at which vomiting in pregnancy is common. The quantity secreted may be so large that a quart or more may dribble away daily in addition to what is swallowed. Astringents have been tried with success, especially belladonna. Chlorate of potash is recommended. Pilocarpine has arrested the salivation occasion- ally, and potassium bromide has had the same effect. Gingivitis is not altogether so uncommon as might be supposed, and it occurs frequently in pregnant women of the lower classes, who do not pay much attention to cleanliness of their mouth and teeth. Care in these particulars, and alkaline and astringent applications are all that is necessary for this mild disorder. Acute Atrophy of Xiver. — This disease has been found in a very small proportion of cases of pregnant women (i- 10,000 about). Of all cases of its occurrence 1-4 have been in pregnant women. This may have some connection with the parenchymatous change ('cloudy swelling') in some glandular organs produced by pregnancy. It is of importance, as pointed out by Matthews Duncan, to remember the possibility of this condition being at the bottom of some cases of pernicious ^•omiting. Its causes are unknown, but it is belic\ed to be due to a bacillus. Its symptoms and progress arc not modified by pregnancy, and the usual slight jaundice, fever, albuminuria, and cerebral symptoms are present. Leucin and tyrosin crystals in the urine are the most distinctive signs. The foetus usually dies ; but abortion does not at once ensue, and when expelled the uterine contents have in some cases been found to be macerated. The treatment is to induce labour immediately the disease is diagnosed, in the hope of arresting the degenerative process. Perimetritis in Pregnancy 287 Uriiutyy Syslcm Albuminuria. See page 504. Bladder Troubles, frequency of micturition, difficult)' of micturition, retention, cystitis, are nearly all due to distortions of the \agina, or pressure on the bladder or urethra, by the displaced uterus. Diabetes and polyuria will be dealt with later. The slight incontinence which occurs some- times has been mentioned in the chapter on Normal Pregnancy. Respiratory System The vital capacity of the lungs has been stated by some authors (Wintrich, Kuchenmeister) to be unaltered, while others (Dohrn) ha\-e found it diminished in a large percentage. However this may be, pregnant women are towards the latter end of their term liable to attacks of embarrassment of respiration. This is no doubt induced partly by the hydrccmia always present, and partly by the impeded action of the diaphragm ; though this latter factor is compensated for to a large extent by the increase in breadth of the base of the thorax. CHAPTER XLH ACCIDENTAL COMPLICATIONS OF PREGNANCY A.— Generative Organs IWetrltls. — As a separate disease, this is probably never i-ecognised during pregnancy. It may, however, occur in conjunction with inflammation of the decidual endometrium (p. 246) or of the peritoneum in the layers of muscle near to the surfaces ; or it may be part of a septic condition occurring" shortly before deli\ery. Perimetritis is found in connection with ectopic gestation (p. 313); but under ordinary circumstances, since women affected with this disease are usually sterile, it can only be freshly produced by injury or some cause acting on the general peritoneum, such as tubercle or cancer. Adhesions, the results of previous inflammation, may, if they bind the uterus down posteriorly, cause and maintain retroversion of the gra\id uterus, which may become impacted in consequence. In other situations, anteriorly or laterally, they seem to readily stretch, sharing in the genera! relaxation of the pelvic tissues. It is possible, though not as yet shown, that the pains from which pregnant women sometimes suffer, and which can be referred to definite spots in the uterus, may be due to stretched adhesions. The only 288 Pathology of Pregnancy treatment for the tenderness and pain, other possible causes tlian perimetritis having been ehminated, is to apply local anodynes, such as hot fomentations, stimulating liniments, or iodine. Parametritis. — This is almost as rare in a recent form as perimetritis. Spiegelbcrg mentions cases due to injury or effusion of blood (hiematoma) where suppuration occurred. The treatment is to be conducted on ordinary principles. Cervical Catarrb. — Excess of secretion, owing to cervical catarrh, which in most, if not all, cases has probably existed in a lesser degree before pregnancy, is not uncommon. It sometimes causes pruritus vuhje. On its wa\' through the vagina, the secretion may cause \aginitis, with rarely the formation of small vesicles or pustules. A pregnant woman may be infected with gonorrlujua, which is sometimes, owing to the venous stasis, severe in its inflammatory results. In all these cases, gentle vaginal douching with some astringent anti- septic is necessary. This is not likely to induce uterine contractions unless too vigorously done ; but still, in cases when there is a known tendency to abort, it must be \cry cautiously employed. IMtucous Polypi of Cervix. — In case a polypus of this kind is discovered — attention ha\ing iDecn drawn to the cervix by profuse leucorrhcta, or slight haemorrhage — the best treatment is to remove it at once, since its presence is more likely to lead to abortion than is the operation for its removal. It should be twisted off with a pair of forceps. Ver>' often, however, sterility is caused by these small growths. Fibroids fmyomata). — Fibroid tumours, if submucous, usually prevent conception, owing to the changes which occur in the endometrium in con- sequence of their presence, and the same may be said of interstitial ones ; but subperitoneal fibroids have little or no effect in this way. Hofmcier has, howe\er, shown ^ that conception very frequently occurs e\en when large interstitial fibroids are present. Fibroids as a rule grow during pregnancy, and sometimes out of all proportion to the developing uterus. If they are in the body, they rise out of the pelvis with the growing organ ; if in the cervix, or in the body very near it, a rare situation, they remain below the brim, and when they are of sufficient size to diminish the canal, arc very awkward obstacles in the course of labour. They may interfere with the growth of that part of the uterine wall in which they occur and cause distortion, leading to premature labour. They may induce this or abortion by causing decidual haemorrhages, and more especially is this likely if the placenta is situated over the tumour, as the former is veiy likely to overgrow the latter ; or the myoma may set up irregular contractions (see Accidental Hitmorrhage). By enlarging the uterine cavity it is possible that they may lead to the placenta being prania, the ovum ha\ ing dropped down to the lower segment before it found a nidus. 1 Zcit. fur Gcb. mid Gyii. xxx. 1894. Fibroids complicating Pregnancy 289 Diagnosis. — If the tumour is a fairly large one, and in the pelvis, the diagnosis is arrived at by the same methods as in the non-pregnant woman. The altered anatomical conditions must be rcmcmlicred, and the softer con- sistence of fibroids during pregnancy. The increased mobility of the gravid uterus, and consequently of uterine tumours, unless they fill the pelvis pretty completely, and are fixed by their size, is a marked and important character. Fibroids of the upper part of the uterus are rather more difficult to recognise than those of the lower segment, for other hardnesses — those of the foetal parts — are sometimes confusing, and softening and flattening of the surface of the tumour or tumours often occur. In some cases it is possible to make out that during contraction the fibroid tumours become more distinct, but this is not universal. If this can be done in the case of any doul^tful tumour, it at once excludes foetal parts as an explanation of the lump, for palpation of the foetus is impossible during contraction.^ Fibroids are sometimes simulated by irregular uterine contractions, which knot up one portion of the uterine wall into a hard mass, and this especially, in the authoi-'s experience, during the months at which the fundus is about, or just above, the brim. Careful palpation at intervals of a few days will readily distinguish this condition ; and, in fact, it may reveal its true nature at a relaxation-period during a single examination. 253. — Fibroid complicatiii Uterus relaxed. Fig. 254. — Fibroid complicating pregnancy. Uterus contracting. In a case recently under the writei-'s care, the woman, who was eight months pregnant, had in her abdomen a two-lobed mass which was the pregnant uterus. The lobes were \ery much alike in shape and feel. When, howe\er, the uterus contracted, one lobe, which was a fibroid, remained quite evident, but the other lost its prominences, and ob\iously was caused by the foetus, whose outlines were then obscured b}- the contracted uterine wall (figs. 253 and 254). Treatment. — Treatment during pregnancy is needed only in cases where I lie tumour, growing from the lower part of the uterus, or in the cervix, occupies and considerably diminishes the pelvic cavity, and then labour may be induced at a time when the child will come through. In severe cases of ' See' a paper by Hraxtou Hicks, Medical Press and Circular, May 9, 1894, 'On In- tormitU'iu Contractions of Utcriuc Fibromata, and in Pregnancy in Relation to Diagnosis.' U 290 Pathology of Pregnancy this kind, induction of aljortion is indicated. If this is to be done, the sooner the better, as nothing is gained by waiting, and the whole ovum is more readily separated in the early months. If the pregnancy is too far advanced for the ovum to be delivered witliout some bruising and compression of the mass in the pelvis, it may be better to wait until term is reached, and then to perform Porro's operation (see p. 401), than to extract by embryotomy. Each case will require careful consideration. If pregnancy has occurred with a myoma which has become polypoid, the polypus should be removed by dividing the pedicle with scissors as soon as possible. Conception is very rare with this complication. Cancer of tbe Uterus. — The only form of malignant growth of any importance in this connection is carcinoma of the cervix. Sarcoma of the uterus is rare at any time ; and as it usually occurs in the body, conception is almost impossible. Carcinoma of the body, too, prevents impregnation ; and as it never affects women under forty years of age, the co-existence of this disease and pregnancy must be practically unknown. Cancer of the cervix, if not advanced, may be of little hindrance, or of none, to conception. Of the two varieties of cervical cancer, that of the cervix proper — cylindrical carcinoma — is probably the more marked in its effects, since it invades the cellular tissue around the cer\ix very soon. Cancer of the portio vaginalis — epithelioma — tends to spread almost exclusively over the vaginal surface, and does not therefore prevent in such an extreme degree dilatation of the birth-canal. Pregnancy has a very stimulating effect on the growth of cancer of the cervix, owing to the in- creased activity of nutrition which is thus established. It has, it is true, been held by some that pregnancy actually retards the growth, but this is highly improbable. As against this belief, it is undoubted that cancer grows much more slowly after labour has occurred, and in some cases the sxmptoms have remained in abeyance for several months after delivery. The cancer seems as a rule to share to some degree in the softening of the cervix which results from pregnancy. The ovum is affected owing to the anaemia and the cachexia induced by the cancer. Intra-uterine death happens in a fair proportion of cases, and there is a tendency to premature expulsion of the ovum apart from its previous death. It is possible that many early abortions occur, but escape notice by their symptoms, haemorrhage and pain, being merged into those of the cancer. The results during labour will be considered in one of the chapters on the Pathology of Labour (p. 457;. Tjrat/ne/it. — Seeing the tendency to rapid growth during pregnancy, and the proneness of the ovum to premature death and expulsion, there is no doubt that in the early months abortion should be induced. In a very few cases, where the cancer only involves the vaginal portion, and an amputa- tion of this part gives a good chance of extirpating the disease, this part of the cervix might be removed with success ; and the pregnancy after the operation has in some such instances gone to term successfully. As a general rule, the best treatment before the sixth month is to empty the utenis, and then deal with the cancer in the most suitable manner. Cancer of the Vagina: Ovarian Tumours 291 In the last three months it is a question whether (ij labour should be induced, and the child extracted (viable, if possible, but if not by some form of embryotomy), the cervix being dilated artificially, preferably by incision ; or whether (2) the patient should be allowed to go to term, and Caesarian section be performed. The former method gives a somewhat longer life to the mother at the expense of the child's possible or certain death, as the case may be ; while the latter may in\'olve shortening the mother's life considerably for the chance of obtaining a living child. The general tendency will be towards sacrificing the child for the sake of prolonging the mother's life. The choice between the two alternatives, howe\er, is one that may fairly be left to the woman and her husband. If the latter alternative be chosen, palliative measures fantiseptic injections, morphia) should in the meantime be adopted. The question of Craniotomy, Caesarian section, and other operative measures will be again alluded to, and discussed more fully, under the Pathology of Labour. Cancer of the Vagina. — The same principles of treatment will apply in cases of vaginal cancer. If it is so extensive as to form masses which will cause complete, or nearly complete, obstruction at term, or if the vaginal walls are so infiltrated as to be undilatable, labour or abortion will have to be induced according to circumstances (see Induction, p. 362). Where projecting or polypoid masses can be remo\'ed, or cancerous tissue scraped away, this should be done, if there is likely to be sufficient room or dilatability to allow the woman to bear a viable child, and if the cancer does not appear to be growing rapidly. All such cases must be treated on their merits, and the fact borne in mind that the cachexia induced by the cancer is presumably as likely to cause premature expulsion of the ovum as in the cases of cancer of the cervix. Ovarian Tumours. — Tumours of the ovar)' do not pre\ent conception unless the whole cortical substance of both ovaries is destroyed. Con- sequently the combination of ovarian cyst (cystic adenoma), which is the commonest form of tumour affecting these organs, with pregnancy, is not \'ery rare. The influence of the tumour on gestation depends on its size, soliditv, fixation, and situation. A small ovarian cyst, say the size of a foetal head if it rises above the brim with the uterus, affects pregnancy in no way whatever nor may one of considerably larger size, if quite free in the abdomen. If the tumour is so large that the abdomen is unable to contain it with the gra\-id uterus, abortion will ensue, being preceded often by exaggerations of those troubles of pregnane)- arising from mechanical causes, namely, venous obstruction and digestive and respiratory disturbances. If the tumour is fixed in the pelvis by adhesions, it will then, although not so large as a fcetal head, interfere with the upward growth of the pregnant womb, and cause incarceration or displacements and produce abortion. The effect of pregnancy on ovarian tumours, whate\cr their nature is as a rule to make them grow more rapidly. u 2 292 Pathology of Pregnancy It may lead to one accident which occasionally happens to cysts— namely, twisting of the pedicle, haemorrhage into the cyst, and rupture. The mutual effects during labour and after, of tlic tumour and pregnancy, will l)e discussed under ' Labour.' Diagnosis. — In the case of a fully distended abdomen with signs of pregnancy it may be one of the most difficult tasks to diagnose an ovarian cyst complicating gestation ; or, on the other hand, just as in the case of fibroids, it may be very easy, and this is likely to be so if the tumour is small and well defined, and everything is freely mo\able in the abdominal and pelvic cavities. Since signs of pregnancy exist in these cases, and will not have existed long enough to correspond to the size of the tumour, the cyst will ha\e to be diagnosed from hydramnios, from hydatid mole, and from twins, as conditions which distend the uterus unduly If the uterus can be differentiated by palpation and bimanual examination from another tumour which is present, there is often no difficulty in obtaining a correct view of the case. If, however, the tumour, say a cystic one, has a very short pedicle, or is fixed by adhesions to the uterus, even examination under an anaesthetic will frequently not be complete enough to clear up the matter. Such an examination should always be made in cases of doubt. The most valuable sign by which to distinguish an o\arian cyst from intra-uterine pregnancy of any kind lies in the periodical contj'actions of the uterus. These may be elicited by gentle handling" or compression. In o\'arian tumours there is no such sign to be made out ; and in cases where cyst and pregnancy are clearly co-existent, the uterus and cyst may in fa\ourable circumstances be accurately distinguished from one another. Examination per rectum often supplies \alual)le e\idencc, and should not be omitted. Tapping is quite inadmissible, not onl)' for purposes of diagnosis, but practically for any other purpose.' Treatment. — It is now pretty universally accepted that the sooner an o\arian tumour is operated on after it is diagnosed the better. Pregnancy causes no modification of this rule, for although the prognosis of the operation is slightly less favourable when the presence of a tumour is complicated by pregnancy than it is in an unimpregnated woman, it is better than when a patient is allowed to go to term, on account of the risks already mentioned, or than when abortion or premature labour is induced. Tapping the tumour with a view of tiding over labour and operating afterwards is a mistake, since if it be a cyst, in which case only would tapping be of any use, it soon refills and the operation has to be repeated. Ovariotomy, on double as well as single ovarian tumour, has now been frequently done during pregnane)-, and is an established operation. The women do very \\ell as a rule, and abortion is not very common ' 'I'hc reasons why tapping should never lie performed are : there is danger of puncturing a large vessel ; of infecting the peritoneum if the cyst is suppurating, or if it is papillomatous, or cancerous. The fluid may be too tliick to run through the trocar or aspirating-needle ; it may give altogether erroneous evidence of the nature of the cyst. Tapping also causes adhesions, which will render the inevitable operation afterwards much more difficult. An exploratory operation is better, and should be the only one entertained. Malfonnations of the Uterus 293 after the operation. It is more likely if there have been many uterine adhesions. For the effect of ovarian cysts on labour see p. 460. Malforiiiatioiis of the Uterus. — If the lower parts of the Miillerian ducts, by the union of which the uterus and vagina are formed, do not unite at all, or do so in an incomplete manner, the several varieties of double uterus, or double uterus and vagina, are produced. If the median septum re- maining" after their union does not disappear, the genital tract from fundus uteri to vaginal orifice may be divided into two halves to a degree accord- ing to the extent of persisting septum. As the lower ends of Miiller's ducts unite first, and fusion proceeds in an upward direction, the commonest abnormalities of the kind above alluded to occur about the higher levels of the utero-vaginal tract. One of the component ducts may be ill-developed, and then some form of one-horned uterus is produced. The example of deformity which is the commonest but has the least influence in causing abnormalities in pregnancy and labour is that one Fig. 255. — Uterus arcuatus. Fig. 256. — Effect of cordate uterus on foetal axis-pressure, tending to produce a vertex presentation ; B, brim of pelvis. Fig. 257. — Same uterus tending to produce a face presentation ; i>, brim of pelvis. where the fundus still shows a trace of its development from two halves. This is the uterus arcuatus or cordatus (fig. 255). The deformity is more marked in the uterus sub-septus. In all three of these uteri the fundus is bi-lobed. There is a depression in, or at all events a flattening of, the fundus as seen from before or behind in the first two. It is not unlikely that in cases where the fcctus is in the cephalic lie the position of the breech of the child in the lobe corresponding to its ventral (fig. 256) or dorsal (fig. 257) surface may have some influence in pro- ducing various presentations (Auvard), by causing the direct uterine pressure (see p. 103) to act downwards obliquely towards the occiput (producing a vertex presentation), or towards the forehead (producing a 294 Pathology of Pregnancy brow or face prcsentationj. Otherwise this shght maldcvelopmcnt is un- important. It may be possible to make out the shape of such a uterus during contraction by inspection and external palpation (see fig. 52;. Sometimes a median septum remains which may extend down to or through or even below the cervix. In the latter case it will divide the vagina into two halves (double uterus, double vagina ; uterus septus, vagina septa). In this case there is no interference with pregnancy, and in most cases none with labour. Fig. 258. — Uterus septus ; C, uterine cavity. Fig. 259. — Utenis bicomutus C, uterine cavitj'. In a few recorded instances of this malformation the placenta has been found situated on the septum, and severe post-partum haemorrhage has ensued in consequence of the imperfect retraction to which the septum is subject. Pregnancy may occur in both divisions simultaneously, or there may possibly be superfoetation (see p. 76). In cases where only one half contains an ovum, the other develops a decidual membrane, which is as a rule expelled at labour. Mistakes have arisen in these cases from an examination made through the wrong cer\ix. The uterus may be two-horned (uteiais bicornutus) ffig. 259), where the cervix opens into the cavity of both the bodies, which spring from it and di\erge as they are traced upwards. The presentation is not infrequently a transverse one.' Sometimes the placenta is situated in one horn, and there is difficulty in its expulsion or extraction. During labour, too, owing to the obliquity of the horn containing the fcEtus, there may be interference with the normal mechanism, and mal- presentations may be brought about. In the rare case of the uterus di- delphys (fig. 260) the two halves of the uterus are distinct and the ^■agince arc separate. Fig. 260. — Uterus didelphys. C, uterine cavity : V, vagina. Ufcrus inihoniis. — Here only one half is de\clopcd, the other being more or less rudimentary or even absent. If pregnancy occurs in a developed horn it goes on normally, and probably ends in a normal labour. If by any chance, however, an ovum lodges in the rudimentary side the course of ' Schatz says 10 in 23. Malformations of Uterus ^95 events is similar to that in tubal gestation, and iu])iurc occnrs during the earher weeks of pregnancy. (Sec Ectopic Gestation, p. 313. Fig. 261. — Pregnancy in a rudimentary horn of the uterus, showing relation of round ligament {L R) to gestation sac (G sac). CH7iical signs. — As a rule these are absent, and if the abnormality is discovered at all, it is disco\-ered after labour, sometimes through attention being attracted to a second decidua ; or in the case of pregnancy in a rudi- mentary horn, after rupture and death. Fig. 262. — The same uterus as fig. 261, unimpregnated. C, cavity of uterus. a, developed horn, b, Tudimentarj' horn. In Uterus bicornis (or bicornutus) the two halves may be made out during the uterine contractions. They do not alwa^■s contract simultaneouslv. Fig. 263.— Complete absence of one horn. C, uterine cavity. Trentiiicnf. — No special treatment is required except for the accident of post-partum haemorrhage during labour or for rupture, or in cases of nialpresentation. 296 Pathology of Pregnancy CHAl'TEK X 1.1 II ACCiDKNTAl, COMPLiCA'llONS OK PKK(;NAXCV — Continued Ix— Other than (jEnkrative Organs Nervous System Hysteria. — This disorder shows itself in many ways during pregnancy. In women who are afflicted by it under ordinary circumstances, the liability to become hysterical at this time is very marked. In others there is often a tendency to some manifestation or other of it \\hich becomes more marked at the time of labour. It is sometimes difficult to say where hysteria ends and insanit)' begins. The diagnosis and treatment rest on ordinary principles. Insanity. — See 'Puerperal Insanity' (p. 556). Epilepsy. — True epilepsy may, of course, occur during pregnancy. The frequency of the fits is sometimes increased, sometimes diminished, and in very rare cases, according to Spiegelberg, pregnancy may be the period at which the first fit occurs. It does not interfere with the pregnancy, thus differing from the eclampsia connected with albuminuria. It has to be diagnosed from this last, and derives its greatest importance from their similarity. Circulatoiy System Heart Disease. — This is an important complication, partly because it is a fairly frequent one, and partly because of the gra\e effects produced by certain varieties of heart disease on pregnancy and labour. (See also p. 502.) During^ pregnancy, owing to the increased arterial tension, incompetence of the aortic valves has its already existing effects accentuated ; and the compensatory hypertrophy of the left ventricle, if sufficient to carry on the work before pregnancy, is so no longer, unless under the conditions of a \ery quiet life. Any efforts will tend to bring on attacks of dyspnoea and syncope, and these may lead to abortion. This result is probably not frequent. In some mild cases patients seem to improve during pregnancy, owing, no doubt, to the hypertrophy of the heart natural to this period. Mitral incompetence^ if not marked, is not a serious complication of pregnancy — at all events, until the diaphragm becomes embarrassed in its action by the uterus in the last months, and then not necessarily to any alarming degree. If, however, the pulmonary circulation is already em- barrassed, all the symptoms of backward pressure — dropsy, albuminuria — in addition to respiratory troubles, become very severe, and abortion or premature labour will probably occur. In mitral stenosis the same results may be expected. The most marked influence of this most dangerous form of heart disease is shown during and after labour. Affections of Respiratory System 297 Trcatntciit. — This will be conducted on ordinary principles. In the case of aortic incompetence, complete rest and free purging at intervals are the best measures to adopt, so as to keep the arterial pressure fairly low. In mitral incompetence digitalis is as useful as at other times, and venesection must be employed when necessary. If the patient's condition in any form of heart disease becomes grave enough to render induction of labour necessary, this should never be done while the heart is considerably embarrassed ; but the patient should by every means possible be got into fair condition before the increased work which labour throws upon the heart has to be undertaken, or the effect of such interference may Idc to bring about a fatal result. Exophtbalmos. Exophthalmic Goitre. If either or both of these conditions are already present, they are as a rule much accentuated by pregnancy. The increase in size of the gland, and the projection of the eyeballs, subside after delivery to their former conditions. Respiratory System Phtbisis. — Phthisical \\omen are often very fertile. The effect of pregnancy on a patient already the subject of phthisis is not, judging from the variety of experiences recorded in such cases, a constant one. It was belie^'ed in times past that its effect was, as a rule, favourable ; but at present the opinion of most authorities is that the health under this combination is deteriorated to an extent dependent on the kind of the phthisis, and on the stage which it has reached. The question is an important one, for, supposing that pregnancy were favourable to the growth of tubercle, it would be right in certain cases, at all events, to induce labour. If abortion is induced, it is most likely to be prejudicial, forjudging from the results of abortion in cases of pneumonia (see below), an acute phthisis would seem to be a contra-indication to the induction of abortion ; and in the chronic cases there would be no justification in the statistics at present available for such a procedure. Near term, if the uterus were interfering with the working-power of a chest with an already very small oxygenating surface of lung, the ad\'isability of inducing labour might be considered, but only on mechanical grounds. The general conclusion, therefore, one would come to is that it would ne\er be justifiable to induce abortion on account of phthisis per se, and that premature labour should only be brought about under the above-mentioned circumstances. In addition, since phthisical women are extremely prolific, the earlier operation would ha\e to be performed very frecjuently to be consistent, and would ineA'itably in the end do more harm than good. From the child's point of view, too — and this must be considered, for the child of a phthisical mother is in most cases exceedingly well developed, at birth at all events — abortion should be avoided. Phthisical women should be strongly advised not to marry, as they hand down their tendency to their children, and run risks themsehes. Pneumonia. — If pneumonia, which seems to be a rare disease in pregnant women, occurs early in pregnancy, it is a dangerous complication, and may 298 Pathology of Pregnancy cause abortion. If il occur nearer the ^iwC^ of gestation, it is a very dangerous condition, and almost always leads to premature laijour, the foetus dying because of the pyrexia and imperfect blood-aeration. Abortion, and still more so miscarriage, under these circumstances may be fatal, owing to the increased strain thrown on the already embarrassed heart, and to the likelihood of septic processes occurring afterwards. Double pneumonia has been found almost universally fatal. Septicaemia and sapra^mia (see p. 527) are favoured by the high temperature, and by the fact that organisms are already present in the blood, and ready to multiply in the tissues damaged at labour. The treatment is that of pneumonia under ordinary circumstances, and no attempt at interference with the pregnancy is admissible. On the contrary, any methods that may suggest themselves for averting miscarriage should be made use of. Broncbitls. — The treatment of this disease in pregnancy is that ordinarily employed. Perhaps on account of the child, bleeding may be resorted to if necessary rather earlier than would otherwise be done. The effect on pregnancy of bronchitis will be much the same as that of mitral disease (p. 296J. Digestive System Under this heading wc only have to consider Simple Jaundice. (Acute Atrophy has been discussed on p. 286.) It is itself a harmless complication. Rarely abortion has occurred, and the foetus and liquor amnii have been found to be stained yellow. Its main interest is its possible relation to acute atrophy, into which it has been Ijelieved in some cases to merge during pregnancy. Uriimiy Sysie/n (For Albuminuria see p. 504.) Diabetes. — This is a very rare disease in connection with pregnancy. Its effect on this state, when it ha,ppens to be a complication, is marked. It may come on during pregnancy, and may exist only then, being absent at other times ; and having ceased at the termination of pregnancy, it may recur afterwards, or never reappear ; or it may appear for the first time soon after parturition. A woman already diabetic may become pregnant, and the pregnancy may be unaffected by the disease. It very frequently happens, howe\er, that the child dies after becoming viable, and it is sometimes dropsical. Hydramnios is frequent ; sugar has been found in the liquor amnii, and in one recorded case the child had glycosuria. In twenty-two pregnancies occurring in fifteen women, collected and compared by Matthews Duncan in a paper' from which the above facts are quoted, four ended fatally after delivery within the puerperal period, death being due to collapse or to coma. The recorded cases are too few for any decided statements to be made as to the probable mutual effects of pregnancy and this disease. This disorder must not be confused with the physiological ghcosuria (see p. 222). 1 Obsf. Trans, vol. xxiv. 1882. Affections of Osseous System ; Specific Fevers 299 Diabetes Insipidus. Polyuria. — 'flic condition in which large quan- tities of urine are passed daily has been noted in a few cases of pregnant women. The amount passed has reached over 300 oz. per diem, and with this was associated in two cases ' some diminution in the daily excretion of urea. The pol)uria disappeared in a few days after labour in all the cases re- corded but one, it which it had existed for many years. In cases where it disappeared after labour it seems to have begun about the fifth or sixth month. The symptoms resemble those of the milder degrees of Diabetes Mellitus. Osseous System Osteo-malacia. IMCalacosteon. — This disease is extremely rare in Great Britain. It is connected with pregnancy in a marked degree, often appearing first during gestation or the lying-in period, and being aggravated by succeeding pregnancies. It consists in a degeneration of the bones, especially of the pelvic and vertebral bones, and results in the loss of lime- salts and consequent softening. Cases are recorded where during pregnancy the union of fractures has been much delayed, and it is possible that here and in the disease in question the lime-salts are diverted to the nourishment of the foetus. Sometimes the disease is arrested and the bones harden again, but for the most part the disease is progressive. Its effect on the pelvis constitutes its greatest interest ; it produces a special form of distortion (see p. 449, Malacosteon Pelvis). Se\eral cases have been reported \\here Porro's operation has resulted in checking the disease, and acting on this suggestion Hofmeier, Schauta, Fehling, and others have removed the ovaries with some success. Schauta - collected twenty-four cases of osteo-malacia in which remo\al of the uterus and ovaries by Porro's operation cured the patient in twenty cases and caused improvement in the remainder. The blood has been found much less alkaline than normal in osteo-malacia, and the urine to contain great excess of fatty-acid compounds, while uric acid, nitrates, phosphates, limej and magnesia were deficient.'' The treatment ' during pregnancy consists in endeavouring to raise the nutrition to the highest degree possible, by cod-liver oil, iron, and other means. If Porro's operation is not performed at the time of labour (see p. 401 ), it seems to be certainly worth while to try the effect of oophorectomy afterwards. Specific Fevers Some of the zymotic diseases seem to have no modifying influence on pregnancy, but most of them tend directly or indirectly to cause abortion or premature labour. The direct effect is obser\ed in small-pox, t}^phoid, and, ' Matthews Duncan, Obst. Trai/s. vol. x.xix. 1887. - IVici/. Med. Prcsse, No. 27, 1890. ^ See also a paper by Curatulo, Ohsf. Trans, vol. xxxviii. 1896. ■' Rasch, Obsf. Trans, vol. xxxv. i8q^. 300 Pathology of Pregnancy il used to be said, relapsing fever. In these three fevers aljortion or premature hibour may occur independently of any considerable rise in temperature. The effect of the disease then appears to be exerted mainly by way of the uterus, for the foetus in cases occurring in the later months is often born alive. High teinperafure alone (io6° F.) will cause aljortion by killing the fetus, and it is this element in zymotic diseases that renders them liable to be complicated with miscarriage in pregnant women. The amount of illness leading to starvation of, and other interferences with the foetus is also, as in cases apart from fever (see Abortion, p. 303), a very important factor. The effect of the disease on the ftetus apart from high temperature is very marked in one of the specific diseases — namely, syphilis. The lesions caused by syphilis in the foetus and placenta have already been discussed (see p. 268). As regards the liability of pregnant women to infection, it is pretty much the same as in the unimpregnated : and there is no proof that, as was formerly believed in the case of scarlatina for instance, pregnancy has the power of protecting the woman from, or postponing the invasion of, any infectious disease (see Scarlatina in Puerperium, p. 544). No doubt the chance of abortion with its complications makes the fever a much more dangerous matter in a pregnant than in an unimpregnated woman ; and, as will be seen when puerperal fevers are discussed, new- dangers are added to the fever on account of the breaches of surface and the exhaustion induced by labour. Typhoid Pever. Enterica. — Typhoid is, according to statistics, commoner during the earlier months of pregnancy, and abortion or premature delivery occurs in about 65 per cent, of all cases. Abortion is more frequent in the more severe cases, and here it is also more likely to give rise to a fatal result. In the milder cases, and also when it occurs early in the disease, abortion does not appear to appreciably increase the patient's danger. It does so markedly when the woman is in the later stages of a severe attack of the disease. Hyperpyrexia exerts its influence in causing abortion in typhoid as in other conditions, and cases where the temperature is persistently high are almost certain to be complicated in this way. This is shown by statistics ot cases published by \'inay.i He found that abortion occurred in 55 per cent, only where the cold bath was used to bring down the temperature whenever it became dangerous. Whether this mode of treatment is employed, or some other which causes less shock to the patient, it is obviously important to be on the look-out for much fever, say over 103-5 ^ "> ^"d to take measures to reduce it at once. He found abortion to be usually preceded by a rigor or a rise of tempera- ture, and hcC-morrhagc. Small-pox. — Pregnancy and small-pox ha\c mutually damaging relations. The effect of pregnancy on small-pox is to cause a tendency to the haemorrhagic form. ' Lyon Mddicale, Dec. 3, 1893. specific Fevers 301 The eftect of small-pox on pregnane)' may l^c considered in its effects on {a) the mother, {b) the viable foetus. In epidemics of small-pox abortions are found to often occur even wlien there is no sign of the disease in the woman. This absence of maternal infection may be due to vaccination (see a few lines below). The general tendency is to produce abortion ; in the haemorrhagic form it has been observed to occur in nearly 60 per cent. ; in one of the milder epidemics in about 25 per cent. In the severer cases, confluent and hnemorrhagic, a \er)' large majority of women, 90 per cent., have been found to die. In the milder epidemics small-pox is fatal in about 8 per cent. In the case of a \iable foetus it is rarely born free from signs of the disease. This may be in the pustular stage, or show the characteristic cicatrices ; or the rash may appear within eight or ten days of birth. Cases have been recorded ' where an infected child was born of a healthy mother. The child of a woman who has been vaccinated during pregnancy is seldom found to be protected, that is, insusceptible to vaccination. The child of a woman who has variola during pregnancy, if born health)', is on the other hand always found to be insusceptible for some long period. Vaccination, however, does appear to have some influence on the foetus^, for it has been noticed - that if a woman was successfully vaccinated during" pregnancy the foetus was very rarely affected in utero. The treatment of the disease is that adopted in unimpregnated women. From the above facts it is seen that pregnant women should be carefulh" \accinated in case of an epidemic, both for their own sake and that of the fcetus ; and that the child should be \'accinated very shortly after birth. Relapsing Pever. — This is an extremely rare disease. It has been found most recently by Weber ^ to cause abortion (which is often delayed until the relapse) in about 36 per cent, of all cases. The spirillum has been found in the foetal blood. Measles in the adult is more dangerous to pregnant than to other women (Fagge), and they are liable to abortion owing to the severit)' of the disease. Sometimes the rash has been found on the new-born child. Typhus rever. — This does not affect pregnancy as a rule, but some- times aljortion occurs between the tenth and fourteenth days of the disease (Fagge), the mother afterwards doing well. Malaria. Ag:ue. — The presence of this disease has a certain influence on pregnane)', interrupting" it in about 40 per cent. The abortion is due most probably to the pyrexia, but maybe caused by the anaemia so constantly accompanying this fever. The foetus has been born at term or prematurely with an enlarged spleen. Sir Thomas Watson mentions a case where the fffitus was felt by the mother who had a tertian ague (alternate days) to shake ' Cursclinian, 'Z/tcvtsscn' s HandbKch. - Zi-itsch. f. Gcb. u. Gyn. Bd. viii. p. i8. •" Deiiin. Klin. Woch. W\. vii. 1893, p. 22. 302 Pathology of Pregnancy on the days on which she was well. Other and more recent observers have recorded similar instances. Scarlatina is dealt with in the chapters on the Pathology of the Puerperium (p. 544). Erysipelas. — This disease has no effect on pregnancy, and its only danger is that if it exists at the time of delivery it may attack the genital surfaces when lacerated or bruised at that time, and thus cause septic troubles (p. 542). Cbolera. — There is one change caused by this disease which seems to occur pretty frequently in cases where the patient does not die too rapidly for its development, and that is haemorrhage into the decidua. From this cause and on account of the blood-change (inspissation, diminished blood- pressurej abortion, if there is time, may occur, but the patient often dies undelivered. Sypbilis. — The modes of infection and special effects on the embryo and foetus are described on p. 268, and the unsatisfactory state of our knowledge of syphilis of the placenta alluded to on p. 262. It only remains now to deal summarily with the effect of syphilis on pregnancy in general. Syphilis, if contracted during pregnancy, is apt to cause somewhat more marked local symptoms at the site of inoculation, owing to the increased venous engorgement and oedema of the genital canal. Its constitutional effects are, however, mild always, and sometimes entirely imperceptible. Partial proof that the mother has been infected exists in the birth of a syphilitic child, and absolute proof in her resistance to subsequent infection by the child. This state of things is expressed in what is known as Colles' law — namely, that a woman who has given birth to a S)'philitic child may expose herself to infection by suckling it or otherwise without danger. Although a few cases have occurred of infection under these circumstances, the truth of the rule may be considered as practically uni\ersal. It must be again mentioned that a child born of a woman infected late in pregnancy may be, as far as can be seen, quite healthy, and may actually have escaped infection, and that in a case of this kind the mother must not be allowed to nurse it (see Rules as to Nursing, p. 232). In the case of syphilis contracted before pregnancy the woman tends to be sterile, but this is by no means constant, and diseased women may conceive frequently. In such cases those conceptions which occur soonest after infection are most likely to end in early abortions. After some time the poison, even in the absence of treatment, and more rapidly when the woman's nutrition is otherwise good, becomes attenuated, and the ovum is retained for longer and longer periods until a full-term child is born. This child is then subject to a greater or less extent of hereditary syphilis. If the woman still has children the effect of the disease will become less and less marked, and quite healthy offspring may be at last produced. Tending to the same end, the father's syphilis under fa\ourable circumstances will be Abortion and Prevuxture Labour 303 vanishing in the same manner as the mothers If it happens that impregna- tion by a different father occurs, the chance for the child is so much the better. Treat i)ient.—T\\Q. effect of this as regards the foetus is as a rule particularly favourable. ])efore impregnation both parents should be treated, and after- wards mercurials administered to the mother by the mouth or by inunction during the whole of pregnancy. It is not hopeless, as evidenced by a case of the author's, e\-en when the woman has reached the fourth or fifth month untreated. In this patient miscarriages and dead children had been the only result of conception. She bore on this occasion, having taken 5i ss of liq. hyd. perchlor. three times dailyduring the last five months of her pregnancy, a quite healthy child, which one month after birth had shown no sign of syphilis. CHAPTER XLH' ABORTION AND PREMATURE LABOUR The terms Abortion and Premature Labour are really identical in mean- ing, but it has become the custom to use the word 'Abortion' for cases of premature expulsion of the ovum occurring before the child is viable, meaning- up to the end of the seventh month ; and ' Premature Labour' when delivery takes place after then, but before term. The term 'Miscarriage' is also in common use, and is pretty well synonymous with ' Abortion,' though it is usually applied to such abortions as happen in the later part of the time comprised within the abortion period. No more rigid definition can be given than this. It is also modified into ' Missed Abortion,' which although something of a contradiction in terms, readily explains itself (see chapter on Intra-Uterine Death). This phrase is founded on analogy with ' Missed Labour.' Causation. — Although the two processes of abortion and premature labour differ from one another clinically, a list of causes will in either case include practically the same agents, the only causes not common to both being those which bring about premature labour by over-distension of the uterus (hydramnios, and twins), or by faulty positions of the placenta (placenta pntvia). The most natural classification is into, first, causes primarily fatal ; second, those primarily maternal. A third group, consisting of those due to the introduction of foreign bodies into the uterus, and those caused by injury to the genital canal, may conveniently be considered apart, although this group includes some cases which strictly belong to (i) or (2). It will be unnecessary to enter here into the mode of action of each cause, as this is done in every case under its respecti\e heading in other parts of this work. 304 Pathology of Pregnancy Table of Causes of Ai;ortiox and Prkmaturk Lahour (i) Primarily Fatal. Afifections of Membranes and Cord, and of Fcetal I'lacenta. {e.g. Vesicular Mole, Hydramnios.) Affections of Foetus or Embryo. (See chapter on Intra-utcrine Death, under Inherent fcetal causes, p. 269.) (2) Primarily Maternal. Local aftections. Decidua. (Haemorrhages, and Degeneration ; and Placenta Prievia.) Uterus. (New Growths, Incarceration of Retroverted Uterus, Pregnancy in one horn of a double uterus.) Surrounding organs. (Tumours interfering with growth of uterus, Adhesions.) General affections. General Diseases of Mother. (Pyre.xia ; An?emia, as from Pernicious Vomiting ; Starvation ; ZxTnotic Poisons; Lead; Diabetes; Nephritis.) Reflex causes. (Mental Shocks ; Convulsions including Eclampsia, Chorea, Tetany : Operations ; Purging.) Drugs. (Alcohol, in chronic alcoholism : and \ery doubtfully. Ergot, Savin, and Digitalis.) (3) Mechanical. Introduction of Foreign Bodies into the Uterus, Injuries to the \''agina (action mainly reflex), Rupture of Membranes. Most of the causes mentioned bring about expulsion of the ovum by making it a foreign body. They do this either by interposing a layer of blood between the o\um and the uterine wall, or by killing the embr\o in the first instance. Others act directly on the uterus, and make it contract so as to expel the ovum, and these are best exemplified by what are called in the table ' Reflex Causes,' and include alsb some mechanical causes, and some diseases of the ovum. Nearly all of these causes are more prone to act at what would ha\e been menstruations if the woman were not pregnant than at an)- other time ; and in some cases threatening occurs at se\eral of these occasions in succession. Some women abort in man)- pregnancies in succession, never going to term. This recurrence has given rise to a term ' Habitual Abortion,' which is now fallen into disuse. It was merely a confession of ignorance. The cause of recurrent abortion cannot be habit, as the term implied ; it must be one of those enumerated abo\e, which acts constantly. The commonest causes are : — Syphilis ; retroversion of the uterus, leading to incarceration ; tumours preventing uterine growth ; diseases of the endometrium ; renal diseases, and possibly obstructive cardiac and pulmonary diseases ; alcoholism. Tbe Expelled Ovum. — Wiicn the o\uni is expelled early, say within six weeks or two months, it usually comes awa)- entire. It is then not more X Abortion 305 closely connected with the endometrium at one point of its circumference than another, as there is as yet no indication of placenta ; its attachments I generally are not very firm, and for its size its envelopes are fairly thick. The decidual membranes may or may not come away attached to the cliorion, and the earlier the abortion the less likely are they to do so. Numerous specimens of ova at about the second month are to be seen in museums (see fig. 46). When fresh the outer surface of the mass expelled consists of clot partly entangled among and partly enveloping the chorionic villi. If this clot is removed by floating the ovum in water and gently clearing its surface, the characteristic pale, seaweed-like appearance is seen (see 'Physiology of Pregnancy'). On opening the sac the embryo may or may not be found. A week or two later the placental area is becoming marked ('ninth to tenth week), and the ovum is often ruptured during expulsion. The foetus will have escaped among the blood-clots, and sometimes (probably if there are adiiesions near the lower pole of the ovum) the membranes are turned inside out, the smooth amnion being external and enclosing the chorion and blood-clot. On the amnionic surface the attachment of the cord, with perhaps a shred of the semi-translucent tissue forming the cord, may be seen. As the age of the o\"um increases the embryo becomes more and more frequently found, and, if not altered by disease, will present the characters proper to its period of growth. The placenta is now fully differentiated, and as a rule remains behind the embryo, to be expelled afterwards with the membranes. The decidua usually at this period of pregnancy either remains attached to the uterus and then may cause septic trouble, or it may come away with the membranes. The disease which has caused the abortion may make the separation still more difficult than usual during the difficult period by causing abnormal adhesions from inflammation, or possibly from partially organised blood- clot. On the other hand, the recent effusion of a layer of blood may make separation and expulsion very easy ; and this last effect is probably the commoner, seeing how many abortions occur (e\en after the placenta has begun to grow) without any septic results. Bleeding. — During the separation of the o\um man\- \essels arc ruptured, and blood in varying quantities is lost. Speaking generally, the longer the process of abortion — that is, the firmer the attachment of the chorion or placenta to the maternal structures — the greater is the httmorrhage. It is practically all maternal blood, and its frequently large amount in proportion to the size of the uterus is due to the fact that retraction is prevented by the presence of the ovum and of clots, which are constantly irritating the uterus and causing contraction followed by relaxation only. Directly all or nearly all its contents are expelled, the uterus retracts and the hiemorrhage ceases. The uterus, after complete abortion, diminishes considerably in size, the shrinkage being more marked the more advanced the pregnancy. It is found to be much flatter from before backwards than when it contains the ovum. In the latter case the uterus is globular. Its internal surface is fairly smooth, and on it adherent pieces of chorion and decidua, where there are any, may be detected by the examining finger. If sufficiently marked X 3o6 Patholot^y of Pregnane}' by tliis time tlic placental site may be felt as a slighth' con\cx, loughish surface. Up to the middle of the third month, and perhaps a little later, the whole interior will be smooth if e\ erything has come away. In a \ery few hours after complete e\acuation, the cer\ix will ])robabl\' be found impassable by the finger. If, howe\er, any products of conception are retained, and especially when any haemorrhage of importance exists, the internal os is nearly always open, or veiy easily dilatable. Symptoms and Course. — The two characteristic symptoms of impending or actually occurring aliortion arc Pain and Hccinoi-rliagc. The reason for the bleeding has been described ; and it is seen that no abortion in the early months can occur without it, since at every contraction some detachment with rupture of \essels will take place. When the embryo is of some bulk, and is expelled separately, tiie process is like that of labour at term, because there is no rupture of vessels of any significance until the foetus and liquor amnii have been expelled, and the placenta begins to separate. In the very early weeks an abortion is often mistaken for a delayed menstruation, which the patient is not surprised to find excessive. At this date the haemorrhage is a more marked symptom than pain. The ovum easily escapes notice among'the clots, and has to be carefully looked for. At the time when the placenta is in process of formation — namely, during the third month— the course of events during expulsion is most characteristic and recognisable. Bearing-down pains in some degree are always present. The process begins with some of the symptoms of commencing labour. There is often a considerable discharge of mucus, and this more or less rapidly becomes blood-stained, and then merges into almost pure blood. The c|uantity of blood lost varies very much, depending on the rapidity with which expulsion occurs ; the more steadih' and rapidly the ovum is separated from the uterus (meaning, as a rule, the fewer and less resistant the adhesions) the less blood is lost. Different Phases. — (rt) Tlircaiened Abortion. — Occasionally, after making a beginning in a fairly active manner, the uterus becomes quiet and the detachment and hivmorrhage cease ; and if the bleeding lias not been free nor the pains very regular, there is a chance that the attack will pass oft" and the pregnane)' go on to term or until another attempt at abortion is made. While there is this chance of subsidence the abortion is said to be tluratcncd. Threatenings of abortion ha\e been known to subside even when a piece of decidua has been expelled. If this has happened, however, there is practically no hope of saving the o\ um. {b) Inevitable Abortion. — \{^ instead of quiescence, steady uterine con- tractions and free loss of blood go on, the abortion becomes inevitable. The abortion is likewise practically ine\itable when these symptoms reappear after an interval of quiet ; and if a portion of chorion or (if the ovum is developed sufficiently) the liquor amnii is discharged. The ovum, at all events, dies, and may very exceptionally be retained for a time (Missed Abortion, p. 269). Incoiiiplete Abortion 307 In ihc favourable cases tlic complete separation and expulsion of the ovum and decidua take place in the way already described, and on this completion the hemorrhage ceases. A kind of lochial discharge often goes on for a day or two after, and sometimes this consists of nearly pure blood. The quantity lost is, however, very small. (f) Incomplete Abortion. — If any of the decidua, or chorion, or placenta when this exists, is left behind, owing to morbid adhesions, the ha?morrhage usually goes on more or less continuously until it is expelled ; or decom- position may occur, and septic infection result. Retention is more likely to occur when the ovum has been ruptured, whatever its age may be up to the third montli. Sometimes nothing escapes but the licjuor amnii and the Fig. 264. Section of a retained piece of placenta, showins villi eiiibedJjd in clot. (.Eden.) foetus ; and the whole membranes and incipient or partially dcxelopcd placenta are left behind. Incomplete abortion does not always at once lead to continuous bleeding or septic changes. Occasionally the uterus becomes quiet and the internal OS closes for a longer or shorter period, and all seems well. S(M)ner or later the retained portion gives evidence of its presence. It ma\- be b\- menorrhagia of a severe type, or metrorrhagia. In some of these cases, where there is no reliable histor\' of a previous abortion, the true diagnosis of the case is not arrived at until the uterus has been dilated and its contents examined. Even wlicn the uliolc placenta is retained the uterus may make no effort X 2 \oS Patliolo^y of Pregnancy to expel it for weeks or even months ; and this happens ahiiost always in cases where very little or no detachment of the placenta has taken place, and the organ is able to keep up its vitality by means of its normal or abnormal vascular connections to the uterus. When a small portion of placenta is retained, tibrin often deposits on and in it, and forms what is known as a placental polypus. This causes much the same symptoms, though they, as a rule, occur later, as an in- complete abortion, and may be considered as such. The placental site, in the absence of adherent structures, may be rough enough for such a polypus to form upon it. Decomposition of retained portions of the ovum is likely to occur, if by any means septic or putrefactive organisms have obtained Fig. 265. — Section of a retained piece of placenta, showing villi (pale) with old and retracted blood-clct between (dark). There is no connective-tissue formation in the clot. (Kden.) entrance into the uterus during abortion. Such contamination is due to the introduction of dirty fingers or instruments, or to extension from the vagina. The results may be mild or severe, and may occasion any of the local or general forms of puerperal septic;emia which are possible after labour at term. As a rule the milder forms occur, owing to the uterine sinuses being smaller and fewer than at term, and to the absence of lacerations and abrasions of the genital tract caused by the passage of a full-grown child. After abortion, the uterus is as a rule found to be flatter than before, and this character of shape is a more valuable sign of the state of affairs when there is a doubt as to whether abortion has threatened or has actually Abortion — Coinplicatioiis, Diagnosis 309 occurred, than the actual size of the organ, unless the period of pregnancy at which abortion occurred is exactly known. Involution takes place pretty rapidl)- if the process is complete, and the patient in good health ; and milk often appears in the breasts for a very short time. Abortion is, however, a \ery fertile cause of subin\olution. Complications and Sequelae. — Abortion, more frequently than deli\ery at term, leads to uterine trouble, acute or chronic. Owing to the aftection of the membranes which causes it, the ovum may during time be abnormally adherent, and thus be imperfectly expelled. In the second place the cause of the abortion may remain, and may be a general or a local condition. In the third place, abortions are frecjuently considered as a matter of little importance, and they are improperly treated during the process and afterwards. The lompUcatioiis which ma)- occur comprise (i) Haemorrhage much more profuse than usual, and sometimes but rarely fatal ; (2) Septic infection, local, as peri- or para-metritis, salpingitis ; or general. The possible jc^z^t'/r? are menorrhagia and metrorrhagia, and with these always subin\olution. This last is caused by one or more of the conditions enumerated above, as leading to ill effects after abortion. Tetanus, though rare in England, is not so uncommon in hot climates, and inversion of the uterus has occurred in a limited number of cases. Siagrnosis. — The first thing to settle is whether the patient is or has been pregnant. This is not difficult in most cases where the question arises of possible pregnancy advanced to the fifth, fourth, or even third months. In cases which can only have reached the second or first month it is often impossible to decide, as the patient will have only missed one period at the most. Howexer, when there is a history of sudden haemorrhage occurring in a healthy woman, abortion should always be the first thing to be thought of> and in the absence of any physical signs of other causes, such cases must always be treated as if they were abortions. There is no doubt, of course, if portions of chorion with villi are found in the discharge. (See also Ectopic Gestation.) Expulsion of a membrane, or a substance like membrane, occurs also in cases of pregnant double uterus (p. 294), membranous dysmenorrhcea, and in cases such as those referred to on p. 251. Fragments of old clot and flakes of fibrin are sometimes expelled. The microscope will, as a rule, by showing the presence of villi, settle the matter at once (figs. 264 and 265). The next point, if the case is considered to be one of abortion, is to decide whether the abortion is threatened^ ine^'itable, ccmiplete^ or incomplete. Thcsymptoms and signsof these various phases have been already considered. In the case of indications (continued haemorrhage, signs of septic absorption) pointing to incomplete abortion, the question should be at once settled by dilating the cervix, if this will not admit the finger, and digitally exploring the uterine cavit\-. Treatment. —If abortion have occurred in previous pregnancies, the cause should be sought for, and when found, removed if possible. The 310 Pathology of Prcgnaucy cause will be found among the list of those given in connection with recurring abortion, j). 304. The woman should rest much, especially during the days which would ha\e been days of menstruation, avoid all \ iolent exercise, and abstain from intercourse. Threatened Abortiofi. — The object here is to arrest the process. A careful examination of the pelvic organs should be made once for all, sf) as to exclude any possible mechanical causes (retroversion, tumours). The patient should be kept absolutely at rest in bed, and put on the simplest possible diet. No application to, or interference with, the genital organs, even the external ones, must be permitted. The uterus should be quieted by small doses of opium, with which, in cases where the haemorrhage is small in amount and inclined to be con- tinuous, five or ten minims of the Liquid Extract of Ergot may be usefully combined. The effect of this last drug is, in such small doses, to steady the uterus. Digitalis in small doses is recommended by Spicgelberg, or acetate of lead in large doses. If it is necessary to open the bowels, mild laxati\es, such as Conf Sennte or Pulv. (jhcyrrhizte Co., are the safest ; enemata must not be employed. This line of treatment must be persisted in for some days. All clots and substances passed by the woman must be carefully preserved for examination. Inevitable Abortion. — When it is found that attempts to prevent mis- carriage are futile, and that the process is going on in a regular manner, without too much htemorrhage, it is best not to interfere, but to watch the process and be ready to help in case the bleeding becomes excessive, or the uterus is not completely emptied. (Incomplete abortion.) If the h;emorrhage becomes dangerously free, some measures must be taken to check it which will at the same time hasten labour, since directly the uterus is empty the bleeding will cease. The choice of treatment lies between removing the ovum with the finger, assisted or not by instruments, and plugging the vagina or cervix and vagina. The ovum may at once be removed by the finger, aided or not by a quite blunt curette if the cervix is sufficiently dilated to admit the finger into tin- uterus. This should be done if the ovum is presenting at the cervix ; or if the membranes have ruptured and are retained with the placenta (if this is formed) ; or if plugging has been resorted to, and has failed to bring about expulsion of the ovum, the cervix being, however, dilated. The operation is performed as follows :— The vagina and vulva are made aseptic in the manner described on p. 184 ; a catheter is passed, and the rectum emptied if necessary. The forefinger of the right hand, carefully made aseptic, is introduced into the vagina and the uterus is caught bimanually. The forefinger of the internal hand is passed through the cervix, and the uterus is pressed down on to it by the external hand through the abdominal wall. As the uterus is pressed down it comes to lie about in the axis of the cavity of the pelvis, and this is the position which allows of the most complete introduction of the finger. In multipara" the hand if necessary may be introduced into the vagina under an anaesthetic. The tip of the finger is passed to the fundus and sweeps the contents of the uterus down before it, gently detaching them from the uterine wall. If a hold cannot be obtained Plugging the Vagina and Cervix 311 of the substance to be extracted, a wide, blunt curette with a scrapinjf (not a cutting) edge may be carried up on the palmar surface of the finger, and the site of attachment being already made out, the ovum or placenta is gradually detached and brought down. The external hand should be at the corre- sponding place outside, so as to make counter-pressure. The uterus can thus be cleared out without any damage being done to it. .\ sharp curette is inadmissible, for the tissues of the uterine walls are softish and may be lacerated. A weak antiseptic intra-uterine douche ( i in 4,000 solution of perchloride of mercury) should now be gi\en, great care being taken that a free outflow is maintained. This is best insured by the use of Budin's catheter (see p. 228). If the cervix is not sufficiently dilated to admit the finger readily, it may be dilated with Hegai-'s dilators (see p. 357) up to the necessary size, and the uterus evacuated as just described. Plugging the Vagma, or Cervix and Vagina. — Either of these methods may be employed if the cervix is still undilated and the bleeding is too free, whether the ovum is still entire or has ruptured. They are, however, not admissible when septic changes have occurred. As regards the relative merits of plugging the vagina alone, or plugging the cervix by a tent which will also actively dilate it, there can be no question that the latter is a more rapid and satisfactory method of completing the process of abortion. For although the cervix, when the uterus is stimulated by a vaginal pkig, dilates as a rule, and the ovum or its remains are expelled, this does not always happen, and the dilatation has then to be completed by the use of tents, or by Hegar's or other rapid dilators (see p. 356 for description and mode of using tents). After the tents have been removed the \agina is douched, and the aseptic finger is passed into the uterus, if sufficient dilatation has been obtained to clear it out as described above. If the finger cannot be passed, it is far safer to complete the dilatation with Hegar's dilators than to use the tents again, as the risk of sepsis is thus rendered much less. It not infrequently happens that on the withdrawal of the tent the ovum, follows. If no tents are available, the cervix may be plugged with a strip of anti- septic gauze. Phii:;o-ing the Vagina. — The cases in which the \agina alone may be plug-ged are, as already mentioned, the same as those in which tents may be used. Material for plugging the vagina can always be found. The best substance is iodoform gauze, as it packs into a very solid mass, not altering much in shape when it is soaked through with serum. Carbolic gauze will do, but is not nearly so pleasant to wnrk with in these cases, or cyanide gauze or any other antiseptic kind may be used. In an emergency strips of linen, previously soaked in an antiseptic solution ([ in 1,000 sublimate, i in 20 carbolic acid) and carefully wrung out, or boiled for a few minutes, will answer quite well. The gauze or linen is most convenient when torn into strips 3 to 4 inches wide and 2 to 3 yards in length, and then rolled up ready for use. 3 1 2 Pathology of Pregnancy The vayina is rendered aseptic, and a Sims' speculum passed, the patient being placed in the semi-prone or in the lithotomy position. The end of the strip is made into a lump the size of a walnut, and passed into the posterior fornix with the fingers. It is held there by the point of a pair of uterine forceps, or by the forefinger of the other hand. The rest of the strip is gradually passed up, filling the fornices tightly, and thus completely surrounding the \aginal portion of the cervi.x. More of the plug is passed up, until the vaginal canal is filled. The lower end of the vagina must not be tightl)' packed, or the urethra will be compressed and occluded. This plug is left in for eight or ten hours, a catheter being used if neces- sary, and the patient, as in the case of the tent, will remain in bed. At the end of that time it is remo\ed, and a douche gi\en. The o\um ma\- be now found on the plug, or just ready to be removed from the cervix. If not, the latter should be rapidly dilated with Hegar's dilators, and the ovum or its retained portion taken away with the fingers. Incomplete Abortion. — When, after the embryo or the greater part of the ovum has escaped, the placenta, if it is formed, or portions of the o\um are retained, even if they do not give rise immediately to haemorrhage, they should be removed from the uterus within twent\--four hours. After that time they become dangerous, on account of possible decom- position and septic absorption. It has been mentioned that sepsis under these circumstances is not so common after abortion as after term deli\ery, and the reason for this has been given. There is, however, a sufficient probability of the accident to make the abo\e rule the only good practice. The best wa)' is to clear out the uterus within an hour after the foetus has passed, and finish the matter. The mode of doing this has been already described in the case where haemorrhage renders it necessary. Dilatation of the cervix ma>- or may not be needed. Supposing a case is seen when there is a histor\- pointing to an abortion, and where there are symptoms of retention of something— namely, liiemorrhage and a foul discharge, with a still large and possibly globular uterus. In this case, especially if the haemorrhage is in progress, the cervix will probably be found dilated enough to allow digital exploration. If not, it must be rapidly dilated with Hegars dilators, and no tents or plugs used, as they would certainly increase the risk of sepsis. The finger may find some or all of the placenta, or may only find a shreddy or fungous internal surface. If e\erything can be removed by the finger, there is no need of any other instrument ; but, even where there is a good-sized piece of tissue, this is often difficult, and a large blunt curette worked by the other hand should be used to oppose the finger introduced into the uterus. The small masses can be readily caught between the curette and finger and drawn out. The curette can then be carefully used to complete the clearing of the surface. The uterus should then be washed out, with the precautions already mentioned, a Budin's catheter being used. The treatment of cases which come under notice some months after abortion, and where fibrinous polypi are found, is conducted on the same lines. After evacuation has been completed the uterus undergoes involution very rapidly. Hi topic Gestation 3 1 3 If septic absorption has already occurred, there is all the more reason for immediate action of this sort. It is sometimes difficult, however, when there is a mass of parametritis on one side of the uterus, or where peri- metritis exists, to judi^e whether interference is best or not. If the cervi.x is dilated, the uterus may Idc \ery gently curetted with a blunt curette, and washed out ; but if it is closed, it is probably safer not to i-isk causing e.xtension of the inflammatory process into the surrounding tissues by dis- turbing the uterus. In this case erg'ot may be given, and the vagina should be frequently douched with an antiseptic solution. Aftcr-t?ratiiicut of Aho7-tion. — When the uterus is empty, involution goes on with rapidity as a rule. The greatest obstacle to involution, excepting pelvic inflammation, is too early getting up. The woman must be kept in bed for at least a week in any case, and where possible for longer, and treated as if labour at term had occurred. Ergot given in 5ss doses is recommended as a routine treatment by many, but under ordinary circum- stances the course of involution will go on as well without it. CHAPTER XLA' ECTOPIC C; E S T .\ T I O N Definition. — In this abnormal variety of pregnancy the ovum becomes implanted on some other surface than that of the endometrium of the body of the uterus, and there undergoes more or less complete development. These cases are known also as extra-uterine. ' Ectopic,' howe\er, is the more inclusive term, since in one variety of this abnormality, the inter- stitial, the ovum is not placed altogether outside the uterus, but in its wall, and lies in the intramural portion of the Fallopian tube. In no case docs the ovum develop in any part of the genital canal below the internal os ; and in the cases under consideration the ovum finds a site before it reaches the uterine end of the Fallopian tube ; on some spot between the ovary and the uterine cavity. An ectopic and a normally placed ovum may de\elop simultaneoush". Causation and Frequency. — Any condition which interrupts the journey of the o\um to the uterus may bring about ectopic gestation. Among such conditions are usually mentioned adhesions of the ends of the tubes to sur- rounding parts, or other distortions which might cause difficulty to the ()\ um in reaching and passing the abdominal ostium (see p. 2) : and chronic tubal disease, without oljliteration of the lumen, but resulting in the loss of the normal ciliated ci^ithcliimi which helps to carry the o\um along to the uterine orifice. These are merely proliable, and not proved causes ; for after the very considerable changes in all the tissues and their anatomical arrangements 314 Pathology of Pregnancy which the development of an ovum amon^,' them Idlings about, it is almost impossible to say what the state of things was at the time of conception. Considering the large number of women who have had perimetritis and adhesions before conception, such causes as these cannot be finally accepted, and some special kind of cause or disease must be proved. The absence of cilia, owing to inflammatory destruction of the epithelium, sounds a possible explanation of the resting^ of an ovum in the tube ; but the peristaltic contractions of the tubes must also play an important part in the journey of the ovum. It is believed by some that implantation of an ovum can occur only on a surface from which the covering epithelium has been removed. This removal of epithelium is said to happen in health in the case of the endo- metrium of the uterine body only. Decidual changes, which are no doubt necessary for implantation, have been found, however, in some cases of tubal gestation, in the non-pregnant tube (Webster). This suggests that such changes may sometimes occur in the tubeson conception taking place, as well as in the uterus. If in such a case the ovum is fertilised high up in the tube, and some distortion of the tube interferes with the free continuity of its lumen, the ovum will find a spot suitable for its implantation in the tube so altered. Women who are the subject of ectopic gestation are more commonly than not middle-aged, from 28 to 40 : and, being married, have been sterile for some years, either after one or more pregnancies, or from the begin- nii|g of married life. This fact sup- ports in some measure the view that obstruction is a factor, as such women are possibly sterile on account of some anatomical change. There must of course be room enough for spermatozoa to pass along the tube so as to reach the ovum, and it is assumed that fertilisation may occur in the tube under ordinary circum- stances. Ectopic gestation occurs no doubt in a far larger number of cases than can be proved ; and it has been found of late years with infinitely greater frequency than formerly. It is now believed that practically all large intra-peritoneal ha^matoceles have their origin in the rupture of a tubal gestation. Fig. 266. — Sites which ovum is capable of occupying. 6 is unproved as yet.' Varieties. — These include, according to the most recent views, tubal cases only, with sub-varieties developed from them. The following classification, founded on our present know ledge, is taken from Webster. - ' .\ccordiiig to old ideas, the ovum niighi Ijeconie ini])!antcd in any one of the situa- tions marked in the diagram. ^ Kctopic Gestation. I \irjctics of Ectopic Gestation 3 i 5 1. Aiiipi///ai% in which the gestation begins in the am])ull;i of tlic tube. This is by far the most common origin. ''3, fig. 266.) i. Persistent. In rare instances the tubal gestation may go on to full term, ii. Rupture may take place early into the broad ligament, — sub-peritoneo- pelvic, tubo-hgamentous, e.xtra-peritoneal, broad ligament gestation. (a) The gestation may continue to develop, — sub-pcritoneo- abdominal. {b) A secondary rupture of the sub-peritoneo-pelvic gestation may take place into the peritoneal cavity. {c) The gestation may come to an end ; (i) by the formation of a ha?matoma. (ii) by suppuration. (iii) by mummification, achpocere, or lithopai'dion formation, iii. Rupture may take place into the peritoneal cavity. (/;:) Tubo-peritoneal gestation, in which escape of the foetus in the membranes occurs into the peritoneal cavity, the placenta remain- ing in the tube and its development continuing. {b) The gestation terminates in various ways : — By the formation of a haematocele, the patient dying from the shock and loss of blood, or from peritonitis. In some cases the absorption of the mass may occur. In others, mummi- fication, adipocere, or lithopi^dion formation may take place in the foetus, or suppuration may result. i\-. The gestation may be destroyed — ■a) by the formation of a tubal abortion, and its passage through the fimbriated end of the tube into the peritoneal ca\ity. {b) by the formation of a hcemato-salpinx. {c) by the formation of a mole. ((/) by suppuration resulting in a pyo-salpin.x. {e) by absorption after early death, by mummification, adipocere, or lithopaedion formation. 2. Interstitial. — The gestation may dc\ clop in the interstitial part of the tube (I, fig. 266) : — [li) The gestation may go on to full time. (^) Rupture of the gestation into the peritoneal cavity may occur. ic) Rupture into the uterine cavity may occur. {d) Rupture into both the uterine and peritoneal cavities may occur. {e) Rupture may occur between the layers of the broad ligament. (/) After the death of the foetus it may remain in its sac, and possibly undergo the same changes as in other forms--v._i,'-. mummification, adipocere, or lithopa^dion formation. 3. Lifiiiuiibutar. — The gestation begins in the outer end of the tube, or in an accessory tube-ending (4 and 5, fig. 266). Under this heading are to be included the forms described as tubo-ovarian and tubo-abdominal — names which appear to be unnecessary, since the gestation is a tubu- lar one in origin, the end of the gestation-sac merely becoming adherent to the abdominal wall, the ovan,', or other of the viscera. 3i6 Pathology of Pregnancy Anatomy and Development. It is thus seen that an ovum may become iinplanlcd at any point in tlic- length of the tube. The commonest place is in the anii)ulla, and in the middle of the length of the tube ; but in the rare interstitial variety the ovum lies at the uterine end, and in the infundibular it lies in or near the ostium abdominale. These sub-varieties resemble one another in the fact that the ovum can, as a rule, grow only to a limited extent before a crisis occurs, but differ in the fact that in the interstitial kind the ovum may possibly be expelled ' into the cavity of the uterus with symptoms resembling those of abortion. In the other two kinds various results occur, as shown in the tables. Ainpiilhiry Form. — As the tube enlarges, its relation to surrounding parts becomes modified, modifying in its turn the whole anatomy of the 267.— Uterus (enlarged, with decidua) and a gravid tube, the left. The embrj-o is seen to lie at the junction of the isthmus and ampulla. (St. George's Hospital Museum.) pelvis, and the abdomen if it extends into that ca\ ity. The tube is, until fixed by peritonitis, movable within certain limits. Its increased weight causes it to f:ill below its normal level, and it may be found at almost any part of the pelvic floor or in Douglas's pouch. As it grows it pushes the uterus to one side. It may be closely adherent to the uterus, or only attached by its proximal end, forming a distinct mass. The ovary may form part of the sac or be quite distinct. Webster describes the development of the decidua into a compact and a spongy layer, as in intra-uterine gestation. That area of the decidua which is to form the maternal placenta, and corresponds to the serotina, grows more rapidly than that in the rest of the tube, and occupies proportionately a larger ' Grun's case, Obst. Trans. 1885. Ill a to III}' of Ectopic Gestation 317 surface ilian is the case in tlie uterus. A decidua rcflexa lias been found in early specimens ; it appears to degenerate rapidly, and to give rise to haemor- rhages early in tlie pregnancy ; being, according to Webster, probaljh' the main source of the blood found in that part of the tube outside the gestation. The placenta seems to be formed in the same way as in the case of intra-utcrine gestation, and sinuses are developed in the decidua. The same proliferative change occurs in their endothelium as is found in the sinuses and vessels of the normally-seated organ (see p. 26) ; but it would appear to take place at an earlier date, and in fact can only be recognised in the early months. Haemorrhages and their remains are very frequent in the placenta in these cases, and will account for the belief of some authors in the possibility of growth of the placenta after death of the foetus. The ha?morrhages sometimes convert the p'.acenta into a more or less spherical liver-like mass.^ The muscular coat of the tube thickens ? hypertrophies) for about two months (Hennig), with considerable enlargement of the nuclei in its muscle- cells, and then it thins. The abdominal ostium becomes closed.'- The cyst usually grows mainly towards the free aspect of the tube, but sometimes protrudes between and separates the layers of the broad ligament. Death of the o\um may occur at a very early pei'iod, and in that case nothing is found but a clot, forming a small blood-mole in the tube, which may be extruded from the ostium abdominale (see tubal abortion, p. 323), bleeding- being the usual accompaniment or the cause of the death of the embiyo. In this case the symptoms and signs of gestation cease, and the small mole seems to cause no trouble. The o\um, as a rule, continues to grow, and in two-thirds of the cases of the ampullary kind rup- ture occurs before the end of the second month ; in somewhat less than the remaining one-third in the third month ; and it may happen as late as the fourth month. In one or two cases the pregnancy has reached the sixth month without rupture, and has e^■en gone to term. The cause of the rupture is no doubt the thin- ning of the tube, and the crisis is brought about, at all events in many cases judging from specimens, iDy a haemorrhage, probably maternal but in some cases appearing to be from the ovum, which suddenly distends the tube beyond its power of resistance. Rupture probably occurs oftenest into the peritoneal cavity ' tig. 268), and this may happen simultaneously with rupture into the broad ligament. When rupture takes place there is nearly always a large effusion of blood, which may be so copious as to kill the woman in a few hours. In very early rupture the loss is often only of moderate quantity, but may be repeated on two or three occasions, with an eventually fatal issue. During the intervals between the h;cmorrhages, the symptoms of which will be described later, 1 John Williams, Obst. Trans, vol. x.xix. p. 482. - See Sutton's Surgical Diseases op Ovaries and Tubes, pp. 311, 312, and 314. Fig. 26S. - Rupture of the tube into the peritoneal cavity. 3i8 Pathology of Pregnancy the sac must be supposed to increase in size, most prf)bably by gradual accretion of blood and lymph to its mass. If the woman survive, as, if the loss is not too large at first, she sometimes does, a pelvic htemaloccle is produced. If the mother recovers the embryo dies, and is absorbed at this age in most cases. Some- times, according to recent observations, rupture at this stage may produce what used to be called ' aljdominal ' pregnancy, the embryo retaining some attachment to its original site in the tube and continuing to grow, being free from its envelope of chorion if this has ruptured, or, if not, lying in it ; and a cyst is formed round the embryo by peritoneal exudation. In other cases, instead of the tear being on tiie peritoneal surface of the tube, it may be (about one- third of the cases)on that segmentof itscross-scction which lies between the layers of the broad ligament (fig. 269). Rupture in such cases is usually in the Blood is thus effused into the ligament, the two layers of which stretch to a limited extent, and then as a rule are sufficiently strong to maintain enough tension to check the bleeding, and to prevent immediate rupture into the peritoneal ca\ity. There is now produced a htematoma of the broad ligament, and in this the embryo may be ali\c or dead. If alive it goes on growing, the placental site being sufficienth attached to the torn portion of the tube to maintain the life of the embr) o, Fig. 269. — Rupture of the tube into the broad ligament. middle third in length.^ pla. RECT. ri'.;. 270.— Ectopic gestation : iiitra-ligamentous, with llie placenta below the foetus. /Vrt, placenta ; A' tv/, rectum ; /Vr^, vagina; t.V, uterus. and then gi\es rise to the intra-ligamentous form of ectopic gestation. This may go to term, or may undergo secondary rupture in a short time. The result of rupture into the broad ligament, if the ovum does' not ' Sec Sulton, Lc. cit. p. 322. l)ilra-/ii^a)ncntoiis Gestation 319 |)c'iish, depends iif)w to ;i considerable extent on llie relative positions of the fdjtus and the placenta. If this lies l)cloio the fcetus it grows down into the t onnective tissue of the broad ligament, and implants itself on new tissues as it grows. It becomes attached beneath the peritoneum to neighbouring RtCT. VAG. Fig. 271. — Ectopic gestation : intra-ligamentous, with the placenta above the fielus Red, rectum ; Vag, vagina ; Ut, uterus ; Pla, placenta. viscera, to the back of the uterus, or the front of the rectum,"and to parts of the pehic floor (fig. 270). The ovum as it grows lifts oft" these parts any peritoneal covering they ma}- have. Connective tissue of '" ' ' ^ broad ligament /,. I Decidua and chorioi, - -/-,- il- Amnion- '•-'■(l Peritonenl covering ■=■-'-"' "5H\\\' Bladder \\^- Utero-vesical poucb .. Peritoneal cavity Douglas' pouch --•• Kectum Fig. 272. — Sac and placenta in intra-liganienlou> gestation (sulj-peritonco abdominal). If the placenta lies oboi'c the foetus on rupture into the broad ligament, it is the foetus and its membranes which burrow into the connective tissue, while the placenta is raised up gradually as the ovum grows, to the brim of the pelvis (fig. 27 f), and in Jessop's celebrated case ^ it covered the pelvis like ' the lid of a pot.' By the growth of the ovum, and the consequent stretching, ' Obst. Trims, vol. xviii. 320 Pathology of Pirgiiancy the placenta suffers ; its tissue is damaged by li;i^morrhaj^cs, and the pregnancy is not so likely to go to term as when the placenta is below. The walls of the sac in each case are formed partly of peritoneum, to the serous surface of which those surrounding organs which are covered by peritoneum become adherent, and partly of organs and structures from which the peritoneum has been more or less stripped. Among these organs is the ovary, the intimate connection of which with the sac has no doubt caused the impression that the gestation was originally an 'ovarian' one commencing in a Graafian follicle. The sac, as the ovum grows, continues to rise, stripping the peritoneum oft" the adjacent organs and off the abdominal walls in varying degrees, and may be found to reach above the level of the umbilicus (sub-peritoneo- abdominal form, fig. 272). Secondary rupture of the sac into the peritoneal cavity may occur at anv time after the primary rupture of the tube into the broad ligament. It has been already mentioned that rupture may occur in both directions simultaneously. In secondary rupture such severe bleeding usually occurs that the woman dies unless operated on, and there is no chance of further development of the ovum. It is, however, possible that even now the pregnancy may go on, if the placenta is not too much disturbed or damaged ; and it would be difficult to say, in most cases when the pregnancy is in a sac outside the tube and the broad ligament, whether its position was the result of the rupture of a tubal pregnancy direct into the peritoneal cavity, or of an intra-ligamentous gestation. In fact, in a very large majority of the cases it is impossible to say at all whether the sac is intra- or extra-peritoneal, and no doubt many cases have been described as 'abdominal,' i.e. intra-peritoneal, which were really adxnnccd broad ligament gestations. It is asserted, although it is not proved, that the fcetus, to thus survive either primary or secondary rupture, need not be still contained in its membranes after rupture. It is most unlikely, considering the absorbent power of the peritoneum, that this should be the case: and remembering the difficulty of determining the true relations of the gestation-sac to the peritoneum, cases obser\ed in which the child was found floating free among the intestines must not be received as proving its possibility. In the case of ampullary or infundibular gestation, after rupture of the sac into the peritoneum or broad ligament, the foetus may die. If this happen and the woman survive, the ovum is either absorbed with the h;rmatocele produced, or the foetus may become mummified, converted into adipocere, or into a lithop;cdion. The earlier ovum will be aljsorbed, and the later undergo one or other of the above changes : or suppuration may occur, and the abscess may burst into the bowel (commonest ), through the abdominal wall (rarely), into the bladder or vagina, or even into the uterus or througli the perin;cuni. Suppuration is what usually happens in the older gestations. Infection of the sac no doubt occurs in consequence of its proximity to the bowel. When the foetus is converted into adipocere, the liquor amnii disappears and the sac falls in on its contents. After this, or after mummification (drying-up) of the foetus, the sac may become calcified. Sometimes the foetus becomes calcified too, and is converted into a lithopnedion. The mummy or the Ectopic Gestation 321 Intestine FcEtal bones' Intestine Fig. 273. — Fcctal bones in a sac formed by adherent intestines. (St. George's Hospital Mnseum.) 322 Pathology of Pregnancy lithopa'dion may be retained in the abdomen for an indefinite time, and pregnancy has been known to occur during such retention. Cases of long retention are extremely rare, and slight disturbances are very liable to set up suppuration in the sac. If the ovum is dead, the hasmatoma is gradually absorbed, or may rarely suppurate, the pregnancy being at all events at an end. Tubal Abortion. — Until the abdominal end of the tube is closed, it is always possible that the ovum may be extruded through it into the peritoneal cavity. This extrusion, which occurs in the earliest weeks, resembles abortion of an early intra-uterine pregnancy. Large quantities of blood, up to fifty ounces, may be lost in the process, and will, of course, lie in the peritoneal cavity, forming an intra-peritoneal haematocele if the woman survives the loss. Large amounts of blood have been found extravasated while the ovum w^as still in the tube, so that tubal abortion probably resembles ordi- nary abortion in that the bleeding persists until the ovum has been expelled. The ovum is during or before this process converted into a blood-mole. Sutton points out that this accident during a tubal gestation 'accounts for many of the cases of so-called ' reflux of menstrual blood ' when metrorrhagia has occurred ; the metrorrhagia being that connected, as will be seen later, w'xXh expulsion of the uterine decidua formed in cases of tubal gestation. In other cases a mole may be formed, and remain in the tube ; and it may then form part of a h^emato-salpinx. Interstitial. — This is a rare form. The gestation developes in the actual wall of the uterus at the place where the tube perforates this, and thus lies internal to the round ligament. As it grows the sac extends either into the uterine cavity or into the broad ligament, and the uterine wall expands over it. It is very seldom that the pregnancy in this position goes on to term ; rupture usually occurs before the fifth month. The time of its occurrence is, however, very variable. The effect of rupture is an almost uniformly fatal one, partly because it occurs late (later than in the case of tubal pregnancy), and the vessels are therefore larger, and partly because the placental area is almost sure to be torn on account of the arrangement of the sac' I7tfu7idibnlar. — Part of the ovum is enclosed in the abdominal end of the tube, and part projects from the fimbriated extremity. This latter part is enclosed in a sac formed by the surrounding viscera. Among these is the ovar)', which is intimately welded with the wall of the cyst, and is expanded over the ovum. In this situation development can proceed to term, for there is no limit to the growth of the ovum away from the tube but that set by the adhesions. If these adhesions give way new ones may be formed beyond them, and the sac thus re-enclosed. It has been suggested that in some cases the pregnancy has occupied a previously existing ovarian sac.- Prcgnancy in a rudimentary uteritie horn may be included here, for it is clinically indistinguishable from tubal gestation, and imitates this in its ' See a case of Bland Sutton's. Obst. Trans.'yoV xx.wii. 2 Bland Sutton's tunica vaginalis ovarii ; Vulliet : A. f. G. 1883, vo]. xxii. p. 427. lictopic Gestation — Changes in Uterus 323 mode of termination, namely, by rupture. The mass has in most cases Ijcfore rupture been taken for a fibroid. After deatli or at operation, for the preg- nancy cannot go on after rupture, it maybe made out that the Fallopian tube Fig. 274. — Pregnancy in a rudimentary horn of the uterus, showing relation of round ligament {L A') to gestation sac {G sac). rises outside the sac, and is normal in length. The round ligament also arises outside the sac. In tubal gestation both arise internal to the sac, and the tube is much curtailed (compare figs. 274 and 275). Fig. 275. - Relations of sac to round ligament in tubal gestation ; L K, round ligament. Changes in the Uterus and EjidonietriiiDi of Uterine body. — No case of ectopic pregnancy developes without certain changes in the uterus. This organ grows during the pregnancy without changing its shape up to a certain size, namely to that of a third or, at the outside, a fourth month's gestation ; though it may increase in weight beyond this time, and may continue to do so as long as the pregnancy goes on. The endometrium forms a decidua indistinguishable from the decidua vera, but of course having no serotina or reflexa. This decidua is cast off when the embryo dies ; or at the time of the false labour at term, if this period be reached, or before term. It s sometimes expelled as a complete cast. It is then thick (about { to -I of an inch), and its size corresponds to that of the enlargement of the uterus existing, measuring about 3.^ inches as a rule from fundus to the lower end. The uterus, as already mentioned, is pushed out of its normal position by the growing ovum and its sac ; the displacement's usually somewhat forwards, owing to the fact that the tumour mostly occupies or bulges towards Douglas' pouch ; and almost always considerably to one side. Y 2 324 Pathology of Pregnancy Symptoms and SIgrns. — Sometimes a woman who is the subject of this aftectioii may lia\c the symptoms so well marked that it is impossible to overlook its existence ; while in other cases there may be for a time nothing to suggest that the pregnancy is abnormal. In some instances, with the symptoms of pregnancy present, there have been found certain abnomial phenomena which have suggested a physical examination ; and the signs then found have caused suspicion of, or indicated the actual condition. In yet another kind there ha\'e been no definite signs of pregnancy at all, and the symptoms of rupture, mild, severe, or even fatal ; or later still, the dis- charge of bones through a fistulous opening, ha\c been the first events which suggested the true nature of the case. It will be understood from this statement that the recognition of early ectopic gestation is, as a rule, not an easy matter. In fact the instances where tul)al gestation has been recognised before rupture might only a short time ago almost be counted on the hand.' It will be remembered that rupture in this variety commonly occurs before or about the eighth week, and that at this time the indications of pregnancy in any case are not very marked or characteristic. Syinptovis. — In a typical case the patient has been regular in menstruation for some time.' She has probably been sterile for several years of married life, eithev before or after having had children or miscarriages. She misses a period, and may or may not suspect that she is pregnant ; but she shortly has irregular attacks of bleeding, and, as a rule, combined with these spas- modic abdominal pains. The symptoms so far may suggest a threatened abortion, and suspicion of this may be strengthened by the passage of portions of decidua. Or one of the attacks may be more intense than the preceding ones, and sufiiciently so to cause collapse. The occurrence of collapse and its degree depend on the extent of the rupture which has now probably happened, and on the quantity of blood extravasated. If this attack be survived, others of a like character ma_\' follow, and the haemorrhage may sooner or later be fatal : or the o\um, being torn from its base, may die and be absorbed with the hitmatoccic formed b)- the extra- vasated blood, thus ending the matter ; or the case may go on as an intra- ligamentous pregnancy with a growing tumour, further signs of pregnancy, and evidence of the presence of a living foetus. In this last case the patient usually comes to have much abdominal pain, with symptoms of compression of the bladder and rectum, and possibly of inflammation about the tumour. These conditions go on till term is reached or until the false labour occurs, and a decidual cast, if one still remains in the uterus, is expelled. In some cases secondary rupture takes place, when the patient almost always dies of haemorrhage or peritonitis ; but oftener the foetus becomes a mummy or a lithopicdion, and is retained for some time, finally becoming expelled through a fistulous opening. Otherwise the cyst shrinks and undergoes with the foetus the changes ahead}- described. In rare cases of interstitial gestation the ovum may be expelled through the uterus, and is then, of course, likely to be mistaken for an ordinary abortion. ' Of late, the cases which are diagnosed and operated on before rupture have become much more numerous. PJiysical Signs of Ectopic Gestation 325 Sigjis. — The physical signs maybe di\iclcd into three groups, each grtjup being characteristic of a period. In the first four months of pregnancy the mass formed l^y the ovum and its surroundings has much in common with other tumours whicli may occupy the pelvis ; in the second half of pregnancy the gestation resembles most an intra-uterine pregnancy ; in a third period, when the foetus is dead, it forms a mass which lies in the abdominal ca\ity, and it then may or may not be giving rise to symptoms of a dangerous character. A description of the local changes produced by each kind of ectopic gestation has been given. It will, therefore, be easy now to under- stand how the physical signs are brought about. In the first four months of pregnancy the results of vaginal andbi-manual examination are much the same as those got from examining cases of tubal disease or of perimetritis, namely, a mass on one side of, or behind, the uterus. The uterus cannot, as may happen in these cases also, be always defined. If it is defined, it is found to be somewhat enlarged, but not to the extent that would exist in an intra-uterine case at the same stage of pre^' nancy. It is pushed to one side to a varying extent by the mass, and sometimes, but not in a very early case, fixed. If the sac bulges into Douglas' pouch the mass there may be mistaken for a retroflexed gravid uterus, especially where the fundus cannot be found in its normal position ; and both con- ditions may cause retention of urine. The occurrence of contractions in any mass show that it is uterine. This, if elicited, will be a final point m deciding whether such a mass is gestation sac or misplaced gravid uterus. The use of a sound would, as a rule, show the direction and size of the uterine cavity, though in cases of acute retroflexion it might not be possible to pass it beyond the angle of flexion, and a mistaken conclusion might be arrived at by its means. It is undesirable to pass a sound in these cases, at all events until every other means of clearing up the diagnosis has been ex- hausted ; for if the ovum is outside the uterus the tube may be made to rupture by contractions set up by the passage of the instrument ; if it is inside, the ovum will most likely be expelled. If the uterus is shown to be empty, a small portion of the endometrium may be curetted off and examined microscopically to see if any decidual cells are present. If the scraping proves to be decidua, it is very valuable, but not conclusive,' evidence of ectopic g-estation, supposing abortion to be excluded. The undoubted growth of a mass by the side of the uterus is, if fairly rapid and accompanied by symptoms of pregnancy and by pain, strongly indicative of ectopic gestation. In the case of tubal gestation there will only very rarely be an opportunity of making out any progressive enlarge- ment, but in intra-ligamentous cases this sign may be recognised. Rectal examination will often give valuable information as to the con- nections of the mass. The cervix is, as a rule, found to be little if at all softened. After riipiiirc. — In tubal pregnancy, after rupture into the abdomen has liappened the signs in a patient who survives are eventually those of a haematocele, and, as a rule, those of a large one. ' See cases recorded by W. S. .A. Griffith, Obst. Trans, vol. xxxvi., and by the author, vol. x.xxviii., in both of whicii a typical entire decidual cast was expelled in the absence of pregnancy. 325 Patholoij^y of Pregna)icy If the woman is seen soon after rupture there is httle to be felt. There may he some thickening on one side of the more or less fixed uterus, but, if rupture has happened in the first few weeks there will probably be nothing but slig'ht abdominal fulness. In a day or two the efilised blood hardens, and then forms the tumour characteristic of an intra-peritoneal h;ematoceIe. If rupture and bleeding occur on several occasions, the blood-tumour will increase more or less distinctly after each attack. Under favourable circumstances the hii^matocele will be eventually absorbed. When the rupture is intra-lig"amentous there is less shock and more immediate swelling, and the swelling is felt to be limited and to resemble that of parametritis. The blood may be both intra- and extra-peritoneal, and is sometimes found widely diffused beneath the peritoneum. In the second half of pregrnancy there is no difficulty, if the child is alive, in recognising the fact that the woman is in the family-way. It is much easier, too, to make out where the pregnancy is. The foetal cyst does not contract under any circumstances ; it is usually more to one side of the belly than the other ; and the uterus, as can often be established, is distinct from the cyst, being pushed away to the opposite side. If the uterus cannot be defined bimanually, the lower segment can be felt per vaginam not to be globular as in normal pregnancy ; the cervix is Aery slightly if at all softened, and points to the same side as the cyst, and not away from it as it would if the c)st consisted of the tilted uterus. The uterine sound should, if used at all, here be used with very great caution, and under the same conditions as in the early months. Localisation of the placenta is sometimes possible if it is on the anterior abdominal wall, or between this and the foetus. This can only be done by palpation ; no stethoscopic signs can be relied on. The heart-sounds can be made out and foetal movements felt while the child is alive. Ballottement can be obtained in many cases. When the foetus dies before or after false labour these signs of course cease, as does another sign of pregnancy — namely, the secretion of serum by the breasts. In the third period, as above defined, the death of the foetus reduces the gestation-sac and its contents to the level of a solid tumour, which is fixed in some part of the belly, and is ready to undergo further changes. Changes may occur at once, and consist in suppuration of the sac and its contents. The patient will then have the signs of septic absorption com- bined with those of an abdominal mass, and possibly the history of a previous pregnancy. In the absence of such a history, or of recognition of the fcEtal parts through the parietes, the condition is probably undiagnosable without an exploratory operation. If a woman is seen when fistuUe ha\e formed by perforation of the abdominal wall, or by communication of the cyst with the rectum, vagina, or bladder, the state of things is not difficult to recognise owing to the bones which are discharged. If the change .is one of mummification or calcification, there is nothing characteristic but the absence of growth in the mass. As already mentioned, a mummified fcetus or a lithopasdion may at Diagnosis 327 an)' time cause irritation, and give rise to tlie same physical signs as a recently suppurating cyst. Diagnosis. — For the purpose of making a diftcrential diagnosis it is again necessary to divide ectopic gestation into the two periods of {a) the first four months and {l)) the remainder of pregnancy and subsequent periods, since the conditions likely to be confounded with it in each of these periods separate themselves naturally into two groups. /;; the fi7'st half, Isefore any sign of foetal life is, as a rule, found beyond mistake, ectopic gestation must be distinguished from : — (i) Ordinary pregnancy (with certain added conditions). (2) Retroflexed or retroverted gravid uterus. (3) Abortion. (4) Fibroids (with certain added conditions). (5) Tubal diseases, peri- and para-metritis, broad ligament cysts. (6) Ovarian tumours. (i) Inira-iiteri7ie pregnajicy with pain, and lateral displacement Giving to adhesions, inflammatory masses, or tumoitrs Intra-iiterinc Signs of early pregnancy as a rule well marked If the utenis can be made out sepa- rately from the mass, it corre- sponds to the period of pregnancy, as does the softening of the cer\i\ Uterine contractions maybe elicited No haemorrhage Extra-uterine Signs of earl)' preg^nancy not always present or complete Uterus, if made out separately, is too small for the period, and the cervix is not enough softened No contractions in the mass Irregular haemorrhages and partial discharge of decidua, and the continued growth of the mass (2) Retroflexed or retrotierted gravid uterus; signs of pregnancy — mass felt behind the cervix, possibly ballottenient — pain and pressure symptoms possibly present Retroflexion and Version Uterus not found elsewhere Ectopic Gestation Uterus may be defined in front of mass Mass as a rule reducible,' or at least Mass often fixed, Ijut this is not mo\able without force constant No h;vmorrhage as a rule, unless Hamorrhage and discharge of de- abortion is occurring cidua Pain usually 'bearing-down ' in clia- Pain usual!)- acute and spasmodic racter Uterine contractions No contraction in mass ' If the mass is fixed dingnosis may be impossible. 328 Pathology of Pregnancy (3) Abortion ii-'ith injlaiiiniatory masses or tumours. Hceinorrliage and discharge of mondrancs ivi/h pain Abortion Ectopic Gestation Uterus, if dififerentiated, enlarg-ed ; Uterus, if made out, not much en- sound passed if necessarj' larged Uterine contractions may be felt No contractions in mass Cervix soft and patulous Cervix almost unchanged Chorionic villi are present in the No villi found in discharged mem- membrane discharged brane Uterus ceases growing Mass continues to grow if no rupture occurs (4) Fibroids luith hccmorrhage^ especially if complicated with perimetritis andfxed, and if the cervix is softened Fibroids Ectopic Gestation History of pre\ious dysmenorrhosa Usually amenorrhoea for one or two and haemorrhage months No symptoms of pregnancy Symptoms of pregnancy may be present Uterine mass usually definite Uterus, if defined, not markedly enlarged No discharge of decidua Decidua often discharged (5) Tubal disease, peri- and para-metritis. — Physical signs much alike (fig. 276), and in a certain proportion there is menorrhagia or metrorrhagia at some tinie or aftother., usually early, in the course of the disease Inflammation Ectopic Gestation Cause possibly found (Gonorrhoea, abortion) No symptoms of pregnancy Usually symptoms of pregnancy Mass usually diminishes somewhat Mass grows on rest Fever occasionally No fever No decidual discharge Decidua often discharged The diagnosis here is very difficult, and is usually not made before rupture of the tube. Rupture of an [aneurism, rupture of the stomach or intestine, intus- susception, ovarian tumour with twisted pedicle, may each on account of the sudden shock and collapse they cause be confounded with ruptured ectopic gestation. In the second half of preg?uincy the diagnosis, as regards pregnane)-, is usually easy when the foetus is alive, and the distinction has to be made only Diagnosis 329 between intra- and extra-uterine gestation. If the child is dead, however, the gestation sac may be confused with other abdominal tumours such as dermoids, or malignant disease of the pelvic viscera or peritoneum. If the foetus is alive, attention has to be paid to the position of the mass, whether central or lateral, and to the actual situation and size of the uterus. If this can be separately examined bimanually the distinction is easy ; but even if the lower segment only can be reached, its shape and cur\^ature, and its position with regard to the mass, will be sufficiently indicative of the condition of its body. In ectopic gestation the cervix is little if at all softened ; the lower segment is not lax, and its curvature is small ; it is pushed to the opposite side by the gestation sac ; and there is no well- VAGINA RECTUM Fig. 276. — Para-metritis. (Compare with figs. 270 and 271.) defined impulse conveyed to the cer\ix from the upper part of the mass felt in the abdomen. Uterine contractions and relaxations are absent from the main part of the mass. The fcetal parts maybe abnormally distinct as felt through the abdominal wall in extra-uterine cases, and the placenta may also be made out h\ palpa- tion. It should be remembered that some cases of scanty liquor amnii have been taken for cases of extra-uterine gestation on account of this distinctness of outline and seeming nearness to the surface. Whe7i the foetus is dead the diagnosis may rest on the history alone, for the physical signs may be insufficient to clear up the case. An exploratory incision is here the proper measure to adopt, unless there is fairly definite history of some inflammatory cause producing a large peri- or para-uterine swelling, or of the occurrence of a ha^matocele at an early period of ectopic gestation. Prog-nosis. — The prognosis almost entirely depends on (i) the recognition of the case in time to avert the numerous accidents that have been described, and (2) the proper management of the case when its nature is ascertained or strongly suspected. This is most true with regard to the first few months of such a jM-egnancy 330 Pathology of Pregnancy for then the danger lies in rupture alone, and the woman is made safe if the gra\ id tube is diagnosed and removed, or if the symptoms of internal haMiiorrhage are at once assigned to their proper cause and laparotomy immediately performed. In the later months the causes of danger are more various, and lie in the changes which may occur in the mass if untreated — namely, rupture, suppuration, and in the difficulty, in any operation, of dealing with the placenta satisfactorily, and of checking the haemorrhage from its site. As regards the child, it can only be born alive if operation is undertaken after it has become viable. It is often malformed. Treatment. — In former years, owing to the reluctance felt by medical men to open the abdominal cavity, almost any seemingly milder expedient was resorted to which gave a chance of putting an end to the pregnancy by killing the embryo. Such methods were : puncture of the c)-st and foetus fro'm the vagina ; the admmistration of strychnine to the limit of the mother's safety ; starAa- tion ; blood-letting ; electrical currents passed through the cyst, faradic or gahanic ; electro-puncture ; and the injection of morphia (gr. ^ or so) into the cyst. These methods have the following drawbacks. In the first place, if the foetus is killed it is left behind to be absorbed. This may happen, it is true, if the ovum be young and soluble enough, but it is also possible for the dead embryo to act as a cultivation ground for septic organisms, to suppurate, and thus cause trouble. If young enough to be absorbed it is just the case when the operation to be immediately discussed — namely, removal by laparotomy — is likely to be the easiest and most favourable. In the second place, these methods of treatment may have no effect on the foetus, and this may survive, for instance, the strongest faradic current capable of being borne by the mother, or the treatment may be fatal to her — and this is the commonest result — by suppuration of the sac and peritonitis, or by hcvmorrhage and injury to the intestines, or by bringing about con- tractions in the sac, and rupture. In the third place, valuable time is lost and the risk of ru|)lure continues. The only satisfactory metbod of dealingr 'wltb an ectopic grestation, nrherever seated, is tbat of extirpation as soon as possible after tbe dlag:nosis is made. Our experience of this affection and its results to the patient under all circumstances is now very large. Even as long ago as 1891 (long in the history of our knowledge of the matter) Schauta collected 241 cases in all stages where with expectant treatment the mortality was 68"8 per cent. ; while in 335 which were operated on it was 26 per cent. At the present time the latter percentage would be found very much smaller than this. The character of the operation rccjuired at each different period in the history of an ectopic gestation varies in its degree of difficulty, and thus in the prognosis for the patient. While the gestation sac is still contained in the tiilH\ or this has only recently ruptured^ and while no adhesions to the peritoneum ha\e been formed by the jilacenta, the operation is as a rule fairly simple, and the tube Treatment of Ectopic Gestation 331 and its contents can Ijc removed completely. During the latter half of pregnancy this removal is often most difficult and dangerous, owing to the attachments of the placenta to a large area which possibly includes intestinal surface, and because of the non-contractility of the placental site. An exception to this rule is found when the ovum is intra-ligamcntous, and can be more safely separated. In discussing the opcrati\e treatment proper to each class of case, no attempt at detail will be made, but the principles and the general scheme of procedure only will be noticed in each instance. Class I. — Cases where ectopic gestation is diagnosed or strongly suspected, but direct signs of a living child have not yet appeared. This will include cases up to the end of the fourth month. The gestation sac may be — {a) Tubal and unruptured. {b) Ruptured, whether tubal or intra-ligamentous. (- by cutting (care being taken in the latter procedure that the peritoneum is not opened;, the pieces removed, and the cavity completely drained If the fistula be into the bladder, the urethra should be first dilated and the state of things investigated : very likely the fragments can be removed in this way. If necessary for complete examination, \ aginal cystotomy must be performed. If the remains of the fictus cannot thus be extracted without 1 Obst. Trans, vol. x.xix. 1887. - King. Loud. Med. Rrprin/s, vol. xii. \y. 241, 1820; aiul Mathiescn, Obst. Trair. vol. xxvi. p. 132, 1834. H(Bniorrhages dut-ing Pi^egnancy 335 much damage to the Ijladder or other organs, the sac should Ije cut down upon through the abdominal wall immediately above the pubes, a\'oiding the peritoneum. Cases which discharge through the bladder are always sub- peritoneo-pelvic. Discharge through the rectum is sometimes spontaneously completed. If not, and septic symptoms arise, an abdominal operation would be the safest way out of the difficulty as a rule, unless the opening is so near the anus as to be within eas)- reach. CHAPTER XLVI H/EJMORRHAGES DURING PREGNANCY The period during which pregnancy lasts is naturally one of amenorrhoea. Any haemorrhage from the \agina is therefore abnormal, and should be carefully investigated. Among the causes of bleeding, some act during the early months more especially, some during the later, and some throughout the whole period. The causes more characteristic of the yfrjr/ half 2iX& : Abortion, proceeding or only threatened ; Hydatid mole ; Carneous mole ; Ectopic gestation ; (?) Menstruation during pregnancy. Of these, abortion and the two kinds of mole have been already dealt with ; ectopic gestation is treated of in Chapter XLV ; and the last will be here discussed. In the latter half more particularly in the last two months of pregnancy, haemorrhage occurring then for the first time is almost invariably due to detachment of the placenta. Bleeding from detachment of a normally situated placenta is called Accidental Haemorrhage. That from a placenta occupying some part of the lower uterine segment (Placenta Prtevia), Unavoidable Haemorrhage. At atiy time during pregnancy^ the haemorrhage may be due to disease of the cervix — erosion, cancer, or polypi : or to other accidental complications, such as urethral caruncle or ulceration of vagina ; or to wounds, especially if enlarged or varicose veins are involved. All these conditions are likely to lead to much freer bleeding during pregnancy than under ordinary circum- stances, because of the venous engorgement then existing. Haemophilia, though rare in women, has been recorded as giving rise to attacks of uterine hiiemorrhage, not usually ending in abortion. Menstruation during- Fregrnancy. — It is not a very uncommon matter for a woman to have what seems to be a monthly period once after concep- tion. \^ery rarely this happens twice, and still more seldom oftener than 336 Pathology of Pregnancy this. In the absence of one or more of the causes in the third group, the bleeding must be due either to a tlireatened abortion or to menstruation. In a very large majority of cases it will have to be put down to a threatened abortion ; for the process of menstruation, in\olving as it does exfoliation of a certain amount, even if only the most superficial layer of the endometrium, with haemorrhage into its substance, is \cry unlikely to go on without con- siderable risk to the continuation of pregnancy. There is, of course, a potential cavity between the decidua refle.xa and decidua vera up to the third month, and blood may be discharged without interfering with the ovum. The more fully, however, cases of alleged menstruation during pregnane)' are in\estigated, the more of them are found to be explained by some morbid condition, or anatomical aberration such as a double uterus. To make a general statement ; one monthly bleeding may be allowed to pass as a menstruation in the absence of any discoverable cause or of further disturbance, but any repetition of this should always be looked upon as a threatening of abortion, and the patient treated on this assumption. It has been mentioned that abortions are more prone to happen at what would, had the woman not been pregnant, have been menstruations ; and that abortion may be threatened on several such occasions in succession. The diagnosis and treatinent of cases where the bleeding is due to abnor- malities of pregnancy will be found in the chapters on the Pathology of Pregnancy. That of wounds and other incidental causes is discussed in each special case. ACCIDENT.\I. H.1':.M0RRHAGK Definition. — Accidental haemorrhage means haemorrhage which is not a necessary part of labour, and which is usually defined in hcrmorrhage occur- ring betiealh a norinnlly-sitiiated placenta. It is so called to contrast it with the unavoidable haemorrhage which occurs during the dilation of the cer\ix in labour when the placenta happens to be attached to the lower segment of the uterus, constituting a placenta praevia.^ Causation. — In some cases this disorder is to be traced to a blow on the abdomen or to a fall or some over-exertion, by which forcible rupture of vessels and detachment have been brought about, ^'cry often, however, no such cause is to be found, and the separation must be due to disease of the uterus, or of the maternal or foetal placenta ; and occasionally it comes on in the night after the woman has been at rest for some time. It is not common in primigravid;u ; and occurs, as a rule, in an;cmic and debilitated subjects, and women who have borne many children. It is thus probably due in nearly all cases to some abnormality in the decidua. Interstitial and submucous fibroids have been found in connection with this kind of bleeding, and may possibly bring it about by producing irregular uterine contractions. Mental shocks also have been said to set up sufificient local contraction to detach some of the placenta, and certain blood diseases (of which anaemia 1 Hjemorrhage often occurs in placenta praevia before labour lias begun, and is then really of the nature of accidental hjemorrhage, as will be seen later. A ccidcnt(xl H temoi'vliasre IZ7 has been already mentioned) including the group of symptoms named purpura h;emorrhagica, are associated with a tendency to sub-placentai hicmorrhages (Jolm Phillips). Bright's disease is not improbably an impor- tant cause. Anatomy. — The blood eftuscd beneath the placenta from the maternal sinuses usually finds its way to the edge of the decidua at the internal os, and escapes per vaginam, percolating through the looser laj'er of decidua, or forcibly separating the membranes at or about this plane ; and causing further bleeding by tearing fresh vessels. The haemorrhage rarely is ^ concealed^ which means that the blood is retained in the uterus, not escaping by the vagina. This retention is eftected by {(I) adhesions at the edge of the placenta. A considerable amount of blood may then collect beneath the placenta, {b) The membranes may be abnormally adherent rcund the edge of the internal os, and the uterine inertia always present in cases of this kind of haemorrhage allows a large collection of blood beneath the membranes. (c) The head of the foetus may fill up the lower uterine segment, {d) Rarely the blood has been found to break through the membranes into the amniotic cavity. In nearly all cases, however, even when the mass of the blood is retained, there is some haemorrhage externalh-. When the blood is thus retained there is more or less distension of the inert uterus. Marked symptoms will arise from this, and it is recorded that the distension has been sufficient to rupture the uterus. Symptoms. — The bleeding comes on during the last weeks of pregnancy in nearly all cases ; but of course there may be haemorrhage beneath the placenta at any time after its formation. The earlier the bleeding happens the less characteristic are its symptoms and the more likely to be merged in those of abortion. The quantit}' of blood lost varies, and in a large majority of cases is not of dangerous amount. It may, however, be so extensive as to call for immediate treatment to save the woman's life. The concealed variety is rare (about i in loo of all cases of accidental haemorrhage), but these cases are by far the most dangerous, for the bleeding goes on for some time unsuspected by the woman, who, if the detachment of placenta is at all extensive, soon suffers from the effects of internal hcrinorr/iai^e, and in a very marked degree from those of shock due to uterine distension. She feels severe pain over the uterus, with the sensation of abdominal distension. There may or may not be a history throwing some light on the nature of the case. She has all the signs of collapse and of se\cre loss of blood, the uterus is found tightly distended and tender to the touch, and there is an absence of contraction and relaxation. Fig. 277. — Accidental hjemor- rhage ; the dotted area repre- sents blood. 338 Pathology of Pregnancy In slight cases these symptoms are present in a lesser degree ; in severe ones the signs of hicmorrhage and, in the concealed kind especially, of shock, become more marked, and death may take place, ushered in by convulsions, loss of sight, and intense dyspnoea. Progrnosis. — The mortality of accidental h;cmorrhage, taking all cases together, is computed to be about lo per cent. It is probable that this is a high estimate, for no doubt a large number of slight cases remain unrecorded. In the concealed kind about 50 per cent, of the mothers and 90 to 95 per cent, of the children die. hiertia titeri during labour, and from this cause, post-partum hitmorrhage after delivery, is very apt to occur owing to the collapse, the over-distended condition of the organ, and often, no doubt, to the originally unhealthy state of the uterus. Biagrnosis. — The condition most likely to be confused with accidental ha:morrhage, if blood appears externally, is placenta prcc7'ia. Other haemorrhages are at once excluded by a careful examination by touch and sight of the genital tract. If the finger can be passed through the internal os, the question of the presence or absence of a placenta there may be at once settled. Hut bleeding often occurs before the cervix is wide enough to admit a finger. In this case, if by steady but gentle pressure upwards for a time, the internal OS cannot be passed by the finger,' it may be possible to make out, by examining the anterior vaginal and uterine walls, if there is any structure (placenta) between the head and the anterior uterine wall. If accidental hsemorrhage happens as late as it usually does, the absence of ballottement will be of no help, but before the seventh month this sign will be obtainable if the placenta does not intervene between the head and finger. .A. clot might give rise to the same sensations as a placenta if felt through the vaginal or uterine walls. The diagnosis is obscured also if the lie is not cephalic. The history is of some value if quite definite — that is, if the bleeding has come on shortly, not necessarily immediately, after one of the accidents enumerated, and if it has never happened before in the pregnancy. A history of shock followed by haemorrhage is not conclusive, as a shock may, and probably often does, bring about bleeding from a placenta pra-via, by causing partial detachment of the placenta. The absence of such a history, moreover, as we ha\e already seen, does not by any means exclude accidental haemorrhage. In fact, the only reliable sign is the absence of placenta from over the internal os. If the blood is mainly retained in utero, the signs of internal bleeding and shock have to be distinguished from the same signs in cases of 7-iipture of the uterus (p. 489), or of luptured ectopic i^vstatio/i (p. 324). Rupture of the uterus before labour has obviously begun is an extremely rare event. If it did occur it would resemble accidental haemorrhage in its main symptoms, but on examining the woman's abdomen the uterus in the case of rupture would be found to be smaller than would correspond to the date of pregnancy, owing to escape of the liquor amnii, and possibly the ' Accidental haemorrhage is rare in primigravidas, and in muliiparre the os can usually be dilated by the finger. Trccxtvicnt of Accidental Hicmorrliage 339 f(i,'tus, through the rent. The fcetus might be felt in the abdomen as a mass lUstinct from the uterus. The symptoms of rupture after labour has begun are \ery characteristic, and will be dcscriljcd in their proper place. Treatment. — The bleeding from the placental site cannot be arrested, if any 1:)ut \ ery small vessels are torn, as long as the uterus is prevented by its contents from contracting and retracting. The obvious principle on which treatment must be based, therefore, is to empty it. This can be begun at once, and completed in a short time. In the slighter rases, where the bleeding is not serious and there is no symptom of collapse, it is right to try the effect of rest and absolute quiet, and the administration of sedatives — opium being" the best, in moderate doses. By these means the uterus may be quieted down, and the blood will then clot where it lies, without being forced by uterine contractions under the adjacent portions of placenta, thus tearing fresh vessels and causing increased bleeding. The patient, supposing she is less than seven months pregnant, may be enabled to have a li\ing child or even to go to term. If the case is severe and immediate action is necessary, it is to be remembered that the uterus is nearly always inert, certainly so if the hitmorrhage is concealed, and an assistant should, if possible, be ready to compress the flaccid organ as its contents are evacuated. If there is no possible obstruction present to a speedy labour, a dose of ergot may be given and repeated once or twice if it is appearing to do good. A binder (p. 229) should be very carefully adjusted ready to be tightened if no skilled assistance can be obtained. When these arrangements have been made the membranes must be ruptured or punctured. Rupture may be accomplished by means of the finger-nail or by the sound, care being taken that all instruments used are aseptic. If the OS is dilated this is easy. // the OS ts imdilated the diagnosis of the nature of the bleeding cannot, as just stated, be made with certainty. It may be possible to pass the tip of the finger through the internal os by gctitle pressure, and this must always be attempted ; for since most women suffering from this accident are, as already said, multipant, and so have a cer\ix which is pretty freely open as far as the internal os, a little pressure will be enough to enable the finger to reach the presenting part of the ovum. If digital pressure will not effect dilatation, either because the woman is a primipara, or because the os is too resistant, it is best to dilate the cervix with Hegar's dilators to a diameter which will admit the finger, or in the absence of Hegars dilators a sponge-tent may be inserted, and careful watch kept for evidence of concealed hasmorrhage. If the uterus begins to distend, and the woman to show signs of fresh loss of blood, it wil be ob\ious that the case is one of accidental haemorrhage which the tent has converted into the concealed variety ; and upon this a sound may be passed and the membranes ruptured or punctured without delay. If the case is one of placenta pra^via, the tent will ha\c been the best possible treatment under the circumstances. After dilatation by any of these means the membranes are to be ruptured. z 2 340 l^athology of Pregnancy In an extremely urgent case, if no dilating instruments are at hand, and the internal os cannot be passed by the finger, an attempt must be made to rupture the membranes with a sound. If when the sound has passed the internal os it is felt to go through membrane suddenly, and liquor amnii is discharged, the case is one of accidental haemorrhage in all probability ; and if the uterus now contracts on the foetus, and there are no more signs of bleeding, the labour may take its course, help in dilatation and expulsion being given according to ordinary principles. If when the sound has passed the internal os a sensation of placental tissue is felt, the \agina should be plugged for a few hours if no sponge-tent or other dilator can be obtained. It is better not to puncture the membranes at their most bulging point for two reasons. First, it is a good plan to let the liquor amnii drain away somewhat slowly, so that the uterus may recover itself and follow the diminish- ing ovum down ; second, it is well to allow any blood pent uj) h\ adhesion of membranes around the internal os to escape. To fulfil these conditions the sound should be introduced a little way Ijetween the membranes and the uterus, and then pushed through the former. If inertia still prevail, or if the cervix after rupture of membranes be rigid, the os must be dilated by Hegar's dilators or digitally, and then some form of hydrostatic dilatation — Barnes' or Champetier de Ribes' bags — employed. The forceps should be used as soon as the size of the OS permits, so as not to cause any further risk of exhaustion, or allow of more bleeding. During traction by the forceps the uterus must be well supported through the al)dominal walls. In cases of great urgency, and before the cerxix is dilated enough for the forceps, turning is the l)est treat- ment. Where the child is dead, perforation, followed by extraction by means of tiie cephalotribe, gives the best chance of safety to the woman, and in extremely urgent danger threatening" her, with a moderately dilated or easily dilatable os, perforation, of a living child has been found necessar)-. For such straits as would necessitate destruction of the child it has been proposed to perform Porro's operation, liut this seems unnecessarily severe treatment. Post-partiiin haiiiofrhagc must be guarded against by careful supervision of the uterus during the whole process of labour and for some time after. Even when the uterus seems fairly well contracted, free oozing may go on for some time, and is, of course, dangerous in a patient already sufficiently bled. Ergot should in most cases be given in full doses, the ])ulsc being carefully watched for any sign of cardiac failure, which ergot sometimes promotes. A hot intra-uterinc douche (ir5° F.) should be used, and in some instances it might be well to plug the uterine cavity (see p. 354), and stop the bleeding entirely. Further, if the patient does not seem to be improving, and rallying from the ha:;morrhage, the infusion of saline fluid (p. 360) would be highly advisable, and might be the means of saving" her life. Placenta J''rcevia 341 Unavoidable H.emorrhacie. J't-acenta Pr/Kvia Definition. — The placenta or some part of it is attached to the lower uterine segment (see p. 42), and some is of it necessarily detached during the expansion of this part in labour, owing to the limited elasticity of the placenta, and to the advance of the lower pole of the ovum which in this case is represented by placenta, and not membranes. Causation and Frequency. — There is little known about the cause of this abnormality. Like accidental haemorrhage, it is rare in primiparce as compared with multipara;, and it is said to occur more frequently in connection with subinvolution, and therefore with enlargement of the uterine cavity. It is not unlikely that in uteri whose walls, anterior and posterior, are not in apposition, and whose mucous membrane is unhealth)', the o\um might not make an attachment near the uterine end of the tube, but might fall down to the lowest point and adhere somewhere near the internal os. Its frequency is Aariously estimated, but it probably happens about I in 1,000 or i in 1,200 cases. Anatomy. Placenta. — The placenta is nearly always thinner than normal, and at the same time larger in area. PlacentcC succenturiat?e are common. These characters are due to the decidua being thinner near the internal os, and to the fact that the \ascular arrangement of the lower uterine segment is less suited to supply the needs of a placental circulation. Placenta prsevia, central 279. — Placenta pricvia, lateral. Owing to the increased \ascular supply over the placental area the lower segment does increase \ery much in thickness, and this thickening, as will be seen, has sometimes an important bearing on the progress of labour. Morbid adhesions and fibrous lumps arc common, and are due to previous hirmorrhages and thromboses. Site. — The placenta may be situated so that its centre corresponds or nearly so with the internal os, central insertion ; or its edge may overlap the edge of the internal os, partial or lateral insertion ; or some of its area may merely reach into the lower segment, as far as or nearh" as far as the 342 Pathology of Preg)iancy edge of the internal os, marginal insertion (see figs. 278, 279, 280;. As the internal os widens during labour it exposes more and more of the placenta in the lower segment, so that a placenta originally marginal may become, as dilation goes on, a laterally inserted one. Besides this e.xposure of surface by widening of the os, it will be readily seen that the placenta must ad\ance to some extent through the cer\ix during labour, since it takes the place of the membranes at their area of yielding. The circular line which limits the lower or distending segment of the utcnis lies at a distance of about three inches from the internal os at the beginning of labour, and indicates the level at which the calibre of the uterus is such as to allow the head to pass through it without stretching it to an appreciable extent. It is easily seen that the uterine wall abo\c this line need not, and in fact docs not, stretch for tlie passage of the fretus ; and so any part of the Fig. 280. — Placenta praevia, ninrginal. I'ig. 281. Placenta pra;via. Inner surface oflower part of uterus, c, closed internal os. In full dilatation an area such as ecu has to expand to area of adci.. u V represents diameter of he.id. placenta Cm normal cases of course the whole placenta^ attached above it is not disturbed, since its site is not stretched. At the line, and for an inch or so below it (zone of possible detachment, fig. 281, >, there is slight stretching, and any part of the placenta seated on this zone may possibly be detached during labour. Below this zone, that is, within a distance of two inches from the internal os (zone of necessary detachment, fig. 281), detach- ment unavoidably occurs as the os dilates for the head to pass.' Source of B/ood.— The h\nod shed is practically all maternal, for the separation occurs as usual through the ampullary layer. A small quantit)- comes from the under surface of the placenta as it is detached, but the greater part by far from the torn sinuses and vessels on the uterine wall. The reason so little comes from the placental surface is that the circulation I This line must not be confused with the ' contraction ' or ' retraction ' ring (see p. 98). The real nature of this last is not yet settled, and although it no doubt indicates the line of division between the contractile and distensible' segments of the uterus, and corre- sponds with the limit of firm attachment of uterine peritoneum — a definite limit — it will be remembered that this ring is steadily moving away during labour from the os towards the Ilccnio! r/ias^c in Placenta Pnevui 343 in iIiL- placenta is \cr\' slow, and thrombosis easily takes place. The detached part has to be supplied with blood through the unruptured vessels of the part still attached, and in its very slow journey through these sinuses the blood clots (fig. 282). The bleeding is very free, since the uterine wall cannot contract, and if a large area of placental site is laid bare before assist- ance is obtained the woman may bleed to death. If the placental site is stretched considerably, the bleeding from it is arrested, for the stretching obliterates the vessels. The stretching ag-ent, the fcetal head or breech, acts by its direct pressure also to the same purpose. Uterine wall Placenta Fig. 282. — Detachment of placenta praevia. The placenta is seen to-be partially detached, and the only blood supply to the sinuses is through those still remaining in communication with the vessels in the uterine wall. The sinuses in the detached part being thrombosed, no bleeding can occur from their cavities. Hcenwrrhage before labour. — Haemorrhage sometimes begins before labour has set in, or at all events before actual pains are experienced. This is almost always due to detachment by shock of some kind, and is produced in the same manner as accidental htemorrhage. The placenta is more liable to detachment when preevia. Detachment has been known to be caused b\- coitus. Signs of old haemorrhage, fibrous masses, and adhesions are \er}' often found. This early bleeding has been accounted for in other ways. It has been considered to be due to slight dilation of the cer\ ix, such as is believed by some to occasionall)^ occur during the latter months (see p. 45) ; by others (Barnes) to the placenta growing more rapidly than the lower uterine segment (it has fundus, and will not ihorcforf coincide pL-rnianently with the ciicle3 inches from the internal os just men- tioned. It will, in fact, beginning quite below, in a very prolonged labour, retreat higher than a circle thus drawn (fig. 283). It is, however, true that all the uterine wall below this line is being stretched by the ovum (p. 409), and that any part of the jilacenta on tlie stretched area will be detached. So that in a prolonged labour the retraction-ring no doubt carries up with it this upper boundary of the zone of neces- sary detachments. The relation of the retraction-ring to the process of labour in placenta prrii'via was indicated by Barnes, though he did not describe the nnatom)- and physiology of tht' production of the ring. Fig. 283. — /. /', zone of possible de- tachment ; y?.\", zone of necessary detachment. The retraction ring is seen to have retreated above the level of the zone of possible de- tachment. 344 Pathology of Pregnancy been stated on p. 341 that the placenta, when it is pnuvia, is larger in area than normal). Symptoms, Sigrns, and Course. — Very few cases of placenta pntvia go to term, for the early separation often starts the process of labour by causing irritation at the internal os ; or possibly the sudden aniemia may do so ; or medical aid is called in, and the physician induces labour. IJleeding due to placenta pricvia is commonest at and after the seventh month, and though instances of bleeding before this do happen, such early hitmorrhage usually turns out to be caused by a threatened abortion. Bleeding is the characteristic sign, and it is usually sudden and profuse. It is sometimes fatal, especially where it occurs in the last week or so of pregnancy. It may, however, be a continuous oozing, or there may be a slight loss, and then complete cessation for a time. It may, and often docs, come on while the patient is in bed and asleep ; or it may appear while she is up and about, possibly during or after some exertion. The bleeding is found to begin earlier when the placenta is centrally situated than when it is lateral. When hitmorrhage has begun in earnest and goes on steadily, the result to the patient depends almost entirely on the active condition of the uterus. If this is inert the bleeding remains unchecked, and will most probably end fatally ; but if the uterus is acting well, and the placenta is not centrally situated, the bleeding may be spontaneously arrested : for where only a small part of placenta is attached on one side of the os, it usually follows the main mass across this opening during dilation I'fig. 284), and the membranes can protrude and rupture, allowing the presenting part of the child to descend and compress the bleeding area. Haemorrhage occurs during the separation of the placenta from the area of necessary detachment only, and ceases when this is completed. In a few recorded cases, total separation of the placenta, when it has l)cen situated centrally or nearly so, has occurred, and it has been e.xpelled before the foetus. The child has nearly always been dead by the time it was born, but in one or two remarkable instances, presumably with a very active uterus, it has been born alive. We may now consider the effect of placenta pnevia on labour, pregnancy, and the lying-in period. Effect on pregnancy. — The occupation of the lower end of the uterine cavity by the mass of the placenta interferes to some extent with the fcttal lie, by pre\enting the head from fitting into this part. The presentation is therefore often abnormal. Unusual lies are more probable on account also of the prematurity of labour prevailing in cases of placenta pne\ ia. Effect on labour. — The course of labour, apart from h;emorrhage, is Kig. 284. — Placenta prsevia en- tirely detached from one side of the lower segment, and allow- ing its membranes to bulge. D2(\L^nosis of Placenta Prtsvia 345 usually considerably modified. The pains, unfortunately, are nearly always very weak. This is due to several causes, of which the most important are (i) loss of blood, and (2) rigidity of cervix and lower uterine segment owing to their thickened condition. This rigidity interferes with polarity, which is further disturbed by (3) the absence of dilatation of the os by the membranes. If there is any malpresentation it will interfere with the course of labour in a manner corresponding to its nature. Prolapse of the cord is not uncommon. Owing^ to the uterine inertia the woman is \ery liable to post-partum h;emorrhage, which thus arises under particularly unfavourable conditions. .Supposing this danger averted, the woman may die from loss of blood within one or two hours of the completion of labour, falling into a state of syncope which is unrelieved by ordinary stimulants. Finally, a woman may be killed by air entering the uterine veins, and causing air-embolism during separation of the placenta (see p. 555). Effect on the lying-in period. — The patient is very liable to septicaemia for the following reasons : (i) In the management of cases of placenta prai\ia there is necessarily much manipulation of the cervix and lower uterine segment during labour, and therefore increased risk of septic con- tamination. (2) Owing to the low situation of the placental site it is verj' liable to septic infection from hands and instruments during labour, and . from its nearness to the germ-containing cervix and vagina during the lochial period. (3) The exhaustion and anasmia nearly always present diminish the patient's power of resistance to septic org"anisms. (4) A placenta succen- turiata may be left behind. The septicaemia may take any one of its forms ('see p. 525). Phlegmasia alba dolens is a form of sepsis which may occur. Other remote but possible results of the aniemia are insanity and pul- monary and other thromboses. Diag-nosiSi — The diagnosis of placenta praevia cannot be made with any approach to certainty until the placenta has actually been felt by the finger to lie in the lower uterine segment. It cannot therefore be made until the cervix is sufficiently dilated to allow the finger to pass. It is true that the only other condition which is likely to be confused with it at the late period of pregnancy at which it usually occurs is accidental haemorrhage, but before the cervix is dilated to the extent mentioned there is no reliable means by which to distinguish between these two forms of bleeding. In the case of placenta praevia the finger will find covering the internal OS, if the insertion is central, the unmistakable texture of placental tissue ; in lateral and marginal insertions the membranes will partly or entirely cover the orifice, and in the latter the finger may have to be passed an inch or more inside the uterine cavity to feel the placenta. Placenta previa is suggested by (i) the history of the onset of the bleeding, though, as has been noted, this will not take us very far, for h;vmorrhagrc, where the placenta is pn^via, is liable to happen sometimes after a fall or shock, and accidental h;vmorrhagc may come on in the absence of any such disturbance. (2) If by abdominal examination the foetus is found to be in the cephalic 346 Pat/ioloi^j' of Pregnmtty lie, it is \ci_\ likfly tliat on examining ])cr vaj^inani there will be felt to be a thickish layer of tissue between the examining finger and the head resting on the anterior uterine wall in front of the cervix. In a few cases of placenta pritvia it has been made out on abdominal examination that a mass, which afterwards was proved to Ije placenta, was lying on the front wall of the lower uterine segment.' The diagnosis is not often to lie established b)- these signs. It requires some practice in such examinations to be able to form an opinion of any value from palpation of the placenta thrcugh the uterine and abdominal walls, and then, too, the placenta in these cases is, as a rule, thin and not readily felt. The occurrence of gushes of blood during the pains or between the pains is of no value in distinguishing placenta prctvia on the one hand from accidental haemorrhage on the other, for the blood in each case must collect in the vagina, and it may be expelled thence at any moment quite in- dependently of the moment at which it was effused. Concealed accidental hitmorrhage is not likely to be confused with placenta prjevia : there is little or no external blood loss in the former, and no distension of uterus in the latter. It may be said also that if the placenta can be made out by abdominal palpation to lie on the upper part of the uterine wall the case is not one of placenta prie\ ia, unless twins are present, when there may be a placenta o\er the os as well. Treatment. — If htemorrhage occurs to a woman during the later months of pregnancy, and a diagnosis between the two kinds of bleeding cannot at once be made, the case must be treated as is recommended for doubtful cases under accidental haemorrhage on p. 339. If, however, a diagnosis of placenta pncvia can be made at the time of the first bleeding, it becomes a question whether the case should be tem- porised with or be brought to a termination at once. It is recommended In- some authorities that when the foetus is as yet not viable, an attempt should be made to carry the pregnancy on to the time of viability of childhood if the loss is not very great. It has been mentioned that the bleeding begins earlier the more central the attachment of the placenta, and so, when bleeding begins before the seventh month, it is very probable that the site is in its more dangerous position. The child, as will be seen immediately, is under these circumstances unlikely to be born alive, and to temporise is to expose the mother to greatly increased risk to try to save a child whose chance of surviving its birth is very small. This is quite contrary to accepted principles ; and, moreover, the difificulty of rearing a premature child has to be considered, for when once placenta praevia is diagnosed no one would allow the pregnancy to go beyond the seventh month. It may be laid down then as a general rule that/^r.v soon as placenta pnevia is diai^^tiosed the uterus should be emptied ; for if the child is \iable there is no reason against, but e\ery reason for, doing so, and if it is not viable there is little chance of its being delivered alive. When a diagnosis of ])laccnta pran ia has been made, the woman should ' .Spencer, Ohst. Trans, vol. xxxi. p. 203. Trcatuicnt of Placenta Pnevia 347 not l)e left fi)i- ;iny lon^ time until deli\ery is complete. If the case be one which has not reached the se\ enth month, the cervix must, if necessary, be dilated by a sponL^c-tent (see p. 356), and the first two fingers must then be Ijushed past the placenta or through the membranes, so that the presenting part of the foetus can be got at. Supposing it is the breech, the foot must be brought through the cervix and drawn down until the half-breech plugs the canal ; if the head or other part of the child presents, bi-polar \ersion must be performed. It very often happens that after the tent has dilated the os to some extent the uterus begins to act well, and expels the ovum without much more bleeding. If the woman has reached the seventh month, the line of treatment depends on (<•?) the activity of the uterus, ip) the situation of the placenta. With an active uterus and a lateral or marginal placeJita there is need for little or no anxiety about the result. A.11 that is necessary is to rupture the membranes at the most accessible point. The head or breech takes the place of the presenting membranes or edge of placenta, and no more forward movement of these last is necessary, and thus one cause of bleeding is eliminated. More important than this, the presenting part is likely to come down into the cervical canal and check the bleeding entirely.' If the placenta is thus favourably inserted, but the uterus is not acting well, the forceps should be applied to the presenting head, and ergot given (i drachm of tr. ergot amnion, twice) if there is no obstruction to the advance of the foetus. The uterus must be carefully supported during extraction, so as to ensure its following the ovum down and retracting properly. Great care is to be taken in applying the forceps not to include any part of the placenta between the foetal head and one of the blades. If the breech presents, one foot should be brought down through the cervix, and the half-breech pulled into the opening. Labour w ill then go on without further hfEmorrhage as a rule, but if there is an\' b'eeding, firm traction on the foot will stop it at once (fig. 286). When the placenta is centrally^ or nearly centrally, inserted the case is very dangerous. Activity or inertia of the uterus are now alternatives which greath- influence the fate of the woman, and (in a much lesser degree) that of the child. Even with an active uterus there is a very small chance of delivering a living child, for when the only possible spontaneous method of delivery — that of the whole placenta first and then the child— takes place, it is a most exceptional event for the latter to be born alive, and, even when the measures about to be recommended are carried out, it is acknowledged that the child's chance is not a good one (the mortality is about 90 per cent.). Practically the result of the case now depends almost entirely on the treatment. What this should be to start w ith is decided by the state of the cervix— whether dilated enough to allow of the introduction of two fingers so as to do bipolar version or not. When dilatation has been produced, the ' Where a large number of placenta; are systematically examined, the insertion of the placenta is found in a certain small proportion of cases to have been partly in the dangerous area without having given rise to marked bleeding, or at least to bleeding sufficient to need treatment or to suggest a placenta pra?via. 548 J\rthology of ]''regnam'v case is handled as if there had been sufficient dihitatioii when the first examination was made. Dilatation enough to admit one finger is necessary before a diagnosis can be made, so we may assume that treatment has ad\anced so far. (The details of the method of dilating with tents are described in the chapter on Obstetric Operations fp. 356). Sponge icnis are the most suitable of any for the cases now under consideration, because they expand more quickly than any other kind, and, owing to their texture, they probably check the bleeding better than the tents of laminaria or tupelo, which are smooth. The\' dilate evenly, and without the force which the fingers, when used for this purpose, are liable to exercise, and they do not involve frequent manipulations. It is very likely that their constant action stimulates the uterus more perfectly than the intermittent stretching caused by most other means.) It can now be carried on by means of the fingers, l)y inserting two, three, or more sponge tents into the cervix, by Hegars dilators, by hydro- static pressure, or by plugging the vagina. Although tents may be used to continue the dilatation after it is possible to introduce a finger, it is better then to go on with some instrument which does its work more rapidly. By using Hegar's dilators the os can be rapidly stretched, but their employment necessitates frequent introductions of fresh instruments into the cervix, and increases the woman's risk by making septic infection more possible. Moreover, unless a special set of large size be used, the os cannot be sufficiently dilated ; and, lastly, they form a very con- siderable addition to the bulk and weight of the midwifery bag. There are two kinds of hydrostatic di- lators — Barnes's dags and the bag of Cliam- petier de Rides already mentioned — and a description of them both will be found in the chapters on Obstetric Operations (p. 358). Since Barnes's bags need changing at least once or twice, and the other kind is not changed at all ; and as, owing to the shape of De Ribes' bag, it compresses not only the sides of the cervix (fig. 285), but also the surface of the uterine wall for one or two inches, depending on the amount of dilation existing at the time, and checks the bleeding in this way more completely, the latter instrument, or one like it, will be found the best thing to use in these cases. Digital stretching x'i very good in the absence of any instrumental aid ; and plugging the vagina (see p. 353; is a means of stimulating the uterus which maybe employed by a nurse with ad\antage pending the arri\al of the medical man, or by him as a temporary measure if the os is still undilaled and he has no other means of effecting this. Before describing the steps of the procedure to be now adopted there is Fig. 2S5.— De Ribes' 1«g applied to placenta pra;via. Tyeatuient of P/acenta Prcevia 349 one manoeuvre to be mentioned — that is, the separation of the placenta over a certain area round the internal os. Barnes attaches great importance to this as a means of stopping", or, at all events, of greatly diminishing, the bleeding which occurs as the os and lower segment dilate. It no doubt does diminish the bleeding from the placenta directly, for it enables throm- bosis to take place at once in that part which is separated, as shown in the diagram (fig. 282). A more important result, howexcr, is the opportunity which the detachment of placenta round the internal os gives to the ovum to ad\ance ; just as sometimes when there is delay in the formation of a bag of membranes in an otherwise normal labour owing to excessive adhesion of the chorion round the os, this may be rectified by passing the finger between the uterine wall and the membranes for a short distance round inside the os. This small manoiu\re can be carried out as soon as the os will admit a finger. The finger should be introduced as far as the second joint, and then swept round under the placenta in a circle, of which it forms roughly the radius. The placenta will be separated over a circular area of about 5 inches in diameter, corresponding roughly to what has been mentioned as the area or zone of necessary detachment ; if the os is somewhat dilated, its diameter will be added to the 5 inches. Thus if the finger reaches 2} inches from the edge, and the os is I inch wide, the diameter of the area separated is 6 inches. If the placenta were quite central, this area would repi^esent more than half the placental surface ; but this situation is very rare, and there is, as a rule, enough placenta left attached to carry on the foetal circulation adequately. We have considered the treatment fully as far as dilating the cer\ix up to a degree large enough to admit the finger. If the dilatation has reached this stage when the patient is first seen, treatment can be commenced at this point. The first thing to do is to separate the placenta in the way just described. In doing this it will be noticed how near the nearest edge of the membranes is to the OS. Next a hydrostatic dilator is inserted and expanded. In the case of Barnes's bags the smallest size is used, and when it has done its work, which will be in a few minutes to a quarter of an hour, it will be found on with- drawing it that two fingers can be passed without difficult)-. If the membranes have been reached and identified, the point to make for is known, and with the two fingers acting on the fcetus at this point, and the other hand external, bipolar version (p. 367) is now to be performed. Perforation of the placenta by the finger so as to reach the foetus is \ery rarely necessarj-, and is not always easy, but if no margin can be found it must l)e done. Fortunately, the placenta is usually thin. The membranes are ruptured, a foot is brought down and caught b\- the fingers, and drawn through the cervix as far as it will come without more than slight force being used. The half breech now acts as a perfect plug (fig. 2S6\ The woman is usually safe for the present, and the completion of labour should be left to nature, unless there is consideralDle uterine inertia, for which a careful watch should be kept. When the uterus is inert, the leg" 350 Pathology of Prcgjiaiicy must be pulled upon and used to extract the child, ergot and firm abdominal support being employed. The separation of the placenta and the slow delivery by the breech give, as has been alrcad\- said, small chance of survival to the child, and on this account Champetier de Rides' bag{\i. 359) will pro- bably, after an extended trial, be found a better mode of treatment than turning. It can be in- serted as soon as the smallest-sized Barnes's bag, and left in the uterus, where it will act as a com- plete plug until it has dilated the os to a sufficient size to allow of delivery of the child by the natural forces, or by the aid of forceps if necessary. The dangers of slow delivery by the breech are thus a\ertcd, and there is, if anything, less risk to the mother, since the manipulations necessary for turning arc avoided. Supposing it is found impossible to do Ijipolar \ ersion at the stage recommended, the cervix must be further dilated so as to allow of the introduction of the hand inside the uterus to seek a foot. This dilatation may be necessary if Barnes's bag's are used ; but if the French dilator be used, the further danger arising from this severer operation is nearly always obviated. On account of the tendency of the woman, if her strength is drained by bleeding, to post-partum hcemorrhage, great care should be taken to ensure complete retraction, and a close watch must be kept on her for some hours after deliver)' to prevent this. When the labour is over and all bleeding has stopped, if the patient has lost considerably during and before delivery, she may fall into a syncope, and sometimes die. If there seems from the woman's aspect and physical state any likelihood of this, she must be well supported with stimulants, her head kept low, external warmth maintained by hot bottles and blankets, and the injection of saline fluid resorted to at once, three or four pints being slowly run into the veins (see p. 360). The observance of strict antiseptic principles throughout the whole process of labour and period of lying-in is essential. Fig. 286. — Wedge formed bychild in half-breech attitude. Epitome of Trcatiiient of HccmorrJiages 351 TREATMENT OF H.EMORRHAGES 1\ LATER .MONTHS OF PREGNANCY Accidental H.«morrhac;e (when a certain diagnosis is made by passing- the finger through the internal os}. The internal os is therefore dilated to a size admitting the finger. 1. Haemorrhage Slight. — Rest, sedatives, d'c. 2. Haemorrhage l^oderate. — Ergot, binder, pimcture of membranes. 3. Haemorrhage Severe. — Same as last, and forceps, version, perfora- tion according to urgenc)'. Pl.\CENT.A. Pr.'EVLV (when a certain diagnosis is made by passing the finger through the internal os.) The internal os is therefore dilated enough to admit the finger. Bring on labour as soo?i as the case is diagnosed. 1. Placenta Central. — Separate placenta round os, insert de Ribes iDag', or dilate the os as much as necessary for turning- b\' bipolar method or if this is impossible, by internal method, and turn. Extract slowly. 2. Placenta ^Marginal or Iiateral. — Rupture the membranes, and :f the head does not come down, apply the forceps or turn. Note. — Dilate with Hegar, sponge-tent, and then with Barnes's bags, or Champetier de Ribes' bag. With the last, turning may not be needed. Accidental H.^-morrhace or Placenta Pr-i-ivia (diagnosis is not clear). The internal os is therefore undilated, and the finger cannot pass. 1. If the bleeding is slight, rest, &c., as in sligdit Accidental Haemorrhage. 2. If the case is at all urgent, or if bleeding recurs, one of the following- alternati\es : {a) Try to pass finger by moderate pressure, and diagnose. {J}) If this is impossible, use Hegar's dilators if thc)- are available. (r) In their absence insert a sponge-tent, carefully watching so as to interfere if the uterus becomes distended. (If this occurs the case is one of accidental haemorrhage, and can be at once treated.) (<-/) If the case is urgent, and no dilating instruments or tents are obtainaljle, pass a sound, and tr\- to rupture the membranes. Then, if the liquor amnii is discharged, the case is accidental haemorrhage ; if no liquor amnii appears, and there is a sensation as of placenta felt, plug the vagina for si.\ or eight hours, and then pass the finger and diasfnose. OBSTETRIC OPERATIONS CHAPTER XL\TI GENERAL CONSIDERATIONS It is better to take these operations in a separate section, so that they may be easily referred to when necessary during the description of the treatment of the various conditions which require them. Each one will be described as far as possible under the following headings : — Definition of the operation. Purpose of the operation. Conditions requiring it. Instruments employed. Method of performance. Advantages and disadvantages in comparison with otlicr operations.' It is most important to remember in all cases how much can be done by the hands alone before resorting to instruments. There is less danger to the mother and child in using the hand, for the educated tip of the finger enables the operator to know exactly where it is going, and what it is doing ; comparatively little damage can be done to the tissues with it ; and the fewer the instruments passed into the genital passages tlie less is the danger of sepsis. The patient, the operator's hands, and all instruments are to be made aseptic in e\ery case. The best way of doing this in the case of the first two has l3een described in the chapter on the Management of Labour, and the instruments are best cleansed by boiling them, and then, before use, placing them in a 1-20 solution of carbolic acid. Practically every instrument can be made entirely of metal or other material, that may be boiled, and can be arranged to take to pieces in such a way that no part of it is inaccessible.- f^or the success of operations which involve opening the peritoneum, as Caesarian section ; or making large wounds, as in symph)-siotom\-, the sur- roundings of the patient are of very great importance ; and unless under 1 Many of the operations can be practised willi an ordinary pelvis and dead foetus or dummy ; but to do some, for instance, version, in anything hke the way resembling thai employed in actual practice, a rather elaborate phantom, such as that of Hudin or of Schultze, must be used. ^ For the best way of making surgical and other . instruments aseptic, see Schimmel- busch, l-',nglisli translation by A. T. Raike, On the Aseptic T/rtitment of Wounds. Plugging the Vagina 353 circumstances of urgency, such operations should not be performed in the insanitary homes of the poorer classes. In these cases the alternative opera- tions which involve the death of the child, l^ut uliich do not bring so much risk to the mother, must be adopted. As part of the preparation for all operations, the bladder and, if there is time, the rectum must be emptied. An;tsthesia is nearly always desirable, and in some cases necessary ; and in the latter case an assistant to administer the anaesthetic is always an advantage. There are, however, some of the operations which will here be classed as major, at which it is cjuite usual and not objectionable for the operator to give the anaesthetic himself, in the manner described in the chapter on Antesthetics (p. 205). The position of the woman varies according as the operation is done per vaginam or involves opening the abdomen or the pubic joint ; but in all operations through the vagina the usual left lateral position is the most con- \enient (see p. 186). The operations of Midwifery may for convenience be divided into two groups : one of which includes the introduction of premature labour ; ver- sion ; the use of the forceps ; the use of the vectis ; and those procedures by which the diameters of the foetus are reduced, namely, craniotomy, with the \arious procedures for extraction after the skull has been perforated ; and embryotomy, including decapitation, evisceration, &c. ; also operations on the mother for the sake of deli\'ering a living child, namely, Caesarian section, simple, or with Porro's modification ; and symphysiotomy ; and abdo- minal section for the purpose of sewing up a ruptured uterus. The transfusion of saline fluid may be considered in this group. The above may be called Major Operations. The Minor Operations are : Plugging the uterus and the \agina ; arti- ficial dilatation of the genital passages ; suturing \aginal and other tears ; extraction of the after-coming head ; expression of the fcetus ; removal of the placenta when its delivery is delayed. Some of these last have been treated of in the place where the conditions requiring them are discussed, and the others are here considered. Plugging the Vagina Definition. — This consists in filling the vagina with some material, such as a water- or air-bag, lint, gauze, cotton wool, &c. The vagina must be completely filled, for plugging the lower orifice is of no use ; and the first- introduced portion of stuff, or the fundus of the bag, must be passed up to the vaginal fornices, particularly the posterior fomix. Purpose and Scope of the Operation. — Two results are obtained by plugging the vagina. The uterus is stimulated by the presence of a foreign body in the genital passage, and contracts, the cervix, in agreement with the law of polarity, dilating at the same time. The plug also acts mechanically in arresting the bleeding. The former is the more important result, but as a rule both are needed. The latter action is maintained for a time ; but since the vagina is contractile it compresses the plug, if made of compressible A A 354 Obstetric Operations stuff; and, unless it is clastic, as a water or air-bag is, the pliiy lies loosel\- in the \agina when tlic latter relaxes a.^ain. Conditions requiring- vaginal plugrgringr. — First, to arrest uterine Jicemor- rhai^e ; {a) in the case of inevitable abortion. Here its stimulating action on the uterus is especially useful, for it thus leads to expulsion of the ovum. Plugging may be safely used where the uterus is not enlarged to more than the size attained at the fourth month of pregnancy, for the uterus up to that time cannot contain enough blood to deplete the woman seriously f unless she has already lost a dangerous amount). The same combination of arrest of bleeding and stimulation of the uterus serves in {b) placenta pnevia. The part pressed on by the plug here is the cervi.x and some of the bleeding lower segment. Second, to induce labour, or to accelerate uterine action in cases of inertia. It is, however, a practically obsolete method of doing this. Third, to fix a tent, which has been inserted into the cervi.v, and to reinforce its action : fourth, as a completio7i of the operation of plugging the uterus ; and fifth, to check bleeding from tears of the cervix and vagina. Instruments. — As a rule, unless the vaginal orifice is patent and the woman anaesthetised, a speculum is required. Sims' is the best instrument, because it opens out the fornices. Fergusson's is not so good, since the plug can through it be introduced up to the cer\ix onh". and not well behind and around it. The material for the plug may be of lint in strips ; pledgets of absorbent cotton ; gauze in rolls ; or strips of linen or cotton stuff of any description. The material must be rendered sterile by boiling, or impregnated with a reliable antiseptic. Water or air-bags are not so good as the materials just named, because they do not fill the fornices. A pair of uterine or long- dressing-forceps is useful, though not necessary. Metbod of Use. — The vagina must be made as aseptic as possible, the woman lying on the side or in the semi-prone position. The Sims speculum is then introduced and held by an assistant, and the tips of the first and second fingers passed into the posterior fornix. A small bunch of the stuff is now carried up in the forceps to the finger-ends, seized by the fingers, and packed into the extreme angle of the fornix. If possible, some of the material should be passed into the cervix. Further bunches are placed in the same way, as tightly as possible, and the vagina thus filled ; the packing down towards the lower end of the vagina need not be so tight as above : it is painful, and is only of use to support the upper part of the plug. .\ T-bandage may be applied if it seems necessary. The plug may under ordinary circumstances be left for six to eight hours. .A.dvantag:es In comparison \irith other Operations. —Plugging is inferior to a tent placed in the ccr-,'ix, for this will do all that a plug does, and more ; except in wounds of the cervix, in some cases of which plugging is necessary (see p. 494). Tents are, however, not always available. Plugging thk Utkrus This means plugging the body of the uterus. Plugging the cervix, which is best done with tents, is described immediately. Plugging the Uterus 355 Purpose and Scope of the Operation. — The object is almost invariably to arrest post-partum h;\;niorrhagc, but the body of the uterus has been tilled with iodoform gauze for the purpose of making a septic uterus clean.* It is only within the last fi\e or six years that the operation has been systematically used by anyone. The eftect of the plug is to stimulate an inert uterus by the direct contact of the foreign matter with its interior ; and to act also as a mechanical compressant, and as material on which coagula- tion will readily take place. The first-named action is the more important. Conditions requiring- it. — Its place in the methods adopted for arresting post-partum hci;:morrhage is shown in the chapter dealing with that subject (p. 480). It would hardly be used by anyone now for making the uterus aseptic, as there are better means available. Instruments Employed. — The materials for the plug are the same as those used in vaginal plugging. A long pair of uterine forceps is required, of length sufficient to reach the fundus uteri while the bows are in the \-agina. It is a good thing to sprinkle iodoform or aristol, or some antiseptic powder on the plug as it is being inserted. The material must be in continuous strips, so as to be easily and completely withdrawn ; and the best substance is a carbolic gauze bandage, for this is stiff" at first, and fills the uterus, but shrinks down under the compression of the contracting uterus, and so does not interfere with retraction. Three lengths of four or five yards each, three to four inches in width, will almost always be found ample. On an emergency a sheet may be used, torn into correspondingly sized strips, and sterilised by boiling. Mode of Performance. — The bladder and rectum are to be emptied if possible, though this will hardly be so in the emergency. The woman may be on her side or on her back, the latter being the moreconvenient position. An aniesthetic will hardly be required, and is in practically all cases unsafe, considering the probably collapsed state of the woman. One hand,'preferably the left, having been made aseptic, is introduced into the uterine cavity so as to reach the fundus. The nurse will hold the roll of gauze or other material, and will supply it as recjuired, sprinkling it with iodoform as it is being passed in. A bunch the size of a small fist or less, is seized in the forceps and carried up along the alread)' introduced hand quite to the fundus, where it is caught between the index and middle fingers and held. The forceps is withdrawn, and a foot or so of the bandage is seized and carried up to the fingers as before, care being taken that each portion of the plug is carried up as high as possible. When one bandage has been used the nurse will knot a second one on to the end of it, and then a third. By the time the second one has been passed in, the uterus will have contracted down on its contents, and there will, as a rule, be room for about half the third. The vagina should then be lightly packed with the remainder. In about twelve liours the plug is to be removed b)- drawing on it from the lower end. It will be found to be saturated with serum, but there will be little, if any, clot on its surf;ice. An antiseptic douche is then to be given. 1 Duhrssi'ii. 356 Obstetric Operations Advantagres. — Tliis method of treatment has undoubtedly saved a very lai^e number of lives. It would seem unphysiological, but it is found in practice not to interfere with retraction. If it is not properly done, and the first part of the plug does not reach the fundus, it may not be successful, for the uterus may bleed into the cavity above the plug ; and this, no doubt, accounts for cases where the operation has failed. It has been argued against plugging that air may be admitted into the uterine sinuses while the plug is being inserted ; but this accident is not in the least more likely to happen than when an intra-uterinc douche is being given. Dilatation of Cervix Purpose of the Operation. — The cervix may have to be artificially stretched so as to allow of the passage of the fa'ttes, or instruments, or of -the finger or hand of the operator ; or to allow the bag of membranes to protrude. Its action is combined with that of plugging when it is used to check hccniorrhage from a uterus which is not too large (see p. 353, vagina! plugging). Instruments. — The instrument used depends on the purpose in view. Where the cervix is as yet small, and will not admit a finger, as in rigid os (p. 456), placenta pra;via, cases of molar pregnancy, inevitable or incomplete abortion, a tent of one of the kinds in common use is the best means. These actively expand in a manner peculiar to each kind. The cervix may be plugged with a strip of linen, and this will act as a dilator. Dilatation can be performed with Hegar's, or other graduated dilators. The cervix can only be stretched to a moderate degree, say enough at the most to admit two fingers by these means ; and, to carry it further, bags of indiarubbcr or waterproof silk, which can be distended with air or water, must be used. The fingers themselves may be employed as soon as one can be passed, by adding one finger after another, first the tip, then the whole length being gradually inserted, until the hand can be introduced in the form of a cone. This method is very fatiguing to the fingers, and if great patience is not exercised, lacerations of the ccr\ ix may be caused. Tents. — The three kinds in common use arc those made of sponge ; of laminaria, or sea-tangle ; and tupelo-wood. Opinions difier as to the relative value of each of these, but in obstetric practice sponge-tents are usually satisfactory, since although they do not dilate with any force to speak of, the dilating power the\- possess is all that is needed in this class of case (and probably to a great degree this is so in any case). Fig. 287.— Lamin.-^ria tent, seeing that their main action is to stimulate the uterine body to contract by reflex action, and so to cause softening and relaxation of the ccr\ix. They do not forcibly expand and stretch the canal against all opposition, for this would mean laceration. Laceration never occurs with tents of any kind, and c\en when laminaria tents, which expand with some force, are used, the interna! o.s, if it is rigid, leaves a mark of constriction on the swollen tent. Tents— Hega/s Dilators 357 The objection made to sponyc-tcnts was that they could not be made aseptic. This process, which is essential, can be carried out as well in the case of sponge as in that of other kinds. The tents before use are placed for an hour or more in a i-iooo solution of corrosive sublimate in absolute alcohol, or in an ethereal solution of iodoform. Of course, a watery solution of any antiseptic would swell them and make them useless. Method of Use. — The bladder and rectum are to be emptied. The vagina must be washed out with an antiseptic solution. The cervix is then caught with a \olsella, with or without the aid of a speculum, and drawn down as low as possible, or at all events, steadied. If the cervix is brought down to the vulva, or near enough to be within easy .reach of the fingers, the tent, lubricated with a solution of sublimate in glycerine (i-iooo), can be placed in position. The largest-sized tent which it is judged will pass should be used, and if possible one or more others should be introduced by its side. In some cases, especially in those of abortion, the short tents usually employed may slip right through the cervix into the body of the uterus, and lie there useless ; so that it is better, where there is not enough resistance (such as a placenta prjevia) above the internal os to prevent this accident, to use a longer tent, which can be obtained from the instrument makers. Another \\-ay of placing a tent is to steady the cervix with a volsella, and to pass the tent in on a Barnes' tent- introducer ; or the uterine forceps may be used through a Sims' speculum. The first-described is by far the best way, for if more than one can be got in, the first tent is prevented from slipping out, which it has a great tendency to do, by the finger of the hand holding the volsella. The narrow end of the tent is passed in first, and the thread attached to the thick end should lie just outside the external os. The vagina is then to be lightly plugged from below, and the tent left in about eight hours, the woman being kept in bed. At the end of the time the tents are to be taken out by pulling on the thread, and the vagina is douched again. The safet)' of the operation depends on its being carried out aseptically. In cases where rapid dilatation is necessar)', as in severe examples of accidental haemorrhage, or where there is a putrefying ovum to be extracted, Hegai-'s dilators are useful. Dilators made of separating blades are dangerous, for one blade may penetrate the tissues if they are at all soft. In obstetric cases rapid dilatation by Hegar's dilators may be at once carried to a degree easih- admitting a dilating bag of some kind without any danger. Hegar's ditators are made of \ulcanite as a rule, they vary from four to six inches in length in different patterns, and are pro\ided with a handle. Their diameters ascend by the increase of I millimetre, the smallest dilator being 2 mm. in diameter. The woman is to be placed in the lithotomy position, and the cervix, seized with a volsella by its anterior lip, is pulled down to the vulva, and then M Fig. 288.- One of a set of Hegar's dilators. 35« Obstetric Opei at ions its posterior lip is cauylit with another vQlsclla. It is safer to use two than one only, for another puncture is not so dangerous as the laceration which will be caused if the one happens to tear through. The largest dilaicjr which] will pass without force is now to be introduced, and then the VffclUp?. Fig. 289. — Hydrostatic dilators modified from Barne.s's original pattern. Others m succession, the moment for proceeding to a fresh dilator being indicated by the loosening of the grip with which the cervi.x first embraced the-one then i?i situ. If any force is required to introduce a fresh one, the last bougie should be re-inserted for a short time. The cer\ix will allow one finger to pass at about No. 20 or 21 ; or the dilatation can be taken further if it is wished to introduce a hydrostatic bag. Ditating Bags. — These are distended with water or with air, after being introduced empty. Water is the better element to employ, as it is incom- Fig. 290. — Champetier ile Rilies' bag. pressible ; and it can be easily made aseptic, so that in case of the bag bursting no danger is incurred from the introduction of micro-organisms. (i) Barnes's Hydrostatic Ditators. — These are india-rubber bags, fiddle- shaped, so as to be caught at the waist by the cervix, the l)ulgc above and below Barnes s and Chainpcticy dc Ribes' Bags 359 keeping- them in place (fig. 289). They are introduced by passing a rod into a tube running up the middle of the bag. The corners f(;ld in when the bag is empty, so as to facilitate the introduction. The smallest size will have to be introduced, expanded, and allowed to remain until it is expelled into the vagina, or is found to be easily withdrawn from the cervix. This will take half an hour or so as a rule, and a bag should not be left in more than an hour without an examination being made of the condition of the cervix. Before introducing it, it is well to find out how many syringefuls each bag will hold when tightly stretched, and not more than this should be pumped into it, for fear of bursting it. The next-sized bag should be inti'oduced in the same way, and so on, until a sufficient degree of dilatation has been reached. These dilators imitate the action of the membranes fairly closely ; they have, however, in com- mon with the kind to be next described, the disadvantage of displacing the head somewhat. The presentation should therefore be examined into after the withdravv'al of each bag, and rectified if necessary by manipulation. Another objection is that the frequent manipulations necessitated by the introduction of successive bags make the chance of entrance of septic matter greater than if a bag such as Champetier de Ribes' is used, where one introduction only is needed. (2) Champetier de Rides' bag, a modification of Tar- nier's, is a conical bag made of water-proofed silk, an unstretchable material. Its base is 3^ inches in dia- meter, and it tapers down to the diameter of the tube by which it is filled in a length of about 6 inches, its axis being slightly curved so as to accommodate itself to the axis of the genital canal. It will hold about 17 ounces of fluid (fig. 290). It is introduced by a pair of long-bladed forceps (fig. 291). These grip it in a roUed-up form, and v.ill pass it through a cervix sufficiently dilated to admit a thumb. It should be passed about half-way through the internal os, and the forceps disjointed and removed one blade at a time. The bag is then expanded by a solution (antiseptic in case of its bursting), about 1 7 ounces being used. As the uterus contracts it forces a wider and wider part of the bag through the os. When the bag has been expelled into the vagina the cervix will have been stretched to a diameter of 3^ inches, and is large enough to allow the head to pass. It has the advantage o\er Barnes's form of dilator, besides the one already mentioned, that although it displaces the head to an equal or perhaps greater degree, it has produced, by the time it has done its work, sufficient dilation to make version an easy matter so far as the cervix is concerned. Further, if there is h;iemorrhage going on from the placental site in a previous placenta, and the uterus is inert (as it most often is), the bleeding area can l'"ig. 291. — Forceps for de Ribes' basr. 360 Obstetric Operations Ijc compressed by pulliiij^ on the tube, and thus Ijiinging a wider part of the Ijay into action. Dilatation of tlie vagina and vulva is dealt with on p. 458. I.MUSiON OF Saline Solution Definition. — In this operation an inert fluid is added to the blood-mass by opening a vein and allowing" the fluid to run in under slight pressure. Purpose of the Operation. — This is to raise the blood-pressure in cases of acute loss of Ijlood. Wlien the vascular system is drained to such a degree that little more will run away, and the person is pulseless and appar- ently dead, there is still enough blood in the body to carry on the vital processes if it can be kept circulating. The blood-pressure has, howe\er, fallen so low that not enough fluid reaches the heart to expand it, and thus no propulsion is possible. Also the heart and its nervous ganglia are staned, since the coronary arteries are unfilled, and it ceases beating. The addition of fluid, before cessation of the heart has happened, raises the blood-pressure and allows of circulation of the remaining blood : and the tissues are supplied with enough oxygen by the remaining corpuscles to keep them ali\e. It was believed up to recently that to obtain any benefit in really sexere cases of haemorrhage actual blood must be transfused, either directly from the vein of the donor into that of the patient : or, indirectly, after defibrinating it so as to avoid the danger of embolism by particles of fibrin formed by clotting. It is probable, from observations made of late, that the transfusion of actual blood did more harm than good, and the only good done was due simply to the increase of the blood-mass. This is effected equally well by using some inert fluid : that is, one which will not damage the blood or its corpuscles. There are other v.ays of utilising the amount of blood remaining in the body after a se\ere bleeding, such as auto-transfusion and inversion of the patient (see treatment of post-partum haemorrhage, p. 485) ; and the blood- mass may be increased by rectal injections of water or saline solution, or by the injection of such fluid into the muscles of the back through a sharp canula (Mlinchmeyer's method) ; but these do not act so quickly or so thoroughly as infusion into a vein, and are only good in slight cases. Saline infusion is very useful, too, in cases of shock unaccompanied or not caused by bleeding, and no doubt acts by raising the diminished blood- pressure. Instruments Employed. — All that is absolutely required beyond what is to be found in nviTl midwifery bags, or in most households, is a canuhr to insert into the vein. This canula (fig. 293) is of the same shape and size as those used for the transfusion of blood.' It is connected with a length of tubing, through which the fluid is poured by a funnel afiixed to it (fig. 292). Any clean funnel will do that will fit the tube, and a piece of tubing is easily obtained by cutting off some of the tubing attached to the douche tin 1 A short bent tube, of metal or of glass, bevelled off or not at the end which enters the vein, and of convenient diameter to go into a vein the size of the median basilic. Infusion of Saline Fluid 361 or lo a Higginson's syringe, if there is none carried in the bag. A canula has in an emergency been made out of a piece of quill pen, or even out of a toothpick, either being of course made as aseptic as possible. The hcsifuid to use is one which is as near the normal specific gravity of the blood-serum as possible, and fortunately this can be readily made by dissohing a teaspoonful of common salt in a pint of water. The water should be boiled, if possible ; but both the boiling and the salt may be dispensed with if there is great urgency. The temperature should be about 102^ P"., but this is not essential, as long as it is not below 90'' F. Fig. 292. — Infusion of saline fluid. (After Horrocks.) A canula takes up no room, and may be taken to every case : and a foot or two of rubber tubing is a most useful article to be included in every obstetric bag. A scalpel to expose and open the vein, and some ligatures and a pad of antiseptic material to tie the \cin and dress the wound with, are needed. IVIethod of Performance. — An incision about two inches long is to be made over the median basilic vein ; this is to be isolated, and a ligature passed under it double. The loop of this is cut, and the two ligatures separated upwards and downwards. The lower one is tied in the inferior angle of the wound, and its ends cut ofif (fig. 293). The vein is then opened by an 562 Obstetric Operatiotis incision at an angle with its long axis and across its length, large enough to allow the canula to pass. When the canula has been passed for about an inch into the vein on the upper side of the incision, the upper ligature is to be tied with one knot only over it as it lies in the vein. The canula and lube must ha\e been previously filled with the warm fluid, and must contain no air. The fluid is now run in from a bottle or funnel about 2i to 3 feet abo\e the level of the patient. .Spencer advises that it be run in very slowly, at the rate of one ounce per minute, because there is a risk of over-distension of the venous circulation, shown by venous pulsation, if this rate is much exceeded. Other operators, however, ha\e run the solu- tion in much faster than this ; a pint every four minutes, for instance, without any ill results ; and in a case of the authors, five pints were infused in fourteen minutes without any harm being done. Four or five pints should be injected as a rule ; or it may be judged how much blood the \\oman has lost, and then rather more than that quantity used. All bleeding" must be arrested before infusion is performed ; for, unless this is done, the solution will merely wash out the vascular system, and lea\e the woman in worse plight than before. The uterus must therefore be satis- factorily contracted and retracted in cases of post-partum hiemorrhage ; and the bleeding points in the broad ligament tied in the case of ruptured tubal gestation, before this operation is done. When enough has been injected, the canula is to be withdrawn, and the ligature tied tight on the vein. The Avound is then cleaned and sewn up, and a pad, bandage, and splint applied. Fig. 293. — Canula and ligatures in position. CHAPTER XLVIII OliS-iKTRic OPERATIONS {continued) Induction ok Premature Labour Definition. — This term is usually applied to cases where induction is employed after the seventh month, when it is possible to rear the child that is born. In earlier pregnancy than this the term Induction of Abortion is most commonly employed. The distinction is merely a matter of convenience and both operations are considered here. Induction of Pronaturc. Labour 363 Purpose of, and Indications for the Operation. — Ihe conditions rcciuiring evaciuition of the uterus may be di\ided into two groups : 1. Q^\%Q.% \\\\(tx& \)l\& genital canal is contracted io %\x<:\\ a degree that the delivery of a Hving child at term through it is judged to be impossible. 2. Cases where it is unsafe for the pregnancy to continue owing to its being complicated by some serious disease, which the cessation of the pregnancy will relieve if not cure ; or where there is some serious and immediate threatening of the woman's life which will certainly or probably be removed by e\acuation of the uterus. In group I the most important reason for the operation is contraction of the bony pelvis. It is also necessary where the space is diminished by tumours of the soft parts which cannot be removed, such as fibroids of the lower part of the uterus, cancerous masses in the pelvis, tumours of the pelvic bones encroaching on the pelvic diameters, and undilatable cicatrices of the cervix and vagina. In group 2 are all cases of albuminuria dependent on renal disease which do not shortly yield to treatment, very severe cases of the vomiting of preg- nancy, some cases of chorea, especially if mania is threatening, some cases of hydramnios, especially if this is complicated with lung trouble, irreducible retroversion of the gravid uterus, signs of acute atrophy of the Ii\er, placenta praevia, some cases of accidental hitmorrhage, and ura:;mic convulsions. In the first group the operation is undertaken entirely on the child's account ; in the second, rather on the mother's, but partly on the child's also. I>Iethods. — The ones now in common use are {a) by the introduction of a bougie into the uterus ; (p) by puncture of the membranes, both of which acts stimulate the uterus directly to contract ; and {c) occasionally by the use of tents, which stimulate the uterus indirectly by dilating the cervix. A large number of other methods have been used at one time or another, and they may be merely enumerated. The use of drugs (ergot, digitalis, quinine, savin, rue, &c.) is a c^uite uncertain way, and one which in a large majority of cases has no effect at all. Electricity has been used to induce labour in the form of the Faradic current, but it is ^■ery tedious and painful to the woman. Injection of water, air, or carbonic acid gas into the space laetween the membranes and the uterine wall ; this is most dangerous, and death has been caused by air-embolism, and by shock in cases where such means have been employed. Glycerine in small quantities has been used also, and this is apparently safe and effectual. Another method is that of the vaginal douche (Kiwisch). This consists in the direction of a stream of water into the \agina during sittings of a quarter of an hour or so at a time. It is tedious and uncertain, and is liable to cause extreme tenderness of the vagina from the long-continued run of \\ ater over its surface, and removal of the superficial epithelium. Dilatation of the vagina by a bag of some kind (the first person to use this method was Huter, who introduced a calf's bladder, smeared with oil of hyoscyamus, in very early times). Braun's colpeurynter is a variety of this : it is uncer- tain, and has caused serious trouble. Other ways are by rectal injections, and by irritation of the nipples, both of which are quite unreliable. Each of the three methods now in general use has a class of case for which 364 Obstetric Operatio7is it is most suitable. In group i the bougie is the best moans ; in group 2 it is also best in all the cases enumerated down to chorea ; in the others, except perhaps when acute atrophy of the liver requires it, puncture of the mem- branes is most suitable. In cases where abortion is necessary, tents may be employed, as they not only start labour, but they also prevent excessive loss of blood, and prepare the cervix for the passage of the ovum without great difficulty. We may take a typical example of each class of case, and describe the method of induction. By Bougie. — In a case of contracted peKis (see p. 439; the time of induc- tion is determined on. The woman is prepared for operation Ijy ha\ing the bowels well cleared out, and the vagina made as aseptic as possible by treatment lasting about forty-eight hours. The instrument used is a bougie with a stilet. A catheter is objectionable, for when its lower end is in the vagina, where it rests, it forms a channel for admitting air into the upper part of the uterus. The bladder is emptied and the woman is placed on her left side. If the placenta can by any chance be felt .externally, its site should be noted. The index finger of the left hand is then to be passed up to or into the cervix, and the bougie with the stilet in its place passed through the internal os. It should then be pushed gently along the posterior uterine wall for about one inch only, for fear of puncturing the membranes ; and then the stilet is to be held by an assistant and the bougie pushed off it into the uterus for seven or eight inches or more, or as far as it will go. The greatest gentleness is to be used, so as to avoid puncturing the membranes or detaching the placenta. It is of no importance towards which surface of the uterus it is introduced, but it will usually run most easily along the posterior wall, as this is most in a line with the vaginal curve. If the placenta has been found on the anterior wall by abdominal examination, it can be avoided. If it is found that the bougie cannot be introduced far enough in one direction or the other, another place must be tried. When all but an inch or so has been passed into the uterus, or when at least seven or eight inches are in, the remainder is to be coiled in the \agina, and a light plug inserted to keep the bougie in its place. The instrument is to be left in until the pains begin, if this happens in less than twelve hours. If it does, nature may be allowed to finish the process ; but if not, a second bougie should be inserted, and left for six hours with the first. There will in all probability be some pains at the end of this time. If, however, there are not, there is sure to be some softening and patency of the cervix, and through the cervix a de Ribes' bag or a Barnes's bag may be passed and expanded. Labour is almost certain to be started in earnest by this ; if not, the process of dilatation may be completed by the bag. After two bougies have been introduced in the way described, it is useless to insert more ; and it is dangerous to wait longer, since the constant examinations and the introduction of air which must take place, add great risks to the operation. The bougies may be left to be expelled with the child or may be removed earlier. By Puncturing the Membranes. — In a case of eclampsia, the passages are made aseptic, and the woman is anaesthetised so as to avoid the induction of fits by the necessary manipulations. She is placed on her side, and a sound is passed through the ccr\ ix and onwards until the resistance of the mem- Version 365 Ijranes is felt. Then with a slight jerk it is pushed through them. Directly the resistance has disappeared, showing that the sound has gone through tlie membranes, its further entrance must be arrested, lest some damage be done to the child above. After most of the liquor amnii has drained off, relieving the uterine tension, the cervix must be artificially dilated with one form of bag or other ; for the first stage will otherwise be long, and will possibly cause the death of the very Hkely premature child. In case it is necessary to induce abortion during the earlier months, for albuminuria or for pernicious vomiting, for instance, tents are on the whole the best instruments, being of course made aseptic. The alternative method is to pass a uterine sound, and rotate it in the cavity of the uterus. The tent has the advantage that it dilates the cervix, and this is important, since dilatation is in these cases often very slow and incomplete, leading to much loss of blood ; and, if the child is at about the fourth month, and it is neces- sary to extract it, the limbs are very readily torn off if attempts are made to drag the body through an undilated cervix. Or if the ovum is of earlier date, a dilated cervix makes its complete expulsion without rupture more likely. If the sound is used in early cases the ovum will very likely be ruptured, and some of it may be retained ; and in later cases, where the amnionic sac could be of some use in dilating the cervix, and the separation of the membranes would go on better if they remained entire until full dilatation, these advantages are lost on rupture. The advantages and disadvantages of Induction of premature labour, as compared with Caesarian section, are discussed in the chapters dealing with Contracted Pehis, Cancer of the Cervix, &c. CHAPTER XLIX OBSTETRIC OPERATIONS {continued) V'ERSION Definition. — Version or turning consists in artificially changing the lie ofafffitus. Transverse lies are in any turning converted into longitudinal ones ; and in certain cases cephalic lies are turned into podalic ones. It will be well for the student, before reading the further description of this operation, to read the chapter on Transverse Lies, and the natural pro- cesses of Spontaneous Rectification and Spontaneous Version (p. 466). Object of the Operation. — This may be {li) to place the child in the most favourable lie for deli\ cry alive ; {b) to save the mothers life by arrest- ing haemorrhage or hastening delivery, and (r) to render delivery possible in the case of certain monsters. In group {a) are included \ersions perfoi'med in transverse lies : in certain forms of contracted pelvis (p. 442) ; in a few cases oi prolapse, and the majority of cases oi expression, of the cord (p. 514}. 366 Obstetric Opcratiinis In group (<^) are cases where the operation is done ior p/iuen/n pnn'id (p. 341) ; in a few cases of accidental hceinorr/uii^e^ in eclampsia, and otlicr instances in which rapid delivery is essential. The delivery of tnofisters by turning is discussed later. Version is in some of the cases whei-e it is required an imitation of the means adopted by nature for relieving the situation. This is seen in the case of transxerse lies ; for these mostly occur in connection with contracted brim, which first of all causes the child to lie with its long axis across the abdomen, and then Spontaneous Version may render delivery possible. In placenta prtevia also, the transverse lie which has a tendency to occur is a step in the direction of version. It is true, however, that nature does not, as a rule, give time for the version to be complete in these cases, particularly in the last-mentioned one ; but the fact that there is a natural tendency for the movement to take place brings the operation of artificial turning into the category of procedures by which nature is assisted, rather than into one in which the natural tendencies have to be disregarded. Metbods of Performance. — -There are three ways of turning. (\) by external manipulations, {2) by combined (bimanual) external and internal manipulations, and (3) by internal manipulations. I. By External Manipulations. — For this operation, which is rather a difficult one as a rule, the membranes must be entire, or only just ruptured, and the woman must have a thoroughly relaxed abdomen and uterus. She must lie on her back at first, so that all the available surface may be readily got at, and the bladder and, if possible, the rectum must be emptied. The exact lie and attitude of the child must be ascertained. Relaxation of the abdomen may be obtained if necessary by an anitsthetic. If it is wished to turn by the head (cephalic version) in a case of trans- verse lie, the only condition under which cephalic version is required, one hand must be placed on that side of the child's head which is furthest from the brim, and the other on the opposite side of the breech. The head is then to be pressed by a series of pushes rather than by steady force towards the middle line of the woman's body, and the same manipulations used at the breech end. After the head has been got to lie o\er the brim, an attempt must be made to press it through this, as described on p. 439. This will shcnv if it will pass through the brim. It is useful, w hen the hands have been arranged on the fcetus, to place the woman on the side towards which the head lies, so that the action of gravity may help to bring the breech over. If it is judged that the head can pass the brim, the membranes may be ruptured when the os is three parts dilated, the head being retained in its relation to the brim as long as is necessary. A binder may be sufficient to keep it there ; or it may have to be held there by the hands. If the brim will not admit the head, podalic version of some kiiul will lia\e to be undertaken. Podalic version is never done in this way, for it is always necessary in turning by the feet to seize a leg or foot, and to bring this down through the OS. It is therefore much easier to turn by .the combined method, to be immediately described. r>ipo/(rr J ^crsioii 1^7 2. Combined External and Internal MetJiod. — ^This is best described in tlic words of Braxton Hicks, to whom is due the origination and description of this operation. He takes the case of a child, presenting' in the first position of the \ crtex, whicli it is necessary to turn for tlie sake of deh\ery in a contracted pelvis, or in the treatment of placenta prcCvia. The OS uteri is chlated to admit one or two fingers, and the membranes are perfect. 'The patient may be placed in the ordi- nary obstetric position. Having lubricated my left hand, I introduce it as far into the vagina as is necessary in order to reach a finger's length within the cervix ; some- times it recjuires the whole hand, sometimes three or four fingers will be sufficient in the \agina. Having clearly made out the head and its direction, whether to one side or the other of the os uteri, I place my right hand on the abdomen of the patient towards tiie fundus ; I then endeavour to make out the breech, which is seldom a difficult matter. The external hand then presses genth' but firmly the breech to the right side it either by gentle palpation, or by a kind integuments, while at the same time the other hand pushes up the head in the opposite direction, so as to raise it above the brim (fig. 294). Fig. 294. — Bipolar version. as it recedes, the hand follows of gliding movement o\'er the Fig. 294 .4. — Bipolar version. Fig. 294 B. — Bipol.ir version. ' It may here be mentioned that when the head has descended a consider- al)le distance into the pelvic cavity, or more than half-way through the os uteri, it is scarcely possible to lift it above brim, especially if the uterus be active. 368 Obstetric Operations 'When the breech has arrived at about the transverse diameter of uterus, the head will have cleared the brim, and the shoulder will be opposite the os (fig. 294 a). That is pushed on in like manner as the head, and after a little further depression of the breech from the outside, the knee touches the finger, and can be hooked down by it (fig. 294 b). 'It very frequently happens when the membranes are perfect that as soon as the shoulder is felt, the breech and foot come to the os in a moment, in consequence of the tendency of the uterus to bring the long axis of the child coincident with that of its own. 'Should it therefore be difficult to hook down the knee, depress the breech still more, and it will almost always be the case that the foot will be at hand. 'It will sometimes render turning more easy if, as soon as the head is above the brim, we pass the outside hand beneath it, and push it up from the outside alternately with the depression of the breech. All this can generally be performed in much less time than I have taken to describe it, although in some it requires gentle, firm, and steady persever- ance, with such a supply of patience as is always required in obstetric operations.' ' It may be said in addition that two fingers should always be introduced through the OS, for the foot cannot be readily brought down into the vagina b)- one finger alone (fig. 295). The operation may be done with the woman on her back, and in this case it will be found more convenient to introduce the fingers of the right hand into the os. The same method may be used for cephalic version ; the head is, as a rule, easily brought between the internal and the external fingers, and, as Hicks says, 'will play like a ball between the two hands,' and may be placed in any position over the brim. He points out the advantages of this over the internal method — namely, that it may be employed much earlier, and that malpositions maybe rectified almost as soon as recognised.' Early version is of very great importance in cases of complete placenta pncvia. Also the entry of the whole hand and forearm into the uterus is avoided, a matter of great weight, and there is no likelihood of admitting air into the uterus. 3. Internal Method. — This mode of turning is now limited to cases where it has been found impossible, either from want of practice on the part of the operator, or from immobility of the fcetus, to employ the combined method. The OS must be sufficiently dilated to admit the hand with gentle pressure if necessar)'. This is to be passed in the shape of a cone through the os and through the hole in the membranes, which must for this purpose be ruptured if rupture has not already occurred. The position of the child Kig. 295. — Bipolar version. ' Hicks, On CoiiibiiicJ Version, p. 12; London, 1864. Podalic Version — lixtractian 369 slioulcl \\A\v bcin made out loeforchand, and the liand is then passed up ils abdominal aspect, the more convenient hand being chosen. If the cliild faces to the woman's right, as is tlie commonest, turning will be most easily done while she is on her back, and with the left hand internal ; while if the limbs face to the woman's left, the right hand is more convenient, ^\ hcthcr she is lying on her back or on her side. The hand is to be passed u]j during the intervals of the ])ains till it reaches a knee. The one that <:(jmes first is to be seized, and this has been shown by Galabin to be the better as well as the easier. The fingers are then run along the leg to the foot, and this is to be bnnight down through the os. While the foot is being ])ulled down the head will easily be pushed up by the other hand if this is necessary ; but it usually rises spontaneoush". Instances M'here this does not happen arise where the contraction-ring pre\ents the head from escaping from below it, or where the shoulder is below the internal os. Turning is, as a rule, not the best operation where this state of affairs exists (see p. 473J. It has been recommended to put a tape round one arm if this is within reach, as it would probably be in transverse lies, before version is begun, and even to bring down an arm for this purpose through the cervix. This is done for the sake of rendering extraction easier, and to prevent the arm from rising above the head. It is \ery likely, however, that some amount of liquor amnii, a very precious fluid at this juncture, will be lost while it is being done ; and unless the arm is very near, or through the os, it is best not to complicate matters in this way. If the child does not turn pretty easily when the legs are pulled upon, and if the uterus is still safe from tetanus or o\er-retraction, it will help matters to act on both poles of the foetus at once. This maybe done by tying a tape round the ankle that has been seized, and pulling on this with one hand while pushing up the head with the other. A small blunt hook with a flexible handle, as recommended by Hicks, ma)- be used to pull down the knee, while the fi^ee hand pushes up the head. Both legs are not to be brought down, for then the child's pelvis passes the OS without dilating it sufficiendy, and the head has to do this for itself, thus considerably imperilling the child (p. 200). When by one or other of these methods the foetus has been brought into a longitudinal lie, it depends on the case whether it is to be left to be expelled or is to be extracted. After cephalic version, if speed\- deli\ery is required, and the brim is large enough, the forceps may be used. If there is no need for quick delivery — as, for instance, in a case of trans\ crse lie in a normal l)ehis— the uterus may be left to finish the labour. After podalic version, however, it is usually necessary to extract, since the reason for version has been either a contracted brim, or else some condition where speedy delivery is required for the mother or the child. Extraction. — The leg which has been brought do^\•n should be wrai)ped in a thin cloth so as to pre\ent its slipping through the fingers. The body is easily drawn into the vagina, and in doing this the operator must allow for the natural rotations, and should help, as he should throughout the \\holc of extraction, by external pressure. The ]nill must at first be as far as possible in the a.xis of the inlet. When the breech is on the ]K'rin.eum the i)ull must lie more in the B n 370 Obstetric Opcratiois tlirection of the outlet, so as to clear the posterior buttock and hip from the \ul\a. The clearance may be helped by hooking the finger over the flexure of the thigh. This stage must not be hurried more than is necessar)-, so that time may be allowed for the \agina and \ulva to dilate in readiness for the head. Traction in the axis of the brim must now be resumed, so that the shoulders may enter properly. The cord will need some attention at this stage.' When the shoulder-blades ha\c come down to the \ul\a the arms should be looked after ; the)- are to be brought down as advised on p. 200. The head may be helped down by jaw-traction at the brim, which will also have the advantage of preventing extension ; and if the vagina is so lax, or the child so small that the whole hand can be introduced by the side of the latter, a finger may be placed on each shoulder, and used for pulling. Or the forceps may be used. When the head has reached the ca\ity, the same methods are to be employed as in an ordinary- breech case where the head is delayed. Contra-Zndications to Version. — This operation must not be attempted when tlie head in a cephalic lie has passed the cenix by its largest circum- ference, and a fortiori when the head is in the \agina ; and it will as a rule be difficult and inadvisable when the head is well engaged in the brim. Advanced retraction of the uterus is an absolute contra-indication. A flat pelvis with a conjugate of less than three inches is not suitable for this treatment, or a generally contracted pelvis of a larger conjugate, unless it is preferred to do craniotomy on the after-coming head (see p. 392). It is not safe in cases of considerable exhaustion of the mother ; and it is useless in the case of a dead child, except possibly in the event of a placenta pnevia, wjicrc a half-breech forms a hand)- plug. Advantagres and Disadvantag-es. — The class of case where turning most markedly comes into competition with other operations is in contracted pelvis, and under that heading it will be found discussed. Perhaps placenta pra;via might be added as an occasion where its value might be compared with that of de Ribes' bag (see p. 346). ' Bru-nes agrees with May and Wigand in recommending ligature of the cord at this lime if the pulsations are slowing, considering that the pressure will compress the vein more than the arteries in the cord, and that the child will thus be to some degree drained (jf blood. If it is done, one would think that the future steps of extraction ought to be as- rapid as is safe for the mother ; but this does not seem in reality to be so ver)- urgent. The Forceps CHAPTER L OliSTETKIC OPKRATIONS (co/l/l/mecl) The Forceps Description. — The forceps ' is an instrument b)' which the head is y rasped, so that it may be pulled through the whole or part of the length of the parturient canal. It is made so as to cause no damage to the head if used in the proper way. The child in a successful operation with the instrument is delivered ali\-e and unhurt. Its construction has gone througli man\- stages of involution since the instrument was first invented by Peter Chambcrlcn in the early part of the ' Forceps. I^nt. pincers ; derived, according to Skeat, E/ymologica/ Dictuwarv, fron> foninis, hot, and the root cip- {capere, to take). This derivation makes impossible such a monstrous word as retrocops, which is coined on false analogy w ith forceps, the for- in the latter word being supposed by the inventor of the former to indicate the anterior end of something, and the retro- being substituted by him to indicate the posterior end. A ' retroceps ' was an apparatus constructed to seize the breech. The use of this instrumcnt is ns incorrect as its etymology. B U 2 3/2 Obstetric Operations seventeenth (-entury. Chanibcrlen's forceps (fig. 296) had the fenestra which has been retained in all patterns since, and a lock something like the one applied to the modern French pattern. Forceps have been found in collec- tions of Egyptian surgical instruments, and therefore date originally from many centuries li.c. The lock was at first only a pi\ot attached to one blade, and working in a hole in the corresponding place in the opposing blade, with a mortice on the apposed side of each blade, so as to allow of close fitting. The lock known as the English pattern was contrived by Smellie about the middle of the eighteenth century. It is the most readily adjustable lock of any yet invented, and is, when the forceps is applied to the head, quite secure, it is also the most easily kept clean of any pattern. The forceps was short and straight at first, and the blades were adjusted to the child's head in the genital passages ' at random, taking hold of the head anyhow, pulling" it straight along, and deli\ering \\ith downright force and violence ; by which means both os internum and externum (cer\i\ and vulva) were often torn, and the child's head much bruised ' (Smellie). Smellie had an instrument made which obviated this, and introduced another great modification — namely, the addition of what is known as the ' pelvic curve.' This curve causes the blades, as seen in profile, to correspond to the curve of the pehic axis. He says : ' In a narrow Pelvis I ha\e sometimes found the head of the child thrown so much forward over the Os Pubis, by the jetting in of the Sacrum and the lower Vertebra of the loins, that I could not push the handles of the forceps far enough back, to include within the blades the bulky part of the head which lay o\er the Pubcs. To remedy this inconvenience, I contrived a longer pair, curved on one side, and convex on the other. . . . .' In this pattern the cranial curve of the blades starts from the lock, an arrangement which is still found in the 'short forceps' of the present day, wliich is, however, an instrument rapidly becoming oljsolete. The lock had to be adjusted in the \agina on account of the shortness of the instrument, and this was likely to lead to nipping of the vaginal walls. Simpson added a shank (fig. 297) to the blade, which enables the forceps to be applied to a head at the brim, and yet to have the lock outside the vulva. This pattern is called the 'long forceps,' and is the one which is used, in some slight modification or other, in all cases at the present time. Neither the pelvic curve nor the cranial curve affects the shank, which is straight and in a line with the handles. The advantage of the pelvic curve is that it allows the head to be caught by the blades while they are lying almost in the axis of the brim, or of whate\er plane of the pelvis is occupied by the greatest diameter of the Blades Shanks Lock Handles Fig. 297. — Simpson's long curved lorccps. The Long Curved Forceps 373 liL-acl, while llic hiindles are in the axis of the outlet (fi- 317; ; it allows traction, as will be described, to be made in the axis of the brim or nearly so, by the hands alone, or completely so by the use of 'traction-rods;' it 'makes the introduction of the blades along- the curved parturient tract easier than if they were straight ; for the end of the blade is always the leading point as it advances, and not some point on the side of the blade, as would be the case if a straight blade had to be passed (figs. 298 and 299). Fig. 298 — Showing disadvantage of long straight forceps in application. )9. — Showing advantage of curve in application of long forceps. Modern loihj; curved Forceps. — This instrument is made in several patterns, each of which has some ad\antage. It is, however, possible to combine their ad\antages in one pattern. It is found that the most uniform pressure is obtained over the surface of contact with the head if the cranial cur\e forms the arc of a circle 9 inches in diameter. If the arc is of a smaller curve than this the pressure is not uniform, and the blades are more difficult to introduce ; if of a larger circle, they are liable to slip off during traction. The tips of the blades are separated by about i inch when the forceps is closed, so as to prexent com- presssion of the neck if this lies between the tips, and yet not to allow the head to escape ; they will be some\\hat \\ider apart when the head is grasped. The distance between the widest points on the cranial curve is not more than 3-^- inches. The length of the l)iade and shank together is about 9.} inches ; this allows the head to be seized above the brim while the lock is still outside the vulva. ri\e length of the shank is about 2.\ inches. The pelvic curve of the blade, which is about 7 inches long, is one of 35°. The handles are not less than 5 inches long, so as to allow of a tn ni grasp, and of power of compression sufficient to hold the head without the hands of the operator becoming readily exhausted. The_\- should be of metal, so that they may be boiled : and should be dceph- grooved to prevent slipi-)ing. and 374 Obstetric Operations not cross-patterned, for this renders them uncomfortable to hold, and makes them more difficult to thoroughly clean. The rigidity of the blades and shanks cannot be too great so long as they are compact. All the edges should be rounded, so that there can be no cutting or scraping of the fcetal or maternal parts. In one form of forceps, that of Assalini (fig. 300J, the t\vstctJ-ic Operations Fig. 317. — Action of left hand in producing axis-traction. J^, ful- crum ; P, power ; IV, weight. The onward movement produced by traction by the right hand is not here indicated. made by eacli hand in tlie line of its forearm as in the diagram the resultant of the two forces will be one very nearly in the axis of the brim.' In practice it will be found that nearly all this force will have to be used by the left hand, as in fig. 317, the right hand acting rather as a fulcrum. As the head descends in the pelvis the use of the left hand at the lock becomes less and less impor- tant, since the lower part of the pelvic axis corre- sponds more and more with the line of direct traction by the forceps. The pull should be made during the pains as far as possible, so as to merely assist the process of expulsion, and not to empty the uterus too fast for the pro- bable rate of retraction. During the intervals of pulling, the handles should be allowed to separate slightly, so as to relieve the head from continuous pressure. 9. If contraction of the brim is the only obstacle to delivery and there is no urgency, /he forceps can be taken off when the head is nearly on the perineeum, and the rest of the expulsion left to nature. It is better to do this, wherever it is possible, as it allows of proper retraction of the uterus, and of com- plete dilatation of the perinceum. To take the blades off, they are allowed to fall apart, when they can be unlocked and taken out one at a time, with as much care as was exercised in their introduction. 10. If delivery is iirgoU il i/ii/st he completed ixntJi tJie forceps. The head is now on the perinteum, and the handles of the forceps are pointing almost directly forwards. The right hand is to be shifted round the end of the handles till it holds them as shown in the diagram (fig. 318) ; this is done without letting go. The left hand has been taken off, and is now placed on the perinaeum as it is in the conduct of an ordinary vertex presentation in a normal labour (p. 190) ; it is used to push the head forward against the pubic arch so as to take as much pressure as possible off the perina-um. The right hand now carries the handles round in front of the mothei-'s abdomen, so that the curve of the blades still corresponds to the curve of the lower end of the genital canal. The traction is thus made forwards and slightly upwards at this stage. The use of the left hand sliould Ije attended to throughout extraction, for this hand plays a very important part — first, in producing axis-traction : and then in backing up the perinreum. Tarnier's axHs-tract ion forceps is applied in the same way as the ordinary kind, except that just as the two halves of the lock are approached to one another, the traction-rod of the upper blade must be lifted over the handle of the lower one so as to lie behind this with the rod belonging to the latter. The screw of the lock is then put together, and screwed up moderately ' Galabin, A Manual of Midwifery , p. 567. Theory of Actio// of the Ju^/rcps 383 tii;luly ; the rod and screw below the lock is screwed up so as to hold the In ad firmly without compressing^' it more than is necessary ; the cross-bar is lilted to the united ends of the traction rods. Traction is now made as described on p. 374. In cases where the forceps is to be api)lied to the after-coming head, which is in these cases nearly always on the perimeum, the child's body is carried as far forwards as possible, and there is then no difficulty in adjusting the blades according to the principles already described. During extraction the handles are to be kept close to the child's body, for this will aid in maintaining flexion of the head. Fig. 318. — ExtiTiction over perinajiini Theory of the action of the forceps. — The forceps acts on the head of the child in two ways ; as a //-ac/o/; and as a co7/tpressor. It cannot act as a tractor without compressing the head sufficiently to obtain a hold ; but it ran of course compress the head without any locomotive action. Compressing- actio?/. — Compression of the head is produced b)- two forces acting on the forceps ; (i) the inward pressure of the sides of the pehis and tlie soft parts ; and (2) the compressing power applied to the handles. Assalini's foixeps depend entireh' on the former factor, and is bad on that account alone ; for it is obvious that the less extra pressure that is applied to the walls of the parturient canal during labour the better. Pressure by the handles is under the control of the operator, and can be made more |)owerful at his will, helping to mould the head in some degree where necessar)-. The distance between the widest part of the blades is about 3^ inches, and the diameter grasped is from 3 f to 4 inches ; so that the handles are kept somewhat apart by the head lying Ijctwcen the blades until they are compressed by the hand, and then a reduction in the diameter of the head grasped can be made of about :ith to ^rd of an inch. If the compression is exercised slowly it can be carried to this degree without any danger. Traction. — This necessitates compression to the degree necessary for 384 Obstetric Operations gripping piiipt)scs ; for unless the cranial curve of the blades exactly rttb the head, the latter will without compression shp out of their grasp. Foreign patterns have most of them a sharper curve than English ones, and tlioy incur the danger of nipping the neck or the skin between their tips. In using the forceps in which the compressing force is entirely controlled by the hands, and not rigidly fixed by a screw as in Tarnier's, or dependent on the reaction of the walls of the passage as in Assalini's, it will be seen that greater compressing force is exercised when greater extracting force is used : the second action, in fact, varies as the first, which is the most desirable arrangement possible. The amount of force which maybe safely used in extraction lies within fairly wide limits : but it may safely be said that a man of ordinary strength should not put forth his full power for more than a few seconds at a time, and that such an effort as this should not be repeated more than two or three times, or very considerable damage will be caused to the mother's parts as well as to the child ; and, in fact, if more than this is found to be necessary for extraction the case is not one suitable for the forceps. Oscillatory /ncnie)nefits.-—^\\.va.ci\on can be helped by oscillatory move- ments of the handles of the forceps. These movements ha\e been described as the leverage action of the forceps, and they are instances of leverage. It is best, however, to leave out the term' leverage action ' in de- scribing the uses of the instrument, for this term has been applied to the action of one blade against the other at the lock considered as a fulcrum by some writers ; and there has been much confusion. The usual mo\ement is one from side to side with reference to the pelvis, but it may be made in an antero- posterior plane. Its advantage may be ex- jilained as follows. If the handles are swung from the right side towards the left, the side of the head in contact with the left blade of the forceps being fixed against the pelvic wall of that side, it will be readily seen that the right side of the head will describe a part of a circle in a downward direction round the lixcd left side as a centre. A bent lexer is formed, the power B being at the handles, the fulcrum D being fi.xed against the pelvic wall, and the weight .\ being the opposite side of the head (fig. 319). If at the end of this movement, the head is now fi.xed against the right side of the pelvis, and the handles are swung to the right, the left side of the head will descend in the same way. If one side is not fi.xed, and moves up on oscillation as much as the other side moves down, the fulcrum being about the .middle of the head, no advance of the head takes place, and the manoeuvre is useless except that it produces Fig. 319. — .Showing inechanicil :kI- vantage of oscillation. D B .1, first position ; then, on moving B to B', the head revolves round D, brings A to. I', and centre of head C loC; .1' next becomes centre of revolu- tion as the handles are swung b.ack to B. Application of the Forceps 385 dynamical instead of statical friction (friction between moving surfaces instead at llic l)rini only. In ordinary cases, if the operat(»r pleases, he may make an attempt to get the blades on the sides of the head^ by bringing them into a diameter slightly removed from the transverse ; for instance, when the head is lying with its long diameter in the right oblique the blades should oppose one another in the left oblique. There is really not much gained by this, since a slightly oblique grip of the head seems of no disadvantage. If it is considered to be so, the head may be allowed to rotate in the forceps as just mcniioned in the case of flat pchis.' \'ectis The vectis or le\er is something like one Ijlade of a straight long forceps. It is, however, much more cur\ed towards the tip, so that it ma\- obtain a hold on the end of the head to which it is applied. Its use is to bring down one pole of the head. Its hold is obtained almost entirely by friction, for it is pressed against the head 1)\- the leaclion of the pelvic wall. It was in former times used to extract the head when there was delay just before the head distended the perinteum, or sometimes earlier than this. It is only of use after the head is engaged. As is pointed out by Galabin, it may be used to bring down the occiput when deficient fle.xion leads to non- reduction of an occipito-posterior position, or to bring down the chin in the corresponding mento-posterior difficulty. It might be used to luring down one pole in brow-presentations. The Blunt Hook is made of a piece of steel rod continued into a handle- below, and cur\ed at the upper end into a hook about two inches in spread. It is used mostly to pull down a child presenting by the breech, being passed over one groin. Its employment is best reserved for the cases where the child is dead (see p. 474). With a flexible stem the hook is useful in some cases requiring version (p. 369), and in certain instances of unduly large child i\y 463). CH.M'TER LI OBSTKiRK' oi'i: kA rioN's {coiitiiiiicd ^ — i;mijkvotomv Cr.\niotomy Befinltion. — In this operation the size of the fcetal head is diminished 1)\ rcmo\ ing the contents of the \ault, and sometimes the vault itself, and then, if necessary, crushing or in some way diminishing the base. The object is to reduce the diameters obstructing delivery. ' Applicatiun of the short foireps. This iiistrumciU i.s practically no vtT used now, for tlu- long forceps are quite applicable at the outlet, and there is no need to add to the mid- wifery l«g. The blades are aj)|jlied much as those of the long forceps, except that they arc accurately adjusted to the side of tiie head. They have no pelvic curve, and no shank. Crdiiiotoiity, l^'crforatioii 387 Conditions requiring: the Operation. — Certain faulty relations of the a i)cn(lul(nis Ijclly or not (sec fif^s. 326, 3:27, after Cameron). It is to Ijc six inches long, and not nearer tlian three inches to the l)ubes, for the uterus will be opened well up towards the fundus, and there will l)c no pedicle to liyatuie or pelvic exploration to make as in most other abdominal sections. When the uterus has been exposed, it should be got as nearly central as possible in the abdomen ; it will often be found rotated considerably, and it is very desirable that the uterine incision should be in its middle line. The pessary above-mentioned is to be laid on the uteiois about the middle of the abdominal incision, and there firmly pressed down by the first assistant. The bleeding being thus checked within the area of the pessary, the uterine muscle can be deliberately cut through, la)'er by layer, till the membranes are reached. The more carefully this is done the better, for it is very important that the membranes should not be opened at this stage. When the membranes are reached, they will probably bulge through the opening, which is as )'et not more than an inch or so long. If the placenta happens to be in the way (its position may have been determined before by palpation, see p. 346) it will bleed, but the bleeding can be arrested b\" using a finger of the left hand as a plug. Now, without rupturing the mem- branes, this finger is to be run along between the membranes and the uterine wall, and tised as a director on which to divide the uterine wall for about three inches above and the same distance below the original opening. The best instrument to use for this purpose is a pair of blunt-pointed scissors, but .a probe-pointed bistoury is used by some. If the placenta lies in the line of the incision, the finger is passed between it and its amnionic layer, which is on the deeper aspect of it, and it is cut through along with the muscle. The membranes are now to be ruptured, the hand passed in at once through the rent, so that as little liquor amnii escapes as possible, and a knee or the head (not an arm) seized, and the child at once extracted. Any dcla)- at this stage may invohe gripping of the child by the contracting edges of the incision. During this time of extraction the assistant is to keep his hands firmly pressed on the abdominal surface just outside the Fig. 328. Incision, edges grasped by assistant's hands, ^r, right, b, left hand ; c, cut surface of muscle in one plane ; d, c, depth 10 which sutures should reacli. incision, so as to allow of no blood or other fluid getting between the surface of the uterus and the under surface of the abdominal parietes, and into the deeper parts of the abdomen. When the uterine incision is completed, he can hook a finger into each commissure of the uterine wound, and so keep the surfaces in close contact. Directly the child is extracted two clips are to 598 Obstetric Operations be pill on the cord, and the di\ ision made Ijetueen them. I'he child is now handed to a third assistant told oft" for this purpose, who will see to the respiration and warmth. The hand is now to be passed into tlie uterus through the incision, and the placenta made out and completely removed with the membranes. The first assistant passes a large flat sponge behind the uterus, and l^resses the organ out of the wound, through which it will easily come in its now empty condition. It should be folded in a warm (iio°F.) antiseptic cloth, leaving the anterior surface and wound exposed. The assistant now grasps the edges of the uterine wound in an ellipse formed by the forefinger and thumbs of each hand, applied just externally to the edges, and everting' them ; by this means all bleeding from the incision is at once controlled. The lips of the wound will by this grasp be forced to lie in one plane (fig. 328). The suturing is now to be done. A method which can be rapidly completed, and one which has piovcd quite satisfactorj', is that of the deep and half-deep series (Cameron only puts in one set, the deep one). It is important that in no case should the sutures reach the inner surface of the uterine wall, for they then aftord a channel by wliich the lochia might reach the peritoneal cavity (fig. 329). The sutures are inserted (the deep ones, if two layers are employed) at intervals of half an inch. The half-deep sutures pierce the muscles about an eighth of an inch from the peritoneum, and emerge on the peritoneal surface between the deep ones. The sutures are to be tied after they have all been inserted — the tying of the deep ones to be completed before the half-deep ones are tied— all blood being carefully sponged off the wound as each one is tied ; and the uterus is now to be squeezed gently but firmly in a fresh cloth of the same temperature as before, when it will contract well. If there is still any oozing from the sutures, a fresh cloth must l)e applied, and the uterus squeezed again. When all is clear the uterus is returned to the abdomen, and if any blood has found its way into the abdominal cavity it must be carefully sponged out, or washed out with boiled water at 110° F. It is very desirable, however, that before the uterus is returned to the abdomen the woman should be sterilised. This may be done by removing a portion of the Fallopian tube. Champneys found that it was very easy to da this by transfixing the broad ligament just below the middle in length of the tube, tying the tube, and then pinching up a loop of tube, tying this with the Fig 329. — Position of deep sutures. Abdoniiiial Sec/ion for Ruptured Uterus 399 ends of the first ligature, and then cutting off the loop of tube. There is no raw or bleeding" edge left by tliis plan. Simple ligature is not enough, for cases are recorded where this did not pre\ent subsequent pregnancy. The abdominal walls are now to be sutured and dressed. In the above description, the practice of some, who apply an elastic ligature round the loNver segment of the uterus before opening it, has not been followed. This method has been found to cause uterine atony by cutting- off the blood supply during the subsequent stages. It also invohes turning the uterus out of the abdomen, or at least ver)- considerable disturbance of it, before the child is extracted. It is recommended by some that the uterus should be turned out in this way ; it is said that there is less risk of fluids finding their way into the peritoneal cavity if this is done. It, however, is dangerous, inasmuch as it cools the uterus much more than the method described here ; and it necessitates a much longer abdominal incision. In this operation, apart from the great point of genei'al asepsis, by means of which the present good results have been mainly obtained, the most im- portant matter is the suturing" of the uterine wound. If this is not accurately and securely done, there is a risk of the escape of lochia into the abdominal cavity, causing" peritonitis ; or of giving way of the wound and free communi- cation between the peritoneal cavity and the interior of the uterus, either event being most probably fatal. Secure stitching was effected in the first operations of the new era by Sanger and Leopold, to whom we owe the re\ival and establishment of the operation as it is now done by means of separate sutures applied to the peritoneal coat alone. This was carried out in \arious ways, many of them very tedious. The same result, that of close and accurate coaptation of peritoneal surfaces, can be obtained simply in the \vay just described, silk sutures being used for the deep layer, and catgut for the peritoneal or half-deep set. Course of Puerperium and After-treatment. — The lying-in period runs a perfectly natural course if there is no fresh reason to the contrary. It should be mentioned that in several recorded cases the lochia have been very scanty without any further peculiarity being observed. This condition should, therefore, give rise to no an.xiety in the absence of septiciemic symptoms. The patient may, with the exception that the abdominal wound has to be attended to, be considered as an ordinary Ijing-in woman. The dressings of the wound should not be removed before the seventh day or so unless attention is directed to it by some discomfort or rise of temperature. On that day the old dressings may be replaced by a wet piece of cyanide or other gauze : this wilf soften the dried serum which has col- lected around the sutures, and will enable them to be removed next day with- out difficulty. A belt will ha\e to be worn for ab(nit a year, as after other abdominal operations. Abdomin.al Section .wn '1"rk.vtment ok Ruitlkkd Uterus The woman is to be anaesthetised, and her aljdomen rendered aseptic. She is placed in the position for abdominal section, either in the ordinarv dorsal position, or in the raised peKis positionfp. 493 . 400 Obstetric Operations The abdomen is opened, and the child and placenta, if not already ex- tracted per vaginam, removed. The abdominal cavity is to be freely douched with water from the tap, if boiled water cannot be procured, at a temperature of about 105° P'. Special care is to be taken to cleanse the rent and its neighbourhood, and the stream should be directed through the rent into the vagina for a time, and the tube may also be passed through into the vagina. The uterine edges are now sutured as described in the Caesarian section, and they are to be as carefully adjusted as in that operation. If the rent is in the back of the uterus, as is most common, it is very difficult and it may be impossible to suture it accurately. In that case, since imperfect suturing is probably worse than none at all, the best plan is to pass a drain consisting of Fig. 330. — .XrrangcnieiU of drninage-tulK;. rubber tubing about as thick as the little finger, or of cyanide or iodoform gauze through the tear into the \agina. If a tube be used it will be necessary t.jmake it self-retaining by using one with a large flange (as in an empyema- tube) and by carefully packing gauze round the end of the tube which lies in the vagina. A self-retaining tube may be extemporised by doubling one end of the tube on itself, and stitching it so, a hole having been made at the out- side of the angle (fig. 330). If gauze is used for the drain, it should be cut into a strip about h^ur inches wide ; and care should be taken that there are no knots or folds in the part that lies above the rent which would interfere with its easy withdrawal per vaginam. Either form of drain may be removed in, as a rule, 48 hours. The question is to be decided by the character of the discharge from Porro's Opei'ation 401 tlic tul)c, whicli may be removed when this is onl)- l^lood-stained serum Either tube or gauze is in a few hours completely shut off from the general peritoneal cavity. The vagina is to be carefully douched twice daily with some liarmless antiseptic, boracic acid being probably the best. I'okKO's Modification of the C.?^.s.\rian Section The modification consists in the removal of the body of the uterus and the appendages after the child has been extracted in the manner just described. The placenta in situ is removed with the uterine body. The stump consists of the cervix and a small portion of the lower uterine segment. The object of the thus modified operation is (i) to remove an organ which if left would probably endanger the life of the woman. It is recommended therefore in cases of Caesarian section where from pro- longed labour the uterus is exhausted (and possibly already septic), and will not contract so as to prevent bleeding after the placenta has been remo\ed. (Porro's operation is not to be undertaken when in the case of a Cjesarian section the uterus fails at first to contract, for the bleeding can in ordinary cases be practically always arrested by compression in a hot cloth.) The operation is advisable also in (2) cases of malacosteon pelvis, where removal of the o\aries is often curative ; for a pedicle which can be safely tied and divided is often very difficult to get when the broad ligaments have been filled up by the lateral expansion that has taken place in the gravid uterus at term. It is also a good operation (3) when from want of experience the operator does not feel certain of being able to manage the complete suturing of the uterus necessary in Caesarian section of the ordinary kind ; or where the materials and other facilities are wanting for that purpose. The instruments necessary for the performance of a Porro's operation are \ery easily obtainable. The instruments required are those needed to open the abdomen and the uterus, nameh', scalpel, scissors, and pressure-forceps, with needles and silk for sewing up the abdominal wound. The pessary is useful here as before. If, as is safest, the stump is to be fixed in the abdominal wound,' in addition to the above instruments, which are to be found in the possession of ever)- practitioner, there are needed a serre-noeud with which to secure the stump, and which will remain on it for about a fortnight : and a couple of long pins which are thrust through the stump to retain it at the skin surface of the abdominal wound. .Substitutes for these last instruments can be improvised from a foot of rubber tubing or cord, and a couple of knitting needles. 1 The intra-peritoneal treatment of the slump by ligature of the ovarian and uterine arteries on each side, and suturing the peritoneum over the cut surface of the cervix and lower uterine segment, is now adopted by some operators. It requires experience in abdominal surgery for its successful application, and the medical man who has not this experience will be wise to adopt the method here described. D D 402 Obstetric Operations Mode of Performance. — Up to the time when the child is removed from tlic uterus the stc|)s arc the same as in a Cii^sarian section, except that the abdominal incision should l)e carried lower (see p. 396). After this stage has been reached the uterus is to be drawn out through the wound, the intestines being kept back with a large sponge or a soft cloth, and the wire of the serre-noeud or the piece of tubing passed round the lower segment as low as possible, including the ovaries and tubes in the part cut off from the circulation. When the wire or tubing is quite tight, it is secured, the wire by the screw, which holds it automatically, the tubing by tying it in a knot, the ends of which may be for the time prevented from slipping by a clip applied over the knot. The body of the uterus is then amputated about one inch abo\e the wire. If there is any bleeding from the stump, the wire or tubing is to be tightened. The pins are now passed through the stump just below the wire, and the peritoneum at the edge of the abdominal wound is sewn to that covering the side of the stump. The pins rest on the abdo- minal wall, and hold the stump up at that level. They should ha\e some wool packed beneath them to protect the skin. The stump may be powdered with iodoform or aristol, or with ecjual parts of tannic acid ; and the wound is then dressed in the ordinary way. The stump is to be carefully looked after, being powdered daily as often as necessary, and its wire tightened if there is any oozing. The distal part will slough off about the twelfth day. The proximal part of the stump will then retract as the pins tear through the thin layer of tissue remaining, and it will retreat down into the wound. CHAPTER LIII SV.MPHVSIOTO.MV Definition. — In this operation the symphysis pubis is divided, so that separa- tion of the two hahes of the pelvis to a varying degree is possible. By this means the transverse diameter, and to a limited extent the antero-posterior diameters of the pelvis are increased. The iliac bones hinge on the sacro- iliac synchondroses, on the flexibility of which the amount of space that can be gained depends. In addition to the space accjuired by the movement forwards of the ends of the pubic rami, there is a gap produced between the divided ends through which some part of the child's head can bulge slightly. Nature has been known to do a symphysiotomy of a rough kind under the bursting strain caused by a large head being forced through the pelvis, the ligaments of the pubic symphysis being torn through. This mode of assisting labour is a very old one. It was first advocated by Sigault of Paris in 1768, and soon fell into oblivion. It has been revived by Morisani of Naples within the last few years, and it has been practised with the ad\antagcs to be obtained by the use of antiseptics. Conditions for which the Operation is 8ug:g:ested. — It is of course essential that a living child be nljlaincd by tliis method, or its object would SympJiysiotoDiy 403 l)e lost, for craniotomy would deli\-er the woman of a dead child without damaging her. If the child is at term, the pelvis must have a conjugate of at least i\ inches, since only h inch can be gained by symphysiotomy with safety to the synchondroses. If labour is premature a smaller pelvis would still be suitable ; but it would not be justifiable to risk the mother in any way for a premature child, and in such a pehis if any operation to obtain a living child is to be undertaken, Caesarian section at term should be unhesitatingly chosen. In a generally contracted pelvis the lowest limit, as given above, would have to be made as high as about 3^ inches. Now a living child may be born through a pelvis with a conjugate of 3;^ inches, or possibly even 3 inches, if the circumstances are otherwise favourable. So that the range of the operation may be considered to lie betiveen conjugates of i^ inches a?id 3 inches, or perhaps 3^ inches in an otherwise normal pelvis, and both limits will be raised in a generally con- tracted pelvis. Narrowing of the outlet, as in a kyphotic pehis, would also be an indica- tion ; and the operation would act in a more directly favourable manner on the deformity, since widening would occur mainly in the transverse, in which diameter of both the brim and the rest of the pelvis the narrowing is most marked. Also if from any malpresentation of the head it has become impacted in the pelvis' with a conjugate of 3^ inches or more, and cannot be moved by the forceps, the child being alive, the operation might be indicated. Instruments required. — These are a scalpel, a probe-pointed curved bistoury (unless the special knives contrived for the purpose of dividing the symph)-sis, Galbiati's or Morisani's, are to be used), sutures of silk or wire, curved Hagedorn's needles, strapping and dressings. The Operation. — The operation is done during labour, and the os must be almost fully dilated. The woman is to be prepared as completely as possible in the usual manner and anaesthetised. She is then placed in the lithotomy position at the edge of the table or bed, and the legs should be held- up, one by each of two assistants. The incision is to be made in the middle line, beginning one to two inches abo\'e the top of the symphysis, according to the amount of fat o\erlying it, and ending just abo\e the clitoris. If it is necessary to go a little lower the cut must run to one side of this organ. The incision is carried down to the joint and the sheath of the rectus muscle. Bleeding vessels are secured ; and then the origin of the jjyramidales is separated, and the finger is passed down behind the symphysis. The joint is then cut through from behind forwards with the probe-pointed l)istoury. The bones will fly apart, but must be prevented from separating far by the two assistants who are holding the thighs, who \\\\\ keep them moderately close together. Wide separation of the legs increases considerably the separation of the ends of the pubic bones ; and this is likely to cause much tearing of the soft parts, including the urethra. A few layers of iodoform gauze are now placed on the cut surfaces, and the child is extracted by the forceps. An assistant must take charge of the placental stage. The wound is cleansed, and the ends of the bones pressed together, the thighs being D D 2 404 Obstetric Operations iipproxiniatcd. Sutures arc to be placed in the skin ; and strapping care- fully adjusted, and then a firm bandage of some strong material fitted round the pelvis, so as to fix the bones immoveably. The dressings are applied, and the woman should then recover as any ordinary lying-in case. Results. — The mortality of the operation is stated by Garrigucs ' to have been from 1886 to 1892 inclusive 4-5 per cent, in the hands of experts. Herman makes it about 10 per cent, in all cases of later years. The mortality of the children is said to be about 1 2 per cent. The result to the woman as regards the firm union of the divided bones is not so definitely stated ; and though many get well, some remain unable to do hard work or take active exercise on account of incomplete union. The woman is of course liable to become pregnant again, and the operation may have to be repeated an indefinite number of times, unless premature induction of labour is undertaken. Relation to other o-peTa,tioii&.^I?iduclio/i. — This can be done with little or no risk to the mother,- and down to three inches conjugate measure- ment there is a fair chance for the child's survival, since labour will be in- duced at the thirty-first or thirty-second week at earliest. Labour can Le induced down to 2iJ inches with a moderate chance of rearing the child. So that induction has a considerable advantage over symphysiotomy, and with pelves of this size, if the cases are seen early enough, the safest course will Ix- to induce labour ; or if it is wished to have a living child, and one certain to be reared in the case of a pelvis below three inches, the woman should go to term, Caesarian section should then be done, and the woman sterilised. When labour has begun at term in a pelvis between 2f inches and 3j5 inches, the choice may be based on the question whether the woman is anxious to have a living child, and will undertake the necessary risk of Ccesarian section or symphysiotomy ; or is not anxious to do so, and does not care to run any risk for this purpose, when cratiiotoniy will of necessity be the opera- tion. The advantages of Caesarian section have been mentioned ; but it will be contra-indicated if the head has become impacted, since that means nearly always an exhausted uterus. There is, too, the possibility that the child w'li not be able to be drawn out of the pelvis after the uterus has been opened, either on account of the impaction of the head, or because of its being gripped by the retraction ring. The alternative in this case would be craniotomy or symphysiotomy. If the possible results of symphysiotomy as regards the life of the child, her own risk, and the possible after-consequences in the matter of the symphysis, and the possible recurrence of pregnancy, are explained to the woman and her relatives, it will be right to accept her and their decision as to the procedure. The field of symphysiotomy is thus narrowed down to the conditions of a pelvis with a conjugate of between i\ inches and 3^ inches with the head impacted, when it is the alternative to craniotomy. 1 Americav Journal of Medical Science, March and April 1893. * III inductions have been performed in the General Lying-in Hospital in 6 years, with no maternal death, and with 78 children born alive. 405 PATHOLOGY OF LABOUR This section is occupied in describing the various kinds of abnormal labour. The abnormality may lie in one or more of the three factors in the process — namely, in the expelling force, the body to be expelled, or the passage through which expulsion is effected (see p. 78). The term 'Labour' is here, as before, understood to mean labour at or near term. Before passing on to a description of the examples of abnormality in labour, it may perhaps Ije expected that a definition of normal labour should l)e given. This is not so easy as it might appear, and, in fact, is not easier than it is to define health. If we were to say that the ordinary relations between the mother and child in space and dimensions, combined with an efficiency of the expelling force, constituted normal labour, we should have merely expanded the term, without getting any nearer to a practical definition. The nearest that can be got seems to be to consider a labour normal when the three stages have each been completel)' accomplished in some space of time not very far removed from the figures given on p. 407 as the average duration of the respective stages ; when labour has been com- l)leted without damage to the child, and without more damage general or local to the mother than what is described as the usual amount of laceration on p. 212,' and when not more than the usual amount of blood (p. 127) has been lost. It is impossible to Idc certain at any stage of labour Ijcfore the end that a case which has been pcrfcctl)- natural so far will end naturally ; and it is only after it is finished that ajiy labour can be described as a normal one. In addition to freedom from aberrations in the intrinsic factors of labour enumerated above, it is implied in our attempt at a definition of the normal that the other systems of the woman, the circulator)-, the respirator)-, and the excretory sxstems, are in such order that they will not interfere with the |)rocess of labour. This will be seen to be important when the diseases of the heart, lungs, and kidneys which may affect the course of labour are considered. ' It is unnecessary to mention the lie and presentation of the child in such a definition. I r the above conditions arc fulfilled, it can be assumed with safety that the he and presenta- tion have been of the best kind, and therefore satisfy the requirements of ' normaUty.' 406 Pathology of Labour CHAPTER LIV prkcipitate and prolonged labour Precipitate Labour Definition. — The time occupied in the three stages of labour has been seen to vary, in cases which may be considered normal, within fairly wide limits. It is therefore rather difficult to define accurately what is meant by 'pre- cipitate' labour. It may in a general way be taken to mean that the foetus is expelled through the maternal passages too rapidly for them to modify themselves by the physiological processes of dilation in such a way as to allow the transit of the child without more than slight lacerations. Or, on the other hand, labour may be too rapid for the foetus, and especially its head, to adapt itself by moulding to the size of the rigid part of the maternal passage — namely, the bony pelvis. Labour may also be called precipitate if, in the case of complete dilation of the parturient canal and the easy passage of a small head, deliver)' takes place much more suddenly than was expected, and finds the woman un- prepared ; for instance, the child maybe suddenly expelled while the woman is at stool or in an upright position ; and then it may run considerable risks from falling on to a hard surface, or into fluids in which it is suffocated ; or the umbilical cord may be ruptured by the fall. Causation. — Precipitate labour is due to an altered relation between the expelling force and the resistances ; that is, the force is unusually great, or the resistances, either from abnormal size or dilatability of the maternal passages, or from small size or unusual compressibility of the foetus, are usually slight. Effects on tbe iviother. — No harm accrues to the mother except the possible laceration of the parts of the genital tract which normally dilate, unless the uterine pains succeed one another so rapidly, especially in the case of contracted pelvis, that dangerous retraction is quickly produced, and rupture of the uterus results. This, however, is an extremely rare combina- tion of accidents. Emphysema of the neck (see p. 502) is also very rare. The perinaium is the part which is most liable to suffer, but the vagina may also be lacerated (see p. 494;. Effects on the Foetus. — The foetus may be injured owing to the absence of intermission in the pains. The circulation through the placenta is then sufficiently interfered with to cause asphyxia, or the continued pressure on the body of the child itself may damage its nervous centres. By violent pressure of the bony part of the canal on the foetal head dangerous or fatal Prolonged Laboii}- 407 extravasations of blood into the brain or medulla maybe produced. Danger to the fcetus by falls or rupture of the cord on sudden expulsion is not very probable. The cord breaks the fall as a rule, and, if in doing this it is ruptured, bleeding does not usually occur from the torn vessels, since they retract. The cord is usually ruptured close to the umbilicus. From this description it will be seen that precipitate labour affects almost exclusively the second stage. Its results as regards the third stage are practically of no importance, for the uterus contracts well as a rule, and the supposed liability to post-partum haemorrhage is not borne out by facts. Treatment. — In cases due to diminished resistances there is usually little treatment necessary beyond securing a torn cord, and the rescuing of the child from any dangerous conditions into which it may be precipitated. Where the pains are too vigorous and fi"equent, efforts must be directed towards delaying the too rapid advance of the child through the passages. The patient should be placed in the semi-prone or genu-pectoral position, so that gravity may take off some of the pressure on the perinEeum ; she should not be allowed any resistance against which she can press her feet, nor any means of fixing" the upper part of her body ; she should be instructed to abstain from bearing-down eftbrts, and to open her glottis and cry out during the pain. Under these circumstances the administration of chloroform is most effectual, and by it the violence of the pains can be regulated. Some check on the advance of the head may be effected by upward pressure during the pains, and by directing the head, when its escape from the vulva is in- e^■itable, as much as possible forwards under the pubic arch. Prolonged Labour Definition. — Any stage of labour may be prolonged beyond its average length. So as to have a standard of comparison, the table showing the average length of the first and second stages may be here repeated. First Second Total Multipara 8 1-2 10 hours Primiparae . . . . .16 3-4 20 ,, Elderly primipara; (over 26) . 20 4-5 24 „ Any considerable prolongation of the average time given in this table may be considered abnormal. Prolonged labour is of two main kinds, and all cases will fall under one or the other heading. In the first group the pains are originally weak, or they fail after a time ; in the second group the pains arc normal to start with, but the resistances, whether due to abnormalities of the passage or of the foetus, are unusually great. In other words, prolonged labour may bo due to a weak expelling force, or to increased resistances. Of these two groups the second is, on the whole, of far greater im- portance. Cases may be classified: (i) those occurring in the first stage ; (2) those occurring in the sectnid stage ; (3) those occurring in the third stage of labour. 408 Pathology of Labour Effects of Frolongred Iiabour, General and Ziocal. — Prolong^ed labour, from whatever cause, affects the mother generally and locally. The local effects are exerted on both the contracting part of the uterus and on the genital tract below the retraction-ring — that is, on the parts which dilate. It ma)- affect the foetus by direct pressure on the whole or part of its body, and by cutting off the blood-supply to the placenta. In the First stag^e. (a) Before rupture of membranes. Unless there is some organic rigidity of the cervi.K which prevents dilation, the pains must have been weak originally. In this case the effects are not marked, and the only result is a varying degree of weariness due to the irritation and disturb- ance caused by the pain and possiblv by loss of sleep. (See p. 411, Inertia Uteri.) If the cervix is the seat of cancer or is made rigid by cicatrices the uterus may become exhausted or tetanic or over-retracted, and symptoms of ob- structed labour may appear at this stage. (t>) After premature rupture of meml^rancs. In this case almost all the liquor amnii runs away after a time ; the uterus contracts on the child, causing the labour to assume the characters of the second stage ; and the symptoms of obstructed labour belonging to that stage make their appearance. In the Second stage the effects of prolonged labour are most typical. Two classes of case come under this heading ; one where the uterus for some reason l^ecomes exhausted, gi\es up the struggle, and remains quiet and relaxed (see p. 412, Exhaustion of Uterus) ; the other where there is obstruction to the advance of the child, and the uterus, striving still against the obstacle, becomes tetanic. In the former class there are no symptoms be\ond those of fatigue ; this is, howe\er, of a more marked degree than that occurring in the first stage. In the latter class the woman soon reaches a serious condition ; and the low er the head has descended the sooner, owing to the greater reflex action brought about by the pressure on the pcrinit-uni. Constitutional Effects of Obstructed Iiabour These are mainl\- signs of rapidl}- dLcpening exhaustion. The expression of the woman's face becomes anxious ; she is restless. The temperature, pulse, and respiration are all somewhat increased. Of these the pulse is the most important indication of danger, and as will be mentioned later, is as a rule to be taken as the sign which shows when assistance is required. Any rise of the pulse above 100, if maintained between the pains, may be taken ;t:s an indication that the patient is suffering from prolonged labour ; and the rate under these circumstances may be 120, 130, or more. The effect on the temperature is at first to raise it by not more than a degree or so ; but if the woman remains unrclie\ed septic absorption ma\- occur from sloughing of those parts of the genital tract pressed on by the fcetal head, and the temperature may go up to 103^ F. or higher. The rate of respiration is increased proportionately to the pulse. The abdomen becomes tender, the tongue becomes dry and furred, and, later on, brown ; and the ])atient may \omit. She dies in a 'typhoid' state. Tcta)iHS { 'teri — Over-retraction 409 Iiocal Effects of Obstructed Xiabour Effects on the contracting parts of the uterus : — Tetanus TJteri. — In the presence of obstruction the uterine contractions become at first more vigorous, but if the foetus does not advance the intervals between the pains become shorter and shorter, and the distinction between contraction and relaxation finally becomes lost. If the hand be now laid upon the uterus the organ is found to be not relaxed but hard and firm. The uterus is in a condition of tetanus, and is closely contracted on the child. Owing to the liquor amnii having nearly all escaped the projections of the fcietus cause considerable and unintermitting pressure on those parts of the uterine wall which are in contact with them. This continuous pressure damages the areas pressed upon by arresting the circulation in them. Tetanus uteri exhausts the patient very rapidly, and demands immediate delivery. Over-retraction. — -In all cases where the contractions intermit, whether labour be natural or obstructed, retraction of the uterus occurs. This process has been described in the chapter dealing with the effects of normal labour on the uterus (p. 97). Retraction becomes exaggerated when owing to some cause or another the fcEtus is not expelled from the uterus at a rate corresponding more or less closely to the diminution in capacity of the upper or contractile segment. Where such a cause for delay exists the upper segment reti^acts as usual ; that is to say, its walls become of a thickness corresponding to what would ]ia\c been attained if the foetus had been expelled at something like the normal rate. In fact the child is, properly speaking, ex- pelled to the usual extent from this segment, although as regards the birth-canal it may not have made any advance. Consec[uently the greater part of the ovum now occupies, and distends considerably, the lower uterine segment. Owing to this distension the walls of the lower segment become proportionately thin, and this thinnmg may reach a very dangerous degree, e\en to the rupturing point. Over-retraction is a condition almost peculiar to the second stage of labour ; but under rare circumstances, as, for instance, in the case of an undilatable cicatricial cervix, it may begin during the first stage. An over-retracted uterus ma)- at any moment become tetanic. The woman shows the signs of protracted labour as abo\-e described in a degree corresponding to the amount of retraction, and of tetanus uteri, if this is present. Fig. 331. — Much thinned lower segment in a case of contracted hrim. 410 Pathology of Labour On examination of the abdomen, at a height above the pubes depending on the degree of the retraction — that is, from one to four or five inches above the symphysis — a depression is found in the anterior uterine wall, which marks the level of the transition from the thick upper segment to the thin lower segment. This depression is known as Bandl's Ring, and its nature has been already discussed (p. 98). When it is felt, it may be taken as a sign that the uterus has need of assistance ; and the higher it lies in the hypogastrium the more urgent is the need. The effects on the dilating parts of the parturient canal are described on p. 429 ; the effects on the child on p. 430. The general results of prolonged labour in the first and in the second stages of labour respectively are then as follows : In the first stage before the rupture of the membranes there is little or no danger to the mother or child unless there is some organic rigidity of the cervix ; and the patient may go on for many hours or e\en several days without suffering more than slight inconvenience. The amount of disturb- ance caused depends practically on the nervous constitution of the patient. After rupture of the membranes and draining away of the liquor amnii constitutional symptoms appear before very long unless the uterus becomes exhausted and relaxed. If the pains still continue, and the obstacle is an insuperable one, it may fall into the condition of tetanus ; or, on the other hand, if the uterus continue to act vigorously, it will become over-retracted first, and then rupture (p. 489;, or become tetanic. After the fcetus has passed partly into the cavity of the pelvis, and in a more marked degree if the pelvic floor is being stretched, serious symptoms w-ill arise in an hour or two. These mainly consist in the marked constitutional disturbance just described ; and, as will be described later, serious local effects on the vagina and neighbouring organs, and on the foetus. CHAPTER LV .\BNORM.\I.rnKS IX THK EXPKLLING KORCK Ix considering the abnormalities of labour in detail the subject will be best divided into (A) abnormalities in the expelling force ; (B) abnormalities in the passage ; and (C) abnormalities of the fcetus and its appendages. The accidental complications of labour such as cardiac diseases, eclamp- sia, post-partum ha-morrhage, laceration of the genital tract form a separate group. After this follow the accidental conditions affecting the life of the fcetus only, and the subject of still-birth. A. Abno7-nialities in t/ie ExpclUiii^ Force. — These abnormalities maj- affect (i) the uterus ; (2) the auxiliary muscles of labour. bicrtia L ^teri 4 1 i (i) Abiwr)iial Uh'rifie Cofiti-actioiis. — The contractions of tlie uterus may be abnormal — {a) In force and in frequency. {b) In direction. ((■) In character. ((?) Zrregrularities in Force and Frequency. — Too vigorous action of the uterus has been ah-eady considered as precipitate labour (p. 406). Insufficient action of the uterus in relation with the resistances. Linger- ing labour. Insufficiency may be classified into three groups. The distinction between these is most important. It may be, first, primarily uterine ; the uterus is inactive from the beginning, whether the resistances are normal or excessive. Second, the uterus becomes exhausted before it has completed its work, whether the resistances are normal or excessive. Third, the uterine contractions are noimal ; but the resistances are ex- cessive, and lead to changes in the character of uterine action. The term ' uterine inertia ' is applied to the first two of these three groups m the standard works on midwifery ; but it is so important to differentiate between them that the term ' inertia ' will in this work be applied exclusively to what is called the 'primary' form ; and 'exhaustion' to the state at which the uterus arrives during labour, when a condition developes in which no stimulus has any effect. Inertia Vteri Causation. — This condition may be brought about by constitutional or by local causes. Among the former too early pregnancy ; or pregnancy in very late life ; or general ill-health of the patient, usually from temporary causes, are the commonest. \\"omen who are chronic invalids are \er3- often found to have uteri of quite normal activity. Local causes include the worn-out uterus of a woman who has had many children ; a uterus which is overstretched by its contents — by twins, hydram- nios, and concealed accidental haemorrhage ; a full bladder or loaded rectum, which act mainly through the ner\ous system ; and morbid adhesions of the membranes round the internal os. In some cases there is no cause dis- coverable. Characters and Results. — The pains are simply weak and occur only at long intervals throughout labour ; in fact, the process is a leisurely one. No marked constitutional effects arc caused ; the woman does not become anxious, but only weary, if the process of labour is \ery protracted. On placing the hand on the abdomen the uterus can be felt to contract during the pains and to relax completely in the intervals. Although the uterus con- tracts feebly, there is nearly always some slight advance. After the child is born the third stage is safely got through. Treatment. — If the cause is a constitutional one, attention should be directed to improving the patient's condition Ijy the frequent administration of easily digested food in small quantities ; and as much rest as possible 412 Pathology of J.abour should be obtained. The patient, however, should not lie down in bed but recline in a semi-recumbent posture either in a chair or on the bed, so as to enable gravity to act on the uterine contents. Alcohol should not be },Mven except in very minute cjuantities ; and it appears on the whole better to avoid ergot. If there are local causes for the inertia they should be re- moved if possible. If, for instance, hydramnios is present in a marked degree, the membranes, after dilatation has been allowed to proceed to a degree which must be determined by the amount of over-distension, may be ruptured. That is to say in extreme degrees of hydramnios, where the uterus appears unable to contract with any effect, the membranes ma)' be punctured early ; but as a rule the more completely dilatation has taken place, although this has occurred very slowly, the better. In the case of a full bladder or rectum evacuation is the obvious course ; if the membranes adhere round the internal os they should be gently separated by the finger. In concealed accidental h^tmiorrhage the mcmljrancs will be punctured in the ordinary course of treatment. Friction applied to the surface of the abdomen over the uterus, and compression of that organ during a pain, are most useful and should never be omitted. In all these cases after the first stage is completed, when the uterus is not stimulated to more active contraction by contact with the foetus, and no con- siderable advance is made within two or at the outside three hours, the forceps should be applied to the head ; or traction should be made on the breech by the fingers or a leg brought down to pull on, according to the lie. Traction should be made only during the pains, and the uterus should be stimulated by friction and compression at the same time. Exhaustion of the XTterus Causation. — The most usual condition present is some slight obstruction to the ad\ance of the foetus, which would probabl)- be overcome by a strongly acting uterus, but which is sufficient to tire out a uterus which is not adequate to the work. Exhaustion of the uterus, however, may occur where there is a quite normal parturient passage in a uterus which began labour with inertia. Characters and Results. — The pains usually beu;in in a normal manner — although as has just been said there may Jdc primary inertia — and may go on for a variable time ; but at a certain point the uterus gives in and the pains cease. The woman is tired too ; she may go to sleep. Her strength is renewed after this, and the uterus recovers also ; so that when she awakens the pains return and delivery is probably soon completed. The great point to remember is that the uterus in the condition just described is exhausted, and cannot be stimulated. It therefore differs on the one hand from the uterus affected with inertia, and on the other from the tetanic uterus which has been described. The constitutional condition of the patient is simply one of tiredness, and sleep is the only cure for it. Treatment. — -If the patient will sleep witliout drugs she should be allowed to do so ; if not, it is best to give her l)\^\x of tinct. opii, or thirty Uterine lixJiaustion — Tetanus I'teri 413 grains of chloral hydrate. On no account should delivery be brought about before rest has been obtained. It is useless to give ergot to try to stimulate the uterus, for no result of this kind can possibly be produced. It is most dangerous practice to pull the child out with forceps, for the uterus remains rela.xed in spite of being emptied, and post-partum haemorrhage is almost inevitable. The following table taken from Herman's work on Difficult Labour shows in a synoptical form the points of difference between uterine ex- haustion and tetanus uteri ; which, as he says, present certain superficial resemblances, but between which it is \'itally important to distinguish. Uterine Exhaustion Tetanus Uteri {a) Goieral Condition E.xpression placid ; at most showing Expression of face tired and anxious. signs of fatigue ; not anxious. Pulse small and quick ; generally Pulse not over 100. 120 or over. Breathing not hurried. Breathing hurried in proportion to pulse. {b) Abdominal Examination Uterus not tender. Uterus tender if the condition has lasted long-. Outline and limbs of child can be Outline of child cannot be felt, but distinctly felt, and child moved only that of the hard and im- about. movable uterus ; limbs of child cannot be felt. {c) Vaginal F.xami7iation Presenting part can be pushed up Presenting part cannot be pushed up. easily. Caput succedancum small, so that If head in pelvic cavity, great caput sutures can be felt. succedancum, so that sutures can- not be felt. Little or no swelling of \-agina and If head in cavity, \agina and vulva \ulva. swollen. Remember also the contrast in treat- ment. (live the patient sleep; do not Dcli\er without delay, deliver her. He adds : ' In tonic contraction of the uterus ergot ought never to be given ; because its effect is to cause this condition and increase it when present.' The cases where the uterine contractions arc normal Init the resistances arc excessi\e will be treated of under 'Abnormalities in the Passage,' and 'Abnormalities of the Foetus and its Appendages.' 414 Pathology of Labour {b) Zn Direction of the Force. — This class includes forward displace- ment of the uterus, found in the condition of ' Pendulous Belly' (see p. 272) ; lateral displacements ; and backward displacements with reference to the brim, all of which occur mostly in connection with contracted pelvis. A description of each will be found under its proper heading. Bulging of the anterior and posterior walls of lower uterine segment (see p. 454) are included also. {c) In Character. — Under this heading the rare condition known as Premature Retraction is found. It was first described in England by Matthews Duncan.' It seems to be a condition of retraction without a corresponding amount of contraction. The contractions are described as being spasmodic in character. The result of this abnormality is that the separation of the uterus into a thickened upper and a thinned lower segment takes place so rapidly that the normal expulsive action of the uterus is almost entirely abolished. The ring of Bandl is felt quite early in labour and soon rises to somewhere near the umbilicus. After delivery of the child the placenta comes away naturally, or is easily expressed, and post-partum haemorrhage does not occur. It is described as occurring mostly in young primiparye t»f nenous temperament. TreatmenL — Delivery is to be assisted by forceps, or by traction on the breech. Irregular contractions of the uterus have also been described. According to Herman such inequalities of action in the uterine walls are due either to the normally greater \'ascularity of the uterine wall at the placental site ; or where, in obstructed labour, the liquor amnii has been all expelled, and the child is closely embraced by the uterus. At the parts where the circumference of the child is small there appears to be a stricture ; in other words, at this part contraction seems to be greater than it is elsewhere. Such a constriction may be produced also in obstructed labour by imperfect dilatation of the internal os ; or more commonly by the retraction ring. (2). Abfw?-»ial Aitxilicify Forces. — This practically means insufficient action of the abdominal muscles. The abdominal muscles may become exhausted by being used in the first stage of labour ; they may be the overstretched muscles of Pendulous Belly ; or they may act at a disadvantage in cases of considerable diastema of the recti ; they may be rheumatic ; the woman may refrain from using them in bearing-down efforts because she dreads the pain ; or they may be paralysed to a varying degree in cases of paraplegia. The physiology of the auxiliary muscles of labour, and the stages of labour in which their assistance is necessary, have been fully described. If they fail in their action the effects may not be marked, for in cases of para- l)legia the uterus has been found to be equal to the task of expelling the frctus unaided. Their absence would probably be most felt in the third stage of labour ; but if the presentation is one of the breech the expulsion of the after-coming head would most likely be impossible without artificial assistance. ' Obst, Trans, vol. v. Pelvic Deforuiity 415 CHAPTER L\'I K. ABNORMALITIES IN THE PASSAGE I. Abnormal Pelvis General Reiiuifks. — The pelvis should offer no obstacle to the passage of a child of the average size in one of the normal lies (see p. 128). If it does, it is deformed in some way. Deformity thus means smallness in one or several of the pelvic diameters, and from an obstetric point of view concerns the internal measurements only. External deformities, unless, as they usually are, they are combined with internal ones, are of little or no impor- tance. Deformity in fact is only of importance as it affects the relation of the pelvic measurements to those of the foetal head. The commonest diameter to be affected, and often the only one, is the conjugate. It is already in a normal pelvis the smallest diameter with which the foetus comes into relation. It has the thinnest covering of soft parts of any diameter, and on this account also diminutions in its measurements are most important. The pelvis is deformed if the mechanism of labour is by it caused to deviate from the normal ; and this effect is not necessarily shown by actual obstruction, but also by indirect effects, by causing face-presentations for instance, which alter the course of labour. The same pelvis may cause at one labour no trouble at all, and may cause the woman's death at a subsequent one. There are in fact many points besides actual measurements to be considered, and these will be passed under review in their proper order. In any case the effect of contraction in one diameter depends much on whether other diameters are large enough to compensate for the diminution and to take such diameters of the head as cannot pass the pelvic diameters with which in normal labour they come into relation. For instance, contraction in the conjugate to a small degree is of much greater importance if the pelvis is generall)' small than in one in which the conjugate is the only diameter affected. The slighter amounts of contraction are much commoner, and therefore more important than marked contractions. They are more dangerous in many cases because labour can go on to some extent before any suspicion is aroused, and the real state of things may not be discovered until late. Where the contraction is very marked it is nearly always ob\ious at the l)cginning, and preparations can be made early. The frequency of contracted pelvis must vary \ery much in different countries ; for in Germany, according" to Spiegelberg, nearly one pelvis in seven is deformed in some degree. In Great Britain the proportion is nothing like this. iLppearance of the Patient sug:^esting: Pelvic Deformity. — In the case of a primigravida seen before the sixth month or so of pregnancy it is impor- tant to be aware of the possibility of the existence of deformity of the pelvis. 4i6 Pathology of Labour In her case there is no history of previous lalwurs to suggest any cause interfering with normal parturition, and there is tlicrcforc nothing to suggest any pelvic deformity but her external appearance. In some cases there is nothing in the patient's figure which suggests the possibility of any abnormality ; but in others it may be noticed at once that the woman is dwarfed in stature, or has an obviously distorted spine ; or that there is absence or mal-development of one leg, or lameness possibly due to hip disease. Or she may be markedly bow-legged, or the shape of her face and head may be those produced by rickets. When such suggestive appearances are found, external measurement at least of the pelvis is necessary. If the patient has already borne children the history of her previous labours is of the greatest value if it can be obtained from the medical man under whose care she has been. It will be seen, when the treatment of these deformities has been con- sidered, how important it is to recognise them early in pregnancy. Labour may be induced at an appropriate time, and the woman and child may pass through labour with perfect safety. If, however, the contraction is not dis- covered until labour is begun and some delay or difficulty only then forces the deformity on the notice of the physician, it may be too late to save the child, and in some cases the mothers life may be sacrificed. Pelvimetry. — The most important measurement of the pelvis in the lar^^e majority of cases is that of the brim ; and of the diameters of the brim, the conjugate. The normal measurements of the pelvis will be found on p. 83. First of all, if possible, it is well to form some idea as to which kind of deformity is most likely to be present in the case under obser- vation. The indications, suggesting one or the other kind will be found described later under the several classes. The patient should lie on a couch in as absolutely straight and flat a position as possible on her back. The instruments required are a pair of callipers, of which Matthews Duncan's pattern is the best, and a tape measure. Various other instruments have been invented for taking internal measurements, but they are unnecessary. With the woman lying on her back the first measurements to be taken are the distance between the spines and the distance between the crests. The liistattcc between the spines is measured by placing one of the tips of the callipers just external to the tip of each spine in a small pit which can readily be felt outside the origin of the sartorius muscle. This diameter should measure 10 inches. It is sometimes recommended to place the ends of the callipers on the actual tips of the spinous processes. In this position it is more difficult to keep the ends of the callipers steadily applied to the bone ; and since in most records of cases the measurements given are usually taken outside the spines, it is necessary to mention the fact if the last-named method be employed. Disianee between the Crests. — The points between which this distance is measured are those which lie furthest apart on the crests : and these points can easily be found by the callipers in a pelvis which is not ver)' much distorted. If, however, there is so much deformity that the widest part of the crest lies, as it sometimes does, between the spines, the points for Pelvimetry 417 measurement of the crests are arbitrarily taken 2^ inches behind the spines. This corresponds to the middle point in length of the crest. The normal relation of the distance between the spines to the inter-cristal measurement is as about 10 to 11. The importance of these measurements in a pelvis suspected of deformity consists in the demonstration of (i) aclual diiiiinution in one or both measurements, showing that the pelvis is generally small ; and of (2) altered relation of the two measurements. In the commoner forms of pelvic deformity, many of which are due to early rickets, it is found that the inter-cristal measurement either does not exceed the inter-spinous by one inch, or it is no more than equal to it, or is even less than it. It is much more common to find the inter-cristal measurement diminished when this result is obtained than to tind the inter-spinous one increased. In one fonii of pelvis which is much rarer, the malacosteon pelvis, the normal relation of spine and crestmeasurement is exaggerated by diminution of the inter-spinous diameter. External Conjugate. Diameter of Baiidelocque. — This is not a measure- ment of very great value. The variable amount of fat over the symphysis and the back of the sacrum makes only a rough approximation to the actual measurements of the bony pehis obtainable. It should measure about T^ inches. The points between which it is taken have been already described (p. 85). Diameter across Trochanters. — This measurement again is only a very approxi- mate one, and is in practice frec[uently omitted. Distance betiueeji Posterior Superior Spines. — This measurement is of value as indicating the width of the base of the sacrum. The width is diminished in pelves where disease of one or both sacro- iliac articulations has interfered with the growth of the lateral masses of the sacrum. Width between Tubera Ischioritm. — This is obtained by applying the points of the callipers to the middle, as far as can be judged, of the outer edge of the tuberosi- ties ; or it may conveniently be taken by tape measure. Diminution in this measure- ment occurs in the class of pelvis which will be dealt with under the heading of Transversely Contracted Pehis. The above measurements are all ex- ternal ones, and have the advantage that they can be taken without any vaginal examination. The internal measurements are two : the diagonal conjugate, from which the true conjugate can be pretty accurately deduced ; and the direct measure- ment of the conjugata vera by the introduction of the whole hand into the E E ia;. 332. — Method of measuring the diagonal conjugate in the normal dried pelvis. It is seen from the position of the knuckles of the 3rd and 4th fingers that the finger could not be made to reach the promontory in a normal pelvis if the pelvic floor were present without very great displacement of parts and severe pain. 4i8 Pathology of Labour pelvis. This last measurement can as a rule be taken immediately after labour only. Diagonal Conjugate. — This is the distance between the promontoiy of the sacrum and the lower edge of the symphysis. It can be taken up to the time before the head descends too low to allow of the promontory being reached. The patient should lie on her left side with her knees drawn up, and the two first fingers of the right hand passed into the posterior fornix and pushed onwards so as to reach the promontory. The inclination of the brim of the pelvis to the horizon must be remembered, and the fingers will be directed almost in the axis of the trunk. When the promontory is reached, and this can only be effected with difficulty and with much pain in a woman with a normal pehis ffig. 332), the tip of the second finger is kept in Fig. 333. — Method of nie.-isuiiiii; the diagonal conjugate in .t case with contracted lirim. *■, point to be marked. contact with the promontory, and the radial border of the hand is raised so as to be cut by the lower edge of the symphysis (fig. ^tll)- The point thus cut is then marked by the tip of the finger of the other hand. Both hands are then with- drawn, and the distance between the two points measured by callipers. Care must be taken that a projection forwards of the line of union between the first and second sacral \-crtebrit is not mistaken for the promontory. This deformity is occasionally found in rickety pelves and is called a 'false promontory.' If the true promontory can be reached by the forefinger alone, it is certain that the antero-posterior diameter of the pelvis is considerably shortened. The object of taking the diagonal conjugate is to obtain a number from which the true conjugate can be deduced. It will be seen in the diagram (fig. 334) that the diagonal conjugate and the true conjugate form two sides of an obtuse-angled triangle, which is completed 334- — P ^"J ! conjugata vera ; P B, con- jugata diagonalis ; B' and B' , other situations of lower edge of symphysis. Pelvimetry 4 1 9 bya line representing the depth of the symphysis, AB. Since the obtuse angle at A is a fairly constant angle, the length of PA can be deduced from that of PB. The average amount to Ije subtracted is §rds of an inch ; so that supposing that it is found that the diagonal conjugate measures 4^ inches, the true conjugate should then be calculated at something between 3J and '})'h ! this is quite near enough for practical purposes. In cases where the depth of the sym- physis is greater than the normal one of \\ inch (B'),|it will be readily seen that more has to be subtracted from the diagonal conjugate to obtain a just estimate of the measurement required. More has to be subtracted also when the symphysis is inclined away from the usual angle (B"), so that its lower edge is further forwards (%• 334)- In all cases therefore, the depth and inclination of the line AB should be ob- served where this measurement is being taken . Direct Measurement. — This is taken after labour by introducing the whole hand into the \agina. In cases where the pelvis is contracted con- siderably, it will be found that the figxire can be arrived at by passing the extended hand with the thumb apposed gradually up through the brim : the little finger will lie against the promontory, and the radial side of the forefinger or thumb against the symphysis. It is then obser\-ed whether the true conjugate will allow the whole width of the four knuckles and thumb to pass through it, or whether the hand is arrested in its upward passage, and if so at what level. Johnson, who wrote in 1769, is quoted in Herman's work.' He elaborated a system of measurement which is performed with the hand introduced as above, and held in various positions, the measurements of the hand in these positions being previously known. Those of a man's hand of average size are : (i) The fingers being bent into the palm and the thumb extended and applied close to the middle joint of the forefinger, the distance between the end of the thumb and the outside of the middle joint of the little finger is 4 inches. (2) In the alDove position, the distance from the thumb at the root of the nail, in a straight line with the outside of the middle joint of the little finger, is 3:f inches. (3) The fingers being in the same position, and the thumb laid obliquely along the joints next the nails of the first two fingers and bent down upon them, the distance between the outside of the middle joint of the forefinger and the outside of that of the little finger is 3^ inches. Difficidl Labour, p. 176. 420 Pathology of Labour (4) The hand beiiij,-^ opened, and the fingers held straight, the whole breadth from the middle joint of the forefinger to the last joint of the little finger is 3 inches. (5) The fingers being so far bent as to bring their tips to a straight line, their whole breadth across the joint next to the nails is 2i inches. (6) When the first three fingers are thus 1)ent, their breadth across the same joint is 2 inches. (7) The breadth of the first two across the nail of the forefinger is \\ inch. Direct measurement by the whole hand must never be neglected after a labour in which there has been any difficulty that may possibly be ascribed to deformity of the pelvis. Under special circumstances there are two other methods of arriving at the true conjugate. The first is to depress the abdominal wall so that the promontory may be felt through it, and to measure from this point to the front of the upper edge of the symphysis. This is best done by a tape, one end of which can be pressed on to the promontoiy by the forefinger of the left hand, while the other end is carried forwards o\er the top of the symphysis. The thickness of the abdominal wall in front of the promontory is about balanced by the thickness of tissue, including the bone, in front of the pubic end of the diameter. It is impossible to measure the conjugate in this way when the brim is occupied by the uterus, pregnant or recently emptied. A considerable amount of fat in the abdominal wall or rigidity of the abdo- minal muscles is a bar to its employment. The second way is by measuring the foetal head after labour. After labour has taken place through a narrow conjugate, the foetal head is moulded, so as in one diameter which is now measured with callipers to accurately represent the conjugate measurement. If the mechanism of labour has been observed, the diameter through which this measurement should be taken is known ; and if the contraction is con- siderable the promontory may cause the formation of a groove in the bone of the vault which has been pressed against it. Value of Pelvimetry in Practice. — E.xact figures are unattainable by any of these methods except by that of direct measurement, and, as a matter offact, if they could be obtained they would be of no conclusive value, since there are so many other factors in\-olved in the passage of the head through the available space. First, the exact size of the head is unknown ; second, the force of the uterine contractions which will be present in any case is un- known ; third, the degree of ossification in the foetal head is unknown ; so that if the estimated conjugate, or other diameter, docs not vary from the actual one by more than \ of an inch, it is quite near enough for all ])raclical purposes. The history of previous labours is a point of the greatest value and of still more value if labour has been induced prematurely, and careful notes of its progress have been kept. It is important to remember that the head is more ossified in male chil- dren than in female, and in later pregnancies than in earlier ones ; and that the woman's strength and that of her uterus are usually found to be diminished after several labours. This subject will be returned to and further considered when the treatment of contracted pchis by induction is being dealt with. DevelopviCJit of Pelvis 42 1 CHAPTER LVII DEVELOPMENT OF THE ADULT PELVIS The adult pelvis, as described in Chapter X., differs in several important points from the infantile type. A knowledge of the latter type is essential, since most of the deformities to be described arise while the bones are still in process of growth. In young children the sacrum is comparati\'ely very narrow, and the transverse diameters small ; the sacro-vertebral angle does not form a pro- jection to the extent shown by the promontory in the adult ; the tubera ischiorum are, in proportion to the width of the brim, much closer together ; the inter-spinous measurements are nearly as large as the inter-cristal ; the pelvis, as a whole, is smaller in proportion to the body. Changes. — During the whole of the child's life an alteration in size and shape is going on, but at the time of puberty the change is most marked. The alteration is due to (i) the growth of the pelvic bones with the growth of the whole body ; (2) the action of those muscles which are either attached to, or act indirectly upon, the pelvis ; (3) the body-weight transmitted through the pelvis to the femora in standing and walking, or to the tubera in sitting. Speaking generally, the action of growth is mainly exercised in altering the shape of the sacrum ; which becomes wider by the growth of its alte. The body-weight and the muscular action tend in another way to further widen the pelvis. Counteracting the outward thrust of the femora entirel)', howe\er, the muscles attaching the lower end of the spinal column to the femora, principally the psoas, produce an inward thrust. In the standing position the inward thrust preponderates ; in sitting, owing to the i^elaxation of the muscles, the outward thrust of the tubera preponderates. Sacrum. — It has been said that the effect of growth is mainly exerted on the ahv, and the sacrum is thus widened. The effect of the body-weight transmitted through the vertebral column is twofold, and consists in {a) an alteration in the curves ; and (J)) an alteration of the position of the sacrum in relation to the axis of the trunk. The body-weight is found to be transmitted along a line passing vertically through or just in front of the sacral promontory (fig. 335). The sacrum is supported at the sacro-iliac synchondroses, and the line joining the centres of the area of support on these surfaces passes well behind the promontory. The promontory is therefore forced downwards and forwards towards the centre of the pelvis. The alte are held back at the sacro-iliac joints, and so 422 PatJiulogy of Labour the anterior transverse concavity of the sacrum is diminished. It becomes flatter in the greater part of its extent, and at the promontory becomes even slightly convex (fig. 338). ib) When the promontory of the sacrum falls forwards and downwards under the pressure of the body-weight, the sacrum rotates on a transverse axis (the line joining the centres of the area of support alluded to above) running through somewhere about the centre of the sacro-iliac synchrondro- sis, and so the bone tends to move into a horizontal position. The sciatic ligaments, however, with the pyriformis and part of the levator ani and peh'ic fascia prevent the lower end from going backwards and upwards (fig. 335), so the ultimate effect of these opposing actions, one at each end of the sacrum, is Fig. 335. — Development of pelvis (sacrum). (The verte- brae are numbered.) Body-weight falls along line indicated. The arrows show the pull of the sacro- sciatic ligaments. Fig. 336. — Development of pelvis (sacrum). Adult shape. to bend the sacrum and increase its anterior vertical conca\ ity (fig. 336). The body-weight tends also to make the sacrum sink bodily forward and down- wards between the iliac bones (fig. 2)yj)- Innominate Bones. — The sacrum is supported to a very considerable extent by the posterior sacro-iliac ligaments, which suspend it between the posterior ends of the innominate bone. These ligaments, being attached to the innominate bone behind the sacro-iliac synchondrosis, convert each bone into a lever. In looking at these bones as levers of the first kind it will be seen that the effect of the body-weight acting through the above-named ligaments is to pull the posterior ends of the bones downwards and inwards. The fulcrum is at the sacro-iliac synchondrosis, and the anterior ends of the bones are pulled outwards and upwards (fig. '^2,7). For the bones to mo\ e in this way they would have to part company at Development of Pelvis 423 the middle line in front ; but this is prevented by the symphysis pubis, so that the only action produced is an increase in the curvature of the lever, and thus of the transverse dia- <^ meter of the pelvis. The innominate bones in their turn rest on the heads of the femora in a standing pos- ture. Their resistance to the body- weight is directly upwards. Since the points where the re- sistance is applied, namely, the acetabula, lie outside a vertical line drawn from the sacro-iliac synchondrosis (fig. 337), their upward pressure would rotate the iliac beam round this joint as a centre, so that the acetabulum should move upwards and out- wards. The outward component is more than neutralised by the inward pull of the muscles attaching the head of the femur to the pelvis, and the pressure becomes an upward and iiiward one. The most marked instance of the effect of this inward pull is shown m the malacosteon pelvis (p. 449). When the subject is sitting the upward pressure is transmitted from the tubera. These also lie outside a vertical line dropped from the sacro-iliac g. 337.— Development of pelvis (infantile shape). The arrows represent the direction of the inward pull of the sacrum on the posterior ends of the innominate bones, and its result in tending to widen the pelvis. -Development of pelvis. Adult shape. The transverse diameter and the anterior convexity of the sacrum are exaggerated for the sake of contrast. joints, and therefore tend to widen the pelvis ; and, since the muscles are relaxed and there is thus no opposmg inward pressure, the widening action 'is well marked. This effect is most marked in the case of pelves belonging to women who ha\e no legs. 424 Pathology of Labour Effects cf inclination of Pelvis. — -The more tlie brim of the pelvis is in- clined to the horizon, that is, the more vertically, in an antero-posterior plane, the sacro-iliac joint lies above the point of application of upward pressure, the greater is the outward thrust, for the line of the application of the force lies more in the plane of the brim, that is, in the line of direct transmission ; and, on the other hand, the greater the angle between the line of upward pressure in the femora and the line joining the acetabulum to the sacro- iliac joint, the less effectual is the outward pressure, since the upward pres- sure acts in a direction less parallel to the plane of the brim. In consequence, it is a general rule that the greater the inclination of the pehis (as in lordosis of the lumbar ^ertebne) the wider it is ; and the less the inclination (as in kyphosis of the lumbar vertebrae) the narrower. The application of these rules will be seen when the methods of production of the different kinds of deformities are considered. CHAPTER L\'11I VARIETIKS OF DEFOKMED PELVIS The only practical way of classifying deformed pehes is to do so by the resulting deformity and not by the pathological causes. We ha\e the following : — Those with contracted conjugate, in which the pehis ma)- be small, but is fairly symmetrical. Those contracted obliquely. Those contracted trans\ersely. Those which are crumpled up. Cases of spondylolisthesis. Those due to irregular causes, pelvic tumours, iS:c. Pelves CoxTR.\CTEr) ix the Conji'c;ate, Gexerallv Coxtracted OR Not Gexerallv Coxtracted There are three kinds of pel\is in this group : and they are named respectively : the (Generally Contracted pelvis, the Flat pelvis, and the Gcnerall)- Contracted Flat pelvis. The order of their frequency is the Flat, the ( icnerally Contracted Flat, the Generally Contracted. Flat Pelvis. Causation and Mode of Prodi/ction. — In some cases the diminution in the conjugate is caused by the soft condition of the bones brought about by rickets ; but there are many flat peKes in which there is no sign of this disease having existed. The woman is frequently, though by no r^.eans always, small and ill-developed. The deformity is produced by an exaggeration of the changes, especially (ieueraliy Co)itracted Pelvis 425 those in the position of the sacrum, just described in tlic account of the tlevelopment of the pehis. The sacrum is forced further downwards and forwards into the pelvis, and thus the promontory comes to He nearer thepubes. This is possibly due to the body-weight acting excessively in the earlier years of life on the then comparatively soft bones. The sacrum in falling further forwards than normal, widens to an extent varying in its excess the transverse diameter of the brim by pulling on the sacro-iliac ligaments (see fig. 337). Measurements. — The deformity for all practical purposes affects the brim alone. The conjugate is shortened, but not to more as a rule than to about 3| or 3^ inches. In a few cases there is slight lengthening of the trans\erse diameters. The diagonal conjugate is diminished by something near one inch. If this diameter measures less than four inches the pelvis will pro- bably be found to be contracted in other diameters also. The relation of the inter-spinous and inter-cristal measurements is altered in varying degree. The external conjugate is as a rule somewhat diminished ; but this is not a valuable measurement, as it is always a some- what variable one. The sacral spines will be observed to be slightly sunk l^etween the posterior ends of the innominate bones.' Generally Contracted Pelvis. Causation and Mode of Production. — In most cases the cause is not clear. In two varieties, namely the pelvis belonging to the dwarf, and that form which occurs in cretins, it coexists with other analogous deformities, and is so explained. In the more frequently happening instances there is no deformity in the general figure of the woman, which may be of almost any size or shape. In the case of the dwarf, the pelvis has a typically female character, but the bones are particularly light and delicate. In cretinoid cases with ill- dexeloped generati\'e organs, the pehis is rather of the male type, and is often contracted transversely. In the commonest variety where there is no other kind of deformity of the body the pelvis is of the infantile type. The lateral masses of the sacrum are undeveloped, and this bone is more concave transversely and more flat vertically than in the properly developed pelvis. 1 A rare kind of flattening of the pelvis is found in the case of the so-called split pelvis. Here there is no union (symphysis) at the anterior ends of the pubic bones, and their ends are free to part in obedience to the action of the outward lever-action [see p. 422) of the innominate bones on the sacrum. When the widening of the pelvis has proceeded to some degree from this cause, the oiitivard pressure of the femora is, as will be readily seen, much increased, for their upward pressure takes effect along a line more outside the vertical line from the sacro-iliac synchondrosis than in the normal pelvis. This pelvis occurs as part of the deformity in extroversion of the bladder. If pregnancy ever occurred the separation of the ends of the pubic bones would prevent any difficulty in delivery. .■\nother rare ])elvis is that due to the condition, wrongly named, oi to//gcriital disloca- lioii of the hips. Here on accf)unt of the backward displacement of the heads of the femora, the ilio-femoral ligaments pull the anterior part of the pelvis backwards, the force taking effect in a downward and backward direction, owing to the inclination of the pelvis. This inclination is thereby increased, and as shown on p. 424 this will cause the pelvis to widen. The psoas and iliacus muscles will act in the same direction as the ligaments, and their direct inward pressure and that of the other muscles being diminished by the position of the heads of the femora, the outward thrust of the thigh bones will preponderate. The inward thrust is e.xerted further back than normal, and merely renders the iliac bones more up- right. This pelvis has not been found to cause difficulty in labour. 426 Pathology of Labour The promontory is also higher and the sacrum less sunk forwards and downwards ; the posterior superior spines are proportionately wider apart ; but the relations of spines and crests are not much altered, though the actual measurements are diminished. This deformity appears then to be mainly due to arrested development, without there being any special line of ab- normality. The result is a pelvis diminished in all its diameters, the diminution being most marked in the transverse. In measuring the diagonal conjugate and then the conjugata vera in such a pelvis when dried it will be noticed that the former is unusually long as com- pared to the latter. This state of things is due to the unusual height of the promontory, and also in some degree to greater steepness of the symphysis. The diagnosis of this class of pelvis is difficult, and since there is nothing specially pointing to pelvic contraction to be found in the woman's figure in most cases the condition is not disco\cred until after labour has become obstructed. Herman has named this pelvis the 'Small Round' pelvis. Generally Contracted Flat. Causation atid Mode 0/ Production. — This form of contraction is practically always due to rickets. In addition to the deformities described in the flat pelvis there is added some distortion due to marked softening of the bones at an early age, and also to the stunting of growth common in these cases. So that we find the pelvis reduced in all diameters. The sacrum is, owing to the softness of the bones, displaced forwards and downwards as in the flat pelvis, and it has yielded in the centre from the same reason so considerably as to cause the promontory to project forwards and produce the kind of pelvis which, from the outline of its brim, is called the Reniform Pelvis. The slight general concavity of the sacrum on transverse section is changed into a decided convexity, especially at the upper part of the bone ; and the vertical concavity is much exaggerated, so that the upper part of the sacrum looks almost downwards. The relative size of the transverse diameter is increased by exaggeration of the normal widening action already described (p. 422), and the most marked effects in the modification of shape of the several bones will naturally be found at or near their growing surfaces — at the junction of the body and wings of the sacrum, and at the acetabulum where the three divisions of the innominate bone unite. The outlet of the pelvis is somewhat widened in proportion to the brim. This is due to the action of the body-weight through the tuberosities while the child is sitting. Owing to the weakness caused by rickets a child thus affected probably sits a great part of its time. The ilia are everted by the action of the glutei, and the relations of the inter-spinous to the inter-cristal measurement is thus considerably changed. The inclination of the brim to the horizon diminishes in proportion as the promontory is sunk forwards in the pelvis ; for on account of the forward position of the line of the body-weight thus produced there is less need of tilting forwards of the pelvis to bring the line of this weight over the femora. There is probably increased inclination to begin with, owing to the e.vaggera- Effects of Contracted Pelvis on Pregnancy 427 tion of the lumbar cur\c which is common in cases of rickets ; but this afterwards corrects itself as the sacrum comes downwards and forwards. The lumbar and dorsal curves in this disease are as a rule much increased, and there is often more or less lateral curvature of the spine, the promontory being on this account displaced to one side or the other (see p. 444, Skoliotic Pelvis). Result. — We have thus a pelvis with a conjugata vera shortened to anj- degree ; a small, but relati\ely to the other measurements large, transverse measurement, and with all the other characters described as belonging to the flat pelvis. It is of very great importance to remember that the con- traction of the pelvis affects the whole length of the bony canal, and not the brim alone as in flat pelvis. Diagnosis. — The points of importance to be noticed are any signs of rickets which may be observed in other parts of the body, and the relations of the spines and crests. The diagonal conjugate gives as a rule a very fair idea of the true conjugate. The pelvis is usually slightly beaked, owing to the inward pressure of the femora. Sometimes the brim of the pelvis shows an outline something like that of a figure of 8. This rarer form is said to be produced by the action of the recti muscles. Effects of above forms of Pelvis on Preg'nancy, Iiabour, and ILying:- in. — It will be well to consider these effects here, since the forms of pelvis just described are very much commoner than those to be mentioned later, and the modifications caused by them in labour may be taken as fairly typical. Pregrnancy. Displacement of Uterus. — The lower end of the foetus normally occupies the brim, dipping clown into it at term to an extent mentioned and figured on p. 129. When the brim is contracted this cannot happen, at all events when the child has attained its full or nearly full development. The incompleteness of occupation of the brim is, of course, the greater the more the conjugate is diminished. The result of this is that the foetus, and in consequence the whole uterus, have both to grow at a higher le\'el in the abdominal cavity than is the case when the pelvis is normal. As a result also of the failure of the foetus to enter the brim the uterus is more easily displaced forwards or laterally. Thus in cases where the abdominal muscles are much relaxed owing to previous pregnancies, and where there is a considerable amount of diastema of the recti, the uterus falls forward partly by its own weight and partly by the pressure downwards and forwards exerted by the diaphragm. In this way the most marked degree of the condition known as Pendulous Belly (p. 271) is produced. The forward displacement is much accentuated if there is any shortening of the lumbar spine from curvature : this is especially the case when there is lordosis, where the form of curvature of the spine adds another cause of forward pressure. Exaggerated lateral deviation is also common owing to the increased mobility of the uterus. Matpresentations. — These are produced in cases of contracted pelvis l)y several causes acting simultaneously. 428 Pathology of Labour {a) The head is not able to enter tlie brim and rest there. It can thus l)e turned about readily, and extension in \arious degrees and lateral movements may easily occur. (fi) The e.\aggerated obliquity of the uterus may, if the back of tlie fcetus lie to the side towards which the uterus is inclined, cause extension of the head (see Face Presentations, p. 154). (c) The head or the breech, as the case may be, does not fill the brim, since it cannot descend into it, and the hand or cord may slip down in head cases, or the foot or cord in the podalic lie. The He of the child is apt to change often during pregnancy. Incarceration of the Uterus. — If the uterus becomes retro\erted during pregnancy, or if, as is more commonly the case, impregnation occurs in an already retroverted uterus (see p. 273), the uterus, instead of being able to restore itself during its growth, is prevented from rising by the fundus being caught under the projecting promontory. This is an effect most character- istic of the flat or generally contracted flat pelvis, and one which the generally contracted pelvis does not produce. . The increased height of the uterus in the abdomen in contracted pelvis must al\\ays be rememljered in calculating the period of a pregnancy from the position of the uterus. ^Labour : First Stagre. — The head cannot enter the brim as far as usual, and it cannot therefore get low enough to fill the lower uteiine segment, as this is distended and forced down during the first stage. In consequence the intra-uterine pressure comes with its full force on the bag of membranes ; and so this is elongated (as in breech cases from the same reason), dilates the cervix imperfectly, and ruptures early as a rule. (See Results of too Early Rupture of Membranes, p. 1 14. ' The whole of the liquor amnii then drains away, and the pains become characteristic of the second stage of labour. The os is now not dilated by the still too high head, and so collapses again even if, as rarely happens, it has been already well dilated by the membranes. The pains continuing force the head against the brim, and cause the cervix to be nipped between these two hard surfaces. Second Stagre. — The course of labour now depends on the amount of pelvic contraction, and on the strength of the pains. {a) If the contraction is mor/erate, alloiinng the head to pass after much moulding. — Supposing the pelvis is contracted in the brim only, and has a conjugate of sa\- 3^ inches ; then if the uterus responds to the increased resistance by increased activity the head is forced through the brim, and the I rouble is at an end. If, however, the uterus is weak it contracts round the child (tetanus), the mother becomes exhausted, the child dies from pressure, and the uterus is damaged by the long-continued pressure and by local sloughing, and in some cases septicaemia is produced ; or exhaustion of the uterus may supervene (see p. 412). {b) If the contraction is great (f7'om tJirce inches doivnivards). — Incases where the pains are strong they become violent, the patient is greatly dis- tressed and makes powerful bearing-down cft'orts, which at times lead to emphysema of the neck and face from rupture of some of the air-\esicles of Effects of Cotitracted Pelvis o)i Labour 429 the lung- ; the uterus soon becomes excessively retracted and may rupture, or it may contract round the child and become tetanic, and then the effects just described under (^i;) are brought about. {c) If the pelvis is contyacted tiwoiigJiout the results are the same, but the condition is more certain lo become severe since the ol^struction does not cease at the brim. The effects on the maternal tissues in detail are : ia) On the uterus. These have been already described under the heading of Prolonged Labour (p. 409). On the cervix. This is nipped, as has been just mentioned ; it becomes cedematous from strangulation, and from this cause htemorrhages into its substance, and sloughing to a greater or less extent may occur. Fig. 339. — Flat generally contracted pelvis, showing the projection of the promontory, which looks to the left. The relative widths of the inter-spinous and inter-cristal measurements are seen. The head was impacted, Ca;sarian section was performed. (.St. George's Hospital Museum.) {b) On the vagina. This is the most commonly damaged part, for the cervix is usually pulled up out of the way, and leaves the brunt of the pro- longed pressure to fall on the former. The same effects are produced as on the cervix. The result of sloughing in both cases is to produce fistulEe, the size of the opening depending on the extent of the tissues killed. These fistuhe practically always open into the bladder (vesico-vaginal, utero-vesical), and not into the rectum. Posterior fistula; are very rare, since it is quite seldom that the opening occurs into the peritoneal cavity, and this would very soon be closed by the effusion of lymph ; and on the other hand the pressure against the sacrum is never so long continued as that against the back of the pubic 430 Pathology of Labour bone, on account of the curve of the parturient canal. Moreover, the concave surface of the sacrum forms a broader surface for the head to press against, and produces less damage than the comparati\-ely sharp edge of the back of the pubic bones. Recto- \aginal fistulae are extremely un- common, for the head must be moulded very considerably before it can pass the brim, and therefore passes more rapidly through the lower part of the genital tract. ((-) On the child. After the liquor amnii has drained away the intra-uterine pressure is exerted directly on the child and the pla- centa. It damages the nervous centres of the child if it is long con- tinued, in the end causing death ; and it arrests the circulation through the placenta, in this way also leading to a fatal result from asphyxia. The effect on the head is very marked. A very large caput succedaneum is produced in all cases. In flat pelves the Fig. 340. — Vault of skull moulded by pelvis in last figure. The depression at the left half of the coronal suture corresponds to the promontory'. The occiput was to the left. Fig. 341. — Side view of same skull as fig. 340. The great depression of the left side of the skull, and the separation of the edges of bone forming the sagittal suture are seen. caput is formed at the brim, and in a great decree by the cervical ring. In the other two forms the resistance and pressure arc maintained throughout Effects of Conlracied Pelvis on Labour 431 the passage of the head through tlic bony pelvis, and the swelling continues to increase until the head reaches the vulva. The great pressure causes l)ruising of the skin and sometimes local sloughing", the site of this varying in different cases according to the particular mechanism of labour. These injuries are nearly always produced by the pressure of the promontory, which also causes depi'essions in the Ijones of the vault of various kinds. These are sometimes g'roo\es \\hich are found to in\"ol\e those parts of the skull which ha\-e successi\'ely impinged on the promontory, or they may be more or less circular depressions. Fractures of the bones of the vault and hae- morrhages either beneath the scalp, beneath the periosteum, between the bone and the dura mater, or more rarely into the brain substance, are found. The hi^morrhage into the meninges is usually at the base of the skull, not usually over the hemispheres or into the ventricles. The moulding in all these cases D.P.- U.VE Fig. 342. — Abnormal height of uterus post-partum caused by contracted brim. DP, Pouch of Douglas; R, retraction ring; f /, os internum: O E, os externum; UVP, utero-vesical pouch ; />/, bladder. (From a frozen section Ijy Barliour.) (Compare fig. 141, p. 126.) is much exaggerated ; the parietal bone which is posterior being, if not grooved or dinted, considerably flattened. Considerable moulding causes dangerous over-riding of the sutures (fig. 341), and this maybe so great as to lacerate the sinuses, and cause hoemoiThage and death of the child. In head last cases where traction is applied to the base of the skull through the neck the lower bones of the skull ma)- be partially separated from the upper by tearing of the sutures uniting them. Thus the squamous or lambdoid suture may be torn through, or the basilar portion of the occipital may be separated from the squamous portion. Tbird Stag-e. — During and immediately after the third stage of labour the woman runs a certain amount of risk of post-partum haemorrhage. This is liable to occur, firstly, on account of the exhaustion of the uterus 432 Pathology of Labour caused by its efforts to expel the foetus through unusually resisting passages ; and, secondly, because the uterus after its contents have been expelled does not in cases of considerable contraction of the brim completely fill the pelvis and compress the vessels from which it derives its blood supply (fig. 342), as is the case in the normal pelvis (see p. 213). Another likely cause of haemorrhage consists in the lacerations of the cervix, which not uncommonly arise during instrumental delivery through an imperfectly dilated os. Xiyln^-ln. — Owing to the damage of the soft parts produced by their compression between the child's head and the bones of the pelvis, and to lacerations, the woman is more exposed to septicaemia than she is after normal labour. In addition to this, manipulations and operations of all kinds necessitated by the obstruction to the course of labour favour the introduction of organisms, both in the air which is admitted under these circumstances, and on the hands and instruments passed into the vagina and uterus. The production of fistulK has been already alluded to ; they usuallyshow signs of their presence (leakage of urine) towards the end of the first week, when the sloughs separate. CHAPTER LIX MODIFICATIONS OF THE MECHANISM OF LABOUR IX THE COMMONER VARIETIES OF CONTRACTED PELVIS It is necessary to know the various ways in which nature deals with the difficulties met with in parturition, so that we may then be able to help the woman in the best and most scientific way. The three groups of contracted pelvis already described are best divided for this purpose into two classes : first, those in which the obstruction occurs at the brim only, Flat Pelvis ; and, second, those in which there is difficulty at the brim, and at other parts of the pelvic canal as well. Generally Con- tracted Flat, and Generally Contracted pelvis. This division will be found to group in a practical manner certain other differences in the mechanism. First Class ; Plat Pelvis ; Obstruction at brim only. — The shape of the brim in this class is usualh' elliptical ; but it is sometimes reniform, especially if the flattening is clue to rickets. The modifications found in labour are : 1. A new cur\c in the path of the head is added to the line which the head follows in passing through the parturient canal. This is due to the projection of the sacral promontory (see p. 425) ; and the curve added has a concavity backwards, which represents the line in which the head moves as it passes in front of the promontory. 2. A transverse position of the head at the brim. Labour in Case of Flat Pelvis 433 3. Nrigelc obliquity or asynclitism of the head. 4. A tendency of the whole head to move towards that side of the pelvis towards which the occiput points. In all these cases after the brim has been passed the mechanism is as usual. 1. Fat/i of the Head past the Promontory. — Owing- to the encroachment of the promontory on the space at the brim, and the consequent hollowing-out of the sacrum Ijeneath it, the head in entering the brim has to revolve round the promontory, just as it does in normal labour round the pubes. 2. Transverse Position of the Long Diameters of the Head Ovoid. — In an elliptic pelvis the occipito-frontal diameter cannot lie in one of the oblique diameters of the pelvis on account of the sacrum being thrown forwards along its whole width, and the oblique diameters being thus diminished. The only available diameter, therefore, is either the transverse diameter or one parallel to it. It is almost always one in front of the transverse diameter on account of the forward position of the sacrum. This transverse, forward position of the head occurs in both elliptic and reniform pelves (see figs. 346 and 347). 3. Ndgele Obliquity. Anterior Parietal Obliquity. Asynclitism. — This is a want of coincidence of the horizontal planes of the head with the plane of the pelvis occupied at the moment by the greatest transverse diameter of the head. It was supposed by Nagele to occur in normal labour, but this has been shown not to be the case (see P- 135)- It does happen in flat pelves, and is the easiest way for the bi-parietal diameter to pass the brim. Its mechanical advantage is as follows : Supposing that the conjug'ate measures 3i inches, the bi-parietal diameter (3? inches), „. , , . ^ ~. •^^ ' . ^ . ,' fig. 343. — erf, bi-panetal diameter : or even one slightly anterior to this, could not pass « b, super-parietal- sub-parietal with its plane coinciding with that of the brim £"h gainecf.'"''^' '^''^'' '^^ (synclitic). If, however, one parietal bone descends before the other, a super-parietal sub-parietal {a b) diameter engages. This is slightly shorter than the bi-parietal {c d)., and the head slips through in this way like a stud through a button-hole. The mechanical advantage thus obtained is the cause for the assumption of this attitude of the head, and it would necessarily come about after a longer or shorter time spent in attempts at forcing the head through the brim with the plane of the head coinciding with that of the brim. Its production is favoured from the beginning of labour by two circumstances. First, the uterine axis in these cases is somewhat behind that of the pelvic brim. The uterus is in other words inclined backwards, and exactly the same process occurs as the one which in cases of lateral obliquity of the uterus brings about face-presenta- tions, or increased flexion, according to the relative positions of the back or front of the foetus and the side to which the womb is inclined (see p. 154). The front side of the head is pushed down first, and the head passes the brim with the anterior parietal bone in advance of the other, and so the head is flexed towards the posterior shoulder (fig. 344). 434 Pathology of Labour Second, in cases of pendulous Ijclly, common in contracted pelvis. although the inclination of the uterus is anterior instead of posterior to that of the axis of the brim, yet the head eventually finds itself in an attitude of Xiigelc obliquity. For in the beginning the head lies with its anterior ])arietal bone most deeply engaged in the brim, and as the head descends it |)asses the brim in this way, the sagittal suture lying much nearer to the sacrum than to the pubes (fig. 345). The projection of the promontory is said to have much share in causing this obliciuity. If the pelvic brim is looked at from above or below, there is no doubt a projection of this part over the brim together with a forward |josition of all the lower lumbar \ertebr?e ; but if it is seen sideways (as in tig. 342) the promontory does not project in front of the line of the lumbar vertebra:, and there is no reason why the side of the head should catch on it. Fig. 344. — a, pressure transmitted through condyles rotates head round centre c, in \ irtue of )ever c b, so that a tends to move towards a! . .The further a moves in this direction the greater rotating power the force a has. Fig. 345. — Relation cf head to brim in pendtdous belly. Niigele's obliquity is often described as an approximation of the head towards the posterior shoulder of the child, but this is wrong. Its practical aspect consists in the relation of the child's head, not to its shoulders, but to the plane of the brim ; and it may exist with or without lateriflexion of the ffjetal head, as in the case just mentioned of pendulous belly. The result of the obliquity is to bring the sagittal suture nearer to the promontory than to the pubes. 4. Horizfliitnl Moveinent of Head in tlic Direction of the Back of tlir Child. — This movement is caused by the shape of the upper surface of the child's head. The bi-parietal diameter is greater than the bi-temporal. The upper surface of the head thus forms a blunl wedge, which is broadest behind, and when this wedge is forced into the space bounded b)' the symphysis in front and by the promontory behind, it tends to move hori- zontally in the direction of the base of the wedge — that is, in the direction in which the occiput points, and it brings the. smaller diameters of the front of the vault into the narrowest part of the l)rim, namel\-, the conjugate. This Laboin- in Case of Flat Pelvis 435 liori/onlal nio\enicnt is not marked in an elliptic pelvis, since the conjugate is not much narrower than other antero-posterior diameters of the brim ; it is most extensive in the reniform brim, and is limited by the space available for movement in tlic trans\-crse diameter. Passai;v cf tlic Brim. — When the head has arrixcd at its limit of horizontal movement, it passes the brim in one of two wa)'s — Ijy increased flexion, or by extension. In the case of the elliptic pelvis, the bi-parietal diameter is gripped at each pole by the anterior and posterior boundaries of the brim respccti\eh- (fig. 346). .Since the bi-parietal diameter is nearer to the occiput than to the forehead, it happens that when the intra-uterine pressure is applied to the base of the skull, the occipital end of the head is held back and the frontal descends, and so the head is extended. Face and brow presentations arc thus produced. P'ig. 346. — Elliptic brim. Extension of head. Fig. 347. — Reniform brim. Flexion of head. a />, diameter caught by the pelvis. F, forehead ; O, occiput. Diameter caught by pelvis lies nearer frontal than occipital end of head. If, on the other hand, the brim has a reniform shape, the part gripped is somewhere about the bi-temporal diameter, which is caught between the projecting promontory and the back of the symphysis (fig. 347). The front part of the head is now held back, and the occiput descends, producing exaggerated flexion. After f he passage of the brim, which ma}- be effected in favourable cases with a conjugate as low as 3^ inches, the mechanism is as usual. If the extension produced as just described is moderate, the head flexes in the cavity, and the only trouble likely to occur is in the case of occipito-posterior positions, where in consequence of insufficient flexion the occiput may be rotated into the hollow of the sacrum, and may remain unreduced, as has already been described in Normal Labour. (See Unreduced Occipito- Posterior Positions.) If extension is marked, the case goes on as a face- piesentation, or in very rare instances as a brow-presentation. Aftercoming Head. — In breech cases the same delay occurs at the brim when the head is engaging as in head-first cases, and the same horizontal movement takes place. The important difference in the mechanism is that the head enters the brim by the base of the skull, which is the narrower end of the wedge in a vertical section of the skull (see fig. 104, p. 92). This gives a great advantage as regards ease of passage, for there is considerabI\^ less friction owing to the angle at which the sides of the skull meet the pelvic walls ; and there is probably no need of Xiigcle oI)lic[uily \i\ the time the F K 3 436 PatJiology of Labour head has descended sufficienily to brinj( its widest diameter, the bi-parietal, into relation with the brim. When the bi-parietal diameter is ^^ripped in the elliptic peh is the head will flex, for the frontal pole will descend ; when the bi-parietal diameter is gripped in a reniform pelvis, the head will become extended. The results of this gripping, as well as the foetus, are thus inverted. At this stage the uterus has retracted down so as to only contain the head and the placenta, and therefore acts at a diminished advantage, com- paring it with what happens in head-first cases ; and assistance will be required in the passage of the brim. Posterior Parietal Obliquity. — In \ery rare cases the posterior parietal bone presents at the brim, and brings the sagittal suture nearer to the pubes than to the promontory. This may be due to the axis of the uterus being behind that of the brim, and the posterior parietal bone descending and becoming engaged in the brim. The line of force acts here in the same manner as it does in the case of pendulous belly, and not as shown in fig. 344 ; and the head, instead of revolving as it usually does, so as to bring the anterior bone lowest, gets fixed in the brim just as it lies. In face cases the head is found to lie in the transverse diameter of the pelvis just as happens in vertex presentations, and a similar horizontal move- ment of the head takes place. Second Class. Generally Contracted Flat and Generally Con- tracted Small Round) Pelves. Obstruction tbrougrbout Pelvic Part of Canal The transverse position of the head at the brim, Niigelc obliquit\-, and the horizontal movement of the head in the direction of the child's back, occur to some degree in any case where the conjugate is contracted in pro- portion to the transverse diameter. The more the pelvis approaches to the justo-minor shape, the more does labour resemble what occurs in a normal pelvis with an unusually large head. The points in the mechanism of labour characteristic of these pelves are : 1. Flexion occurs to the greatest possible degree. 2. If the occiput is posterior to begin with it remains so. 3. Moulding of the head is very considerable, and a very large caput succedaneum is formed. These further peculiarities of mechanism are mainly due to diminution of the transverse diameters throughout. (i) Increase in Flexion. — If the transverse diameter at the brim is less than 4i inches the occipito-frontal diameter will not pass ; the head then flexes in a marked degree so as to bring the sub-occipito-frontal diameter into engagement. If flexion does not soon happen, or if the transverse diameter of the brim is less than four inches, the head is arrested at the brim. The posterior fontanelle is thus found very low on examination early in labour. In some cases where the brim approaches an elliptic shape, and the bi-parietal diameter is caught, the head will be extended just as happens in flat pelvis. (2) Persistence of Occipito-posterior Position. — The occiput, if posterior to start with, cannot rotate round to the front when it reaches the pelvic Diagnosis of Pelvic Contraction during Labour 437 floor, for ihc transverse diameters of the lower part of tlie pel\ is in which rotation forwards has to occur are too small to allow the sub-occipito-frontal diameter to occupy them ; the long axis of the head engaged has therefore to follow the screw shape of the pelvis, and cannot be influenced by the slopes of the pelvic floor. This mechanism is comparable to that which obtains in the case of an imperfectly flexed head when the occiput is posterior in a normal pelvis (see p. 145). If in the kind of pelvis under consideration the occiput happens to be anterior to start with, it rotates forwards before the vertex reaches the pelvic floor, rotation being caused by the screw shape of the pehis ; and as the head recedes after a pain it can be felt to rotate back again. (3) The exaggerated moulding \% due to the length of time the head is compressed by the walls of the pelvic canal ; and the unusual size of the caput is caused in the same way. Aftcrconiing Head. — In this lie the head may engage more easily ; but after engagement the prognosis is extremely unfavourable, since the delay in extraction will certainly cause the child's death. Diag:nosis during' labour of Contraction, and of tbe kind of Con- traction. The methods of making this during or before pregnancy ha\e been already described. It is often necessary, howexer, to ascertain the fact of contraction after labour has begun. The points to be noticed then fall under the following- headings : {a) General appearance of the woman (as before). ip) The course of labour on this particular occasion; (6") The history of previous labours if any have occurred. We need here consider only the points under {b). If the head is impacted or arrested when the patient is first seen, and there is no mal-presentation such as a brow or an unreduced mento-posterior position, and the uterus is acting well, the pelvic diameters must be somehow diminished, or the child must be too large. In this case the pelvis should be measured, and the appropriate treatment at once proceeded with. Fibroids (p. 455) and pelvic tumours must be excluded. If the case is seen early in labour before the head is engaged, and in all probability attention will have been directed to the nature of the case because the head does not engage, the points to note are the general condition of the woman as bearing on the question of good expulsixe power ; the condition of the uterus (tetanus, inertia) ; the effect of pains if any are present ; whether the head, if it is presenting, can be pressed into the brim ; the size of the child ; the position and attitude of the head on vaginal examination, that is, whether the posterior fontanelle is specially low or not : whether the long diameter is transverse ; and the external, and as far as possible the internal, measurements of the pelvis. 43'^ P (Ethology of Labour CHAl'TER LX TKKATMENT OK THE COMMON FORMS OF CONTRACTKlJ PK1.\IS iHK treatment of contracted pehis may be considered as it occurs in (i) cases where the woman is seen, and the condition recognised early in pregnancy ; (2) cases which are first seen when the woman is in labour. Class 1. — Under these circumstances if the pelvis is still sufficiently large for a child capable of being reared (viable)' to be born through it, labour must be brought on prematurely. If the pelvis is too small to allow of the passage of a \ iable child, the alternatives are (a) the induction of abortion ; and (b) remo\al through the abdomen by opening the body of the uterus (Caesarian section) at full time. Class 2. —Here the line of treatment to be adopted depends on a number of circumstances ; the amount of contraction, the kind of contraction, the general condition of the woman at the time, the presentation, the stage of labour, the condition of the uterus, whether the membranes are ruptured, or not, and if ruptured, whether recently or some time ])rc\ ious, and lastly, whether the child is alive or dead. The following may be considered to be important data, and on them, speaking in a general way, the line of conduct is decided. It is possible for a living child at term to be born through a pel\ is with a conjugate of 3:^ inches ; or even 3, if the circumstances arc fa\ourablc. -Such favourable circumstances are : that the woman and her uterus are in a healthy condition ; the child is lying dorso-anterior, especially in vertex cases ; the head is not larger or more ossified than usual ; that the uterus is in the normal axis ; and that the pelvis is not contracted in any other diameter than the conjugate. A child at term, after its liead has been artificially reduced by craniotomy, can be extracted through a pelvis witli a conjugata vera of anything o\er two inches fsee Craniotomy, p. 386). A child at term cannot pass through a pcKis if the conjugata vera is not more than two inches, even after craniotomy, without \cry considerable danger to the mother. The details of treatment in the two classes defined above are now to be considered. ' On inducing labour before lerni is reached a living child can be burn, and it is possible to rear this if the date of pregnancy is not less than tlie twcnty-eighlh or i\\ cnty- jiinth week. The later the induction can be left the more chance there is of rearing the child. Cases in which the head can be got through the pelvis with a moderate amount of help by the forceps may be considered to have had Tabour induced at the best possible moment. (See p. 362, Induction of Premature Labour.) Treaiuicnt of Contracted J^ek'is Diat^nosed before l.aboiir 439 Class 1. The Woman Is seen early in Pregnancy. — Ihc pcKis may Ijc large enough to allow a \ ial^le cliilcl, prciiiature or otherwise, to pass ; or it may be not large enough. A child born at the earliest \iable age 1 the 28th or 29th week; can pass through a pelvis with a conjugate of 2^ inches to 3 inches. Therefore this measurement is the smallest which \\\\\ admit a woman into the first group, that is, wJiicli gh'cs Iter a cliancc of JiuTing a I'iabtc cliild. The treatment proper for such a case is the Induction of Premature Labour. Where the patient is a primipara there is no guide from the history of pre\ious labours — the most important evidence of all — as regards the date at which induction should be practised ; for all that can be made out in addition to the size of the pelvis is an approximate estimation of the size of the child. The size of the child should be made out by abdominal palpation, bi-manual examina- tion, and if convenient, by the use of the callipers as described on p. 66 in every case; and the dates the woman gives of her last menstruation should not be implicitly accepted. In primiparJE, then, the only guide will be certain approximate dates fixed by taking the average relations of the head and the pelvis at such dates. The measurements of the conjugata vera which indicate induction of labour at an appropriate week are given in the following table : — c.v. Week 2-^ in 29th-3ist — Measuremeni of fietus in utero by callipers. 3 !"• 3 [in. 32nd 34tb 36th After measuring the pelvis and deciding on the date at which labour is to be induced, the physician should tell the patient that she must be seen about a fortnight before this date. He can then make another examination to see if it is not possible for the pregnancy to go on a little longer. The patient should be again measured at that time, and especial notice taken of the size of the foetal head, and whether it can be pressed into the brim from above. If it is found to enter the brim rcadih the ]3aticnt may be allowed to go on for a fortnight longer, when she should be again seen and the size of the head tested as before. The induction must be put off to the most favourable moment for the child, consistent with the safety of the mother. If however, when the woman is examined the head is found to be larger than would be expected at that period of pregnancy, and if it cannot be pressed into the brim, labour must be induced without delay (see Induction of Labour, p. 362). 440 Patholog)' of Laboiir It nuist be rciiKinbcrccl that the mciisurement of tlic conjugate alone, even if it could be accurately determined, does not absolutely fix the date for induction ; but that other measurements of the pehis have to be cofisidered, and if, for instance, the pelvis is a generally contracted one, the dates above given must be anticipated in proportion to the reduction of the transverse and other diameters. If a woman has had children pre\iousl)- the history of her labour or labours is of the greatest assistance. The labour may have been at term : and if an account of what assistance had to be given, and what the result was to the child, can be obtained from the medical man who attended her, it gives valuable data from which the amount of the obstruction can be esti- mated. If labour has been artificially induced in former pregnancies the patient's history is of more value still, for after considering the result of the induction at the date at which it was performed, the most favourable time for that operation in the present pregnancy can be very closely determined. In settling this date it must be remembered (i) that the age of the woman has increased, and that the child's head may be on that account more completely ossified than it was at the same date in the fomier pregnancy ; and (2 ; that male children's heads arc as a rule more ossified than those of females. To take an example. A woman gives a history of ha\ing had three children as follows : The first six )-ears ago at term ; craniotom)-. In the second, four years ago, induced at the thirtieth A\eek, an easy labour, child, a male, not reared. The third, labour induced at the thirty-sixth week, a female, child born dead after prolonged forceps traction. On measuring her pel\ is the diagonal conjugate is found to be 3| in., and the tnjc conjugate is estimated at a little under 35- in., the rest of the measurements being found fairly normal. The best time for induction will be about the thirt)-third week, and the woman should be examined again at the thirtieth, and the date then finally decided upon. In the second group, iv/ierc the pelvis zuill not at any date alloxv a viable child to pass, that is, a pelvis with a conjugate less than 2^ inches, there arc two courses open. Abortion may be induced at once, supposing that the woman is seen in the carh' months of pregnancy or at any time up to the sc\enth month ; or the woman ma)- be allowed to go to term, and then a Ciesarian section may be done. There is a third course, which may have to be adopted when the conjugate measures not less than 2 inches, and will thus allow the mento-glabellar diameter to pass, and the case is not seen till nearly full time, namely, to perform craniotom\-. Abortion. — When abortion is induced the aft'air is ended at once, and if this is done aseptically there is usually no danger. But the patient may at once become pregnant again, and abortion might in this way ha\e to be frequently induced. On one occasion or another it is possible that some accident may happen as a result of this procedure ; further, the woman n'fcver lias a child. Craniotomy. — If the woman is not seen until the end of pregnancy, or if the case has been designedly left so long so. that she ma)- choose between this operation and Ciesarian section, craniotomy will have to be considered, under the limitations abo\e given (conjugate not less than 2 inches). Treatment of Contraeted Pelvis diagnosed at Labour 441 Craniotomy aI)o\c this measurement, unless tlierc is considerable con- traction of the pelvis in other diameters, is an easy and a safe operation ; and involution and the lying-in take place normall}-. But there is a small risk each time the operation has to be repeated, though this cannot happen so often as when abortion is induced ; and again, the woman never Ijecomes a mother. Ccrsnrian scr/ion. — Althougli this is a dangerous operation its mortalitj- in skilled hands is now small, namel)-, about 5 per cent. By the operation a full)- de\eloped health)- child can be obtained ; and, a further advantage, the woman can be sterilised at the same time. In the hands of one unskilled in abdominal surgery the operation would of course be a \eiy risky one, and it would be wise to perform Porro's operation in preference. Among- these three methods of dealing with the case the choice must be finally left in the hands of the woman and her friends, all the facts and possibilities of each operation being put before them. If the pregnancy goes to term, and the pelvis has a conjugate of over 2 inches, she must choose between craniotomy and Caesarian section. At this time if the conjugate measures less than 2 inches, Caesarian section is the safer operation of the two for the i-nother ; if over 2 inches craniotomy is as a rule safer. In case the coiijugate measures less than 2 inches and the patient is seen early in pregnancy, abortion must be induced at once, or the patient must decide to ha\e a living child born at term by Caesarian section. (For methods of induction of abortion, craniotomy, and Caesarian section, see chapters on Obstetric Operations, p. 352.) Class 2. Tbe case is first seen when labour has begun. — The first thing to do when it is judged that labour is obstructed by contraction of the pelvis is to ascertain the existence of contraction, and then to make out its kind and degree. The cases may be divided here into two groups — (A) those in which the conjugate measures ^^ inches or more, and no other diameter in any plane is more than slightly involved. (B) where the conjugate is less than 3^ inches ; or it measures 3^ inches, but other diameters of the pelvis are diminished. (A) Through such a pelvis as this it is possible for a full-term child to pass, alive and viable. The points to obser\-e in the conduct of labour in these circumstances are — 1. T/ie membranes must be kept intact as tong as possible. — It is important to obtain complete dilation if this can be accomplished, for the head may not come down at once to occupy the cer\-i.\, and the os ma)- then contract again to some extent, and cause obstruction to labour. 2. Any deviation of tJic uterus f7'om the normal axis must be corrected. — Displacements of the axis of the uterus are common in contracted pelvis, and lead to malpresentations : and in addition to this, obliquities of the uterus cause much loss of force. 3. The eharaeter of tlie pains must be carefully watched. If the uterus is found to be getting exhausted (the so-called ' secondary inertia,' see p. 412), the woman must be allowed to rest, and opium or chloral should be given. If the inertia is primary ('inertia,' p. 411), it will be right to assist witli forceps. 442 Pathology of Labour If the uterus is licconiing tetanic the woman must be delivered at once, by the forceps or craniotomy. It must be remembered that in exhaustion of the uterus or in uterine tetanus turning and ergot are inadmissible. 4. If iJic ijicmf>raiies rupture, early ^ as often happens, and the os is not easily dilatable by the advancing head, it must be dilated with hydrostatic dilators, Barnes's or de Ribes'. 5. If the membranes have ruptured liefore the physician arrives he must take care that there is no uipping of the cervix or vagina ; and he must pre^'ent ruptujr of the uterus or I'ogiua by delivering the patient at once if there are any signs that such danger is imminent (p. 489). If in a pelvis with a conjugate of }^\ inches or more the head is arrested at the brim, it is necessary before deciding on the form of assistance which shall be given to see if the child is alive or dead. If the child is dead craniotomy can be performed at once, and delivery accomplished, unless the uterus is exhausted. If tlie child is alive the condition of the woman must be noticed ; and if it is good the effect of the pains may be watched for half an hour to an hour, to see if the head will mould sufficiently to come through the brim. If no advance is made the case must be treated as advised in group B. If arrest of the head occurs i7i the cavity or at the outlet., the cliild must be at once delivered by the forceps, or if necessary by craniotomy. Group B. The conjugate measures less than 3^ inches ; or it measures 2)\ inches, but other diameters of the pelvis are diminished. In such cases as these the child cither cannot pass without help, or cannot pass at all. If the head is engaged and arrested. Examine first of all to see whether the child is alive or dead. If it is alive apply the forceps, where the conjugate does not measure less than 3 inches. As modif\ ing this general statement, it must be remembered that if the maternal passages have been too long pressed upon, after, for instance, too early rupture of the membranes, attempts at deli\ery by the forceps may cause further damage to the tissues, and very considerable risk to the mother from septica;mia. .Moreover, it must be clearly made out that the presentation and position of the head are both favourable. If the forceps is contra-indicated under any of these circum- stances, or if after a fair trial it is unsuccessful, the head must be ]iciforated. If the child is dead the head must be perforated. The head may not ha7'e engaged on account of considerable contraction of the pelvis, or of malposition of the head, or of uterine inertia. If the child is alive and the conjugate does not measure less than 2^ inches, there being no marked reduction in the other diameters ; and if there is no other contra-indication, such as over-retraction or tetanus of the uterus, the best method of treatment is to perform version. In doing this, the occiput must l)e induced to descend on that side of the pelvis which is found lobe the larger (sec p. 176, F"ooding). If the child cannot be delivered after \ersion, perforation of the after-coming head must be performed. If the conjugate is less than 2f inches, or if with a conjugate of 3i inches, the other diameters are reduced appreciably, either C;vsarian section or per- foration must be done according as the woman chooses. It is recommended Ijy some authors that forceps should be tried for a short time in cases where Oblique Pelves 443 turning lias just been recommended : if the case is not ui'genl this maybe (lone. Tui-niny- is of little or no use in any but flat pelxes. It is an ojDeration undertaken for the child's sake entirely ; and if the after-coming head, when it has passed the brim, meets with other obstruction lower down in the pelvis, which prevents its rapid delivery, the child cannot be born alive, and the object of the operation is not attained. It has been debated whether craniotomy is a better operation on the presenting or on the after-coming head ; most people will find it easier to do when the head presents (see p. 392, Craniotomy). The treatment of the accidental complications of labour in contracted pelves, such as presentation and prolapse of the cord or of the limbs, and transverse presentation, will be found under their respective headings. In certain cases of contracted pelvis the revi\ed operation of symphysio- tomy is considered by some to be suitable. This operation is fully discussed at p. 402 ; but the following statement of its object may be again made here. By di\iding the symphysis about half an inch can be added to the conjugate measurement ; and since 3:^ inches may be taken as the smallest conjugate through which a living child is likely to be born, the pehis most suitable for this operation is one with a conjugate of 2| inches or more. A case might be suitable, as far as measurements are concerned, where the conjugate measures more than i\ inches if the head refuses to engage on account of its incompressibility alone. CHAPTER LXI IHK RARER KINDS OF DEFORMED PELVIS These consist of oblique pehes ; transversely contracted pelves ; mala- costeon, and pseudo-malacosteon (crimipled) pelves : spondylolisthetic pelves ; pelves with bony or cartilaginous outgrowths into the interior ; pehes deformed by fracture ; ' split ' pelves ; ' funnel-shaped ' pelves. The principle of classification best adapted for practical purposes is a clinical one, or as near an approach to that as possible. Oiii.iQUE Pelves It will.be found that the want of symmetry in this class of pehis depends mainly on an oblique transmission of the body-weight through the pelvis to the femora. Skoliotic Pelvis. — In this case the body-weight is transmitted down that side, say the right side, of tlu' trunk towards whirh the lumbar spine is 444 Pathology of Labour convex. In consequence the pelvis tilts so that the femur of that side comes to lie as nearly as possible in a line with the direction of the weight. The left leg has less than its share of the work, and the right leg takes the greater part of the weight of the body. The following e\ents arc found to happen as the result (fig. 349). The sacro-iliac synchondrosis and the acetabulum on this side are pressed together. The leg on this side is more used, and so the in-thrust of the femur, which, as has been described, is due to muscular action, is increased. On this side, the right, owing to the tilting of the pelvis, the out-thrust of the femur is diminished, and if there is much distortion it will become an in-thrust, for the sacro-iliac articulation will be found to transmit directlv Fig. 349. — l)evelopment of skoliotic pelvis I'ig. 350. — Skoliotic pels the weight of tlie body through its opijoscd surfaces, instead of allowing the sacrum to hang normally by its ligaments between the two innominati- bones. There is in consecjuence no leverage action of the sacro-iliac beam of the affected side. On the opposite side there is a considerable amount of lc\erage, owing to the way in which the weight is transmitted. Between tiiese two forces the symphysis pubis is found to be dragged o\erto the side, in this case the left, which does not transmit the body-weight. The effect of this distortion is that the capacity of the affected side of the |)elvis is somewhat diminished, the innominate bone being raised and turned inwards, so as to lie closer to the sacral promontory. The ala of the sacrum corresponding to the affected side is thickened and shortened, the cft'cct of its transmitting nearly the whole body-weight (see fig. 350). Cases v^liere one leg: is sborter than the other. — The weight of the body will Ijc transmitted mainly through the short leg, and the pehis will be jVaoy/L- Pelvis 445 tilted over towards that side. The result is that the same kind of deformity is produced as in the case of a lumbar skoliosis with the convexity to that side. Amputated or useless leg: on one Side. — The body-weight is trans- mitted through the peh is on to the remaining or useful leg, and the peh is becomes deformed as it would in the case of a lumbar skoliosis cur\ing to the same side as that of the sound leg in this case. XTagrele Pelvis. — In this pelvis there is an absence, more or less complete, of one ala of the sacrum, with or without ankylosis of the corresponding sacro-iliac joint. The condition is clue to mal-development of, or possibly, in Fig. 351. — Caries of left sacro-iliac joint, causing the pelvis to develop into the Nagele shape. From a young subject. (St. George's Hospital Museum.) some cases in which tlic result is almost identical, to caries about, the sacro- iliac joint (fig. 351). The mechanics of the production of this deformity are as follows. Owing to the ankylosis, or absence of the ala of the aftected side, there is no lever action such as that described as existing normally from the downward and inward traction of the sacrum on the posterior sacro-iliac liga- ments (fig. 352). This absence of leverage is due in the case of ankylosis to the fact that thereis no movement downwardsof the sacrum away from the posterior superior spine ; and in the case of the absence of ala it is due to the mechanical advantage being lost by the 'power' lying c[uite close to the fulcrum. On the sound side, on the other hand, the knerage is considerable, as much, in fact, as is found in the normal pelvis ; the symphysis is thus dragged o\cr to the sound 446 Pathology of Labour side. On the affected side, ou iny to the ribsence of leverage, there is no tendency to Isowiny outwards of the pelvic beam, whicli tlierefore becomes straight. On account of the acetabuUun lying nearer than normal to the middle line on the affected side, the out-thrusting component of the upward l^ressure of the femur disappears, and the in-thrust due to muscular action is not antagonised. When the patient is sitting, the pressure on the tul:)cr ischii on this side is an entirely inward one. The tuberosity thus becomes inverted, and the pelvic outlet is diminished. The effect of these ill-directed forces is that the diseased side is con- siderably diminished in capacity, the sacro-cotyloid diameter being lessened. The sacrum f;\ces towards the affected side, for sinking is prevented on that side by its ankylosis with the innominate bone, and by the fact that in cases where ankxlosis docs not exist, the upward pressure of the femur acts directly Fig. 352. — Nagele pelvis, early stage. The dotted lines indicate the direction of the upward pressure of the femora, and the amount of leverage exerted on each side at the sacro-iliac connection. The disease is on the right side. Fig. 353. — Nagele pelvis fully developed. tlirough the joint, the opposed sur- faces transmitting the body-weight, and having no tendency to glide over one another. The puljic arch is found to be narrowed, and to be pointing towards the affected side, owing to the inward displacement of the tuberosity on that side (fig. 353). Biagrnosls of Oblique Pelvis. If tlie woman ha\e a lateral curvature of the spine to a sufficient degree to affect the pelvis, it will probably not escape notice ; or if one leg is absent or shorter than the other, a cause for pelvic deformity is easily seen. It must be remembered that any of these deformities, if it occur after the pcKis is completely developed, may have no influence in altering its shape. Measurements of the pelvis siiould be made as described in the chapter on Pelvimetry (p. 416). It will be found on examining the back of the pelvis in the case of Nagele deformity that the distance between the spines of the sacrum and the posterior superior spine is much lesson the affected side than on the other. On internal examination one side of the pelvis will be found to have Transversely Contracted J^elves ^^j its sacru-cotyloid diameter much smaller than the corresponding diameter on the opposite side. This is best made out by introducing- the whole hand. XVIechanism of Iiabour. — This depends on llic particular distoi'tion |)rcscnt : the head enters with its long diameter in the longest pelvic diameter available, which is as a rule that oblique diameter which starts from the discasctl side ; that being, if the right side of the pelvis is pushed in, the right oblique diameter. If, however, the sacro-cotyloid diameter on the diseased side is too small to admit any part of the head, labour takes place through the sound half almost entirely, and the long diameter of the head may lie more in that oblique diameter \\hich starts from the sound sacro- iliac joint. After the brim is passed the ditificulty in all the above-described pelves, except the Nagele pelvis, is over, unless the deformity is great. There is difficulty in the lower part of the pelvis in the Nagele deformity, since the outlet is always diminished from the inward displacement of the tuberosity. If in the other cases the deformity is very severe, the pehic outlet may be diminished for the same reason. Treatment. — When the pelvis is deformed on account of skoliosis or affec- tion of one leg the treatment is the same as that for flat pelvis, and turning in suitable cases is admissible. In severe cases or in cases of Nagele deformity labour must be induced at a time to be settled by the smallest available diameter if this is not too small to allow a viable child to pass. If it is impossible to deliver a viable child through the pelvis, either craniotomy or Ceesarian section must be done according to the rules already laid down, the latter being in this case by far the better operation since the woman can be sterilised at the operation. Transversely Contracted Pelves There are two kinds of transverse contraction of the pehis ; one being due to kyphosis of the lumbar \ertebr£e, and the other, first described b)' Robert, being due to the occurrence on both sides of that condition of sacro-iliac abnormality which, when it occurs on one side only, produces the Nagele pelvis. I -t: -. Kyphotic Pelvis. — In this case the bod\ - weight is transmitted, not through the lumbar curve as normally, but in front of the re\erscd convexity (fig. 354). The tendcnc)- of the weight is then to increase the l^ackward bow, and thus force the lower end of the cur\c backwards and downwards. By this means the upper end of the %;^o^(^i;{^l^^: sacrum is tilted backwards and the lower end for- wards, in opposition to the normal. The pubes, howexcr, are prevented from mo\ing backwards b)- the ilio-femoral ligaments, which make a brace o\er 448 Pathology of Labour the anterior angle {IF). The conjugate thus becomes lengthened, and the antcro-posterior diameter of the outlet diminished. The body-weight acts further in forcing the base of the sacrum back and down, so that its anterior transverse concavity is increased instead of being diminished in the normal way ; and the \ertical concavity is diminished for the same reason. As the sacrum does not tend to fall downwards and forwards, it cannot pull inwards the posterior end of the iliac beam, and thus the force which tends to widen the pelvis is absent. Owing to the narrowing of the pelvis on this account the outward thrust of the femora is much diminished, as is that of the tuberosities ; but the in-thrust due to muscular action is allowed full play. The ilio-femoral lig^aments above mentioned necessarily rotate the upper edg^e of the anterior part of the brim, and also the ilia, outwards ; and the lower edge of the innominate bone therefore tends to turn in still further. This inward rotation of the tubera causes, when the patient is sitting, a tendency to a further in-thrust of the ischium. The effect is that, as seen in the figure, the pelvic inclination is much diminished; and the pelvis is narrowed transversely throughout. It is, however, lengthened in the conjugate at the brim, but is diminished very considerably in the antero-posterior diameter of the outlet. nXecbanism of Xiabour. — The mode of engagement of the head depends on the amount of narrowing at the brim, and the head as a rule passes this with its long diameter antero-posteriorly without any difficulty. When the outlet is reached there is not sufficient room between the tuberosities of the ischium, and the head may pass out entirely behind the tubera. If the lordosis above the kyphosis is low down in the spinal column (one form of pelvis obtecta) considerable difficulty may be caused to the head in entering the brim. Diag-nosis. — The spinal deformity associated with this kind of pelvis is obxious. The pelvis is generally narrow ; and on internal examination narrowing of the outlet is very marked, and the promontory in all probability cannot be reached. Progrnosis. — If the deformity is marked the prognosis is distinctly bad ; and 28 per cent, of the mothers in all the labours recorded died. Treatment. — In cases of slight deformity the forceps is the best instru- ment to use, for the lateral compressing action which it e.xerts on the head is in this case most favourable. Version is quite unsuitable for the same reason as in the generally contracted pelvis. If the deformity is considerable craniotomy will be necessary, and this must be followed by the cephalotribe, which also compresses the head in the best direction. If the case is seen in time labour should be induced at the proper moment as calculated from the available space. The best treatment of all is todo Ciesarian section and to sterilise the woman. Robert's Pelvis. — This is an extremely rare form of contraction. Its cause is incomplete development or absence of the lateral masses of the sacrum, and it is thus a kind of Nagele pelvis. There is ankylosis on both sides, and owing to this there is no force tending to widen the pelvis by the Triradiatc Pelves 449 leverage action of tlic innominate Ijcam. The pelvis is also narrow cr by the width of the lateral masses of the sacrum. The sacrum lies rather forwards, and its \ertical curve is much flattened. It is diagnosed by the general narrowness of the pelvis in every measure- ment. Treatment. — If the case is seen early enou;^h, that is not later than about the fifth month, labour must be induced. If later than this, since operative measures in such a narrow pelvis where the head cannot possibly descend below the level of the brim are more dangerous to the mother than the Caesarian section, this last operation is the proper procedure. Triradiate Pelves This group includes two forms : the malacosteon pelvis ; and the rick- etty form which, from its resemblance in some respects to the malacosteon, is called a pseudo-malacosteon' pelvis. The Pelvis of MoUities Ossium, Osteo-Mlalacia, or Malacosteon shares in the bone-softening which affects the rest of the osseous system. In consequence of this softening the changes which have been described as those of development are in a degree renewed, and become exaggerated. As the body-weight is transmitted through the sacrum and the upward pressure of the femora meets this the pelvis is squeezed in at the three places of appli- cation of these forces. In addition to this the muscles connecting the femora to the innominate bones tend when in action to pull outwards the points of their attachments. Causation. — Mollities ossium is a disease endemic in certain places in Europe. It is hardly ever seen in this country. The disease has been supposed to be due to insanitary conditions ; but little is known about it. It occurs in the female only, and almost always in connection with pregnancy and lactation. It is very rare in first pregnancies. Pathology. — In this disease the whole bone is softened, and it thus con- trasts with the bone of rickets, in which the softening is only found at the ossifying planes. Sometimes in the intervals between the pregnancies the bone hardens again ; but this is uncommon, and the disease usually increases. It consists in the absorption of the calcareous salts, and though the amount of the disease may vary in different bones, those usually most affected are the bones of the pelvis and spine. It has been found in many cases where during the disease the ovaries have been remo\ed, in Porro's operation or otherwise, that the patients have recovered, and the bones ha\ c hardened in the shape they possessed at the time of the operation. Effect on Pelvis. — The body-weight forces the sacrum downwards and forwards, at the centre of its base more especially, and the sinking may be so extensive as to bring the fourth lumbar \ ertebra down to the Icxcl of the brim. The sacrum drags the posterior iliac spines with it to some extent, and i; G 450 Pat/iologj' of Labour these may yield so as to allow the sacrum to become more or less dislocated off the auricular surface of one or both sides. The sciatic ligaments pre- Fig. 335. — Malacosteon pelvis, seen from alij\e. N-ent any recession of the low er end of the sacrum, so this bone becomes much cur\-ed, and the coccy.x projects far forwards between the tuberosities, which are somewhat pulled backwards. The acetabula are pushed inwards, the pubic rami )ielding at their weakest point, namely, just over the foramen ovale. The anterior part of Fig. 356.-.M;i' Y-M\>. fr.i the brim thus becomes beaked, and the acetabula approximate to one an- other and look more forwards (fig. 356). When the acetabula are dri\en Malacostcoti and Pseudo-Malacosteon Pelvis 451 in beyond a \ertical line dropped from the sacro-iliac synchondrosis there is nothing to antagonise the inward thrust, and the distortion is further increased. The action of tlic muscles is shown by eversion of the rami and tubera of the ischial bones. The pubic bones are pulled forwards by their muscles, and the ilia arc everted ; but as the ilia ha\c their antei'ior ends approximated by the in- ward mo\ement of the aceta- bula, the result is that the curve of the crest of the ilium is much increased (fig. 355). Since the sacrum comes forward the inclination of the pelvis is necessarily diminished. These deformities are mainl)' produced while the patient is walking or standing, seeing that adults only are attacked. The dla§:nosis of this pel- vic deformity is made by the rapid appearance of distortion, and also of tenderness of the bones beginning in pregnancy or lactation. The pelvis is easily recognised by internal and external examinations. Fig. 357, — Malacosteon pelvis from the side and slightly above. Treatment. — If the disease is discovered early in pregnane)', and is advancing, labour should be induced at once ; but if only at or near term an attempt may be made to dilate the pelvis sufficiently by the hand to allow the head to pass. In severe cases the bones yield readily to a small amount of force. If the head cannot be delivered in this way craniotomy ma\' be done. Porro's modification of Caesarian section is by far the best to use as far as regards the ultimate results of the case, for it often cures the disease, as just stated, whereas the other methods allow of repeated preg- nancies, and these ma\- bring about an increase in the diseased condition. Pseudo-IMalacosteon Pelvis, Triradiate Rachitic. — This rare con- dition is found in cases where the ricketty stale has persisted after the child can walk and stand, so that the bones are more generally softened than usual. The pelvis resembles in general outline the malacosteon pehis, but is smaller owing to the defect of growth caused by the disease. The ilia arc not curved in at their anterior ends, as the bones are not soft enough to be appreciably pushed inwards at the acetabula. The relation of the inter-spinous to the inter-cristal measurements is there- fore that common to all ricketty pelves (p. 417). The deformity, owing to the less complete softening of the bones, is never so severe as in bad cases of malacosteon. G G 2 45- Pathology of Labour The diagnosis is made by lindinj^, in a pchis which has most of tlic characters just described as belonging to the pelvis of osteomalacia, that the inter-cristal and inter-spinous measurements have the relations characteristic of rickets ; and that the woman shows signs of rickets in other bones. Treatment. — If the case is seen early induction should be performed ; if later craniotomy or C?esarian section, according to the choice of the woman. Caesarian section will be necessary if the head and pehis are much dispro- portioned, for there is no compensatory widening in any diameter, and the bones will not yield to dilatation as they would in a malacosteon pelvis. SpONDYLOLISTHE-SLS (o-TToi^SuXny, a vertebra, oXia-dfU', to slip) In this kind of pelvis the last lumbar \ertebra has slipped forward off the sacrum to a greater or less extent, and occupies a part of the pelvic inlet. Until this subject was studied by Neugebauer ' no satisfactory reason had been given for the deformity. He believes and proves that the slipping is due to two factors ; a predisposing one, consisting in a congenital deficiency in that part of the arch between the superior and inferior processes of the last lumbar vertebra ; and then the imposition of any great weight in the abdominal region which drags the spine downwards and forwards, such as repeated pregnancies, obesity, carrying heavy weights, or violent driving down of the spinal column, may dislocate the \ertebra off the sacrum. The pre- disposing condition is known as spondylolysis (Xvo-is-, a loosening), and is not so very rare. The deficiency may consist in a failure of the cartilage uniting the two processes to develop into bone or a deficient development of the bone. In one of the specimens that Neugebauer showed the \-ertebra had become displaced forwards on one side, where there was such deficienc)-, and not on the other. The lower articular process with the neural arch remains attached to the sacrum, and the rest of the vertebra slips forwards to a varying extent. Spondylolysis occurs in other parts of the spinal column ; but it concerns us in this part only, and here it is also most common. - Resulting: Cbang^es. — Owing to its slipping forward and downwards the fifth lumbar \ ertebra rotates on a transverse axis so that its anterior surface looks downwards, and thus lordosis of the rest of the lumbar vertebne is produced. The hinder part of the \ertebral bod)' bears the body-w eight which is transmitted through the fourth lumbar ; it is therefore compressed from above downwards. The strain in the new direction on the intervertebral cartilage between the fifth lumbar verteljra and the sacrum causes ossifica- tion of the ligaments on its sides, and of the disc itself. The disc is also ' See Obst. Trans, vol. xxvi. p. 186. - Targett's case [Obst. Trans, vol. xxxiii. p. 108) shows that spondylolisthesis may occur in consequence of fracture of the pedicles. In his case, that of a girl aged sixteen, the pedicles of the third, fourth, and fifth lumbar vertebra: had givi'n way, and tl)e vertebras were dislocated forwards. W. Arbuthnot Lane {Path. Trans, vol. xxxvi. p. 364) considers that pressure alone is able to produce this deformity without any previous con- genital deficiency. SpondylolistJtctic Pelvis 453 depressed liy the inferior posterior edge of the bod)- of the fifth kimbar \ ertebra. There is ossification too of #he remaining attachments of the arches of the \ertebne above it to the body of the displaced fifth \ertebra. The aherations caused in the pelvis generally are as follows : Since the body-weight is transmitted more to the front the pelvic inclination is diminished (see p. 451). The weight now so falls as to press the top of the sacrum backwards, and so the lower end comes forward and diminishes the antero-posterior diameter of the outlet (fig. 358). The sacrum is also pushed bodily backwards, and thus drags on the sciatic ligaments, and dimin- ishes the transverse diameter of the outlet. It also sinks between the ilia in tiic direction of its length, and separates them like a wedge. As happens in the kyphotic pelvis the diminished inclination causes over-action of the ilio- femoral ligaments, which everts the ilia and adds to the narrowing of the outlet. The peh'is is thus not unlike the kyphotic pelvis in a general way, ex- cept that the inlet is diminished in its conjugate diameter instead of being- increased. Fig. 35S. — Spondylolisthetic peK'is. Fisr. 359. — Back view of a voman with spondylolisthesis. (After Winckel.) Diagnosis. — In well-marked cases this can be made from the external appearance of the woman. On looking on her back from behind it appears as if the whole of the upper part of the body were telescoping into the pehis. The figure seems peculiarly short, there is lordosis in the lumbar region, and the ribs are near to or even sunk into the false pel\ is : the upper and back part of the sacrum is very prominent (fig. 359). On examining per vaginam the dropped vertebral bod\- can be felt in the Iirim. It is distinguished from the promontory in a case of marked reniform pelvis b\ the sacrum being felt external!)- too far back ; and b)- there being n) lateral mass on each side of the projection into the brim on internal examination. There is often also a history of injury of some kind, or of liabituallv carrvintj" hca\•.^- weights. Treatment Labour in slight degrees of this deformity may go on un- aided : but as the cases become more severe thev will need treatment in 454 Pathology of Labour corresponding proportion. Labour should l)c induced where this is possible ; forceps, craniotomy, or Cii^arian section may, according to the reduction of the available space, be one or other of them necessary. Version is not admissible on account of the diminution of the outlet. Irregular Forms of Contraction^ Exostoses and ot/icr Oittgroiot/is. — Bon)- or cartilaginous growths, innocent or malignant, may in rare cases encroach on the pelvic canal. They may give no sign of their existence externally, or they may co-exist with tumours of a similar kind in other parts of the body. In osteo-arthritis there are sometimes projections of spiculae of bone on the pubic rami in the situations of the ligamentous attachments. Spicules or irregular projecting masses may lacerate the uterus if the lumen of the pelvis is much contracted, and so great care should be taken during deliveiy in these cases. Craniotomy and even embryotomy should be performed if there is any difficulty. Caesarian section, however, is the best operation by far if the obstruction is great. Fractures of the pelvis may lead to irregular union, or some of the callus may be unabsorbed, thus causing various deformities. CHAPTER LXII .\HNORMALITIES IN THE PASS.XOK {continued) • Soft P.arts Bulgring: of tbe Anterior "Wall of tbe Xiower Uterine Seg:ment. — In this case the head descends into a pouch formed by the bulging, and the os remains high up and directed backwards. It is caused by premature rupture of the membranes ; the anterior lip of the cervix is caught, as the head descends, between this and the pubes, so that the part of the cervix below the point where it is nipped cannot be with- drawn off the head as this descends into the pelvis before the cervix is dilated. The anterior wall of the cervix may thus be crushed and slough, or may be torn off. Cases have been mistaken, owing to the difficulty of finding the cervical orifice, for complete atresia ; and incisions have been made over the bulging anterior vaginal wall. In slighter degrees of nipping oedema of the anterior lip may be found, and is not an uncommon phenomenon. Treatment. — The woman must be placed on her side and told not to bear down. The anterior lip should be gently pressed forwards (and upwards) during the pains and in the intervals so that it is brought to lie in its normal position. This mana'uvre may necessitate the use of chloroform. If the OS cannot be brought forwards it should be dilated \\ ith hydrostatic bags. Abnonnalities of Soft l^arts 455 Bulging' of Posterior "Wall ofUterus. — The os is high up in front, and lies Ijchind and abo\ c the symphysis, and a pouch is formed in the posterior wall. Dcpaul ' found in a case of this kind the posterior wall lengthened on measurement post-partum. He considers it due to sacciform de\elopment of this part during pregnancy. Barnes, on the contrary, says the condition con- sists in incomplete retroflexion existing during pregnancy ; he belie\es that the uterus has its anterior wall pulled up by the body of the foetus while the head lies in the pelvis ; and the tilting upwards of the cervix is thus accounted for. The treatmeiit is practicall)- the same (inutatis mutandis) as that for bulging of the anterior wall. Hew Growths of the Body of the Uterus. — Only myomata are of interest, for cancer of the body is too late in its appearance in the great majority of women's lives to concur with pregnancy. Myomata have been supposed to interfere with the expulsive power of the utems, but it has been shown'- that they have little or no effect in this way ; and this has been the writei-'s experience. The presentation of the child is affected by them sometimes. The only accident that is likely to occur is post-partum haemorrhage ; and to prevent this the uterus must be very carefully watched during and after the third stage of labour. Sloughing of the tumour is|sometimes caused by the pressure during labour. Rupture of the uterus is possible, owing probably to the thinning of the real uterine wall by the fibroid ; and if the myoma is polypoid inversion of the uterus may occur. Uterine fibroids have been said to be one cause of placenta prasvia, owing to the increased size of the uterine cavity. Treatment. — If the tumour is in the way of the head at the brim it must be pushed up, if possible, so as to allow the head to come down. To do this the woman may be placed in the knee-elbow position. If reposition cannot be accomplished under anaesthesia, it may be necessary, if the child is alive, to perform version ; or in some cases the tumour may be removed by enucleation ; or Caesarian section or Porro's operation may be required. Sub-peritoneal fibroids if they lie below the head are to be treated, \\hen they have a pedicle, as ovarian tumours, and pushed up. Atresia of the Cervix. — When complete occlusion of the cer\ix is present it must of course have taken place after conception. This \ery rare condition is due to some form of traumatism, such as the application of caustics, and subsequent cohesion of the surfaces. Care must be taken not to confuse it with the two kinds of bulging just described. Treatment. — After a very careful examination an incision is to be made at any spot indicating the position of the cervix ; or, if there is no indication, at the centre of the bulging surface. The orifice thus made can be somewhat dilated with Hcgar's dilators ; and then with hydrostatic laags. If the membranes will dilate the orifice thus made they should be allowed to do so ; if not, dilatation may be completed by the bags. The incision should, if possible, be made through cicatricial ' Arch, de Tocologic, 1876. - Hofmeier, Zcitsch.fiir Gcb. 11. Cyn. vol. xxx. 189.^. 456 PatJiology of Labour tissue only, the layers bciny dixidcd slowl)- while the ]):irt is exposed by a Sims' speculum. * Rigidity ' of the Cervix. — Onl\ the c:onditions usually classed under organic rigidity will be described here. The so-called 'spasm' of the cer\ix has been mentioned on p. 88. It is a question whether or not the often difficult dilation in elderly multi- ]3ara; is really organic. Rigidity or resistance to dilatation may be due to (i; malformation of the cervix ; (2) cicatricial changes in the tissue of the cervix ; (3) changes in its walls in connection with supra-^■aginal elongations ; (4) new growths ; (5) (?) rigidity in elderly primipane. (i) Malfonnations. — There are two conditions described ; — {a) co?igenitaI elongatioi7 of the portio vaginalis (tig. 360) ; and (b) what has been con- sidered as congenitalh" small os externum. The former no doubt exists, and has been observed in connection with slow dilatation of the cervix. The latter is only conjectural. The treatment is, after allowing a fair time [sa}' in the former {a) four or fi\e hours] without any advance of the head ; and in the latter after dilatation of the cer\ix has reached the external os and the cervix has disappeared, but there is no progress for two hours (in each case there Ijcing no other disco\'erable reason for delay) to dilate the os with bougies (Hegai-'s or others) or with the finger, when this can enter the cer\ix ; and then with hydrostatic dilators to nearly the size of full dilatation. The Fi-. 360.— Congenital hypertrophic elongation of membranes after this will bulge, cervix. Cv, cervi.x (external os) ; ^'r, urethra ; j , i -n i i ^ i Bl, bladder. 'i"d labour Will JK' Completed spon- taneously. (2) Cicalricial iliaiigcs ma}- occur aftei" severe cauterisation of the cerxix ; after amputation ; or after deep ulceration (of some cases of which syphilis has been considered the cause). The lacerations caused by previous labours do not produce 'rigidity.' The treatment of these cases, aftci- allowing laljour to proceed until the cervix is obviously the impediment to further advance, is to carefully make radial incisions through the cicatricial tissue. (3) Changes in the walls in connection w ith elongation of titc supra-vaginal ccnnx (due to prolapse of the \agina). This consists in an increase in the proportion of fibrous tissue. The os usually dilates slowly, and nothing further abnormal occurs ; but the anterior lip of the cervix may become oedematous, getting nipped between the head and the symphisis pubis ; or the cervix maybe driven down and may slough or may be actually torn off. The right treatment is to dilate the cervix with tents or hydrostatic bags ; or, if the tissues are ver\- resistant incisions AbiioiiiiaUtics of Cervix ; of Vagina 457 should he niadL' towardb the sides to avoid openiny tlie peritoneum in Douglas' Pouch. (4) Neii.' Groii'ths. — Polypoid myoniata ('fihroid polypi) arc found in the cervix or in the vagina very rarely ; they should be cut off with scissors before the head descends. Myomata of Cervix. — These are verj' rare. Their effect on labour depends on their size. If small (the size of a filbert) they do not interfere to any extent with labour ; but it is possible that they occasionally cause spasm. If they are larger than this they may hinder dilation, or may prevent the head entering the cervix. The)' are most troublesome when they are sub- peritoneal, and, not being drawn above the brim as the uterus retracts, block up the pelvis completely. If the tumour is submucous and is forced down b)- the ad\'ancing head, its attachment is stretched and maj' rupture. In an}' case the mass ma}' be remo\ed b}- a pair of scissors without fear of haemorrhage. Any fibroid which has sur\-i\-ed lalDOur should, if at all crushed, be re- moved immediately labour is over. If it is not damaged and not, as occa- sionally happens, spontaneously expelled, removal should be accomplished as soon after labour as is convenient, one to three months being a fair time to allo\\-. Cancer of Cervix. — This may be onl}' incipient, or it maybe advanced. If the former, especially if the cancer is soft, it does not cause much hindrance, and dilation takes place much as usual. If the cervix is involved com- pletely dilation is absolutel}' prevented, and symptoms of obstructed labour appear. If the mass is a large one, whether due mainly to growth in the cervix alone, or partly or mainly to infiltration of the connective tissue around, it may prevent delivery even after the os itself is made large enough. Incisions should be made through the diseased tissues, so as to allow the iDag of membranes to form, and it will then be seen whether dilation is pro- gressing. Incisions are better than artificial dilatation, for the infiltrated tissues will tear irregularly and there will be sloughing. If after the incision the bag of membranes will complete dilatation it should be allowed to do so. If not, further incisions must be made laterally, and then the opening will allow the hand to pass without much tearing, or will enable the forceps to be used. If the mass is immo\able, or if no opening can be made of sufficiently large size, the best plan is to do Caesarian section. Craniotomy is not good treatment : the child is thus sacrificed for no ad\"antag"e, since the mother will doubtless die from septicii?mia, due to sloughing of parts of the tumour. Cutting away of projecting masses is useful where it is of service in making a passage, and especially where the cancer is limited to the lower part of the cer\'ix. No appreciable haemorrhage occurs. Vag'ina. Displdccinciits. — The commonest displacement occurring in the vagina is that of the anterior wall, a cystocele being formed. This is occasionally found to project through the vulva. It may be recognised at once by passing a sound or catheter through the urethra and into the C}'^stocele. The urine can then be drawn off, and the tumour pushed up if this is necessarv. It hasljeen incised in mistake for the bag of membranes. 458 PatJifllogy of Labour In addition to the delay it causes there is the danger that it might slough if it were carried down in front of the head, and subjected to long pressure in this position. The posterior wall of the vagina is \ery rarely found to be prolapsed. If such a prolapse is extensive the rectum may bulge from the \'ulva, or even a coil of intestine may come down in Douglas' pouch and project externally, co\ ered by the tissues of the \aginal wall only. The diagnosis of rectocele is readily made by passing the finger through the anus. Less danger accrues from prolapse to the bowel than to the bladder, since there is no unyielding part like the back of the symphysis against which the head can press the base of the tumour and cause strangulation. The rectum may be emptied by an enema if necessar)', and the prolapsed ])art then pushed up. In the case of enterocelc the diagnosis is also easy. The patient should be placed in thegenu-pectoral position and the intes- tine can be restored. If it cannot be restored forceps should be applied so as to obviate prolonged pressure by the head. Atresia. Stenosis. — \Vhen atresia of the vagina is found it must have been produced since impregnation. The so-called 'diphtheritic' inflam- mation complicating cases of enterica or small-pox occurring during preg- nancy have been known to cause this ; and Spiegelberg mentions a case in which impregnation had taken place through the urethra after operative closure of the lower end of the vagina for vesico-x'aginal fistula. .Stenosis is far commoner than atresia, for impregnation may occur through a \ery minute opening. This narrowing of the canal may result (rarely) from damage at pre\ious labours ; or from congenital Ijands, septa, more or less complete, or narrowness, or from cicatrices after syphilitic ulcerations. The chief danger in labour is that the tissues, if cicatricial, do not dilate at all ; and in congenital cases the orifice may be so small as not to be able to dilate sufficiently. In consecjuence very deep lacerations will occur. Treatiiieiii. — An attempt must be made to stretch the stenosed part with dilators, beginning with tents if the contraction be very severe. If there are any obvious bands they should be divided with blunt-pointed scissors, guiding the incision by the finger introduced into the rectum. If neither division of bands nor stretching seems likely to be of much use, the effect of a few pains should be watched where this can be safely done, and then if necessary the child's head must be perforated and extracted with craniotomy forceps. In certain cases where the stenosis does not yield sufficiently to make the delivery of even the perforated head and the body a safe procedure, Citsarian section is the right treatment to adopt ; and this operation will l)c necessary in cases of atresia. Even slight stenoses of the vagina are very troublesome in cases where obstetric operations, such as turning, are necessary. Cysts and other Ttinioiirs. — \'aginal cysts have to be diagnosed from cystocele and rectocele, and must be incised if they arc likely to cause any obstruction. Tumours of the vagina, if rcmoxablc, must be excised according to circumstances. Malfoiinations of Uterus and ]^agina 459 UnrKptiircd Hymen. — Impregnation is of course possible without |)ene- tration ; in other cases when the hymen is formed entire it may have yielded inwards to some extent, or penetration may ha\e occurred without rupture. If it is found to be very thick and tough, it is best to cut it through radially, since, if no assistance is given, the tears caused by the head being- forced through its orifice may in\-oh-e the nympha; very deeply. Vaginisiiius, Spasm of Anterior Fih'es of Levator Ani. — Spasm may occa- sionally occur during labour, and arrest the head (see Levator Ani, p. 87). In this case a tense ridge will be found on each side of the vagina, about an inch from and almost parallel to the plane of its orifice. In the treatment of this the exercise of patience, and the administration of chloroform as soon as it is rendered necessary by the persistence of the spasm, are all that is necessary. Ferinaeum. — The perinteum is occasionally rendered undilatable by cicatricial changes, which may be extensive enough to render dilatation impossible. In this case the best treatment is to make incisions which are as near the middle line as possible, and include the whole thickness of the perineeum. If the centre of the perinaeum is entirely converted into cica- tricial tissue, it is perhaps better to make the incision slightly to one side, through as healthy tissues as possible, so that the healing may be rapid. If there is no cicatricial tissue, but the perinaeum is only congenitally long or thick, it will yield in time, and in all probability will not be much assisted in yielding by the application of hot fomentations or similar measures (see Episiotomy, p. 192). The perineum, like other parts of the vulva, is sometimes oedematous in cases of albuminuria. The forceps may be used if the swelling is not con- siderable, but if it is, and crushing of the tissues as the head passes is pro- bable, it is good practice to puncture the oedematous parts in many places with a needle, and allow the fluid to drain. Before this is done the parts must be made aseptic, and must be kept so afterwards. Malformations of the Uterus and Vagina. — Stenoses ha\ e ahead) been described. The bi-cornute uterus with pregnancy in an undeveloped horn has been dealt with under 'Ectopic Gestation.' If the developed horn alone becomes pregnant, labour is not affected unless possibly by lateral deviation of the uterus. Double Uterus. — Pregnancy has occurred in all forms. The main varieties of double uterus are represented in the diagrams (pp. 294, 295). One or both halves of such uteri may become gravid if they Are quite separate ; and where the vagina on one side is occluded, ha^mato- metra and ha^moto-colpos have been found in combination with pregnancy. In these cases of mal-devclopment pregnancy is, as a rule, little, if at all, interfered with (see p. 293). In labour obliquity of the-uterus is common, caused either by the pregnant half divergingfrom the middle line, by the unim- pregnated half prolapsing into the pelvis (where it may act as a mechanical obstacle), or on account of deficient development of the fundus : or obstruc- tion may be caused by the vaginal septum, in cases where this is present. Where both halves are pregnant laljour may occur at diftcrent dates (sec 460 Pathology of Labour Supcrfcctation, p. 76; ; and uliere labour is going on in both at the same time the contractions in the two hahes are not necessarily simultaneous. When one half only is impregnated the other half, when labour occurs in liie impregnated half, often expels the decidual membrane de\eloped in it (compare what happens in Ectopic Gestation, p. 323). Where the division between the two halves is incomplete the placenta may be found in one part of the uterus, and the foetus more or less entirely in the other. The ccplialic lie is b)' i-.\x the commonest in all these cases, but is not nearly so constant as in the normal uterus. Diagnosis. — This is often not made. Where the \agina is completely double with a double os there can be no doubt ; if the vagina is single and the portio vaginalis is very wide, with possibly two external ora to be felt, suspicion may be excited. On examination by the abdomen, if the two hahes of a double uterus are pregnant, a well-marked median furrow ma)' be observed. This is seen best when the uterus is contracting. If only one horn is pregnant the condition cannot be diagnosed per abdomen. If it is possible to make out the round ligaments during a contraction, their relation to the part of the uterus occupied by the ovum should be observed (see figs. 274 and 275, p. 323). During the puerperium these mal-developments are more easily made out, owing to the relaxed condition of the aljdominal wall. There is no special treatment required. Abnormalities in thk Surrouxdinc. Parts Bladder, {a) Retetition of Urine. — The causes of this ha\e been men- tioned in Normal Labour. Its effect may be to deviate the uterine axis slightly, and it must prevent the changes in the position of the bladder which normall)- occur in labour (p. 1 18). The diagnosis will be made by the history of the case and by examination of the abdomen, and by passing a catheter. ib) Vesical Calculus. — This is \ery rare, but a stone has been found which was large enough to obstruct labour. Its eflfccts would be especially bad if it lay in a cystocele, or if it were impacted in the external orifice of the urethra, as in such cases the parts would be very badly bruised. Diagnosis. — This will be made in the ordinary way with the sound, after finding a hard mass contained in the bladder and moxeable within certain limits. Treatment. — If possible, the stone should be pushed above the brim ; but if this cannot be done the urethra must be dilated and the stone extracted. If the stone is too large to be dealt with in this way vaginal cystotomy must be performed. Crushing is not the best treatment in these cases, for it may involve great danger to the soft parts. Ovarian Tumours. — The history of ovarian tumours during pregnancy will be fountl on p. 291, and the diagnosis and treatment are there fully explained. During labour the dangers which arise from their presence are due to AbiioiDialitics of Ovum in Labour 4G1 {a) the obstruction they cause to the passage of the foetus ; and {b) the damage they themseh'es may sustain. The gravity of the resuUs from their presence depends on their position and their fixation. The most dangerous state of things is where there is one small enough to lie in the pelvis, firmly adherent to surrounding structures, or where a part of a large one lies in the pelvis ; large ones which ha\ e already risen out of the pelvis need cause no trouble if they are not mistaken for something else, as, for instance, an ectopic gestation coexisting with intra-uterine pregnancy. As a consequence of the pressure and bruising brought about b)- the passage of the child in cases where the tumour is in the way, it may rup- ture, slough, or bleed internally. If it is a dermoid it will almost certainly suppurate if damaged. Treatment. — A tumour belozu the brim should, if possible, be pushed up above it, and help will be obtained by posture and by the use of an anaesthetic. In some cases the forceps may be applied while the tumour is held up until the pelvis is filled by the presenting part. If the tumour is immoveable, the best thing is to do vaginal ovariotomy ; puncture is recommended by some, but it has many dangers (see p. 292). If the tumour is large and the main mass above the brim, but is obstruct- ing labour by reason of its bulk, ovariotomy should be done as soon as possible ; if there are no means of doing this we must be content with a tapping ; but tapping is to be avoided if possible on account of its dangers and unsatisfactory results. If there is any doubt as to the tumour being an ovarian cyst the best treatment is still to do an exploratory operation. Some would do craniotomy on the child, deliver it, and then deal with the tumour afterwards ; but unless the body of the child will come through pretty easily after craniotomy, the tumour is likely to be dangerously bruised, which will bring about a fatal result ; whereas o\ariotomy gives a good chance of sa\ing both the mother and the child.^ CHAPTER LXIII C. ABNORMAT.ITIKS IN THE OVU-M AFFECTIXC. L.VIiOUR The foetus and its appendages may be abnormal in \arious ways wliiili interfere with the natural progress of labour. Such are : unusualh' large size of the child, or of some of its parts as in hydrocephalus ; monsters ; hydramnios ; very short cord ; and others which will be found described in this chapter ; or the difficulty in labour may be due to faulty lies, especially transverse ones, or faulty attitudes, as when the arm is displaced. ' Sec a case described in Trans. Obst. Soc. \ol. xxxiii. p. 140. 462 Pathology of Lalwnr DEFORM rriliS AND DISEASES OF THE F(ETL'S 1. Large size. 2. Local enlargements. 3. Monstrosities, single or douljle. I. large size. — Many children weighing as much as nine or ten pounds are born \s ithout an\- great trouble, often without a rupture of the perina^um, even in the case of primiparje. The reason of this is that the excess of bulk is due to the volume of the trunk ; and that the bones of the head at all ev-ents are not much, even if appreciably, increased in size ; though the head may seem large owing to excess of the soft parts, especially about the cheeks and lower part of the face. Such children are also, as a rule, the offspring of well-developed mothers. Signs. — The head, in cases where the skull is really enlarged, may be unable to enter the brim. This state of things gives rise to the same condi- tions as an equal relative disproportion caused by a contracted pelvis. It is a very rare event. There is no way of anticipating it, for measurements of the length of the fcetal ovoid by callipers will not help us, many children being born with no trouble which ha\e an increased length as measured in this way. In cases where trouble from this cause is known to have occurred in any previous pregnancy, it may be possible to find out the moment at which premature labour may be induced by causing the woman to come and l)e examined about a month before full time, and seeing if the head can be made to enter the pehis by pressure from above (see p. 439). When this is becoming difficult, but before it is impossible, labour should be induced. Treatment. — An attempt should be made to extract with the forceps : if this is not successful, or if the forceps cannot be adjusted, perforation is the only re- source. Such a child could not be delivered alive by turning, for the shoulders would cause much delay, and there would be such pressure on the cord, that the child would be asphyxiated : to sa)' nothing of the danger to the mother caused by the operation under the circumstances. After the head is perforated, it maybe necessarj' to perforate the thorax as it becomes ac- cessible ; or to cut off an arm and thus reduce the width of the shoulders. The head ma)' enter the brim, and be born with more or less difficulty, and then the shoulders may become impacted. There is here no doubt, if the pains are good, that the delay is due to the size of, or to some abnormality in, the trunk. • In this case the forefinger should be hooked in the anterior axilla, and Fig 361. — Bisacromial diameter freed by traction applied to anterior axilla. Hydrocephalus 463 this should be pulled upon, attempts being' made at the same time to rotate it forwards under the pubes. If it will come down, the bisacromial diameter will ha\e been tilted so that it comes through obliquel)-, after the fashion of, and ha\ing the same mechanical ad\antage as, the obliquity of Njigele in the case of the head (fig. 361). If the anterior axilla cannot be reached, the posterior one must be tried, and the head must be pulled forwards, so as to induce obliquity of the bis- acromial diameter, but in the opposite direction. Better results will be obtained if the anterior axilla can be hooked down, for the anatomy of the pehis will ^llow of mo\ement of the trunk backwards more readih- than forwards, since the pubes are in the way of the latter movement. As soon as one shoulder is in advance of the other, the two forefingers can be employed, one in each axilla. The perinasum is not unlikely to be torn, but this cannot be helped. If it is possible to draw down an arm or both arms altogether, and thus diminish the shoulder girth, so much the better ; but this will seldom be possible. In making" traction great care must be taken that the finger is 'home' in the angle of the axilla, or the humerus may be fractured ; and in bringing the arm down over the chest and past the head, the elbow is the point on which pressure must be exercised, for the same reason. If the shoulders are arrested at the brim, the head not being born, an attempt must be made to deli\er the head with the forceps, and if this is successful the shoulders must be treated as just described : but if the shoulders cannot be delivered, the blunt hook (p. 386) should be used either for traction, or to bring down one or both arms. If, in spite of all attempts, no progress is made the thorax must be per- forated. In some cases of large children the otherwise normal labour ma\- be modified b}" icmisiially advanced ossification of the cranial bones. As alread\- stated, this condition is more likely to be present in male than in female children, and in the children of middle-aged women than in those of younger ones. Such cases ma)" be recognised by the small size of the anterior fontanelle if this can be reached ; or the hardness of the bones maybe made out by examining their edges. If the child presents by the breech, there is not much hope of saving it, for the cord is, as a rule, compressed so much and for so long that asphyxia is produced. If delivery is not possible within a few minutes (see p. 201), the foetal heart must be frequently examined during the attempts, and directly death occurs evisceration may be done at once. 2. Jbocal enlargements. — This class includes cases of hydrocephalus ; of excess of fluid in other cavities, and in the connective tissue : and tumours of the foetus. HydroccpJialiis The degree to which the cavity of the skull is distended varies \\ ithin very wide limits. It is sometimes enough to be easily recognised, but not enough to modif\" labour, since the flexibility of the cranial bones is usually much increased in this disease, owing to their thinness and to the greater 464 Pathology of Labour normal foetuses. width of the fontanelles and sutures. It sometimes, however, increases the cranial diameters to twice their normal size or more. Frequency. — In the lying-in charity of Guy's Hospital the increase in size of the head was enough to make operation necessary in only one case in more than 20,000. The actual occurrence of hydrocephalus at birth is gi\en by authors in numbers varjing between one in two, and one in three thousand : but these numbers include a very large majority of instances in which there was no trouble at labour. Course of Labour. — The presentation is more commonly one of the vertex than any other : but pelvic lies are commoner in hydrocephalic than in The reason is that the enlarged head finds better accom- modation at the fundus of the uterus than at the lower end (tig. 362). The degree to which this deformity interferes with the course of labour depends on the size of the head and the amount of ossification present : and the head may squeeze through the pelvis if these are not excessive. The great danger in such cases, if assistance is not gi\ en, is rupture of the uterus. This is especially liable to happen, because, in addition to the fact that the labour is obstructed by the inability of the head to enter the pelvis, the lower segment is unusually stretched by the large head in a transverse, as well as in a longitudinal direction: The skull has been known to burst under the pressure of a pain, or in pelvic presentations during traction, and the effused fluid to escape through the anterior fontanelle under the scalp I'occipito-frontalis tendon). Labour is then easily completed. Diagnosis. — When an aljdominal examination is made and the vertex is found presenting, the base of the skull is felt to be unusually high above the brim, and of unusually large size. Per vaginam the head, owing to the wide fontanelles and sutures, may be mistaken for the bag of membranes, or for a breech presentation. Most commonly the increased flatness of curve compared to that of a normal head is made out without difficult)-. If the presentation be of the breech, the large head is, as a rule, readily made out by abdominal palpation ; but if this is not made out, the fact that the head does not follow the trunk will lead to an examination of the abdomen, and, the head being easily felt a])o\e the l)rini, the condition will be detected. Prognosis. — This entirely depends on timely diagnosis. If a diagnosis is not made until the effects of prolonged labour have become severe it is l:)ad ; and worse, of course, if rupture of the uterus has occurred. Treaiincnt. — If there is enough enlargement of the head to completely obstruct labour, the child's life is of no value, owing to the amount of disease of the brain that must be present. In cases where there is not great difficulty in pulling the head through the pelvis with forceps, or it is very important that there should be a living child born, it should be extracted in that way ; but in any case of complete obstruction where the hydrocephalus is well enough marked to be diagnosed, perforation is the right treatment, Labour ivith Monsters 465 whether the child is in a ccplialic or a podalic he. In tlic former case the child may be extracted with the craniotomy forceps or the cephalotribe (p. 386). Fluid in other Cavities of t lie Body Under this heading are hydrothorax, ascites, distension of the bladder, owing to imperforate urethra, and cystic kidneys. The bladder may be so enlarged as to contain twent)', thirty, or even a larger number of ounces of fluid. Ascites, hydronephrosis and hydro- thorax have been described in the chapter on intra-uterine diseases of the toetus (p. 263). Diagnosis. — Some obstruction to labour is found to be present, often after the head has been born, and the condition has to be made out by combined palpation. In cases of abdominal enlargement the abdomen usually presents, and if delivery is able to be accomplished without embryo- tomy, the child is usually born in a retrofiexed attitude. Treatment. — This consists in perforating the most easily got-at part of the collection of fluid. Such cases are usualh' born prematurely, and may need little assistance beyond traction. Fluid in the Connective Tissue. General CEdevux. — This is a \txy rare condition. It has been found in connection with syphilis of the mother and in sporadic cretinism, but there is nothing certain known about its pathology (see p. 268). The treatment is to cut up the child to the degree necessary for extraction. It is always dead. Timtoiirs. — ^There are none that cause absolute obstruction, but it is important to remember them for purposes of diagnosis. The commonest are spina bifida and 'other meningoceles. A spina bifida may be very confusing in a breech presentation if only vaginal examination be relied on. Tumours of the thyroid gland, Ii\er, spleen, and other organs, and included foetuses, ha\e been recorded as gi\'ing rise to obstruction in varying degrees. 3. Monsters, Single and Double. Single Monsters. — Of these the only ones of obstetric importance are cases of ectopia \iscerum and anencephalus. The former is interesting because of the abdominal presentation which is usually found, and because the cord is nearly always absent or very short. In the case of anencephalus (see p. 263), if the lie is cephalic the head will not sufficiently dilate the passages as it comes through them, and the shoulders are arrested. The diagnosis in this case is made by feeling the face, and making out that there is no \ault attached to the skull. This deformity is nearly always found in connection with hydramnios. Double Monsters.— TX^ft best classification for practical obstetric purposes is that of Herman : (r) Those in which only one end of the foetus is double. (2) Those in which there are two foetuses loosely connected. (3) Those in which there are two foetuses closely connected. In the first class of case the end doubled is much larger than normal, and the duplicated parts are fused together, as in double-faced monsters or those with a double pelvis. The diagnosis can only be made with certainty by exploration with the whole hand. If labour has been long in progress H H 466 ■ PatJwlogy of Labour such exploration will pi-ob:ibly be dangerous, and in fact is not very important ; for the treatment in the case of double face is to perforate as in hydrocephalus, and that in double pelvis, which will cause obstruction when the head is born, to cut up the pelvis with strong scissors or the sharp hook. In the second class the union of the two more or less complete foetuses is also at the head or the pelvis. The freedom of movement possible allows the two unattached extremities to be sufficiently separated from one another to lie at the two opposite ends of the mass. Thus, the heads being united, the breech of one child may be born first and the breech of the other last : or, the two foetuses being united by the breech, the heads may di\'erge sufficiently to form the two opposite ends of the descending mass. The children are nearly always premature, and there is little difficulty about the labour. In the third class the ends which are united are fused closely, and the ununited ends are completely, though not widely, separated. Or two complete children may be united all the way down the trunk by the back or the belly or the side. In these cases labour may be entirely obstructed at an early stage, or one child may be partly born and the other may come down into the brim and arrest progress. If the children are small they may become adapted to the pelvis after a time, the head of the second fitting into some compressible part of the first, or a kind of Spontaneous Evolution (see p. 470J taking place in the body of the second one. The treatment which has been found most successful, if diagnosis has been made sufficiently early, is that of bringing down the feet of one of the com- ponent foetuses. If this case is not clear, the diagnosis has to be made from impaction of twins (see p. 476), and embryotomy at once proceeded with. The object of clearing up the question of twins is obviously to avoid indiscriminate cutting and mutilation where, as in the case of impacted twins, only one child need be destroyed so as to make possible the delivery of the other alive. Transverse Lies Cephalic and podalic lies have been defined as the normal ones ; and the few irregular attitudes of the child while in one or other of these lies ha\ e been described m the chapter on Normal Labour. In the transverse lie the long axis of the tietal o\-oid is at right angles or nearly so to the axis of the parturient canal. So-called transverse lies are, however, only rarely really trans\erse, for that would mean that the head and breech were at the same level. In nearly all cases the head is lower than the breech, and the shoulder or its neighbour- hood is the presenting part. Causation. — A full-term child in a transverse lie is in a condition of unstable equilibrium, and there must be some constantly acting cause which keeps it in this lie in opposition to the laws which go\ern the relations of the long axis of the foetus and that of the uterus. Such a cause may be something abnormal in the uterine contents causing overstretching as in the Transverse Lies A^y case of hydramnios, or the presence of another foetus, or the tlUing up of the lower end of the uterus by a placenta pnevia. Or it may be due to some contraction of the pelvic brim which prevents the head from occupyiny the brim, and thus produces uterine and fcetal obliquity ; or a tumour in the pelvic inlet which pushes the lower pole of the child to one side. If the foetus is premature, it may lie in any axis, and this may be a transverse one. ■ The causes in the order of frecjuency are : — Contracted pelvis, usually combined with uterine obliquity. Prematurity. Death, or decomposition of the foetus (absence of muscular tone). Twin pregnancy, especially with an inert uterus. Placenta pra;\ia. Hydramnios. Tumours in pel\-is ; fibroids in the uterine wall ; or cysts or other tumours outside. -Elevation of brim and child. Fig. 364.-Plan of brim and child. The brim is represented by the dotted line. _ Positions.— The child may lie with its back to the front, or posteriorly • It may also have its* head either to the right or the left. Thus there are' four possible positions, of which one has not more importance than another In any one of these the child does not lie with its long axis parallel with the transverse axis of the brim, owing to the usual dextro-rotation of the uterus • but tends to he on this account with its bisacromial, or some axis near that,' parallel with the right oblique diameter of the pelvis, in whiche\er of the four positions the child is. Seeing that a transverse lie is developed from a left occipito-anterior vertex in the majority of cases, the back is most commonly forwards, and, owmg to the right obliquity of the uterus, the head is in the left iliac fossa' In most instances the head will lie somewhat anterior to the shoulders. Events in Cases left to Nature.— The prognosis in an unassisted case of transverse lie, unless the child is small or dead, is very unfa\ourable. What happens is most commonly as follows. During the first staoe of labour the os dilates slowly, owing to the elongated shape of the bag of membranes, which is again due to the absence of any part, such as the h?ad to fill up the lower segment and pre\-ent the full force of the intra-uterine pressure coming on the bag. The cord often presents at this stage, and H II 2 468 Pathology of Labour proldpses when the membranes rupture, also on account of tlic irrcj^-'ular shape of the presenting part, which allows it to slip past; this is rendered easier by the proximity of the child's belly to the os uteri. Rupture of the membranes occurs early, before the os is dilated, and the waters drain away rapidly for the same reason as that which allows the cord to come down. The uterus now retracts on the foetus and placenta. The foetus, with the shoulder advancing into the pelvis, and the arm usually- prolapsing, is driven down into the dilating lower segment, which, together with the upper part of the vagina, is pulled up by the retracting upper segment. In addition to this longitudinal stretching there is considerable transverse tension owing to a longer axis of the child than usual lying across the lower segment. The action of the uterus, responding to the obstacle to advance, becomes more and more energetic, and pains follow one another with increased rapidity. The uterus ijow usually (i) becomes tetanic Csee Prolonged Labour, p. 407), and the woman has all the symptoms of obstructed labour, and may die from exhaustion, or in the other \\a)'s \\'hich ma)' result from prolonged labour. {i\ Instead of this ending, rupture of the vaguui or lower uterine segment may in a \ery small percentage (about i in 60, according to Herman) take place, that of the vagina being commoner because this is a thinner structure. The s}"mptoms of rupture, and the signs which threaten it, are found on p. 4S9. ('3/ A third possibility is the occurrence of one of the forms of spontaneous deli-i'erw to be described immediately. During this prolonged labour the ctiild has suffered considerably. It begins to be compressed when the uterus retracts upon it, and the pressure goes on increasing, unless rupture occurs, until delivery is accomplished, or until the uterus ceases to contract owing to the failing life of the mother. _ The placenta also is compressed until its ^^^fe^ circulation is arrested. From both these ^\ ^^^^B^ causes death occurs pretty soon. ^^V ^^^Hr Spontaneous deliveiy in trans\erse ^^V^ ^"^^^^ '''^^ '^ "'^'y likely to occur in cases where ^^^^ ^^W the child is small, seeing that the com- ^L ^^^iM^^^^ A monest cause of the lie is contracted J W pehis. The mode varies according as- ^ W the child is alive or dead. If it is alive,. \ W and therefore possesses some muscular Fig. 365.— Diagram of transverse lie. tone, the methods possiblc are : (i) spon- taneous rectification ; (2) spontaneous- version ; (3) (rarely) spontaneous evolution. If the child is dead, it may be expelled by either (1) spontaneous evolu- tion, or 1)\- (2) spontaneous expulsion {Corpore conduplicato). Spontaneous Rectification. — This takes place above the brim altogether, and before the membranes arc ruptured. It consists in the restoration of the cephalic lie. Its mechanism is as follows : as the head is lying it bulges the part of the uterine wall overlying it beyond the general le\el of the uterine surface. When the uterus contracts it tends to recover its normal Spo ntancoiis Version 469 shape, and to tlirust the licad towards the centre, thus bringing it more over the brim ; the same process is going on at the breech. The fcx;tus, being ahve and possessed of enough tone to keep its axis fairly rigid, is brought into the uterine axis, and into a cephalic lie. Excess of liquor amnii will interfere with this process, for the head and breech are not then pressed on ^\•hen the uterus contracts, but are protected by the liquor amnii. This iiioveinent corresponds to the operation of cephalic version. Spontaneous Version. — This process was first described Id)- Denman. It takes place at the brim soon after the waters ha\-e begun to escape, and before the uterus has retracted on the child, and where the child is alive and \ its spine has some tone and resiliency. \ On account of its lie the child does ^^ _ not descend into the pelvis, but the ^ ^k ^^^^k' shoulder does to a small distance, being ^^ ^^ ^^^^^W forced down by the pressure of the ^^ ^^ ^^^^Kr uterus on the breech, and the arm may ^k ^V.^ ^^^ ^^ ^ ~J^ even have prolapsed. The pressure M ^ on the breech tends to push the trunk ^ W^ across the pelvis in the direction "f ^ ^ the head, which lies in the opposite | I iliac fossa, the elastic spinal column p;g j.e.-Spontaneous version transmitting the force, and changing its direction along the curve formed by the flexion of the spine with its convexity downwards (fig. 366). As the uterus goes on contracting the breech gets lower and lower, and the lower of the two hips is forced down into the brim, followed by the ^\•hole l^reech (figs. 367, 368). When this has happened, and the child's pehis is below the sacral promontory, it rotates into the hollow of the sacrum, for there is more space there. The head, which has been rising slightly, but not in anv degree corresponding to the descent of the Fig. 367. — Spontaneous version. Fig. 36R. — Spontaneous versii pelvic end, comes to the front (towards which, it will be rememljcred, it had an inclination, the trunk lying in the oblique diameter), and the shoulder may be raised slightly out of the brim. The child now lies almost in the antero-posterior diameter of the pcbis, and its trunk descends, i-e\ol\ing' 470 Pathology of Labour round the pubcs as an axis, the flexion of the spine beinj{ now reversed, and beiny concave downwards (fiy. 368. dotted hne). Tlie child is then born as- It would have been if the breech had presented originallw This process coiirspoids to the operation of Podalic Versio/t. Spontaneous Evolution.'— This mechanism takes place mainly in the cavity and outlet of the pelvis. The child is practically always dead or premature, though cases are on record where a child at term has been born in this way and has survived. The death of the child ma\' occur during the process. The child lies at first, as in spontaneous version, with its shoulder or some part near it presenting at the brim. As the breech is dri\cn down, the shoulder, owing to the absence of tone in the trunk of the child, descends into the pelvis, instead of tending to glide across the brim. The arm usually Fig. 369. — Spontaneous evolulion. Fig. 370. — Spontaneous evolution. prolapses into the \agina at this stage. The uterus now drives the breech down, and the shoulder and side of the thorax deeper into the pelvis. These are followed b)- the breech, which mo\es backwards into the hollow of the sacrum, the head coming to the front. The side of the neck is jammed against the back of the symphisis, the shoulder coming down under the pubic arch and presenting at the vuha. The thorax now distends the perinccum (figs. 369, 370), and the breech is forced past the head and neck, which are still jammed behind the symphysis, flexion being very acute at the angle formed i))- the doubling-up of the trunk in this mo\cmcnt. ' There has been some confusion ns to the meaning of the two terms Version and Evolution in these cases. Dennian, when he first described what we call Spontaneous Version, called it Spontaneous Involution. Soon after, Douglas, of Dublin, described another method of natural delivery in transverse lies, which he called Spontaneous Expulsion, and which we call now S]5ontaneous Evolution. _ spontaneous Expiilsioi 471 The breech clears the space between the head and neck in front, and the pelvic floor behind, and the feet come down (fig. 370, dotted line). The head and posterior shoulder are now all that remain in the vagina, and the case ends as a breech. Spontaneous Expulsion. Partus corpore conduplicato. — In this method it is essential that the child be dead and premature. The body is then doubled up, the flexion taking place somewhere in the lower dorsal spine. The angle thus formed is born first, and the chest and belly apposed to one another arc followed by the head and feet. The head, instead of remaining above the pubes, as in Spontaneous Evolution, comes down alongside the trunk, pressed into the abdomen (fig. 371). Dlagrnosis of Transverse ]bie. — This is usually fairly easy, for the shape of the uterus as made out from the abdomen is altered, its long diameter being nearly transverse instead of ver- tical. The head may be felt lying in one iliac fossa, and the breech on the opposite side of the abdomen, but higher at first than the head (fig. 372). The abdominal examination will be less easy if the uterus has become te- tanic and the abdominal walls tense, though the shape of the uterus will be ., ,, 1 J n r ^ c Fi?- 371- — Spontaneous expulsion. Kirth with then well marked, before rupture of body doubled up {forpore co„dt,piu-ato). the membranes the condition may be obscured by excess of liquor amnii. The situation of the fcetal heart-sounds is not of much help. Per vaginam, the shape of the bag of membranes may be a guide to the abnormality, and it will be found that there is fio presenting parf to be made out, as the trunk does not descend into the pelvis. In case of doubt the whole hand should now be introduced into the vagina, under anaesthesia if the patient is a primipara, and the lower uterine segment thoroughly explored, the operator taking the greatest care not to rupture the membranes. \Vith the external hand on the abdomen the lie of the child can be exactly made out. It is much better, however, to make out the state of affairs by the abdomen, and then there is no need to risk rupture of the membranes, which it is essen- tial to keep intact so as to render as little difficult as possible the treatment which is necessary. If the membranes ha\c ruptured the shoulder can be made out. This part resembles somewhat the knee in its general outlines, but is distinguished from this and from the breech, or the side of the face by the presence of the 472 Pathologj' of Labour cla\icle, the acromion process, and the spine of the scapuhi, Ijut abo\e all by the ribs, which are recognised in the axilla, and are absolutely charac- teristic. The arm will be usually prolapsed, or it can be brought down. The elbow may present, and might be confused with the heel, on account of the projection of the olecranon behind the condyles. The two parts are at once distinguished by passing the finger along the bone with which the projection is continuous. The sole of the foot and the toes are charac- teristic. It remains now to identify the position of the child if this has not already been done, by external or combined examination. The axilla will show the direction in which the head lies ; the spine of the scapula will show the back i^\trour is almost impossible unless the child is presenting by the breech. In cases where the potential length is diminished by coiling round the child this will be discovered when the head is born. Treatment. — If the arrest of laljour is due to coiling, and the difficulty cannot be got over by passing the loop o\er the child's head or its shoulders (see p. 192), or if the cord is really too short, it must be di\ ided ; and then the foetal end held by the fingers or a cli]) while the child is rapidly extracted, the forceps being used if necessar\-. In case rupture occurs, it is usually close to the umbilicus, since this is the weakest part of the cord. If there is any stump left this can be tied ; but if the cord is torn off flush with the abdominal wall the \essels must be under-run as described on p. 5 1 S. CHAPTKK 1,X1\' RETENTION OF ri..\CKNT.\. POST-1'AK'l UM H.EMORRHAllK. INVERSION of the uterus Retention of the Pi..\cent.v Retention of the jilarenta in the uterus for a longer time than that usually occupied in the third stage of labour may be due to either 11 a failure of the uterus to contract in a normal manner so as to expel the placenta ; or (2) to a morbid adhesion of the' whole organ, or of |)aits of it, to the uterine wall. Retention of the Placenta 479 I. Tbe absence of effectual efforts to expel tbe placenta may 1)0 due to {a) inertia uteri, [J)) irrej^ular ccintraction. {(i) Inertia. — This will be fully discussed when post-partum hitmorrhage is dealt with. An inertia affecting especially the placental site is described, and forms the first stage of in\ersion by causing this area to bulge inwards (see p. 486). {/>) Irt-egiilar Contraction.— 1\\e polarity of the uterus proper to this period is here irregular, and this condition is brought about by at present unknown causes. The irregularit)- usually shows itself b)' the development of a tight contraction of the retraction-ring (see p. 98). This has in former times been described as the contraction at the internal os, or at some zone of the uterus higher up than this. The upper uterine segment is in a state of relaxation. The shape of the uterus thus produced is compared roughly to that of an hour-glass, for the lower uterine segment may become as large as, or larger^ than the upper. Symptoms. — The deli\ery of the placenta is delayed, and there is haemorrhage, which is sometimes fairly smart, especially if much of the placenta is separated ; the bleeding will go on until all is separated and the uterus retracts. The amount of blood lost is not so great as in the case of inertia. The uterus may be felt externally to have assumed the shape above described ; internally and bimanually, it can be felt at once to have this shape by tracing the cord up as far as the constriction. Treatmenf.~\i the bleeding is not of any consequence matters may be left for a time, and the uterus will probably expel the placenta after reco\er- ing its normal contractility. If the bleeding is too great to be allowed to go on, the placenta must be removed by passing the hand in the shape of a cone up to the constriction and slowl)' through it, steadying the uterus from abo\e with the other hand. The placenta should then be peeled off from above or from below, or simply remo\-ed if it is already detached. It is most important that no attempt should be made to remove the placenta until it is completely detached., since if attempts are made to extract it while there are still adhesions, some portion of it is sure to be left behind. Chloroform may be useful in relaxing the constriction ; but it is far better not to use it if possible, for the condition is one of morbid contraction of only a small zone of the uterus, the rest of the body being in a condition of relaxation. This irregularity of action has been called ' Hour-Glass Contraction,' but ]\Iatthews Duncan more accurately calls it ' Hour-Glass Dilatation.' 2. Morbid Adbesions. — These are much rarer than they arc usually supposed to be, and adhesions are frequently imagined to exist because the medical attendant is unable to get the placenta away. \\'hen they are present they are due to some disease of the serotina whereby the ampullary layer has been destroyed either in patches or more extensi\el\-. Sympto)ns.—'Y\\& placenta is retained for an abnormally long time, and if there is some separation bleeding takes place in varying degrees according- to its amount. If the placenta is totally adherent, a most exceptional state of things, there is of course no bleediny. 480 Patliology of Labour In ihcsc cases the whole placenta may be retained, or the greater part of it may be torn ofif and expelled, and the rest left adhering (see rules for the examination of placenta and membranes after labour, p. 196). In addition to placental adhesions, adhesion of membranes will also cause hivmorrhage unless the uterus is so well contracted and retracted that the mouths of the sinuses are closed. Small pieces of membrane will give rise to trouble — namely, secondary hiemorrhagc and septiciemia— in the puerperium ; or later, to subinvolution. The cause of adhesion of the membranes may be disease, as in the case of the placenta, but it is more often due to unskilled management of the third stage of labour. Ti'eatment. — If the case is made out to be really one of adhesion of placenta or membranes, or both, the only treatment is to introduce the hand into the uterus to peel them off, observing the rule to completely separate the afterbirth before trying to extract any of it. The cord must never be pulled upon. N.B. — In all cases in which it is necessary to introduce the hand into the uterus, the strictest antiseptic measures must be taken (see p. 181), and an antiseptic douche should be gi\en before and after, if possible, and after in any case. Post-Partum H.emorrhage Tbis is due to Uterine Atony or Inertia. — Profuse haemorrhage occasionally arises before the placenta is expelled, as just mentioned ; but the most typical cases of post-partum haemorrhage, in which the patient may bleed to death in a few minutes, arise after expulsion, and not because there is any of the ovum left behind. The bleeding comes from the large sinuses laid open by the separation of the placenta. Causation. — Women who have suffered from over-distension of the uterus such as occurs in twin preghancy, in hydramnios, and after concealed accidental haemorrhage, are liable to uterine atony. It is very liable to occur in cases of uterine exhaustion (so-called 'secondary inertia,' see p. 412) where the woman's uterus has been emptied in the absence of contractions instead of being allowed to recover its tone by rest ; and in the same way delivery of the placenta in the absence of uterine contractions tends to produce this result. It occurs sometimes where the woman is extremely exhausted ; and fibroids in the uterine wall are occasionally found to interfere with complete perfect retraction. In a lesser degree a distended bladder or rectum may have the same effect. Those medical men who are careful in managing the stages of labour, especially the third, in the way that is now known to be the best (see p. 186 and sqq.) nc\cr ha\e any realh- dangerous cases of post-partum hiemorrhagc. Symptoms. — The loss of blood is ob\ious enough ; and in the worst cases several pints ma\- be poured out in a few minutes, and the woman may die straight awa\-. The uterus in some cases must have ne\er retracted at all during labour ; at all events it may be found on abdominal examination to be distended to a size equal to that of pregnancy at term, and forms then a loose cyst filled Post-Partuui Iheiiiorr/iage 48 I with Ijlood. When the uterus allows itself to be distended with blood to ;in\ thing' like this size it is obviously very much exhausted, and the out- look is \cry much worse than when the size is only slightly increased ;ibo\e that usual after expulsion of the placenta. Sometimes e\en in such bad cases, the uterus suddenly contracts, and the whole contents, amounting possi])ly to several pints of clotted and fluid blood, are expelled. Collapse of the patient from sudden fall in the abdominal pressure is then not unlikely to occur. After such contraction the uterus may again relax, and fresh hcemorrhage be permitted into its cavity. In less severe cases the uterus may be indistinctly felt, not very much enlarged, and when grasped it may contract. Rela.xation may recur in these cases also. The severe loss of blood rapidly induces fainting, and this may be of advantage if the bleeding can be checked at once. If the hsemorrhage goes on the woman will probably die without becoming again conscious. If the li;emorrhage is not se\ere enough to at once cause the woman to faint, marked signs of acute anaemia — rapid small pulse tending" to disappear, cold sweat, feeling of suffocation, failing sight, and sometimes con\-ulsions, will precede death. The result in every case depends on how soon the bleeding is arrested rather than on the quantity lost. There is no absolute measure of the amount necessary to cause death, as some women recover after losses which would kill others. Women suffering from mitral incompetence or disease of the aortic valves bear the loss of large quantities of blood especially badly. The anaemia resulting from this excessive loss is sometimes prolonged through and even beyond the lying-in period ; and sometimes, as mentioned in the chapter on Placenta Proevia, the woman dies after the bleeding has ceased for an hour or more, from shock which is prolonged owing to the want of rallying power caused by the antismia. Tj'cafmeiit. — The object to be aimed at is compression of the bleeding- vessels at the placental site. This is best accomplished by making the uterus contract, for no clotting in the absence of contraction is of the least use. If the uterus has lost its tone to such an extent that ordinary stimula- tion, including that applied to its inner surface, will not act, the mouths of the bleeding sinuses must be stopped by an artificial imitation in some measure of the normal mechanism. This is effected by bi-manual com- pression of the whole uterus, as will be described ; or by introducing" some l)ody into the uterine cavity which will at the same time both mechanicallj- compress the face of the placental site and stimulate the uterine muscle. In following the line of treatment to be now described, the various manu:u\rcs must succeed one another rapidly, and the preparations neces- sary for those to follow must be made while any one method is being- employed. The various methods employed to arrest the hitmorrhage will first be described, and then a scheme of treatment will ])c gi\en. I I 482 Pathology of Labour stimulation of uterus A) directly 8 indirectly (a; Exterxai. Stimulatiox The patient should be turned on her back. The uterus is then found and grasped with both hands with the finger-tips turned towards the pubes. It may thus be squeezed and kneaded. This will expel clots and stimulate the uterus, and may be sufficient. Combined Ixternal axd Exterxai. Stimulation The patient may be on her side or her back, but the lateral position is the more convenient. The uterus is then supported from without by the left hand, which compresses it against the vertebral column and down on to the pelvic floor ; while the right hand (the hand and arm having been made aseptic) is passed into the body of the uterus as far as the fundus. Clots contained in the uteiois can then be cleared out, and the uterine wall compressed and kneaded between the two hands. If the uterus contracts on the internal hand this should be slowly withdrawn, and support should be given for some time by placing the fingers in the posterior vaginal fomi.\, and then compressing the uterus bimanually (see fig. 375. p. 484). Hot Water Injection The best temperature for the water is iiS° F. It is possible that a temperature above this may still further paralyse the muscular fibres, and will in any case be hotter than any but the most tolerant patient can endure. It is safest to first of all make the injection into the vagina only, and this will often succeed in arresting the bleeding. If it does not, the nozzle of the delivery tube is to be introduced up to the fundus. According to some experiments made by Milne Marshall on the relative effects of hot and cold water in causing uterine contractions, hot water is a fraction of a second slower than cold in bringing about contraction, but it produces a result which is more complete at the time, and much more permanent. Two or three quarts of hot water may be used, and if successful, but followed by a recurrence of bleeding, the injection may be repeated. A douche-tin should be employed, for a Higginson's syringe involves the risk of injecting air into the uterus (see Air-embolism, p. 555). Cold water is sometimes employed, but it depresses the patient whether used internally or externally, and its effects, as just mentioned, are not so complete or permanent as those of hot water. There is, however, no harm in passing a small piece of ice into the uterus : but ice should not be used in any quantity, for it will then act like cold water in depressing the patient. Other substances which have been successfully used to apply to the interior of the uterus are turpentine, \inegar, and lemon juice. Electricity might or might not, depending on the degree of atony present, cause contraction. .\n apparatus for generating electricity would be too great an addition to the midwifery bag to be taken to every case : and no doubt those uteri which refuse to contract on stimulation by hot water are not likely to respond to electricity. Plugging the Uterine Cavity 485 Injection of a Sohiiion of an Iron Salt into tlie Uterus This method was at one time the last resource in the treatment of post- partum haemorrhage, and it has doubtless saved many li\-es. There are, however, so many dangers involved in its use that the method next mentioned is far preferable. Barnes ' describes the operation in the following words : ' Place the woman on her back. Get an assistant to press firmly with a hand on either side of the uterus, while you inject. You have the Higginson's syringe adapted with an uterine tube eight or nine inches long. Into a deep basin or shallow jug pour a mixture of four ounces of the liquor ferri perchloridi fortior. of the British Pharmacopoeia and twelve ounces of water, or dissolve half an ounce of solid perchloride or persulphate of iron in ten ounces of water. The suction-tube of the syringe should reach to the bottom of the vessel. Pump through the deli\"ery-tube two or three times to expel air, and to ensure the filling of the apparatus with the fluid before passing the uterine tube into the uterus. This, guided by the fingers of the left hand in the os uteri, should be passed c^uite up to the fundus. Then inject slowly and gently. Cease injecting as soon as the effect of the styptic is noted. A few strokes is often enough.' It is, howe\er, a dangerous method for the following reasons. The solution may pass through the tubes into the peritoneal cavity and set up peritonitis. Thrombosis may extend too far, and involve the pelvic veins and the vena cava ; a clot being thus formed which will almost certainly be carried on to the heart, to say nothing of the damage done even if it remain /;/ situ. The \&r\ tough clot formed in the uterus is tenacious and difficult to expel, and it will not improbably putrefy and cause septic trouble. These dangers are not only bad in themselves, but it will be ob^"ious that, knowing of their existence, a medical man would hesitate before resorting to this method of checking h.tmorrhage, and thus much blood would be lost. In fact, a fairly large proportion of cases did actually die on this account, for Galabin mentions that iron injection was used twelve times in 24,000 deliveries in the Guy's Lying-in Charity, and says that, although the bleeding was checked in all cases, five died from the results of the htemorrhage which had previously occurred. On these accounts this method has fallen into disuse, since the operation of jjlugging the uterus will just as certainly arrest the bleeding, and has none of these strikingly dangerous consequences. Pl.UGGING THE UXKRIXi: CaVITV This operation is described on p. 354. Its advantages are : it is cjuite simple, and the materials can always be handy. In fact, in a case where the patient was in danger of her life if the bleeding were not at once arrested, there need be no hesitation as to running a small risk in the way of possible sepsis, and tearing up a clean sheet, for instance, into strips, powdering with iodoform if this is available, and using this material without further sterilisation. There is no new danger conveyed to the patient if the proper ' Obstetrical Operations. 484 Patholog)' of Labour materials are used, and the physician should resort to it at once after manipulations and hot water have failed, and before the woman has reached a dangerous stage of anicmia. After plugging has been properly performed he may feel that she is quite safe. It has been urged against this method that bleeding has sometimes occurred after the plug was applied, and, further, that air-embolism might be caused b)- the intra-uterine manipulations ; but against these objections it may at once be said that the uterus was in all probability not properly plugged in the cases alluded to, and that there is no more danger of air- embolism in the act of plugging the uterus than in that of manually extracting the placenta, or any other treatment which necessitates the entry of a certain amount of air into the uterus. It is important to remember that this method is quite distinct from (a) that of plugging the \agina, which in the case of post-partum hicmorrhage would be useless and dang'erous ; and from [b) the use of intra-uterine tampons soaked in some styptic. Direct Bimanual Compressiox of the Bleedixc Surface The uterus ma)", in tlie intervals of applying the remedies above described, be compressed bimanually as follows. The hand is introduced into the vagina, and the tips of the fingers advanced into the posterior cul-de-sac, or at least into the part of the vagina behind and below the cervi.x. The left hand must then find the fundus through the ab- dominal wall, and press it down on the hand in the vagina. The uterus can thus be tirmly compressed, and may be held in this grip for an indefinite time. It is not always easy to find the fundus, however, when it is completely relaxed, but in most cases this way of compressing the uterus will be found very effectual. fB There are three other methods of treatment usually alluded to in works on mid- wifery — namely, the adminis- tration of ergot, the application of the child to the breast, and compression of the abdominal aorta. Ergot, whether administered by the mouth or hypodermically, does not act quickly enough in severe cases to Ije of any use in an emergency, but it Fig, 375. — Bimanual compression of uterus. Scheme of Treatment of Post-partiim HcemorvJiage 485 will tend to help the uterus retaiij its tone when that has been recovered ; it has no effect on a completely atonic uterus. The application of the child to the breast is an awkward means in anji case, and will certainly not be of use in an urgent case, though it no doubt stimulates the uterus under oi'dinary circumstances. Compression of the abdominal aorta will arrest the blood-flow into the uterine veins, and will diminish the loss to that extent ; but it will not prevent the reflux of blood from the pelvic veins into the uterine sinuses, and it will, moreover, deprive the uterus of the arterialised blood necessary to the recovery of its muscle. In cases where the bleeding has to be arrested by any manual efforts for a short time, bimanual compression is by far the best way of doing this. Scheme of Treatment of a Severe Case of Post-partum h.e.morrhage If the placenta is retained, remove it. If expression fails, introduce the hand, rendered aseptic, and extract it, peeling it off the uterine wall if necessary. If now the bleeding still continues, or if the case to start with is one where the bleeding begins after the placenta has come away, order se\"eral quarts of boiling water to be made ready so as to prepare a douche of the temperature of about 1 18° F., or as hot as the hand can bear it. Pass a catheter if there is time ; then — (i) Compress and knead the uterus through the abdominal walls. (2) Keep up the pressure by one hand externally, passing the other up to the fundus, clear out all clots, and compress the uterine wall between the hands. (3) With the internal hand in the posterior cul-de-sac of the vagina, compress the uterus bimanually. (4) Give a vaginal douche of the hot water (two c[uarts), and if this does not cause some contraction after a pint or so has run, pass the tube up to the fundus ; or if the bleeding is very severe, pass it up to the fundus at once. (5j Plug the uterus. This is the order in which the various methods are best used, the operator passing from one to the other at once as he finds he is not succeeding in checking the bleeding, and holding the uterus bimanually at any time while the materials necessary for the next manoeuvre are being prepared. After-treat)nent.—H\v^ woman will of course be ver}' bloodless after a severe attack of post-partum haemorrhage ; and although the bleeding may have been arrested before she dies, she may still become syncopic and be lost. She should be placed flat on her back, with her head low, and the foot of the bed raised on blocks of some kind. If her pulse is very bad, that is, rapid (160 or more) and hardly per- ceptible, some means of keeping the heart supplied with blood or fluid of an inert kind must be adopted. The simplest way is l)y the process of auto-transfusion ; nameh\ bandaging the legs and arms tightly, so as to make the circuit of the blood as short as possible. The blood may be forced out of the abdominal veins, in which, owing to the relaxed condition of the abdominal walls and the 486 Pathology of Labour reduction of the abdominal pressure by the emptying of the uterus, it tends to collect, by stuffing a pillow into the abdomen and bandaging it on. At the same time a pint or two of warm water or saline fluid may be slowly injected into the rectum ; it is quickly absorbed from there. If, however, the patient's condition is at all alarming or even unsatis- factory, there is no doubt that the best procedure is the infusion of saline fluid into one of the veins. The mode of action of this remedy and its method of performance are described on p. 360. Miinchmeyer used a trocar which he passed into the connective tissue and muscles of the back, and through this he injected saline fluid. He found it useful in many cases, and it is a simple method of adding fluid to the blood-mass. It is, however, slow, and if the woman is realh- in a dangerous state, too slow to be of any use. If the woman survive the blood-loss she should be carefully dieted, and fed in small quantities and often with easily digestible food. The greatest possible care must be taken to a\oid any risk of sepsis, for after acute and large hjemorrhage women are peculiarly liable to septic absorption (see p. 526). Secondary Post-Partinn Ha:nw7-rhage This name is given to bleedings either in excess of the normal amount during the time when there is still blood in the lochia, or occurring later during the in\olution of the uterus at a time when no blood should be lost at all. The bleeding depends on deficient uterine retraction, and if at all severe is practically always due to retention of part of the placenta or membranes. The subject is dealt with at the end of the chapters on the Pathology of the Puerperium, under the heading of Abnormalities of the Lochia (p. 576). Inversion of the Uterus The uterus is turned inside out more or less completely, not turned upside down onl)', as the term might, suggest, one if the inversion is complete, for as the fundus descends into the cavity formed by the peritoneal surface of the uterus, the tubes and o\arics are The anatomical change is a severe Fig. 376. — Inversion of uterus. R /-, round ligament; B L, broad ligament; Inf, In- fundibulum ; Ov, ovary ; A A, cornua ; O E, OS e.\ternum. Fig. 377. — Complete inversion, showing relations of ovaries and tubes (letter- ing as in last figure). dragged down with it, and may be entirely contained in the cup (fig. yjl). The ovarian vessels are strangulated in degree corresponding to the Inversion of the Uterus 487. aiiioLinl (if in\ersion, and in complete cases the uterine vessels are also compressed. Inversion may l)e partial or complete : and the vagina may in its turn become part of the in\crsion, and form part of a large mass protruding from the vulva. Frequency and Causation. — It is a very rare accident, and is computed to occur only about once in every 200,000 labours. To produce it there must be two factors ; relaxation of the uterus on the one hand, and some force, acting from above or from beloAv, which causes the fundus to descend towards and then through the cervix. If atony of the placental site as a special area ever exists, it is easy to understand how this area might bulge into the uterine cavity, and when this has happened how the amount of the uterine wall thus inverted might be increased b)^ the increased intra-abdominal pressure produced by bearing- down efforts ; or if the rest of the uterine walls had some tone, the placental site being the only part relaxed (fig. 133, p. 121, shows the comparative thinness of the uterine wall at the placental site) the inverted part w ould be gripped when enough of it had fallen inside the cavity to be gripped, and then expelled in the same way as the placenta itself by the contractions of the zones originally below the descending part but now above it. Small amounts of bulging would be at once reduced by the contracting uterus. Fibroids in the uterine wall sometimes cause inversion, this being due partly to the absence of contractile wall in their site, and partly to their actual weight. Inversion may occur before or after the birth of the placenta. The force acting from above is almost certain to be the hand of the attendant which is applied over a small area of a relaxed uterus ; inversion can only be produced by 'abdominal contractions after a bulge inwards has been already started. A force acting from below is most likeh' a more frecjuent cause. This ma)' lie due in very rare cases to a short cord, and then the inversion must at all e\ents be begun during the second stage. Or at the same period the cord maybe found se\eral times round the child's neck, thus producing \irtual shortening. Pulling on the cord to extract the placenta has no doubt been responsible for a certain number of instances of the accident. Inversion during the puerperium has very rarely been noticed ; it must ha\e begun during labour, and the expulsion completed during the contrac- tions and retraction going on in the lying-in period. Symptoms. — These are collapse and haemorrhage. The collapse is no doubt due to the strangulation of the uterus and its appendages. Diminution of abdominal pressure, which is assigned h\ some authors as the cause, can have but small effect in its production. The hccmoj-rhage is, of course, due to the relaxation of the uterus, and is intensified by the greater effect of strangulation on the veins than on the arteries. These two symptoms \ar\- in degree according to the amount of inversion. Signs and Diagnosis. — When an in\ crsion is complete, with or w ithout vaginal participation, and especially if the placenta is attached, there should 488 Pathology of Labour be no difficulty in recognising what has happened. If the placenta is not attached a tumour is found in the vagina, or is occasionally even seen at the vuha or projecting outside, which has to be -distinguished from a fibroid polypus. To exclude this the fundus must be felt for per abdomen : if it is absent from its proper place a circular rim, the angle formed by recession of the fundus, may be made out in the brim of the pehis, an impulse on which is transmitted to the mass in the vagina. It must be ascertained that the uterus is not relaxed and thus missed on examination, as might be the case when post-partum haemorrhage is going on. There may be inversion and a tumour as well, and this must be made out by a careful examination of the outline of the uterus per abdomen. Inversion has been mistaken for the head of a second child. If only a small part of the uterine wall is affected, the condition will in all probability be recognisable on abdominal e.xamination only. Results. — Death is rather frequent in cases of the complete degree, and has taken place from shock and haemorrhage in about 75 per cent, of the recorded fatal cases in a few hours ; and in the remainder later from continued shock and haemorrhage, and from inflammation and sloughing. Afterwards, in the sun'ivors, involution will g-o on to a certain extent, and the inversion becomes chronic, causing somewhat the same symptoms as a fibroid polypus. Prophylaxis and Treatinenf. — This accident can l)e prevented by avoiding any traction on the cord, and by keeping the cord under observa- tion if there are any signs of its being short or coiling round the child's neck to a sufficient degree to drag on the placental site. Care must also be taken during the third stage of labour not to press on the fundus during relaxation so as to indent its surface. When inversion is an accomplished fact the only treatment is to reduce it as speedily as possible. No time should be wasted in attempts to restore the woman, as she cannot be ""estored until the uterus is reduced. If the placenta is attached, it should be removed, as reduction will probably be easier after this has been done ; but no long time should be occupied in this ; it is not of great importance whether the placenta is attached or not, but it is of the greatest importance to reduce the uterus as soon as possible. To effect reduction the left hand must be placed on the abdomen to steady the rim, if this is felt ; then the fundus is to be pressed up by the fist in the vagina if the mass is small. If it is large, it appears better to restore the utervis by grasping the fundus in the palm of the hand, and pushing up the re-entering angle, so that reduction advances at the rim, as in this way the four thicknesses of uterine wall which would be produced by bulging the mass inwards from the fundus first are avoided. An anaesthetic is often necessary in these cases ; but if there is no delay in the attempt, reduction may be effected without one. Rupture of the Uterus 489 CHAPTER LXV LACERATIONS OF THE GENITAL TRACT The uterus, vagina, and perinieum may any of them l^e torn during the progress of labour. Some of the tears are comparatively unimportant — such are the slight lacerations, which are the rule rather than the exception, of the fourchette in primiparae ; while others, like rupture of the uterus, are very frequently fatal, and in any case are among the most dangerous accidents which can happen to the parturient woman. Lacerations of the Uterus. Rupture of the Uterus Rupture may affect the iDody or the cer\-ix of the uterus, or both. In describing these lacerations it will be assumed, as described on p. 98, that the lower uterine segment is a part of the body, and that the retraction ring is not, except perhaps at the beginning of labour, at the same level as the internal os. Rupture of tbe Body of the Vterus. — This may be complete, involving both muscular and peritoneal coats ; or incomplete, affecting only one of them, so that there is no communication between the peritoneal and the uterine cavities. Frequency and Causation. — Rupture of the body is found to occur about once in 3,000 labours. There are said to be predisposing causes of the nature of pre\ious degeneration of the uterine \\alls, but such changes have not been demon- strated. They have been supposed to exist so as to account for a few rare cases where rupture has taken place during pregnancy or during an easy labour. The cicatrix of a Caesarian section might be expected to gi\e way under a great strain, and the want of the assistance of the abdominal muscles in the second stage of labour will allow of more read)- tearing ; but these are only conjectural predisposing causes. The immediate causes are undoubted. The most important group Ijy far is that comprising cases of obstructed and prolonged labour. The obstruc- tion may be due to contraction of the bony pelvis or of the soft parts (cervix and vagina), to a too large head for the pelvis where the latter is normal, as in the case of a hydrocephalic head, or to transverse presentation of the child. Such causes are intensified by misapplied treatment — namely, by attempts at internal version when the uterus is already over-retracted or tetanic, or by the administration of ergot in cases of obstruction. When the head nips the cervix, as has been explained in the description of labour in the contracted pelvis (see p. 428}, the cervix is not able to rise and be withdrawn from the head, especially if the membranes have 490 Pathology of Labour ruptured prematurely. Thus the lower segment is excessively thinned and may be lacerated. In the case of Pendulous Belly, where the anteversion of the uterus causes the expelling' force to be directed against the promontory, the part of the uterus lying between the head and the promontory is crushed, and a hole is made. Whether the rupture is due to tearing or to crushing, the tear is always in the lower uterine segment according to the definition given on p. 98. Tube Ovary and fimbrieE Retraction ring Roinid ligament Retraction E.xternal os 378. — Laceration of vagina, cervix, and lower uterine segment into the right broad ligament and abdominal cavity. Other and accidental causes are ])erforations by instruments in attempts at criminal abortion, or in unskilful embryotomies of one kind or another : ^\■ounds from the horns of cattle : or crushings or perfoiations, from the woman being run over, for instance. Mo7-bid Anatomy. — A tear beginning in the thinned lower segment may extend transversely or parallel with the axis of the uterus, depending on the direction of the line of greatest tension, to which the line of tear is always roughly at a right angle. Thus if the rupture is due to nipping of the cervix, the line of tension is longitudinal, and the tear will be across the lower end Symptoms of Uterine Rupture 491 of the uterus ; but if it is due to radial stretching, as by a hydrocephaUc head, the tear is through the rings of unyielding tissue, and therefore longi- tudinal. It often has an oblique direction, and is very irregular and jagged. The laceration may extend into the vagina, or further up into the uterine body, or it may run round the lower segment and separate the cer\i.\; frcm the uterine body. The posterior wall is the one which is most commonly completeh' ruptured, owing to the attachment of this to the posterior valve of the pehis (see fig. 131, p. 118), and to the fact that the peritoneum extends lower here than elsewhere. Rupture is commoner on the left side than the right, owing to the usual uterine obliquity, and, as Spiegelberg points out, to the fact that in transverse lies the head is most commonly to the left. In cases of lateral rupture the peritoneum is not so commonly perforated, for its lateral attach- ment is loose, and the layers of the broad ligament are somewhat separated close to the uterus by the growth of the latter in pregnane)'. After a fairly large rupture and escape of the uterine contents the upper part of the organ contracts down to a firm mass, and is usualh' displaced by the body of the child which lies in the abdominal cavity. In case of complete rupture the bleeding takes place into the peritoneum and into the vagina. In cases where the peritoneum is not torn a ha^matoma will form beneath it, and the broad ligament of the side on \\-hich the tear has occurred will become distended with blood. If the tear is complete the foetus may at once be e.xpelled into the abdo- minal cavity, and be followed by the placenta. Or only the trunk of the child may escape, especially if the head be impacted in the pelvis. The placenta may be left in the uterus, and may be deli^"ered by the vagina ; and'a case of Matthews Duncan's is recorded by Spiegelberg in which after rupture had occurred during" the birth of the first twin the second was born naturally. Symptoms. — In the most common kind of case, that due to obstruction, the symptoms which indicate a probable rupture are increased rapidity in succession of the pains and increased violence. On examination of the abdomen the ring of Bandl, already described, ma}- be felt somewhere near the navel, often running obliquely across the belly ; and under certain circumstances it may even be visible. At the moment of rupture, if this is complete, the woman becomes suddenly collapsed, the pains cease, and there is a greater or less haemorrhage from the vagina. On making a ^■ag•inaI examination the physician finds that the presenting part, if not well engaged in the cavity of the pelvis, recedes ; if it is engaged it can be pushed back, unless it is impacted. B)' the abdomen the child may, if any considerable part of it has escaped, be felt distinctly under the abdominal wall : and pro- bably the retracted and contracted uterus is found beside it. The placenta may then be born, or it may too have been expelled into the abdomen. If it is born, its emergence before the child should at once suggest a rupture of the uterus, supposing this has been hitherto unsuspected. A coil of intestine may prolapse into the vagina. The woman is in a collapsed condition, with a small, quick, irregular pulse and cold extremities ; and death ma\- speedih- result from shock, or, more rareh", a little later from hirmorrhage into the al)domen. If she sur- 49- Pathology of Labour vive these risks she may die in a day or two Irom peritonitis caused by infection carried by the lochia and the secretions of the wound into the peritoneal cavity. The total mortality is recorded as about 90 percent. In very rare cases the child has been cncapsuled and the woman thus sa\ ed for a time. The child dies almost immediately after expulsion into the abdomen. The symptoms of incomplete rupture are not well marked. There is some collapse, depending on the amount of tissue torn, and a \ariable amount of bleeding. The blood may not be able to pass the child's head, and may collect in the uterus. If the rupture has been an extensive lateral one there may be recession of the fcetus when it is not impacted ; but the pains do not cease in cases of a lesser degree, and beyond the shock there may be little to suggest a rupture until there has been a fair amount of bleeding. Emphysema of the anterior abdominal wall may occur in case air is admitted into the subperitoneal tissue through the rent. There may be a mass consisting of the extravasated blood, and possibly the child, to be felt in the broad ligament, and the uterus may be felt alongside this. The diagnosis of complete rupture cannot be difficult if the important symptoms and signs above mentioned are observed. In the incomplete \ariet\- the case might possibly be mistaken for accidental hiemorrhage, or for placenta prtevia if the placenta were expelled before the child ; but the existence of obstructed labour will at once distinguish the con- dition. Prophylaxis and Treati>ieni. — Rupture of the uterus is almost invariably due to want of attention on the part of the medical attendant, if he has had an opportunity of watching the course of labour from the beginning. The way to avoid it is to take such measures as will prevent the uterus from getting into the condition of over-retraction ; by noticing the relations of the child to the pelvis, as regards size and lie ; and in correcting any abnormality of either kind before the uterus has begun to close on the child ; to at once deliver the woman, leaving all consideration of the child's prospects out of consideration, if the signs of obstructed labour become evident (p. 408 . The improper use of ergot and of turning must be avoided. After rupture has occurred, the case will have to be considered under one of two headings ; {a) where no part of the ovum has escaped into the peritoneal cavity, and {b) \\here the jjeritoneal cavity has been opened, and there has been some such escape. That is, the cardinal point is whether the peritoneum is or will be contaminated by the blood and liquor aninii at the time or by the discharges from the wound before this has been shut ofit by lymph from the general peritoneal cavity, or whether it will not. In cases where the shock is so great that the woman dies \ery soon, there is little or no chance of treatment. Under any circumstances the child must be at once extracted with the placenta. If this is easy by the vagina it will be best to extract it by that way, after perforating, decapitating or what is necessary to enable the child to pass through the parturient canal. If the child is at all gripped by the edges of the rupture, or a fortiori if it has escaped into the abdominal ca\ity, the abdomen must be opened. The extraction of the placenta must be con- ducted on the same principles. After removal of the child by the vagina the interior of the uterus must be Treatment of Uterine Rupture 495 examined by introducing the hand. An an;Esthetic will be necessary, and if ether is available it will be well to use it. Possibly a loop of intestine may be found in the uterus or vagina ; or the fingers may come into contact with peritoneal surfaces if passed through the \vound. Tears in the posterior wall are certain to ha\-e reached tlie peritoneal cavity ; but those at the side may have opened up the Inroad ligament only, and the extravasation of blood and other fluid is then extra-peritoneal. If the child has escaped into the peritoneal cavity, or is partly through and is gripped by the edges of the rent, no force should be used in attempts at extraction per vaginam, but preparations should at once be made, if the woman is in an at all hopeful condition, to perform abdominal section, and i-emo\-e the ovum that wa)\ The abdomen is opened in the same way as in a Caesarian section fsee p. 396 for full detailsX The child and placenta, if the latter also is in the abdo- men, are now to be remo\-ed, and the peritoneal cavity well washed out with plain water at a temperature of about io5°to 1 10^ F. This frees the peritoneum from blood, meconium and licfuor amnii, and cleans the edges of the rent. The rent is now to be found, and if it is not low down on the posterior wall and inaccessible, it should be sutured as after Caesarian section. If the tear cannot be well got at so as to be sewn up, a drainage-tube of large size should be passed through the tear into the vagina, where its lower end should be surrounded with iodoform gauze (fig. 330). Or iodoform gauze ma)- be used for the drain altogether, a wisp of it being passed in the manner directed for the tube. The abdominal end will in a few hours be surrounded by Ij^mph and isolated from the general peritoneal ca\it)'. Either the tube or the gauze may be removed in forty-eig-ht hours. The most convenient position in which to put the woman during the operation is what is known as Trendelenberg's, or the raised-pehis position. This can be managed, as suggested by Herman, by ' putting on the bed a chair resting on its top rail and the front of its seat, and pinning a towel oxtx its legs. The patient is then placed on the back of the chair, her knees being- supported by the towel.' After the intra-peritoneal part of the operation is done the abdomen will be sewn up as usual (see p. 399). Supposing that the case is not one where it is necessary to open the abdomen, as where the tear is incomplete, or into the broad ligament ; or supposing the physician does not feel ecjual to abdominal section, or the woman's surroundings are unfavourable, it will still be necessary to wash the tear, and the abdominal ca\ity or the ca\ity in the broad ligament with warm water as in the more serious operation. Plenty of water should be used for this purpose, and the tube must be introduced well into whatever ca\ity is Ijeing- irrigated. The drain must next be arranged, and in this case it \\ ill ha\-e to be pushed upwards from the vaginal aspect of the wound. Porro's operation has been recommended and performed for this accident. It can only be of use when the rupture is confined to the body, as the cervix cannot be removed or secured in this way (see p. 401 for a description of tlie operation). This objection is of course stronger if the tear extends into the vagina. Complete removal of the uterus per 494 Pathology of Labour abdomen would answer well in cases where the vagina was not injured, but it is too long and tedious an operation to be the best in this particular case. The treatment may be summarised as follows : — If the presenting part is in the \agina, extract at once. If the lie is transverse decapitate, or if the child is hydrocephalic or the pelvis contracted, perforate, and extract at once. If the breech is presenting, use the blunt hook, and if necessary perforate the abdomen and the after-coming head, and extract at once. Get the placenta out through the vagina if this can be done without force. If the child or enough of it to be gripped is through the rent, or if the placenta has passed through, do abdominal section, and, if possible, suture the tear accurately, cleansing the peritoneal cavity by irrigation ; if the tear cannot be accurately sewn, drain. If abdominal section is not done, cleanse the tear and the cavity opened up, and drain. In rare cases the peritoneal coat is alone ruptured. The tears in this are always found on the anterior or posterior surface, and are to be ascribed to want of elasticity in the peritoneum (see p. loo). They seem to be alwaj-s very numerous, or at all e\ents ha\e been so in the fatal instances which have been described. Death occurs from shock or from hiemorrhage into the peritoneal ca\ ity. They are undiagnosable. Lacerations of the Cervix These are for the most part merely exaggerations of the tears which occur at nearly every labour, and are therefore mainly in a longitudinal direction. When the tear extends upwards into the supra-\aginal cervix the base of the broad ligament is opened; and downward extension involves tearing of the upper part of the vagina. Transverse or circular tears are due to nipping of the cervix ("see p. 428) or to the anterior lip being carried down, as in cases of premature rupture of the membranes, and being crushed between the head and the back of the pubes. These tears are of no great importance in themselves, except that occa- sionally they give rise to troublesome haemorrhage after the child is born ; and indeed this bleeding may be mistaken for httmorrhagefrom the placental site. They are, however, most important as being possible channels through which septic organisms can enter. When a circular piece is nearly torn off it may slough and give rise to septic danger. The bleeding is best treated in these cases by plugging the cer\ ix for a few hours with iodoform gauze, for attempts at suture — which would, if feasible, be the correct treatment — are practically useless. Strict antiseptic conduct of the case will ensure safet>- from absorption, and any very loose pieces may be at once cut off. Lacerations ok the Vacina The injuries in this case may^ be caused by the pulling up of the lower segment in prolonged labour, as in a transverse lie ('p. 466) ; by rigidity Lacerations of Vagina 495 of the vagina, such as may be (but is rarely) found in elderly primipanu ; by the action of instruments in the vagina, especially forceps ; or by the intro- duction of the hand with violence ; or by extension from the cervix. Anatomy. — The rupture may reach the peritoneal cavity if it takes place in the part of the vagina in relation with Douglas' pouch, but not other- wise. The tear is usual!)- transverse, since the tension, where this is the cause of rupture, is mainly longitudinal. The tension is rarely transverse or circular, for if a head has come through the cervix it will always come through the vagina, unless the latter is cicatricial or abnormally small. Laceration occurs mainly under two conditions : {a) In transverse lies, in which, owing to the cervix not being nipped by the presenting part fitting the brim closely (see p. 466), it is drawn up as the uterus undergoes re- traction, and the tension comes on the vagina as much as on the cervix. The vagina is the thinner of the two, and the tension, by the time the cervix has been drawn above the greatest circumference of the head, is still further increased, {b) In pendulous belly (anteversion of the uterus) it has been explained that the vaginal walls are unduly stretched (fig. 247, p. 272). The tears which extend down from the cervix are as a rule longitudinal. When, however, laceration is caused by the use of the forceps, the tear may be in any direction. If it is caused by the edge of the forceps projecting above the general plane of the head-surface in cases where the head rotates and the forceps is held too tightly, the tear is mostly longitudinal ; but if it is caused by forcible dragging of the head through a vagina which is unable — owing to cicatrices or other organic narrowing — or has not had time to dilate, the tear will probably be mainly longitudinal also, though in the latter case it may be transverse or oblique. Symptoms. — Unless the tear is a very extensive one, or opens the peri- toneum, there is nothing to call attention to the accident but an amount of bleeding which is according to circumstances. The tears are, as in the case of the cervix, possible channels of septic infec- tion, but in a greater degree, since they are nearer the external air, and are more likely to be contaminated by decomposing matter. Treatment. — If the tear in\olves the peritoneum it will need exactly the same treatment as a correspondingly grave uterine rupture. If the child has escaped into the abdomen, as may happen, abdominal section is indi- cated, as in the case of the same event from rupture of the uterus ; and drainage and careful antiseptic treatment are equally necessary. When the laceration is in the lower part of the \'agina, which is less common, the rent may be sewn up if it is large, bleeding freely, and within reach ; but other- wise it may be left alone, and attention devoted to keeping the parts as aseptic as possible. Laceration of Submucous Tissue, Fasci.+:, and Muscles Near the lower end of the vagina there is sometimes a tearing of the submucous tissue : this is most commonly brought about by a glacier-like movement of different planes of this tissue on one another to an extent which ruptures their connecting fibres. The gliding is caused by the mucous 49^) Pathology of Labour iiiembranc bcini; forced down by the head, uliicli may carry a fold of it bodily down in front of itself. Such tearing of tissue brings about one kind of vaginal thrombus, the blood being extravasated between the super- ficial and deep layers ; the clot may suppurate, or may l)c the origin of one form of vaginal cyst. No treatment is required for this condition if it be diagnosed, but rest and antiseptics are necessary to satisfactory healing. Over-stretching and tearing of the levator ani muscle and of the fascia forming the pelvic tloor (pp. 86 and 89) have been described, but no cases have been dissected. Lacer.\tiox of thk Perix.eum Lacerations ne\er extend further back tlian the anus : they usualh- begin at the fourchette, which is nearly always torn at the first labour, and extend backwards to a variable distance, the most complete ones thus involving the anterior part of the sphincter. In this, the ordinary kind of rupture, the whole thickness of the tissues included between the skin and the mucous membrane of the \agina gives way (fig. 378 b;. Rarer forms ai'e (i) a central rupture, where the first part to gi\e way is the centre of the jDerina^um, or some point between the anus and the fourchette ; this tear begins on the mucous surface, and not at the anterior border of the perinaium, and perforates the pehic floor, thence extending backwards and forwards, but not necessarily in\ol\ing either fourchette or anus. The child has been born through such an opening. (2) Herman describes a form which begins in the recto-vaginal septum, and advances from above clown. There is also (3; a \ariety where the same 'glacier movement' occurs as that described between the planes of tissue under the lining membrane of the vagina. Causation. — The tear and its amount depend in all cases, even those of the smallest degree, on three factors ; («) the size of the body which has to pass through the parturient canal — that is, the size of the greatest circumference which distends the vulvar orifice. The tear is practically always caused by some circumference of the head. The most and the least favourable diameters of the head ha\e been already considered in the mechanism of laljour. The shoulders rarely, if c\er, begin a tear, but they not uncommonly enlarge one already commenced by the head. Their circumference passes more easily through the \ulva than that of the head, since although it may be a little larger than some circumferences of the head, it encloses a softer and more compressible material. {b) Rapidity of Labour. — This cause is shown in a most marked degree in instances of Precipitate Labour (p. 406), and in lesser degrees it is present whenever the head is too rapidly dragged through an imperfectly dilated vulva in extraction with the forceps. (f) Conditio7i of the soft parts. — The dilatabilitjof the periuieal structures varies in difTerent women. There is no rule by which the accident can on this account be foreseen, for in thick, resistant ones it is not oftener torn than in thin lax-fil)recl perinieums. Nor can any ])rognosis be made on Rnf^liirc of Pe)'in(SU)n 497 account of the lciiL;tli of llic pcrinaaim, for in cases wlicrc il is lon,n this may be due to the anus l)cin;^ placed turtlier l^ack and more away from the symph)-sis than usual. The perina:uni is, ho\\e\er, no douljt more often torn in el(l(;i-|\' priniipai",::; than in young ones, owing to diminished dilatability. {d) Formation of the Pelvis. — The shape of the pubic arch is an important matter, for if tliis is very narrow the head has to pass through the outlet more posteriorly than when there is plenty of room for the skull to enter completely into the sub-pubic angle, and in consecjuence there is more yielding rec[uircd from the perin;cum. A most marked example is in the case of the kj'photic pelvis (p. 447) in which the child has in some cases to pass through the posterior half of the outlet, entirely behind a line joining the tuberosities. ((•) The perin^eum is sometimes torn by rough handling and introduction of the hand before sufficient dilation of the vagina is present. Alethod of tear. — The rupture in tears which begin at the fourchette is always antero-posterior, and though it is often somewhat irregular, it keeps about the middle line. This shows the direction of the stretching force, which is radial and not longitudinal. In cases of central rupture it is possible, though it has never been shown by dissection, that the force may act longitudinally, thus carrying the anterior part of a long perimeum forwards in front of the presenting part. As the process is watched in the ordinary form, it is seen that the skin gives way first at the anterior border of the perinasum and all along the line of rupture, the subcutaneous layers parting just after. The angle of the tear is thus one with a bevelled face, the least amount of tearing having taken place in the mucous membrane. In the central tear it is beliexed that the rupture begins in the deeper structures, thus rather suggest- ing a glacier movement, and so a longitudinal force. The tear looks very large while the head is still distending the perina^um, but after delivery it will diminish to about a quarter of this length, and will become thicker in its lips. The process of rupture may stop short at an)' point in the length of the perinaeum, or it may reach far enough to e.\pose the fibres of the sphincter ani, sometimes forking as it reaches the ring of muscle and running for a fraction of an inch on each side of it, or diverging entirely to one side. Carried still furthiT it goes through the anterior part of the sphincter, and jjossibly some distance I'lialf an inch to two inches) uj) the ivcto-vaginal septum. After an incomplete rupture (the sphincter not torn)(.VA, fig. 379) the tear forms merely a prolongatioii backwards of the vulvar slit, the torn surfaces being K K I'ij;. .^79. — Laceration of perin.uuni. 1", fourcliette ; A", rectum ; A A incomplete, ^^ complete, rupture. 49!^ ]''athology of Labour coarsely granular and oozing blood. The surface exposed at the angle of the tear is continued into the surface of the mucous membrane on the posterior vaginal wall (fig. 380). In the case of complete rupture, where the sphincter has gone, its ends maybe seen widely separated from one another and marked by a depression in the tear. The sphincter flattens out, and no longer forms a ring, and the tear in the recto-vaginal septum forms an angle whose composing lines converge from the two ends of the sphincter (fig. 381 1. Results, immediate and remote. (,11) Immediate. 'V\\txG. is practically no bleeding, as the rupture is through the non-vascular middle line. The prospects of its healing if untreated are in the case of comi)letc rupture almost none, for the edges are kept apart by the action of- the sphincter. Complete ruptures ha\e been known to heal, however. In the incomplete cases, healing will probably occur to some extent (or rarely even entirely) — though this is not to be relied on — if the parts are kept clean and at rest. The most important immediate result is that a surface is produced at which septic absorption may take place freely. A perinieal tear is, in fact, the commonest site for the absorption of septic matter. ip) Remote. — In the complete form the woman will have incontinence of liquid faeces. She accpires the power of retaining solid ones after a time. She may later on suffer from prolapse of the vagina, and subsequently from prolapse of the uterus. This is brought about, not by the loss of support to the parts caused by aljsence of the perina;um, but by interference with involution of the vagina, probably owing to septic absorption, or to too early getting up. The sub-involuted vagina finds its descent made easier by the absence of perinccum. Lacerations, by enlarging the vulvar outlet diminish the retaining power of the vagina for a ring pessary, which it is often necessary to apply in cases of vaginal prolapse. They also diminish to some extent the power of satisfactorily discharging the sexual function. Damage to the fascia forming the pcUic floor is combined to a greater or less extent with laceration of the perinxum, and this will assist in the production of prolapse of various kinds. Treatment. — In the case of any tear involving more than the fourcliette the best practice is to stitch it up at once. If the woman is still drowsy from the effect of the aniesthetic which may have been given during labour, It should be done without any more being given. If the patient is unable to bear the pain without some aniesthetic, there is no reason for withholding it. Galabin rccomn\cnds that two or more hours should elapse before the patient is narcotised, so as not to run any risk of relaxation of the uterus under chloroform ; but it is probably best to put in the stitches before she has come to from the eftect of the anii^sthetic of the second stage, leaving them untied till after the placenta is expelled. There is no doubt that a better result ma)- lie expected from an immediate ojjeration, both as regards healing and immunity from the danger of septic absorption. It also does away with the need for disturbing the woman during her first sleep. Method of Stttinr. — The woman is to be placed on her back in a posture as nearly approaching the lithotomy position as can be managed under the circumstances. Suturing should not be done- while she lies on her side, for in that posture neither can the extent of the laceration be pro|ierly seen. Suture of Periuccuvi 4t;9 nor is it possible to place the stitches accurately. The operation is also rendered more painful to the woman (if she is conscious), since the sutures will ha\e to be passed from the outside inwards — that is, through the skin hrst, instead of from within outwards. The material used for the sutures is unimportant ; Ixit it is better to use one which will require removal of the stitches, for the result will then be necessarily seen when the)' are removed. Silk is the most comfortable for the patient : wire or silkworm gut may prick the skin when the patient moves. The needle is a matter of some importance.. Whatever kind is used it must be one which is rigid along its curve if it be curved, or ciuite rigid if it is a straight one. The position of the point is then always known and the point can also be kept in the line wished, instead of being liable to be di\crtcd by planes of tissue. Hagedorn's needles fulfil this condition better Fig. 380.— Suture of incomplete perinjeal rupture. than any. The writer is accustomed to use a 'half-circle,' or ' quarter-circle,'' in a needle-holder which can be extemporised out of a Spencer Wells' clip. Or a needle in a handle may be used, but this is more difficult to keep well sharpened. In a case of incomplete rupture the stitches should be placed about I inch apart in the thicker tissues, and about ^rd of an inch apart in the thinner anterior lips of the tear. The posterior ones should be inserted first, and left untied. The needle must -be entered in the middle line of the tear — that is, at the bottom of the wound, where the \-aginal mucous mem- brane is not torn ; and on the \aginal surface, where the lips have free edges, for the skin is the most sensitive structure. In this way it is only per- forated at the last moment, and the needle can also be passed more rapidly through it in an outward direction because counter-pressure can be applied to its surface as the needle emerges. When the needle is entered K K 2 500 Patlioloi^y of l^abonr on tin.- skin-siirf;ice there is pain all the time the thread is Ijcing dragged through the tissues. The needle should be brought out at the edge of the wound, for then none of the skin is tucked in, and the edges come accurately together. The suture may be arnicd with a needle at each end, as is best, or the same needle may be threaded on to the end now at the centre of the wound. It (or the second needle on the suture) is then entered at the same jjoint as that at which the first half of the suture entered, and brought out at a point in the skin-surface cxacth- o|)positc the point of emergence of the first half (fig. 380). When all the stitches are inserted the wcnmd should be carefully cleanbcd with warm water or a 1-2000 solution (jf corrosi\e sublimate, and the sutures tied. In complete rupture the sphincter ani must receive special attention, for if the ends are not secured in apposition its action will infallibly prevent satisfactory healing. It is best to first of all sew up the torn recto- \aginal Fig. 381. — Methcd of instrtiiig sutures in complete rupture, a. catgut sutures for reclo-\Mgiii.il septum ", S/iliy silk suture for sphincter. septum with catgut stitches, as these can be left to be ab.sorbed. They should be passed as in the diagram (- the fr;tnum and prteputium clitoridis in front. Sometimes the labia minora are button-holed. The cracks on the vestibule are irregular in shape, but usually radiate from the edge of the vaginal orifice : they sometimes embrace the uretbra. The urethra itself is never torn, at least only three or four cases are on record in ordinary labour. In a series of 100 women (i-para? and multipar^e) taken consecutively Auvard found that there was — No tear of the vuha in ....... 5 Perinajum alone torn . . . . . . . -14 Lateral or anterior parts (pcnnteum intact) . . ■ 32 Lateral and anterior parts and pcrin;i;um . . . -49 These figures give an idea of the frequency with which these small tears may be found if they are looked for. They are important if they' reach an appreciable size for two reasons. They might cause some haemorrhagre which, if excessive, could be mistaken for post-partum haemorrhage — bleeding from a torn clitoris has been known to be considerable ; like other wounds of the lower end of the \agina the) are dangerous for septic reasons. TreaiDient. — These wounds seldom want a stitch, but they may. As a rule pressure for a few hours is all that is required if there is any bleeding. Rupture of the Pelvic Articlm.ations The softening which takes place in the pelvic joints in pregnancy has been described (p. 48) ; and the structure of the joints rarely gives way. Rupture may occur in cases where there has been forcible extraction with the forceps in a contracted (usually transversely contracted) pelvis ; and during this operation the symphysis, which is the synchondrosis usual!)- damaged, has been heard to crack. These lesions usuall)' heal without trouble. If the symphysis is much separated there is a strain on the sacro- iliac joints, just as occurs during symphysiotomy (p. 402). If the relaxation of the joints, especially of the symphysis, persists, it may be severe enough to prevent standing or walking. There is much pain felt over the pubes when the movement between the two ends is ai all considerable, and sometimes movement can be made out on examination. It is easier to identify this when it is present at the sacro-iliac joints, as a good grip can be got of the crests of the ilia. 502 Pathology of Labour The only treatment is to make the patient, when she gets up, wear a strong pelvic band, reaching from the level of the crests of the ilia to below the trochanters. Matthews Duncan recommends that with this the woman should be encouraged to brave the pain and to go on walking, since the irritation caused by the friction on moxcmcnt may set up some slight inflam- mation and fix the joints. Physometra. Tympanites TTteri. Air or other Gas in tbe TTterus. Air is said to sometimes enter the uterus spontaneously during a long labour when the liquor amnii has drained away ; but it usually gets in while some obstetric operation is being performed which needs the introduction of the hand, especially if the intra-uterine pressure is relaxed. It is favoured also by relaxation of the abdominal pressure brought about by change of the posture of the woman, a sudden inspiration, or the like. Also in syringing, either intra-uterine or only vaginal, air may get in if care be not taken to expel it from the syringe before beginning to pump. Gases of decomposition are given off where putrefactive organisms have been admitted to a retained dead ovum ; this condition is usually com- bined with septicaemia, and the uterus may become relaxed and tympanitic in serious cases of the kind. The prognosis here is very bad. In the instances where air has been admitted there is always some danger of air-embolism. Treatment. — If the physometra is due to the admission of air during an operation, and all is aseptic, there arises no need of treatment. If there is the least decomposition the uterus must be cleared out and douched with some antiseptic in the way recommended for septicaemia and sapntmia (see p. 531). If the child is alive when the air finds its way into the uterus it ma\- make an attempt at inspiration, and a cry has in a few instances been heard in utero. The lungs of such a child, if examined after it has been born dead, would show signs of partial expansion, and one of the tests of live- birth would therefore prove fallacious under such circumstances. Empbysema of the TTeck and Neig-hbouringr Subcutaneous Tissues. Numerous cases of this accident are recorded. The air finds its wa_\- out of the pulmonary vesicles ruptured by bearing-down efforts into the sub- cutaneous tissues of the neck, face, and thorax. No ill-result beyond inconvenience seems to result from this condition. There is some pain for a day or two, and the emphysema gradually passes off. Sudden Death in Iiabour and shortly after.— It is only necessary here to classify the causes, since, where they are directly caused by the ])rocesses of abnormal labour, they arc dealt with under their respective headings. 1. '{"hose directly caused by abnormal labour : Embolism and thrombosis of the pulmonary artery and right side of the heart. Air-embolism. S\ncope from post-partum hiumorrhage or placenta pr\ there are many theories, in support of any one of \\ hich there is little but conjecture. The principal ones are : 1. That the ureters are obstructed by the pressure of the gravid uterus. This may sound plausible as accounting for some of the acute cases where albuminuria rapidly appears ; and then as rapidly diminishes directly the uterus is emptied, or rather immediately the liquor amnii is tapped, and the uterine bulk lessened. It must be abandoned, however, since there has never been any oedema of the kidney found post-mortem, and this is a constant change where the ureters ha\e been ligatured or otherwise experimentally obstructed. No dilation of the pehis of the kidney nor of the ureters abo\e the point of supposed obstruction has been found. 2. That there is, increased work thrown on the kidneys b)- the addition to I he blood of the foetal waste products. Against this hypothesis it may be said that after excision of one kidney the other will at once prove itself cc[ual to the work of two, and it can therefore hardly be true that the addi- tion of the comparati\el\- small amount of waste product from the foetus or embryo (for albuminuria may begin before the third month) is enough to cause the least embarrassment. 3. That it is caused b\' the increased arterial pressure normal to preg- nancy. When the renal and splanchnic nerves are divided, so that the l)lood pressure in the kidney is enormously increased, no albuminuria is found, nor is it in any other experiment by wliich the intra-renal arterial tension is increased. The amount of albumin is small in the high tension of chronic liright's disease, with arterio-capillary fibrosis. It has also been shown that increase of filtration pressure diminishes the permeability of a membrane to alluimin.' 4. The old theory of ' reflex " interference with the function of glandular ' RuiiehcrEr, .Irc/i. drr Ucilk. vol. xviii. p. i. 5o6 Pathology of Labour organs is a hypotlicsis which hardly accounts for lonj^-c oniinucd cffcctb mp ii as that now being considered. 5. That the venous return from tlie kichicy is impeded by the increase of abdominal pressure brought about by the growth of the uterus. When the uterus is large enough to considerably raise the abdominal tension, and also to be pressed directly against the back of the abdomen by the reaction of the anterior abdominal wall, it is possible that the renal veins may be narrowed, or at all c\ents the return of blood from the kidney retarded, and the pressure on the venous side of the kidney thus increased. A slight narrowing of the renal vein is found experimentally to immediately decrease the quantity of urine, but never to suppress it.' After a few hours, the urine, which becomes albuminous at once, contains red corpuscles and casts (hyaline). This change is due to damage of the tubular epithelium, and to the fact that ' any considerable circulatory disturbance renders the membranes concerned in the excretion permeable to albumin' (Cohnheim). Albuminuria is not very uncommonly found in the urine of patients who arc the suljjccts of large abdominal tumours. Albuminuria, however, occurs in pregnane)' before the uterus has reached anywhere near the level of the renal veins, so that this cannot be the only cause. It is true that the quantity of albumin in such early beginning cases is as a rule small, and the disorder perhaps might, in some instances, be referable to group {a). The amount of albumin in group {h) is as a rule large and first appears late in pregnancy, so that in this class renal venous obstruction is a not unlikely cause. In a case of Herman's, where there were both twins and hydramnios, the albumin diminished from enough to make the urine solid on boiling before deHvery to a trace only on the fourth day after deliver)', with an increase to five times the quantity of urine passed during the day. This form of albuminuria is commoner too in primigravid;e, where the abdominal walls are still unstretched, and thus presumably keep the intra-abdominal pressure high. It must be remembered that diminution of the abdominal tension means also diminution of the general blood-pressure, and that bleeding is found to have the same effect in diminishing the amount of albumin for a time as is produced by evacuation of the uterus. ncorliid Anatomy. — In all fatal cases some change in the kidney has been found. In class {11) the disease may be originally nephritis, the acute tubular a ariet\-, but this is rare ; or the chronic tubular ; or the chronic interstitial form. These have acute tubal nephritis superadded when the disease is fatal by the kidney alone ; but death may be caused by haemor- rhages into the ner\ous centres and in other wa\s. In class {b) 'congestion' has always been described, though many specimens are mentioned as being 'pale' in appearance. 'This was no doubt the ])alc cortex of acute tubal nephritis.^ Tubal nephritis, commencing or established, has been found in all their cases by many, and especially by more recent authors. Practically all the deaths occurring in this class arc due to eclampsia or its effects when death is not caused, as much less often happens, ' Robinson, Med. Cliir. Truns. vol. .\xvi. p. 61 ; and WeibSgciber and Perls, Airh. ]. Expcr. Pai/i.'j;o\. vi. p. 113. Albuiiiinnria 507 l)y septic aftcctions arising after lalx)ur, or by pneumonia or post-parluni iuomorrliagc. Symptoms and Course of the Disease. — The symptoms in class (^nant ; her kidne\'s arc undergoing damage all the time from the mere passage of albumin, or at all e\ents from the persistence of the condition which is causing the albuminuria ; and the child will not in the large majority of cases survive. If retinitis occur, there should be no hesitation about emptying the uterus, even if the albuminuria and other signs of renal disease are slight ; and the same is of course true in cases where any paralysis, houe\er slight, has made its appearance. \i \\\& albimiinuriii first appears near the end of piri^na/iey, -awA there is much albumin and scanty urine, active measures must be undertaken at once, and no palliative treatment must be attempted. The woman must be freely purged, and on account of the possible imminence of eclamptic con- \ulsions bromides and chloral should be given in large closes on any sus- picion of a threatening of fits ; and preparations should be made for inducing labour at once under chloroform. If the woman is a primigravidii, the case is the more urgent (see last page). In cases where the c[uantity of albumin present is small, and the urine is passed in fair quantity, the pregnancy may be allowed to go on, the woman being carefully watched until the eighth month ' or longer, if no threatening symptoms occur. Eclampsia Definition and Pathology. — The con\ ulsions in cases of puerperal eclampsia are of an epileptiform character. They occur before and during, and sometimes after labour. The)' are always associated with albuminuria, and are now pretty universally believed to be due to renal insufficiency, or at all events to the retention of some waste products which are normally excreted by the kidneys. In a few cases there may be other toxic substances present in the blood than those specially excreted by the kidney, but at present there is no definite information as to how often this occurs. Instances have been reported, howe\er, where changes in organs other than the kidne)s — the liver, for instance — have been found ; and there is reason to beliexe that albuminuria, though constantly associated with eclampsia, is in a few cases merely an accompaniment of some blood-chang-e not yet understood.- The fits, in the very large majorit)- of cases, howe\er, may be considered to be un^mic ; and it is a peculiarity of pregnancy that in it fits are of infinitely more frequent occurrence in persons affected with albuminuria than in those so affected apart from pregnancy, in whom, indeed, excejning in scarlatinal cases, uncniic fits are \ery rare. There is a more or less definite relation between the amount of urine, of albumin, and of urea passed and the occurrence of convulsions. Herman 1 It is extremely diflicult to rear a .sexeii-mdiulis' child, akhdugh this amount ut" maturity is usually considered sul'ticicnt to ensure viability. In reality a very small i)rci- portion of children so immature as this are ever reared. - In two cases described by Sir John Williams leucin and lyrosin were founil in the urine, and there were other signs and symptoms suggestive of acute atrophy of the liver. Praciilioiier, January 1895; also see Doleris and P.utte, Noii7\ Airli. d'Obsict. ct Gyn. 5IO PatJiology of Labour found that in the acute torni, whicli usually leads to c(jn\ ulsions, a large quantity of albumin was passed (mainly paraglobulin), that thei^e was great diminution in the amount of urine and of urea.' The scantiness of the urine is most marked in the cases belonging to class iti) (see 'Albuminuria'). In chronic renal disease there is usually a large quantity of urine passed. - It is quite likely that, in addition to the large quantity of water passed in the total urine, the tolerance bred of custom ma>- enable tlic woman who has suffered from chronic albuminuria for some time presiously to escape fits. The Pit. — The tit resembles that of epilepsy when it is fully developed, but it rather more rapidl)- reaches the stage of clonus. No mention has e\ er been made by any observer of an aura, such as is not uncommonly found in true epilepsy, and such a prelimmary e\ent probalsly does not occur. The most important distinction between the convulsions now being considered and the last-mentioned is that the Jits in epilepsy arc single in almost all cases, and i7i pitei-peral eclampsia they are almost invariably multiple. Premonitory symptoms. — There is sometimes no warning that a fit is impending, and the woman appears quite well ; or possibl)' there may have been some oedema noticed for a shorter or longer time beforehand. Usually, however, there are some symptoms of uraemia, such as headache, neuralgias, pain in the epigastrium. If the pulse is examined it will be found to ha\e a high tension. The fits are commonest during the last two months of pregnancy. The actual moment of onset probably depends on an accumulation of the poison, and, when this has reached a certain degree of concentration, the trigger is pulled, so to speak, by some disturbance of the nervous system, such as the first pain of commencing labour, or a vaginal examination. Sometimes, as far as can be seen, the fit comes on spontaneously ; for instance, in the seventh month, well before labour has begun, or during the puerperium. The convulsions last about one or two minutes, and the woman may bite -her tongue and pass urine and fteces as in epilepsy. A more or less comatose condition follows, and is as a rule succeeded after a few minutes, or possibly several hours, by another fit. The number of fits varies from two or three up to, in severe cases, as many as a hundred. The freciuency of the fits depends on and indicates the se\erity of the attack. In the severest instances the patient falls into a condition similar to the status epilepticus. The temperature rises to 107°, 108°, or e\en to 1 10° F. The woman is quite comatose, and the fits succeed one another ' Obst. Trans, vol. .wxvi. , whciu there are references to numerous other pajiers b\- the same author and others on the subject. - This agrees with the lesults of Voits cx]3eriments on clogs fed on urea, in whicli. if there was an unUniited c|uantity of water allowed them, there were no fits, because the 'poison' was all carried off; but on diminishing the amount of water taken to a ver) little, or withholding it altogether, the unemic condition appeared {/.ci/sr/i. fiir Bi"/ogie, vol. iv. p. 116, et sqq.) It has been found, also, that^the injection into the blood of dogs of all the constituents of the urine (the ureters being ligatured) was more rapidly fatal than the injection of urea alone ; so that no douh)t the amount of urea excreted inider these circumstances is only a measure of the excretion of urinary solids in general. liclmiipsia. Diagnosis 5 1 1 almost uninterruptedly. This shows great injury of the ner\e centres, including- the heat-regulating mechanism. There is no effect on the tem- perature in moderately severe cases. During the fit there is not uncommonly an increase in the amount of albumin passed. Effect of Fits on the Fcetus. — The child is, as has been mentioned, not rarely killed b)' an amount of kidney disturbance not sufficient to bring about a convulsion, so that it may be easily imagined that when there are fits the child is not very likely to survive. It has been known to do so^ howe\er. Death of the foetus may be due also to the asph)-xia of the mother during the fit ; but this is not \-ery likely, since the foetus can live without oxygen for a longer time than its mother can. If the tetanic con- tractions of the uterus described by Braxton Hicks' are universal or usual, cessation of placental circulation sufficiently long to asphyxiate the child would take place ; but they are not allowed by all obser\ers to be present during the fits. The co7tdition of the icrme in connection with the fits has been already mentioned. Hicks has described cases Avhere there was no albuminuria until after the fit ; but such cases must be phenomenally rare. After deli\ery the fits cease at once or \&\y soon, and the urine loses some of its albumin and, if in class {b\ eventually the whole. Even in class (a) the albumin is diminished, but probably never disappears ; and, as far as remote prognosis is concerned, except for the liability of the renal trouble and its complications to recur in future pregnancies, the woman is in the same condition as any male with a chronic nephritis. In cases that are going to do well the quantity of urine and urea in\ariabl)' increases in twent)'-four hours or so to the normal, or to much more than normal. If no impro\ement in this respect occurs, the prognosis is bad.'^ IVIorbid Anatomy.— There is in all recent cases which ha\e been examined more or less tubal nephritis. The cortex is pale and the pyramids congested. Diagrnosis. — Eclampsia has to be distinguished from hysteria, from epilepsy, and from apoplexy. There should not be any difficulty in this. The absence of unconsciousness, of violent convulsions, of illness, combined with a self-conscious manner easily recognised, is enough to make the condition of hysteria unmistakable. On testing the urine for albumin there is, of course, none. In the case of epilepsy the fit is single, there is almost always a history of the disorder ha\ing occurred before, and there is no large quantity of albumin, though there may occasionally be a little. The convulsions in apoplexy are not marked ; they are usualh- unilateral and they do not soon recur when once they ha\-c ceased : there is only a little albumin present in the urine, which nia\ 1k' tliat characteristic of chronic Bright's disease. I Obst. Trans, vol. xxv. p. 118. In one case the uterus remained tigflulv contracted for ten to fifteen minutes during the fits. - Sec Herman, loc. cit. 3 I 2 Patholo,i!:y of Labour Progrnosis. 1 liis is not j^ood. Tlie moilality of all cases is about 30 per cent., that of the children being about 50 per cent.' The earlier in preyfnancy the fits begin the worse the prognosis ; and on the other hand, the percentage mortality in cases where the con\ulsions begin after labour is a small one, being about 8 per cent. Further gravity is given to the prognosis b\' the presence of complica tions — Septicaemia, Pneumonia, and Post-partum Haemorrhage. The failure of the urine and urea passed to increase after labour is a bad sign ; and if there is any retinitis the outlook for the future is not a very bright one. The Prophylaxis in cases of albuminuria has been described as the treat- ment of Albuminuria in Pregnancy. Treatment.^There are many ways of treating the convulsions of pregnancy, and most of those described arc identical with the mode of treatment of cases other than puerperal. The class of case under considera- tion differs, howexer, from the fits of scarlatinal nephritis, for instance, inas- much as they can be arrested at once by emptying the uterus. The first thing that will suggest itself, therefore, is the induction of labour, and the induction must be done by the most rapid means available consistent with safety. The adtninistration of chloroform is found to check the fits, and in nearly all cases to prevent their recurrence. Looked at from the point of view of the child there is not much hope of its being born alive, so that unless for some great reason for attempting to save the child's life, or possibly in a case where the mother is the subject of some disease such as cancer, soon to become fatal, the child must be left out of consideration altogether. Induction of Labour. — The best way to do this is ]j\' administering chloro- form and puncturing the membranes. The actual letting-off of some of the liquor amnii and the consccjuent diminution of intra-abdominal tension has at once a favourable eftect on the fits, diminishing them in frequency. The cervi.x can then be dilated with one of the forms of hydrostatic dilator. Champetier de Ribes' bag is the best, for with this instrument one insertion is sufficient to completely dilate the os, and the disturbance and septic danger of frequent vaginal manipulations is obviated (p. 509). Labour will be usually rapid, but if there is any delay and urgency arises, the forcejis must be early employed. If the ( iiild is found to be dead, craniotomj- should be at once performed. Chloroform. — As already said, this drug prevents the occurrence of tits nearly always, but it has even a further action than this. When it is administered to a woman in the status epilefiticus, the cyanosis is found to diminish, the breathing to impro\e, and the pulse to slow. It seems to prevent also the pyrexia which may occur then. It should therefore be given under all circumstances, and the an;vsthesia may be kept up for many hours in a modified degree in cases where this is necessary. Diaphoretics. — The only diaphoretic of any use is hot wet-packing. Pilocarpin is dangerous, owing to its filling the bronchial passages with 1 These are the figures given by (jalabin. ami they agree fairly well with tho.se of Herman and others. Treatment of Eclampsia 5 1 3 mucus, and its effect is very uncertain in these cases.' It is not really of much use to spend time in trying to excite sweating. Cathartics. — It is most useful to purge the woman freely at the first opportunity ; it does much good eventually, if not at once, and it does not interfere with other treatment. If she is conscious, a drachm or more of jjulv. jalaptE CO., or ten grains of calomel, or castor-oil containing two or tliree minims of croton oil, are among the best. If the patient is unconscious, croton oil in a small lump of butter slips down pretty easily. Sedatives. — Apart from chloroform, the commonly used drugs are chloral, the bromides, and morphia. The first two are most useful after labour if the fits still continue ; they seem to act best in combination, in the quantity of half a drachm of each given either by the rectum or the mouth. If chloroform cannot be obtained they may be given before labour. They ]ia\ e not, however, a powerful action on the fits. Morphia has often a very marked action, and in the absence of chloroform is always well worth trying. It is not a good drug for renal cases, and should not be repeated unless urgently required. Venesection. — Blood-letting will almost invariably stop the fits, at least for a time, and it used to be the remedy for convulsions. It may act in some cases as it does in other convulsive disorders, tetany for instance, by knocking the patient down, so to speak ; but in many instances it must do good by relie\ing the vascular tension. It has the disad\antage that since renal patients are frequently anaemic, or likely to become so, it deprives them of some of the blood they will badly want later on. It is true though that puerperal eclamptics are not always, in fact are often not, anaemic, and in the absence of chloroform, bleeding to say ten ounces is good treatment. There is one condition where it is necessary, altogether apart from any effect it may have on the fits themselves : namely, where the right heart is o\er- distended, and the venous engorgement must be relieved at once for the sake of the patient's life. This will be necessary occasionally in the status epilepticus of puerperal eclampsia. Epitome of Treatment The following is a summary of the line of treatment recommended in a case where the convulsions begin at the time of commencing labour, or at any time before labour is due : Administer a purge ; put the woman under chloroform, and rupture or puncture the membranes, according to the degree of expansion of the cervix. Then dilate the cer\ix with a de Ribes' bag, and assist labour with forceps, doing craniotomy if the child is dead. If no chloroform can be got, give a hypodermic injection of morphia (-0 &''•) o'' chloral and bromide by mouth or rectum. If the patient is a suitable case, or if none of the just-mentioned drugs have a sufficient effect, bleed to ten ounces or more. The treatment of cases in the puerperium, which have cither begun then, or are continuations of the eclampsia of labour, must be conducted on ordinary medical principles. ' John I'hillips, Obst. Trans, vol. xxx. p. 3:;4. L L 514 Pathology of Labour CHAPTER L.W'II ACCIDflNTAI. COMPLICATIONS OF LAliOrR AI-1' KCTIXC. THK I, IKK of thk child oxlv Presentation-, Prolapse, and Expression of thk Umbilical Cord Definition.— The cord presents when it lies in front of the head or pre- senting p;iit before the membranes are ruptured. \\. prolapses \\\\mic cases arc foetid, as a rule, bearing out to some extent the belief that the kind of organism mainly engaged in the production of the disease is a saprophytic one. Boxall has shown, however, that taking all feverish cases together, fever almost invariably precedes foetor of the lochia. This may be accounted for either on the supposition that the fever is the result of the presence of both septic and saprophytic organisms, the former producing fever before the latter have rendered the lochia foetid : or by the fact that ptomaines have been found to be produced in putrefying material before the foetor is recognisable.' 1 BriegcT. Fliigge s Micro-organisms in Disease, p. 573, New .Sj-denhani Society. Ho believes that putrefaction probably eventually destroys the ptomaints. Septicmnia 529 The rise of internal temperature in any case no cloulit promotes the growth of the organisms, \vhich in turn, hy the accompanjing increased l)roduction of poison, intensifies the fever. The lochia maybe, and in many rases arc, rendered foetid by vaginal decomposition alone, the interior of the uterus being germ-free ; and in such cases the ad\antage of prompt treat- ment is obvious. The lochia, in severe cases, sometimes cease altogether. Milk. — In mild cases the secretion of milk is unaffected in quantity, tliough it may disagree with the child. In patients who ha\e continued high temperature the flow often ceases. The s\-mptoms in cases of true septicaemia of a mild character are practicalh- identical with those just described, Ijoth in time of appearance ruer por "i- 1 5 6 7 8 9 10 1 1 12 13 1* 15 16 1^ 1 0' day M £ f / E ^ /I E m'e M E M £ M £ M £ M E M i M £ M E M E M E 106° 105° 104° 103° 102" lor 100° 99° 98° 97' .- 1 r 1 ^' ■Of: £ fi ^1 1 ^ r| \ k^ •or) / \ 1 i I I /I f^ ^ f \ J < 1 \ ij / -i J i 1 / V J / ^ ji / *" 1 / t » \ 1 u J Fig. 3S4. — Case of puerperal septica;mia ending in death. The average chart of a sapr^mic case would resemble this up to about the eighth day as here shown. (This chart begins on the fourth day.) (probably most constantl)- on third day), and in progress. In some instances, however, the lochia are never foetid, showing that no putrefaction is occur- ring, but that the onl)- organisms at work are pathogenic. In the foregoing clinical sketch we have a fair t)-pe of the effect of fe\-er in general on the lying-in woman. It illustrates the fact that there is no such distinct entity as puerperal fever, but that the symptoms are the same as in a non-puerperal person ; with the addition, that in the two character- istic secretions of this state —namely, the lochia and the milk — there may or ma\- not Ix' modifications. B. Severe Cases of Septicaemia These cases, fortunately \ery rare at the present time, are the result of infection by intensely virulent poison, and usually occur in a patient who is. 530 Pathology of the Puerperal Period Ijy great loss of blood or other powerful depressing causes, or by diseased excretory organs, rendered incapable of resistance to the entry and development of pathogenic organisms. The severity of the case may be such that the invasion jjcriod is reduced to a few hours, and in one or two days the patient is dead ; killed by the profound general alteration in the blood and tissues— before any local signs of inflammation have had time to appear in internal parts. The rapid development of high fever with severe constitutional symptoms is the main characteristic of this group of cases. The patient has a rigor within a few hours of delivery, or during or before deli\ery if infection has occurred during or before labour from examinations made with septic fingers —for instance, in a case of placenta prania — the pulse and temperature quickly rise, the latter often establishing itself at 103" or 104° on the appearance of the rigor, and the pulse which is hurried in proportion (130-160 per minute), though hard and incompressible at first, becomes very soon thready and weak. The skin is bathed in sweat, and the respiration is shallow and rapid Diarrhoea is often troublesome, and is nearly constant, after the first few hours, at all events. The typhoid condition is now developed, and perineal and vaginal tears become sloughy. There may or may not be abdominal tenderness, but there is nearly always distension. The temperature often now declines, and becomes subnormal ; but the pulse, which is therefore the most reliable criterion of any, shows increasing signs of weakness, irregular- ity, and rapidity. The mental state varies : as a rule, the patient is in no great anxiety about herself, and she suflers no pain. Delirium of a low muttering type may occur at night ; and towards the end drowsiness, deep- ening into coma, supervenes ; and death occurs on the third or fourth day of the lying-in period. During this rapid illness the lochia sometimes disappear when the fever developes, and sometimes a bloody discharge persists throughout. Milk, as a rule, is not secreted. The spleen is often tender and enlarged. Various kinds of rashes, mostly of a scarlatinoid type, may make their appearance. Post-mortem nothing is found but the signs of acute septic poisoning, namely, changes in the blood, staining of tissues, and softening of paren- chymatous organs. Treat)iient. — The treatment of all cases in this group should be carried out on the same principles. By removing the microbe-containing matter in the sapra^mic cases, the temperature and other symptoms of fever will at once disappear if, by the time treatment is begun, septic organisms have not obtained access to the deeper structures ; and as it is impossible to diagnose at once whether the case is sapraemic or septicemic, an endeavour must be made to render the interior of the uterus germ free in any case. When the patient appears to be the subject of the more virulent form of the disease the attempt must still be made, for even here marked relief will at once follow this course, if the case has, as is possible, been really one of free absorption of substances of the ptomaine class. On the temperature in any puerperal woman rising markedly, the con- dition of the bowels and breasts must be ascertained, and any disorder cor- rected ; or if the patient has been excited and has a temperature, it should Fever with Pelvic Lesions 5 3 1 !)(_' iii;ulc out that there is no real fever (see pp. 562 and 569, for various causes of rise of temperature). These possibiHties having been cleared away as far as may be, and a vaginal douche of 1-2000 corrosive sublimate, if this has not already been employed, ha\ing been given, ergot should be administered for twelve hours, 5iss or gij of tlie tr. ergota^ ammoniat., or inj. ergotin hypoderm., iT\viij — x every four hours, to stimulate the uterus to expel any clots or other decomposing matter. If nothing is expelled, and there is no improvement at the end of this time, the uterus should be explored by the finger, under anaesthesia if necessary, an intra-uterine douche (2 quarts of 1-2000 corrosive sublimate) being given at the same time.^ Debris and placentae succenturiatae are by this means detected and removed. The finger is the safest instrument, the nail being very carefully used. It would be good practice to at once explore the uterus without waiting" for the action of ergot, if the case seem at all urgent. If it does not, it is perhaps as well not to alarm and disturb the woman until ergot, used as directed, has proved useless. The patient often now loses her symptoms, and may convalesce uninter- ruptedly. Sometimes, however, the temperature rises again after a few hours of subsidence. In this case, or if it never goes down, the uterus should again be douched, and the interior of the uterus may be mopped with pure carbolic acid or iodised phenol, and in these cases carbolic acid must have been used in the douche, and not sublimate.-' The patient's strength should be carefully maintained by nourishing food and stimulants, and the bowels made to act freely once or twice. Very large quantities (Von Jaksch) of alcohol have been gi\en in puerperal septic;emia with ffreat advantatje. 2. Fever with Lesions in, or in connection with, THE Pelvic Organs This class includes a large number and variety of local manifestations of the presence of organisms in the tissues. Causation and PatJiology. — It must be rememljcred that tlicre are two ways in which organisms can reach the lymphatic tracts (considering the peritoneum also as a lymphatic space) : one, in the way which we have con- sidered hitherto, namely, b)- breaches of surface, and in this case the connec- tive tissue and structures contained in it are first in\'olved ; the other, by extension along the mucous membranes lining the genital canal from the vagina to the abdominal openings of the Fallopian tubes. Those inflam- mations produced by absorption through the former channel form a Para- metritic group ; and those by the latter, affecting mainly the peritoneal sur- faces of the organs, form what may be called a Perimetritic group. The structures affected in the former class comprise the substance of the ' There is no need to employ instrumental dilatation of the cervix in these cases, for the pressure of the finger is practically always sufficient to enable it to pass the internal os. ^ The use of the curette recommended by some, has not been always satisfactory. It is probable that under some circumstances, the exposure of a new raw surface by its means may facilitate the absor]3lion of the septic matter already in the uterine cavitv. M M 2 532 Pathology of the Puerperal Period uterus and its vessels, the connective tissue of the pelvis, and the lymphatics and \essels running in its substance. Those in the latter are the peritoneum of the pelvis, with the viscera covered by it (whose structure is only superficially affected at first, though later the inflammation may extend deeper), comprising the ovaries and tubes, the part of the rectum covered byperitoneum, and any intestine that may happen to be close at liand. Parametritic Group. — Absorption of septic poison occurs at some breach of surface in the vagina or the cervix, or at the placental site. It is no doubt most commonly at a laceration of the cer\ix or the lower part of the vagina. Cellulitis follows. If infection have occurred at the uterine surface, the uterine wall is inflamed to a degree varymg from that of simple oedema to that of the production of a breaking-down tissue containing numerous abscesses, these being usually the result of suppuration in the thrombosed sinuses. Parametritis. — Verj' marked anatomical disturbance occurs when the connective tissue is widely affected. Free efflision of lymph, nearly always unilateral, takes place into the large tracts of this tissue found in the pelvis. These tracts lie on each side of the uterus, in the broad ligament, especially at their bases at about the level of the cervix ; be- hind in the utero-sacral ligaments : in front be- tween the supra-vaginal portion of the cervix and the bladder, and between the symphysis and the bladder. If, as is most common, the cellulitis is on the left side of the cervix, the base of the broad ligament on that side swells up into a hard mass, filling up that side of the pelvis and depressing the forni.x, fixing the uterus and displacing the cervix to the opposite side of the pelvis (fig. 385). The ovary and other structures in the broad ligaments are liable to take part in the inflammatory process. Extension may take place from the broad ligaments to the connective tissue about the psoas muscle, and even along the course of that muscle up to the perinephric fat ; or beneath the parietal peritoneum of the abdomen ; or sometimes forwards, along the round liga- ment to the inguinal canal. From the utero-sacral ligaments it may extend so as to surround the rectum, and the anterif)r parametric \ariety ma)- spread upwards to the anterior abdominal wjiU. The effect of this spreading is sometimes curious and confusing, in that the cellulitis may disappear at its pelvic origin, leaving masses of inflamed VAGINA RECTUM FiK- 385. Remote Paramcti-itis S. CONTRACTING] INFLAMMATORY EFFUSION. VAGINA. -KLUIl. Fig. 386. — Remote parametritis tisuic in diftcrent parts of ihc abdomen as just mentioned uilliout anything toaccountforthem. Such cases are instances of remote parametritis (fig. 386;.' When resolution occurs, the removal of the effused lymph is nearly always complete. During the process of absorption the contraction common to all rcsohing inflammatory deposits takes place, and the uterus is found drawn over to the side originally affected (see fig. 386). Displace- ment of the cervix is most marked in parametritis of the base of the broad ligament (see fig. 385). In an early stage of parame- tritis the mass pushes the uterus over to the opposite side of the pelvis and the contrast between the posi- tion of this organ in the earh- and late stages of the disease should be remembered, as it may be important from a diagnostic point of view. Parametritis, instead of undergoing resolution, as is the rule, may suppurate. In such case the abscess, which is occasionally fairly large, opens usually above Poupart's ligament, but sometimes below it ; or less commonly into the vagina, rectum, or bladder, or through the sciatic or obturator foramina, according to its position. Abscesses rarely open into the ischio-rectal fossa, their progress in this direction being arrested by the pelvic fascia (see p. 89). The ovary in some cases is converted into an abscess, and it is occasionally found in tliis state in the midst of merely inflamed connective tissue. The cellulitic deposits in the case of remote parametritis sometimes suppurate. They usually do so — if it happen at all— some weeks or even months after labour, and when this occurs along the course of the psoas muscles it may cause considerable confusion, the collection of pus being liable to be mistaken for abscess due to caries of the spine or pelvic bones. The hip joint has been found affected and disorganised by ths invasion of pus. To complete the general account of the changes produced by para- metritis, it may be mentioned that in cases where the inflammation extends forwards, affecting the connective tissue in relation with the bladder, marked symptoms — frequency of micturition and pain connected with the filling and emptying of the Ijladdcr — are, as a rule, present ; and that whcMi the utero- sacral ligaments arc involved, the tissue round the rectum has been known to swell up so as to cause temporary occlusion of its lumen. PJilebitis. — The veins in the broad ligaments, including the uterine vein and the plexuses, oxarian and pampiniform, corresponding to the ovarian ' Matthows Duncnn. Clinical Lectures. 534 Pathology of the Puerperal Period artery, may be invaded by septic organisms, and these may obtain access either at the exposed mouths of the thrombosed sinuses at the placental site, in which the contained clot forms a good cultivation medium, and a path to the interior ; or by means of an intense cellulitis in the tissue around the veins, which by damaging the nutrition of their walls, renders them easily penetrable by the organisms now abounding in these tissues. Thrombosis, if not already present, and afterwards possibly suppuration, then occur. If thrombosis is the only result of the inflammation the affection is commonly limited to the veins immediately round the uterus ; but even this condition maj' advance further, and clotting ma-y spread into the internal iliac, common iliac, external iliac, and femoral veins. It is quite possible that a 'remote' phlebitis analogous to remote peri- or parametritis occurs, the phlebitis extending along to the femoral vein, for instance, and undergoing resolution between this and the uterus, but ha\-ing caused complete femoral thrombosis, which remains as the most conspicuous result. There is always in these cases a possibility of detachment of a piece of clot by a sudden movement of the patient, and of embolism occurring in the thorax. There may be infection of the cardiac valves if the endocardium by reason of the blood-changes has its vitality diminished (see p. 540). This infection is obviously most probable when the thrombus in the pelvis is distinctly septic, and when small particles conveying organisms are carried into the general circulation. As all these complications are in no way special to puerperal cases, the reader is referred to works on surgery in which the subject of Septicaemia in general is treated. Affections of the lymph \cssels ha\c not to be considered separately. As in any other case of cellulitis, the lymph vessels and their origins in the interstices of the connective tissue are found full of organisms as far as the nearest lymphatic glands, wliich, becoming inflamed, close the road leading to the blood stream. It may be remarked that in some cases the lymph vessels may be seen post-mortem to be distended with pus beneath the peritoneum co\-ering the sides of the uterus. Perimetritic Affections and Salping-itis. — Inflammation of the tubes and of the peritoneum arc taken together, since they are both due, as a rule, to extension of the disease in the same direction. Septic endometritis, affecting the whole inner surface of the uterus originally, or spreading over it from an infected spot — as, for example, the site of an adherent portion of placenta — extends rapidly to the tubes, damaging to a greater or less extent their mucous membranes. When it has reached the fimbriated ends it causes inflammation of the peritoneal surface of the fimbriae and of the serous covering of the ovaries. In consequence of this, a quantity of lymph is poured out, which mats the fimbria; and adjacent parts together and seals up the ostium abdominale. If the aftection is acute, and if sufficient pus or infective secretion escapes before the ostium is sealed up, a pelvic peritonitis is set up, which in virulent cases may spread over the whole peritoneal surface. If the infection is not severe to start with, the inflammatory process may (i) be arrested by the sealing up of the tube, and the peritoneum is then protected ; or the inflammation may (2) be limited Symptoms of Para- ami Perimetritis 535 to t]"ie peritoneum in tlic immediate neighbourhood of the ovary, or to this and Douglas' pouch, by the formation of adhesions which isolate these parts from the general peritoneal cavity. When the tubal orifice is occluded the tubes often become distended with pus, producing pyosalpinx. This is usually bilateral. If the surface of the ovary is affected, the whole organ may become involved and converted into a mass of loculi containing pus, or into one large abscess. Organs in the pelvis, including any loops of small intestine that may be present, are matted together into fairly definite tumours, if the second degree above mentioned be reached. Resolution, as in the case of parametritis, may be the fortunate sequel, or pus may form in the interstices of the organs. 'Remote' perimetritis may occur later, and packets of intestine thus matted together, apparently unconnected with any peh'ic lesion, may mislead the observer. The pus in these cases, if it forms, may find its way out through the abdominal walls or through adjacent viscera, as intestine, bladder, or vagina, just as in those instances where it is obviously of pelvic origin. The so-called ' metastatic ' inflammation of the ovaries, the term meaning that inflammation may arise without direct continuity with a septic focus in the uterus, or without septic embolism, probably does not exist, and such cases may be explained as resulting from parametritis. The peritoneum is always more or less affected in parametritic cases, and the sub-peritoneal connective tissue m a similar way in perimetritis. As a rule, cases where the inflammation is greater in one or other of these structures arise as described, though owing to the free intercommunication between the very numerous lymphatics in the submucous and subperitoneal coats of the uterus, the peritoneum may in virulent cases be directly infected through these vessels. Symptoms. — {a) Parametritis. In typical cases the infection takes place through a laceration made at labour, usually in the cervix. On the second or third day the woman has a rigor, and suffers pain in the pelvis and lower abdomen. She has well-marked fever (fig. 387), and, according to the severity of this, the lochia and milk are affected to a varying degree, as described under Septicaemia. On examination of the abdomen, one or other side of the hypo- gastrium, usually the left, is found to be very tender, and there may already be some resistance to be made out ; or perhaps the abdominal muscles are too rigid to allow of this. In a day or so there is a well-marked mass rising out of the pelvis by the side of the uterus (which organ is of course still three or four inches above the brim), fixed and very tender. On bi- manual examination the cervix is found fixed and displaced as already de- scribed, and often the mass of effusion has depressed the fornix, and is felt to fill up the affected side of the pelvis entirely. This it easily does, for the space is just now small, and the still enlarged uterus occupies most of the available room. According to the severity of the disease the mass remains for three or four or more weeks, and if under favourable circumstances no change for the better (diminution in size, loss of pain and tenderness, and of fever) occurs in a week, a look out should be kept for evidence of pus-formation. {b) Perimetritis. The mass produced by a perimetritis and the feverish symptoms are later by a day or two in developing themselves than the same 536 Pathology of the Puerperal Period symptoms and signs in cases of parametritis. It is not uncommon for both peri- and parametritis to affect the same patient, and then their relative times of appearance may sometimes be observed. This mass is not so markedly lateral, and it does not displace the uterus so much as that of parametritis ; and on vaginal examination it is usually found to lie more in Douglas' pouch, depressing the posterior vaginal fornix, and not the lateral ones at all. The uterus is often felt to be fixed in the midst of an effusion which surrounds rather the middle (in length) of the organ, and which has been well com- pared to the fixation which would be produced by pouring plaster of Paris into the pelvic peritoneal cavity. It is necessary herC; as in parametritis, to remember the size of the uterus at this time, and in case, as often happens, the outline of the organ is quite blurred by the effusion and matting of structures, to allow for this in estimating the amount of perimetritis present Day of Puerpcr 1 2 3 4- 5 6 7 8 9 10 11 12 13 H IS Hours ot day. M t M £ M i M E M c M £ M E M £ M E uh M £ M £ M £ Ml L M E 106° 105° 104° 103° 102° lor 100° .<59° 98° 970 -c > ex: c a_ u ■0 Z'. ! c >q -a c P- i\ / \ A \\ -c- X % / y V f \ \ 1 ! c 2 i / f \ \ f '\i K a J- S 1 1 / \ \ / V / K t\ — ^ %_ M V i V V s! Vy y' J \, -S. *M*S ' t 1 . i' ill. jSy.— MiUl cuMc ui paranictrilis. in any pelvis. The immediate after-history of these aises is very like that of cases of parametritis, but the disappearance of the disease entirely is by no means so probable. Chronic perimetritis is not infrequently left behind, and the woman becomes more or less an invalid, with affections of the tubes or ovaiies, which may be many years before they are cured, and which will be liable to again awaken into acute inflammation. The late after-history and treatment belongs to the subject of Diseases of Women. (c) Phlcl)itis and thrombosis. The recognition of these afi'ections is not easy, even if it is possible. There are some cases, however, where in the absence of any distinct mass in the pelvis, but with some resistance and tender- ness on one side or the other, the woman's temperature continues to remain high for some time, and one is led to suspect that something of this kind is causing the protracted septic symptoms. .If at the end of a fortnight thrombosis of the femoral rem, or phlegmasia dolens, occur, such a diagnosis Trealmcnt of J^ehnc Infiammations 537 may be considered as justified ; as it certainly may if any signs of septic embolism occur in the lungs, or septic infection of the cardiac valves. Treatment.— i:\\c treatment of this group of cases is to be directed mainly to keeping the patient's strength well supported, ensuring absolute rest, and obtaining free action of the bowels if the septica^mic condition is not too severe. If the patient is very septic, diarrhcea is sometimes a troublesome symptom. Morphia should be given if there is severe pain, and hot fomenta- tions are useful in most cases. Where there is evidence— in recurring rigors and in the temperature always keeping somewhat above the normal and occasionally making irregular and considerable rises — that pus is forming (as in chart, fig. 384), a look-out should be kept for the signs of its approach to the surface of the abdomen or towards the vagina, and a careful bi-manual examination of the pelvis made. Long persistence of swellings while the patient is under favourable conditions for their resolution is, as already mentioned, suggestive of pus-formation ; but this is not always reliable. Such tumours are often observed not to alter in character for one or two weeks, and still to disappear completely, if parametric, after they have once fairly begun to do so. When an abscess points, the natural course is to open it at once. Matthews Duncan seems to ha\e doubted the wisdom of this proceedmg, because in some cases he found that there was considerable haemorrhage from the interior of the abscess so opened. This haemorrhage, which was enough to ^\eaken an already enfeebled patient in some cases, he considers would not occur if the abscess were allowed to burst spontaneously. Since this compli- cation might in any case probably be obviated by lightly plugging the ca^■lty with iodoform or some other antiseptic gauze, it may be fairly stated that the best treatment is to evacuate and thoroughly drain any abscess that is near the surface. Where an abscess has been diagnosed, or is strongly suspected to exist at some depth in the peh-ic cavity, the question of making an explorator>- abdominal incision will have to be considered. The procedure in such cases is to find the pus-containing cavity, evacuate it with an aspirator, and then stitch the edges of the cavity to the wound, ensuring thorough drainage by means of a tube in gauze packing. The abscess ma\' be a pyosalpinx (Cullingworth says nearly always, and that therefore it is nearly alwaxs able to be remo\ed), and this admits of more complete treatment. In some cases the evacuation should be done per vaginam, especially if there is distinct bulging there. The great difficulty is to make the diagnosis. This is not the place to enter into the very large question of how to deal with cases of suspected suppuration in the pelvis. It may, however, be laid down as a general rule that in an)- case where operation is considered necessary, and the nature and relations of the swelling in the abdomen are not clear, and there is no certain evidence, such as cedema and pointing, of the path to the tumour being shut off from the general peritoneal cavity, the incision should be made in the middle line of the abdominal wall, and the relation of the viscera to the suspected abscess clearly made out before an attempt at evacuation is made. After the acute stage of pelvic inflammation has passed, the best treat- 538 Pathology of the Puerperal Period ment is to give iron in some form, with or without mercury, or iodide of potassium as an absorbent, and to apply tr. or lin. iodi to the surface over the site of the inflammatory mass, or to bhster the same region. During this period the bowels should be kept freely open by saline aperients, and rest in bed enforced. 3. Cases where Acute General Peritonitis is the most MARKED Symptom These cases form a sufficiently important clinical group to entitle them to a separate consideration. Local peritonitis is a regular accompaniment of cases in Group 2, even when it is not the main disease ; and general peri- tonitis of a sub-acute or mild kind, and sometimes that coming within the definition of acute, may occur in connection with established suppurative pelvic disease, or in cases of pyosalpinx where, from some cause producing further extension of inflammation into the peritoneum, the fresh attack of inflammation affects the tissues around the tubes and allows the organisms to reach the general serous cavity. The acutest form of peritonitis, such as is dealt with liere, is fir more fatal than any of these, and recovery from a well-marked attack is distinctly rare. It is, in fact, the commonest form of puerperal septica;mia which proves fatal. Pathology. — The septic matter no doubt reaches the peritoneum through the lymphatics running between the site of inoculation and the serous covering of the uterus or the broad ligaments, for the symptoms make their appearance too early for the infection to have spread through the tubes, and inflammation spreading through tubes is usually at once limited. The whole or a great part of the peritoneal surface becomes affected, and, if there is time, coils of intestine or other viscera cohere firmly and are glued to the abdominal walls, pus forming a little later. In \ery acute cases there is little adhesion, except here and there, but the surface of the intestines is covered with ragged yellow lymph in parts, and in parts is intensely congested. The- coils of intestine are bathed in sero-purulent fluid, and collections of this are found in Douglas' pouch and other a\ailable spaces. In cases rather less virulent than these last, the septic inflammation has time to spread to the pleura and pericardium, which it reaches by the lym- phatics which run between the large serous cavities. The surface of the viscera and the fluid are crowded v.ith septic organisms. Symptoms. — These are of a markedly septic type. There is always a severe rigor, which appears about the second or third day after deli\ery. The temperature suddenly rises to io3°-io5° F., the abdomen becomes dis- tended, and the patient usually has intense abdominal pain, which spreads from the hypogastric region. This pain may disappear later, or may even never exist. The pulse is hard and typically peritonitic at first, but may soon become small and irregular, being rapid all the time (120-160); and the temperature often falls to sub-normal. Vomiting is always present, becoming bilious after a few hours if it is severe. There is obstinate con- stipation, except just at the end, when it is usually replaced by diarrhoea. Acute General Peritonitis 539 The patient \"ery soon falls into the typhoid state, with a dusky skin, profuse perspiration, inability to lie up on the pillow, sordcs on the lips and tongue, and a still weaker and more irregular pulse. She has lost her abdominal pain before the last stage, but never the distension, and now becomes comatose and dies. In very rare cases the patient recovers from general peritonitis. If this is to happen, the symptoms do not run their course so rapidly, and the typhoid state is established slightly, if at all. The pulse is the best indica- tion of the probable result. This improves slowly, or its strength is at all events maintained. The vomiting ceases, the intestines expel their con- tained flatus, and distension is diminished. The lochia and milk behave as in severe cases of pure septicaimia ; the former being suppressed as a rule, and often, though not always, being offensive when present, the latter secre- tion never being established. Treatment. — Treatment is nearly always of little avail as far as a cure is concerned, and attention must be directed mainly to the alleviation of pain and discomfort. Inasmuch as these cases do sometimes recover, it is the duty of the physician to neglect no chance ; and therefore the uterus and vagina should be explored for retained substances, and well irrigated with a hot 1-1,000 solution of sublimate, or carbolic acid 1-30, the moment the above symptoms appear. On the same principle — namely, that of neglecting no chance for the woman — abdominal section and cleansing the peritoneum ha\-e been recom- mended. It is possible that if the peritoneum is washed out quite early and drained, the patient's life may be saved. On the other hand, seeing how rapidly septic organisms develop in a favourable medium, and that infection has arrived through the uterine walls, which are not removed by this means, the chance of benefit arising in the large majority of cases where operation is undertaken is very small. At the beginning it is hoped that the infection is not going to be severe ; and later on the favourable moment may have passed. The case differs from those where septic infection and peritonitis have occurred from direct contamination of the peritoneum, or after abdominal section— when it has been found that washing out the peritoneum, opening the intestines freely and allowing the contents to escape, and afterwards sewing them up again, has been often followed by good results ' — ^in that the infec- tive process does not begin in, and is not so strictly limited to peritoneum ; for the uterine walls are in most cases crowded with organisms and full of septic foci, which cannot be got rid of. Removal of the septic corpus uteri has been performed with success in instances of this kind ; and if an opera- tion is undertaken such entire removal must be its logical completion. Purgation is a valuable measure in such cases of peritonitis, if only the bowels can be got to act. Their muscular walls are as a rule paralysed, as evidenced by the tympanites ; but if saline or other aperients will rouse them into activity they furnish a means of getting rid of some of the poisoned fluid in the abdominal cavity. Since there is in these cases no primary disease of the alimentary canal, and therefore no necessity for absolute rest for that part, there is no reason why it should not be utilised as a drain. Treves has ' Ix)ckwood, Med. Chir. Tram. 1894. 540 Pa///oIoj{)' of the Puerperal Period shown that cases of peritonitis where there is diarrhcea are less fatal than those where there is constipation. If the vomiting- is very troublesome and copious, great relief is afforded by washing- out the stomach with warm water ; or short of this, by giving the woman larg-e quantities of warm water, half a pint at a time, once or twice. The patient will then vomit with greater ease, and the stomach will for a time be cleansed. Alleviation of pain may be obtained by hot fomentations and morphia injections. The latter must be discontinued on the appearance of collapse, which is best shown by the pulse. A long rectal tube may be carefully passed to allow the flatus to escape ; and if this happens freely great relief is given. It very seldom does, however. Turpentine cncmata are occasionally useful to the same end. The woman does not suffer from pyrexia, and so quinine and other anti- pyretics are of no use. She may have large doses of alcohol, gixen in frequent doses ; and this is a most useful drug, as it enables the patient, if she has the least chance, to tide over the period of vital depression. Subcutaneous injections of strychnine, and also of digitaline and atropine, have been by some found valuable means to this end, and may be advantageously combined with the alcoholic treatment. The extremities should be kept \cry warm. The injection of antistreptococcic serum is yet on its trial in septic cases. Doses of ten, fifteen, or twenty cubic centimetres are employed on consecutive days. This treatment has its dangers, but in such desperate circumstances as the above, as well as in severe cases of septictemia, it should not be omitted. 4. Cases where Metastatic Inflammations Occ-fu. 1'\.e.mia No attempt at detail will be made in reference to tliese cases, as they differ in no way from instances of surgical pyaemia. The septic focus is most often a thrombus at the placental site or some- where in one'or in several of the \enous plexuses around the uterus. From this point infective etnboli arc distributed by the blood current to the various small branches and capillaries in the course of the general circulation. In cases where the cardiac I'alves are already affected by previous endo- carditis, the organisms find a resting-place in the irregularities on their surface ; or, if the epithelium is intact, may act on it so as to destroy its protective power, and a fresh attack of endocarditis of an ulcerative kind is produced in the right heart. Want of resisting power on the part of the endocardium may be due also to nutritive changes that have recently occurred in connection willi tlic blood dctcri(M-ation during the present attack of septicaemia. The pericardium and cardiac muscle may be affected as in any kind of septicaemia. Septic emboli travelling from the venous side enter capillaries for the first time in the Imigs, and here if anywhere miliar)- or larg'-er abscesses resulting from their deposition are found. The pleura is also affected by such embolism ; but pleurisy may arise by extension from the peritoneum. Gonorrluva 541 111 the further course of the circulation those emboli which have not been arrested by the lung capillaries, or emboli arising afresh from suppurating foci in the lung, cause septic embolism in other organs. T\\' striking (see Embolism of the Pulmonary Artery). Thrombosis rarely occurs in the vessels of the arm. Such a case was recently observed in the General Lying-in Hospital in conjunction with thrombus in the saphenous and upper part of the superficial femoral veins. Treat)ne7i1 . — This is the same as for phlegmasia alba dolens ('p. 553;. B. Thrombosis of Heart and Pulmonary Artery or Arteries. — As a rule this condition in puerperal women is secondary to embolism from a pelvic or a femoral vein. Thrombosis does occur in the auricles and other parts of the heart when the blood-current is not rapid in the case of debilitated persons, and no doubt it ma\- do so in exhausted puerperal. The clotting may extend from the right side of the heart into the pulmonary artery, or a portion of the clot may become detached and impacted in that vessel or one of its branches. The symptoms usually arise after the second week. In the cases where the clot is produced by extension from the auricle or ventricle, the symptoms may take some little time in developing. Where, however, the thrombosis is secondary to embolism either from a systemic vein or from the cavity of the heart the first signs are very urgent, and sudden death sometimes ensues (see Embolism). If the embolus is a small one, and secondary thrombosis develops around it, as is believed to be the usual course, the symptoms begin suddenly with the dyspnoea of embolism. This subsides to some extent if the patient is going to recover, and the woman's symptoms vat}' according to the amount of coagulation subsequently occurring. That is, the dyspnoea may again arise suddenly and increase steadily. Fresh symptoms of embolism also may arise during the course of the Pulinonary Enibolisni 5 5 i thrombosis from detachment of a clot which has incompletely plugged a vessel, and its being driven into a branch which it completely fills. Although the woman's state is a most serious one, she may finally recover. The pJiysical signs consist of a bruit heard over the pulmonary area, with some irregularity of the heart's rhythm, while at first, at all events, air enters the lungs freely. Portions of the lung-tissue may later become pneumonic by the process of infarction. If the woman recovers, all clears up. The Prophylaxis and Treatfneitt are dealt with under Embolism. Embolism The embolism may be one of two varieties, pulmonary or systemic. Pulmonary Embolism This is the kind which is characteristic of the puerperal period, and for its occurrence a previous thrombosis is necessary. As already mentioned, the usual place of origin for such a plug is in the pelvic veins, particularly the plexuses of the broad ligaments, and in the veins of the lower limb. The embolus may be of sufficient size to be arrested in the heart, and may then cause sudden death ; or it may pass through it and reach the pulmonary artery, blocking up the first branch which is too small to allow it to pass. The embolus is, however, sometimes arrested at a fork, getting astride the angle between the two branches. In this last case the clot ma)' later on break into smaller pieces, and each of these may go on until it is again arrested in a smaller branch. Thrombosis frequently follows embolism — always if there is time — and the embolus may indeed collect more clot around it on its journey. Embolism has been known to happen during labour. In case of such a rare event, the sudden onset and the severity of the symptoms might suggest rupture or inversion of the uterus, and lead to considerable mistake. Embolism at this period is due to detachment of clot from the placental site, and this probably happens during some sudden and violent contraction. Symptoms and Signs. — Sudden death in the lying-in period is most commonly due to embolism of the heart or pulmonary artery. The woman may, if the blocking is only of arteries of tertiary size, reco\er after the shock of the sudden obstruction. The time of onset is usually during the third week or so, though it may be in the first few days. It may have been preceded by some e\idence of septic pelvic mischief or of femoral or other thrombosis, or there may ha\e been an uninterrupted convalescence up to the moment at which the attack occurs. The woman is seized with the most intense dyspnoea. She can breathe and fill her lungs, but the feeling of suffocation is not relieved. The heart is acting tumultuously, and the face is livid and horror-stricken. If death does not occur at once or in a few minutes she may gradually improve, and the blood may be sufficiently aerated to carry on life if absolute rest is 552 Pathology of tJic Puerperal Period maintained. If, however, any movement is made, she may have a fresh attack, or she may have one without liaving moved, and this again may be fatal or not. If she recovers, areas of lung corresponding to the blocked branches will become solid, being high-pitched on percussion, with signs of deficient or of no entry of air and of localised pleurisy. Prophylaxis. — This is carried out by keeping e\'ery l)'ing-in woman who has shown any sign of pelvic mischief, or who has a thrombosed vein, or who has any disease of the heart or vessels likely to lead to thrombosis, absolutely in bed and at rest. In the last-named cases this must be done until she has completely recovered her strength, and in the others until there is no marked pelvic tenderness on examination, and no evidence of any existing clot that may be disturbed. Of course no part where there is a thrombosed vein must be rubbed with liniments, or manipulated more than is absolutely necessary for diagnosis. Treat ))icnt. — The first thing to do is to pre\ent the woman from using more of the oxygen of her blood than is required, and to gi\e the heart as little work as possible. Absolute immobility will do this. The collapse may be relieved by diffusible stimulants — ether and ammonia. The in- halation of oxygen, if this, as is the case usually in hospital practice, is available, should ha\e a very marked effect, though the author at the moment of writing is acquainted with no record of its use in such a case. Opium is recommended after the acute attack is over, and no doubt it will help to keep the heart quiet and make the woman comfortable. There may be occasion and opportunitx' for venesection if the patient becomes intenselj' cyanosed, for by the relief thus afforded to the right side of the heart, which is over-distended by thedammed-up blood, the pulmonar)' circulation is enabled to be to some extent improved. The idea that ammonia given internally may dissolve the clot is purely hypothetical, and the drug is, as far as is known, useful only as a general stimulant. Systemic Ejiibolisin. — This process ma)' occur in cases where there are vegetations on the cardiac ^■alves, and differs in no way in its pathology or clinical course from ordinary examples of the same kind. Emboli may plug the cerebral, femoral, or brachial, or in fact any systemic artery. The emboli may be septic, and the possibility of ulcerative endocarditis, causing multiple embolism, with its peculiar train of septicasmic symptoms, must always be borne in mind when such symptoms arise in a puerperal patient with previously existing or newly developed endocarditis. Phlegmasia Alba Dolens 553 CHAPTER LXXII DISEASES OF THE VASCULAR SYSTEM {continued) Phlegmasia Alha Dolens Defittiiwn.— T\\\s is a disease almost, but not quite, peculiar to lying-in women. When fully developed it has an unmistakable appearance and feel. It consists in a tense, white ('white-leg,' 'milk-leg') swelling affecting the whole thickness of the leg, or, in exceptional instances, the arm. There is in the fully developed stage of the disease no pitting on pressure as there is in the case of simple thrombosis. By Continental authors no clear distinction is made between this affection and ordinary thrombosis, the latter of which has been just described (p. 548) ; Ijut in British works such a distinction is made, and with reason, as will liecome evident. The disease is not at all common. Pathology. — The pathology of phlegmasia dolens is not yet completely ascertained. We know that there is always or nearly always thrombosis of the femoral vein to be felt at one stage or another of the disease. We know also that the fluid in the swollen limb is not simple serum, such as is found in ordinary thrombotic cases, but coagulable lymph. This great peculiarity, added to the fact that in the fully developed condition there is no pitting on pressure, distinguishes it at once from the other kind of oedema. It is supposed that some obstruction of lymphatics exists. This of course can only be a temporary obstruction, lasting for two or three weeks in its most marked stage, and is difficult to account for. Elephantiasis Arabum is the disease which would be most akin to it on the lymphatic- obstruction theory, for this consists in a hard oedema of the skin and sub- cutaneous tissue ; and many cases of this are due to obstruction of the lymphatics by filarite in a certain stage. In elephantiasis dilated lymphatics are found in the affected parts, and in the e\ent of ulceration lymph is often discharged. But in the case of this disease either the obstruction of Ixmphatic channels can be shown, or the condition can be assigned to repeated attacks of deep dermatitis or chronic dropsy. In phlegmasia, on the other hand, there is no constant e\idcnce of lymphangitis, of enlarged inguinal or other glands, or of dilated lympliatics, and the swelling attacks a previously healthy limb. It will probably turn out eventually to be a special form of cellulitis. This view is supported by the fact that the disease is 'metastatic,' and appears in the other leg very frequently when the one originall)- affected is recovering ; and that it frequently arises, possibly always if the facts were known, in connection with septic processes of some kind. It may arise in cases of sloughing cancer of the cer\ix apart from pregnancy. Thrombosis of the vein of the limb affected is not always to be felt, and obstruction of lymphatics is not easily demonstrated, so that the only absolutely constant fact is the hard oedema. There is always some fe\er ; and occasionally rigors arc obscr\'ed. 554 Pathology of the Puerperal Period Syniptoins and Course. — The attack most often happens about the third week of lying-in. It may very rarely begin as early as the first. The first symptom is an acute pain in the calf or inner side of the leg attacked. The temperature rises moderately (io3°), and there are some- times rigors. Very often some pelvic inflammation is found to exist already, and then the temperature is already raised to start with. In a few hours a certain amount of swelling appears, affecting the whole length of the limb as a rule, but occasionally not extending below the knee. The swelling pits on pressure at this stage. It gradually increases, and the limb becomes more tense and white, until some five or six days after the appearance of the first symptoms the skin looks as if the leg were distended with lard. It is shiny, and there may be seen groups of superficial blood- vessels which are probably thrombosed. In the case of the leg the femoral or saphenous vein may have been felt as a hard cord while the oedema was soft, but cannot be made out in its tense condition. There is great pain on moving the limb, and tenderness on touching it. The fever is of a septic type as a rule. After a week or a fortnight in this state the tension in the leg begins to relax ; and the pain and fever, if the case is uncomplicated, subside. The leg goes through the soft stage again, and the thrombosed vessels may again be felt. As one leg gets well the other may begin and then go through the same process of swelling. This happens in a fairly large number of cases. The left leg is the one most commonly attacked, and if both suffer it is the first to do so. This at once suggests some connection with septic inflam- mation in the pelvis, since it is on the left side that parametritis is by far the more common. After the characteristic oedema has disappeared, the course of things is the same as in the case of ordinary thrombosis. Suppuration is a most rare event ; if it occurs it is most likely due to septic phlebitis. Treatment. — This is similar in the case of the present disease and in thrombosis. If the woman has got up after her confinement she must return to bed at once on the appearance of acute pain in the leg. She must lie on her back with the limb raised on a pillow which supports its whole length, for any edge will exert special pressure on the part lying on it. A cradle should be adjusted to protect the limb from the pressure of the bed- clothes, and sand-bags may with advantage be laid alongside the leg. If necessary morphia may be given hypodermically for the pain, and hot fomentations of belladonna or laudanum may be continuously applied. In making such applications the greatest gentleness should be used for fear of displacing the clot ; and in no case should more handling be employed than is absolutely necessary. The woman must be moved as little as possible, and very slowly, for the purpose of passing evacuations alone. When the swelling goes down — usually in a month or six weeks — and the thrombus has shrunk to a firm cord, the leg should be lightly bandaged from the toes upward with a flannel roller, and the patient must not be allowed up until all pain and tenderness has gone. There will be a tendency for the leg to swell after it has been used to stand upon, which will remain for many months, as a rule for at least a year, just as in the case of ordinary thrombosis. A ir- Em holism 555 AlR-EiMBOLISM This rare accident consists in the admission of air into the veins in too great quantities to be dissolved, or to be sufficiently finely divided to pass through the pulmonary capillaries. The bubbles then act as emboli, com- pletely obstructing the lumen of the smaller arteries and capillaries, and, if a sufficiently large amount finds its way into the vessels, filling the cavities of the right side of the heart with froth. Morbid Anatomy and Mode of Origin. — The air seems, in most of the recorded cases, to have entered the veins during some intra-uterine operation, such as the administration of an intra-uterine douche, either before the placenta was detached or after. More commonly it has happened before complete detachment. The nozzle of the douche-tube has, in some of the cases, not been inserted even as far as the cervix, and the douche has been intended merely as a vaginal one. Air-embolism has happened in cases where it has been necessary to introduce the hand into the uterus. In a few of the cases there was no artificial interference, and the air must have entered spontaneously ; in others gas was formed in the uterine cavity by decomposition of the foetus. Bubbles of air may be found in the vena cava and the pelvic veins ; and in the subperitoneal vessels of the uterus. The right heart may be distended with froth ; air has been seen in bubbles in the coronary vessels, showing through the visceral layer of the pericardium ; and in all cases froth is found in the pulmonary arteries. The mechanism of the entry of air is as follows : The mouths of the recently opened sinuses at the placental site, if they are not closed by thrombosis, are unable to close themselves independently of uterine con- traction. If the uterus is distended passively, or possibly if a contraction raises the intra-uterine pressure while the placental site remains in a relaxed condition, as is believed sometimes to happen (see Inversion of Uterus), any air or gas which lies in contact with the open mouths of the sinuses is liable to be forced into them. This is no doubt rendered much more certain if an inspiratory effort is made at the moment. No doubt a comparatively large amount of air must enter to give rise to the severe symptoms characteristic of this accident ; and it is quite possible that small quantities do enter occasionally, but are dissolved at once, or are at all events not large enough to give rise to important obstruction of vessels while they are being dissolved ; or they may not find their way to the heart at all, but remain in the pelvic veins during solution. When the blood has been mixed with the air in the right side of the heart, the froth forms a complete plug in the pulmonary artery beyond, since it is unable to flow through the smaller divisions of the artery. The cardiac valves have no chance of acting properly, for the froth cannot float them up and force them into the position of closure. Moreover, owing to the elasticity of the air, it will undergo diminution in volume readily on con- traction of the heart, and onward movement will not be a necessary result of contraction. Symptoms. — The effect on the patient is similar to that of embolism of 556 Pathology of the Puerperal Period the pulmonary artery. There are spasmodic inspiratory efforts, convulsions, and sudden death. It is said that a churning sound has been heard over the heart in some of the cases Naturally all recorded cases have been fatal ones, so it is quite impossible to say that some other instances where attacks of dyspnoea have occurred, but where the woman reco\ered, were not due to this accident. Treatment is unfortunately of no avail, or at all events has not yet proved so, in cases of this kind. Venesection has been tried, having been indicated by the asphyxia ; but, as might be expected, has been useless. To prevent the accident, e^•er}' care should be taken to a\oid introducing air during any vaginal, and, a foj'tiori, during any uterine, douching. This is best prevented by using the constant current from a douche-tin, and not the intermittent one from a Higginson's syringe, and by taking care that the delivery-tube and the nozzle are emptied of air before the nozzle is introduced into the vagina. Since a majority of cases have occurred before complete separation of the placenta, and some where water was injected into the uterus to induce labour, especial attention should be paid to the above points during the first and second stages of labour. Labour must never be induced by intra-uterine injections of water or air (see p. 362). CHAPTER LXXIII DISORDERS OF THE XERVOUS SYSTEM IXSAMTY The subject of insanity in all states of the child-bearing woman has to be considered here, and it may be divided into the insanity of pregnancy, of labour, of lying-in, and of lactation respectively. Child-bearing is known to have a particularly marked influence in causing insanity in those women who have an hereditary taint of madness or of other marked neurosis ; and 14 or 15 per cent, of all female lunatics owe their first attack of this disorder to the supervention of pregnancy. In about two-thirds of all puerperal cases of insanity there is a famih' histoiy of nervous disease. The disorder occurs in about the proportion of one in e\cry 4,000 births. It is not especially frequent in primipara:, as possibly it might have been expected to be, but according to Savage it is commoner — during pregnancy, at all events — in multipant.'. It is more common in elderly primipant than in young ones. The patient, in the great majority of cases — almost always, in fact — is one who is debilitated by malnutrition, or excessive h;i?morrhage, or exhaustion during labour, or by some illness occurring immediately after labour. Pregnancies rapidly succeeding one another, especially when the child is suckled in each case, have a very marked effect in helping to produce insanity. Clouston finds that a large proportion of the insanity of lying-in occurs after illetritimate births. Insanity of Pregnancy 557 So, given an hereditary tendency, and some cause producing exhaustion, or intense mental excitement in a child-bearing woman, there is a fair chance of her having insanity of one kind or another either before, during, or after, labour ; and the first time it happens in a patient's history is most commonly during the puerperium. The kinds of insanity which may occur in connection with child-bearing have no very special peculiarities, and its character may be that of mania, melancholia, or dementia ; but it will be seen, as the several periods are dealt with, that the nearer to parturition, before or after, the woman is affected, so much more likely are the symptoms to be of a maniacal character ; and the more remote the attack from delivery, the more commonly does melancholia occur. Of all cases of insanity in connection with child-bearing the percentage in the different periods is about as follows : Pregnancy Parturition Lying-in Lactation 12 per cent, under i per cent. 58-60 per cent. 30 per cent. (Mostly melancholic) (Maniacal) (Mostly maniacal) (Mostly melancholic) Insanity of Preg^nancy This is nearly always of the melancholic type. It begins sometimes in the second or third month of pregnancy ; sometimes towards the end. It is usually associated with an(S7iiia, which to a greater or less degree is developed in any pregnancy, but which in these cases is often due to the exhaustion of previous pregnancies. Savage says that the common mode of production is as follows : — ' A woman of insane family becomes pregnant, and with the pregnancy has some marked ner\ous peculiarities, which pass off and are forgotten till after delivery, when they reappear ; or when sleep- lessness, irritability, and change of character usher in an attack of ordinar}- puerperal insanity. A second and third pregnane)', occurring within short intervals, are each followed by attacks of insanity. But with the fourth and fifth pregnancy the eccentricity of pregnancy becomes undoubtedly an insanity, and the patient, during the earlier months of pregnancy, suffers either from maniacal or melancholic symptoms, which may pass off to re- appear after pregnancy, or they may continue steadily through the pregnancy up to delivery, and beyond it ; the patient seeming to become more and more unstable in consequence of preceding attacks of insanity, till at last a very much less force is required to upset the balance.' ' It has been mentioned that the normal mental state of women often undergoes some change during pregnancy, and no sharp line can be drawn between this almost physiological change and the milder forms of insanity occurring during this period. Apprehension of the approaching trial, or vaguely of nothing particular, becomes sometimes, especially in women with hereditary tendencies, or who have been affected previously, a settled dread, . and developes into melancholia. The patient interprets insanely the slight dis- orders of pregnancy, and may imagine that her \-omiting is due to poison, and so refuses food. She is often apathetic, caring nothing for her usual interests, and despairing of everything. Other moral aberrations may be present, 1 Savage, Insani/y tuul Allied Neuroses. 5 5 8 Pathology of the Puerperal Period such as kleptomania, but this is rare. The intellect is affectedonly in severe cases, so that delusions, such as that just described of poisoning, are not the commonest phenomena. A tendency to suicide may be present. In cases coming on in the earlier months the probability is that the patient will get better before term is reached ; but she may become insane again after delivery, and will very likely, but not certainly, be attacked again in future pregnancies. Insanity making its appearance in the later months of pregnancy is ver)' much of the same character as that which appears early, and the cases often reco\"er before labour, possibly to relapse after. Savage has noticed several cases of General Paralysis of the Insane during pregnancy, which have begun about then, and have continued to develope afterwards. Insanity of Kabour The parturient woman ma)- ha\"e a momentar\- attack of frenzy during the passage of the foetal head. Lesser degrees of this are not uncommon and are of course only to be observed where an anaesthetic is not used. Mania limited to this period of labour is probably rare, but an attack of puerperal mania may begin at this stage of affairs. The onset of labour has sometimes a temporarily restorative effect on women who have been insane during pregnancy ; they may become sane while labour is in progress, and relapse after it is over. It is an important point also that an insane woman may be delivered un- consciously, and that she may be found in bed with a child which has been smothered : in this case she will probably know nothing of the matter, and cannot be held responsible for the child's death. Insanity of tbe Puerperium During this period, and especially during the first fortnight, the most characteristic form of the insanity associated with child-bearing arises. It is probable that at this time primipane suffer more frequently than multiparce, taking all cases together ; and this is to some extent because illegitimate children are usually the result of a first and not a later pregnancy. A moral shock of some kind is a very frequent precipitating cause, but given an hereditary tendency physical causes are of great or even greater importance than psychical : as, for instance, an;rmia from pregnancies frequently repeated in a short time, especially if they have been followed by over-lactation. Septic illness is not infrequently found to precede an outbreak, and in con- sidering this it will be remembered that primiparie, with their more numerous lacerations, are rather more likely to be affected than multipanu. It is very questionable whether the administration of chloroform during labour can be considered a cause or only as a coincidence in the development of insanity ; cases, however, are recorded where labours conducted under chloroform have been followed by insanity in women who ha\e had children before and after without an anaesthetic and without insanity. Combinations of these causes as a rule co-exist, but heredity must always be remembered as the most potent factor. Insaiiily of Puerperium ; of Lactation 559 Before describing the usual kind of case, the transitory mania wliich sometimes comes on early in the puerperium must be mentioned. Attacks of this kind are of great importance, as in the hallucinations under which their victim suffers she may kill her child. She has a rapid pulse and excited appearance, and is talkative and violent. This goes off in a day or two ; and she will then know nothing of what has happened in the meantime, and cannot be considered responsible for what she has done. An ordinary case of puerperal mania has the following main features : The woman becomes gradually uneasy in her mind, and is very irritable and depressed for no reason that can be made out. She sleeps badly, and sleeplessness should always put the physician on his guard in a puerperal case, and should (in every recently delivered woman) be carefulh' inquired after. She takes a dislike to her child, and very often to her husband. Her depression is succeeded soon by excitement, and she talks rapidly and maybe incoherently. She is often indecent and blasphemous, and she refuses her food in a large number of cases. Savage says that in puerperal insanity there are a few symptoms which may pei'haps be considered to be more commonly present than in other cases of mania : namely, sleeplessness, anxiety, aversion to relatives, erotic tendencies, mistakes of identity, with hallucinations of smell and taste, and refusal of food. The dislike' felt for her child and husband may culminate in attempts at murder, especially of the child. This may happen not only in cases where the child is illegitimate and embodies to the woman the disgrace of her position, but also in cases where there is every reason for welcoming an infant. She may also have suicidal impulses. When the acme. of the disorder is reached — and this is very soon in puerperal cases — the excitement is very marked, and illusions of sight and hearing, or of the other senses ; delusions ; and hallucinations are common. The woman is often reckless of all decency ; and she talks and behaves dis- gustingly, probably more so than in other forms of mania. Insomnia is frequent, and this, combined with the continued excitement, rapidly wears the patient out. The bowels are confined, and the digestive functions generally are in- active. The milk and the lochia are usually diminished, or may be suppressed ; but this is probably most often the result of the exhaustion or the septic absorption so often co-existing with, and perhaps, especially in the latter case, causing the insanity. The melancholic type becomes commoner in cases beginning in the later days of the puerperium ; and after a fortnight or three weeks is rather the rule. It begins in much the same way as an attack of mania. The delusions are of a hypochondriacal kind, and suicidal and homicidal tendencies are common. Insanity of Xiactatlon The disorder is at this time always associated with exhaustion and anaemia. Instances of it are therefore commoner among the poor and ill-fed, and occur usually after some months' suckling. The longer the time which 560 Pathology of the Puerperal Period has elapsed since labour, when the attack begins, the more likely is the case to be entirely Melancholic. The woman is pale, and has all the other symptoms of anaemia, breath- lessness, oedema of legs, palpitation, and indigestion and constipation. Her mental condition is much the same as that of the woman who becomes mad during pregnancy ; but her intellectual faculties seem to be more commonly affected here, in addition to her moral ones. Delusions are far more frequent, and she may suspect her friends and others of plots against her, and of persecuting her. She also has hallucinations. Deme7itia sometimes begins after delivery. The woman becomes apathetic, and indifferent to cleanliness and her personal condition generally. She may get better of this, or it may be the beginning of a progressive dementia. A ver\- large proportion of the cases of insanity after labour eventually recover. The outlook is best in the later, melancholic type of patient, who gets better in three to six months according to Savage's experience. The same author says that a fair proportion of the cases of acute mania die. In future pregnancies there is always a prospect of recurrence, either during the puerperium or during pregnancy ; this has been already mentioned. If, however, the woman never becomes pregnant again, it does not follow that insanity will be prevented. Generally speaking, then, the immediate prognosis is rather good than otherwise, taking all cases together ; but a certain number are found to not recover their reason at all ; or to remain permanently weak-minded, e\en after a first attack. Savage believes that as long as the physical condition remains at a low ebb, in the case of insanity or weak-mindedness which has gone on for many months, there is hope of the patient's recovery of her reason : but that if the physical health is re-established without mental gain the prognosis is bad. Diagnosis. — Hysteria may in some phases resemble an attack of mania, and in a few it is \&xy difficult, if not impossible, to distinguish at once. The main point is that the former is quite a temporary and short-lived aberration, and that the element of intense self-consciousness is always to be made out at some moment or another by anyone who has been accus- tomed to observe such cases. Delirium of Fevers. Delirium Tremens. — These two conditions resemble for a short time — especially the latter in its hallucinations and the former in its incoherence — attacks of mania. They are both liable to occur in the recently delivered woman ; the former in septic cases, and the latter in alcoholic patients in whom the strain of delivery has caused an attack. There will be no difficulty in diagnosis if the possibility of their occurrence is remembered. Insane women may become pregnant. The prognosis in such cases will be much graver than that in recently developed madness. Cases of lunacy cured by pregnancy have been cited, but are not sufficiently frequent to be taken as more than coincidences. As a rule the effect of pregnancy is not good, and the offspring is certainly most undesirable. Treatment.— Simple treatment only is required in the great majority of instances. It becomes in a certain proportion a question whether the patient Treatment of Insanity 561 should be sent to an asylum or not. If the necessary attendants can be afforded, and the patient isolated from her relatives, it is better to treat the case at home, for both the woman and her friends will feel that asylum treat- ment is something- always to be ashamed of. When the above-named opportunities do not exist, and the patient needs constant watching to pre\ent her from damaging herself, or special feeding, removal to an asylum is realh' the only reasonable means to employ. There is no doubt that instances ha\'e occurred, and often occur, where insanity has become estab- lished, owing to injudicious treatment, which would in all probabilit}- have completely recovered under the influence of the isolation discipline, and skilled treatment of an asylum. Seeing that the majority of puerperal lunatics suffer from anaemia or exhaustion, it is obvious that the feeding is most important. The patient should be made to take milk, eggs, and meat juices, either cooked or raw, at certain determined intervals, in addition to her ordinary meals, which should always be retained as a basis for the diet-sheet. In a certain proportion of cases forced feeding may be of benefit, and in some absolutely necessary. Iron preparations will be most useful in anaemic cases, alone or with arsenic. Cod-liver oil, maltine, and other foods of this kind should be given when needed. Sedatives and Stinnilants. — Sedati\es, certainly in maniacal cases, arc only effectual during the actual time that the patient is held down by the drug, for she wakes up as bad as ever. Savage says they usually fail, and often do harm. In melancholia they are possibh- of more avail, but they tend in all cases to further lower the patient, and the reverse of this is what is wanted. Opium in the form of morphine is possibly useful in a few cases ; and nyoscin in doses of litT-gV grain has been used, and in some cases has answered well. Paraldehyde in 5ss-ij doses is said to ha^•e no unpleasant effects. Alcohol, however, is free from objections of the abo\e kind if gi\en in suitable doses. It helps assimilation and thus nutrition, and often acts as a sedative. It should be given in small doses frequently, and the indications for its use are those relied on in other circumstances. A fairly large dose taken at bedtime is often the best narcotic. The bowels should be carefully attended to in all cases. Any rise of temperature should have its cause at once investigated, and remo\ed if possible. Septic cases are treated on ordinary principles. The patient should be sent into the country or to the seaside as soon as it can be managed. Induction of premature labour, which has been recommended in cases of insanity of pregnancy, should only be used when other conditions — such as intractable vomiting — recjuire it ; ne\'er for insanity alone. During labour any great excitement, cspeciall)- if due to the agony of the head-delivery stage, is an indication for chloroform and assistance. In cases treated in asylums, which threaten to become chronic, it has been found useful in many instances if there is no distinct contra-indication, to send the woman home on probation for a short time. At this stage the familiar surroundings and duties of the house may work a cure. O O 562 Pathology of the Puerperal Period Hysteria and Emotion Xut infrequently in women inclined to be hysterical at other times, hysterical manifestations occur during; or after labour. l%V^.r 1 2 3 4 B 6 7 8 9 10 11 \z 13 14 1 oMai' M I M E M E M I M E M E M E M E M E M E M I M E M t M E IOS° 104" 103° 102° lor 100" 9&° 98° A f \ 1 \ 1 \ \ / h A f\ n ^, N ' \ A A V. ^ ki / L i V n V. U \, '> r I / k 1 f ^yv \/ V \ \ ^ s / •v ^ _ J -J _j Fig. 388. — Mrs. F., set 24. Primipara. Rise of temperature due to emotion. A visit from .a lunaiic husband occurred immediately before each rise. The patient was quite well throughout. Those occurring when the patient is suffering pain, and is excited, and loses some of her self-control from that cause are unmistakable, and their intensity varies between the widest extremes. Day of Puerper 1 2 3 4 5 G 7 8 9 10 11 12 13 14 Hours of day M E M E M i M E M E M E M E m|e M E M E M I M E M t M E 103° 102° 101° 100° 99° 98° 97" 1 1 1 i / L 1 / \ r^ \i \ ^ / \ J \/ /\ r % V / V "S I ; .A / > kJ / V v^ ' ' ^, V J Fig. 389. — Mrs. H., act. 26. 5-para. Rise of temperature accompanying a hysterical tii. After labour, however, women sometimes suffer from symptoms of a hysterical nature which recjuire care to distinguish them from more serious affections. Many cases have been recorded of higdi temperature, uninfluenced by medical treatment, and unassignable to any physical cause. Paralyses and Pareses 563 Though, no doubt, a proportion of them were really septic, or clue to mammary tension or to constipation, instances are frequently met with where slighter moral disturbances, caused by some exciting news, a first visit from the husband after labour (fig. 388), or some event which has annoyed or alarmed the patient (fig. 389), are accompanied by a rise of temperature. .Such examples of sudden pyrexia show a correspondingly rapid return to the normal, after a night's rest, or a small dose of some sedative. Hysteria of a more pronounced type if accompanied or evidenced by fits must be distinguished from eclampsia. It is not at all difficult to do this, it ordinary care is taken to observe the character of the convulsions. It is only necessary to mention that hysteria may simulate also tetany, mania, tetanus, more especially trismus, various paralyses ; and collapse suggesting haemorrhage, to put the medical man on his guard, and lead him to recall or ascei'tain his patient's previous history. Paralyses and Pareses It has been mentioned under Embolism (p. 552) that plugging of cerebral arteries may occur during lying-in. The symptoms here differ in no respect from softening in the non-puerperal woman, and will not be now enlarged upon. The effects of the plugging of other arteries than the cerebral are also unmodified by lying-in. Apoplexy has been mentioned in connection with Bright's disease in pregnancy. The paralyses and pareses belonging essentially to labour, are those caused by the pressure of the head during birth on the structures in the pelvis ; or more rarely, from spread to the nerves in the pelvis of inflammation of the neighbouring tissues, due to me- chanical injury and septic absorption. True paralyses of the bladder and urethra are extremely rare, and will be dealt with on p. 567. Paraplegia and hemiplegia are caused either by pressure on parts of the sacral plexus, or by extension of inflammation to its nervous trunks. As the lumbo-sacral cord (fig. 390) enters the pelvis from above to join the sacral plexus it crosses the brim over tlie ala of the sacrum. In a normal pelvis it is protected from pressure by the slight projection of the promontory, but in some cases of prolonged laljour from malpresentation, or in some contracted pelves, it is exposed to injury from the tightly fitting head. This pressure affects one side only. The usual course is that great pain is felt in one or both legs durin<>- labour ; and this remains in a lessened degree afterwards ; at the same time there is paralysis of the leg corresponding to the plexus pressed upon. The sensory fibres soon recover, but the motor affection remains. The muscles -Lumbo-sacral cord crossing the lirim. 564 Pathology of the Puerpei-al Period most likely to be affected arc those on the outer side of the tlii^'h, and those of the calf and the i)eroneal region corresponding to the ultimate distribution of those fibres which run in the lumbo-sacral cord. The patient is unable to move her leg normally, or perhaps at all : and when the time comes for her to get up, cannot walk on it. The symptoms in inflammatory cases are much milder. Recovery gradually ensues, and is almost universal. Sometimes, however, trophic changes in the muscles have occurred ; and rarely the lumbo-sacral cord has been so damaged that per- manent paralysis has resulted.' The only way to prevent it is not to allow pressure to be e.\ercised on the structures at the brim, but to help the head by some means (forceps, craniotomy) through it ; or to rectify mal-positions. The forceps, although often blamed for causing it, would really, if used in time, prevent it ; and in cases where its use is supposed to ha\e led to paralysis, the damage has probably been done before it was applied. The ordinaiy treatment for muscles with lesions of their nerve-trunks will be necessary if any nutritive changes commence ; and in slowly reco\ering cases, a careful watch should be kept on them, their electrical reactions being tested occasionally, so that no time may be lost in beginning the necessary treatment. Cases of parah'sis should not be confused with those of relaxation or rupture of the pelvic articulations (p. 501), which cause in severe instances great lameness ; nor should femoral thrombosis be missed in examining a case with symptoms resembling paraplegia. Tetaxu.s This very grave disease is fortunately rare after delivery in this country. In India and in other hot climates it is commoner, just as tetanus is under all traumatic conditions. There is nothing special in its features when it attacks a lying-in woman, except that the wound or wounds at which the tetanus-organism finds entrance will be somewhere in the genital tract. It occurs about as frequently after abortion as after labour at term. In cases where a post-mortem examination has been made, a fair proportion have proved to be septic, though of course it will be understood that this fact has nothing to do with the tetanus, beyond showing that septic organisms have been able to obtain access to the internal tissues, and explaining how those of tetanus have been able to do so too. It is prol)able that this is the route of infection in all puerperal cases of tetanus, and that it is so is pretty well proved by the fact that most cases arise after manual interference in labour or abortion. • Idiopathic Tetanus ' is not now admitted to exist. The interesting experiments of Xicolaier, who produced tetanus by introducing common garden, soil into wounds, and similar ones by Carlo and Rattone who used the dust from some old buildings during the demolition of which numerous cases had occurred among the workmen, show tliat tetanus poison or its specific organism is to be found in unexpected ' Inf. Jour. Med. Sci. 1893, ii. p. ii6 : Lainy, ' reripheral Neuritis.' Tetany 565 ])laci's ; and other observations liave been made connecting instances of this affection with recent exposures of sr This name was given by Sanger to a form of malignant growth occurring in the uterus, and having the nature of a sarcoma. He called it by this name because it showed on microscopic examination numbers of cells like decidual cells (see p. 6) and also larger numbers of similar cells massed into Plasmodia (the so-called syncytium). These masses and cells were found also in the secondaiy growths which occurred numerously in the lungs and other organs. Since his case was described, many others ha\ e been reported ; but the later cases have no constancy in their characters, nor in the mode of origin ascribed to them. Some of them have been supposed to arise from sarco- matous degeneration of the villi of the chorion, and 'almost every malignant uterine growth discovered in the puerperium has been called " deciduoma "' in Germany.' ^ The most important point relied on by those describing such cases for 1 Eden. For an account of the present slate of opinion in England on this subject, the reader is referred to a most important series of papers published in tiie Obstetrical Trans- actions, vol. xxxviii., 1896, by Malcolm, Rutherford Morison, Spencer, and Eden ; to the discussion by Kanthack, Clarence Webster, and others ; and to the Reportof a Committee in the same volume. P P 57^ Pathology of tlie Puerperal Period identifying them as 'deciduoma malignum,' is the presence of the syncytium alcove alluded to. Similar masses are, however, to be found in cases where there can be no question of any decidual tissue in or near the primaiy growth ; for instance, in sarcoma testis, one instance of which displayed the ' syncytium ' most typically in the secondary growths in the li\er and lymphatic glands. It is clear that no well-defined class of tumour to which the name of deciduoma malignum can be with justice given exists, or has been demon- strated at present. The growths are to be looked upon as sarcomata occur- ring in the uterus during the puerperium. Cases of \esicular mole have been recorded where a growth occurred in the uterine wall after the removal of the mole ; in both this and in the secon- dary deposits which were found the characteristic vesicular structure was evident. Apart altogether from the theoretical aspect of the matter, the practical inference to be drawn from what has been made out on the subject of the sarcomatous growths above-mentioned, is that where there is haemorrhage during the puerperal period which does not readily yield to treatment exploration of the uterus by the finger should on no account be omitted, and if a friable mass in the uterine wall is discovered, which on microscopic examination shows sarcomatous characters, the uterus should be excised without delav. 579 PATHOLOGY OF THE NEW-BORN CHILD CHAPTER LXXVII PATHOLOGY OF THE NEW-BORN CHILD It is proposed to give here only a short account of the diseases to which the newly-born child is liable. For a fuller treatment of the subject the reader is referred to works on the Diseases of Children. Nervous System Occasionally a paralysis of one of the facial nerves is caused by the pressure of a blade of the forceps. The disturbance of balance in the features is not very marked as a rule, but it may be detected on careful examination. The condition lasts only a few da)'s or weeks at most. Fig. 392. — Paralysis of left side efface (drawn from a case in the General Lying-in Hospital). The forceps is sometimes responsil^le for damage to the brachial plexus^ when \arying degrees of paralysis of the arm occur. The arm is more F V 7 580 Pathology of the Nen'-born Child commonly injured, however, by roiij^h attempts to ]hi11 it down when it is extended above the head ; or by attempts at extraction of the body byhook- ing^ a finger in the axilla, the brachial plexus being thus damaged. The prognosis in such cases is not very good ; but in slight cases im- provement will be found in the course of months, or sometimes the paralysis may last over several years. The arm should at first be kept at rest by being wrapped in cotton-wool and bandaged to the side. When the extra\asated blood has been absorbed, which is usually in about three or four weeks, movement and galvanism should be employed. Tetanus is ver}' rare in the present day, and especially in this climate. It is caused by want of cleanliness as regards the navel. Opbthaltnia, due to g-onorrhoeal infection, has been mentioned as one of the possible results of want of care in cleansing the vagina in women, who, before labour, are found to have a purulent discharge. The inflammation appears about the second day of life as a rule, and if untreated rapidly becomes very severe. The eyelids are very red and swollen, and there is considerable difficulty in separating them so as to get a view of the conjunctiva. The great danger is that the cornea may slough, and the eyeball shrink, total blindness resulting. The means of prophylaxis are detailed on p. 240. When the disease has appeared, the important point in treatment is to keep the con- junctival sac as free as possible from discharge, which is constantly tending to collect under the eyelids ; and since the edges of the eyelids are gummed together by the dried pus, and also spasmodically contracted by reflex action, a certain amount of tension must be present, unless care is given to this point. This is best done by washing the eyes at least every hour with a dilute solution of corrosive sublimate (1-4000), or a saturated solution of boracic acid, until the discharge is reduced to a thin state, and the swelling of the eyelids disappears. It should then be done at less frequent intervals, until the eyes are well. If the case does not very soon yield to this treat- ment, a solution of nitrate of silver (10 or 15 graiiis to the ounce) should be brushed over the conjunctiva once a day. It is to be impressed on the nurse that the result depends in great measure on the diligence with which she uses the weak lotion, and if necessary an extra nurse should be obtained to carry on the treatment during the night. CiRCUL.\TORY System The occurrence of numerous baemorrbagres into the tissues of children, in whose birth there has been any difficulty, has been alluded to on p. 108. These arc found in the brain substance, and on the surface beneath the pia mater. They are due to \enous rupture in practically all cases, and are Ijrought about either by pressure of the forceps or merely by congestion due to pressure on the umbilical cord. They are thus commoner in breech cases than in other presentations. The child may survive, and die after a few days : or it may be paralysed in correspondence with the seat of the damage done to the nerve-centres ; or it may possibly be affected in intelligence. CephalJicsniatoina ; Hcemopliilia Neo7iatoriwi 581 Cephaltasematoina. — This is a hitmorrhage from the periosteum cover- ing the skull, and is usually considered to be due to an intensification of the conditions which produce the caput succedaneum (p. io8j. The blood may be effused beneath the occipito-frontalis tendon in rare cases, but its com- monest seat is beneath the periosteum. In this last case it cannot extend beyond the edge of the particular bone over which it occurs. The swelling in nearly all instances is found in the situation of the caput succedaneum. It is, however, occasionally double, and a specimen of this condition (double) was shown at the Obstetrical Society quite recently.' There is usually a ridge found round the edge of the swelling after it has begun to be absorbed ; this is no doubt due to the deposition of bone by the lower surface of the periosteum. The lump often becomes quite hard and bony. It takes several months to disappear entirely. A cephalhasmatoma is distinguished from a caput succedaneum by its fluctuation, its persistence beyond a day or two, and its limitation by the edges of the bone o\er which it lies ; and from a meningocele by the latter being seated over a fontanelle or suture, and swelling when the child cries. As far as the blood tumour is concerned the prognosis is good ; but it may be complicated by haemorrhages into deeper tissues. Haemorrhages may occur into the lung-s and into the kidneys, and cause symptoms ; in the former case, Spencer (quoted on p. 109) found that it was usually into the base, and if the child survives, pneumonia may aftect this part ; in the latter the same observer found that suppression of urine might occur. A haemorrhage may occasionally take place into the sterno-mastoid muscle, after attempts to e.xtract the after-coming head. It is usually situated in the upper part of the muscle. There is a tumour to be seen and felt, of much variety in size and shape. It disappears after a few weeks : but it is to be remembered that it may, owing to destruction of the muscular tissue, lead to subsequent wry-neck. Haemophilia neonatorum. — A tendency to bleed may show itself within a few days of birth b)' haemorrhages from the nose, stomach, intestines, and kidneys, and from subcutaneous vessels. In a large majority of cases the child is found to suffer from syphilis or septicaemia or both.- Congenital heart-diseases show themselves in all cases at this period of life by cyanosis in varying degn-ees. The varieties are numerous, and their diagnosis almost impossible, but the treatment usually necessary is the same in all instances, namely to keep the child constantly warm. These cases must be distinguished from cases of atelectasis pulmonum, which causes the same appearance. The cardiac condition persists, while the pulmonary disorder is either accompanied by other conditions of debility in the child, and takes part in causing its death ; or gradually clears up as the child gets stronger and the lungs expand completely. Icterus neonatorum. — A slight degree of yellowness of the skin is almost the rule during the first ten days or so of the life of a new-bom child, and may be demonstrated by .pressure on the surface so as to make it ' W'heaton, Obst. Trans., vol. xxxv. p. 6. - .Ashhy and \\'iight, Diseases of Children. 582 Pathology of the New-born Child anicmic. A yellowness sufficient to be at once recognised occurs in about 25 per cent, of all cases. There is never more than very slight discolouration of the sclerotics, and in the large majority of cases these remain quite un- affected, even when the skin shows unmistakable signs. The discolouration of the skin appears about the second or third day, gradually becomes more intense, and lasts about a week. The urine is not affected in the milder cases, and the normal amount of bile-pigment appears in the motions. The health of the child is not affected unless the jaundice is more severe ; but in this event the symptom is probably due to a more serious condition than in the commoner kind. It has been said by some that those children on whom late ligature of the cord has been practised (see p. 193) are more liable to be yellow than others ; but the result in a series of cases in the General Lying-in Hospital in which in 50 cases the cord was, contrary to the usual practice there, ligatured early, was that these cases were the subjects of icterus with rather more frequency tiian the rest of the cases.' Quite in consonance with this fact is the experience that premature children are much more frequently coloured than those born at term ; and that children which are weakly from any other cause, without having any disease which directly induces jaundice, are almost universally yellow. In contrast with the insignificance of this condition, which is icterus neonatorum par excel/ence, the jaundice which is found to accompany septiccemia in the newly born is an extremely grave symptom. Jaundice occurs also in two other diseases, which are, however, very rare — namely, WiitckePs disease and the Acute fatty degeneration of the New-born^ described by Bulil.'-' Jaundice may also be due to actual diseases of the liver, as in the perihepatitis of syphilitic children ; or to some congenital malformation of the biliary ducts. Finally, in verj' rare cases a child may have jaundice and die on the ninth or tenth day without any disease being discoverable post- mortem. There are many theories to account for the simple jaundice first described. It is certain that there is a considerable change in the histological elements of the blood soon after birth. The disintegration of some of the corpuscles which then takes place must set free a certain amount of haemoglobin, and if this is not soon reabsorbed (by the remaining corpuscles) or altered or excreted by some organ, it is probable enough that it maybe deposited in the tissues and stain them yellow. The fact that there is no excess of bile-pigment in the urine, and no lack of it in the motions, supports this view. Another hypothesis is that the ductus venosus may remain patent in some cases rather longer than in others (p. 236). In this case the portal blood, not having passed through the liver and got rid of its bile-pigment, runs straight through into the general circulation. As regards diagnosis between the harmless kind and the severe symptomatic kinds, the child has only to be watched, and the absence of any possible cause for septicaemia and of the symptoms belonging to the ' .See also Schmidt, Arch. f. Cyn,. vol, .\lv., 1894, who is quoted on p. 194. - For these conditions, works on the Diseases of Children should be consulted. Thrush 583 other diseases mentioned as causes of jaundice will indicate the nature of the case. No treatment of the cases which merely suffer from discolouration of the skin is necessaiy. ALniENTARv System The only disturbance of the functions of the alimentary canal which can be called congenital is the condition of imperforate anus. This need only be mentioned here, since its treatment is surgical. During the first fortnight or even earlier in the child's life it may suffer from some form of digestive disturbance. The commonest are flatulence and colic. These mild troubles may be remedied by attending to the principles mentioned at p. 240, and need not be further alluded to here. Thrusb. — There is, however, one disease which will come more especially under the notice of the obstetrician — namely, aphthous stomatitis. This disease is always found in connection with a weakly condition of the child. It consists of tlie growth of a fungus (oidium albicans) in the epithelium of the mouth. The appearance produced is that of small white patches on the tongue, the inside of the cheeks, the lips, and the soft palate. The patches are sometimes surrounded by an area of redness, but the mucous membrane around them may be quite noiTnal in appearance. They are distinguished from particles of curd by their bemg firmly adherent to the surface. In a few cases the fungous patches have been found further down the alimentarj' canal, in the stomach and intestines. They have been seen in the lungs also. The frequent statement of women of the lower classes that the ' thrush has gone right through ' the child is, however, not to be accepted, for the diarrhoea which so frecjuently accompanies the mouth-symptoms, and which presumably suggests this progressive invasion of the digestive system, is probably the cause, or at most the accompaniment of the disease, and not the result. The patches are not found to grow in the mouths of those children \\ho are carefully looked after, and are attended to after each time they have taken the breast (see p. 232). When they occur, the mouth must be swabbed out frequently, immediately after each meal, and in the inter\als, with a strong solution of borax (half a drachm to a drachm to the ounce). The great point is to improve the child's health as cjuickly as possible. Skin and Subcutaneous Tissue The newly-born child is not liable to many diseases of the skin. The commonest is a form of /ichcfi, '■ red guni^ which is by most believed to be produced by digestive disturbance, and by others to be the result of sweating freely. In later months it concurs with the eruption of a tooth. It causes some irritation to the child. It may be treated by dabbing on a weak lotion of lead, or by powdering the skin with a mixture of starch and oxide of zinc, and at the same time attending to any signs of indigestion. PcinpJiigus is found in cases of cong'enital syphilis. Sclerona Nco/iatorit/ii. — This is a rare disease. It is characterised bv a 584 Pathology of the Neiv-borti Child hardening of the skin and subcutaneous tissue, which begins as a rule in the lower extremities and gradually involves the skin over the whole body. The child wastes, and has a very low temperature ^between 80° and 90° j. The disease begins a few days after birth, and the child nearly always dies within a few days more. The cheeks and tissues round the mouth are rendered so stiff that the child cannot suck, and the limbs are made quite rigid in the severest cases. No very definite changes have been found in the tissues on microscopical examination. General GLdema. — This has been mentioned as an intra-uterine disease, or perhaps it should rather be called symptom, for it may occur in connection with diseases of the kidneys, or with some interference with the venous return of blood. Diseases of the Navel Inflammation and Ulceration may occur in cases where there has not been sufficient care taken to protect the surface left after separation of the stump of the cord from septic infection. This disease used to be ver)' common in lying-in hospitals before the principles of antiseptics were understood and observed. It is hardly ever seen now, and never need be. Cleanliness and antiseptic measures are all that is required in the way of treatment. Formerly the complaint used to go on to sloughing, and when it was sufficiently severe for this the child invariably died. The disease sometimes affects the vessels mainly, and suppurative changes may spread inwards. In rare cases the na\el refuses to heal because there is a persisletice of the vitelline duct {MeckePs diverficiiluin), which then opens on the surface of the navel. A polypoid mass is sometimes found, and this, on section, is seen to have a central canal, lined with a mucous membrane similar to that of the small intestine.' T/ie nrachus has been found to remain f>atent at its umbilical end. Haemorrbagre from tbe navel sometimes occurs shortly after birth, and is then due to careless tying of the cord. It is easily arrested by putting on a fresh ligature. A more dangerous kind of bleeding may take place after the stump has separated. The commonest time for this bleeding to occur is about the ninth day. It is always an oozing from the surface. The child is as a rule a healthy one, though of three cases seen by the author, the child in one was born of a hitmophilic family, and had numerous bruises, some of large (i^ inch in radius) size scattered over the surface of its body ; and another was born ofa mother who had had thrombosis at previous labours, and in whose left radial %ein there was a phlebolith remaining, and who also had thrombosis of her external saphenous vein at the time she was under observation. The child had a 'show' from the vagina on the eighth day (see p. 239), and began to bleed from the navel on the ninth. The third was, as far as could be seen, bom of healthy parents, and had no other bad symptom. In all probability, the bleeding is due to some constitu- tional cause. Jaundice is often found in connection with the bleeding ; * See a case shown by Wheaton, Obst. Trans, vol. .\x.Kiv. p. 184. Ti'eatiiioit of Umbilical IlceinorrJiage 185 but jaundice is so common that its occurrence simultaneously with bleeding is very likely nothing but a coincidence. Septicccmia has been found in connection with the bleeding, and so has 'fatty degeneration of the new- born.' There is on!)- one kind of treatment that is of the least avail, and that should be employed at once, for children of this age cannot bear the loss of e\en very small quantities of blood without danger. The treatment is to under-run the navel with a hare-lip pin, or a long needle, and apply a figure- of-eight ligature over it, as described in Rupture of Cord (p. 518). If the navel is pinched up by the finger and thumb of the left hand while the child is inspiring, and the abdominal walls are relaxed, there is no danger of wound- ing intestine, which is thus kept out of the way. The ordinary methods recommended are pads, styptics, and filling the navel with plaster of Paris. f'g- 393- — Isolation of umbilical vessels by finger and ihumb Int. intestine. These are of no avail, and if the medical man cannot be at once obtained, the nurse must pinch the na\'el between her finger and thumb, and thus arrest the bleeding until he comes. Congrenital Umbilical Bernla. Ectopia Viscerum. — The abdominal contents are sometimes found to l^e e.vtruded in a sac of peritoneum and amnion. This requires surgical treatment, which is, however, rarely successful. Syphilis. — The signs of congenital syphilis are very often absent during the first two months or so of independent life, but some infants are born which show more or less unmistakable signs at the moment of birth. The child may survive its birth for a few hours only, and in this case it is usually a shrivelled-up, yellow little object, with a hoarse cry. The commonest sign is perhaps pemphigus, which shows itself first on the buttocks, or the child may be born witli pemphigus on its palms or soles (p. 269\ There 586 Pathology of the New-born Child may be interstitial hepatitis and jaundice. It is not uncommon to find in children which afterwards show distinct signs of syphilis, that there is some deficiency in the ossification of the bones of the cranial vault, and the bones are over a large area found to be replaced by membrane. One form of treatment at this age is by inunction of a minute quantity of blue ointment (half a grain to a grain night and morning). It is best smeared on under the flannel binder, and the place of its application under this can be frequently varied. Better, perhaps, is Baginsky's method of giving a sublimate bath, containing ten grains of perchloride of mercur}' (about 1-4000) in which the child is to remain for five minutes. Care is to be taken that none of the solution gets into its mouth. Or the mercury may be given internally in half-grain doses of hyd. c. cret. The child's strength must be well supported, and a few drops of cod- liver oil or some iodide of iron mav be given. APPENDIX A. THROMBUS VAGIN/E, H.EMATOMA OF VULVA This is an effusion of blood into the connective tissue beneath the mucous membrane of the vagina, usually affecting only the lower end ; or into one of the labia majora ; or in both situations. The term ' thrombus ' is, according to modern nomenclature, incorrect. Catisatw7i.—V\'h.sX is supposed by many to be a predisposing cause of this con- dition — namely, a varicose state of the veins of the labia majora and lower end of the vagina— is mentioned on page 283. It is found, however, that extravasation occurs in a large proportion of cases in the absence of varicosity. It is a rare accident — one of the rarest in midwifery practice. The actual cause, apart from injury (which may produce a hematoma during pregnancy), appears during labour in the increased tension brought about in the vessels of the part by the pressure of the descending head and the strain during bearing- down. When the Ijlood has been effused in the situations named, it may travel, according to the amount of tension in the effusion, to varying distances, and separates the planes of fascia as it advances. Its path is marked out by the anatomy of the fascia in its neighbourhood. If the blood is effused into the labia it may travel beneath the super- licial fascia up on to the abdominal wall. If it is effused above the level of the visceral layer of the pelvic fascia, it will travel along the planes of the tissue above this, not descending into the ischio-rectal fossa nor the labium. The commoner site is below the pelvic fascia. Here the swelling produced may be ijuite small and of no importance, or it may be very extensive and the woman may be in danger from loss of blood. An elastic, tense swelling, of a dark purple colour, is found on one side of the vulva. It may block the vaginal orifice. The tension of the mass may be enough to check the bleeding after a varying amount of blood has been effused ; or the blood may travel for an indefinite distance in the abdominal wall ; or the enclosing skin and tissues may give way, and the blood escape at the surface. The effusion gives rise to considerable pain of a tearing character, and the woman may be rendered faint if the loss of blood is sufficient, w hether there is an external opening or not. Later, in cases where external rupture has occurred, the wound may suppurate, and grave septic symptoms may arise. Treatment. — Where the effusion is small the child must ht rapidly extracted by ihe forceps, unless it is just on the point of being born. If the tumour formed is large enough to prevent the passage of the head an incision must be made, and the 588 Appendix contents evacuated ; and directly the labour is over the cavity must be filled with iodoform gauze or some other antiseptic material, every antiseptic care being jKactised, While the head and trunk of the child are passing over the bleeding point, their pressure will be en 545. 568, Appendix Eberth (and Breslau), 256 Eden, 11, 26*, 27*, 250*, 307*, 308*, 577 Engelmann (and Kundrat), 5* Fagge, Hilton, 266, 331 Farre, 36 Fehleisen, 543 Fehling, 299, and Appendix Fischel, 223 Franque, von, 527 Friedlander, 18, 43 Fuller, 71 Galaein, 66, 74, 369, 382, 483, 512 Garrigues, 404 Garrod, 57 Gassner, 217 Gautier, 565 Giles, 55, 217 Graefe, 283 Griffith, W. S. A., 325 Grun, 316 Guyon, 225* Hart, Berry, ii8 Hecker, 65, 156 H^He, 41 Helme, 41, 43, 214 Hennig, 317 Herman, 57, 145, 198, 334, 413. 41Q, 4,6, 465, 506, 5og Hicks B.raxton, 38, 289, 367, 369, 511, 544 Hildebrandt, 261 Hofmeier, 28S, 299, 455 Hoggan, 44 Horrocks, 361* Hunter, John, 42 Hunter, William, 6 Hypolitte, 57 Jaksch, von, 531 Jessop, 319 Jungbluth, 19 King, 334 Kitasato, 565 Kiwisch, 363 590 Index of Authors referred to in Text Klein, 543 Kulliker, 41 Kninig, 542 Kuchenmeistcr, 287 Kundrat (and Engelmann), s*'' Lamv, 564 Lemser. 124 Leopold, 262, 399, 542 Leopold (and Cr^d^ , Lockrt'ood, 539 Luwenhardt, 65 Lusk, 20S McCann, 281 McCann (and Turner), 222, 223 McClintock, 25S Maguire. 507 Martin (and Ruge), 237, 239 Mathiesen, 334 May (and Wigand), 370 Mayor, 62 Menge, 255 Mermann, 542 Mever, 545 Minot, :2*, 13*, 14* Money, Angel, 219 Montgomery, 54 Morisani, 402 Miinchmeyer, 486 Nagele, 135, 433: 445 Nettleship, 366 Neugebauer, 452 Neumann, 262 Noeggerath, 542 OsBORK, 392 Parrot, 266 Perls (and Weissgerber), 506 Pestalozza, 121 Phillips, C. N., 543 Phillips, John, 337, 513 Pinard (and Varnier), 145'', 210, 259* Playfair, i8i Polk, 48 Popow, 4 Porak, 206 I'robyn-Williams (and Cutler), 220*^ 503 Rai.fe, 507 Ranvier (and Cornil), 266 Rasch, 290 Robinson, 506 Rokitansky, 57 Rotch, 2i8 Roux, 565 Ruge (and ^L'^rtin' Runeberg, 505 SaNOEK, 399, 542 Savage, 556, 557 Schatz, 199, 294 Schauta, 299, 330 Schimmelbusch, 352 Schmidt, 194, 238 Schultze, 121 SemmeKveis, 181, 182 Sigault, 402 Simpson, 372 Sinclair, 261 Slavjansky, 261 Smell:e, 372 Smith, Tyler, 34, 117 Spencer. Herbert, 108, 346 Spiegelberg, 76, 128, 145, 204, 214, 222, 280, 415, 491 Stadtfeldt, 65 Sutton, Bland, 267, 317, 318, 322 Sutugin, 66 Tait, E. S., 222 Tanner, 36 Targett, 452 Tarnier, 279 Tarnier (and Chantreuil), 57 Teufel, 257 Trautmann, 394 Turner (and McCann , 222, 223 Vaillard, 565 Varnier (and Pinard), 145*, 210, 259' Vernois (and Pjecquerel) 575 Vinay, 300 Virchow, 237, 261 Voit, 510 Wai.cher, Appendix Watson, Sir Thomas, 301 Weber, 301 Webster, Clarence, 7, yj*, 48, 208, 209, 210* 3'4 Weissgerber (and Perls), 506 Weit, 65 Werth, 3^3 Wheaton, ;8i, 5S4 Wigand (and May), 370 WiUiams, Sir John, 43, 215, 217, 509 Winckel, 57, 210, 222, 223 Wintrich, 287 Wolff, 32 Wright (and Ashby), 238", 243, 5S1 INDEX Abdomex, fetal-, enlargement of, 465 pain in, during labour, loo pregnancy, 2S7 pendulous, 271, 427 in pregnancy, appearance of, 60 auscultation of, 61 enlargement of, 60 examination of, 60 pain in, 2S7 palpation of, 60 pigmentation of, 57 position of uterus in, 39 shape in transverse lies, skin of, 51 striae of, 51, 69 in puerperal state, S22 section of, see Caesarian Section, Ectopic Gestation section of, for rupture of uterus, 399 Abdominal bandage in anteversion, 271 after delivery', 229 cavity, escape of foetus into, 320 examination, 150 foitation, see Ectopic Gestation tumours, diagnosis of, from preg- nancy, 69, 70 muscles, action of, in labour, 100, 126 palpation in pregnancy, 60 palpation in labour, 141, 142, 143, 150, 157, 160, 161, 169, 173, 174, 175 pregnancy, see Ectopic Gestation pressure, use of, in breech cases, 200 section, see Ca;sarean Section, Ec- topic Gestation, and Rupture of Uterus tumours, see also Fibroid, Ovarian Cyst tumours, diagnosis from pregnancy, 69, 70 walls after labour, 215 during (.rdgnancy, 50 increase of fat in, during preg- nancy, 51 stria; of, 51, 69 Abnormal uterine action, see Inertia, Tetanus, &c., and Uterus Abnormalities of uterus in pregnancy, 75 Abortion, 303 in albuminuria, 507 anaemia, 2S3 arrest of threatened, 310 artificial induction of, 440 in albuminuria, 50S in cancer of cervix, 290 Abortion, artificial induction of, in chorea, 282 in contracted pelvis, . 439 in eclampsia, 512 in icterus, 286 methods of, 362, 365 in pernicious ans- mia, 283 in placental praevia, .346 in retroversion of gravid uterus, 277 bleeding in, 305 causes of, 304 decomposition of remains of ovum after, 308 . definition of, 303 diagnosis of, 309 ergot in, 310 exploration of uterus after, 312 ' habitual,' 304 haemorrhage in, 305 after, 307 incomplete, 307 indications of, 307 results of, 308, 309 inevitable, 306 management of incomplete, 312 of inevitable, 310 of threatened, 310 missed, 250, 251 ovum in, 304 pain in, 306 placenta, expulsion of, in, 305 premon tory symptoms of, 306 recurrent, causes of, 304 remnants left in uterus after, 307 retention of membrane>', 307 placenta, 307 septica;mia after, 30S, 313 sequela; of, 309 subinvolution after, 309 symptoms of, 306 tents in, 310 tetan s after, 309 threatened, 306 uterus after, 305 vaginal plug in, 311 chorionic villi in diagnosis of, 309 Abscess of breast, 571 mammary, 571 in mastitis, 571 in puerperal fever, parametric, 533 in phlegmasia dolens, 554 pelvic, 533, 535, 537 sub-mammary, 573 592 Index Acardiac foetus, 74 Accessory placenta, 23 Accidental complications of pregnancy, 287, 296 haemorrhage, 336 diagnosis of, 338 Acetone in urine, 222 Acid carbolic, 184, 227 compatibles with, 183 Acini of breast, 53, 217 Acormi, 74 Acute yellow atrophy in pregnancy, 284, 286 Adaptation of foetus to uterus, 34 fcetal head to birth-canal, 95 Adhesion of foetus to amnion, 259, s6o placenta, 260 of membranes, causing delay in first stage, 188 of placenta, 261, 479 Adult circulation, establishment of, 235 ^quabiliter justo-minor pelvis, 425 Aeration of foetal blood, 22 After-birth (see Placenta and Membranes) period of (see Third Stage &c.) After-coming head, application of forceps to, 202 in contracted pelvis, 413 danger in, 178 deliverj' of, mechanism, 172 extraction of, 201 perforation of, 387 After-pains, 217 prevention of, 231 treatment of, 231 Agalactia, 575 Age, fcetal, how estimated, 65, 66 influence of, on labour, 127 child's head, 440 Ague in pregnancy, 301 Air, entrance of, into uterus, causes, 502 veins, causes, 555 Air-embolism, 555 Air-vesicles, rupture of, during labour, 502 Albumin in colostrum, 218 liquor amnii, 19, 20 milk, 218 urine, 57, 504 Albuminuria, abortion due to, 507 death of foetus from, 507 diagnosis of, 508 during pregnancy, 57, 504 in eclampsia, 507, 508 in hydramnios, 506 in new-born child,_237_ induction of abortion in, 508 prognosis of, 508 symptoms of, 507 treatment of, 508 in puerperal insanity, 507, 556 Alcohol in insanity, 561 puerperal fever, 531 Alimentarj- system in pregnancy, 57 Allantois, formation of, 9 Amenorrhoea of pregnancy, 58 ... pregnancy commencmg during, 59 Ammonia, carbonate of, in treatment of pul- monary' embolism, 552 Amnii, liquor, see Liquor Amnii Amnio chorionic fluid, 29 causing two bags of mem- branes, 114 Amnion, 8, 19 adhesions of, to foetus, 259, 260 affections of, 257 development of, 8 dropsy of, 257 fluid of, 19 formation of, 8 pathologj' of, 257 .\mnion prolapse of, 114 relations of, to placenta, 16 sac of, 18 separation from chorion, 114, 125 at term, 19 .\mnions, two, in multiple pregnanc>% 73 Amnionic bands causing amputation of limbs, 260 Amnionic cavity, dropsy of, 257 Amnionic fluid (and see Liquor Amnii), 19 absorption of, after foetal death, 270 anomalies of, 257, 259 characters of, 19 composition of, 19 deficiency of, 259 discolouration of, 29, 257 excess of, 257 source of, 19 uses of, 20 variations of, 29 Amount of )ilood lost at labour, 127 Ampullar^- layer of decidua, 7, 16, 247 Amputation of fcetal limbs by amnionic bands, 259. 267 ■ ■ i. Amputation, spontaneous intra-uterine, 267 Ansmia acute, see Placenta Previa, Post-partum Hsemorrhage Ana;mia as contra-indication to lactation, 232 during pregnancy, .s6, 282 of mother, causing abortion, 283 necessitating abortion, 283 pernicious, 282 transfusion in, 340, 360 treatment of, after placenta previa, 350 Anaesthesia, 205 during labour, 192, 205 in first stage, 206 in second stage, 192, 206 in third stage, 206 in eclampsia, 512 effect on pains, 192 child, 206 in operations, 206 Anal fascia, 89 Anasarca, see CEdema and Dropsy , , „ , . , Anatomy, see under several headings of Pelvis, ' Uterus," ' Labour," &c. Anencephalus, 263 . Animation, suspended, of fcetu4, see btiH-birth Annular laceration of the portio vaginalis, 494 Anomalies of cord, 27, 262 expulsive force, 410 membranes, 246, 252, 257 ovum, obstructing labour, 461 pains, 411 pelvis, 415 uterus, 293 Anorexia in pregnancy, 55 Anteflexion of gravid uterus, 271 normal, 39 in puerperal state, 208 -•^nte-partum ha;morrhage, see Hemorrhage Anterior fontanelle, 92 lip of cervix during labour, 115, 190 parietal obliquity, see Nagele Obliquity Ante-version in pregnancy, 39, 271 Antipyrin in after-pains. 231 .Antiseptic douching after labour, cases where necessarj-, 226 Antiseptics, 18 1 drugs, 183 incompatible, 183 in labour, 181, 197 in puerperium, 226 .\nus, condition during labour, 118 imperforate, 583 Index 59: Anus, laceration of sphincter of, 498 traction on after-coming head through, ioi Aorta, compression of, for post-partum heemor- rhage, 485 Aorta, pulsation of, in abdominal examination, 63 Aortic disease in labour, 503 Apex of heart, change of position in puerperium, 218 Aphthous stomatitis, 5S3 Apnffia, in new-born child, 519 Apoplexy, diagnosis from eclampsia, 511 during pregnancy, 507 of decidua, 248 of ovum, 248 in ectopic gestation, 322 Appetite during pregnancy, 55 Arantius, ductus venosus of, 235 Arch, pubic, see Anatomy of Pelvis, p. Si relation of ioetal head to, in labour, 13S. 191 Area of safe attachment of placenta, 342 Areola, changes in, during pregnane)', 53 sebaceous follicles of, 53 secondary, 54 Arm, dorsal displacement of, 475 presentation of, 472 prolapse of, 472 with head, 475 in transverse presentations, 472 Arms in normal labour, breech, 172 vertex, 139 liberation of, 200 Arterial pressure during puerperium, 220 Arteries of cord, 21 ' curling,' 14 errant, 24 placental, thickening of walls of, 26 thrombosis of, 26 pulmonary, embolism of, 551 in foital circulation, 235 thrombosis of, 550 umbilical, 21 uterine, after delivery, 214 in pregnancy, 42 of villi, 14 endarteritis of 26 thrombosis of, 26 Articulations, ilio-sacral, 86 in pregnancy, 49 rupture of, 501 pelvic, 86 after labour, 215 changes in during preg- nancy, 48 injury to, in labour, 501 laxity of, in pregnancy, 48 in puerperium, 56S rupture of, 501 sacro-coccygeal, 86 pubic, 86 in pregnancy, 48 puerperium, 56S Artificial aljortion, 440 feeding of infants, 2^2 human milk, 242 premature labour, 440 respiration, 520 rupture of membranes, 189 Ascites in diagnosis of pregnancy, 59, 60 fcetal, 265 obstructing labour, 465 Asepsis in midwifery, 18 r, 226 Asphyxia in air-embolism, 555 embolism of pulmonary artery, 551 thrombosis of pulmonary artery, 550 fcetal, in breech presentations, 178, 5 '9 Asphyxia, f(£tal, in delayed delivery, 430 pelvic contraction, 430 coiling, twisting of cord, 262 neonatorum, causes, 5 '9 diagnosis, 519 livida, 519, 520 pallida, 519, 523 Schultze on, 521 symptoms, 519 treatment, 520 varieties, 519 Aspiration of blood by foetus, 193 Asses' milk, 242 Asj-mmetry of head after labour, 144, 149 pelvis, see Pelvis Asynclitism, 135, 433 Atelectasis pulmonum, 523 Atmosphere as cause of illness in puerperium, 526 Atony of placental site, 4S7 uterus, 411 Atresia of cervix, 455 vagina, 458 Atrophy, acute, of liver in pregnancy, 284, 286 Attitude, foetal, 32, i63 abnormal, 168, 474 causation of special, in extension, 154, 165, 169 effect of, on labour, 474 maternal, ni pregnancy, 60 in rectification of malposition of fffitus, 197, 199 in rectification of uterus, 441 Walcher's, see Appendix of woman for labour (Eng- lish), i86 Auscultation of abdomen, 61 of air in heart, 555 in breech presentations, 169 in diagnosis of fcetal positions, 151, 152 of life or death of foetus, 62, 270 of pregnancy, 61 -sounds heard over abdomen in, 61, 62, 63 Auto-transfusion, 485 Auxiliary muscles of labour, 100 forces in labour, clescription of, too inefficiency of, 414 Average amount of blood lost at labour, 127 duration of labour, 127, 1S6 Axillary lumps, 58 Axis of foetus, 79, 90 of parturient canal, So of pelvis. So - pressure on foetus, 103 causing flexion, 133 - traction, 374 forceps, 374 of traction with forceps, 374, 3S1 of uterus, 150 obliquity of, 41, 154, 197, 199 Bacilli, see Micro-organisms Back, relations of fcetal to maternal parts, see Special Mechanisms Bag, dilating, of Barnes, 349, 358 of Chanipetier de Ribes, 359 of membranes, see Membranes, 104 Ballottement of fcetal head, 61 of foetus, 64 Bandage, abdominal, after delivery, 229 Q Q 594 Index llaiidage, aljclominal, in anteversion of uterus, 273 during labour, 339, 473 pelvic, 50 r, 568 P.andl, ring of, 98, 118, 410 Dands, amniotic, 239 Karnes' bag>i, 349, 358 Bath for new-born child, 240 Battledore placenta, 27 Baudelocque, diameter of, 417 Bedroom of lying-in woman, 180 Belladonna in arrest of lactation, 233 phlegmasia dolens, 554 Bilobed uterus, 293 effect on presentation, 293 Bimanual compression of uterus in post-partum haemorrhage, 4B4 Bimanual examination of uterus in pregnancy, .63 Bimanual version, 367 Binder, abdominal, see also Bandage, 229 application of, 229 Biparietal obliquity, 135, 433 Bipolar version, 367 in placenta prsevia, 349 shoulder presentations, 473 Bladder after labour, 212, 230 anatomy during labour, 115, 118 aspiration of, in retroversion of gravid uterus, 276 calculus in, 460 care of, in labour and child-bed, 189, 230 condition of, during first stage, 115 second stage, 118 pregnancy, 49 distended, causing inertia, 411 in retroversion of gravid uterus, 275 fcetal, fulness of, at birth, 19 inflammation of, after delivery, 566 with retroversion of gravid uterus, 275 injury to, with pelvic contraction, 429 irrigation of, in cystitis, 567 obstructing labour, 411 puncture of, 276 relations of, during pregnancy, 49 sloughing of, in retroversion of preg- nant uterus, 275 stone in, 460 - symptoms, with incarcerated uterus, 274 Blastodermic membrane, 7 Bleeding (venesection) for eclampsia, 513. Also see Haemorrhage Blindness in lactation, 566 in pregnancy, 507 Blood, amount lost during labour, 127 aspiration of, by fcetus, 193 changes in, during pregnancy, 56 in puerperium, 220 diseases of, in pregnancy, 282 causing abor- tion, 2B3 effusions of in fcetus during delivery, 108, 5S0 transfusion of, 360 Blood-mole, 248 Blood-pressure in puerperium, 220 Blood-vessels, entrance of air into, 555 of placenta, see Placenta uterine, changes in, in pregnancy, Blue ' asphyxia, 519 Blunt hook in impacted breech presentation, 474 version, 369 Body of uterus, isthmus of, 42 lower segment of. 42, 98 upper segment of, 98 Body-weight of child, affected by ligature of cord, 193, 238 daily increase in, 238 loss of, after birth, 238 effect on developing pelvis, 421, 422, .■♦23.. Bones, cranial, overlapping of, in labour, 92 excessive, in de- formed pelves, ■ • '♦^i fcetal, changes in, in intra-uterine rickets, 266 in sporadic cretinism, 266 in syphilis, 265 fractures of, intra-uterine, 267 histology in cretinism, 266 in rickets, 266 parietal, fracture of, 431 pelvic, softening of, in osteomalacia, 449 Bottle for infant feeding, 244 cleansing of, 244 frequency of adminis- tration, 244 Bougie in induction of labour, 364 Bowels, action of, post partum, 222, 230 Brain, foetal, destruction of, after perforation, 388 haemorrhages into, 5S0 Braun's colpeurynter, 363 Braxton Hicks's cephalotribe, 388 method of version, 367 in placenta pra;via, 349 Breast-pump, 570, 571, 573 Breasts, abscess of, 571, 572 acini of, in pregnancy, 53 areola of, in pregnancy, 53 in puerperal state, 217, 231 secondary, 53 bandage of, 233 care of, in puerperal state, 232 changes in, in pregnancy, 52 puerperal state, 217 colostrum in, after labour, 217 during pregnancy, 53 diseases of, 569 abscess, 571, 572 causes of, 572 galactocele, 574 galactorrhcea, 574 inflammation of, 571 mastitis, 571 varieties of, 572 nipples, fissured, 570 retracted, 569 sore, treatment, 571 eczema of, 574, 575 engorgement of, 233, 572 erj'Sipelas of, 574 in new-born child, 239 symptoms of pregnancy in, 53 tension in, causing rise of temperature in puerperium, 220 I'reech, impaction of, 474 presentation, abdominal examination in, 169, 173, 174, 175 au'^cultation in, 169 birth of head in, 172 cause i of, 168 caput succedaneum in, 176 dangers to child, 178 diagnosis, see Abdominal and Vaginal Examination Index 595 Breech presjiitation, external rotation in, 172 extraction of head in, 201 frequency of, 168 heart-sounds in, 169 impacted, 474 incomplete, i5S lateral flexion of trunk in labour with, 171 management of, 199 mechanism of labour in, 171, 174 modes of, 168 moulding of head in, 176 positions of, 169 prognosis in, 178 rotation of fcetus in, see mechanism of labour in sacro-posterior cases, 174, ^75 ... vagmal exammation in, 170,. 173, 174, 175 varieties of, 16S Bregma, 92 Bright's disease. ?ee Albumintn-ia Brim of pelvis, Si diameters of, 83 forceps at, 374 Tarnier's a*^, 375 Broad ligaments, change in pregnancy, 47 puerperium, 213 in labour, 100 Bromides in eclampsia, 513 Bronchitis in pregnancy, 298 Brow presentation, caput succedaneum in, 167 causes of, 165 management of, 199 mechanism of labour in, 166 moulding in, 167 prognosis of, 17S rarity of, 165 treatment of, 199 vaginal examination in, 166 Bruit, cardiac, in puerperium, 219 ' placental,' 62 umbilical, 63 uterine, 61 Brunettes, pigmentation of areola in, 53, 54 Budin's intra-uterine tube, 227 Bulging of anterior wall of lower uterine seg- ment, 454 Bulging of posterior wall of uterus, 455 Butter in milk, 218 C.iiSAR[AN section, 394 abdominal incision in, 396, 397 after death, 395 after-treatment of, 399 assistants' duty in, 398 checking hjemorrhage in, 397 cleansing peritoneum afier, 398 _ extraction of fcetus in, 397 for atresia of vagina, 458 for cancer of cervix, 457 for pelvic contraction, 441 for vaginal stenosis, 458 incision into uterus in, 397 indications for, 395 instruments for, 395 modification of, Porro's, 401 Ca;sarian section, modification ot, Porro's, advan- tages of, 401 Ca;sarian section, modification of, Porro's, instru- ments required, 401 Caisarian section, modification of, Porro's, modes of operating, 401 , 402 Cassarian section, object of, 401 preparations for, 396 removal of placenta in, 398 scope of operation, 395 sterilisation during, 398 sutures in, 398 time of operating, 396 uterine rupture after, 489 Calcareous degeneration of decidua, 27 sac in ectopic gesta- tion, 320 Calculation of age of foetus, 66 date of pregnancy, 65 time of delivery, 65 Calculus, vesical, in labour, 460 Callipers, 416 ' Canalised fibrin,' 18 Cancer o* cervix in labour, 457 in pregnancy, 290 as a cause of haemorrhage during _ pregnancy, 335 of uterus in pregnancy, 290 of vagina in pregnancy, 291 Canula for saline infusion, 360 Caput succedaneum, 119 after delivery, 239 in breech presentations, 176 in brow presentations, 167 in contracted pelvis, 430 at different stages of la- bour, 106, 119 in face presentations, 163, 165 mode of production, loS in vertex presentations, 119 Carbolic acid, compatibles with, 183 use of, in midwifery, 184, 227 Cardiac disease in labour, 503 pregnancy, 296 sounds, fcetal, 62 in lying-in period, 219 Carneous mole, 248 Cartilage in rickets, 266 Carunculae myrtiformes, 68 Casein in milk, 242 Caseinogen, 242 Catheter, cystitis caused bj', 189, 230 in labour in first stage of, 1S9 second stage of, 118 method of passing, 189 post-partum, use of, 230 precautions before passing, 1S9 in reposition of uterus, 276 Caul, 115 Cavity of pelvis, 82, 84 Cellulitis, see Parametritis Central placenta prasvia, 341, 347 rupture of perinaium, 496 Centre of gravity of foetus, causing certain lies, 34 Cephalhaematoma, 581 Cephalic lie, 129 causes of, 34 frequency of, 34 version, 366, 473 Cephalotribe, 38S advantages of, 389 contrasted with craniotomy forceps, 391. . description of, 388 mode of use, 389 Cervical hook, 391 myoma, 457 Cervix after delivery, 209, 211 anterior lip, management of, igo cedema of, 115, 190 apparent shortening of, 45 artificial dilatation of, 356, 456 QQ2 596 Index Cervix, atresia of, 455 _ blue discolouration of, 46 cancer of, in labour, 457 pregnancy, 290 catarrh of, in pregnancy, 288 changes in, in pregnancy, 44 cicatrices of, 456 difference in shape of, according to parity, 46, 68 dilation of, 104 dilatation of, 356 by dilating bags, 35b by Hegar's dilators, 356 in rigidity, 456 by tents, 356 in uncontrollable vomiting, 286 displacement of, 454, 455 ectropion of, 68 erosion of, in pregnancy, 335 aversion of lips of, after labour, 68, 21 t glands, Nabothian, of, 46 hajmorrhage from lacerated, 494 hyperemia of, after labour, 212 incision of, in cancer, 457 . . in cicatricial conditions, 450 involution of, 214 laceration of, 68, 494 left side, why commoner on, 68 treatment of, 494 in lying-in state, 209, 211, 214 malformation of, 456 Nabothian glands of, 46 new growths of, 456 nipping of, 428 obliteration of, in labour, iii, 112 oedema of anterior lip, ii5i ^9° in pelvic contraction, 428, 429 in placenta praevia, dilatation of, 347! 34°. 349 _; rigidity of, 345 plugging of, in abortion, 311 in placenta previa, 347 post-partum condition of, 211 in pregnancy, 44 rigidity of, 456 secretion of, in labour, no shortening of, apparent, 45 real, no softening of, in pregnancy, 46 spasm of, 188 stenosis of, 456 supra-vaginal elongation of, 456 violet discolouration of, 46 Chamberlen, forceps of, 371 Champetier de Ribes' bag, 359 in placenta praevia, 348 Change of circulation in foetus, 235 Chest in pregnancy, 57 Child, asphyxia of, 519. See also Fojtus and New-born Child breasts of new-born, 239 care of new-born, 240 effects of contracted pelvis on, 430 first inspiration of, 237 icterus of new-born, 238, 581 after late ligature of cord, 194, 582 injuries to, in breech presentation, 178 management at birth, 194 physiology of, 235 pulse of, 237 size of, excessive, 32_ temperature of. at birth, 237 urine of. 237 Child-bed, see Puerperium Chloral in eclampsia, 513 Chloroform, deaths from, 205 during labour, 205 during operations, 206 in eclampsia, 512 effect on fcctus, 194, 206 effect on pains, 206 excreted in urine of new-born child, 206 mode of administration, 205 in precipitate labour, 407 in rigidity of cervix, 206 Chlorosis in pregnancy, 282 Choice of leg in ver.sion, 369 Cholera in pregnancy, 302 Cholesterin in lochia, 217 Chorea in pregnancy, 280 causes of, 281 course of, 281 frequency of, 280 hyperpyrexia in, 281 mania in, 281 symptoms of, 281 treatment of, 282 during puerperium, 282 treatment of, 282 Chorion, degeneration of, hydatidiform, 252 myxomatous, 252 development of, 5, 8 in moles, carneous, 248, 250 vesicular, 252 in multiple pregnancy. 73 myxoma of, diffuse, 256 pathology of, 252 retention of, 114, 125 rupture of, without amnion, 114 separation from amnion, 114, 125 villi of, 5 in carneous mole, 248, 250 Cicatrices of genital canal, 455, 458, 459 rupture of uterus through, 489 Circular rupture of portio vaginalis, 494 Circulation, changes in. at birth, 235 disorders of, during pregnancy, 56, 282 effect of pregnancy on, 56 in foetus, 235 in new-born child, 235 in placenta. 12, 15 Circumference of fetal head, 95 Cleanliness, aseptic, 226 Clitoris, lacerations of, in labour, 501 Clothing of new-born child, 240 " during pregnancy. 76 Clots in abortion, examination of, 309 Coccygeus muscle, 87 Coccyx, 87 Coelom, 8 Coiling of cord round foetus, 192, 478 Coitus, date of, in date of pregnancy, 05 i/bi during p'-egnancy, 77 effect of, on hymen, 67 Colic, uterine, 109 Collapse afier pl.acenta prrevia, 350 due to accidental haemorrhage, 337 in inversion of uterus, 487 due to rupture of uterus, 491 Colles' law, 302 Colostrum corpu'^cles, 53 . . . stage, breast-acini in, 53 Coma in eclampsia, 510 Combined version. 367 Commencement of labour, diagnosis o', no Compound presentations, 476 Compression of a-rta for post-partum haemor- rhage, 485 Compression of uterus for post-partum hjemor- rhage, 484 Index 597 Concealed accidental ha;niorrhage, 337 Conception, false, see Mole time of, 65 Condensed milk in infant feeding, 244 Confinement, see Labour Conformation of woman in pe'.vic contraction, 415 * Congenital dislocation of hips,' pelvis of, 425 Conjugate diameter of pelvis : anatomical, 83 conjugata vera, 83 diagonal, 417, 418 external, 417 in flat pelvis, 425 in generally con- tracted pelvis 426 in generally con tracted flat pel vis, 426 measurement of, 419 measurement of, through abdo minal wall, 420 measurement of, direct, 419 measurement of, Johnson's me- thod, 419 obstetrical, 83 Constipation in pregnancy, 57 puerperium, 222 causing rise of tem- perature, 220, 569 retroversion of gravid uterus, 275 Contraction of abdominal muscles in labour, 126 hour-glass, 479 pelvic, 415 abortion in, 440 after-coming head in, 443 anteflexion and anteversion of uterus with, 271 appearance of patient sug- gesting, 415 bag of membranes in, 428 Caesarian section in, 441, 442 causing breech presentations, 169 causing face presentations, cephalotripsy in, 442 cervix in, 429 course of labour with, 428 craniotomy in, 440, 442 dangers arising from, 427 diagnosis of, during labour, 437 displacement of uterus in, 427 effect on cervix, 429 child, 430 labour, 428 pregnancy, 427 puerperium, 432 uterus in labour, see Prolonged Labour vagina, 429 face presentations with, 155 face presentations, manage- ment of, with, 199 figure-of-eight, 427 fistula; caused by, 432 forceps in, 442 frequency of, 415 Contraction, pelvic, induction in, 439 injury to skull during labour with, 431 labour in, 428 management of,in, 441 mechanism of labour in, 432 (and see under each variety of deformity) oblique, 443 pains in, 428 pendulous belly with, 271, 427 perforation in, 440, 442 post-partum haemorrhage with, 431 presentation in, 427 pressure-marks on skull after labour with, 431 rare forms of, 443 relative, 415 reniform pelvis, 426 rupture of uterus in, 489 symphysiotomy in, 443 transverse, 447 treatment of common forms of, 438 varieties of, 424 version in, 442 Contractions, uterine, abnormal, 411 characters of, 96 with contracted pelvis, 428 definition of, 97 duration of, 9& during labour, 96 action on uterus and contents, 102 in first stage, iii during pregnancy, 38 uses of, 38 Contractions, uterine, effect on circulation in foetus, io5 Contractions, uterine, effect on circulation in placenta, 106 Contractions, uterine, effect on circulation in uterus, 96, io5 Contractions, uterine, effect on eclamptic fits, fcetal pulse, io5 maternal pulse, 106 nervous system of mother, 107 respiration, 107 shape of abdo- men, in shape of fcetus, 103 shape of uterus, III skin, 107 uterine bruit, 106 intermission o'i, 96 irregular during labour, 414 irregular during preg- nancy, 70 pain of, 97 causes, 97 post-partum, 208. Also see After-pains rhythm of, 96 Contractions, vaginal, 100 Convulsions, eclamptic, 510 puerperal, 510 Cord, umbilical, anomalies of, 27, 262 arteries of, 21 atheroma of, 262 development of, 22 598 Index Cord, umbilical, arteries of, dilatations in, 22 walls of, 22 capillaries, ring of, at base of, 239 care of, after exit of head, 192 care of, in infant, 240 circulation in, 21 coiling of, round foetus, 192, 478 cysts of, 28 development of, 21 diagnosis of prolapse of, 514 division of, before deliver>', 478 early and late ligature of, 193, 238 falling off of stump of, 239 formation of, 21 haemorrhage from, 584 in breech presentation, 200 insertion of, central, 27 lateral, 27 marginal, 27 velamentous, 27 intestine in base of, 22, 30 knots of, 28, 262 laceration of, 517 late ligature of, 193, 194 gain in weight after, 194 jaundice after, 194, 582 length of, 21 ligation of, 193, 194 best time for, 193 loop of, round neck, 192 management of, in breech pre- sentations, 200 marginal insertion of, 27 modes of insertion, 27 nodosities of, 28, 262 over-torsion of, 262 pathology of, 262 presentation of, 514 in face presenta- tions, igg pressure on, 178, 200 prolapse of, 514 in face presentations, . ^99 , . . m podalic lies, 179 version for, 516 pulsation in, cessation of, 193 reposition of, 516 round neck, 119, 192 rupture of, 478, 517 in precipitate labour, 478, 517 treatment of, 518 sepal ation of stump of, 239 sheath of, 21 short, 478 treatment of, 478 structure of, 21 torsion of, 21, 30 excessive, 262 traction on, in labour, causing inversion, 487 tying the, 193, 194 vein of, 21 velamentous insertion of, 27 vessels of, 21 diseases of, 262 Cordate uterus, 203 Coronal suture, 92 Coronary vein of placenta, 17 Corpus liiteum, 2 of pregnancy, of menstruation, 4 constancy of occurrence. 4 Corrosive sublimate, compatibles with, 183 use of, in midwifery, 184 Cotyledons of placenta, 13 Cow's milk, composition of, 242 preparation of, 242 Cracked nipples, see Nipples Cranial bones, injuries to, during labour, 430 relative displacement of, during labour, 92 Cranioclasm, 390 Cranioclast, 390 Craniotomy, see also Perforation, 386 with after-coming head, 392 in cancer of cervix, 457 conditions requiring, 387 extraction of child after, 388, 391 in face presentations, 199 in flat pelvis, 442 -forceps, see Craniotomy Forceps mode of operation, 3S7 mortality after, 592 prelitninarj- version in, 392 in rupture of uterus, 492 in sma'l round pelvis, 442 version after, 391 Craniotomy forceps, 389 contrasted with cephaiotribe, 391 mode of use as cranioclast, 390 as tractor, 389 patterns of, 390 Cranium, alterations in shape due to labour, 92 fontanelles of, 92 fracture of, 43c injury' to, during labour, 430 ossification of, advanced, 440 shape of, in breech presentations, 176 bow presentations, 167 face presentations, 162 Cream in infant feeding, 243 Cr6d6's method of expressing placenta, 195 treating eyes, 240 Crests, iliac, distance apart, 416 Cretinism, sporadic, 266 Crotchet, use of, after perforation, 391 Croton oil in eclampsia, 513 ' Crowning,' period of, 119 Cry, foetal, in utero, 502 Curette in puerperal fevers, 531 Curvature, spinal, causing pelvic deformity, 443 Curves of forceps, 372 Cutaneous diseases in syphilis of fojtus, 585 disorders during pregnancy, 56, 282 Cyst, mammary, 574 ovarian, in labour, 460 in pregnancy, 292 treatment of duringpregnancy, 291 during labour, 461 placental, 27 Cystic mole, 252 tumours, diagnosis of, from pregnancy, 292 Cystitis after delivery, 566 due to incarceration of gravid uterus, 275 Cystocele causing dystocia, 457 diagnosis of, 457 Dangerous zone, 342 Date of delivery, calculation, 65 by size of ftetus, 66 uterus, 66 Death, apparent, of new-born child. 519 of fretus, intra-uterine, 269 causes of, 269 diagnosis of, 71, 270 Index 599 Death of f(i.-tus, intra-utorinc, eflc-ct on attitude, effect on liquor amnii, 270 effect on mammary glands, 270 effect on presenta- tion, 155, 467 effect on uncon- trollable vomit- ing, 285 results of, 270 signs of, 270 of mother during child-birth, 502 puerperium, 502 sudden, 502 delivery of child in, 398, 503 of one of twins, 74 Decapitation, 393 delivery after, 393 instruments for, 393 with locked twins, 393 mode of, 393 in transverse lies, 393, 473 Decidua, affections of, 246 ampullary layer of, 7, i5, 247 apoplexy of, 248 calcification of, 27 cells of, 6 development of, 4, 5 imperfect, 252 discharge of, in ectopic pregnancy, 324, .325 diseases of, 246 causing adhesions of pla- centa, 479 in ectopic pregnancy, 323 encksure of ovum by, 5 endometritis of, 246, 247 fluid between reflexa and vera causing second bag of waters, 114 glands of, 6 hsemorrhage into, 248 causation of, 248 inflammation of, 246 in multiple pregnancy, 73 pathology of, 246 reflexa, 6 atrophy of, 7 serotina, 6 vera, 6 Decidual cast, 324 process, 13 ' Deciduoma malignum,' 577 Decomposition of foetus, 270 Deformities, see Fretiis and Pelvis Degeneration of chorion, hydatidiform, 252 of fcetus, calcareous, 320 of uterine tissue, causing rupture, 489 Delayed delivery, see Delivery Delivery of arms in cephalic lie, 139 collapse during, 502 in contracted pelvis, 422 corpore conduplicato, 471 date of, calculation of, 65 by size of foetus, 66 by size of uterus, 66 diagnosis of recent, 223 first stage, see Labour of hips in cephalic lie, 139 obstructed, see Obstructed Labour placental stage, see Labour post-mortem signs of, 224 Delivery, precipitate, see Precipitate Labour premature, 303 induction of, 362 protracted, 407 and septicaemia, 408 recent, signs of, 223 retraction of uterus after, 20S of shoulders in head presentations, 139 signs of recent, 223 by spontaneous evolution, 470 version, 469 in transverse lies, 468, 469, 470, 471 Dementia, 560 Depressed nipples, 569 Dermoids, suppuration of, 461 Desquamation in new-born child, 238 Detachment of placenta, 121 Detrusion of placenta, 121 Development of membranes, 7 ovum, 7 pelvis, 421 body-weight in, 421, 422, 423 sacrum, 421 Dextro-rotation of uterus, 41 Diabetes with hydramnios, 257 in pregnancy, 298 during puerperium, 298 Diabetes insipidus, 299 Diagnosis of commencement of labour, 11 of contracted pelvis, 415 of death of fcetus, 71, 270 of delivery, 223 of time of, 65 between first and subsequent preg- nancies, 67 of lies and positions, 149 between tonic contraction and inertia 411, 412 differential, of pregnancy, 69 of parity, 67 of period of pregnancy, 65 of pregnancy, 58 differential, 69 of puerperal s'ate, 223 of sex before birth, 62 Diagonal conjugate, 417, 418 method of measurement, 41S Diameter of Baudelocque, 85, 417 of foetal head, 93 of pelvis, contracted, 415. See the \'arious forms normal, 83 Diaphoretics in albuminuria, 508 in eclampsia, 512 Diaphragm, action of, during labour, 100 effect of uterus on, during pregnancy, 57. Diarrhoea in septicasmia, 530 Diastema rectorum, 216 with pendulous belly, 271 Diet during puerperium, 230 of new-born child, 240 Difficult labour, see Pathology of Labour Digestion, disorders of, in pregnancy, 57, 284 286. 298 in new-born child, 237 Dilatation of cervix, 356 artificial, 356 in accidental has- morrhage, 339 for carneous mole, 252 to induce labour, . 356, 365 in placenta praevia, 34S 6oo Index Dilatation of cervix, artificial, in nncontrollable vomiting, 286 of pelvis in osteomalacia, 451 Dilation of cervix, 104, 112 delay during, 272, 408, 411, 456. duration of period of, 127, 407 during labour, 104, 112 during pregnancy, 110 inertia during, 411 slow, see delay during Dilators, see Tents, Barnes's Bags, Champetier de Ribes Dilution of cow's milk, 243 Dinting of fcetal head, 431 Diphtheria and puerperal septicaemia, 548 Diphtheritic membrane in septicaemia, 548 'Dipping' in abdominal examination, 153 Discharge of fluid during pregnancy, 247 lochia!, see Lochia purulent vaginal, during labour, 188 Discus proligerus, 2 Disinfectants in midwifery, 183 Disinfection of, genital canal, 188 of hands, 184 of instruments, 352 of vagina during labour, 1S8 of vulva before catheterism, 189 during labour, 1S8 Dislocation, congenital, so-called, of hips, 425 of lumbar vertebrae, causing spon- dylolisthesis, 452 Displacements, dorsal, of arm, 475 of OS uteri, 454, 455 of uterus in contracted pelvis, 427 with pendulous belly, 271 causing protracted labour, 414 causing rupture of uterus, 490 in ectopic gestation, 325 post-partum, 576. See Anteversion, Pro- lapse, Retroversion of vagina, 279, 457 Distension of bladder of foetus, causing dystocia, 465 of uterus, causing after-pains, 231 inertia, 411 Distortion of pelvis, oblique, 443 Disuse of leg, causing pelvic deformity, 445 Diuretics in albuminuria, 508 Dolichocephalic head in face presentations, 156 Dorsal displacement of arm, 475 Dorso-anterior positions of breech, 169, 173 in transverse lies, 467 Double monsters, 465 uterus, 294, 459 in superfcctation, 76 in twin pregnancy, 75 vagina, 294, 460 Douche, administration of, 226 after labour, 226 to induce premature labour, 363 routine in lying-in cases, 185 -tin, 185 uterine, 227 hot uterine, 482 uterine, in puerperal septicaemia, 531 vaginal, after labour, 226 before labour, in case of vaginal discharges, 188, and see Injections in puerperal septicffimia, 530 Douglas, spontaneous evolution of, 470 Drainage, after rupture of uterus, 400, 493 Dress during pregnancy, 76 Dropsy, see also O'Mema of amnion, 257 of fcL-tus, 268, 465 albuminuric, of pregnant woman, 507 Drugs in the milk, 218 Duct, umbilical, 9, 10 Ducts, milk, infection through, 572 Ductus arteriosus, 235 venosus, 235 patency of, causing jaundice, 582 Duration of labour, 127, 406 abnormality in, 406 of pregnancy, 65 Dwarf pelvis, 425 Dyspepsia, 286 Dyspnoea, foetal, see Asphyxia in pulmonary embolism, 551 thrombosis, 550 Dystocia, see Obstructed Labour Dysuria after delivery^, 222 due to retroversion of gravid uterus, 275 ECCHYMOSES in foetus, 580 stillborn, 108 Eclampsia, 509 albuminuria in, 508, 509 blood letting in, 513 cause of, 509 chloroform in, 512 convulsions and pains in, 510 course of, 510 diagnosis of, 511 diaphoretics in, 512 effect of, on uterus, 511 frequency of fits in, 510 induction of labour for, 512 morphia in, 513 mortality in, 512 pathology of, 509 premonitorj- symptoms of, 510 prognosis of, 512 prophylaxis of, 508 purgation in, 513 sequela; of, 512 status epilepticus in, 510, 512, 513 symptoms of, 510 terminations of, 511 treatment of, 512 urine during, 509, 511 venesection in, 513 wet-packing in, 512 Ectopia viscerum, 264, 585 Ectopic gestation, 313 ' abdominal,' 318 abdominal section in, 331 ampullar, 315 anatomy of, 316 cast of uterus in, 323 causes of, 313 coexisting with intra-uterine, 313 death of foetus or embryo in, 320, 326 decidua in, 316, 323 definition of, 313 diagnosis of, 327 efiect on uterus, 323 endometrium in, 323 fistula in, 326 operations on, 334 fwtal sac in, 317, 332 Index 60 1 Ectopic gestation, Octal sac in, calcification of, 320 frutus, death of, in, 320 mummification of, 320 frequency of, 313 hsematocele in, 314, 318 ha;morrhage in, 325 into ovum, 322 infundibular, 322 in hernial sac, 320 infundibular, 315 interstitial, 315, 318, 322 lithopaedion in, 320 membranes of, 320 mole in, tubal, 322 mummification in, 320 ovary in, 316 peritoneum of pelvis in, 320 placenta in, 317, 333 prognosis, 329 rupture of sac of, 320 'secondary,' 315, 320 signs of, 325 sub-peritoneo-abdominal, 315, 320 sub-peritoneo-pelvic, 315, srg suppuration after, 320 symptoms of, 324 terminations of, 315, 318, 319 treatment of, 330 tubal, 315 abortion in, 322 rupture of, 317 varieties of, 315 uterus in, 323 vaginal operation for, 334 Eczema of breasts, 574 in galactorrhoea, 575 Elastic bags, 349, 35S Elasticity of uterus, 100 ElboWj diagnosis from heel, 472 Electricity in ectopic gestation, 330 in galactorrhcea, 575 in post-partum haemorrhage, 482 Elongation of fcetus in labour, 103 hypertrophic, of cervix, 456 Elytrotomy in ectopic gestation, 334 Embolism in puerperal septicaemia, 540, 552 of pulmonary artery, 551 causing sudden death, 551 symptoms of, 551 treatment of, 552 of systemic arteries, 552 Embryo at different months, 29 in carneous mole, 249 development of, 29 Embryonic area, 7 Embryotomy, 386 indications for, 387, 393, 394 in transverse lies, 393, 473 Emotion, causing rise of temperature in puer- perium, 220, 562 Emphysema efface and neck, 502 subperitoneal, 555 of thorax, 502 Encephalocele, 264 Enchondromata obstructing labour, 454 Endocarditis in puerperium, 540, 552 Endometritis after deliverj-, 534 decidualis catarrhalis, 247 causing abortion, 261, 304 causing adherent placenta, 479 polyposa, 246 morbid anatomy of, 247 tuberosa, 246 Endometrium after labour, 212 Endometrium in puerperium, 215 Enema at beginning of labour, 187 nutrient, in uncontrollable vomiting, 285 Engagement of head, 130 Engorgement of breasts, 233 Enterica during pregnancy, 300 in puerperium, 548 Entrance of air, see Air, entrance of, Epiblast, 7 Epidemics of puerperal septicaemia, 182. Epilepsy, diagnosis from eclampsia, 511 during pregnancy, 206 Epiphyses, changes in, in cretinism, 267 in rickets, 266 in syphilis, 266 Episiotomy, 192 Epithelioma of cervix in labour, 45 in pregnancy, 290 causing hae- morrhage, . . 335 Equitation of cranial bones, 93 Ergot in abortion, 310, 313 in accidental ha;morrhage, 339 for after-pains, 231 causing rupture of uterus, 489 contraindications to, 413 in galactorrhcea, 575 imperfect retraction, 576 induction of labour, 363 inertia, 412 placenta pra;via, 350 post-partum haemorrhage, 484 puerperal period, 231 uterine inertia, 412 Erosion of cervix in pregnancy, 335 nipple, 570 Erratic vessel in placenta, 24 Erysipelas of breasts, 574 in pregnancy, 302 puerperium, 542 coccus of, 542, 543 Erythemata in puerperium, 568 septicaemia, 528 Estimation of age of fcetus, 65, 66 conjugate, 418, 419, 420 period of pregnancy, 65, 66 time of delivery, 65, 66 Ether in thrombosis or embolism of pulmonary artery, 552 Ether in obstetrical cases, 205 Eustachian valve, 235 Eventration, 304 Evisceration, 393 Evolution, spontaneous, 470 Examination, abdorninal, 150 bimanual, 63, 72 of breasts, 53, 72 of placenta and membranes, 196 of perinaeum after labour, 196 systematic of cases, 72 vaginal after labour, 196 during labour, 134, 186 in pregnancy, 63 of vaginal orifice after labour, 196 Exanthemata in pregnancy, 209 puerperium, 544 Excessive size of child, 32 quantity of liquor amnii, 257 . ""'k, 574 Excitation of respiration in stillbirth, 520 Excitement during lying-in, 220, 562 Excoriation of nipple, 570 Exercise during pregnancy, 76 Exhaustion of uterus, 412 Exomphalos, 265 Exophthalmos in pregnancy, 56, 297 602 Index Exostoses of pelvis, 454 Expansion, area of, in placenta pra;via, 342 hour-glass, 479 Expression of cord, 514 foetus, 193, 200 head after decapitation, 393 placenta, 195 Expulsion, corpore conduplicato, 471 of membranes, 125 of placenta, 125 spontr.neous, 471 Expulsive forces, action of, 95 abnormalities of, 406, 410 weakness of, 411 Extension of foetus in face presentation, 153 of head in flat pelvis, 435 in normal labour, 137 in occipito-posterior presenta- tion, 145 External conjugate, 85, 417 restitution, 138 rotation, 138 version, 366 Extraction after perforation, 388 of arms in brecch presentation, 200 of head in breech presentation, 201 in Caesarian section, 397 in death of mother, 395 by forceps, 371 of placenta, 479, 480, 485 Extra-peritoneal pregnancy, see Ectopic Gesta- tion Extra-uterine pregnancy, see Ectopic Gestation Extroversion of viscera, 585 Eye affections of new-bom child, 580 during pregnancy, with albumin- uria, 507, 509 Face, emphysema of, during labour, 502 presentations, abdominal examination in, 157, 160, 161 aetiology, 154 caput succedaneum in, 163 compared with vertex pre- sentations, 136 configuration of head in, in contracted pelvis, 155 craniotomy in, persistent men to-posterior cases, 164 with dead children, 155 diagnosis of, 157, 160, 161 duration of labour in, 157 extension in, 153 external rotation in, i6o flexion of, head at outlet in, 160 frequency of, 154 goitre in, 156 heart-sounds in, 152, 157, 160, 161 management of, 198 mechanLsm of, 156, 160, 161, 162 mechanism of, contrasted with that of vertex pre- sentations, 162 men to-posterior positions, unreduced, 163 mode of production of, 154 moulding of head in, 157, 162 positions of, 157 prognosis of, 178 i57i Face, presentations, proportion of left and right dorsal positions in, 155 rotation of foetus in, 157 head in, 158 subconjunctival hsemor- rhage in, 163 treatment of, by Schatz's. method, 198 vaginal examination in, 157 Facial nerve, paralysis of, 579 Fa;ces, incontinence of, after perinaeal rupture, 498 Fa:ces of new-born child, 238 Fallopian tube after labour, 212 ligature of, in Caisarian section, 398 . ^ . ^ pregnancy in, see Ectopic Gesta- lion in puerperal septicaemia, 534 False conception, sec Alole False corpus luteum, 2 labour, 71 pains, 109, i86 promontoiy, 418 curve of, 432 Faradism, see Electricity Fascia of pelvis, 89 injury to, 495 Fat, deposit of, during pregnancy, 57 proportion of, in milk, 218 Father, syphilis in, 268 Fatty degeneration of placenta, 260 uterine muscle in involu- tion, 214 Fecundation of ovum, 2 Feeding, artificial, of infants, 242 bottle, 244 cleansing of. 24.4 frequency of administration, 244 Femur, ' dislocation ' of, causing pelvic de- formiiy, 425 Fergusson's speculum, 354 Ferments, digestive, in new-born child, 238 Ferri perchloridi liquor, 483 Fever, enteric, in pregnancy, 300 malarial, in pregnancy, 301 relap^ing, in pregnancy, 301 scarlet, 544 septic, 526 smallpox in pregnancy, 300 tj"phoid, in pregnancy, 300 typhus, in pregnancy, 301. See also Puerperal Fevers Fibrinous polypus after abortion, 308 Fibroid, uterine, causing inversion, 455 of cervix, 457 changes in, during pregnane^", 288 complicating pregnancy, 288 diagnosis of, from pregnancy, 6q ectopic gestation, 328 extirpation of, 455 ha;morrhage from, during pregnancj', 288, 336 labour with, 455 necessitating abortion, 290 obstructing labour, 455 ' Fibroma ' of placenta, 261 Figure-of-eight pelvis, 428 Fillet in extraction of head, 386 Fimbriae of tube, 2 Finger in extraction of breech, 474 Fissure of nipple, 570 Fissured pelvis, see Split Pelvis, 425 Fistula, after ectopic gestation, 326, 334 in contracted pelvis 432 lacteal, 572 rectal, 429 Index 603 Fistula, vaginal, 429 vesico- vaginal, 429, 567 Fit, eclamptic, 510 Flat pelvis, 424 causation of, 424 description of, 425 diagnosis of, 425 malpresentations in, 427 measurements of, 425 mechanism of labour with, 432, 436 Nagele obliquity in, 433 varieties of 425 Flat generally contracted pelvis, mechanism of labour in, 436 Flat split pelvis, 425 with congenital dislocation of hips, 425 Flattening of foetal skull, 140 of one of twins, 74 Flexion of head during labour, 132 , causes of, 132 during pregnancy, lateral, 137 insufficient in occipito-posterior positions, 145 of trunk, lateral, in breech presentations, 171 ni haad presentations, 139 of uterus in pregnane}', 39 puerperium, 209, 213, 576 Floor of pelvis, £6 effect on head, 116 Fluid, amnio-chorionic, 114 amnionic, 19 Foetal axis pressure, 103 causing flexion of head, 133 Fcetation, ectopic, see Ectopic Gestation Foetus, abdominal enlargement of, obstructing delivery, 465 abnormal attitudes of, 474 abnormalities of, obstructing delivery, 463 acardiacus, 74 adhesion of amnion to, 259 of, to placenta, 259 anasarca of, 465 anatomy of, 90 anencephalus, 263 ascites of, 265, 465 asphyxia of, 519 aspiration of blood by, 193 at different months of pregnancy, 29, 66 attitude of, in utero, 32 ballottement of, 64 bladder of, distension of, 265 bones of, diseases of, 265 fractures of, 267 causes of death of, 269 centre of gravity of, 34 affecting lie, 34 changes in dead, 270 characters of, mature, 30 at earlier periods, 29 circulation in, 235 coiling of cord round, 192, 47S cranium of, 91 cretinism, sporadic, of, 266 cry of, before delivery, 502 death of, intra-uterine, 269 treatment, 271 decapitation of, 393 decomposition of, 270 causing physometra, 502 degeneration, fatty, of, 270 diagnosis of dead, 270 of living, 62 diameters of head of, 93 trunk of. 91 Foetus, diseases of, 263 dropsy of, 268, 465 earliest movemenis of, 59 ectopia visceruni in, 264 effect of chloroform on, 206 effect of pains on, 106, 107 encephalocele of, 264 epiphysitis of, 265 estimation of age of, 66 evisceration of, 394 excessive size of, 462 expression of head of, 200, 201 expulsion of, see Second Stage of Labour extrauterine, 330 flexion of, 31, 90, 129 fontanelles of, 92 fractures in, 267 funis of, see Cord, Umbilical glabella of, 92 goitre of, 267 haemorrhage into, during birth, 108, 580 head of, at term, 91, 93 diminution of volume of, dunng labour, 93 measurement of, immediately after labour, 420 heart, sounds of, 62 in face presentations, 157, 160, 161 in hydatidiformmole, 255 in pregnancy, 62 hernia, umbilical, of, 265 hydrocephalus of, 263 obstructing labour, 263, 463 hydrothorax of, 265, 465 intra-uterine diseases of, 263 death of, 269 lanugo of, 31 large size of, obstructing labour, 462 length of, at different periods of preg- nancy, 66 at term, 30 lie of, in uterus, cause of, 34 definition of, 32 varieties of, 32 maceration of, 270 malformations of, 263, 465 malpresentat'ons of, in contracted pelvis, 427 malpresentations of, in contracted pelvis, causes, 42S maturity, signs o'', 30 measurements of, 91 meconium of, 238 membranes of, see Amnion, Chorion, Decidua membranes of, in twin pregnancy, 73 meningocele of, 264 monstrosities affecting labour, 465 movements during pregnancy, 61 when lirst felt, 59 mummification of, in ectopic gestation, 320 nutrition of, 22 ojdema of, 268, 6,()~, ovarian cysts in, 265 ovoid s of, 90 papyraceus, 74 pathology of, 263 perforation of, see Perforation pleural effusion in, 465 position of, definition of, 32 in utero, 34 cause of, 34 presentations of, definition of, 33 putrefaction of, 270 retention of. in utero, 269 6o4 Index Fa-tus, retroflexion of, 264 rickets in, 265 separation from mother, 193 septic infection of, 584 sex, date of distinction of, 30 size of, at different months, 20 skull of, 91 base of, 91 diameters of, 93 vault of, 91 plasticity of, 92 small-pox in, 301 spina bifida of, 264 sporadic cretinism of, 266 sutures of, 92 syphilis in, 265, 268 temperature of, at birth, 237 trunk of, 91 tumours of, 465 umbilical hernia of, 265 urine of new-born, 237 vernix caseosa of, 31 weight of, at term, 30 Fretuses, multiple, 72 causing inertia, 204, 411 Follicle, Graafian, i of areola, 53 Fontanelle, anterior, 92 position of, in labour, in occipito-posterior posi- tions, 145 lateral, 92 perforation through, 388 posterior, 92 temporal, 92 Food for new-born children, 242 manufactured, 244 Foot, diagnosis of, 472 prolapse of. 476 selection of, in version, 369 Footling presentation, 168 mechanism of labour in, 176 Foramen ovale, 235 closure at birth, 237 valve of, 235 Foramen, obturator, see Pelvis, p. 8i Forceps, 371 action of, 383 application of, 377 to after-coming head, 202 at brim, 378 at outlet, 385 routine of, 377 Assalini's, 374 axis-traction, 374 Barnes's, 374 blades of, introduction of, 378 relation to head, 385 pelvis, 385 causing facial paralysis, 579 Chamberlen's, 372 conditions requiring, 376 contraindications to, 377 in contracted pelvis, 442, 448 craniotomy, see Craniotomy Forceps curves of, 372 description of, 371 etymology of term, 371 extraction of after-coming head by, 202 force, amount of, required, 384 Galabin's axis-traction, 375 history of, 372 indications for, 376 introduction of blades, 378 lever action of, 384 lock of, 372 locking of, 381 Forceps, long, 372 curved, 373 oscillation of, 384 in placenta prarvia, 347 preparations for, 377 in protracted labour, 412. See also Contraction of Pelvis rotation in, 385 short, application of, 386 Simpson's, 372 Tarnier's, 374 traction, direction of, 374, 381 in vaginal thrombus, see Appendix A Forces, expulsive, 95 of abdominal muscles, 100 auxiliary, 100 magnitude of, loi of round ligaments, 100 of uterus, 96 of vagina, 100 Fore-waters, action of, 105 definition of, n.6 isolation of, 106 Form-restitution force, 103 causing flexion of head, 133 Fossa navicularis, injuries to, 191 Fourchette, rupture of, 191 Fracture, intra-uterine, 267 of cranial bones in contracted pelvis,43i of pelvis, causing pelvic deformities, 454 Fundus uteri in cordate uterus, 293 height of, during pregnancy, 39, 66 puerperium, 209, 213 insertion of placenta on, 15 inversion of, 486 lateral displacement, 208 Funic souffle, 63 Funis, see Cord, Umbilical Galactocele, 574 Galactogogues, futility of, 575 Galactorrhea, 574 Galvanism in ectopic gestation, 330 Gangrene of fibroid, 455 of inverted uterus, 488 of mucous membrane of bladder m retroversion of gravid uterus, 275 Gases in uterus, 502 General intra-uterine pressure, 102 paralysis of the insane in pregnancy, 558 Generally contracted flat pelvis, 426 after - coming head in, 437 causation of, 426 description of. 426 diagnosis of, 427 eflTect of, on labour, 428 lying-in, 432 pregnan- cy, 427 mechanism of labour in, 436 Generally contracted pelvis, 425 after-coming head in. 437 causes, 425 characters of, 425 diagnosis of, 426 measurements of, 426 mechanism of labour in, 436 dwarf variety, 425 Index 605 Generally contracted pelvis, infantile variety, 425 Genital canal, atresia of, 455, 458 description of, 79 disinfection of, 184, 1S5 lacerations of, 4S9 in septicsemia, 526 rupture of, 489 -Genu-pectoral position in replacing presenting cord, 516 in replacing prolapsed cord, 516 in retroversion of gravid uterus, 277 Germinal area, see Embryonic Area, 7 spot, 2 vesicle, 2 Germs, infectious, 525, 526 putrefactive, 525 in puerperal septicaemia, 525 saprophytic, 525 _ septic, 525 Gestation, see Pregnancy Gingivitis in pregnancy, 57 Girdle of contact, see Slechanism of Labour, 132 Glabella, 92 Glands, cervical, 46 decidual, 6 mammary, see Breasts Nabothian, 46 salivary, during pregnancy, 57 sebaceous, of skin in pregnancy, 58 sweat-, in axillary lumps, 58 uterine, 6 Glass tubes for irrigation, 227 Globules, milk-, 218 Glottis, action of, in labour, 117 Glycerine in induction of labour, 363 Glycosuria, 227. See also Diabetes Goitre causing face presentations, 156 fcetal, 267 in pregnancy, 56 in sporadic cretinism, 266 Gonococcus, 541 Gonorrhoea in puerperium, 541 Graafian follicle, bursting of, 2 description, 2 maturation of, i number of, i Gravid uterus, anteflexion of, 39, 271 anteversion of, 39, 271 changes in cervix of, 44 hernia of, 280 incarceration of, 273 lymphatics of, 44 muscular fibres of, 41 nerves of, 44 prolapse of, 278 retroflexion of, 278 retroversion of, 273 treatment of, 276 vessels of, 42 Gravity, action of, in labour, 105 efTect of, on lie and position, 34 Grooves on fcetal head, 431 separating body of uterus from lower segment, 98, iiS, 410 Growth, changes in shape of pelvis during, 421 Gummata, syphilitic, in fcetus, 268 Haisitual abortion, 304 Haimatemesis in new-born child from cracked nipples,. 233 Haematocele, 320 Haematoma of pelvis, 318 of placenta, 261 in placenta praivia, 343 Haimatoma of sterno-mastoid, ;8i sub-placental 122 due to tubal pregnancy, 318 of vagina and vulva, see Thrombus Vaginae Hasmatometra, diagnosis from pregnancy, 70 Haemophilia neonatorum, 581 Haemorrhage due to abortion, 305 accidental, 336, 507 ' concealed,' 337 diagnosis of, 338 symptoms of, 337 treatment of, 339 after labour, see Haemorrhage, Post-partum due to albuminuria, 507 before delivery, 336 cerebral, with paralysis, 507 cervical, 494 into decidua, 248, 507 due to detachment of placenta, 336, 341 in ectopic gestation, 317, 324 during expulsion of placenta, 123 in foetus, 108 intra-cranial, 108 sub-periosteal, 108, 581 hot irrigations for, 4^2 due to hydramnios, 258 due to inversion of uterus, 487 from lacera ions of cervix, 494 in molar pregnancy, carneous, 251 vesicular, 255 from navel in new-born child, 108, 580 into placenta, 261, 343 in placenta praevia, 341 from placental site, see Accidental Haemorrhage and Post-partum Haemorrhage from polypus, 335 during pregnancy, 335 causes, 335, 507 postpartum, 480, 507 secondary, 576 prophylaxis, 1S6 treatment, 481 purpuric, 337 due to retroflexion of uterus, 576 due to rupture of uterus, 49r from ruptured cord, 517 secondary puerperal, 576 into sterno-mastoid in child, 581 subconjunctival in face presenta- tions, 163 syncope after, 350, 485 transfusion in, 350, 360, 486 from umbilicus, 517, 5S4 unavoidable, 341 from vagina in new-born children, 239 ^^ from varicose \ems, 283, 335 from vulva, 2S3, 495 Hand, descent of, with head, 476 feeding by, 242 introduction of, info uterus for post- partum hemorrhage, 482 for removal of pla- centa, 479,480 selection of, in version, 369 Hands, cleanliness of, 184 Head, fretal, afterconiing, 172 application of forceps to. 202 in flat pelvis, 435 6o6 Index Head, foetal, aftercoming, management of, 201 perforation of, 392 alterat'on of shape during labour, i^o, 144, 162 anatomy of, 91 articulation of, with spine, 78, 133 asymmetry.of, after labour, 144 attitude of, 129 • at term, 91 in breech presentations, 172 caput succedaneum of, 108 descent of, see Laljour diagnosis of, from breech, 150, see Special Mechanisms diameters of, gi dolichocephalic. 156 effects of contracted pelvis on, 430 engagement of, 130 entrance of into pelvis, 130, 131 extension of, 137 external rotation of, 138 extraction of aftercoming 201 flexion of, during labour. 132 lateral, 137 insufficient, 144 fontanelles of, 92 with hand, 476 influence of age of mother on, 440 sex on, 440 internal rotation of, 135 management during passage over perinaeurr., 191 measurements of, 93 after labour, 420 moulding of, 140, 144, 162 disappearance after de- li ver>-, 239 movements of, during delivery, see Several Mechanisms horizontal, in flat pelvis, 434 in occipito-anterior, '32 . in occipito-postenor, unreduced, 144 sinnmary of, 140 ossification of, 440 pa-sage of brim by, in flat pelvis, 435 perforation of. 387 planes of, causing flexion, 732 position of, definition, 32 presentation of, 33, 129 rotation of, external, i ?8 internal, 135 size of, see Measurements of sutures of, 02 transverse position in fiat pelvis, 433 Headache in albuminuria, 507 Hearing in new-born child, 239 Heart, changes in, during pregnaricy, 56 puerperium, 219 disea.se, congenital, 581 during labour, 503 during pregnancy, 296 - sounds, foetal, 62 in diagnosis of presentations and positions, 151, 152 effect of pains on, 106 . frequency of, 62 in diagnosis of sex, 62 in hydramnios, 258 a proof of living fcetus, 62, 270 maternal, in puerperium, 219 Heart, thrombosis of, 550 Heel, diagnosis from elbow, 492 Hegar's dilators, description of, 357 uses of, 339, 348 sign of pregnancy, laxity of lower uterine wall, 64 Helme on involution of uterus, 214 Heredity, influence in insanity, 556 Hernia of gravid uterus, 280 umbilical, of foitus, 265 Hicks, cephalotribe of, 388 method of version, 367 in treatment of placenta pra;via, 349 Hips, delivery of, 139 Historj' of previous labours, value of, in con- tracted pelvis, 440 Hook, blunt, in impacted breech presentations, 474 dangers of, 474 in version flexible, of Hicks, 369 Oldham's vertebral, 391 Ramsbotham's, 393 sharp, 393 vertebral, 391 Horn of uterus, rudimentary, pregnancy in, 322 Hospitals, antiseptics in lying-in, 182 puerperal fever in, 182 septica;mia in, 1S2 Hot water, injections of, 482 Hour-glass ' contraction ' of uterus, 479 relaxation of uterus, 479 Humanised milk, 243 Humerus, injury to, in extraction, 200 Hydatidiform mole, see Vesicular Mole Hydraemia during pregnancy, 56 Hydramnios, 257 albuminuria with, 258 cause of, 257 causing atony, 258 breech presentations, 258 dystocia, 258 inertia, 258 pendulous belly, 258 premature labour, 258 transver-se lie, 467 definition of, 257 and diabetes, 257 diagnosis from ovarian cyst, 258 twins, 259 in ectopic gestation, 257 eft'ect on fru'tal heart-sounds, 258 involution, 258 lie of foetus, 258 foetus in, 257, 258 morbid anatomy of, 257 obscuring pregnancy, 258 prognosis of, 259 signs of, 258 symptoms of, 258 tre^itment of, 259 in labour, 259 in twin pregnancy, 257 Hydrocephalic skull, 263, 463 rupture of, 464 Hydrocephalus, 263, 463 breech presentation with, 168 causing rupture of uterus, 464 course of labour with, 464 diagnosis of, 464 mechanism of labour in, 464 progn sis in, 464 treatment of, 464 version in, 464 Hydrops amnii, see Hydranmios Hydrorrhoea gravidarum, 247 causing premature labour, 247 Index 607 Hydrorrhoea, diagnosis of, 247 treatment of, 248 Hydrostatic dilating bags, 358 Barnes's, 358 Champetier de Ribes', 359 Hydrothorax of foetus obstructing delivery, 465 Hygiene of pregnancy, 76 Hymen, anatomy of, after connection, 67 after labour, 67, 212 bifore connection, 67 integrity of, after coitus, 67, 459 laceration of, during labour, 67, 212 rigidity of, 459 imruptured, at labour, 459 Hypertrophy of abdominal walls in pregnancy, 5° congenital, of cervix, 456 of heart during pregnancy, 56 Hypoblast, 7 Hysteria in pregnancy, 296 diagnosis from eclampsia, 511 in puerperium, 562 diagnosis, 563 Hysterotomy, see Caesarian Section Icterus in new-born child, 581 during pregnancy, 286, 29S connected with pernicious vomiting, 286 Iliac crests, distance, 416 spines, anterior superior, distance, 416 posterior superior, distance, 417 Ilio-sacral joint, ankyloss of, 445, 448 injury to, 501 in symphysiotomy, 402 Impaction of breech, 474 head in pelvic contraction, 428 forceps in, 442 Imperforate anus, 5S3 Impregnation, period of possible, 65 Incarceration of placenta, 479 of retroverted uterus, 273 in contracted pelvis, 428 Incision in atresia of genital canal, 455 in Cassarian section, see Csesarian Sec- tion in cancerous cervix, 457 of pfrinaeum, see Episiotomy Inclination of pelvis, abnormal, 424 of symphysis, 419 of uterus to right, 41 Incomplete rupture of perina;iim, 497 of uterus, 491, 492 Incontinence of faeces, 498 urine, 567 after labour, 567 due to fistula, 567 during pregnancy, 274, 275 Induction of abortion, 362, 365 of premature labour, 362 in contracted pelves, . 439 time tor, 439 in eclampsia, 512 methods of, 363 Inertia, 411 in accidental ha;morrhage, 338 causes of, 411 during dilatation, 412 during expulsion, 412 ' secondary,' effects of, afterdelivery, 413 Inertia in multiple pregnancy, 204, 411 in placenta prsevia, 345 treatment of, 411 Inevitable abortion, 306 detachment, zone of, 342 lacerations in primipara; 67, 119, 191 Infant, artificial feeding of, 242 apparent death of, 518 asphyxia of. 518 care of, 240 caput succedaneum in, 119 circulation of, 235 diet of, 240 digestion of, 237 diseases of, 579 eyes of, 240 fsces of, 238 foramen ovale of, 235 icterus of, 581 mammarj- glands of, 239 management of, 240 navel of, 239 treatment of, 240 nursing of, 240 ophthalmia in, 580 treatment of, 580 respiration of, 237 selection of wet-nurse for, 241 skin of, 238 suckling of, 240 temperature of, 237 umbilicus of, 239 urine of, 237 weight of, 238 Infarct, placental, 26 renal, of uric acid in new-born child, 237 Infection of eyes of new-born, 580 of navel of new-born, 584 puerperal, 525 prevention of, 180 septic, of foetus, 5S4 Infectious diseases, causing intra-uterine death 269 during pregnancy, 299 in puerperium, 544 Inflammation of breasts, 571 of new-born, 239 local specific, 541 of pleura, see Septicaemia Inflation of chest at birth, 236 of foetal lungs, artificial, 520, 522 Inhalation of chloroform, 205 of liquor amnii, 179 Inhaled matters, removal of, 520 Injection, antiseptic, see Douches of antistreptococcic serum, 540 of fluid into uterus for inducing labour, 363 Injections into bladder in cystitis, 567 intra-uterine, 227 causing of sudden death, 227 for induction of labour, . 363 in post-partum haemor- rhage, 4S2 in septica;mia, 531 vaginal, for induction of labour, 363 in puerperium, 226 Injuries to cervix, 494 to genital canal, 4S9 of pelvic joints, 501 to perina;um, 496 to uterus, 489 against promontory, 273, 490 Inlet of pelvis, 81 diameters of, 83 6o8 Index Inoculalion in septicaemia, 525 Insanitary conditions in septicaemia, 526 Insanity, 556 Jiagnosis of, 560 of labour, 558 during lactation, 559 of parturition, 558 of pregnancy, 557 pregnancy during, 560 of puerperium, 558 treatment of, 560 Insertion of cord, 27 central, 27 lateral, 27 marginal, 27 velamentous, 28 of placenta, 15 Insomnia in puerperal insanity, 559 Inspection of abdomen m pregnancy, 60 of vulva after delivery, 196 Inspiration at birth, 236 premature, in breech cases, 179 Instruments, disinfection of, 352 obstetrical, see Operations Insufflation in asphyxia, 522 Intercourse, sexual, during pregnancy, 77 Inter-cristal measurement, 416 Interlocking of twins, 476 Intermittent fever during pregnancy, 301 Internal rotation, 135 causes of, 135 version, 36S Interspinous measuremant, 416 _ anterior, 410 posterior, 416 Interstitial pregnancy, 317, .322 ^ , o Intestine of new-born child in base of cord, sBj prolapse of, after uterine rupture, 491 Intoxication, septic, 527 Intra-abdominal pressure, see Labour Intra-cranial hsemorrhage, 580 Intra-ligamentous pregnancy, 318 Intra-uterine death, 269 detachment of limbs, 200 douche, 227, 531 haemorrhage, 336 irrigation, 227, 531 pressure, general, 102 rickets, 266 vaccination, 301 Intravenous saline injection, 360 Inversion of uterus, 486 causes of, 487 diagnosis of, 487 frequency of, 487 haemorrhage in, 487 passive, 487 results of, 488 sequelae of, 488 symptoms of, 487 treatment of, 488 Involution of broad ligaments, 215 cervix, 214 tubes, 215 uterus, 213 after abortion, 309 clinical course of, 213 vagina, 215 Iodine, compatibles with, 183 in pernicious vomiting, 285 Iodoform pessary, 252 Iron, injection of, into uterus, 483 Irrigation, see Douche Irrigator, 185 Ischia, planes of, 82 spines of, 84 tuberosities of, S2 Ischio-pagus, see Labour with Monsters, 465 Isthmus of uterus, 42. See also Lower Segment of Uterus Jaborandi, see Pilocarpin, 512 Jalap in eclampsia, 513 Jaundice in new-born child, 581 after late ligature of cord, 194, 582 with septicaemia, 582 theories of, 582 in pregnancy, 298 Jaw traction in pelvic lies, 201 injury to child during labour by. 202 Jelly of Wharton, 21 development of, see Changes in Ovum, 7 thickenings in, 28 Johnson's method of measurement of pelvis, 419 Joints, pelvic, 86 after labour, 216 during pregnancy, 48 rupture of, during labour, 501 Kidneys, disease of, in pregnancy, 506 acute, 505, 507. chronic, 505, 507 paraglobuhn in urine in, 507 in eclampsia, 511 fcetal, and liquor amnii, 19 uric acid infarcts of, 237 Kiwisch's method of induction of labour, 363 Knee presentations, 168 diagnosis of, from shoulder, 471 Knee-elbow position in reposition of cord, &c., see Genu-pectoral Knots of cord, 28 Kyphotic pelvis, 447 . ,. . diagnosis of, 448 mechanism of labour in, 448 mode of production of, 447 treatment of, 44S Labia majora, hajmatoma of, 47 varicose veins in, 47, 283 minora, changes in, during pregnancy, 46 oedema of, 459 Labour, abdominal muscles in, loi action of expelling forces in, 95 action of vagina in, 100 anaesthesia during, 190 antiseptics in, iSo anus in, 118 bag of waters in, 105, T12 blood, amount of, lost during, 127 causes of, 128 cervical dilatation in, no chloroform in, 190 in contracted pelvis, 428 contractions of uterine ligaments in, 100 uterus in, 96 course of, 109 date of labour, determination of, 65 death, sudden, of mother in, 502 definition of, 78 diagnosis of, commencing, no previous, 67, 224 recent, 223 Index 609 Labour, duration of, 127 several stages of, 127 ether in, 205 examination during, 184, 187 expulsion of head in, 138 trunk in, 139 external rotation in, 138 factors of, 78 false, 71, 109 first stage of, anatomy of soft parts m, 115 bladder in, 115 duration of, 127 haemorrhage in, normal, 127. See also Accidental Haemorrhage and Placenta Praevia induction of premature, 362 insanity of, 558 intra-abdominal pressure in, loi irrigations in, 185 lacerations during, see Lacerations list of articles required in, 185 management of, 180 first stage, i£6 second stage, 190 third stage, 193 mania in, 558 mechanism of, see Breech, Brow, Face, Vertex, &c. membranes in, 113 rupture of, 113 artificial, 189, 364 missed, 269 in multiple pregnancy, 203 normal, 78 definition of, 405 obstructed by atresia, see Atresia cicatrices, see Cicatrices rigid hymen, 459 perinaeum, 459 effects of, constitutional, 408 local, 409 pains of, 96 action of, on uterus and contents, 102 patholo.g>' of, 405 placental stage of, 121 posture during, 186 precipitate, see Precipitate Labour, 406 premature, 303 induction of, 362 premonitorj' signs of, 109 preservation of perinaeum in, 191, 192 processes of, epitome of, 78 progress of, 109 prolonged, 407 pulse in, 106 recent, signs of, 223 rectum during, 118 second stage of, 116 duration of, 127 typical pains of, 116 signs of previous, 223 spurious, 71 stages of, 109 first, no, 186 second, 116, 190 third, 120, 193 sudden death in, 502 temperature during, 107 third stage of, 120 duration of, 127 management of, 193 time of commencement of, 12S termination of, i28_ uterine tumours complicating, 455, 457 Labour with monsters, 465 twins, 203 Lacerations of cervix, 494 fascia, 495 hymen, in intercourse, 67 labour, 191 muscles of pelvic floor, 495 parturient canal, 196, 489 perinaeum, 191, 196, 197, 496 immediate suture of, 197 sub-mucous tissues, 495 uterus, 489 vagina, 196, 494 vaginal orifice, 191, 196, 496 Lactalbumin, 242 Lactation, contraindications to, 231 diet during, 230 disorders of, 574. excessive quantity of milk in, 574 influence of, on involution, 231 insanity during, 559 management of, 231 means of arresting, 233 septicaemia, effect of, on, 529 Lacteal fistula, 572 Lactiferous ducts, plugging of, 233, 572 Lactose in milk, 242 Lambdoidal suture, 92 Laminaria tents, 356 in dilating cervix, 356 disinfection of, 357 Lanugo, 31 Laparotomy, 394 after rupture of uterus, 399 in ectopic gestation, 330 in puerperal fever, 539 Lateral flexion of head in normal labour, 137 trunk in head presentation, 139 obliquity of head, 135, 137 placenta praevia, 341 Leg, absence of one, in pelvic deformity, 445 selection of, in version, 369 thrombosis of veins of, 54S varices of, 50 Length of foetus at term, 30 Leucocytosis of pregnancy, 56 Levator ani, anatomy of, 87 rupture of, 496 spasm of, 459 Lever action of forceps, 384 head of foetus as, 133 Liberation of arms, 200 Lichen in new-born child, 583 Lie of foetus, cause of, 34 cephalic, 32, 129 proportion of, 34 changes of, 35 definition of, 32 diagnosis of, 149 influence of pelvis on, 35, 427, 428 instability of, 35 longitudinal, 32 pelvic, 32 podalic, 32, 168 transverse, 466 Life of fffitus, di.-ignosis of, 62 Ligaments, broad, involution of, 213 in labour, 100 relations of, after labour, 213 during pregnancy, . 47 ^ • round, changes m, durmg preg- nancy, 48 contraction of, in labour, 100 sacro-sciatic, see Development of Pelvis, 422 R R 6io Index Ligature of cord, early, 193, 238 late, 193, 238 with tivins, 204 vessels in umbilical haemorrhage, 518, 585 . . , . Limb,one,disuse of, causing deformity of pel vis,445 Limbs, foetal, intra-uterine, amputation of, 260 presentation of, 475, 476 prolapse of, 476 recognition of, in abdominal ex- amination, 151 twisting of cord round, 478 of woman, paralysis of, 563 Lime, chloride of, in disinfection, 182 Lineae albicantes, gravidarum, maternas, see Striae Lip, anterior cervical, during labour, 115, igo Liquor amnii, 19 abnormal, 257, 259 absorption of, after death of foetus, 270 albumin in, use of, 20 action of, in labour, 20, 105 composition of, 19 deficiency of, 259 derivation of, 19 discharge of, 113 premature, 114 discolouration of, 25, 257 excess of, see Hydramnios, 257 causing podalic lie, 169 inhalation of, 179 insufficiency of, 259 origin of, 19 quantity of, ig variations in, 19, 29 scantiness of, 259 adhesions in, 263 foetus in, 259 intra-uterine amputa- tions in, 260 resembling ectopic gestation, 259 sugar in, 257 urea in, 19 uses of, 20 variations in colour, 29 quantity, 19 List of special requisites for labour, 185 Lithopjedion, 320 formation of, 320 Lithotomy during labour, 460 -position during operations, 498 Liver, acute atrophy of, in pregnancy, 2S4, 286 changes in, in pregnancy, 284, 286 syphilitic changes in fcetal, 268 Living foetus, diagnosis of, 62 Lochia, 215, 216 abnormalities of, 576 composition of, 216 definition of, 216 excessive, 576 offensive, 528, 577 quantity of, 217 return of, 230, 576 in septicaemia, 528 sudden arrest of, 529, 577 Locking of forceps, 381 twins, 476 decapitation in, 393 ' Longings ' during pregnancy, 54 Longitudinal lie, 32 Loop of cord round child, 192 Lordosis of spine, 424 Lower segment of uterus, 42, 08 boundaries of, 42, 98 laxity in pregnancj', Hegar's sign, 64 Lower segment of uterus, in placenta praevia, see Placenta Pravia placental insertion on, see Placenta Previa rupture of, 490 Lubricant for fingers and instruments, 184 Lumbar vertebrae, prolapse of, in spondylolis- thesis, 452 Lumbo-sacral cord, pressure upon, 563 Lumps, axillary, 58 Lungs, diseases of, in pregnancy, 797 effects of pregnancy on, 56 inflammation of 297 inflation of, at birth, 236 artificial, 520. 522 in puerperal septicaemia, 540 Luteum corpus, 2 Lying-in hospitals, antiseptics in, 182 puerperal septicasmia in, 182 contracted pelvis, effect of, on, 432 room, arrangements of, 180 period, see Puerperium Lymphangitis, 534 Lymphatics of uterus in pregnancy, 44 septicaemia, 534 Maceration of foetus, 270 Malacosteon, see Osteomalacia, 299 Malaria in pregnancy, 301 Malformations of foetus, 263, 465 pelvis, 424 uterus, 293 affecting labour, 459 vagina, 458, 459 Malignant disease in pregnancy, of cervix, 290 uterus, 290 vagina, 291 Malposition of os uteri, 273, 454, 455 Malpresentations, causes, see various kinds of Mai presentation Malted foods, 242 Mamma, see Mammary Gl^nd Mammarj' gland, abscess of, 571, 572 affections of, 569 after delivery, 217 alternate use of, 232 areola of, in pregnancj", 53 secondarj', 54 care of, during i>regnancy, 77 cleansing of, after nursing, see Nipples diseases of, 569 examination of, in wet-nurses, inflammation of, 571 lines on, in pregnancy, 53 in new-born child, 239 in pregnancy, 52 changes in, after death, of ovum, 270 in puerperium, 217 secretion of, after delivery, 217 changes in the characters of, in pregnancy, 54 in puerperium, 217 effects of drugs on, 218 excessive, 574 scanty, 232, 575 treatment of, 575 Index 6ii Mammary gland, signs of pregnancy in, 53 stria; of, 53 Mania with chorea, 280 during deUverj', 558 lactation, 559 pregnancy, 557 puerperal, 558 Marasmus from uncontrollable vomiting, 284 Marginal insertion of cord, 27 placenta praevia, 342 Marshall Hall's method of artificial respiration, 520 _ Mastitis, causes, 571, 527 treatment, 573 varieties, 572 Maturity of foetus, signs of, 30 Meals, arrangement of, for infants, 231, 240 Measles during pregnancy, 301 Measurement, see also Pelvimetry of brim of pelvis, 83 cavity of pelvis, 84 diagonal conjugate, 83 external conjugate, 85 foetal head, 91 foetus, gi iliac crests, 85 iliac spines, 85 pelvic outlet, 84 pelvis, 83 pelvis, table of, 84 true conjugate, 83 uterus during pregnancy, 36 Mechanism of labour, see under respective headings Meckel's diverticulum, 584 Meconium, composition of, 238 discharge of, after deliverj', 238 in asphj'xia, 29 in liquor amnii, 29 Melancholia during lactation, 560 pregnancy, 557 puerperium, 559 Membranes, abnormalities of, 246, 252, 257 action of, on cervix, 105 anatomy of, in multiple pregnancj", 73 bag of, 104 second, 113, 114 delayed rupture of, 114, 125 detachment of, 124 examination of, 196 expelled unruptured, 115 expulsion of, 125 fibrous masses in, 28 functions of, 104 in pelvic contraction, 428 prolapse of, 115 puncture of, in accidental haemor- rhage, 339 retention of, in abortion, 307 after labour, 576 rupture of, 113 artificial, 189, 339 delayed, 114, 125 in accidental haemor- rhage, 339 in inertia, 412 modes of, 113 premature, 113, 114, 124 spontaneous, 113 separation of, from uterus, 121, 124 at term, 18 in transverse presentation, 467 two bags of, in twins, 203 wrinkhng of, in separation, 124 Membranous placenta in placenta pra:via, 341 Meningeal haemorrhage, 108, 580 Meningocele, 264 Menopause and pseudo-cj'esis, 71 Menorrhagia after abortion, 307 Menstruation in calculation of date of delivery, 65 . cessation of, in pregnancy, 58 continuance of, in pregnancy, 58 in ectopic gestation, 324 Mental activity in new-born child, 239 Mental disorders, see Insanity Mento-posterior positions, management of, 199 unreduced, 163 Mercurialism after douching with sublimate solutions, 226 Mercurj', see Sublimate, Corrosive Mesoblast, 7 Metritis after deliver^', 532 Metrorrhagia after abortion, 307 Micro-organisms in erj'sipelas, 542 gonorrhoea, 541 sapraemia, 527 scarlatina, 545 septicaemia. 526 Micturition, difficulty of, after delivery, 230 during pregnancy, 50 Milk, addition of cream to, 243 arrest of secretion of, 233 artificial human, 243 asses', 242 in breasts of new-born children, 239 casein, removal of, from, 243 condensed, 244 cow's, 242 composition of, 242 curdling of, 242 deficiency- of, 575 dilution of, 243 ducts, obstruction of, 572 excess of, 574 -fever, 218 fistula, 572 globules, 218 human, characters of, 218 composition of, 218 changes in, 219 humanised, 243 in new-born children's breasts, 239 -leg, see Phlegmasia Alba Dolens method of arresting secretion of, 233 of goat, 242 of mare, 242 peptonised, 243 preparation of, for infants, 242 proteids of, 242 kinds of, 242 quality of, determination of, 219 reaction of human, 242 secretion of, 217 defective, 232, 575 effect of drugs on, 219, 575 exce.ssive, 574 in women not pregnant, 71 sterilisation of, 243 sugar, amount of, in, 218 Swiss, 244 Miscarriage, see Abortion and Premature Labour Missed abortion, 250, 251, 269 labour, 269 miscarriage, 250, 251, 269 Mitral disease in labour, 503 pregnancy, 296 Mobility of foetal head on trunk, 78 pelvic joints, 86 abnormal, 568 Mole, carneous, 248 6l2 Index Mole, corneous, causes of, 248 causing ha;morrhage, 251 decomposition of, 250 diagnosis of, 251 ectopic, 317, 322 expulsion of, 250 putrefaction of, 250 signs of, 251 symptoms of, 251 trc;atment of, 252 cystic, hydatidiform, vesicular, 252 anatomy of, 253 definition of, 252 diagnosis of, 255 causation of, 252 embryo in, 254 expulsion of, 255 evacuation of uterus in, 256 _ foetus in, 254 foetal heart in, 255 haemorrhage in, 255 septicaemia from, 255 size of uterus in, 254 symptoms of, 254 treatment of, 255 in twin pregnancy, 252 villi of, perforating uter- ine wall, 254 MoUities osslum, pelvis of, 449 Monsters, acardiac, 74 anencephalic, 263 classification of, 465 causing difficult labour, 465 diagnosis of, 465, 466 double, 465 management of labour with, 466 presentations of, 466 varieties of, 465 Morbility of child-birth, 182 Moribund woman, Caesarian section in, 395 Morning-sickness in pregnancy, 55, 59 excessive, 284 treatment of, 2.85 pernicious, 284 uncontrol- lable, 284 Morphia in eclampsia, 513 in ectopic gestation, 330 Mortality of child-birth, 182 Moulding of head, 140 disappearance of, after delivery, 239 during delivery, see the several presentations in Contracted Pelvis, 431 Mouth of infant, cleansing of, after meals, 244 Movements of coccyx, 86 foetal, cessation of, 270 earliest, 59 of pelvic joints, 86 of sacrum, 86, and see Appendix B Multipara, definition of, 109 floor of pelvis in, 67 labour in, length of, 127 perinajum in, 67 quickening in, 59 Multiple pregnancy, 72 acardia in, 74 development of children in, 74 . ^ diagnosis of, 75 frequency of, 72 foetus papyraceus in, 74 Multiple pregnancy, haemorrhage after, 204, 480 inertia in, 203 interlocking of foetuses in, 476 interlocking of foetuses, treatment of, 477 labour in, 203 mode of production of, 73 mummification of foetus in, 74 number of foetuses m, 72 premature labour in, 203 presentations in, 204 prognosis in, 203 sex of foetuses in, 74 superfecundation in, 7^ superfoetation in, 76 varieties of, 72 Mummification of foetus, 270, 320 Miinchmeyer's method of transfusion, 486 Muscles, abdominal, action of, in labour, 100 action of, in development of normal pelvis, 421 of deformed pelvis, 424 of pelvic floor, 86 sterno-mastoid, iiijurj- to, 581 tone of, in asphyxia of foetus, 520 uterine, condition in contraction, 96, 97 relaxation, 97 retraction, 97 pregnancy, 41 involution of, after labour, 214 Myoma, causing haemorrhage, 288, 336, 455 inertia, 455 inversion, 487 placenta praevia, 288, 455 post-partum haemorrhage, 455 rupture, 455 cervical, complicating pregnancy, 289 corporeal, 289 diagnosis of, 289 from ectopic gestation, 328 pregnancy, 69 Myxoma fibrosum of chorion, 261 Nahothian follicles, 46 Nagele, oblique pelvis of, 445 obliquity of foetal head, 135, 43^ in pelvic flatten- ing and con- traction, 433 Nails, cleanliness of, 184 Narcotics in accidental haemorrhage, 339 exhaustion, 412 insanity, 561 threatened abortion, 310 See also Anaesthesia Naso-frontal suture, 92 Nausea in pregnancy, 55 Navel, see Umbilicus Neck, division of, see Decapitation emphysema of, 502 traction on, in delivery of head, 193 Nephritis, see Albuminuria Nerves, injury to, in delivery, 563 of uterus, changes in pregnancy, 44 Nervous disorders of pregnancy, 54, 280. See also Insanity, Chorea Nervous system, changes in, in pregnancy, 54 Neuroses during pregnane}-, 54, 280 puerperium, 556 New-born child, activity of senses in, 239 albuminuria in, 237 alimentary system in, 237 apnoea of, 518 Index 613 New-born child, application of, to breast, 231 artificial feeding of, 242 asphyxia of, 518 brachial plexus, damage to, by forceps, 579 breasts of, 239 secretion by, 239 caput succedaneum of, 119 care of, 240 changes in circulation of, 236 skin of, 238 circulation in, 235 clothing of, 240 colic in, 583 desquamation in, 238 digestion in, 237 eyes of, 240 facial nerve, paralysis of, 579 faeces of, 238 first respiration of, 236 food of, 240, 241, 242 gain of weight in, 238 haemorrhages in, 108, 580 hand -feeding of, 242 icterus of, 238, 581 jaundice in, 238, 581 loss of weight in, 238 mammary glands of, 239 management of, 240 meconium of, 238 mental activity of, 239 navel of, 239, 240 ophthalmia in, 240, 580 pancreas of, 238 paralysis of facial nerves in, 579 pathology of, 579 preparation of milk for, 242 puerperal infection of, 584 renal secretion in, 237 respirations of, 237 salivary glands of, 238 senses of, 239 septic infection of, 584 skin of, 238 stomach of, 238 suckling of, 231 temperature of, 237 tetanus of, 580 umbilical cord in, 239, 240 urine of, 237 vision in, 239 washing of, 240 weight of, 238 wet-nurse for, 240 Nipping of soft parts in labour, 428, 429 Nipple, changes in, during pregnancy, 54 cracked, 232, 233, 570 depressed, 569 eczema of, 575 erectility of, 54 erosion of, 570 fissure of, 570 management of, in pregnancy, 77, 570 suckling, 232 retracted, 569 -shield, 233, 570 sore, 570 infection of breast through, 572 treatment of, 233, 571 ulceration of, 571 Nodules in placenta, 26 Nozzle for douche, 227 Nullipara, uterus of, 225 Nulliparity, signs of, 67, 224 Nurse, selection of wet-, 24 1 Nursing, contraindications to, 231. See Suck- ling Nutrition of foetus, 238 Nymphffi, injury to, 501 Oblique contraction of pelvis, 443 diameters, 83, 84 pelvis, 443 Obliquely contracted pelvis, 443 causation of, 443 diagnosis of, 446 labour in, 447 treatment of labour in, 447 varieties of, 443, 444, 445 Obliquity, anterior parietal, 433 of foetal head, biparietal, 433, 436 posterior parietal, 436 Nagele's, 135, 433 Roederer's, 133 Solayres', 130 of uterus, causing extension, 154 causing face presentations, 154 causing flexion, 133 causing transverse presenta- tions, 467 Obliteration of cervix, no of foetal blood channels, 237 Obstetrical conjugate, 83 examination, external, 150 internal, see Various Lies and Positions history, 72, 440 operations, 352 Obstructed labour by abdominal swellings in foetus, 465 by abnormal foetus, 462 by ascites of foetus, 465 in atresia, uterine, 456 vaginal, 458 vulvar, 459 by broad shoulders, 462 by coiling of cord, 78 by cystocele, 457 by displaced arm, 475 by displacements, uterine, 454, and see Anteversion by distended bladder, 460 by ectopia viscerum, 465 by fibroids, 455 by hydrocephalus, 463 by hydrothorax, 465 by hypertrophy of cervix, 456 by locked twins, 476 by malformation of uterus, 459 . , . by malformation of vagina, 459 by monsters, 465 by morbid growths, 457 by ovarian tumours, 460 by rigid hymen, 459 perinaium, 489 Obturator foramen, 82 muscles, 86 Occipital bone, rupture of, 431 Occipito-anterior position, 132 flexion of head in, 132 mechanism in, 132 Occipito-frontal diameter, 93 Occipito-posterior position, causes of unreduced, 143 . , ^ forceps in unreduced, 19S 6i4 Index Occipito-posterior position, management of un- reduced, 197 mechanism in, 145, »47 mechanism in rarer form of, 147 moulding of head in, 148 prognosis in unre- duced, 177 rotation in, 145 rotation as treatment for, 197 vectis in, igS Occlusion of cervix, 455 vagina, 458 vessels and blood channels after birth, 15, 127 I Edema of anterior lip of cervix, 115, 190 in albuminuria, 507 of foetus, 268, 465 generative organs during pregnancx". _ 283 _ with hydramnios, 268 of incarcerated uterus, 274 new-born child, 584 placenta, 268 Oidium albicans, 583 One-horned uterus, 294 Operations, obstetric, 352 Ophthalmia neonatorum, 580 prophylaxis of, 240 treatment of, 5S0 Opium in eclampsia, 513 exhaustion of uterus, 412 threatened abortion, 310 Orifice of urethra in labour, 118 Os uteri, dilatation of, 356 dilation of, 104, H2 displacement of, anterior, 455 posterior, 454 internum, after labour, 214 definition of, 45 dilation of, in labour, 104, 112 pregnancy, 45 occlusion of, 455 relation to retraction ring, . 45. rigidity of, 456 stricture of, 456 Ossification of skull in successive pregnancies, 440 Osteomalacia, 449 pelvis of, 449 in pregnancy, 299 Osteophytes, 57 Outlet of pelvis, measurements of, 84 in various deformities, see under special headings Ova, description of, 2 number of, in ovaries of young girl, i Ovarian cyst in labour, ifi 193 delivery of, in head presentation, de- layin, '93 rotation of, 138 ' Show' in labour, no, in Sickness, morning, excessive, see Vomiting Siege d^compMt^, 474 Sigault on symphysiotomy, 402 Silver nitrate for eyes of new-born, 240 Silvester artificial respiration, 520 Sinus, marginal, of placenta, 17 placental, 11 Sinuses, uterine, after labour, 214 proliferation of endothelium of, 43 thrombosis of, 43, 214 Site, placental, after labour, 209 normal, 15 in puerperium, 212 in third stage, 121 Sitting, effect of, on development of pelvis, 423 Size of foetus in diagnosis of date of pregnancy, 66 uterus after labour, 20S Size of uterus in nullipara and multipara, 67, 224 pregnancy, 36 puerperium, 213 Skin, diseases of, in pregnancy, 282 effect of pregnancy on, 51, 57 pigmentation of, in pregnancy, 57 in puerperium, 219 striae of, 51 of foetus, 23S rashes on, 5S3 syphilitic affections of, 585 yellow staining of, 238 Skoliosis with pelvic contraction, 443 Skoliotic pelvis, 443 Skull, foetal, diameters of, 93 fontanelles of, 92 fractures of, due to contracted pel- vis, 431 hardness of, according to age of mother, 440 hydrocephalic, 463 injuries to, in contracted pelvis, 431 moulding of, 92, 144 relation to pelvis, see Various Me- chanisms Sleep after labour, 229 in exhaustion of uterus, 412 Sleeplessness in puerperium, 559 Sloughing of cord in separation, 239 after injury to parturient canal, 429 in inverted uterus, 48S Small-pox in foetus, 301 in pregnancy, 300 in puerperal state, 548 vaccination in, 301 Small round pelvis (generally contracted pelvis), 425. See Generally Contracted Pelvis Smellie on curves of forceps, 372 Softening of bones in osteo-malacia, 299, 449 cervix, 46 joints in pregnancy, 48 Solaj'res' obliquity of head, 130 Somatopleure, 8 Sore nipples, see Nipple Souffle, funic, 63 so-called placental, 62 umbilical, 63 uterine, 61 Sound, uterine, in diagnosis of ectopic gestation, 325, 326 Sound for rupture of membranes, 339 Spasm of cervix, 88 of uterus, see Tetanus Uteri Spasmodic rigidity of cervix, 83 Specific gravity of liquor amnii, 19 parts of foetus leading to various lies, 34 Spencer on diagnosis of placenta praevia, 346 haemorrhages in still-birth, 108 Spermatozoa, vitality of. in female passages, 65 Sphincter ani, in floor of pelvis, 87 rupture of. 497 Spina bifida, diagnosis of, ante-partum, 465 Spinal curvature in pelvic deformity", 443, 447 Spine, articulation of head with, 78 Spines, iliac, anterior, distance apart, 416 posterior superior, distance apart, 4t7 ischial, distance, 84 Spiral arteries of uterus, 15 turns of umbilical cord, 21 Spirilla in blood of foetus, 301 Splanchnopleure, S Spleen during pregnancy, 56 syphilitic ftjetal, 268 Split pelvis, 425 Spondylolisthesis, 452 624 Index -Spondylolisthesis, causation of, 452 diagnosis of, 453 results of, 452 treatment of, 453 Spondylolysis, 452 Spondylotomy, 394 Sponge-tents in accidental hEemorrhage, 356 d^isinfection of, 357 for inducing labour, 365 in placenta prjevia, 347, 348 Spontaneous evolution, 470 expulsion, 471 rectification, 468 version, 469 Sporadic cretinism, 266 Spot, germinal, 2 Spurious labour, 7i_ pains, 109 pregnancy, 71 Stages of labour, see Labour Starch, digestion of, by new-born child, 242 State, puerperal, see Puerperal State Steepness of symphysis in pelvimetry, 419 Stenosis of cervix, 456 vagina, 458 Sterilisation during Csesarian section, 398 of instruments, 352 milk, 243 Sternomastoid, heematoma of, 581 spastic contraction of, 581 Stethoscope, see Auscultation Still-birth, 518 causation of, 519 classification of, 519 treatment of, 520 Stimulants in insanity, 561 in septicaemia, 531 Stomatitis, aphthous, 583 Straits of pelvis, 82 Striae of abdomen, 51, 69 new, 52 old, 52 of breasts, 52 histology of, 52 of thighs, 52 Styptics in post-partum haemorrhage, 482 umbilical haemorrhage, 584 Subinvolution after abortion, 309 diagnosis of, from pregnancy, 70 Submammary abscess, 573 Suboccipito-frontal diameter, 94 at vulva, 192 Subperitoneal emphysema of uterus, 555 heematoma, see Ectopic Gestation operation for ectopic gestation, Subperitoneo-pelvic form of ectopic gestation, 315) 318 Subplacental ha;matoma, 122 Succenturiate placenta, 23 Suckling, contraindications to, 231 effect on involution. 231 frequency of, 231 Sudden death in labour, 502 puerperium, 502 Suffocation, see Asphyxia Sugar in milk, amoiint of, 242 liquor amnii, 257 preparation of milk, 243 urine in pregnancy, 298 puerperium, 298 Suicide in insanity see Insanity, 556 Superfecundation, 73 Superfcetation, 73, 76 Superinvolution, 224 Support of perinaeum, 190 Suppuration, see Abscess in breasts, 571, 572 dermoids, 461 ectopic gestation, 315, 320 Sutures in Caesarian section, 398 in ruptured perinaeum, 498 uterus, 400 of skull in diagnosis of positions, see Various Positions of Vertex in hydrocephalus, 464 overlapping at, 92 Symphysiotomy, 402 conditions for which suggested, 402 definition, 402 effect of, in enlarging brim, 403 instruments,, 403 mode of operating, 403 relation to other operations, 404 results, 404 Symphysis pubis, height of, 85 inclination of, in pelvimetry, 419 _ relaxation of, 86 rupture of, 501 section of, see Symphysiotomy synovial ca\ity of, 86 Synchondrosis, see Articulations of Pelvis Syncope, see Collapse Syncytium, 577 Syphilis causing abortion, 304 death of foetus, 269 detachment of epiphyses, 265 pemphigus, 269 peritonitis of fcfitus, 268 contracted during pregnancy, 302 as contraindication to suckling, 232 effect of, on bone of foetus, 265 liver of fcEtus, 268 lungs of foetus, 268 placenta, 262 serous membranes of fcctus, 268 skin of fcetus, 269 spleen of foetus, 268 in father, 268 foetal, 268 in mother, 268 in new-born child, 585 in nursing woman, 232 in pregnancy, 302 transmission to fcetus, 268 treatment during pregnancy, 303 Syphilitic condylomata in child, 269 epiphysitis, 265 osteophytes, 266 Syringing, see Douche Tampon, see Plug Tannin in relaxation of anterior vagin wall, 279 sore nipples, 571 Tapping of ovarian cysts, 292, ^61 of uterus in incarceration, 277 Tarnier, forceps of, yj\ Taste, perversion of, in pregnancy, 55 Tears of parturient canal, see Ruptures and Lacerations Teat, indiarubber, 570, 571 Temperature of douche in post-partum hasmor- rhage, 482 of foetus, 237 high, causing death of fcetus, 300 in labour, 107 in obstructed labour, 408 in puerperal septicaemia, 528, 530 in puerperal state, 220 Index 625 Tents, disinfection of, 357 laminaria, 356 sponge, 356 tupelo, 356 use of, in abortion, 311 induction of labour, 365 placenta praevia, 347 Tetanic contraction of uterus, 409 Tetanilla, see Tetany Tetanus after abortion, 309 delivery, 564 of new-born child, 580 uteri, 409 Tetany in pregnancy, 282 in puerperium, 565 during suckling, 565 Thorax, emphysema of, 502 after labour, 216 in pregnancy, 57 Thrill, uterine, 61 Thrombosis, cardiac, 550 of femoral veins, 548 symptoms of, 549 after injection of iron salt, 483 of pelvic veins, 548 of placenta, 26 in puerperal septicaemia, 548 of pulmonary arteries, 550 of uterine sinuses, 43 of veins of arm, 550 venous, 548 of villous arteries, 26 Thrombus, detachment of, 550, 554 of pulmonary artery, 550 vagina, 283 causes, 283 frequency. Appendix treatment. Appendix Thrush, 583 Thyroid, enlargement of, see Goitre in pregnancy, 56 Tonic contraction of uterus, 409 Torsion of cord, 21, 30 excessive, 262 Torticollis, 581 Trachea, catheterisation of, 520, 523 Tract, genital, anatomy of, see various headings Traction, axis, see Axis Traction on cord, causing inversion, 487 direction of, in forceps extraction, 381 on jaw, in delivery of after-coming head, 201 Transfusion of blood, 360 of saline solutions after hemorrhage, 340 method of, 360 Transverse diameter of brim, 83 cavity, 84 outlet, 84 lie of foetus, 466 causation of, 466 decapitation in, 393, 473 diagnosis of, 471 embryotomy in, 393, 473 natural course of labour in, 467 in pelvic contraction, 427 rectification of, 473 spontaneous delivery in, 468, 469, 470, 471 treatment of, 473 version in, 473 Transversely contracted pelves, 447 Transversus perinsei, 87 Triplets, 72 frequency of, 72 Triradiate pelvis, 449 Triradiate rachitic pelvis, 451 Trismus uteri, see Spasm of Cervix, 188 Trochanters, distance between, 85 Trophoblast, 14 Trousseau on tetany, 565 Trunk, delivery of, in cephalic lies, 139 podalic lies, 171 lateral flexion of, in head presentations, 139 Tubal pregnancy, see Ectopic Gestation Tube, Fallopian, in Caesarian saction, 398 position of, after labour, 212 in pregnancy, 47 Tuberosities, ischial, distance apart, 417 parietal, distance apart, 94 Tubo-abdominal pregnancy, 315, 318 Tumours complicating pregnancy, 288, 290, 291 diagnosis of, from pregnancy, 70 fibroid, see Fibroid of foetus, 465 obstructing delivery, 465 ovarian, see Ovarian Tumours parametritic, see Parametritis phantom, 70 of scalp, see Caput Succedaneum and Cephalhaematoma of uterus, 28S, 455 Tunica fibrosa, 2 granulosa, 2 vaginalis ovarii, 322 vasculosa, 2 Tupelo tents, 356 Turning, see Version Twin labours, 203 Twins, 72 causing transverse lies, 467 conjoined, 465 course of labour with, 203 decapitation in, 477 delay between births of, 204 deliver^' of, 203 development of, from ovum, 73 diagnosis of, 75 different fates of, 74 in double uterus, 75 early expulsion of one of, 74, 75 expulsion of placenta of, 203 flattening of one of, 74 inertia, due to, 203 interlocking of, 476 labour with, 203 ligature of cord in, 204 management of, 204 placentas of, 203 post-partum haemorrhage with, 204 premature delivery in, 74 presentations of, 203 in producing post-partum haemorrhage, 204 prognosis of labour with, 203 sexes of, 74 superfecundation in case of, 73 superfoetation in case of, 73, 76 unequal development of, 74 Twisting of cord, excessive, see Torsion round foetus, see Coiling of pedicle of ovarian cyst, 292 Tympanites uteri, 502 Typhoid fever in pregnancy, 300 puerperium, 54S Typhus fever in pregnancy, 301 puerperium, 548 Ulcer of nipple, 570 '.puerperal,' 530, 548 Umbilical arteries, 21 s s 626 Index Umbilical arteries, dilatation of, 25 hajmorrhage from, after birth, 584 haemorrhage from, treatment of, 585 bruit, 63 cord, see Cord, Umbilical duct, 9, 10 hernia of foetus, 265 souffle, 63 vein, 21 vesicle, 9 on placenta at term, 16 vessels, 9 - -, _ haemorrhage from, 5-4 ~-oe€lusion of, 237 Umbilicus, care of, in new-born, 240 haemorrhage from, 585 hernia of, 585 infection at, 584 Unavoidable haemorrhage, see Placenta Praevia Uncontrollable vomiting, see Vomiting Urachus, patent, 584 Uraemia, 509 Urates in urine of lying-in woman, 222 Urea administered to dogs, 510 in eclampsia, 511 liquor amnii, 19 Ureters during pregnancy, 50 supposed compression of, by uterus, 505 Urethra, affections of, after labour, 567 injuries to, 501 after labour, 213, 567 during labour, 118 laceration of, 501 Uric acid infarcts in new-born, 237 Urinary system in puerperium, 222 Urine, acetone in, 223 albumin in, see Albuminuria chlorides in, 222 difficulty of pa.ssing, in puerperal state, 222, 567 during eclampsia, 507, 50S, 511 fcetal, characters of, 237 chloroform in, 206 incontinence of, due to fistula, 567 retention, 222, 567 of new-born child, 207 peptones in, 223 during pregnancy, 57 in puerperal state, 222 during recovery from eclampsia, 511 retention of, in labour, 460 during pregnancy, due to incarceration, 274 during puerperium, 222, 567 .secretion of, in puerperium, 222 specific gravity of, 222 sugar in, 57, 222 urates in, in puerperium, 222 Uterine action, 96 abnormal, 406, 411 after deliverj-, 208 atony, 411 bruit, 6r cause of, 61 palpable, 61 in puerperium, 220 contractions, see (.Contraction, Uterine douche, 227 endometrium, changes in, in pregnancy, 4 puerperium, inflammation of, 247, 534, and see Endometritis pigmentation of, 215 glands, regeneration of, after labour, 215 Uterine haemorrhage, see Ha;morrhage, Uterine inertia, see Inertia muscle, changes in, during pregnancj', 41 puerperium, 214 segment, lower, 42, 209 sinu.ses, see Sinuses souffle, 61 tumours, 288, 455 Uterus, abnormalities of, 75, 294, 459 action of, in labour, 96 pain on walls of, 102 adhesion of placenta to, 479 air in, 502 anteflexion of gravid, see Anteflexion normal, of, during pregnancy, 39 ante\vrsion of, see Anteversion arcuatus, 293 causing face and brow pre- sentations, 293 arteries of, 15 changes in, after labour, 214 changes in, during pregnancy, 4-. proliferation of endothelium of, 43 atony of, see Inertia atresia of, 455 bicornutus, 294 bimanual compression of, 484 body of, 42, 98 bruit of, 61 cancer of, see Cancer of Uterus capacity of gravid, 36 I cervix of, see Cervi.x changes in position in pregnancy, 39 shape in pregnancy, 36 size in pregnancy, 36 complete rupture of, 491 condition of, after deliver^-, 208, 210 connective tissue of, 41 continuous action of, see Tetanus Uteri contractions of, see Contractions, Uterine cordatus, 293 ' deciduoma malignum ' in, 577 decrea-se in size after labour, 209 descent of, after delivery, 209 detachment of placenta from, artificial, 479, 480 detachment of placenta from, normal mode of, 124 de\iation of axis, 41 dextro-rotation of, 41 didelphys, 294 dimensions of gravid, 36 displacements of gravidj 271 m contracted pel- vis, 427 double, 75, 294, 450 relation of, to superfoetation, 76 twins in, 75 in ectopic gestation, 323 elasticity of, 100 evacuation of, in abortion, 312 carneous mole, 252 vesicular mole, 256 exhaustion of, 412 contra-sted with tetanus uteri, 413 treatment, 412 exploration of, after labour, 196 extirpation of, for cancer, 290 fibroid of, see Fibroid fundus of, see Fundus Uteri glands of, 6 regeneration of, after labour, 215 Index 627 Uterus, gravid, displacements of, 271 incarceration of, 273 haemorrhage from, see Haemorrhage height above pubes in pregnancy, 39 puerperium, 208 stages of labour, 119 hernia of gravid, 230 hour-glass contraction of, 479 incarcerated, 273 in contracted pelvis, 428 inclination of, to right, 41 incomplete rupture of, 491 increased mobility in contracted pelvis, • 4^7 ... . . mcrease in size of, in pregnancy, 36 inertia of, see Inertia inflammation of, 532 injections into, 227 ^ causing sudden death, 227 to induce labour, 363 in post-partum haemor- rhage, 482 in septicaemia, 531 injurv to, 489 internal surface of, in puerperium, 212 introduction of hand into, 196 inversion of, see Inversion involution of, 213 after ^.bortion, 309 irrigation of, 227, and see Injections into Uterus isthmus of, 42 lacerations of, 489 lateral deviation of, 41 length of, after delivery, 208, 213 ligaments of, in labour, 100 in pregnancy, 47 post-partum, 213 lower segment o', 42 after delivery, 209 bulging of anterior wall of, 454 lymphatics of, 44 m.alLrmation of, 293, 459 management of, in third stage, 195 measurements of gravid, 36, 66 post-partum, 208 mucous membrane o'", after labour, 212 in puerperium, 215 muscle of, changes in, during pregnancy, during puerperium, 214 muscularlay^rs of, 41 myoma of, se; Fibroid nerves of, in pregnancy, 44 nipping of, in labour, 428 nulliparuus, 225 obliquity of, 41 causing face presentations, 154 fle.xion o' head, 133 one-horned, 294 OS of, see Os Uteri over-.-etraction of, 409 effects on child, 430 parous, 224, 225 passive inversion of, 487 perforation of, from pressure, 273 pigment on inner surface of, 215 plugging of, for hajmorrhage, 483 polarity of, gg polypus of, fibroid, 457 mucous, 288 placental, 308 position of, in ditTcrent postures, 197 Uterus, posterior wall of, bulging of, 455 post-partum condition of, 208 pressure on, in haemorrhage, 482, 484 prolapse of, in pregnancy, 278 in puerperium, 20S puncture of, 490 relaxation of, 97 removal of, 290, and see Porro's Opera- tion retraction of, 97, 208 exxessive, in obstruction, 409 premature, 414 retroflexion and version, see Retroflexion and Retroversion rupture of, Sre Rupture of Uterus sarcoma of, 577 after second stage, 1 19 in septicaemia, 532 septus, 294 shape of, after delivery, 224 gravid, 36 affecting lie, 34 signs of delivery in, 224 sinking of gravid, 209, 213 sinuses of, 43, 214 after labour, 214 proliferation of endothelium ofi 43 thrombosis of, 43, 214 size of gravid, at different months, 36 nullip rous, 36 souffle of, see Souffle subinvolution of, after abortion, 309 subperitoneal emphysema of, 555 subseptus, 293 tenderness, post-partum, 208 tetanus of, 409 thickness of walls of, at term, 36 after third stage, 126, 127, 208 in third stage, 120 tonic contraction of, 409 tumours o'', 288, 455 causing dystocia, 455 tympanites of, 502 unicornis, 294 veins of, 42 changes in, during pregnancy, 42 vessels of, 42 changes in, during pregnancy. 42 . . changes in, during puerperium. 1 2 14 walls of, after labour, 210 weight of, 36 VaccIxVATIon in pregnancy, 301 effect on ftetus. Vagina after labour, 212 atresia of, 458 cancer of, in pregnancy, 291 changes in, after labour, 215 during pregnancy. 46 during puerperium. 215 colour of, in pregnancy, 46 contractions of, 100, 173 cystocele of, 457 cysts of, 458 disinfection of, during labour, i88 displacement of, in labour, 457 pregnancy. 279 double, 294 douching of, see Douche duplex, 294 expulsive action of, 100, 173 fistula of, 429 628 Index Vagina, fornices of, 532 ha;matoma of, see Appendix ha;morrhagc from, in new-born children, 239 lia:morrhage from, at labour, 188 inflammation of, ' diphtheritic,' 548 injuries to, in labour, 494 involution of, 215 laceration of, 494 mucous membrane of, in pregnancy, 46 occlusion of, 458 operation in ectopic gestation through, 334 . perforation of, 494 by foetal head, 273 plugging of, 353 in abortion, 311 for placenta prsvia, 348 post-partum condition of, 212 prolapse of anterior wall of, 457 during preg- nancy, 279 purulent discharge from, during labour, 188 rupture of, 273 septa, 294 spasm of, 459 sphincter of, 87 stenosis of, 458 thrombus of, see Appendix tubercle of, 47 ulcers on walls of, 54S veins of, in pregnancy, 47 Vaginal bleeding in new-born children, 239 douches, see Douches examination in pregnancy, 63 labour, 186 growths, 458 incision in ectopic gestation, 334 muscles, 100 orifice, examination of, after delivery, 196 orifice, laceration of, 191 portion, see Portio Vaginalis tampon in hsemorrhage, 353 Vaginismus, 359 Vaginitis, ' diph'heritic, 548 at labour, 188 Valve, Eustachian, of foramen ovale, 235 falciform, 15 of pelvis, 118 Valvular disease in labour, 503 pregnancy, 296, and see Heart Varices, see Varicose Veins Varicose veins of external organs, 283 hjemorrhage from, 283 of legs in pregnancy, 50, 283 n pregnancy, 47, 50, 283 diminution of, after labour, 220 of rectum, 50 Variola in ftttus, 301 pregnancy, 300 Vas aberrans in foetal membranes, 24 Vectis, 386 in occipito-posterior positions, 386 Vein, coronary of placenta, 17 portal, 235 umbilical, 21, 235 Veins, entrance of air into, 555 of leg, thrombosis in, 548 pelvic, in pregnancy, 50 in puerperal septicaemia, 548 \'aricose, see Varicose Veins Velamentous insertion, 28 dangers of, 28 Venesection, 513 in eclampsia, 513 Venosus ductus Arantii, 235 Venous thrombosis, see Veins Vernix caseosa, 31 removal of, 240 Version in accidental ha;morrhage, 340 after craniotomy, 391 perforation, 391 before craniotomy, 392 bimanual, 367 bipolar, 367 Braxton Hicks on, 367 cephalic, 366 combined, 367 in contracted pelvis, 442 contraindications to, 370 external, 366 extraction after, 369 in face presentations, 199 internal, 368 methods of, 366 objects of, 365 in placenta previa, 349 podalic, 366, 367, 368, 369 for prolapse of cord, 517 in shoulder presentation, 473 spontaneous, 469 in transverse lies, 473 Vertebrae in ^po^dylolisthesis, 452 Vertebral column, see Spinal Column hook after perforation, 391 Vertex, positions of, 130 foreign nomenclatures, 13J presentation, 128 caput in, 119 cause of, 34 diagnosis of, 141 frequency of, 120 mechanism of, 128, 141 moulding of he.ad in, 140, 144 occipito-posterior positions of, 142, 143 unreduced, 144 prognosis of, 177 signs of, 141 Vesical calculus in labour, 460 fistula, 429, 567 Vesicle, germinal, 2 umbilical, 9 at term, 16 Vesico-vaginal fistula, causing incontinence of urine, 567 Vesicular mole, 252 Vessels, uterine, after labour, 214 Vestibule, tears in, after labour, 212 Villi, chorionic, 10 in carnecus mole, 248, 250 degt neration of, 26, 248, 252, 256 development of, 10 structure of, 14 vascularisation of, 9 vessels of, 14 placental, 11 degeneration of, 261 Virgin, hymen of, 67 uterus of, 225 Viscerum ectopia, 264, 585 V ision in new-borji child, 239 Vital capacity of lungs in pregnancy, 57 Vitelline duct, 9, 10 persistence of, 584 Volition in new-born child, 239 Vomiting of blood in new-born child due to cracked nipples, 233 caused by pains, 107 Index 629 Vomiting in pregnancy, 55, 59 pernicious, 284 causes of, 284 relation to acute atrophy, 284 symptoms and course, '284 treatment, 285 in septic peritonitis, 538 as sign of pregnancy, 59 Vulva after labour, 212 changes in, in pregnancy, 47 dilation of, 117, iiS, 119 disinfection of, in labour, 184 puerperium, 226 haematoma of, see Appendix inspection of, after laljour, 196 laceration of, 501 oedema of, in labour, 459 pregnancy, see Albuminuria thrombus of, see Appendix- ulcers of, 548 varices of, 47 Walls, abdominal, see Abdominal Walls of uterus, penetration of, by vesicular mole, 254, 256 Water bag of Champetier de P^ibes, 359 hot, in post-partum haemorrhage, 482 intravenous injection of, at term, 36 rectal injection of, 360 Waters, bag of, see Liquor Amnii Weakness of pains, see Inertia Weaning, see Lactation Wedge action of head, 105 Weight of child at term, 30 variations in, 31 variations in, factors governing, 31 changes in, after birth, 238 Weight of child, after immediate ligature, 238 late ligature, 238 gain of, in new-born child, 238 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