COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00063169 ££IZ± AlZ. JSol Columbia (Hntoeraitp intljpCitptjfiUfmgork College of IPfjpsittans anb burgeons librae? Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/americantextbook01came [ section showing the relation of the viscera in their normal positions (Dickinson). (For details see Fig. 22, p. &2.) THE AMERICAN TEXT-BOOK OF OBSTETRICS FOR PRACTITIONERS AND STUDENTS BY James C. Cameron, M.D., Edward P. Davis, M.D. Robert L. Dickinson, M.D., Henry J. Garrigues, M.D., Barton Cooke Hirst, M.D., Charles Jewett, M.D., Howard A. Kelly, M.D., Richard C. NORRIS, M.D., CHAUNCEY D. PALMER, M.D., GEORGE A. Piersol, M.D., Edward Reynolds, M.D., Henry Schwarz, M.D., J. Clarence Webster, M.D. Richard C. Norris, M.D., Editor Robert L. Dickinson, M.D., art Editor WITH NEARLY 900 ILLUSTRATIONS Second lEDition, IRevisefc Vol. I. W. B. SAUNDERS & COMPANY philadelphia ___„ london 925, walnut Street 9, Henrietta St., Strand T - 5>-f N ■elvis and be- longs to the abdominal cavity, to the contents of which it affords support and protection. The true or lesser pelvis is a short curved canal whose superior strait, or inlet, is marked by the brim, a bony ring defined by the anterior border of the promontory of the sacrum behind, the ilio-pectineal lines laterally, and the posterior margin of the pubis in front. The plane of the inferior strait, or outlet, passes through the tip of the coccyx, the tubera ischii, and the lower border of the symphysis pubis. In addition to the foregoing planes marking the upper and lower boundaries of the true pelvis, two others, corresponding with its widest and most contracted parts, are recognized with advantage. The plane of greatest pjelvic expansion extends from the union between the second and third sacral vertebra? behind to the middle of the symphysis pubis in front, its lateral boundaries corresponding on either side with the mid-point of the inner surface of the acetabulum. The plane of least pelvic diameter lies somewhat lower, being defined by lines passing through the saero-coccygeal articulation, the ischial spines, and the lower third of the symphysis pubis: this plane, marking as it does the point of greatest permanent constriction, really constitutes the pelvic outlet in an obstetrical sense more than do the lower and more yielding confines to which the term is usually applied. The superior strait, or inlet, of the true pelvis is slightly cordiform in outline, since the low-arched posterior border of its generally oval figure is encroached upon by the sacral promontory, the indentation, however, being much less in the female than in the male pelvis. The dimensions of the inlet (PI. 2, Fig. 1) are represented by the antero-pos- terior or conjugate diameter of 11.5 centimeters (4J inches), measured from the middle of the promontory of the sacrum to the middle of the upper border of the symphysis pubis, and the transverse diameter of 13.5 centimeters (5f inches), determined by the greatest distance between the ilio-pectineal lines; since, however, the pubic portion of the pelvic brim lies slightly in advance of the posterior surface of the pmbis, the available antero-posterior diameter, or obstetric conjugate, is somewhat less than the anatomical dimension, measuring 11 centimeters (PI. 2, Fig. 2). Supplementary to these measurements, the ob- lique diameters of 12.75 centimeters (5^ inches), measured from the intersection of ANATOMY OF THE PELVIS. Plate 1. The relation between the pelvis and the pelvic organs and the surface of the body : p, promontory of the sacrum ; s, symphysis pubis ; F, fundus of the uterus ; 0, the ovary embraced by the Fallopian tube ; the line of the psoas muscle indicated ; E, the rectum. ANATOMY OF THE PELVIS. Marristal Interspinal Ischial lutwosity __ Transverse \> c/"ac.ruTO— ' 1. Diameters of pelvis at brim, with transverse iliac diameters. 2. Diameters of pelvic outlet. ANATOMY OF THE GENERATIVE ORGANS. 19 the sacroiliac articulation with the ilio-pectineal line to the pubic spine of the opposite side, are usually noted. The measurements of the plane of greatest expansion include an antero-posterior diameter of 12.75 centimeters (5J inches) and a transverse diameter of 12.5 centimeters (5 inches). The plane of least dimensions possesses an antero-posterior diameter of 11 centimeters (4| inches), as measured between the end of the sacrum and the summit of the pubic arch, and a transverse diameter of 11 centimeters (4| inches), taken between the inner surface of the ischial bones near their posterior border; the distance separating the spinse isehii is about 10.5 centimeters (4^ inches). The inferior strait, or anatomical outlet, of the pelvis, although less regular in outline than the inlet, possesses a general ovate form, the smaller end of the figure being directed anteriorly, while its larger end is impressed by the prominence of the coccyx; in addition to the latter point, two other osseous pro- jections, the tubera isehii, aid in denning the boundaries of the outlet. Between Fig. 2. — Female pelvis, viewed from below, with ligaments (one-third natural size) these tuberosities in front is included the subpubic arch, bounded by the pubic and ischial rami, while behind, between them and the sacrum, lie the deep sacro- sciatic notches, which are bridged over and converted into foramina by the greater and lesser sacro-sciatic ligaments (Fig. 2). The dimensions of the plane of the pelvic outlet (PI. 2, Fig. 2) include the antero-posterior diameter of 9 centimeters (3J inches), measured from the tip of the coccyx to the summit of the pubic arch, and the transverse diameter of 11 centimeters (4-| inches), measured between the middle of the ischial tuberosi- ties. It must be remembered, however, that while the antero-posterior diame- ter under ordinary conditions is only 9 centimeters (3J inches), the mobilitv of the coccyx is usually such that this diameter, or obstetric conjugate, is increased to 11 centimeters during parturition (PI. 2, Fig. 2). The cavity of the true pelvis, as appears from the foregoing, is an irregular cylinder of somewhat varying diameter; the imaginary pelvic axis is produced 20 AMERICAN TEXT-BOOK OF OBSTETRICS. by uniting the central points of the antero-posterior diameters of the superior, the inferior, and the intermediate planes above described. The pelvic cavity is enclosed by the smooth surfaces presented by the surrounding bony parts ; its anterior wall, formed by the symphysis and the bodies of the pubic bones, is ccmvex and shorter than the posterior, measuring but little more than 4 centimeters (about 1 J inches) in depth ; its posterior wall, including the con- cave anterior surfaces of the sacrum and the coccyx, is much longer, extend- ing 11.5 centimeters (about 4 J inches) from the sacral promontory to the end of the coccyx. The lateral walls correspond with the broad quadrilateral sur- faces of the ischial bodies, and present an intermediate depth of 9 centimeters (3^- inches). The position of the pelvis, evidently, must vary with the changes in the posture of the body. In the erect attitude the plane of the inlet of the true pelvis is well elevated, forming with the horizontal an angle of about 55° (50° to 60°), the inclination being generally somewhat greater in the female ; the plane of the outlet coincides more closely with the horizontal, subtending with the latter an angle of about 11° (PI. 3, Fig. 1). In the erect position the planes of the perpendiculars let fall from the anterior superior iliac spines and from the symphysis pubis coincide; the base of the sacrum lies about 9 centi- meters (3J inches) above the upper border of the symphysis, the tip of the coc- cyx at the same time being about 2 centimeters (f inch) above the summit of the subpubic arch. The axis of the pelvic inlet is directed forward and upward, toward the umbilicus ; if prolonged downward, it strikes the tip of the coccyx. The axis of the outlet, naturally downward and a little backward, will meet the promontory if extended upward. The plane of the symphysis forms an angle of from 90° to 100° with that of the pelvic brim. The importance of obtaining definite information concerning the dimensions of the pelvis, but, at the same time, the impossibility of determining many of the foregoing measurements on the "living subject, has led to the substitution of external, readily accessible measurements which bear a direct and constant relation to the internal diameters. The most useful of these external meas- urements include — the distance between the anterior superior iliac spines, 26 centimeters ; the distance between the iliac crests, 29 centimeters ; the dis- tance between the greater trochanters, 31 centimeters ; the distance between the spinous process of the last lumbar vertebra and the upper margin of the pubic symphysis, or external conjugate, 20J centimeters ; the distance between the posterior superior spinous process and the anterior superior spinous process of the opposite iliac bone, or the oblique diameter, 22 centimeters ; the distance between the ischial tuberosities, 11 centimeters. These external diameters, which are readily obtained by means of direct measurements by the pelvimeter, bear sufficiently constant relation to the internal diameters to make them of much practical importance. As pointed out by Klein, however, the antero-posterior diameter is subject to considerable normal variation. The aver- age thickness of the bony walls at the points of measurement being known, the subtraction of this amount from the ascertained external diameter evidently ANATOMY OF THE PELVIS. 1. Sagittal section of female pelvis, showing anatomical and obstetrical diameters. 2. Diagram of the structures composim.' the pelvic Hour: 1, pelvic fascia, which at white line splits into rectovesical taseia (2) and obturator fascia (1), a thin additional sheet, the anal fascia iiii, covering the inferior surlace of the levator ani muscle; ft, fi, the superior and inferior layers of the triangular ligament; 7, S, deep and super- ficial layers of the perineal fascia; 9, skin. ANATOMY OF THE GENERATIVE ORGANS. 2"J supplies data con: parable with the recognized average of the internal dimensions. Thus, the distance between the lower edge of the spinous process of the last lumbar vertebra and the middle of the upper margin of the symphvsis, meas- ured by the pelvimeter, is 20 centimeters ; from this are deducted the 9 centi- meters which represent the combined average thickness of the vertebral body and the pubic symphysis, the remaining 11 centimeters corresponding closely with the conjugate of the superior strait as determined by direct measurement. The size of the female pelvis, although presenting many individual varia- tions, is not unfavorably influenced by stature, since short women often possess pelves of more than average breadth. The distinctive characteristics of sex are acquired after puberty, although, according to Fehling, indications of these peculiarities are present even at birth. Some asymmetry of the pelvis, as of other parts of the body, is usually to be detected. Fig. 3.— Male pelvis (slightly less than one-third natural size). The following table exhibits the average dimensions of the fully developed female pelvis, the measurements being taken from the dried pelvis : Centimeters. Greatest distance between crests of ilia 28 Distance between anterior superior iliac spines 25 Distance between last lumbar spine and front of symphysis pubis 20 True Pelvis. Antero-posterior Diameter Transverse Diameter Oblique Diameter (Centimeters). (Centimeters). (Centimeters). Plane of pelvic inlet .... .11. 13.5 12.5 Plane of greatest expansion .... 12.75 12.50 Plane of greatest contraction . . . 11. 11. Plane of pelvic outlet 9.5 (increased to 11.5 cm. n. H 5 by displacement of coccyx). ^ The distinguishing characteristics of the female pelvis (Fig. 1) as contrasted with the corresponding portion of the male skeleton (Fig. 3) include slighter 22 AMERICAN TEXT-BOOK OF OBSTETRICS. bones with less marked muscular impressions ; less height of the entire pelvis ; greater breadth and capacity of the true pelvis, but, owing to the more verti- cally placed iliac bones, relatively and absolutely less expansion of the false pelvis than in the male (Thane). Both the inlet and the outlet are larger in the female, the outline of the pelvic brim approaching more nearly the circular form, owing to the slighter projection of the sacral promontory. In the female pelvis the sacrum is broader and less concave, the depth of the symphysis is less, and the subpubic arch is wider, embracing from 90° to 100° as against 70° in the male. In addition to individual peculiarities, the influences of race markedly impress the general form of the pelvis, particularly the relation of the antero- posterior to the transverse diameter : the broad, cordiform outline of the Caucasian female pelvis is replaced by one nearly circular among the native Australians ; among the Bushman and Malay women the usual ratio between the conjugate and transverse diameters becomes so altered that the outline of the pelvis is an upright oval, the antero-posterior dimension surpassing the transverse. Articulations of the Pelvis. — The component bones of the pelvis are united with one another by four articulations (Fig. 4) : one in front, between Fig. 4.— Female pelvis (viewed from above) with ligaments (one-third natural size). the two pubic bones ; two behind, between the iliac bones and the sacrum ; and one between the sacrum and the coccyx. The opposed bony surfaces are closely united by fibro-cartilaginous plates and external ligamentous bands, and admit of very limited motion ; these articulations, therefore, are usually classed as amphiarthroses or symphyses. The pubic articulation, or symphysis pubis (Figs. 5, 6), is formed by the approximation of the two oval articular facets occupying the mesial borders of the pubic bones, which are connected by the interposed fibrous disk and thesur- ANATOMY OF THE GENERATIVE ORGANS. 23 rounding external ligaments. The slightly convex surfaces are covered with plates of cartilage which fill up the inequalities of the bones, the opposed sur- faces being held together by the intervening mass of fibrous tissue and fibro-car- n , ^ Fig. 5.— Section across symphysis pubis, showing interpubic disk (Lusk). tilage constituting the interpubic disk (Fig. 5). This layer, which projects ante- riorly and posteriorly beyond the adjacent bony margins, is thickest in front ; the deficiency of the intermediate tissue above and behind sometimes results in the formation of an interspace or fissure. The fis- sure within the interpubic disk extends usually about half the length of the cartilage, and is produced during life by the absorption of the fibro-cartilage : it appears after the seventh year, and is of larger size and more constant in the female. While undue tension exerted upon the joint during labor may jjredispose to the production of this fissure, the latter is not a sequence necessarily of pregnancy, as is shown by its existence in pelves of males and of virgins. A slight separation of the pubic symphysis during pregnancy is regarded by many as probable; this tendency, however, is reduced to a minimum through the bracing effected by the decussating fibres of the oblique muscles. The external ligaments which additionally strengthen this articulation are the ante- rior, the posterior, the superior, and the inferior. The anterior pubic ligament, of considerable thickness, consists of several strata of interlacing fibres, the deepest of which passes directly across between the bones in front of the interpubic disk, with which they are blended ; the superficial layers include oblique interlacing fibres continued from the tendons of the external oblique and the recti muscles, and of the more superficial adductors of the thigh. The posterior pubic ligament consists of a few sparingly distributed fibres which unite the bones behind, and it is little more than the somewhat thick- ened periosteum. The superior pubic ligament is represented by a meagre bundle of fibres occupying the upper surface of the articulation. Fig. 6.— Frontal section through symphysis pubis, exposing interpubic cleft (Farabeuf). 24 AMERICAN TEXT-BOOK OF OBSTETRICS. The inferior or subpubic ligament, on the contrary, is thick and triangular in form, and it contributes the smooth boundary to the summit of the sub- pubic arch. Throughout the middle of its span the ligament is closely united Fig. 7.— Anterior view of symphysis pubis. with the interpubic disk, being attached at the sides and below to the descend- ing pubic rami (Fig. 7). The sacro-iliac articulation (Fig. 8) lies between the lateral surfaces of the sacrum and the ilium ; the rough articular surfaces of both bones are covered by thin plates of cartilage, that on the v •..,'« 'Vfl".; 5*.:' V . . sacrum being thickest. With the ad- vance of age these cartilages often be- come roughened and partially separated by spaces containing a glairy fluid. Not infrequently the apposed bones are united by intervening bundles of fibrous tissue, these bands constituting the interosseous ligament. The prin- cipal bonds of union are the anterior and posterior ligaments. The anterior sacro-iliac ligament comprises a number of thin irregular fibrous bundles stretching between the front of the sacrum and the adjacent border of the iliac bone. Associated with the upper and lower margins of this ligament are thickened bundles of fibrous tissue that spread over the ilium respectively as far as the ilio-pectineal line and the posterior iliac spine ; Fig. 8. — Section through the left sacro-iliac articu- lation (Luschka). ANATOMY OF THE GENERATIVE ORGANS. 25 these bands constitute the superior and the inferior sacro-iliac ligaments some- times described. The posterior sacro-iliac ligament, which is of great strength, extends be- tween the back of the sacrum and the posterior border of the iliac crest. The general direction of the fibres is downward and inward from the ilium ; some of the fasciculi, however, pass almost horizontally, while a special bundle extends nearly vertically from the posterior superior iliac spine to the third and fourth sacral segments, and forms the oblique sacro-iliac ligament. The sacro-coccygeal articulation includes the oval facet at the end of the sacrum and the base of the coccyx, and it corresponds in its ligamentous struct- ures with the intervertebral joints, to which series it belongs. The bones are united by the anterior, the posterior, and the lateral bands as well as by the interposed intervertebral disk. The anterior sacro-coccygeal ligament is the continuation of the anterior common ligament of the vertebras, and it consists of a few irregular bands of fibrous tissue that pass from the anterior surface of the sacrum to that of the coccyx to blend with the periosteum. The posterior sacro-coccygeal ligament, stronger than the preceding, is the prolongation of the posterior common ligament, and it descends from its attach- ment around the lower orifice of the sacral canal, the lower hind wall of which it largely forms, to the posterior surface of the coccyx. Additional posterior bands descend from the sacrum to the coccyx as con- tinuations of the interspinous ligaments intimately blended with the aponeuro- sis of the erector spinas ; the lateral expansions which connect the cornua of A. o - 1 Jt -' Fig. 9. — Variation in sacral curves (Hirst) : P, promontory of sacrum ; C, coccyx. the last sacral segment to the coccygeal cornua constitute the supracornual or lateral ligaments. The intertransverse ligament is represented by fibrous bands which pass from the lower lateral angle of the sacrum to the transverse pro- cess of the first piece of the coccyx. The intervertebral disk is a rudimentary member of the series of fibro-car- tilaginous plates interposed between the vertebras ; a distinct cavity sometimes exists within this disk (Cruveilhier), especially when the coccyx is freely movable ; this mobility seems increased during pregnanev. 26 AMERICAN TEXT-BOOK OF OBSTETRICS. The coccygeal segments are held together by the extensions of the anterior and posterior ligaments and by the rudimentary intervertebral disks which lie between. The individual pieces remain distinct in the female during early adolescence, but become united by the close of the childbearing period ; in later life ossification between the sacrum aud the coccyx sometimes takes place. Closely associated with the boundary of the true pelvis are the important sacro-sciatic ligaments. The great or posterior saero-sciatic ligament extends from the posterior inferior spine of the ilium, the lower tubercles of the sacrum, and the inferior portion of the lateral border of the sacrum and the coccyx to the inner mar- gin of the ischial tuberosity, whence the fibres are continued along the inner edge of the adjoining ramus as the falciform process, the concave border of which affords attachment for the obturator fascia. The lesser or anterior saero-sciatic ligament, triangular in form, passes from its wide attachment on the lateral margin of the sacrum and the coccyx to the spine of the ischium, thus dividing the large space enclosed by the great sacro- sciatic ligament into an upper larger opening, the great sacro-sciatic foramen, and a lower smaller aperture, the lesser sacro-sciatic foramen. The anterior boundaries of these foramina are respectively the greater and lesser sacro- sciatic notches of the innominate bone. Muscles of the True Pelvis. — The osseous and ligamentous framework of the true pelvis is supplemented by muscles and fascia which complete its boundaries as well as somewhat lessen its capacity, these structures, however, being so located that they but slightly diminish the size of the parturient canal. In order to facilitate a study of the fasciae, a consideration of the muscles related to the cavity and floor of the true pelvis first claims attention. These muscles, on each side, are four in number — the obturator internus, the pyriformis, the levator ani, and the eoccygeus. The obturator internus muscle (PI. 3, Fig. 2) comes in close relation with the pelvic cavity throughout a considerable part of its extended origin, which in- cludes almost the entire part of the pelvis contributed by the innominate bone. The muscle arises from the inner surface of the obturator membrane, except at its lower part, the fibrous arch completing the canal for the obturator vessels and nerve, and the inner surface of the innominate bone anteriorly and internally between the obturator foramen and the margin of the pubic arch, and poste- riorly and externally from the foramen as far as the ilio-pectineal line above and the sacro-sciatic notch behind. The external surface of the muscle rests upon the hip-bone and the obturator membrane ; its inner or pelvic aspect, below the line of origin of the levator ani muscle, is covered by the obtura- tor fascia, the continuation of the pelvic, and comes in relation with the internal pudic vessels and accompanying nerve. The pyriformis muscle arises by digitations from the second, third, and fourth sacral segments between and external to the anterior sacral foramina, from the ilium below the inferior posterior spine, and from the great sacro- sciatic ligament. In its course to the great sacro-sciatic foramen, through ANATOMY OF THE GENERATIVE ORGANS. 27 which the muscle escapes from the pelvis to seek insertion into the femur, its fan-shaped mass aids in forming the posterior and outer wall of the pelvic cavity. The remaining two muscles, the levator ani and the coccygeus, are of especial interest, since they largely supplement the fascia? in the formation of the septum, or pelvic diaphragm, which stretches across the bony canal and materially aids in supporting the vagina and the rectum and in the constitution of the floor of the pelvis. The levator ani (Figs. 10, 11), the most important muscle of the pelvic dia- phragm, in general, with its fellow of the opposite side, presents the form of a horseshoe, open in front, rather than that of a funnel, as very commonly stated. The true relations of this muscle have especially been emphasized by Luschka Fig. 10.— Female pelvis, showing the form and attachments of the levatores ani muscles (Dickinson). and by Dickinson, whose descriptions are here utilized. These two muscles con- stitute a sling attached to the pubis in front, and, sweeping almost horizontally backward, embrace the vagina and the rectum and become attached posteriorly to the coccyx. While fulfilling the function indicated by its name, the action of Fig. 11.— Female pelvis, showing the levatores ani muscles from before and below (Dickinson). the levator ani is especially to drag the lower ends of the vagina and rectum forward to the level of the symphysis. The muscle consists of numerous thin flat bundles often separated from one another by intervals filled by connective 28 AMERICAN TEXT-BOOK OF OBSTETRICS. tissue, by means of which all are united into a membranous sheet, the regu- larity of which, however, is usually interrupted by the variations in the planes of attachment of the median ends of the component muscular bands. The origin of the levator ani is partly bony and partly fascial. The bony origin provides for the anterior and posterior portions of the muscle, the intervening and most extended part arising from the tendinous arch which bridges over the obturator interims. The anterior portion takes origin principally from the horizontal ramus of the pubis, about 1.25 centimeters (\ inch) from the middle of the symphysis, and 3.5 centimeters (If inches) below the upper border of the ramus. The posterior portion is narrow, being little over .5 centimeter (about J inch), and arises from the inner side of the ischial spine in front of the origin of the coccygeus. The broad intervening portion of the muscle springs from fascia along a curved line extending from the back of the pubis to the ischial spine, the low- est point of its sweep lying 5.5 centimeters (21 inches) below the ilio-pectineal line. This curved line of tendinous origin closely corresponds with the posi- tion along which the division of the pelvic fascia divides into the inner recto- vesical lamella and the obturator, the line of sepai'ation being marked by thickening of the fascia which produces the tendinous marking or the " white line." The origin of the muscular fibres is by tendinous bands,. which may not, however, although closely associated, be directly connected with the line. The course of the fibres of the various parts of the muscle varies : stretch- ing down and back, the fibres divide into unequal portions, of which one passes to the anterior aspect of the rectum, another to its posterior and lateral surfaces, while the fibres attached to the pubic bone extend along the vagina, with which they are united by strong connective tissue, but do not terminate within its walls. The belly of the muscle sweeps backward, almost horizon- tally, surrounding the rectum, the margins or edges of the musoular band being often especially thickened ; when hypertrophied, as this portion of the muscle sometimes is, severe vaginismus, dyspareunia, and dystocia may result. Accord- ing to the observations of Dickinson, the inner edge of the levator ani lies about 1.5 centimeters from the vaginal orifice, the position of the muscle being indicated by a sharply defined double band. Contraction of the muscle causes the upper end of the vaginal canal to rise from 15° to 20° toward the pelvic brim. The average muscle exerts a power of ten pounds. The insertion of the post-rectal part of the levator ani varies with its posi- tion : the posterior and smallest part is attached by tendon to the front of the fourth coccygeal vertebra ; the middle part becomes aponeurotic and joins its fellow at the tip of the coccyx ; and the anterior and largest part unites directly, without tendinous structure, with the muscular bundles of the oppo- site side. The coccygeus muscle supplements the levator ani behind, presenting a tri- angular sheet which passes from the ischial spine to the adjacent surfaces of the coccyx and the sacrum. The muscle arises by its apex from the spine of the ischium and from the inner surface of the pelvic fascia, and expands to be ANATOMY OF THE GENERATIVE ORGANS. 29 inserted by its base into the lateral margin of the coccyx and the lower part of the sacrum. The pelvic surface of this muscle aids in supporting the rec- tum, and its external surface is closely related with the lesser sacro-sciatic ligament. Fasciae of the Pelvis. — The pelvic fascia is the direct continuation of the iliac and transversalis fascial sheets. It is attached laterally along the pelvic brim and around the origin of the obturator interims, and behind it extends over the pyriformis and the adjacent nervous trunks as far as the sacrum ; anteriorly it closely follows the outline of the obturator interims, aids in bounding the inner opening of the obturator canal, and at the lower part of the pubic symphysis becomes attached to the anterior pelvic wall. A thickened baud of light colored fascia, the so-called "white line" (see p. 28), which extends from the lower part of the posterior surface of the symphy- sis to the ischial spine, indicates the position along which an inner or visceral Fig. 12.— Sagittal seclion showing relations of the several layers of fascia within the pelvic floor (Dickinson). lamella, the recto-vesical fascia, diverges from the parietal or main pelvic sheet ; the latter, which adheres to the pelvic wall and covers the obturator interims muscle, is now known as the obturator fascia; the latter, therefore, is that part of the parietal lamella of the pelvic fascia that lies below the " white line " and forms the external fascial investment of the ischio-rectal fossa, the deep triangular recess included between the ischial tuberosity and the contiguous parts of the innominate bone and the external and inferior sur- face of the muscles of the pelvic diaphragm. A thin sheet given off from the parietal layer or obturator fascia below the ''white line" covers the under 30 AMERICAN TEXT-BOOK OF OBSTETRICS. surface of the levator ani muscle and constitutes the anal or ischiorectal fascia. The internal pudic blood-vessels and the accompanying nerve in their course across the outer wall of the ischio-rectal fossa are invested by an additional special layer of the obturator fascia, which thus separates the vessels from the fossa and encloses them within Alcock's canal. The visceral lamella, or the recto-vesical fascia, is, as pointed out by Webster, a structure of great importance in enabling the pelvic floor to resist inter- abdominal pressure at the pelvic outlet. Springing from the parietal layer along the " white line," the recto-vesical fascia covers the inner and upper sur- face of the levator ani and continues over that muscle to the bladder, the vagina, and the rectum, where it divides into four layers — the vesical, the vesico-vaginal, the recto-vaginal, and the rectal. The vesical layer expands over the lower lateral aspect of the bladder, forming of that organ the lateral true ligaments, which become greatlv thinned out as they pass over its walls. The anterior part of the visceral lamella on each side is attached to the back of the lower part of the pubis in front, lat- erally to the symphysis, and behind passes to the anterior surface of the bladder to become the anterior true ligament of this organ : the "space between these bands, the pubis, and the bladder, sometimes called the " space of Retzius," is occupied by the retropubic tissue, consisting principally of adipose and areolar tissue. The vesico-vaginal layer extends between the bladder and the anterior vaginal wall, and aids in connecting these parts by its firm union with both, blending with the attachment of the posterior part of the bladder to the uterine cervix. The recto-vaginal layer passes between the vagina and the adjacent wall of the lower part of the rectum ; the union, except behind the upper part of the vagina, is very intimate, while below, this layer is continuous with the fibrous tissue of the perineal body. ' The rectal layer extends behind the rectum and is attached to its walls, becoming continuous with the corresponding layer of the opposite side. The Pelvic Floor. — The exact structures which should be regarded as taking part in the constitution of the pelvic floor has occasioned much dis- cussion, since by some authors its constituents are limited to those structures which directly contribute to the continuity of the septum closing in the pelvic outlet, while by others all parts directly or indirectly contributing to the support of this septum, as the bladder, the upper part of the vaginal canal, the uterus, and the rectum, are included within the category of the floor. In the present consideration of the pelvic floor only those structures will be included that directly contribute to its formation, thus excluding, with Symington, the bladder and the uterus, and reckoning as belonging to the floor only those portions of the walls of the vagina and of the rectum that lie inti- mately united with the septum. The close relation which these excluded organs bear to the pelvic floor, however, must not be overlooked, since by their intimate connection with the tissues of the floor, on the one hand, and by ANATOMY OF THE GENERATIVE ORGANS. 31 their suspensory apparatus, on the other hand, they exert an important influ- ence, as emphasized by Webster, in supporting the tissues closing the outlet of the pelvis. The pelvic floor, in the sense here accepted, is bounded externally by the skin and internally by the peritoneum, and includes the several intervening structures which stretch across between the osseo-ligamentous boundaries of the pelvis and enclose the irregular outlet of its cavity. Viewed in mesial sagittal section, the floor is seen to be divided by the vaginal slit into two portions, an anterior and a posterior, which have been designated by Hart, respectively, as the pubic and the sacral segments. The anterior or pubic segment appears triangular, being attached to the pelvis in front, and including the structures lying between the symphysis and the vaginal orifice ; the urethral and the anterior vaginal walls, together with the dense intervening fibrous tissues, contribute largely to this portion of the floor. The posterior or sacral segment includes the structures between the vaginal orifice and the posterior bony pelvic wall, to the sides of which it is closely attached. The portion of this segment interposed between the vaginal slit and the anus constitutes the important perineal body (Fig. 13), whose elastic yet resistant tissues enable the septum to undergo great distention during labor. The perineal body is triangular in sagittal section, and its boundaries are the posterior vaginal wall in front, the anterior wall of the rectum behind, and the integument between the vagina and the anus below. The base of the perineal body measures about 2.6 cen- timeters, and the height from 3.0 to 3.6 centimeters. In addition to the strong bundles of fibro-elastic tissue and invol- untary muscle that constitute the body, it is traversed by the muscles which join in the common tendinous perineal centre. The female perineum proper — by which term is to be understood the anterior portion of the pelvic floor included between the ischio-pubic rami as far back as a line drawn through the tubera ischii — corresponds in general with the similarly situated structures in the male, subject to the modifica- tion brought about by the mesial cleavage of the parts by the vulvo-vaginal opening. The perineum must be distinguished from the perineal body, the latter including only the limited tissues intervening between the vagina and the anus. As in the male, so also in the female perineum, the fascia? constitute im- portant and resistant structures (Figs. 14-16). Of these structures there are three : the deep layer of the superficial fascia (corresponding with Colles' Fig. IS.— Sagittal section of the perineal body, showing its component structures (life size). 32 AMEBIC AX TEXT-BOOK OF OBSTETBICS. fascia), the superficial or inferior, and the deep or superior layer of the trian- gular ligament. These fascial layers are attached at various levels to the ischio-pubic rami anteriorly and laterally, and converge as they proceed back- External j Internal superficial rineal j Superficial perineal Infer rhoidal artery. rhoidal . Tendinous centre of Fig. 14.— Superficial structures of the female perineum (Weisse). ward to become continuous at the posterior free border of the so-called " peri- neal shelf," the middle of which marks the perineal centre. The interval enclosed between the superficial fascia and the superficial or inferior layer of the triangular ligament is divided by the genital orifice into two triangular spaces which together correspond with the superficial perineal interspace. The various structures contained within this space include the crura of the clitoris with the associated ischio-cavernosus muscles ; the bulbi vestibuli, with the sparingly developed constrictores vagina, the homologues of the bulbo-cavernosus; the superficial transversi perinsei; the glands of Bar- tholin ; together with the superficial perineal vessels and nerves. On removal of the skin and the superficial fascia the ischio-cavernosus muscles appear as slender bands which arise from the inner surface of the tuberosities and rami of the ischium and the pubic rami, and converge toward the anterior commissure of the genital fissure, to be inserted into the cavernous bodies of the clitoris, these muscles corresponding closely with those of the male except in size, their reduced dimensions agreeing with the diminutive clitoris. The bulbo-cavernosus, or constrictor vaginae muscle, is represented by atten- uated fibres which pass on either side of the vaginal orifice over the bulbi ves- tibuli and the slender stalks connecting them with the clitoris. The action of these fibres seems to be largely confined to exerting pressure upon the adjacent ANATOMY OF THE GENERATIVE ORGANS. 33 masses of erectile tissue, with little, if any, direct role as constrictors of the vagina, compression of this canal being exercised, as already stated, by the contractions of the anterior portions of the levator ani muscle. The superficial transversus' perincei muscles closely resemble those of the male, being, however, reduced in size. They arise from the inner surface of the tuberosities and rami of the ischium, in close relation with the origin of the ischio-cavernosi, and extend inward toward the perineal centre, where they blend with the fibres of the sphincter ani and the constrictores vaginae. The roof of the superficial interspace is formed by the inferior or superficial layer of the triangular ligament, the somewhat thickened anterior part of the Dorsalartery of clitoris. Inferior pudendal Inferior hemorrhoidal Inferior hemorrhoidal Fig. 15.— Dissection of female perineum: on the left side the perineal muscles are exposed by the reflection of the perineal fascia ; on the right side the muscles and the superficial layer of the triangular ligament have been removed, thereby exposing the deep layer of the ligament (modified from Weisse). deep fascia of the perineum. This layer is attached antero-laterally to the pubo-ischial rami above the line of attachment of the superficial fascia, and stretches almost horizontally across the subpubic arch to the posterior perineal border, where it fuses with the other layers taking part in the perineal ledge. The superior or deep layer of the triangular ligament is a resistant fibrous septum which expands inward on each side from its line of attachment along the ischio-pubic rami and constitutes the floor of the anterior extensions of the ischio-rectal fossse, at the posterior margin of the perineal ledge joining the superficial layer in the common fusion of the fascial layers occurring at that point. This layer may be regarded as a reflection derived from both the obturator and the recto-vesieal fascia, since the septum is formed by the union of the contribution given off laterally from the obturator fascia with that sup- 34 AMERICAN TEXT-BOOK OF OBSTETRICS. plied mesially by the recto-vesical fascia : this relation is especially evident in frontal sections passing through the ischial tuberosities. The deep perineal interspace lies between the inferior and superior layers of the triangular ligament, and it contains within its wedge-shaped area the urethra and the surrounding venous plexuses, the internal pudic arteries and accom- panying veins and deeper nerves, and the fibres of the deep transversus peri- nsei muscle, here divided by the genital fissure, and represented by thin groups of variable muscular tissue surrounding the urethra. On removing the skin and fascia, that part of the pelvic floor lying poste- rior to the perineum proper is divided by a median ridge extending from the ^J*** I .<0f • m Fig. 16.— Dissection of female perineum, showing the deeper structures after removal of the levator and sphincter ani muscles (much modified from Weisse). perineal centre to the tip of the coccyx, that consists of the lower end of the rectum surrounded by the deep muscular band of the sphincter ani externus. This muscle comprises voluntary fasciculi which extend from the perineal centre in front, where they blend with the fibres of the superficial transverse perineal and vaginal constrictor, to the tip of the coccyx behind, enclosing the anus in their course. Superficially the anal sphincter is closely related with the integument, deeply with the levatores ani and the internal sphincter ; the muscular tissue of the rectum is closely related to the external sphincter, since numerous bands of the former blend with the encircling fasciculi of the sphincter. Externally the anal sphincter comes in contact in its deeper parts with the tissue occupying the ischio-rectal fossse ; the latter extend as two ANATOMY OF THE GENERATIVE ORGANS. 35 deeply receding spaces whose superior boundary follows the lower surface of the levatores ani. The ischio-redal fossce are continued anteriorly and posteriorly within the pockets situated respectively above the triangular ligament and the sacro-sciatic ligaments. Viewed in sagittal sections passing through these recesses, the Fig. 17.— Dissection of female perineum, showing superficial blood-vessels and nerves (Savage) : C, clitoris; M, meatus urinarius ; V, vaginal orifice; A, anus; 0, coccyx; T, tuber ischii; L, sacro-sciatic ligament ; 1, 6, internal pudic artery, giving off its inferior hemorrhoidal (3), cutaneous, and muscular branches (2, 4) ; 5, superficial perineal ; S, artery of bulb ; 7, 9, terminal branches going to dorsum and cavernous bodies of clitoris ; 10, pudic nerve ; 11, hemorrhoidal and muscular (12) branches ; 13, 14, inter- nal and external superficial perineal nerves ; 15, communications with inferior pudendal nerve (16) ; 17, continuation of deep branch of pudic nerve, terminating as dorsal nerve of clitoris (IS) ; 19, terminal twigs of ilio-inguinal nerve ; 20, small sciatic; 21, cutaneous branches; a, cut surface of gluteus maxi- mus; 6, sphincter ani; c, levator ani; d, transversus perinei ; e, bulbo-cavernosus ; /, gracilis; g, ischic- cavernosus ; h, expansion of cms clitoridis ; i, adductor magnus. ischio-rectal fossa presents an outline, as described by Anderson, not unlike that of an anvil. In frontal sections the fossa appears as an open A-shaped recess except at its extreme ends, where, as just described, the perineal ledge and the sacro-sciatic ligaments close in the space below. The blood-vessels of the pelvic floor include the arterial branches derived 36 AMERICAN TEXT-BOOK OF OBSTETRICS. directly or indirectly from the anterior division of the internal iliac, and the venous trunks accompanying the arteries, as well as the venous plexuses occur- ring in close relation with the vesico- vaginal walls (Fig. 17). The inferior vesical and the vaginal arteries, together with twigs from the external pudic, supplement the branches derived from the internal pudic, of which the inferior hemorrhoidal and the superficial perineal especially supply the muscular structures connected with the pelvic floor. The superficial peri- neal artery pierces the superficial fascia and gains the superficial perineal interspace, supplying the contiguous structures and giving off the transverse perineal branch. The continuation of the internal pudic artery maintains a more deeply situ- ated course, lying along the lateral boundary of the deep perineal interspace between the two layers of the triangular ligament. In this position are given off the arteries of the vestibular bulbs and of the crura of the clitoris. The internal pudic terminates, after piercing the anterior layer of the triangular ligament, as the dorsal artery of the clitoris, from which twigs extend to the corpus cavernosum, the glans, and the prepuce. The veins of the pelvic floor consist of the trunks which closely correspond with the arteries, of which veins the most important are the tributaries of the pudic vein and those which pursue an independent course and take part in the formation of the rich vesico-vaginal and hemorrhoidal plexuses. The nerves supplying the structures of the floor are derived principally from branches of the sacral nerves, either directly or after their formation of the plexus, supplemented by some few filaments from the ilio-inguinal as well as by numerous branches from the neighboring hypogastric plexus of the sympathetic (PI. 4). The anterior division of the fourth sacral nerve supplies important muscu- lar structures, including the levator ani, the sphincter ani, and, in conjunction with the fifth sacral, the coccygeals. The superficial perineal branches of the pudic and the inferior pudendal branch of the small sciatic nerve chiefly provide for the integument and the more superficial structures of the pelvic floor, including the perineal muscles (the ischio-cavernosi, the constrictor vaginae, and the transversi perinsei) and the more external portions of the genitalia; the ilio-inguinal contributes fila- ments to the labia. The termination of the pudic nerve passes forward as the diminutive dorsal nerve of the clitoris. Sympathetic filaments from the hypogastric plexus are additionally distributed to those parts containing abundant vascular tissue. II. Anatomy op the Female Generative Organs. The structures constituting the female reproductive apparatus consist of three groups — (1) the external, ("2) the intermediate, and (3) the internal generative organs. 1. External organs of generation (PI. 5), or the genitalia, include the mons veneris, the labia majora and minora, the clitoris, the vestibule with the ANATOMY OF THE PELVIC FLOOR. Plate 4. ANATOMY OF THE GENERATIVE ORGANS. 37 meatus urinarius, and the vaginal orifice. These parts are collectively known as the vulva or pudendum. The mons veneris presents au eminence surmounting the pubes in advance of the vulva, and is composed of stout integument abundantly supplied with crisp hairs, and a thick cushion of subcutaneous adipose and areolar tissue upon which the rounded contour of the part depends. The labia majora, the homologues of the scrotum in the male, are two con- spicuous longitudinal folds of integument extending from the mons veneris downward and backward to within about 2.5 centimeters (1 inch) in front of the anus. The elongated fissure included between these folds, the uro- genital orifice, occupies almost a horizontal position in the erect posture, and is limited by the anterior and the posterior commissure, formed by the union of the labia in front and behind. Immediately within the posterior commissure a crescentic fold extends transversely and constitutes the fourchette ; the space between the latter and the posterior commissure is the fossa navicularis. The labia majora are continuous anteriorly with the mons veneris, and are thicker in front than behind ; they present, the usual appearance of integument, being covered on their outer surfaces with scattered hairs and pigmented epidermis ; their protected inner surfaces are more delicate in texture than their outer surfaces, and where least exposed they partake somewhat of the character of a mucous membrane. The tegmental fold of each labium includes areolar tissue, some involun- tary muscle, and a considerable mass of fat which receives the distal end of the round ligament of the uterus. Descent of the ovary into the labium occurs in very exceptional cases, the displaced organ following the round ligament and taking up a position within the labium after traversing the inguinal canal. The labia in the young and well-developed subject are closely approximated and occlude the vaginal orifice. The labia minora,, or the nymphce, are two thin diverging folds of delicate skin that lie protected within the greater labia, so that their arched free borders are often completely covered and not visible externally ; unless arti- ficially separated their mesial surfaces lie in close contact. The nymphse are subject to great individual variation in size, in some cases, as conspic- uously seen in Hottentot women, reaching excessive dimensions ; usually they extend downward and backward from the clitoris (about 3.5 centimeters) along the genital fissure, fading away at the sides of the vaginal orifice. Directly continuous with the labia majora externally, their smooth inner surfaces pass directly into the mucous membrane of the adjacent vestibule, which they closely resemble in appearance and structure. Vascular papilla? and well-developed sebaceous follicles are common to both surfaces of the nymphse, but sweat-glands, hairs, and fat are wanting. The interior of each fold contains abundant venous spaces, which, in connection with the unstriped muscle present, produce a structure resembling erectile tissue. The converging and often unsymmetrical labia minora, just before meeting anteriorly, separate into two divisions, the outer and upper leaflets continuing 38 AMERICAN TEXT-BOOK OF OBSTETRICS. over the clitoris to unite to form the preputium clitoridis, the lower or inner lamina? joining below the glands to constitute the frenum clitoridis. The clitoris, the homologue of the penis, presents great similarity to the male organ, possessing all the parts of the latter reduced in size and influenced by the absence of the urethra and by the cleft and modified condition of the corpus spongiosum as represented by the bulbi vestibuli. The somewhat laterally compressed body of the clitoris consists of the dimin- utive corpora cavernosa, which diverge behind and are attached by their crura along the pubic and ischial rami, the suspensory ligament aiding in maintain- ing the position of the organ. In front the cavernous bodies are capped by the rounded glans clitoridis, which contains papillae occupied by arterial tufts and the peculiar special nerve-endings, the genital corpuscles. The nerves of the clitoris are relatively better developed than the corresponding ones of the penis, the organ being the especial seat of voluptuous sensation. Sebaceous follicles surround the glans, and they are also present in the outer layer of the prepuce, being almost wanting, however, on the glans itself. These follicles secrete substances prone to decomposition and to the production of a peculiar odor. The erectile tissue constituting the diminutive corpora cavernosa and the glans corresponds in structure with similar tissues within the penis. Two small muscles, the ischio-cavernosi or erectores clitoridis, extend from the ischial tuberosities to be inserted in the crura of the clitoris, and correspond with the homologous muscles of the male. The vestibule includes the triangular space lying between the clitoris in front, the vaginal orifice behind, and the nymphse at the sides. Its smooth mucous surface is broken by the urethral opening, the meatus urinarius being situated in the mid-line of the posterior vestibular wall about 2 to 2.5 centimeters (1 inch) behind the clitoris, slightly in advance of the orifice of the vagina. The urinary meatus varies in form, but oftenest appears as an ovoid cleft, frequently presenting short irregular lateral branches, surrounded by a border of slightly corrugated elevated mucous membrane, due to the encircling ring of muscular fibres (PI. 5). The bidbi vestibuli are two elongated leech-shaped masses (about 2.5 centi- meters in length) situated on either side of the vestibule a little behind the nymphse, and attached above to the crura of the clitoris by means of a con- tracted intermediate portion, thenars intermedialis. They are composed prin- cipally of close and intricate venous plexuses corresponding with the tissues of the male corpus spongiosum, of wdiich part the bulbi vestibuli must be regarded as the cleft homologue. The constrictores vaginas muscles lie in close relation with the bulbs, and by their contractions, as during sexual excitement, com- press the venous channels and render the tissue turgid and erect. The glands of Bartholin, the homologues of Cowper's glands, are two round or oval yellowish bodies (about 1 centimeter in diameter) which lie on either side of the lower part of the vagina. These bodies are less deeply situated than the corresponding structures in the male, being contained within EXTERNAL GENEEATIVE ORGANS. 1. Virgin hymen. 2. Characteristic hymen and fourehette of a married woman ; large wrinkled labia minora and prepuce. 3. Multipara, showing remnant of hymen, pouching anterior and post-vaginal wall, scar in perineum, large labia majora. 4. Diagram on a different scale from the preceding figures. ANATOMY OF THE GENERATIVE ORGANS. 39 the superficial perineal interspace, and not between the two layers of the tri- angular ligament. They are muco-serous racemose glands, and pour their secretion upon the mucous membrane by long slender ducts which, after au oblique course, open into the vestibule just external to the vaginal orifice. Dorsal nerve of clitoris. *orsal artery of clitoris. Artery of corpus i Fig. 18.— Dissection of female perineum, showing the vestibular bulb and the clitoris (Weisse). The hymen consists of a thin, usually crescentic duplicative of mucous membrane, strengthened by fibrous tissue, stretched across the posterior part of the vaginal opening, which it partly occludes. The hymen varies greatly in form and in extent, at times being represented by a slight semilunar fold Fig. 19.— Erectile structures of the female genitalia, particularly the highly vascular bulbi vestibuli (Kobelt). whose concavity looks upward toward the pubes, at other times forming almost a complete and imperforate membranous septum. The variations in the shape and extent of the fold and its orifice include the circular, cleft-like, cordiform, cribriform, and other types, well illustrated on Plate 6. Rupture of the 40 AMERICAN TEXT-BOOK OF OBSTETRICS. hymen usually, but by no means necessarily, occurs during the first sexual intercourse ; in rare cases the septum persists until the event of parturition. In women who have borne children the orifice of the vagina is surrounded by irregular papillary elevations, the carunculce myrtiformes : these are tne remains of the ruptured hymen, but are usually present only after labor has taken place, since, as established by Schroeder, the rent hymen is converted into these eminences as the result of the pressure incident to childbearing, and not to coitus. Dorsal artery. Dorsal vein of clitoris. Deep perineal muscle. Superficial layer of trian- gular ligament reflected. Deep layer of' superficial perineal fascia reflected. Fig. 20.— Dissection of female perineum, showing structures within the deep interfascial perineal interspace ; the vulvo- vaginal glands, however, belong to the superficial space, but are she TO resting on the deeper structures (Weisse). The female urethra (Fig. 21) is short, being only about 4 centimeters in length, and lies beneath the symphysis pubis, firmly imbedded within the ante- rior vaginal wall. It descends from the neck of the bladder to the vestibule almost vertically, presenting usually, however, a slightly marked double or sig- moid curve, or at least a curvature, forward. Its vestibular orifice, the meatus urinarius, is indicated usually by an elevation of the mucous membrane situated from 2 to 2.5 centimeters behind the clitoris. The meatus marks the most con- stricted part of the canal, the average diameter of which is about .6 centimeter. Owing to the elastic character of its tissues and to the yielding nature of the surrounding structures, the female urethra is capable of great distention, a matter of importance in examination of the bladder. The walls of the urethra comprise a mucous, a submucous, and a muscular layer. The mucosa is covered by stratified squamous or transitional epithelium directly continuous with that of the bladder ; tubular glands occur near the s vesical end of the canal, where the mucous membrane is soft and spongy. Skene has called attention to the existence of two small tubes (from 10 to 20 millimeters in length) which lie within the muscular walls of the female urethra and which open by minute orifices situated about 3 to 4 millimeters within or above the meatus. These tubes probably represent the remains of Gartner's duct derived from the fetal Wolffian duct. EXTERNAL GENERATIVE ORGANS. Plate 6. „- a L__ ANATOMY OF THE GENERATIVE ORGANS. 41 The submucous stratum contains much elastic tissue and a rich venous plexus. The muscular tissue of the bladder is continued over the urethra as an inner longitudinal and an outer circular layer, in addition to which the tube receives an investment between the layers of the triangular ligament from the compressor urethra? or deep transverse perineal muscle. The numer- ous blood-vessels and nerves of the female urethra are derived from the same sources as those of the vagina. The female bladder, relatively broad and capacious, bears important rela- tions to the vagina and the uterus. When empty and relaxed the organ lies entirely within the true pelvis, behind the pubes and usually to one side; the fundus is then greatly flattened out and somewhat indented, so that the cavity of the bladder and the urethra together appear Y-shaped in section (Fig. 22), the widely-separated hinder limb and the corresponding posterior vesical wall lying against the upper part of the vagina and the lower segment of the uterus ; Fig. 21.— Sagittal section, showing relations and form especially of the bladder, urethra, and vagina (Hart) : V, U, urethra ; B, B, bladder. sometimes, however, the empty organ is strongly contracted, the cavity of the bladder then presenting a slit-like lumen. Maximum distention carries the bladder, together with the peritoneum, well above the pubes, with the conse- quent tendency to backward displacement of the uterine fundus. The Female Ureter. — The ureter ir the female (Pis. 7, 8) presents peculiar- ities in its relations within the pelvis that deserve notice. After the usual relations of the abdominal portion of its course — proceeding downward and inward upon the psoas muscle and its fascia, being crossed by the ovarian ves- sels, and crossing the iliac vessels about 1.5 centimeters below the division of the common iliac artery — the ureter passes into the true pelvis in front of the sacro-iliac synchondrosis, thence upon the obturator internus muscle and its fascia toward its termination, running beneath the root of the broad ligament. About opposite the origin of the vesical and uterine arteries from the 42 AMERICAN TEXT-BOOK OF OBSTETRICS. internal iliac, the ureter forms a sweeping curve which is most pronounced where the uterine artery crosses the ureter, about on a level with the os exter- num. The ureter crosses the uterus at a point closely corresponding with the position of flexure of the uterine body upon the cervix, here lying between the vesical venous plexus laterally and the utero-vaginal venous plexus and the uterine artery internally. The lower part of the ureter passes at first at the side of the upper third of the vagina ; it then reaches the vesico-vaginal septum, within which it lies for 1.5 to 2 centimeters before entering the bladder-wall. The ureter does not extend lower than about the middle of the anterior wall of the vagina ; as it rests directly upon the latter, it is enclosed for a Pi 'Oinoiitory. Ovario ligan -peh lent. >ic —Tube. -- —Ova> y. ~~ B road liga Pt, ft?* ^Retropubic triangle. % v v ; j j i X \! i I Internal sphincter ani. ^"-i Clitoris. Bulbo-cavernosus. 'External sphincter. 1 i iLevbtor.'i Fig. 22.— Mesial section, showing the relation of the viscera in their normal position (Dickinson). short distance (about 1 centimeter) within a distinct fibrous sheath continuous with the bladder-wall (Waldeyer). The course of the ureter within the vesical wall is obliquely downward and inward for a distance of about 1.5 centimeters. The lower part of the tube, from its investment by the above-mentioned sheath to its termination, is cylindrical in form, in contrast with the remaining flattened portions of the canal. 2. Intermediate Organ. — The Vagina. — The musculo-membranous canal of the vagina forms the intermediate tract connecting the internal and the GENERATIVE ORGANS. Blood-vessels of the pelvis (Boursrery and Jacob) : the anterior part of the pelvis has been removed, and the bladder and the anterior vaginal wall have been partially cut away. The uterus is drawn up and the Fallopian tubes are displaced into the iliac fossse. GENERATIVE ORGANS. Plate 8. Pelvic organs in situ of a young woman of sixteen years ; seen from above after careful removal of the intestines without dislurhimr' the relations : .1, abdominal aorta; 17', inferior vena cava . If, psoas mni-'ii s: /V, promontory of sacrum: J:, cut rectum; 1>, pouch of Douglas; BV, body of uterus; I- 1, fundus , it "ens 111, bladder: (>, ovary; T, Fallopian tube; BL, round ligament; Ur, ureter: OA, ovarian artery (redrawn from Waldeyer). ANATOMY OF THE GENERATIVE ORGANS. 43 external organs of generation. Piercing the pelvic floor with its lower end, it lies chiefly within the cavity of the pelvis, in relation with the bladder and the urethra in front and with the rectum behind, the vesico-vaginal and the recto-vaginal septa intervening. The axis of the vagina (Fig. 23), while corresponding in general with that of tbe pelvic cavity, resembles that of the urethra and the rectum in presenting a double or S-like curvature. The axis of the lower third of the vagina corresponds closely with the plane of the pelvic brim ; that of the upper two-thirds lies parallel with the axis of the lower third of the rectum, forming almost a right angle to the axis of the anal extremity of the gut. The two principal vaginal walls, the anterior and the posterior, ordinarily lie in contact except at the sides, where the lumen of the canal laterally Fig. 23.— Sagittal section of female pelvis, showing axis of the vagina. expands. In cross-section, therefore, the vaginal passage under normal con- ditions appears H-shaped (Fig. 24) ; when distended it is club-shaped, being more capacious above than below, where the entrance marks the least diameter. The shorter anterior ivall (Fig. 25) extends from the vaginal entrance to the apex of the corresponding utero-vaginal recess or anterior fornix, and measures about 6.5 centimeters, or about 1\ inches; seen from behind, this surface appears triangular in its general form, the base being above, corre- sponding with the greater superior diameter of the canal. The anterior wall is very conspicuously marked by transverse rugae (Fig. 26), which are especially prominent in the virgin ; an additional vertical fold, the anterior column, is 44 AMERICAN TEXT-BOOK OF OBSTETRICS. Ua present at the lower part of the passage, where, also, this wall, distinctly thicker than its fellow, is most robust. The posterior wall, much the longer, extends from the vaginal orifice or the hymen to the apex of the deep posterior fornix (Fig. 25) or retro-cervical fossa ; it lies in front of the anterior rectal wall, with which, throughout its lower two-thirds, it is united by areolar tissue. The posterior wall measures about 9 cen- timeters, or about 3-J- inches, in length, being broader above than below ; its supe- rior third receives an imperfect covering of the peritoneum which forms the most dependent portion of the anterior wall of Douglas's pouch. While distinctly less corrugated than the anterior wall, the pos- Fig. 24. — Section illustrating the characteristic form of the vaginal cleft (Henle) : Ua, urethra ■ Va, vagina ; L, levator ani ; It, rectum. Fig. 25.— Sagittal section, showing vaginal walls ami relation of cervix uteri (Skene). terior surface in the virgin possesses numerous transversely disposed rugse as Fig. 26.— Sagittal section of vagina of a virgin, showing rugous condition of walls and enlarged upper extremity (Hart). Fig. 27.— Sagittal section of vagina of a multipara, one-half natural size (Hart). well as a vertical, and sometimes double, posterior column. Subsequent to the dilatation incident to parturition the vaginal rugse are much less conspicuous ANATOMY OF THE GENERATIVE ORGANS. 45 (Fig. 27), those on the posterior wall often almost entirely disappearing, leav- ing the somewhat pouched surface relatively smooth ; the folds of the anterior wall are retained to a much greater extent. In structure the walls of the vagina consist of a mucous membrane, a mus- cular coat, and a fibrous tunic. The mucosa is covered by a thick stratified, squamous epithelium, and possesses numerous papillae. The rugse include within their structure not only the tissues of the mucosa, but also bundles of involuntary muscle and large veins. True glands, if found at all, are repre- sented by a few sparingly distributed tubular structures within the upper part of the vaginal mucous membrane, the acid secretion which bathes its surface being the product of the general mucosa. The deepest part of the mucous mem- brane, that corresponds with the submucous layer, is succeeded by the mus- cular coat, composed of an inner circular and an outer longitudinal stratum of unstriped muscle. The fibrous tunic consists of a dense coat, rich in fibro-elastic tissue, which is derived as a prolongation of the recto-vesical fascia and materially con- tributes to the strength of the vaginal wall. The lower extremity of the canal is encircled by a thin plane of muscular fibres constituting the con- strictor vaginse muscle, and is closely attached to additional bands derived from the levator ani. Blood-vessels and Nerves. — The vascular and nervous supplies of the vagina are very generous. The arteries are derived from the vaginal, the internal pudic, the vesical, and the uterine branches of the internal iliac. Correspond- ing veins return the blood to a large extent, in addition to which the vaginal plexus surrounds the lower part of the canal and communicates freely with the neighboring vesical and hemorrhoidal plexuses. The urethral plexus around the upper portion of the urethral canal receives the dorsal veins of the clitoris. Within the submucosa large and plentiful venous radicles, together with bands of involuntary muscle, give this layer the character of erectile tissue. The lymphatics of the vagina constitute two groups, those from the lower and the upper portions of the caual. The former join the lymphatics of the external genital organs and end within the superior or oblique set of inguinal glands ; the latter, together with the vessels from the lower part of the uterine body and the cervix, proceed outward within the broad ligament, joining with the lymphatics from the oviduct and the ovaries, and terminate in the lumbar glands. The nerves of the vagina are contributions from both the sympathetic and the cerebro-spinal system. The branches of the former are derived from the infe- rior hypogastric plexus, those of the latter from the fourth sacral and the pudic nerve. The sympathetic fibres are largely distributed to the vascular tissues. 3. Internal Organs of Generation. — The Uterus. — The uterus, the thick- ened and specialized segment of the generative tube for the reception, the reten- tion, the development, and the final expulsion of the product of conception, in its mature but virgin condition is a slightly pyriform body whose thick, dense walls enclose a narrow, cleft-like cavity. The organ lies within the pelvis, 46 AMERICAN TEXT-BOOK OF OBSTETRICS. held by supporting peritoneal folds and muscular bands extending between the bladder in front, the rectum and the sacrum behind, and the pelvic walls at the sides ; the most dependent portion of its lower and smaller segment, the cervix, projects within the upper part of the vagina. The virgin uterus (Figs. 28, 29) measures about 7.5 centimeters (about 3 inches) in length, 4 centimeters (about 1J inches) in its greatest width, and Fig. 2S. — Anterior view of virgin uterus, show- ing relations of cervix to corpus uteri and reflec- tion of peritoneum at isthmus. Flu. 29.— Sagittal section of virgin uterus, show- ing position of os internum, fusiform character of the cervical canal, and relations of the peritoneum. about 2.5 centimeters (1 inch) in thickness ; of the entire organ, approxi- mately three-fifths belong to the body and two-fifths to the neck, the latter being relatively much longer in the nulliparous adult than after pregnancy has ^^ VflCINA <^ ^ Portion Portion, Fig. SO.— Diagram illustrating the relations of the uterus to the vagina, bladder, and peritoneum. occurred. The division of the uterus into body and neck is indicated exter- nally by the constricted isthmus uteri, which is situated about midway in the organ ; internally, however, this boundary is uncertain, since the contours of the cervical mucous membrane gradually pass into those of the general uterine linino-. A FA TO MY OF THE GENERATIVE ORGANS. 17 The pyriform body is almost flat on its anterior surface, but posteriorly is distinctly convex ; its superior and anterior arched border is thick and rounded, and passes over into the slightly convex lateral borders at the superior angles. The upper part of the organ, including its superior arched border, constitutes the fundus and is completely invested with peritoneum. The serous covering of the anterior surface extends only as far as the isthmus, whence it is reflected to the neighboring vesical wall. The peritoneum on the posterior wall is complete, since the serous membrane is prolonged downward and backward about 2.5 cen- timeters beyond the cervix upon the posterior wall of the vagina before passing to the rectum. The lateral borders mark the attachment of the broad ligaments. The cervix, slightly spindle-form in general outline, may be divided into three portions or zones (Fig. 30), the supravaginal, the intermediate, and the intravaginal. The first of these zones occupies the upper half of the cervix, extending somewhat farther forward along the anterior surface, where it comes in relation with the bladder, than posteriorly, where covered by the peritoneum of Douglas's pouch. The intermediate portion includes the zone of vaginal attachment, hence it is narrow and oblique, extending higher behind than in front. The intravaginal segment, or os ideri, projects within the vaginal canal in such manner that its axis is directed toward the posterior wall, and it Fundus split open. Fig. 31.— Cavity of uteri: anterior d by removal of nii-'ims rendition ,,l' die cervi presents the transversely oval orifice of the cervical cavity, bounded by the rounded and prominent anterior and posterior lips or labia, the anterior of which is somewhat the thicker and shorter. The proportion between the body and the cervix varies with age : in the young virgin adult the uterus is about equally divided between these segments ; in early life the cervix greatly pre- ponderates over the imperfectly developed fundus ; while after childbirth the fundus never returns to its former size, always remaining enlarged and nearly twice its original length (Fig. 31). With the advent of old "age the entire organ suffers marked atrophy. 48 AMERICAN TEXT-BOOK OF OBSTETRICS. The cavity of the virgin uterus is very narrow, the apposition of the anterior and posterior walls of its body reducing the space to little more than a longitudinal cleft, as seen in mesial sagittal sections (Fig. 29). Viewed Fig. 33. — Casts of the cavities of uteri of various ages and conditions (modified from Hagemann) : 2, 3, from nullipara; of eighteen and twenty-four years ; 4. from a woman of forty-eight years who had one child fifteen years previous. from in front, the uterine cavity is triangular, the expanded base extending be- tween the orifices of the oviducts, and the apex corresponding with the inner Fig. 35.— Front and pro- file views of casts of the Fig. :U.— Casts of the cavities of uteri from (5) a nullipara of sixty- uterine cavity of a new- eight years, and (6) from a parous subject of seventy years (modified from born infant (modified from Hagemann). Hagemann). opening of the cervical canal. On account of the encroachment of the uterine walls, the cavity of the uterus between the angles presents concave outlines. The cavity of the cervix is fusiform, being of larger diameter at its middle than at the ends, the os internum and the os externum. The os internum, which marks the point of greatest contraction, possesses a lumen of circular outline: the ANATOMY OF THE GENERATIVE ORGANS. 49 os externum before pregnancy appears as a narrow, transversely placed orifice. The anterior and posterior walls of the virgin cervical canal exhibit conspic- uous plications depending upon the arrangement of the bundles of muscular tissue ; these ruga? are arranged as principal longitudinal folds, the anterior and posterior columns, from which secondary plications extend laterally. These corrugations collectively form the arbor vitce (Fig. 35) of the uterus, being best marked in the virgin and being effaced by repeated parturitions. Structure. — The uterine walls include a mucous, a muscular, and a serous coat. The mucosa consists of a tunica propria of delicate bundles of fibro- elastic tissues covered by an epithelium composed of a single layer of ciliated columnar cells. Numerous wavy tubular depressions, the uterine glands (Fig. 36), are also lined by the ciliated epithelium. Since a submucous layer is Fig. 36.— Section of human uterus, including mucosa (a) and adjacent muscular tissue (6) ; c, epithe- lium of free surface and tubular uterine glands (d) ; /, deepest layer of mucosa, containing fundi of glands ; h, strands of non-striped muscle penetrating within the mucosa (Piersol). wanting, the blind and often forked extremities of these glands abut directly upon the muscular tissues. The cervical mucosa differs from that of the body, being thicker and firmer, supplied with papillae, and covered with stratified squamous epithelium within the lower third. In the upper half or two-thirds of the cervix the epithelium is ciliated columnar, similar to that of the body. In addition to the tubular follicles, the representatives of the usual uterine glands, numerous short, widely- expanded mucous crypts lie within the cervical mucosa. Retention of the secretion of some of these mucous sacs often takes place, the resulting greatly distended cysts appearing as translucent yellowish vesicles, the so-called ovulce Nabothi. In its meagre supply of glands the mucous membrane of the lower part of the cervix still further resembles that of the adjacent vaginal surface. The muscular coat (Fig. 37) of the uterus consists of bundles of unstriped muscle (Fig. 38) separated by bands of connective tissue and surrounding vas- cular channels. Although irregularly arranged, the muscular tissue is disposed 50 AMERICAN TEXT-BOOK OF OBSTETRICS. in three general strata — an inner, a middle, and an outer layer. The inner layer, 88© Fig. 37. — Arrangement of uterine muscle, as seen from in front after removal of serous coat (He'lie). composed principally of longitudinal bundles, is in direct contact with the mu- Fig. 38.— A, isolated muscle-elements of the non-pregnant uterus ; B, cells from the organ shortly after delivery (Sappey). cosa, and is sometimes regarded as belonging to that layer, as being a hypertrophied ANATOMY OF THE GENERATIVE ORGANS. 51 muscularis mucosae. The middle layer is most robust, and forms the greater part of the muscular coat, consisting chiefly of bundles having a general circu- lar disposition. This layer is also distinguished by the numerous large venous channels enclosed between its bundles, hence the name, stratum vasculare. The outer layer includes both circular and longitudinal bundles, the latter predomi- nating and lying in close relation with the superimposed serous coat. Many bundles of the outer layer pass into the broad ligaments ; some of these enter the round ligaments and accompany the areolar tissue and the blood-vessels composing these structures toward the groin, while others extend along the oviducts and ovarian ligaments. Muscular bands pass also from the uterus into its supporting folds, the sacro-uterine band being particularly robust. The musculature of the cervix is distinguished by greater regularity in its arrange- Fig. 39. — Broad ligaments viewed from the posterior surface, showing uterus, oviducts, and ovaries ; the natural position of the latter has heen disturbed in consequence of the separation of the supporting attachments. ment, which includes a distinct inner longitudinal, a middle circular, and an outer longitudinal layer. The serous coat of the uterus comprises the usual constituents of the peritoneum. Ligamenis. — The supporting apparatus of the uterus consists of two parts, the folds of peritoneum and the muscular bands which extend from the uterus to adjacent structures. The first group includes two anterior, two lateral, and two posterior ligaments ; the second group, the so-called " muscular ligaments," is represented by the utero-inguinal, the utero-ovarian, the utero-pelvic, and the utero-sacral muscular bands; the last of these, the utero-sacral, are included within the posterior peritoneal folds ; the remaining ones lie between the layers of the lateral or broad lio-aments. 52 AMERICAN TEXT-BOOK OF OBSTETRICS. The anterior ligaments are two inconspicuous semilunar peritonea] folds which pass between the upper part of the cervix on each side to the adjacent posterior surface of the bladder, and bound the vesico-uterine pouch. The lateral or broad ligaments (Fig. 39), as implied by their name, are two wide duplicatures of peritoneum that extend from the sides of the uterus and the vagina to be attached to the lateral wall and the floor of the pelvis. Each of these broad folds presents four borders, the superior, the inferior, the inter- nal, and the external ; of these but one, the superior, is free, the others being intimately joined with neighboring parts. The superior or free border encloses the oviduct, whose tortuous course it follows as far as the fimbriated end ; at this point the plication diverges toward the pelvic wall and forms the infun- dibulo-pelvic ligament, which fold connects the end of the tube with the side of the pelvis and transmits the ovarian vessels. The inferior border is united with the recto-vesical fascia covering the levator ani, the subperitoneal tissue intervening between its diverging lamella? giving transit to blood-vessels and nerves as well as to the ureter. The internal border is attached to the sides of the uterus and the vagina, the blood-vessels and muscular bands passing into the tissue of the broad ligament between its divergent layers. The external border comes in relation with the obturator fascia and affords transit for the uterine vessels and the round ligament. The broad ligaments enclose within their serous folds structures of import- ance (Fig. 40). Along their unattached superior margins lie the oviducts; a Fig. 40.— Diagrammatic section of broad ligament, showing relations of the contained structures. little lower and anteriorly are situated the round ligaments ; posteriorly, the ovaries and their muscular attachments ; numerous blood-vessels, nerves, and lymphatics, together with the parovarium, the paroophoron, and the utero-pel- vic bundles of involuntary muscles which pass from the uterus and the vagina to the obturator fascia, are additional structures included within these folds. The round ligaments (Fig. 41) are two flattened cord-like bands, from 10 to 12 centimeters in length, attached to the upper segment of the uterus in front of the oviducts, and extending from this point downward, outward, and forward, winding round the deep epigastric artery on the inner side of the external iliac artery, to the internal orifices of the inguinal canals, through which they pass ANATOMY OF THE GENERATIVE ORGANS. 53 to blend with the tissues of the labia rnajora. The round ligament possesses a covering of peritoneum, and in the young subject a funnel-like depression marks Fig. 41. — Dissection of the pelvic organs, showing the relation of the abdominal parietes to the round liga- ments and the bladder : 1, 3, the obliterated hypogastric arteries ; 2, the urachus (Bourgery and Jacob). a tubular extension of the peritoneal sac along the cord as it leaves the abdomen ; this extension constitutes the canal of Nuch, and is homologous with the pro- Fig. 42.— Posterior view of the uterus and ovaries, with the peritoneal folds composing the broad liga- ments and the utero-rectal fossa (modified from Hodge). cessus vaginalis of the male. It is usually obliterated after early life, but may persist, and, in rare cases, be accompanied by an abnormally descended ovary, 54 AMERICAN TEXT- BO OK OF OBSTETRICS. which then occupies a position within the labia, behind the peritoneal sac. In structure the round ligament consists of bundles of connective tissue and blood- vessels, together with plain muscular tissue derived from the uterus. The posterior or recto-uterine ligaments are two peritoneal folds which pass backward from the cervix and the upper part of the vagina to become con- tinuous with the serous covering of the second portion of the rectum. The deep fossa included between these folds laterally, the uterus anteriorly, and the rectum posteriorly constitutes the pouch of Douglas (Fig. 42), which is fre- quently occupied by coils of small intestine. Between the layers of the posterior ligaments flat bands of involuntary muscular tissue, the so-called utero-sacral Fig. 43. — Sagittal section of female pelvis, showing the utero-sacral ligaments suspending the uterus, also the pubic segment part of tne supporting apparatus of the uterus (Dickinson). ligaments (Fig. 43), extend on each side from the highest segment of the cervix to the sides of the sacrum, at the level of the sacro-iliac juncture. These bands, among the most important parts of the supporting apparatus of the uterus, are intimately related with the muscular coat of the rectum, which tube they encircle near the union of its first and second parts ; laterally and anteriorly they are in close relation with the pouch of Douglas. The position of the normal uterus (Fig. 22) during life has received considera- tion from many investigators, whose conclusions, however, have been so contra- dictory and uncertain that almost every situation of the organ has in turn been^ regarded as representing its normal relation. This discrepancy has been due in large measure to the methods of examination employed, which include observations on the cadaver, bimanual examination of the pelvic organs of the living subject, and frozen sections of the parts shortly after death. The examination of the viscera in the cadaver in the usual way, even when carried out with skill and precaution, must necessarily be untrustworthy ANATOMY OF THE GENERATIVE ORGANS. 55 as to the details of topographical relations, on account of the uncertainty in- troduced by reason of the unavoidable post-mortem alterations and inevitable distortions affecting the organs. The apparent exactness of the method of frozen sections likewise is unfavorably influenced by the relaxation after death of the supporting bands which during life maintain the positions of the organs ; it follows, therefore, that the testimony of sections cannot be accepted as unim- peachable evidence as to relations during life, since the relations preserved are only those existing at the time of fix- ation ; likewise, the possibility of en- countering the effects of pathological changes in frozen sections must also be appreciated. The testimony of the most competent and careful investiga- tors points to the conclusion that the most valuable and trustworthy observa- tions as to the normal position of the uterus are to be gathered from careful examinations of properly preserved bodies, where the organs have been hardened in situ immediately after death. The results of such investigations closely agree with the opinions of the most expert observers derived from repeated examinations on the living subject. Fig. 44. — Diagrams illustrating range of va- riation in position of uterus as affected by dis- tention of the bladder (Van de Warier). -Longitudinal section of Fallopian tube, exposing the complicated longitudinal plications of the mucosa which expand into the fimbria; ISappey). In accordance with the conclusions based on such grounds, the normal uterus most probably occupies a position almost horizontal in the upright posture : the fundus, usually slightly to one side of the mid-line, rests on the bladder and is directed forward and upward, while the cervix forms a slight deflection with the axis of the uterine body and looks down and backward against the 56 AMERICAN TEXT-BOOK OF OBSTETRICS. posterior vaginal wall. Whether the uterus lies most frequently to the right or to the left of the mid-line is still in dispute ; the latter position, to the right, is probably most usually encountered (His), although the opposite con- dition, as shown on Plate 8, is certainly not uncommon. The topographical relations between the uterus and the bladder are so close that the position of the womb is materially influenced by vesical distention. The range of varia- tion in the position of the normal uterus is diagrammatically represented by Figure 44. The oviducts, or Fallopian tubes (Fig. 38), the representatives of the un- united portions of the fetal Mullerian ducts, extend from the superior rounded angles of the uterus, within and along the free upper margin of the broad ligaments for a distance of from 10 to 12 centimeters, to the vicinity of the ovaries, where each terminates in an expanded funnel-shaped orifice, the pavil- ion or infundibulum, surrounded by a series of fringed processes, the fimbriae (Fig. 45). Examined in carefully-preserved specimens retaining the typical position of parts, the tube at first passes outward closely related with the pelvic floor ; it then turns upward along the attached anterior border of the ovary, when, after reaching the upper pole of the gland, the tube bends downward upon the free posterior border and the inner surface of the ovary (Figs. 22, 41), which are by this means partly masked (Waldeyer). The oviduct commences at the inner attached extremity as a narrow tube, the isthmus, about 2 millimeters in diameter; during its further slightly wavy course it gradually gains in width until the tube measures 4 millimeters or more, when it again becomes somewhat nar- rowed, but beyond the ovary it rapidly expands into the ampullas and the fimbriated extremity (Fig. 46). The lumen of the tube is narrowest at its inner end, where it opens into the cavity of the t" uterus by a minute orifice, the Fig. 46.-Portion of broad ligament stretched to show os f mm internum, which Scarcely the parovarium (P) lyim; between the folds and consisting ... , of the head-tube and cross-tubules (Gegenbaur). admits a bristle ; the diameter of the canal gradually increases until it presents, just before its final expansion into the fimbriated orifice, a distinct opening, the ostium abdominale (from 4 to 6 millimeters in width), situated at the bottom of the cleft-like depression leading from the attached border of the fimbriated expansion. Structure. — The oviduct consists of three coats — an inner mucous, a middle muscular, and an outer serous. The mucous lining presents numerous longi- tudinal folds (Fig. 47) ; these become more conspicuous within the infundibu- lum, where they greatly increase in size and complexity and terminate in the sinuous border of the fimbriae. All parts of the canal, including its expanded ANATOMY OF THE GENERATIVE ORGANS. 57 outer end, are clothed by a single layer of ciliated columnar cells, whose ciliary current sweeps from the fimbria? toward the uterine end of the tube. At the free edge of the fimbriae the columnar epithelial cells give place to the low, plate- like elements of the peritoneum covering the exterior of the tube. Glands are absent within the mucous membrane of the oviduct. The muscular tunic includes a principal inner layer of circularly-disposed bundles of involuntary muscle and a slightly-developed outer layer of longitudinal bundles. The Fig. 47.— Transverse section of Fallopian tube, showing the complicated arrangement of the longitudinal plications which are here cut across (Martin). serous coat consists of the fibro-elastic stroma and endothelium of the general peritoneal investment contributed by the broad ligament. The blood-vessels of the oviducts are branches from the ovarian and the uterine arteries and the corresponding veins, the arteries possessing an unusu- ally tortuous course. The nerves are derived from the ovarian and uterine plexuses, and consist of both medullated and pale fibres. The Ovaries. — Each ovary presents a flattened ovoid mass, somewhat almond-shaped, which appears as an appendage of the posterior surface of the broad ligament (Fig. 39), to which the organ is attached by its straighter anterior border. The dimensions vary with the individual as well as with the condi- tion of functional activity ; the longest diameter usually measures about 3.5 centimeters, the width about 2 centimeters, and the thickness a little over 1 centimeter. The weight of the ovary is ordinarily between 6 and 7 grams, the right being commonly slightly heavier and larger than the left ovary. The anterior border alone is attached ; the arched posterior border and the broad surfaces are free and are covered with modified peritoneum, the germinal 58 AMERICAN TEXT-BOOK OF OBSTETRICS. epithelium, directly continuous with the serous covering of the broad ligament. The position of the ovaries in situ (PI. 8 ; Figs. 22, 41) and during life, at least before the permanent displacement attending pregnancy has taken place, Fundus of uterus. Utero-marian ligament. \ Fig. 48.— Ovary (natural size), with the Fallopian tube in relative position, of a woman twenty-three years of age (Sutton). is probably such that the long axes of the organs are nearly vertical (Wal- deyer, His, Cunningham) and correspond closely with the sagittal plane, so that the broader surfaces may be spoken of as mesial and lateral rather Rottnd ligament. Fig. 49.— Ovarian sac or recess on the posterior aspect of the broad ligament (modified from Richard by Bland Sutton). than as anterior and posterior. The position of the fundus uteri is a factor of moment in determining the ovarian axis, since, as pointed out by His, the ANATOMY OF THE GENERATIVE ORGAN'S. 59 pull of the uterus when not occupying a mesial position predisposes to increased obliquity of the ovarian axis of the opposite side. The smaller and lower end of the ovary, or the uterine pole, points toward the uterus, with which it is united by means of the fibro-muscular bands consti- Fundns of uterus. Co/:-. < 'luted tube. Ovary. Cervix. Fringes. Fig. 51.— Uterus, tubes, and ovaries of a child (Sutton). Fimbria. Broad ligament. Fig. 50.— Ovary and tube (natural size) of a woman of sixty-eight years (Sutton). tuting the ovarian ligament; the upper and blunter end, or the tubal pole, after being embraced by the arching oviduct, receives the lower border of the fimbriated extremity of the Fallopian tube, and is further connected to the wall of the pelvis by the ovario-pelvie fold of the peritoneum. The ovary lies within a peritoneal recess, the fossa ovarii (Claudius), which occupies the posterior part of the side wall of the pelvis, usually bounded by the internal iliac artery and the ureter behind and the obturator vessels and nerve in front. Both the anterior and posterior borders of the gland, as well as its inner sur- face, are closely related to and are partly masked by the curves of the oviduct. Structure. — The ovary is divided into the cortex and the medulla (Fig. 52), the boundaries of which are conventional and not sharply defined. The cortex includes the peripheral zone, containing the Graafian follicles and the ova, and occupies approximately the outer third of the organ. The medulla embraces the remaining central portions of the organ, in which the blood-vessels, enter- ing through the hilum, are conspicuous. The bulk of the organ consists of the ovarian stroma, a peculiar form of connective tissue in which lie imbedded the Graafian follicles, distinguished by the great number of its spindle-cells. These cells are especially closely packed in the cortex immediately beneath the surface covered by the germinal epi- 60 AMERICAN TEXT-BOOK OF OBSTETRICS. thelium, in which situation they constitute a layer of greater density than the adjacent stroma, to which the name tunica albuginea is applied ; this stratum, however, is only a condensation of the ordi- nary stroma tissue, and is not an independent envelope. The Graafian follicles, the most import- ant constituents of the cortex, are exclusively limited to this part of the ovary, where they occur in all stages of development. The least mature follicles consist of ova sur- rounded by a single layer of flattened cells, the progenitors of the membrana granulosa. Among the immature follicles are others in . Fig. 52.— Section of human OTary, including cortex : a, germinal epithelium of free surface ; b, tunica albuginea; c, peripheral stroma contain- ing immature Graafian follicles (d); e, well-ad- vanced follicle from whose wall membrana granu- losa has partially separated ; /, cavity of liquor fol- liculi ; g, ovum surrounded by cell-mass consti- tuting discus proligerus (Piersol). Fig. 53.— Ovary with mature Graafian follicle about ready to burst (Eibemont-Dessaignes). various stages of more advanced development, where the ova are encircled by two or more rows of polygonal cells which by their division give rise to the numerous elements lining the follicle. Both the ova and the surrounding cells are derivatives of the germinal epi- thelium covering the free surface of the ovary, from which they dip into the stroma as cylindrical cell-cords.' With the increase in size which accompanies their development the Graafian follicles pass toward the inner limits of the cortex bordering on the medulla, where they undergo further enlargement ; after a time their diameter includes almost the entire cortex, and extends from the medulla to the surface of the ovary, the position of the follicle becoming evi- dent on the free surface as a distinct projection (Fig. 53), marking the point at which the final rupture of the sac and the escape of the ovum take place. The mature Graafian follicles appear as clear, slightly elongated vesicles 8 to 12 millimeters in diameter; they are defined from the surrounding tissue by a condensed layer of the ovarian stroma, the theca folliculi. Within the theca fol- lows the vnembrana granulosa, consisting of many layers of small polyhedral epithelial cells. At one point the membrana granulosa presents a thickening which encloses the ovum and constitutes the discus proligerus. The cells of the discus next the ovum lie vertical to its surface, forming a radial zone, the corona radiata. Within this layer lies the sexual cell, the ovum, which will be considered more fully in the section relating to its development. The formation of new follicles continues only for a short time after birth ; ANATOMY OF THE GENERATIVE ORGANS. 61 ovisacs are then most numerous, the entire number contained within the two ovaries of the child being estimated at over seventy thousand. In view of the unquestionably large number of follicles in very young ovaries, and the relatively small proportion of ova which reach maturity, the degeneration of many follicles after attaining a certain development seems certain. The atrophic remains of such degenerating Graafian follicles continually encountered point conclusively to the fate of a large contingent. The medulla contrasts with the cortex by its looser structure and the number and size of its vascular, and particularly its venous, canals. A con- siderable amount of involuntary muscle is intermingled throughout the fibrous tissue separating the blood-vessels. Irregular groups of polyhedral cells are encountered between the fibrous bundles of the medulla ; these elements, the ijiterstitial cells, represent the remains of atrophic parts of the fetal Wolffian bodies. On the escape of the ovum, surrounded by the cells of the discus pro- ligerus, the ruptured and partly collapsed follicle becomes filled with blood poured out from the torn vessels of the walls of the follicle. Subsequent changes lead to the conversion of the follicle into a corpus luteum. This characteristic structure is formed by the ingrowth and rapid proliferation of the vascular tissue of the follicular wall, spindle-shaped connective-tissue cells and large cells containing yellow pigment, lutein, being the most active ele- ments in the process. The history of the corpus luteum is materially affected by the occurrence of pregnancy, since, instead of being almost entirely absorbed within a few weeks, as is the rule with the ordinary bodies, when fertilization takes place they persist until after the end of gestation. It is usual, therefore, to distinguish the corpus luteum of pregnancy, or the corpus verum, from the coiyas luteum of menstruation. The mode of growth is iden- tical in both, the stimulus of impregnation leading usually to excessive devel- opment. The primary blood-clot occupying the ruptured follicle becomes invaded by the enlarged and thickened wall, which soon becomes corrugated, the plications encroaching upon the clot and increasing to such an extent that the folds crowd against one another and eventually form an irregular broad envelope surrounding the remains of the central clot. When pregnancy occurs the processes are continued beyond their usual length, resulting by the end of the first month in the production of a mass from 12 to 20 millimeters in diameter, characterized by a brilliant yellow peripheral zone surrounding a lighter centre. This condition is succeeded by the gradual reduction and cica- trization of the central area and the lighter tint of the now greatly corrugated broad outer belt. By the end of gestation the white nucleus constitutes about one-third of the entire corpus luteum, which has already become somewhat smaller (10 to 13 millimeters) than at the sixth month. After delivery absorption progresses rapidly, but for some months later the position of the corpus is distinguishable. The characteristic yellow color of these bodies is due to the presence of a peculiar pigment, lutein, and not merely to disinte- grated blood. 62 AMERICAN TEXT-BOOK OF OBSTETRICS. The peculiarities distinguishing the corpus Iuteum of pregnancy from that of menstruation have long been regarded as of especial significance as supply- ing positive evidence that pregnancy has taken place. While the presence of the typical yellow body must be regarded as strongly indicative of such condi- tion, the occasional encounter in the ovaries of undoubted virgins of cor- pora lutea possessing the characteristics of those of pregnancy, as recorded by Fig. 54.— Ovaries of tv Fringes. hoving large corpora lutea, resembling those of pregnancy (Hirst). Hirst (Fig. 54), should lead to some reservation and to a demand for cor- roborative evidence in the acceptance of these bodies as infallible signs of the existence of pregnancy. The Parovarium. — The parovarium, the epoophoron, or the organ of RosenmuUer, consists of a group of inconspicuous tubular structures within the broad ligament, between the oviduct and the ovary, not far from the attached border of the latter organ (Fig. 46). The parovarium consists of a series of from twelve to eighteen short tubules which lie irregularly parallel, their ovarian ends slightly converging, and which are connected at their opposite extremities with the longitudinal head-tube of larger diameter extending for some distance within the broad ligament toward the uterus. The tubules are lined with low columnar epithelial cells, the representatives of the elements clothing the embryonic canals. The parovarium represents the partially obliterated remains of portions of the Wolffian body of the fetus ; the short canals correspond with the tubules of the body, while the head-tube is identical with the upper part of the Wolff- ian duct. When this latter canal persists throughout the greater part of its original extent, it constitutes Gartner's duct, the homologue of the vas deferens ; the entire parovarium corresponds morphologically with the tubules constituting the globus major of the epididymis. Additional fetal remains in the form of rudimentary tubules are sometimes encountered within the broad ligament in the vicinity of the ovary, although situated rather nearer the uterus than the parovarium. These structures con- stitute the paroophoron, and represent the atrophic transverse tubules of the lower part of the Wolffian body, being homologous with the paradidymis of ANATOMY OF THE GENERATIVE ORGANS. 63 Fig. 55— Stalked hydatid at- tached to fimbriated extremity of Fallopian tube (New York Hospital Cabinet). the male. The closed tubules of the paroophoron are lined with low columnar epithelium and are often occluded by partially shed cells. The tubules of these atrophic organs possess a practical interest from their liability to become diseased and converted into cysts which may assume large diameters. The stalked hydatid of Morgagui frequently forms a conspicuous appendage to the broad liga- ment near the fimbriated extremity of the ovi- duct (Fig. 55). This pedunculated vesicle, which varies greatly in size, represents the remains of the pronephros, being common to both sexes. Low columnar or cuboidal epithelium forms the lining of its dilated sac and stalk so far as pervious. The Vessels and Nerves of the Internal Generative Organs. — The vascular and nervous supplies of the uterus and its appendages and of the ovaries are so intimately related that they may conve- niently be considered together. These organs receive their blood from three sources — the uterine, the ovarian, and the funicular arteries (PI. 7). The uterine artery is given off from the internal iliac close to the pelvic wall, along which it runs as far as the broad ligament, within whose folds it then passes, in front of the ureter, toward the cervix uteri. After giving off twigs which surround this part of the uterus the artery ascends along the body of the uterus, sending off branches which anastomose with those from the oppo- site side to encircle the organ. The upper terminations of the uterine freely communicate with the branches of the ovarian and the funicular arteries. The ovarian artery, the homologue of the spermatic, is a branch from the abdominal aorta, and gains entrance through the infundibulo-pelvic band into the broad ligament, within which it divides into its two principal branches — the tubal and the ovarian. The tubal branch extends along the border of the oviduct, dispensing numerous twigs for the nutrition of the tube and the tissue of the broad ligament. The ovarian proper is of larger size, and passes close to the free border of the ovary, which it particularly supplies, finally anastomosing with the uterine and funicular arteries near the upper angle of the uterus. The funicular artery is given off from the vesical, after which it joins the round ligament at the internal abdominal ring and divides into ascending and descending branches, the latter passing into the labium along with the liga- ment, there to anastomose with the external pudic ; the former ascends back- ward within the ligament as far as the angle of the uterus, where it joins the ovarian and the uterine arteries. The veins of the uterus and of the ovaries are large and numerous and tend to form plexiform networks. Those of the uterus, always large, but of enormous size during pregnancy, form a plexus within the broad ligament, which plexus subsequently gives place to a trunk which accompanies the artery and terminates in the internal iliac vein. The ovarian veins are particularly well developed in the vicinity of the hilum ; within the broad 64 AMERICAN TEXT- BOOK OF OBSTETRICS. ligament they form an intricate meshwork, the pampiniform plexus, which surrounds the artery and on the right side terminates in the inferior cava, on the left in the renal vein. The subperitoneal tissue contains great numbers of venous channels, the presence of which is a matter of practical import. The lymphatics (PI. 9, Figs. 2, 3) connected with the internal organs of gen- eration begin as interstitial lymph-clefts and radicles which these viscera, in com- FlG. 56.— Nerves of the pelvic organs of the female (Frankenhausen) : 1, nerves to fundus of uterus ; 2, right Fallopian tube ; 3, right round ligament; 4, nerves to Fallopian tube; 5, communication between ovarian and uterine nerves ; 6, ovarian plexus of veins ; 7, ovarian vein ; 8, nerve passing to join ovarian plexus ; 9, fimbriated extremity of Fallopian tube : 10, reflected peritoneum ; 11, uterine nerves ; 12, supe- rior hypogastric plexus ; 13, branches from hypogastric plexus to uterus ; 14, inferior hypogastric plexus ; 15, vesical nerves ; 16, communicating branches to vesical plexus ; 17, cervical ganglion ; IS, branches of hypogastric plexus to cervical ganglion ; 19, first sacral nerve ; 20, branches passing to bladder ; 21, branches passing between bladder and rectum ; 22, communicating branches from second sacral to cervical gan- glion : 23, branch from third sacral nerve to cervical ganglion ; 24, second sacral nerve ; 2.5, branches from third sacral nerve to vagina and bladder ; 26, branches passing from fourth sacral to cervical ganglion. mon with others, possess in large numbers. The vessels thus originating are arranged as three principal groups : 1. The set composed of those coming from the body of the uterus, the ovary, and the oviduct, which end in the prevertebral lymph-glands in front of the aorta and the inferior cava ; 2. Those from the EXPLANATION OP PLATE 9. Fig. 1. — Lymphatics of the uterus, which has been turned forward (Sappey) : a, aorta; B, common iliacs ; c, bifurcation into internal and external iliacs ; D, vena cava Inferior ; E, common iliac veins ; F, uterus toppled forward ; G, rectum ; H, ligament uniting sacrum with fifth lumbar vertebra ; 1, lymph- atic vessels passing under ovaries to follow the course of ovarian vessels ; 2, lymphatics from body of uterus, which end in lymph-glands accompanying the iliac vessels ; 3, lymph-glands receiving the lymph- vessels of mucous membrane of cavity of body ; 4,4, lymphatics from lower portion of surface of uterus, going to the glauds behind internal iliac vessels, which glands (5) vary in number and volume. Fig. 2.— Lymphatics of the pelvic viscera and the abdomen (Sappey) : b, common iliacs ; c, external and internal iliacs ; D, vena cava inferior ; g, common iliac veins ; H, ureters ; I, rectum ; K, uterus ; L, cervix ; M, M, section of vagina ; x, N, Fallopian tubes ; o, o, ovaries ; Q, Q, round ligament ; 2, superficial renal lymphatics ; 3, converging trunks of same, emptying into lymph-glands (4) ; 7, 7, lymphatic plexus of the ovaries; 8, 9, trunks receiving ovarian plexus following course of utero-ovarian veins; 10, 11, glands receiving the lymphatics from ovaries ; 12, lymphatics from fundus, joining ovarian plexus, with same terminations; 14, glands receiving (13) trunks from surfaces and borders of body of uterus; 15, lymphatics originating in lower part of cervix, mucous membrane of uterine cavity and vaginal for- nices; 16, lymph-glands occurring along the course of these vessels ; 17, efferent vessels of these glands taking their course to the glands beneath external iliac vessels ; 18, lymphatics which proceed from the posterior surface of the cervix, terminating in the glands accompanying the internal iliac ; 19, excep- tional lymph-trunk from cervix passing to gland in front of fifth lumbar vertebra; 20, another excep- tional lymph-gland and vessel situated along the course of the common iliac. Fig. 3. — Lymphatics of the breast (Sappey) : A, cellulo-adipose cushion supporting mammary gland ; B, contour of mammary gland ; c, superficial blood-vessels ; 1, network of superficial lymphatics ; 2, net- work of lymphatics originating in and draining the lobules of the gland ; o, large lymphatic trunks orig- inating in the peripheral network ; 4, plexus of lymphatics having their origin in the deeper parts of the gland; 5, large vessels originating in the inner part of this plexus; 6, 7, 8, large lymphatic trunks. GENERATIVE OEGANS. 1. Lymphatics of the uterus, which has been turned forward (Sappey). 2. Lymphatics of the pelvic viscera and abdomen (Sappey). 3. Lymphatics of the breast (Sappey). ANATOMY OF THE GENERATIVE ORGANS. 65 cervix and adjacent part of the vagina, which extend along the base of the broad ligament and terminate within the internal iliac glands of the pelvis near the iliac artery at its point of division ; 3. Those which accompany the round ligament and pass to the inguinal glands. These latter, as in the male, include two groups, those lying along the course of Poupart's ligament, which constitute the oblique set and receive the lymphatics from the genitalia, and those arranged about the saphenous opening as the vertical set, into which empty the superficial lymphatics of the lower limb. The great abundance of the lymphatics of the uterus, the cervix, and the vagina is a matter of much prac- tical importance, since these channels furnish the paths by which septic mat- ters may invade and affect parts widely removed from the focus of infection. The nerves (Fig. 56) of the uterus, the ovary, and the oviduct are derived partly from the sacral nerves, particularly the third and the fourth, and partly from the sympathetic system as represented by the hypogastric and ovarian plexuses. The nerves include, therefore, both medullated and pale fibres, the latter being especially destined for the blood-vessels and the masses of invol- untary muscular tissue. The Mammae. — The mammary glands, being really but highly specialized and greatly developed sebaceous follicles, belong to the integument, and, strictly regarded, have no place among the sexual organs. The closely asso- ciated functional relation of these organs in furnishing the nutriment for the newly-born animal, however, as well as convenience, has made it customary to describe them in connection with the organs of generation. The present pur- pose will require the consideration of the glands as developed in the female alone, the rudimentary organs of the male being disregarded. The mammary glands of the human female (Fig. 57), as seen in well-devel- oped women prior to pregnancy, protected by the integument and the fascia? and the associated masses of adipose tissue, collectively form a pair of hemispherical prominences, the breasts, surmounted by the conical mammillae or nipples. The breasts as a whole are not cpiite circular in outline, since their attached bases present slight extensions inward over the sternum as well as outward, above and below, toward the axilla. Neither is the gland always limited by the deep fascia, since small aggregations of the glandular tissue may pierce the fascial septum and lie upon or become imbedded within the pectoral muscle — a matter of much practical moment in amputations of the mamma for malig- nant disease. The size of the breasts depends so evidently upon the functional condition of the glandular tissue and the quantity and tonicity of the surrounding adi- pose tissue and other protecting structures that the dimensions of the organs must include a wide latitude of variation. The breasts may be said ordinarily to extend from the third to the seventh rib and from the sternal border to the anterior axillary margin, with a prominence depending much upon the amount of fat or upon the condition of the gland. The nipple is usually situated on a line corresponding with the level of the fourth rib, being directed somewhat outward and upward. 66 A ME HI CAN TEXT-BOOK OF OBSTETRICS. Varying with the general complexion, the nipple is of a roseate or a pink- ish-brown tint, and is surrounded at its base by the areola, an area of modified integument about an inch in diameter, possessing the same color as the nipple. The changes in the appearance of this zone induced by pregnancy are more or less permanent, the deeply pigmented areola of the dark brunette never re- Greater pectoral muscle. Integument. , Glandular tissue. Mass of adipose tissue. Lesser pectoral muscle. Intercostal muscles. Third rib. Deep fascia. Superficial fai Fourth rib. Areola.. Interlobular adipose tissue.~^~_ Nipple. -^^^^^ """_ - " , - \ Lactiferous duct. -^5^7^?^ /9 "7-7\ Interlobular adipose tissue. \J\rY^O^- — fj ' Glandular tissue. Peripheral acini. Mass of adipose tissue. ■ -:. Horizontal c ■ nipple. Fibrous septa. Integument. External oblique muscle. - . Fig. 57.— Longitudinal section of mammary gland in situ; frozen subject of twenty years (Testut). gaining its former tint; in light blondes the darkening of the areola accom- panying pregnancy is often very slight, and may subsequently almost entirely disappear. The skin covering the areola is characterized by its variable pigmentation, by its delicacy, by the absence of subcutaneous adipose tissue, and by the presence of large sebaceous follicles, and, in addition to well-developed sweat-glands, small groups of glandular acini, the accessory milk-glands, of which from five to twelve are usually present. The sebaceous follicles during pregnancy become greatly increased in size and form prominent ele- vations, the glands of Montgomery. In addition to independent ducts open- ANATOMY OF THE GENERATIVE ORGANS. 67 ing on the surface of the areola, the accessory glands sometimes are connected with the milk-tnbes traversing the nipple. Both the nipple and the areola contain numerous bundles of unstriped muscular tissue, arranged as circular and radiating fibres, which respond to mechanical stimulation. The contrac- tion of the circularly disposed fibres causes the nipple to become more prominent or " erected ;" the radial fibres, on the contrary, tend to depress or retract the nipple. The secreting tissue of the mamma consists of an aggregation of pyramidal masses (from fifteen to twenty in num- ber) of acini and ducts which corre- spond with the lobes composing the organ (Fig. 58). Each lobe represents a single highly developed and specialized seba- ceous gland, whose excretory tube is the lactiferous or galactophorous duct, and whose secretory portion is the associated group of acini. The individual component glands, the lobes, are invested by the surround- ing connective tissue which constitutes the general supporting framework of Fig. 5S— Arrangement of glandular tissue of breast, the fat having been removed to show the ducts and acini (Astley Cooper). SL Fig. 59. — Section of mamma (Siin'ty): a, a, lobules of secreting tissue, con- sisting of acini (6, 6) lined with active epithelium ; c, c, sections of excretory ducts ; d, rf, interlobular connective tissue. the organ and the septa. The latter penetrate within the aggregations of acini and subdivide the lobes into lobules. AMERICAN TEXT-BOOK OF OBSTETRICS. Before the occurrence of pregnancy and of the functional activity asso- ciated with lactation the secreting tissue forms but an insignificant portion of the entire volume of the mamma (Fig. 59), but during lactation the acini become enormously developed, the lobules of true glandular tissue being readily discovered as nodular masses within the more yielding areolar adipose envelope. Under the stimulus of the unusual demands made upon the organ under such conditions, it is probable that new glandular tissue is formed as extensions of the existing acini. The acini of the fully developed but non- functionating organ are lined by a single layer of short columnar or polyhedral epithelial cells, the protoplasm of which appears gran- ular. The cells rest upon a delicate ruem- brana propria which envelopes the acinus and which is continued on to the minute excretory ducts with which the acini are connected. These passages, lined with a modification of the glandular epithelium, join with others to form larger tubes, which in turn take part in forming the interlobular canals. These canals are superseded by the wider excretory tubes draining the entire lobe, which, directly or after joining other tubes, become the con- verging lactiferous or galactophorons ducts. The lactiferous ducts (Fig. 60) on reaching the areola undergo dilatation and form the Wivpulhe or milk-sinuses. These ampulla? lie beneath the areola, and during lactation attain each a diameter of from 4 to 6 millimeters, constituting important reservoirs for the milk secreted during the periods intervening be- tween the evacuations of the gland. At the base of the nipple these ducts undergo a re- duction in size and become closely collected, the larger tubes occupying the centre of the group; surrounded by areolar and muscular tissues, they ascend to the summit of the mammilla as independent tubes, where they terminate by distinct orifices which open into minute depressions occupying the apex of the nipple. The epithelium lining the ampulla? and the lactiferous ducts is of the low columnar or cuboidal variety ; within a short distance of the termination of the ducts upon the nipple, the lining of the tubes changes its character to cor- respond with that of the adjoining epidermis, becoming stratified squamous. The changes taking place within the lining cells of the acini on the estab- lishment of lactation are very marked. In the earliest stage of activity, when Fig. 60.— Dissection of breast, show ing suspensory ligaments and milk ducts (Astley Cooper). ANATOMY OF THE GENERATIVE ORGANS. 69 the flow of milk first begins, many acini still retain their primitive condition of solidity : in such cases the elements occupying the central parts of the tubules undergo fatty degeneration, some becoming disintegrated, while others are cast off as masses which constitute the colostrum-corpuscles found in the milk during the first few days. The uniformly granular protoplasm of the cells at rest becomes invaded by oil-drops when functional activity begins, and, as secretion progresses, it becomes broken up and displaced by the accumulation of oil-globules within the cell. The minute oil-drops exist at first as separate particles, which gradually increase in size until they become confluent and form a single large globule occupying the greater part of the entire cell. The nucleus in consequence is displaced toward the periphery, next the basement membrane, where it lies imbedded within the thin belt of protoplasm occupying the outer zone of the cell. The cells within a single acinus generally contain very unequal amounts of oil ; some of the elements are so loaded that the entire cell is occupied by the oil-drop, while, on the other hand, the neighboring cells may contain so little oil that the presence of the fatty particles is masked by the protoplasm. Between these extremes all gradations may be found. Upon attaining a certain tension the contained oil-globules, escaping in the direction of least resistance, are discharged into the cavity of the acinus, where they, together with the granular debris of old epithelial cells, are collected within an albuminous fluid and constitute the lactiferous secretion, or milk. During secretion the acini possess a comparatively wide lumen, the epithelial layer forming but a thin lining to the irregular spherical or tubular spaces. At the cessation of lactation the acini become once more reduced to narrow tubules, many being atrophic, surrounded by the thin preponderating areolo- adipose tissue. With each succeeding pi-egnancy a new period of cellular activity and new growth takes place in the preparation of the gland for its active role during lactation. The close of the period of sexual activity is followed by gradual permanent atrophy of the secreting structures, so that secretions of the mammse of aged women show little more than the atrophic remains of the sometime conspic- uous gland-acini imbedded within the connective tissue which, with a variable amount of fat, now constitutes almost the entire bulk of the organ. The blood-vessels of the mamma are derived from two sources : principally from the internal mammary artery, through its perforating branches within the second, third, and fourth intercostal spaces, and from the axillary artery through the thoracic branches, the long thoracic or external mammary artery often sending off robust twigs for the supply of the gland. The veins returning the blood from the deeper part of the organ follow the corresponding arteries ; the superficial veins form a subcutaneous plexus which becomes conspicuous during lactation. The lymphatics are very numerous, as demonstrated by the brilliant prepa- rations made by Sappey (PI. 9, Fig. 3), and they constitute a superficial and a deeper set. The former exist as an intricate subcutaneous network in which 70 AMERICAN TEXT-BOOK OF OBSTETRICS. the larger vessels are situated at the periphery, and join the lymph-paths con- verging toward the axilla. The deeper lymphatic vessels accompany the deeper veins and pass off in two groups : one set enters the axilla and termi- nates in the costal group of axillary lymph-glands ; the other takes its course into the thorax and communicates with the chain of lymphatic nodules situated behind the sternum. The profuse supply of lymphatics and the intimate rela- tions these bear to the lymph-glands situated deeply and at some distance greatly facilitate the conveyance of infectious materials to other parts, there to establish, as in the case of carcinoma mammas, new foci of disease. The nerves supplying the mammary gland are derived from the cervical plexus through the superficial descending supraclavicular branches, and from the fourth, fifth, and sixth intercostals ; numerous sympathetic filaments accompany the latter into the substance of the gland. Variations in the number and position of the mammae have frequently been observed. "While reduction in number or absence of these organs is extremely rare, increase in their number, as well as abnormal location, is by no means of great infrequency. The nipple alone may be involved, being either multiple or suppressed, or entire additional glands may be present. Supernumerary mammae have been observed in many locations, among which the arm, the axilla, various parts of the anterior body-wall, the back, the buttock, and the thigh are the most conspicuous. The interesting observations of O. Schultze on the presence of definite "milk-ridges" along the antero- lateral aspect of the trunk in embryos, extending from the root of the upper limb to the inguinal region, suggest the location in which supernumerary mammse are most frequently encountered, such superfluous organs resulting from the persistence and development of areas which ordinarily disappear. The presence of such markedly aberrant mammse as those found on the back, the arm, or the buttock is less easily explained, since they arise probably in consequence of the unusual development of structures representing the ordi- nary sebaceous glands of the integument of the part. III. Physiology of the Female Generative Organs. 1. Ovulation. — The differentiation of certain of the cells derived from the ingrowth of the germinal epithelium covering the young ovary into the sexual elements proper, the ova, takes place very early, so that at birth the formation of the ova is already nearly completed, the production of new cells after birth being very limited, and probably entirely ceasing after the second year (Bischoff, Waldeyer). The ovaries of the child of two years, therefore, con- tain the full quota of ova, although the vast majority of these cells always remain immature and undeveloped. The entire number of these primitive sexual elements stored up within the ovaries of the young child has been esti- mated at about seventy thousand. While it is probable that a variable number of the immature ova undergo partial development before puberty, yet the advent of sexual maturity at that period marks the establishment of the full ANATOMY OF THE GENERATIVE ORGANS. 71 and regular development of the Graafian follicles and their contained ova, accompanied by the usual attendant phenomena of menstruation. Throughout the entire childbearing period, or from about the fifteenth to about the forty-fifth year, the development of the Graafian follicles, terminat- ing in the rupture of the follicles and the discharge of the ova, is continually occurring. The liberation of the ova usually takes place at definite times, which in general coincide with the menstrual epochs, one or more ova being set free at each period. This agreement, however, is by no means necessary or invariable, since ovulation, as the ripening and discharge of the sexual ele- ments is termed, undoubtedly proceeds independently of menstruation. The ripe human ovum is a typical spherical cell, about 0.2 millimeter in diameter, consisting of granular protoplasm or the vitellus, in which lies a nucleus or germinal vesicle, about 0.045 millimeter in diameter, containing a well-marked nucleolus, the germinal spot. The proper cell-wall is the vitelline membrane, a structure of great delicacy, and often overlooked, outside of which the ovum is invested by the conspicuous zona pettucida (about 0.01 millimeter thick), which must be regarded as a secondary envelope contributed by the cells of the surrounding discus proligerus. The fully-developed Graafian follicle is ovoid, and consists of an external investment of vascular connective tissue, the tunica fibrosa, which is lined by a thick layer of granular polyhedral epithelial cells, the membrana granulosa. At one point these cells are continued as a mass which immediately invests the ovum and which is known as the discus proligerus. The interior of the well- US Fig. 61.— Section of well-developed Graafian follicle from human embryo (Von Herff ) ; the enclosed ovum contains two nuclei. developed follicle (Fig. 61) contains a fluid, the liquor foUiculi, separating the ovum and its surrounding discus from the opposite wall of the sac. The most prominent part of the ripe follicle is less vascular than those parts subjected to less pressure, one spot, the Jiilum foUiculi, being free from blood-vessels, and corresponding with the point at which the distended matured sac, from 2 to 4 millimeters in diameter, finally ruptures. 72 AMERICAN TEXT-BOOK OF OBSTETRICS. 2. Menstruation. — At regular intervals throughout the childbearing period the lining of the uterus undergoes changes primarily designed to prepare a favorable resting-place for the product of conception. In the case of the non-occurrence of pregnancy these changes terminate in the disintegration of the uterine mucous membrane and in the discharge of blood, mucus, and tissue- debris that constitutes the phenomena of menstruation. Should pregnancy occur, menstruation is, as a rule, suspended during the entire time that the em- bryo is within the uterus, reappearing usually from six to eight weeks after the birth of the child. Exceptions to the customary prompt cessation of men- struation are by no means infrequent, the catamenial phenomena often recurring with regularity during the early months of gestation. The anatomical explan- ation of this variation is found in the fact that the uterine cavity is not obliter- ated by the apposition of the decidua reflcxa against the mucous membrane of the uterus or the decidua vera until the end of the fifth month. The very rare occurrence of the menses throughout gestation is probably associated with an abnormal and imperfect fusion of the deciduas. The reputed instances of women menstruating only during pregnancy must be viewed with suspicion, since the discharge in such cases probably always results from pathological conditions of the cervical canal. The complete menstrual cycle, which typically occupies twenty-eight days, may be divided into four stages (Marshall), following one another in regular sequence and lasting a definite proportion of the entire period : (1) The first or constructive stage is one of preparation for the reception of an ovum, and is characterized by the formation of a menstrual decidua in the preparation of which swelling of the mucous membrane, enlargement of the uterine glands, and increase of the connective tissue all take place. This stage probably lasts about one week, and is followed, when pregnancy has not occurred, by degenerative change^. (2) The second or destructive stage is marked by the destructive processes which give rise to the usual phenomena of the menstrual period, including the discharge of mucus, blood, and disintegrated uterine mucous membrane. Five days constitute the average duration of the menstrual flow, although its continuance may be extended or curtailed, owing to individual peculiarities. (3) The third or reparative stage is one of repair, during which the deeper and unaffected parts of the uterine mucous membrane institute constructive processes which within the short period of from three to four days result in the formation of a new mucosa. (4) The fourth or quiescent stage includes the remaining twelve or four- teen days of the menstrual cycle, and represents the quiescent period preceding the initiative changes marking the beginning of the next period. The relations between ovulation and menstruation are of great interest, for, although the discharge of the ripened ovum and of the degenerated uterine decidua takes place usually simultaneously, it is well established that it is neither invariably nor necessarily so, since authenticated observations have shown that menstruation may be unattended by the liberation of an ovum. While these ANATOMY OF THE GENERATIVE ORGANS. 73 two processes, as a rule, may be regarded as associated, the determination of the exact relation between the discharged ovum and the uterine changes coin- cident!)' taking place is not yet positively established. It may be assumed that the first or constructive stage in the cycle of uterine changes is particularly favorable for the reception of the ovum : this being the case, it is evident that the preparation of the uterine mucous membrane cannot be directed toward the reception of the ovum, whose discharge takes place with the coincident menstrual phenomena, since it is probable that at least a week is occupied in the transit of the egg from the ovary to the uterus. Marshall's conclusions, that "the decidua of a particular menstrual period is related, not to the ovum discharged at that period, but to the ovum discharged at the preceding period,", are fully warranted by the more exact data furnished by careful observation. The well-known coincidence of ovulation and menstruation finds its partial explanation, at least, in the marked congestion of the ovaries and the conse- quent stimulation and vascular engoi-gement which the uterus experiences by reason of the close arterial anastomoses between the vessels of these organs, the resulting turgescence probably being an important factor iu establishing the menstrual flow. II. PREGNANCY. I. PHYSIOLOGY OF PEEGNANCY. I. Development of the Embryo and the Fetus. 1. Maturation and Fertilization. — Coincident with the growth of the Graaf- ian follicle, which culminates in the rupture of the sac and the discharge of the liquor folliculi and the egg surrounded by the discus proligerus, the ovum passes through a series of changes collectively termed maturation, by which the female sexual cell is prepared for the reception of the male element, without the com- pletion of which preparation fertilization of the ovum is impossible. The maturation of the ovum consists essentially in the very unequal and repeated division of the egg, by which two minute portions of its substance, Fig. 62.— Portions of ova of Arteritis glacialis, showing changes affecting the germinal vesicle at the beginning of maturation (Hertwig): a, germinal vesicle; b, germinal spot, composed of nuclein and paranuclein (c) ; d, nuclear spindle in process of formation. the polar bodies, are extruded ; the remainder of the cell after the completion of this cycle returns to a quiescent condition to await the advent of the male sexual element. Maturation takes place entirely independently of the influ- O— t Fig. 63.— Formation of polar bodies in ova of Asterias glacialis (Hertwig) : ps, polar spinale ; pb', first polar body ; pb", second polar body ; n, nucleus returning to condition of rest. ence of the male or of the probability of fertilization, every healthy ovum undergoing these changes before it becomes sexually ripe. The process, in brief, consists of the following phases : («) The migration of the germinal vesicle or nucleus toward the periphery of the cell (Fig. 62) ; (6) the rupture and the disappearance of the nucleus, and the formation of the PHYSIOLOGY OF PREGNANCY. 75 nuclear spindle and other elements of the complicated mitotic cycle of indirect cell-division ; (c) the extrusion of a minute portion of the ovum as the first polar body (Fig. 63) ; (d) short quiescence followed by a repetition of division, resulting in giving off the second polar body ; (e) the establishment of equi- librium, the appearance of a new and smaller nucleus, the female pronucleus Fig. 64.— A, mature ovum of echinus : n, female pronucleus ; B, immature ovarian ovum of echinus (Hertwig). (Fig. 64), and the return to a condition of rest.'* Maturation usually takes place just before the rupture of the follicle and the escape of the ovum. On the completion of the phenomena of maturation, the ovum is prepared for the reception of the male element, the meeting of the sexual cells in mam- mals usually taking place within the upper portion of the oviduct. In order to appreciate the significance of maturation, as now accepted by embryologists, it is necessary to take into account certain of the structural details of the sexual cells. The nucleus of the ovum possesses, in common with other typical cells, a reticulum of nuclear fibres containing a substance known as chromatin, which is the vehicle by which the maternal characteristics are transmitted to the offspring. During the division of the ovum incident to maturation the chromatin becomes arranged as curved or looped segments, the chromo- somes, of which an invariable and fixed number is always present in the cells of a given species ; the number of chromosomes in man is placed at sixteen. In the course of the mitotic changes affecting the dividing ovum each chro- mosome splits longitudinally into two chromatin threads, the entire number of chromatic segments being thereby doubled. The later phases of mitosis bring about a redistribution of the chromatic substance, so that each new nucleus resulting from the division receives exactly one-half of the chroma- tin of the maternal cell, but the same number of segments, the constancy of this definite number being thereby maintained. Brief reference to the manner in which the male sexual elements are pro- duced is necessary for the interpretation of the significance of the division of the ovum which occurs during maturation. The spermatozoa are the direct descendants of the cells lining the seminiferous tubules. Certain of these elements, the primary spermatocytes, undergo mitotic division whereby the chromatin is equally distributed to the resulting cells, the secondary sper- matocytes; each of these daughter-cells, in turn, gives rise to other elements, 76 AMERICAN TEXT-BOOK OF OBSTETRICS. the spermatids, which are directly transformed into spermatozoa. These latter elements, therefore, are cells of the third generation and contain in the so-called "head" the chromatin of the spermatid, corresponding in their genealogical relations with the ovum after maturation, which, likewise, io the representative of the third generation - resulting from the repeated division of the maternal cell. In the light of these facts, the polar bodies may be regarded as abortive ova cast off in order to bring the female germ-cell into morphological correspondence with the male element. An additional consideration of great importance must be noted before the full significance of the preparatory changes anticipating the union of the two germ-cells during fertilization can be appreciated. Bearing in mind the fact already stated, that the number of chromosomes is constant in the cells of any given species, it is evident that union of the parent elements would result in numerically doubling the chromatin segments in the new being were not some provision made by which the number of chromosomes of the sexual cells was reduced to one-half the normal number in each. As a matter of observation, such.pe'1 uetiov does take place during the development of both sexual cells, so rn« ' in man the spermatozoon, on the one hand, and the ovum after maturation, on the other, each contains only eight chromo- somes, the normal number, sixteen, being restored only after the intermin- gling of the contributions from both parents in the nucleus from which segmentation proceeds. The number of the more vigorous seminal elements deposited within the vagina that work their wa}' through the uterine cavity and into the oviducts must be but an insignificant part of the entire number lodged about the exter- nal os. Of those, moreover, fortunate enough to overcome the obstacles pre- Fig. 65. — Portions of the ova of Astenas glacialis, showing the approach and fusion of the spermatozoon -with the ovum (Hertwig) : a, fertilizing male element; ft, elevation of protoplasm of egg; V, b", stages of fusion of the head of the spermatozoon with the ovum. sented to their progress within the uterus and tubes, but a single spermatozoon actually takes part in the fertilization of the ovum. After reaching the surface of the egg and penetrating the zona pellucida, the successful spermatozoon is met by a slight projection of the protoplasm of the ovum, with which the head of the male element soon becomes blended (Fig. 65). The tail is lost, and the head later sinks within the substance of the egg. Subsequently the position of the impregnating element is indicated PHYSIOLOGY OF PREGNANCY. 77 by the appearance of a small round or ovoid body, the male pronucleus (Fig. 66, A, b), which contains the paternal chromatin represented by the eight chromosomes into which the head of the spermatozoon soon becomes resolved ; the position of the male pronucleus, or sperm-nucleus, as this structure is now frequently termed, is rendered conspicuous by the radial striation marking the surrounding protoplasm. The male and female pronuclei now approach, and sooner or later meet, their chromosomes forming two groups of chro- matic segments for the resulting secjmentation-nucleus (Fig. 66, c), from which are formed the new generations of elements, to the constitution of which both parent-cells have thus contributed. It is of interest to note that, since the parts of the sexual cells most con- cerned in the production of the segmentation-nucleus are rich in chromatin, a fusion of the nuclei seems to be the essential feature of the process of fer- tilization. The contribution of an equal number of chromosomes by each parent-cell to the segmentation-nucleus furnishes the explanation as to the fundamental manner of transmission to the offspring of the individual pecu- liarities of both father and mother, since the nejpr. being depends for its origin upon a nucleus to which both parents have cbT'sjibuted and by which the characteristics of both are perpetuated. Should the matured female element fail to meet the spermatozoon, the ovum after a few days loses its vitality and perishes. The period during which the human egg retains the possibility of fertilization has been variously estimated, about eight days being the probable limit of the retention of this power, since the death of the unfecundated ovum usually occurs before the egg reaches the uterus. 2. Segmentation. — The meeting and fusion of the male and female pro- nuclei, already described, result in the formation of the new segmentation- nucleus (Fig. 66, C), whose appearance institutes the process of cell-division by J Fig. 66.— A, fertilized ova of echinus (Hertwig) : the male (a) and the female pronucleus (6) are approaching ; in B they have almost fused ; C, ovum of echiuus after completion of fertilization (Hert- wig) : s.n., segmentation-nucleus. which the original egg-cell gives rise to an extended series of generations, leading to the production of the blastoderm. Since the youngest human embryo carefully examined and recorded — that of Peters — was already probably nearly four days old, the early phenomena of impregnation and segmentation have never been observed in man. Direct 78 AMERICAN TEXT-BOOK OF OBSTETRICS. observations upon higher mammals, as the clog, the mouse, and the rabbit, have supplied our knowledge of the details of these early stages of development, which, in the main, probably closely correspond with the changes taking place within the human ovum. Nagel's examination of a ripe human ovum and the discovery of the presence of two polar bodies, as in other mammals, still further justify the assumption of this similiarity. The minute amount of food-yolk possessed by the mammalian egg is uni- formly distributed throughout its protoplasm, and is not collected as a distinct body ; such ova are therefore known as alecithal. As influenced by the amount and arrangement of the yolk, these ova experience entire cleavage during their division, and are said to undergo total segmentation, being there- fore holoblastic. Since the resulting cells may be regarded as practically equal in size, their type of segmentation may further be designated as equal. The human ovum, therefore, is technically described as an alecithal, holoblastic egg undergoing equal segmentation. Almost directly after the formation of the nucleus of segmentation the phenomena of cell-division acppear within the parent-cell, the cycle resulting in the formation of the first pair of daughter-cells (PI. 10, Figs. 1-3). These cells in turn become the seat of similar activity by which four cells are pro- duced, the process of cell-division continuing until the original element is rep- resented by many generations of direct offspring. While, for convenience, the segmentation of the mammalian egg may be regarded as equal, yet, when closely examined after the third or fourth cleavage, a slight difference may be noted in the size of the resulting elements, or blastomeres. This discrepancy, insignificant in its individual variation, becomes gradually manifested by the separation of the blastomeres into an inner and an outer cell-group, the cells of the outer group undergoing more rapid increase than those of the inner group, ■which latter cells, in consequence of this inequality in growth, gradually are invested by an enveloping layer composed of the outer cells (PI. 10). This process of covering-in progresses until the outer cells constitute a complete envelope, the entire segmented ovum now corresponding with the mulberry mass, or morula, of the older anatomists. Examined in section, the ovum at this stage consists of the single layer of outer cells, to the inner surface of which at one point adheres the less- expanded group composed of the inner cells, the space between the two, the segmentation-cavity, being occupied by a clear albuminous fluid. This stage of the hollow sphere of the mammalian ovum is known as the blastula or blastodermic vesicle (PI. 10, Fig. 4). The further changes within the blastula are marked by the rapid and enormous increase in the size of the ovum, in consequence of which increase the outer cell-layer undergoes great extension, with corresponding attenuation of its elements, which are changed into thin, scale-like plates. Coincidently with these changes affecting the layer of outer elements, the group of inner cells has undergone an important although inconspicuous modification, in consequence of which a differentiation of these cells into a rapidly proliferating peripheral layer, next the thinned-out stratum of invest- SEGMENTATION OF THE OVUM. Segmentation— 1-3. Diagrams illustrating the segmentation of the mammalian ovum (Allen Thompson, after E. t. Beneden). 4. Diagram representing the relation of the primary layers of the blastoderm (Bonnet). PHYSIOLOGY OF PREGNANCY. 79 itif outer cells, and a more slowly dividing central mass has taken place (PI. 10, Figs. 1-3). This peripheral layer is the primitive ectoderm proper ; the inner mass is the primitive entoderm. With the growth of the eetodermic layer the primary outer cells become more attenuated, and after a time blend with the developing eetodermic tissue, the two together constituting the early true ectoderm. When this structure is examined its surface is found covered with flat elements, fusiform in profile, known as Rauber's cells (PI. 10, Fig. 4), . , #V" - : ->i Node of which later disappear and seemingly take ft- $§5 '■ ~*r^ //<•««•« . . „ f ?M — Neunnteric little or no role in the formation of the permanent eetodermic structures. The cells of Rauber are probably the remains of the attenuated layer of the primary outer cells. The ectoderm expands on all % f~i~- / — Fr "t"l'ak C .sides until the entoderm as well as the f*. .entire yolk-cavity of the ovum is com- .,.■'.... '. J pletely enclosed. \ ■ /' If a mammalian ovum at about this ~* ■■=-'- i -. n ,, n xl Fig. 67.— Embryonic area of rabbit embryo stage be examined from the surface, the (E> T . Be neaen): primitive streak beginning blastodermic vesicle on one side presents in cell-proliferation, known as the " node of an oval or pyriform field of greater den- sity : this is the embryonal area, and corresponds to that portion of the blastula especially concerned in the development of the embryo. Very early a linear opacity known as the primitive streak (Fig. 67) makes its appearance at the smaller or posterior pole of the embryonal area, and seemingly grows for- ward toward the centre of this field. On section the primitive streak is seen to depend upon a line of proliferat- ing tissue which marks the position of fusion and intimate union of all the ■embryonal blastodermic layers (Figs. 68, 69). Very soon the primitive streak becomes occupied by a median longitudinal furrow, the primitive groove. The significance of this pre-embryonic structure is still a subject of much discussion. Without entering into the details of the somewhat theoretical and complicated considerations of the subject, it may be mentioned that there are ample grounds for accepting the views of His, Minot, and others that the primitive streak of the higher types represents morphologically the fusion of the lips of the blas- topore — the opening formed among the lower types by the invagination of the blastodermic vesicle at one point in the production of the gastrula stage. In contrast with the usual appearance of mammalian ova, the early human ovum is characterized by the precocious development of villous projections, so that as early as the twelfth day, as represented by Rei chert's ovum (see Fig. 83), its exterior presents well-marked elevations. These villi, however, are not uniformly distributed over the ovum, but are limited to the marginal zone of the compressed spherical egg, the two flattened sides being smooth .and devoid of villi. The embryonic area corresponds in position with one of 80 AMERICAN TEXT-BOOK OF OBSTETRICS. the poles of the shorter axis of the ovum that connects the smooth sides, although at this stage little if any trace of the embryo is to be seen. Coincidently with the further growth and differentiation of the two- layered blastula, a third layer, the mesoderm, makes its appearance (Fig. 68). The origin of this lamina is still a subject of much discussion, but it may be accepted as demonstrated that the mammalian mesoderm arises from "two- sources — principally by a splitting off or delamination from the entoderm. Fig. 68.— Section across the primitive streak of rabbit embryo (Kolliker) : ec, ectoderm ; ax. ec, axial ecto- derm undergoing proliferation, as shown by karyokinetic figures (k) ; ent, entoderm ; m, mesoderm. supplemented by a proliferation involving the ectoderm along the anterior part of the primitive streak. This latter structure therefore marks the axis along which complete fusion of the three blastodermic layers takes place before the formation of the true embryo has started. The primitive streak is a transient structure, and gives rise to no part of the embryo ; later it entirely disappears. The growth of the mesoderm is rapid, and soon produces a layer partic- ularly developed toward the caudal pole of the embryo, expanding in broad lateral fields on either side. Viewed as a whole, the mesodermic sheet appears pyriform, with its smaller end directed anteriorly or opposed to the corre- sponding part of the embryonal area. At first a continuous layer, the Parietal Ectoderm. \„{ esoc i'e. Visceral layer of mesoderm. Entoderm. Fig. 69.— Transverse section of the embryonic area of a fourteen and a half day ovum of sheep (Bonnet).. mesoderm later becomes displaced along the immediate axis of the embryo, this division resulting in the formation of two closely approximated but separated halves : in each of these a paraxial and a lateral tract are further to be recognized. The latter undergoes cleavage by the formation of the intra- mesodermic body-cavity or the celom (Fig. 69) ; the resulting upper and lower lamella; constitute respectively the parietal and visceral layers of the meso- derm. The parietal or somatic layer joins the ectoderm to form the somato- PHYSIOLOGY OF PBEGNANCY. 81 pleure; the visceral or splanchnic layer unites with the entoderm to form the splanchnopleure (Fig. 70). These structures later produce the body-walls and the walls of the primitive digestive tube. About the end of the second week the human ovum enters upon the earliest initial stages of the formation of the embryo proper. In addition to Lateral plates/or body-ivalls. Lateral plates fc gut-tract. Parteta! we.Wi/er Vitellin Fig. 70.— Transverse section of a seventeen and a half day sheep embryo (Bonnet). the primitive streak, which, as above stated, is a transient structure having nothing directly to do with the embryo, the fundamental developmental processes include the formation of the neural folds and the neural canal, the chorda dorsalis or noto- chord, and the somites or provertebraz. Neural Canal. — The de- velopment of this structure consists first in the appear- ance of the neural or medul- lary folds, which together constitute a A-shaped dupli- cature embracing the anterior extremity of the primitive streak ; by the thickening and the approximation of the summits of these folds the neural or medullary groove is produced (Fig. 71). This furrow is later converted into the neural canal, the early representative of the nervous system, by the further growth and union of the folds along the dorsal line of contact, the closure being first effected near — not, however, at — the cephalic extremity of the embryo, but some little distance farther caudally, at a position which later corresponds with Fig. 71.— Surface view of area pellucida of an eighteen hour chick embryo (Balfour). 82 AMERICAN TEXT-BOOK OF OBSTETRICS. the cervical region of the spinal cord. The extreme cephalic end of the neural canal undergoes expansion into three primitive brain-vesicles. The neural folds of the caudal portion for a long time remain widely separated. Chorda Dorsalis. — The appearance of the chorda dorsalis, or the notochord, establishes the earliest representative of the longitudinal axis which constitutes the fundamental characteristic of all vertebrates. The earliest development of this structure in man, recently observed, shows the close correspondence of the process in the human embryo with that in other mammals. The mesial portion of the entoderm gives rise to a cell-group (Fig. 72) which gradually becomes separated from the inner layer and displaced, so that the Ccll-massfor Wolffian body. Celom. 31,'M>!h<*lium. Notochord. Fig. 72.— Transverse section of a fifteen and a half clay sheep embryo possessing seven somites (Bonnet). resulting cell-mass forms a ^lender cylinder which stretches from the anterior extremity of the embryo to its caudal pole. On section the notochord appears as an oval group of cells situated immediately beneath the neural groove or canal and above the entodermic layer (Fig. 74). The notochord, for a time representing the longitudinal axis of the embryo, is usually replaced by the permanent vertebral axis, at first cartilage and later bone. The remains of this embryonal structure in man are seen in the central areas of spongy material occupying the intervertebral disks. Somites. — The formation of the somites or prevertebral marks the estab- lishment of the segmentation which later is permanently effected by the devel- opment of the vertebrae and the associated parts of the trunk. The production of the somites is so closely related to that of the mesoderm that the primary arrangement of this important sheet must be recalled. After its origin from the double source of entoderm and ectoderm, the mesoderm rapidly expands laterally, the growth being particularly active toward the caudal pole of the embryo, in consequence of which the layer becomes pyriform in outline when seen from its upper surface. At first a continuous sheet, the further develop- ment of the neural groove from above downward and of the notochord from PHYSIOLOGY OF PREGNANCY. below upward soon divides the mesodermic tract along the embryonic axis into two great wings (Fig. 73). Each of these wings undergoes further differentiation into a paraxial band next the mid-line, and a lateral plate which blends away laterally into the Pleur _ dial cavity. Fig. 73.— Transverse section of a sixteen and a half day sheep embryo (Bonnet). widely extending mesodermic area (Fig. 74). The lateral mesodermic plate undergoes cleavage into an upper and a lower lamina which respectively adhere to the ectoderm and the entoderm. The upper and outer of the result- ing two-layered lamella? constitutes the somatopleure; the under and inner one, Notocliord '. Somite. Gut entoderm. Fig. 74.— Transverse section of a sixteen and a half day sheep embryo possessing six somites (Bonnet). the splanchnopleure. The space included between the two leaves of the cleft lateral mesoderm is the primitive body-cavity or celom, which afterward becomes the pleuro-peritoneal cavity. 84 AMERICAN TEXT-BOOK OF OBSTETRICS. The paraxial band of mesoderm does not undergo cleavage as do the neighboring lateral mesodermic areas, but instead it suffers a transverse divis- ion into a series of small quadrilateral areas, the somites or provertebros. These areas first appear immediately behind the cephalic expansion of the neural canal and progress toward the caudal pole, at particular stages of the human embryo, as from the twenty-first to the thirty-fifth day, forming a series of usually thirty-seven conspicuous markings on each side of the dorsal mid-line as far as the extreme caudal extremity (Fig. 129), The somites, as such, are transient and are not directly represented by adult structures, since the permanent vertebras which later appear do not correspond with the somites. Each somite contains a central core of loose mesodermic tissue which breaks through the mesial boundary, forming a fan- shaped mass known as the sclerotome, from which the permanent vertebrae are developed. The remaining poi'tions of the somite become differentiated into a lateral and a mesial mass, called respectively the skin-plate and the muscle-plate; the former contributes the cutis vera, the latter the primary segmented voluntary muscular tissue of the trunk, from which later, when the extremities appear, the limb-muscles are derived. •3. Petal Membranes. — Coincident]}' with the progress of the fundamental processes just described, the formation of envelof>es for the protection and establishment of means for the further nutrition of the embryo takes place : these envelopes are known as the fetal membranes (Pis. 11, 12), which, in con- nection with the structures derived from the thickened uterine lining, con- stitute the membranes thrown off at birth. The amnion (PI. 11, Figs. 4, 5), the earliest of the envelopes, appears soon after the formation of the neural folds and groove as duplicatures of the soma- topleure which start in front, behind, and at the sides of the embryo. The anterior amniotic fold in man grows with unusual rapidity, and, aided by the lateral folds, soon covers in the embryo from before backward, the caudal extremity being the last to be enveloped. The line of union of the several duplicatures has received the name amniotic suture. Examined in section, the amnion is seen to comprise not only the ectodermic tissue, but also the exten- sion of the parietal or somatopleuric layer of the mesoderm. On reference to the Figures of Plate 11 this relation will be seen illustrated, as well as the mode by which the folds meet over the dorsal surface of the embryo to form the amni- otic sac, which, when entirely closed, contains the amniotic fluid separating the envelope from the developing animal. While union and fusion of the innermost layers of the ecto-mesoclermic folds of the somatopleure produce the true am- nion with its contained sac lined with ectoderm, the separation of the fused outer laminae of the duplicatures from the amniotic portion gives rise to a sec- ond externally-lying envelope, the false amnion, or serous envelope, in which the disposition of the component layers is reversed, since the ectoderm lies with- out, and the mesodermic tissue next the included space. The latter is directly continuous with the interval between the parietal and visceral laminae of the cleft mesoderm, and is the extra-embryonal portion of the primitive body- cavity, which thus extends widely beyond the limits of the embryo proper. DEVELOPMENT OF THE FETAL MEMBRANES. Plate 11. Embryo. 1-6. Diagrams illustrating the formation of the mammalian fetal membranes (modified from Roule). PHYSIOLOGY OF PREGNANCY. 85 With the accumulation of the liquor amnii the amnion becomes separated from the embryo and is pushed against the surrounding envelopes. The amniotic fluid, or liquor amnii, is a serous fluid produced probably by the amnion itself, having a specific gravity varying from 1.007 to 1.008 ; it contains from 1.07 to 1.06 per cent, of dry solids (Prochownick). The amount of the amniotic fluid is subject to great variation, the average quantity at full term being between 700 and 800 cubic centimeters, or less than one liter. Not- withstanding numerous investigations, there appears to exist no constant rela- tion between the quantity of the amniotic fluid and the weight of the child or of the after-birth. In addition to the evident use of the fluid for the mechanical protection of the embryo, it is probable that it affords a source of water to the developing animal, since there is strong evidence to show that the fluid is con- tinually swallowed during the latter part of intra-uterine existence. Toward the latter months of gestation the pressure induced by the growing fetus and the large amount of the amniotic fluid pushes the amnion into close contact with the surrounding false amnion, the two becoming closely, although not inseparably, united by the end of gestation. As the embryo gradually assumes a more definite general form, the roots of the true amniotic folds sink more and more ventrally until they meet, thus closing in the body-cavity and forming its anterior wall. In the early stages, when the yolk-sac or umbilical vesicle communicates with the widely open gut-tract by means of its broad stalk, approximation of the somatic plates is prevented. With the decrease of the umbilical vesicle and the corresponding diminution in its stalk the ventral plates grow together and rapidly close the pleuro-peritoneal cavity except at one point, the umbilical opening, through which pass those structures that connect the embryo with organs lying with- out its body, as the atrophic vitelline and allantoic blood-vessels and stalks with their disappearing lumina. The Allantois. — The allantois appears as an outgrowth from the hind-gut (PI. 11, Figs. 5, 6) after the primitive digestive tube has become well defined and partially closed. When typically developed the allantois grows out as a free sac into the space between the true and the false amnion, rapidly increasing in size. In man, however, the allantois at no time exists as a free vesicle, since it almost at once forms attachments with the structures extending from the caudal extremity of the human embryo as the abdominal stalk (Fig. 75), in which is included the lumen of the imprisoned allantoic sac. The primary function of the allantois is to act as a receptacle for the excre- tory allantoic fluids thrown off by the Wolffian bodies, by which primitive organs the effete, matters are removed as by the kidneys at later stages. Sub- sequently the allantois takes an important part in building up the chorion, from which the fetal contribution to the nutritive apparatus of the placenta is directly derived. The abdominal stalk is peculiar to the human embryo, in which it very early appears as a pedunculated extension of its caudal portions to the sur- rounding false amnion, over which it expands and with which it fuse's, the 86 AMERICAN TEXT-BOOK OF OBSTETRICS. allantoic tissue taking part in the formation of the chorion (PI. 12, Fig. 1). The allantois in man, therefore, is never free, and finds its expression in the entodermic diverticulum, which passes from the hind-gut through the abdom- inal stalk toward the chorion.* Whatever its initial mode of formation, the allantoic tissue grows with rapidity and extends over the inner surface of the false amnion, with -which it soon becomes intimately united, the two membranes together constituting the chorion, a structure of much importance in providing for the nutrition of the embryo during the last two-thirds of its intra-uterine sojourn, by reason of its active participation in the formation of the placenta. The allantois being a direct outgrowth or evagination of the primitive gut, its wall consists of an inner entodermic and an outer mesodermic layer — ex- tensions of the splanchnopleuric tissues forming the digestive tube. Coinci- dentlv with the later development of the allantois, blood-vessels extend from the arterial trunks of the embryo within the mesodermic layer of the sac and invade this tissue, which has become closely united with the false amnion in their joint production of the chorion. Fig. 75.— Diagrammatic sections representing growth and arrangement of the amnion in the earliest stages of the human emhryo (His). The chorion, covered with simple and compound villi, is at first devoid of blood-vessels, and is composed of the eotodermic and entodermic layers on its outer and inner surfaces, between which lies the thicker lamella formed by the fused amniotic and allantoic mesodermic strata. Shortly after the establish- ment of the chorion, the arteries conveyed by the allantois spread out within the mesodermic layer of the chorion and invade the villi, which then display vascular loops within their characteristic leaf-like, club-shaped processes. These processes often consist of a main primary stalk from which second- ary twigs branch, from which diverge the ultimate leaves. ^JThe term "chorion" is here used in a restricted sense as indicating the membrane resulting from the fusion of the false amnion and the allantoic tissue ; by some authors the ''chorion" represents the entire extra-embryonic somatopleure, which gives rise alike to the true and the false amnion. DEVELOPMENT OF THE FETAL MEMBEANES. Plate 12. Vascular villi of placental chorion. I 'itelline vesicle. Allantoic blood-vessels. Allantoic stalk. 1, 2. Diagrams illustrating the later stages of the formation of the mammalian fetal membranes (modified from Roule). PHYSIOLOGY OF PREGNANCY. 87 The form and arrangement of the villi vary somewhat with the duration of pregnancy: at the third month, or when the placenta is formed, the villi are short, thick-set, and of irregular shape ; later they become less irregular, and the secondary branches leave the parent stems less acutely; finally, at full term, the villi are more regularly disposed and their branches have become long and slender and less closely set. The recognition of the villi of the cho- rion is often a matter of much practical importance, since their presence, as determined by microscopical examination of suspicious matters discharged per vaginam, is positive evidence of the existence of pregnancy. Their peculiar arrangement, and their flattened, petal-like form, together with their vascular connective-tissue stroma and epithelial covering, usually suffice to establish the diagnosis. The Placenta and Deciduce. — The primary uses of mechanical protection afforded by the membranes in mammalian embryos are supjfleruented by the important role of assisting in establishing an efficient nutritive organ through which the maternal tissues may extend the necessary aid to the maintenance of the developing animal during the latter two-thirds of its intra-uterine life. Such oi'gan is the placenta, in whose production both fetal and maternal struct- ures take an active part. The early villi of the chorion are practically identical in all parts where developed. Very soon, however, the villi occupying the area which later will correspond with that of the placenta exhibit unusual growth, and outstrip in size aud vigor those of the remaining parts of the envelope. This difference in the development of the villi marks the division of the membrane into the chorion frondosum and the chorion losve, the former being that part of the chorion which contributes the fetal portion of the placenta (Fig. 76). The villi of the chorion lseve undergo gradual atrophy and finally disappear. The fertilized ovum on reaching the uterus, after descending the oviduct, becomes entangled and retained within the folds of the soft, thickened mucous membrane prepared for its reception. Immediately after its lodgement, which is usually in the vicinity of the fundus, the ovum, according to the recent studies of Peters, erodes the uterine lining, sinks beneath the surface, and becomes embedded within the subepithelial tissue of the mucous membrane, the orifice of entrance becoming closed. Thus encapsulated, the ovum rapidly increases in size, with the result that the overlying hypertrophied mucous membrane becomes elevated and projects into the uterine cavity as the decidua reflexa. In view of the fact that the mucosa of the uterus is discarded at the close of labor, the thickened uterine lining is appropriately termed the decidua; of this membrane three regions are recognized : the decidua reflexa, or that por- tion which encloses the ovum by the reflected folds ; the decidua vera, or that portion which constitutes the greater part of the general lining of the uterine cavity ; and the decidua serotina, or that portion of the uterine lining included within the embryonic sac completed by the reflexa (Fig. 76; PI. 13). The decidua serotina derives especial significance from the fact that it contributes the maternal part in the formation of the placenta. 88 A3IEBICAN TEXT-BOOK OF OBSTETRICS. The changes affecting the maternal tissues consist primarily in proliferation of the epithelium and the glands, the latter becoming greatly enlarged both in size and in the number of the tubules, the increase particularly involving their deeper parts. Subsequently the pressure exerted upon this hypertro- phied tissue by the rapidly growing embryo and its surrounding structures induces atrophy and degeneration, so that the outermost part of the thickened uterine mucosa becomes the stratum compactum, and the middle part the stra- tum spongiosum (Fig. 77). The limited zone embracing the fundi of the tubular uterine glands remains unaffected, and, after the expulsion of the structures Fig. 76.— Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy (modified from Allen Thompson). constituting the after-birth, institutes the processes of repair by which the new mucous membrane of the uterus is produced. As the result of the penetra- tion of the ovum into the subepithelial portions of the uterine mucosa the vascular chorionic villi are brought into close relations with the vascular connective tissue of the uterus, by which the interchanges between the fetal and maternal circulations are facilitated. The relations between the fetal and the maternal structures, in placental of RELATIONS OF FETUS AND DECIDUJE. Plate 13. PHYSIOLOGY OF PREGNANCY. 89 the simplest type such as possessed by the hog, consist essentially in the recep- X v Fig. 77.— Section through uterine wall and attached placenta (Wagner) : u, uterine wall rendered spongy by greatly-developed uterine sinuses (us) ; iia, branches of uterine artery ; ds, decidua serotina ; s, line of separation ; fp, fetal portion of placenta, consisting of a mass of vascular fetal villi (v.v.v.), sur- rounded by the maternal blood-sinuses ; am, amnion covering free internal surface of placenta. tion of the simple chorionic villi within corresponding depressions in the maternal tissues, the circulation of the villi coming into close approximation Fig. 78.— Placenta viewed from uterine surface of attachment, showing divisions into cotyledons (Bidloo). with the enlarged blood-vessels of the mother. These simple relations become complicated in the higher mammals and in man by the complex 90 AMERICAN TEXT-BOOK OF OBSTETRICS. character of the chorionic villi, whose irregular form and disposition are further masked by actual attachments formed between the tips of many large villi and the maternal tissue (PI. 14). The exterior of the early human ovum, using the latter term as indicat- ing the embryo with its investing membranes, is covered with villous pro- jections composed of the proliferating epithelium derived from the ectoderm of the primitive chorion ; this layer rapidly acquires considerable thickness and sends its projections into the surrounding maternal tissue, thereby, even at a very early stage, becoming an active agent in securing nutritive mate- rials for the young embryo. This ectodermic envelope has received the name of trophoblast in recognition of its important nutritive function. Fig. 79.— Placenta at full term, showing superficial distribution of blood-vessels (Minot). Coincidently with the changes affecting the decidua serotina, the capil- lary blood-vessels of this part of the uterine mucous membrane undergo enormous expansion, so that, finally, they are converted into the large and conspicuous blood-spaces occupying the intervals between the attached cho- rionic villi and the adjacent maternal tissue. These intervillous blood-spaces, the enormously dilated maternal capillaries, are supplied by arterial twigs and are drained by corresponding venous trunks connected with the larger uterine vessels. Notwithstanding the attachment of many large villi, the DEVELOPMENT OF THE FETUS AND ITS APPENDAGES. Plate 14. 55 'H fr PHYSIOLOGY OF PREGNANCY. 91 greater number, comprised by the smaller villi, are not so bound clown, their free ends floating within the large lakes of maternal blood, from which they ' are separated by the attenuated and atrophic remains of the ectodermic trophoblast, now known as the syncytium. The human placenta at full term, as seen after the expulsion of the after- birth, is a discoidal mass, usually oval, sometimes circular, but often irregular in outline, about 18 centimeters in diameter and 2.5 to 3 centimeters in thick- ness. It presents an inner smooth surface, covered by the amnion and look- ing toward the fetus, and an outer rough, spongy, uterine surface of attach- ment subdivided by furrows into numerous more or less distinct areas or cotyledons (Fig. 78) composed of the lacerated decidual tissue and vessels torn through at the time of the separation of the placenta, the decidua serotina split- ting, one part adhering to the outer surface of the placenta, the other remaining attached to the uterine wall. In contrast with the dark blood-clot hue of this tissue, the smooth, shining amniotic surface appears of a generally lighter, somewhat mottled tint, made up of reddish-gray patches alternating with yellowish areas, which depend respectively upon the contained blood and the fetal villi, whose colors shine through the superimposed transparent amnion. The placental blood-vessels (Fig. 79) — the two umbilical arteries and the single umbilical vein — spread out in all directions from the usually eccen- tric point of insertion of the umbilical cord, when distended with blood their courses being readily traced both by sight and by touch beneath the overlying amnion. The arterial twigs are more superficial than the veins, which are considerably larger in diameter. Both sets of vessels pass from the smaller to the larger twigs without anastomoses. Structure. — If the freshly-cut surface of the thickness of the placenta be carefully examined with the unaided eye or with a low magnifying glass, the entire organ is seen to be composed of an inner and an outer membranous boundary, between which is included a thick spongy layer contributing almost the entire thickness of the organ. Closer investigation shows that the spongy layer is composed of the loosely held masses of chorionic villi (Fig. 80), with the intervillous blood-spaces, separated into the cotyledonous areas by con- nective-tissue septa. The outer mem- branous boundary consists of the con- densed portion of the decidua serotina, which adheres to the fetal villi and sup- plies the outer wall to the blood-spaces ; the inner boundary includes the denser portion of the chorion together with the adherent amnion. Microscopic examination of the spongy placental tissue, as seen in sections >0.— Portion of injected villus from a pla- centa of about five months (Minot). 92 AMERICAN TEXT-BOOK OF OBSTETRICS. (Figs. 81, 82), shows the villi, although differing greatly in size, to be made Fig. SI —Section through placenta of seven months in situ (Minot) : Am, amnion; Clio, chorion; Yi, root of a villus ; vi, sections of ramifications of the villi among the maternal blood-spaces ; D, deep layer of the decidua, showing remains of enlarged glands of stratum spongiosum; IV, uterine blood-vessel connected with placental sinus ; Mc, muscular wall of uterus. up of a stroma of embryonal connective tissue containing large branched cells PHYSIOLOGY OF PREGXAXCY. 93 and blood-vessels ; these latter consist of the larger twigs, encased by the robust primary stalks, and of all gradations of size to the slender capillary loops supplying the terminal petal-like processes. The exterior of the very voting chorionic ectodermic villi is covered by a layer of epithelium, to which reference has already been made as the trophoblast. "With the pro- gressive intimacy between the latter and the maternal tissue, the trophoblast tio&H Fig. 82.— A, section through margin of placenta at full term (Minot): D, D, deep layer of decidua; Vi, chorionic villi variously cut, blood-vessels injected ; Si, marginal space nearly free from villi ; vi, atrophic extra-placental villi; Clio, chorion; 6, vessel of uterine wall; Fib, canalized fibrine derived from modified chorionic ectoderm. B, decidual tissue from placenta at full term : d, d', decidual cells ; v, blood-vessel. undergoes marked change and diminution due to the encroachment of the rapidly invading blood-vessels of the uterine mucous membrane. Owing to the action of the maternal blood-stream, according to Peters, the trophoblast bordering the vascular spaces becomes converted into a modified stratum, the syncytium, the origin of which must be referred, therefore, to the fetal tis- sues. When examined in section, about the fourth month, the placental villi possess an ectodermic envelope consisting of two layers, an inner, composed of low cuboidal epithelial elements, nucleated and well defined ; and an outer stratum, the syncytium, which appears as a protoplasmic layer in which lie numerous nuclei, but no well-defined cell boundaries. Sections of the placenta during the later months of gestation fail to reveal any definite endothelial partition between the exterior of the villi and the maternal blood-spaces, the villi seemingly coming directly in contact with the blood of the mother. The determination of the existence or absence of a dis- 94 AMERICAN TEXT-BOOK OE OBSTETRICS. tinct wall to the blood-space has given rise to much discussion and conflicting as- sertion. The solution of the question, as so often is the case, seems to be found in the more careful study of the development of the tissues, which study has shown that in the earliest stages the fetal villi are separated from the maternal blood-vessels by an intervening layer of decidua as well as by the endothelium of the vessels. With the progressively increasing capacity of the blood- capillaries the compression and atrophy of the interposed structures follow, during the later months of pregnancy the external surface of the chorion and its villi, covered by the syncytium, constituting the immediate wall of the maternal blood-space. 4. Umbilical Cord. — The formation of the human umbilical cord is closely related to the primary abdominal stalk. The latter, as already noted, may be regarded as the extension of the embryo — as a sort of pedicle connect- ing its caudal parts with the chorion and containing the allantoic diverticulum. In the early stages the somatic folds which form the amnion bear the same relation to the abdominal stalk as they do to the more anterior parts of the embryo ; later they bend around the stalk to meet and join on its ventral surface, the amnion in consequence becoming separated from the stalk, which thus becomes gradually enclosed within a tubular amniotic sheath. The closure of the somatopleuric folds around the abdominal stalk imprisons the umbilical or vitelline duct within a space which is, in fact, part of the celom. This space soon becomes greatly reduced, and finally is obliterated. The foregoing rela- tions point out the fact, strongly emphasized by Minot, that the umbilical cord is covered with the direct extension of the embryonic somatopleure, and not with the amnion, as is often asserted, since the amnion gradually becomes sepa- rated from the embryo along the cord as far as its distal end, where it still remains connected. The most important constituents of the umbilical cord in its earlier con- dition are the two umbilical arteries, the two umbilical veins, the allantoic diverticulum, and the extension of the celom containing the vitelline duct and, possibly, traces of the vitelline vessels. Later, the umbilical veins fuse and constitute a single vessel ; the allantoic lumen and the celomic space atrophy and disappear. The atrophic vitelline or umbilical duct long remains, even after birth the vesicle and its duct appearing as a minute sac and stalk lying between the amnion and the chorion, in close proximity to the placenta. The human umbilical cord at birth measures about 55 centimeters (22 inches) in length, with from 15 to 160 centimeters (6 to 64 inches) as the extremes of its variations; its diameter is from 10 to 15 millimeters (| to f inch). The cord usually joins the inner smooth surface of the placenta eccentrically, its insertion at times being marginal, or, in rarer cases, even altogether outside the immediate area of the placenta. The apparent twisted condition of the cord is often very marked, the spirals, sometimes to the number of thirty or more, being emphasized by the contained blood-vessels. While this phenomenon has long been known, a satisfactory explanation of the twisted appearance, which begins before the third month, still remains to be given, notwithstanding nu- merous theories and discussions. A point of especial interest, as pointed out PHYSIOLOGY OF PREGNANCY. 95 by Minot, is that there is no evidence that the entire cord really undergoes torsion, but rather that the blood-vessels become coiled within the soft tissue as the result of an excessive unequal growth still insufficiently understood. The structure of the cord includes an external covering of epithelium directly continuous at its distal end with that of the amnion. The bulk of the cord consists of the peculiar form of embryonal connective tissue known as the jelly of Wharton, rich in branched cells with anastomosing protoplasmic processes. Shortly beyond the umbilical opening both capillaries and nerves are apparently wanting; lymphatics, in the sense of definite canals, are also absent. In addition to the large umbilical blood-vessels, epithelial masses indicate the remains of the allantoic diverticulum and the vitelline duct. 5. Development of the External Form. — Adoptingthedivisions suggested by His, it is convenient to distinguish three stages in the development of' the human subject. The blastodermic stage embraces the first two weeks of gesta- tion, and is occupied by the earliest developmental processes ; the embryonal stage includes from the third to the fifth week, during which time the charac- teristic embryonal features are pronounced and the principal organs and symptoms are well established; the remaining weeks of pregnancy are devoted to the fetal stage, during which the embryonal characters are gradually replaced by those of the fetus and the full-term child. While it is evident that no sharp demarcation separates these stages, yet certain well-pronounced charac- teristics distinguish, in general at least, embryos of particular developmental epochs, and consequently serve to determine their probable age notwithstanding individual variation. Stage of the Blastoderm. — Opportunities for examining early human blas- todermic vesicles are rare. One of the youngest well-authenticated specimens is the classical ovum of about twelve days described by Reichert (Fig. 83). The Fig. 83.— Human ovum of about twelve days (Eeichert) : A, side view ; B. front view. The villi are seen p to be limited in distribution, leaving the poles free. appearance of this ovum emphasizes the early and precocious development of the villi which encircle the flattened lenticular vesicle (5.5 millimeters in its greatest diameter by 3.3 millimeters in thickness) as a closely set equatorial zone. Of the embryo proper no trace was discoverable, a patch of thickened cells alone representing the embryonal area. The earlier processes of seg- mentation and blastnlation have never been observed in the human ovum. Stage of the Embryo. — The thirteenth and fourteenth days witness the evolution of the early embryonal form as effected by the development of the 96 AMERICAN TEXT-BOOK OF OBSTETRICS. medullary groove and canal and their cephalic expansion. The embryo is attached by the allantoic stalk to the surrounding membranes, the axes of the stalk and the upright embryo generally coinciding (Figs. 84, 85 ; see also Fig. 97) ; what flexure exists at this time is backward, and results in a concave dor- sal outline. The ventral aspect of the embryo of this stage is largely occupied by the relatively huge vitelline sac, which freely communicates with the imper- fectly defined gut along almost the entire length of the embryo. The preco- ciously developed amnion has completely enveloped the enibryo and its stalk as far as the distal attachments of the latter. The heart is first represented by two longitudinal folds corresponding with the primary halves from which Fig. S4.— Human embryo of about the fifteenth day (His) : the embryo is attached to the wall of the blastodermic vesicle by means of the belly or allantoic stalk, and is enclosed within the amnion ; the large vitelline sac freely communicates with the still widely open gut. the organ is formed ; slightly later, these folds fuse into a single heart, which then appears as a conspicuous projection between the yolk-sac and the cephalic vesicle. The third week (Fig. 86) is productive of many important additions to the exterior of the embryo. Its form becomes more definite "; the brain-vesicles, together with the optic vesicles and the auditory sacs, are differentiated ; the" visceral arches and the corresponding furrows are formed ; the yolk-sac is much more constricted, and its narrower connection with the gut foreshadows the later vitelline stalk. During the twenty-first clay the first rudiments of the limbs appear. The fourth week (Fig. 86) is marked by great increase in size and by con- spicuous changes which give to embryos of this age distinctive features, growth being relatively more active at this period than at any other. At the termination PHYSIOLOGY OF PREGNANCY. 97 of the third week the embryo is still erect. During the next day flexion takes place with great rapidity, so that during the twenty-third day the cephalic and caudal poles of the embryo actually meet or even overlap, the dorsal outline approximating a circle (Figs. 86, 87). The individual brain-vesicles are better developed, as are also the visceral arches and furrows, the eyes, ears, and nose ; the heart has increased in size, and the limb-buds have become more pro- nounced. At the end of the twenty-third day extreme flexion has taken place, from which time until the close of the fourth week the embryo gradually becomes less tightly coiled on itself, the larger and more conspicuous head slowly rising and leaving the tail. During the latter half of the fourth week, in addition to the increased development of the visceral arches, the individual cephalic flexures become Fig. 85.— Human embryo of about the thirteenth day (His) : the caudal pole of the embryo is con- nected with the blastodermic vesicle by means of the abdominal or allantoic stalk; the amnion already completely encloses the embryo, and the large vitelline sac communicates throughout the greater part of the mitral surface by means of the unclosed gut-tract. very conspicuous. These flexures consist of a sharp bending of the ante- rior parts of the head upon the posterior half, resulting in a change of nearly 90° in the cephalic axis, with the production of a conspicuous prominence marking the position of the mid-brain. Posteriorly, the cervical flexure sharply indicates the junction of the cephalic and trunk segments; farther caudally, the dorsal and coccygeal flexures mark less pronounced changes in the direction of the embryonic axis. On either side of the dorsal mid-line, extending from the cervical flexure to the tip of the caudal extremity, a series of prominent quadrilateral areas indicate the position of the somites or provertebra? (Fig. 86, 11 and 12). The development of the visceral arches reaches its highest expression by the 98 AMERICA!? TEXT-BOOK OF OBSTETRICS. termination of the fourth week, when the series of arches is seen in its best condi- tion (see Fig. 129). In man andin mammals fivearchesare successively developed from before backward, the last, however, being scarcely differentiated and very inconspicuous. The first arch when fully formed is partially divided into an upper and a lower secondary division, the maxillary and mandibular p'ocesses, '■^ J' so called from the parts to whose construction they respectively largely con- tribute. The maxillary processes of the first arch, in connection with the inter- vening naso-frontal process, contribute the parts which eventually become the upper boundaries of the oral cavity ; the mandibular processes of the same arch join to form the lower boundary of the mouth. During the fifth week the margins of the centrally projecting naso-frontal plate differentiate into two PHYSIOLOGY OF PREGNANCY. 99 secondary processes, the processus globulares, forming the inner borders of the nasal pits, and the lateral frontal processes, which contribute the outer wall of the nasal fossa? and separate these depressions from the eyes. These processes normally unite co form the continuous structures around the nose and the mouth. Faulty union or imperfect closure of the intervening fissures gives rise to the varieties of hare-lip and cleft palate and to other forms of congenital facial defects. The second or hyoid arch, as well as the third, fourth, and fifth arches, eventually fuses with its neighbors and loses its identity ; a similar fate awaits the intervening outer visceral furrows or " clefts," with the excep- Fig. 87.— Development of the face of the human embryo (His) : A, embryo of about twenty-nine days. The naso-frontal plate differentiating into processus globulares, toward which the maxillary processes of first visceral arch are extending. B, embryo of about thirty-four days : the globular, lateral, frontal, and maxillary processes are in apposition ; the primitive opening is now better defined. C, embryo of about the eighth week : immediate boundaries of mouth are more definite and the nasal orifices are partly formed, external ear appearing. D, embryo at end of second month. tion of the first, since they gradually become obliterated by the fusion of the surrounding arches. The first outer furrow, or hyomandibular cleft, contrib- utes largely to the formation of the external auditory canal, while the sur- rounding portions of the mandibular and hyoid arches contribute the tissue from which the external ear is derived. 100 AMERICAN TEXT-BOOK OF OBSTETRICS. The Second Month.— The fifth and sixth weeks (Figs. 86, 88) add to the size and the general advanced development, although the phenomenal rate of growth of the preceding week is replaced by more gradual increase. The limbs con- stitute the most characteristic features of this period, since what prior to the fifth week were but rudimentary limb-buds now undergo differentiation into distinct segments, at first two, then three. Toward the close of the fifth week the flattened terminal segments representing the future hands and feet exhibit distinctions as thin marginal plates and thicker proximal portions. The marginal areas very soon exhibit traces of the digits as small elevations separated by shallow grooves which gradually extend toward the free ends. The fore limbs appear slightly earlier than the hind limbs, and retain this lead throughout their development. By the middle of the sixth week the fingers are sufficiently developed to project be- yond the hand, although the toes are Fig. SS.— Human embryo of about sis weeks, enlarged five times (His). Fig. 89.— Human embryo of about seven weeks, enlarged five times (His). just beginning to be outlined, and represent a stage of ten to fourteen days later. Coincidently with these changes the general development of the embryo has steadily progressed (Fig. 89), with the result of supplanting the embryonal characteristics by those of distinctly fetal type. The head, though propor- tionately large, has become partially once more raised ; the boundaries of the mouth have become definitely located ; the external parts of the eye, the ear, and the nose are well advanced ; and the general contour of the trunk has assumed more of the characters of the child. The second month witnesses the disappearance of the cervical flexion and PHYSIOLOGY OF PREGNANCY. 101 the further lifting of the head, which is still very large (Fig. 90). The face shows distinct advancement toward its completed type, although the nose is yet unduly broad, and indications of the fissures surrounding the mouth are dis- cernible. The limbs project from the body, and the fingers, including the differentiated thumb, and the toes are well defined. By the close of the second Fig- 90.— Human embryo of about eight and a half weeks, enlarged five times (His). month the fetus measures from 25 to 30 millimeters (1 to If inches) in length and weighs from 15 to 20 grams. The Third Month.— The third month establishes the human form, although the head still unduly preponderates. The limbs have acquired their definite shape, and the imperfect nails are present on both fingers and toes. During this month the external organs of generation become definitely differentiated, 102 AMERICAN TEXT-BOOK OF OBSTETRICS. although they make their appearance several weeks earlier. At the end of this period the fetus measures about 7 centimeters (2f inches) in length and weighs about 120 grams (4 ounces). The Fourth Month. — Short hairs, devoid of pigment, appear on the scalp and on some other parts of the body, which is now covered with firmer skin of rosy hue. The eyelids, nostrils, and lips are closed. The anus opens, and the coils of intestine, which before extended into the umbilical cord, now lie entirely within the abdominal cavity. The point of emergence of the umbil- ical cord lies low down, close to the pubes. The head forms about one-fourth of the entire body ; the bones of the skull, while ossifying, are still widely separated. The sexual distinctions of the external organs are well defined. At the end of this period the length of the fetus has increased to about 12.5 cen- timeters (5 inches), and its weight to between 230 and 240 grams (7f- ounces). The Fifth Month. — The heart and the liver share with the head in the undue preponderance which these parts present. The contents of the small intestine — the meconium — show traces of bile, being of a pale yellowish-green color. The lower extremities are now longer than the arms ; the nails are well formed. Hairs are more plentiful, but are devoid of color. At the termination of this month the fetus measures 20 centimeters (8 inches) in length and weighs about 500 grams (1 pound). The fetal movements are now distinctly felt by the mother. The Sixth Month. — The surface presents many wrinkles and a dirty-reddish hue ; the sebaceous coating, the vernix caseosa, begins to appear. This whitish substance is composed of the dead and shed surface-epithelium, mingled with the secretions of the sebaceous glands ; its primary function is the protection of the fetal integument from maceration by the amniotic fluid. Eyebrows and eyelashes begin to grow. The length of the fetus by the end of this period has increased to 30 centimeters (12 inches), and its weight to about 1 kilogram or 1000 grams (2 pounds). The Seventh Month. — The continued deposition of subcutaneous fat causes a general appearance of greater plumpness, although the surface is still some- what wrinkled ; hairs about 5 millimeters ( T 3 g- inch) in length ; eyelids are now permanently open. The liver is still relatively large ; meconium occupies the entire large intestine ; the testicles have descended as far as, or even into, the inguinal canals. Children born at the end of this period may survive, although they usually succumb. The fetus now measures about 35 centi- meters (14 inches) and weighs about 1J kilograms (3 pounds). The Eighth Month. — This and the succeeding month are occupied by in- crease in bulk rather than by great gain in length. The skin assumes a brighter flesh-color ; the scalp is plentifully supplied with hair ; the nails almost reach the finger-tips. The vernix caseosa forms a complete coating ; the lanugo, or embryonal down, begins to disappear. The subcutaneous fat has increased, giving less harsh outlines to the body. The close of this month finds the fetus measuring about 40 centimeters (16 inches) and weighing from 2 to 2J- kilograms (4 to 5 pounds). . The Ninth Month. — The fetus at full term presents usually a well-rounded PHYSIOLOGY OF PREGNANCY. 103 body, from which the lanugo lias almost entirely disappeared. The skin is less highly colored, and is covered in places, particularly the head, the axilla, the groin, and the flexor surfaces, with a layer of protecting veniix. Both tes- ticles have descended into the scrotum ; in the female the labia majora are in contact. The intestinal tract contains the dark-greenish-colored meconium, consisting of the secretions of the intestines and the liver mixed with the epi- Fig. 91.— Diagram illustrating the outlines of the human fetus at various stages, from the end of the second to the end of 'the eighth week, magnified five times (modified after Mall). thelium from the digestive tube, together with epidermis and lanugo swallowed by the fetus. The umbilicus has reached a position almost exactly in the middle of the body. The first epiphyseal ossification to appear, that of the lower end of the femur, is often the only one present, but ossification may have commenced also in the upper epiphyses of the tibia and the humerus. 104 AMERICAN TEXT-BOOK OF OBSTETRICS. A convenient simple method of determining the approximate length of the fetus at any period during gestation has been given by Haase. The length in centimeters may roughly be estimated up to the end of the fifth month by squaring the month ; beyond the end of the fifth month, by multiplying the month by the common coefficient 5. Computed by this method, the approximate greatest or entire lengths of the fetus for the several months are : t the end of 1 i nonth the length = 1X1= 1 centimeter = | inch. " " 2 months " " = 2X2= 4 centimeters = H inches. 3 " " " = 3X3=9 = 3f " " " 4 " " " = 4 X 4 = 16 " = 6| " " " 5 " " " = 5 X o = 25 " = 10 " " 6 " " " = 6 X 5 = 30 " = 12 " 7 " " " = 7X5 = 35 = 14 8 " " " = S X 5 = 40 " = 1(3 9 " " " = 9 X 5 = 45 " = 18 " " 10 " " " = 10 X 5 = 50 " = 20 The full-term fetus measures, on an average, about 50 centimeters (20 inches) in its entire length, and weighs from 3 to 3^- kilograms (from 6 to 7 pounds), the average weight for boys being 3340 grams (7 pounds, 6 ounces), and that for girls 3190 grams (7 pounds). The individual variations in weight of new-born children include a wide latitude, as indicated by the extremes of 717 grams (1 pound, 94; ounces) and 6123 grains (13 pounds, 8 ounces), as accepted by Vierordt. Children really exceeding 5 kilograms (about 10 pounds at birth are very rare, notwithstanding numerous reputed cases. Waller, how- ever, reports a case of a living infant, delivered by him with forceps, that weighed 15 pounds 15 ounces ! In addition to sex, boys being heavier than girls, the size of the child is materially influenced by the conditions of ma- ternal parentage; thus: (1) Ypung mothers have the smallest children, and mothers between thirty and thirty-five years have the heaviest. (2) The weight of the child increases with the number of previous pregnancies, providing that the successive children are of the same sex and that the pregnancies do not follow too rapidly ; the children of priiuiparse, therefore, average less than those of multiparas. (3) The weight of the child increases with the weight (Gassner) and the length (Frankenhausen) of the mother. In addition, ob- viously, all causes adversely affecting the physical condition of either parent may exert an unfavorable influence on the vitality and development of the fetus. 6. Development of the Circulatory System. — The vascular system is formed by the development of two parts, at first entirely distinct — the extra- embryonic blood-vessels, and the central circulatory apparatus represented by the heart and the great primary trunks. The extra-embryonic blood-vessels constitute successively two distinct systems, the vitelline and the allantoic cir- culation. The first of these in mammals and in man is comparatively unim- portant ; the second is of the utmost importance, since it takes an active part in securing the nourishment of the embryo from the maternal tissues by means of the formation of the placental circulation which it becomes. PHYSIOLOGY OF PREGNANCY. 105 Very early in the development of the embryo the germinal area becomes mottled by the appearance at its periphery of an irregular network of branch- ing patches of darker tint than the surrounding tissue, due to the active cell- proliferation. These patches are the blood-islands of Pander, so called from the active role played by them in the production of vascular tissue — vessels and blood-cells. By the extension of the blood-islands and the newly-formed vessels the circulation within the area vasculosa (PI. 15) rapidly extends cen- trally and toward the embryo, with which communication is later established by the vitelline arteries and veins, large trunks which connect with the cephalic and caudal extremities respectively of the primitive circulatory apparatus which has meanwhile been developed within the embryo. The significance of the vitelline circulation in mammals is probably merely suggestive of its far greater importance in the lower types, where absorption of nutritive materials from the large and conspicuous yolk constitutes an evident reason for its development. In man and in mammals it is doubtful whether the vitelline circulation contributes nutritive substances in any appreciable degree. Coincidently with the decrease in the yolk-sac and its vitelline circulation, the vessels supplying the allantoic tissues become more prominent, the growth of the two systems proceeding in inverse order. The conversion of a portion of the vascular chorion into the fetal contribution of the placenta advances the importance of these vessels to that of the placental circulation, as first represented by the two umbilical veins and the two umbilical arteries, the latter the direct continuations of the intra-embryonic hypogastric arteries. Later, the two veins fuse within the allantoic stalk, thereby producing a single venous trunk which accompanies the arterial stems. Within the body of the fetus, however, the umbilical veins, which there remain separate, develop unequally, the right suffering atrophy and finally disappearing, while the left increases in size and persists until birth as the important umbilical vein con- veying the blood to the liver. The Heart. — Coincidently with the formation of the primary extra-embry- onic blood-vessels within the vascular area, the heart early begins its develop- FiG. 92. — Section of early embryo of rabbit (Piersol), showing two separate heart-tubes (H, H): e, primitive endothelium; on, mesoderm forming cardiac wall ; ec, ectoderm; en, entoderm; gf, folds pro- ducing ventral wall of gut-tract ; hg, head-gut ; a, a', primitive aorta ; n, neural canal. ment. The first trace of this important organ appears as a folding off and hollowing out of a limited mesodermic area on each side ; the two heart-tubes 106 AMEBIC AN TEXT-BOOK OF OBSTETRICS. thus formed lie within the splanchnic mesoderm and are at first widely sepa- rated from each other (Fig. 92). With the bending together and approxima- tion of the visceral layers in the formation of the gut-tract the heart-tubes are brought into apposition, and finally fuse, the union resulting in the production Fig. 93.— Diagrams illustrating arrangement of primitive heart and aortic arches (modified from Allen Thompson) : 1, vitelline veins returning blood from vascular area ; 2, venous segment of heart- tube ; 3, primitive ventricle ; 4, truncus arteriosus ; 5, 5, upper and lower primitive aorta? ; 5', 5', continu- ation of double aortSB as vessels to caudal pole of embryo ; 6, vitelline arteries returning blood to vascu- lar area. of a short, straight receptacle, into the caudal end of which empty the vitelline veins, and from the cephalic extremity pass the primitive arterial trunks (Fig. 93). This early straight heart-tube, l} T ing attached to the floor of the pharyngeal region, is very transient, since the rapidly increasing length of the organ, its Fig. 94. — A, heart of human embryo of 2.15 mm. (His) : a, truncus arteriosus ; 6, primitive ventricle ; c, venous segment. B, heart of human embryo of about 3 mm. (His): a, truncus arteriosus; b, venous segment (behind) ; c, primitive ventricle (in front). ends being relatively fixed, soon necessitates flexion, which takes place in both sagittal and transverse planes, and results in giving to the tube the S-form. The lower and posterior limb of the heart receives the great veins and is the sinus venoms (Fig. 94) ; the lower and anteriorly directed loop is the auricular VI TKLLIXE CIRCULATION. Vascular area of eleven-day rabbit embryo (E. v. Beneden and Julin) : capillaries not shown : the terminal sinus is seen to be arterial. PHYSIOLOGY OF PREGNANCY. lU? or venous compartment; the upper and posteriorly directed loop is the ventric- ular or arterial compartment ; the upper limb is the truncus arteriosus, from which arise the primitive aortic arches. The heart, therefore, at this stage — about the fourteenth day — consists essentially of two imperfectly separated Fig. 95. — A, heart of human embryo of about 4.3 mm. (His) : a, atrium ; 6, portion of atrium corre- sponding with auricular appendage ; c, truncus arteriosus ; (/, auricular canal ; e, primitive ventricle. B, heart of human embryo of about the fifth week (His) : a, left auricle ; 6, right auricle ; c, truncus arterio- sus ; d, interventricular groove ; e , right ventricle ; /, left ventricle. divisions — a lower and posterior venous chamber and an upper and anterior arterial compartment — into and from which pass the larger primitive venous and arterial trunks. The venous or auricular division during the third week develops two con- Fig. 96.— A, section of heart of human embryo of 10 mm. (His) : a, septum spurium ; b, interauricular septum ; c, mouth of sinus reuniens ; d, right auricle ; e, left auricle ; /, auricular canal ; g, right ven- tricle ; ft, interventricular septum ; i, left ventricle. B, section of heart of human embryo of about the fifth week (His) : a, septum spurium ; b, auricular septum ; c, opening of sinus reuniens (leader passes through foramen ovale) ; d, right atrium ; e, left atrium ; /, septum intermedium ; g, right ventricle ; ft, ventricular septum ; i, left ventricle. spicuous lateral dilatations which assume a position above and behind the grow- ing arterial chamber. These dilatations are the auricular appendages (Fig. 95), which for some time are the most conspicuous parts of the auricles. At this 108 AMERICAN TEXT-BOOK OF OBSTETRICS. time the auricular and ventricular portions of the heart are imperfectly sepa- rated by a marked constriction, the canalis auricularis. During the fourth week the conversion of the single into a double heart commences by the gradual growth of partitions from above downward within the auricle, and from below upward within the ventricle (Fig. 96, a); in addi- tion, the primitive auriculo-ventricular canal becomes divided by the formation of an especial partition, the septum intermedium. The division of the heart- chambers progresses to complete separation, with the exception of an orifice in the lower part of the interauricular septum, which orifice remains until shortly after birth as the foramen ovale. The entrance of the venous blood into the auricular compartment is effected for some time through the single opening of the sinus venosus. Guarding this orifice are folds of the cardiac lining, one of which folds becomes prominent as the Eustachian valve, directing the blood- current through the foramen ovale. Later, the sinus venosus becomes included within the wall of the heart, and the three principal venous trunks emptying within the sinus — the two ducts of Cuvier and the primitive inferior vena cava — open directly into the auricular cavity by as many separate orifices ; that of the left Cuvierian duct is represented by the mouth of the coronary sinus, which this trunk eventually becomes. The truncus arteriosus, the ante- rior primary arterial trunk, undergoes an independent division by the forma- tion of the aortic septum, the partition beginning at some distance from the heart and approaching the latter from above downward. The vessels resulting from the division of the single truncus arteriosus afterward become the aorta and the pulmonary artery, and are limited respectively to the left and right halves of the ventricular compartment by the simultaneously developed inter- ventricular septum. The primitive heart, as well as the earliest blood-vessels, consists of a double wall, the outer layer representing the muscular and fibrous tissue, and the inner layer representing the endothelial lining. These two coats are for a time entirely distinct, the endothelial heart representing the general arrange- ment and division of the organ, and lying within the surrounding layer as a shrunken cast within a mould (see Fig. 106). The interval separating the endo- thelial from the muscular heart later becomes bridged by numerous connecting bands of tissue, the network of trabecular becoming closer and the intervening spaces smaller as development progresses. The consolidation of the cardiac walls, however, never is completely accomplished, indications of its imperfec- tions being clearly seen in the arrangement of the conspicuous columnar carnece of the adult organ, in which the more or less isolated bands represent the thickened remains of the bridging trabecular connecting the endothelial heart with the denser surrounding capsule. Arteries of the Fetus. — The early arterial circulation of the fetus dif- fers in many details from that of the later stages. Conspicuous among these differences is the development of the series of aortic arches which extend from the anterior end of the truncus arteriosus around the primitive pharynx, within the visceral arches, and converge into the dorsal longitudinal vessels, PHYSIOLOGY OF PREGNANCY. 109 the primitive aortce, on each side. Five pairs of aortic arches (Figs. 93, 97) are Fig. 97.— Human embryo of about three weeks, showing visceral arches and furrows and then- rela- tions to aortic arches (His) : mx, mn, maxillary and mandibular processes of first visceral arch ; a 1-alV. first to fourth aortic arches ; jv, cv, primitive jugular and cardinal veins ; dC, duet of Cuvier ; at, v, atrium and ventricle of primitive heart ; vs, vitelline sac ; va, da, ventral and dorsal aortee ; ov, ot, optic and otic vesicles ; uv, ua, umbilical veins and arteries ; iro, vitelline vein ; al, allantois. formed, the first pair lying within the corresponding mandibular arch, the last 110 AMERICAN TEXT-BOOK OF OBSTETRICS. within the tissues of the imperfectly defined fifth visceral bow. The first pair earliest appears and soonest disappears, all five at no time being found simul- taneously fully developed, since by the twentieth day, when all are present, the anterior arches have already partly atrophied. These aortic arches in man and in mammals transiently represent the branchial circulation of gill-bearing types ; their identity in the higher animals is lost in the metamorphosis which they undergo in the development of permanent trunks. The fate of the several aortic arches and their relations to persistent struc- tures is briefly as follows (Fig. 98) : (1) The first or mandibular aortic arch early in the fourth week loses its middle segment, the anterior limb taking part in the formation of the external Common carotid. Recurrent hit v>:£Cal }wrve. Right subclavian Fig. 98. — Diagram illustrating the fate of the aortic arches in mammals and man 'modified from Rathke). carotid artery and its branches ; the posterior or aortic limb aids in forming the internal carotid artery. (2) The second arch has a fate identical with that of the first, its straighter ventral and dorsal limbs taking part in producing the carotids. (3) The third arch, which remains almost complete, gives rise to the connec- tion between the external and internal carotid arteries, to the latter of which the arch particularly contributes. (4) The fourth arch undergoes important changes resulting in its retention on the two sides, since from it are largely derived the innominate, together with the subclavian and vertebral arteries on the right side, and the important arch of the aorta on the left. PHYSIOLOGY OF PREGNANCY. Ill (5) The fifth arch is devoted to the production of the pulmonary arteries, a small portion of the right arch persisting as the right pulmonary artery, and a larger part of the left giving origin to the corresponding pulmouary artery and the ductus arteriosus. During the fifth week, as before noted, the truncus arteriosus undergoes divis- ion into two tubes by the formation of the aortic septum ; the resulting aortic tube retains connection with the fourth arch, becoming the ascending portion of the arch of the aorta, while the right tube becomes connected with the fifth arch and forms the pulmonary vessel. The two primitive aortse for a time extend on each side of the notochord as longitudinal vessels which almost completely terminate in the large omphalo- mesenteric or vitelline arteries supplying the circulation of the yolk-sac, the early continuation of the aortic stems being slender, relatively insignificant branches which extend toward the caudal pole of the embryo. With the development of the earliest allantoic structures the posterior segments of the two primitive aortse unite to form a single trunk, the dorsal aorta, the fusion beginning about the junction of the cervical and thoracic regions and pro- ceeding caudally. At a slightly later period the aortic trunk divides, at the end of the lumbar region, into the allantoic arteries, which pass along the allantoic stalk and are distributed to the chorion, and later to the fetal placenta ; they are then known as the umbilical arteries as far as the body-wall, being continued within the embryo as the hypogastrics. The primitive allantoic arteries eventually become the common and the internal iliac arteries, the external iliacs being formed as new branches when the limbs are developed. After birth, when the fetal placental circulation ceases, the distal parts of the hypogastrics beyond the bladder atrophy and remain as solid fibrous cords passing to the umbilicus ; the proximal parts of these vessels retain their lumina and persist as the superior vesical arteries. Veins of the Fetus. — Toward the close of the embryonal period, about the fourth week, the venous arrangement includes three distinct sets of vessels returning the blood to the heai*t (PI. 16) ; these are — (1) The Cuvierian veins, returning the blood from the body of the embryo ; (2) the vitelline veins, re- turning the blood from the circulation of the yolk-sac ; (3) the allantoic, later the umbilical, veins, returning the blood from the chorion and the developing placental structures. The early systemic veins consist of an upper trunk, the anterior cardinal or primitive jugular veins, by which the blood from the head is carried to the heart, and the jiosterior cardinals, collecting the blood from the trunk and the important Wolffian bodies. These vessels, along with the vitelline and allantoic veins, pour their blood into a common receptacle, the sinus venosus, which opens directly into the primary auricular division of the heart. For a short time these veins are about equal in size and are evenly developed on the two sides ; soon, however, the results of unequal growth become manifested in the disproportionate advance of some and the retrogression of others. The vitelline veins in man, as may be anticipated from the relative insig- 112 AMERICAN TEXT-BOOK OF OBSTETRICS. nificance of the mammalian yolk-sac, never reach the development seen in lower types. After passing along the vitelline stalk and entering at the umbil- ical opening, the veins run in front and then at the sides of that part of the primitive gut-tract corresponding with the duodenum, and become closely asso- ciated with the liver (Fig. 99). The vitelline veins become connected by three newly formed transverse trunks, thus establishing two vascular rings which encircle the gut. The early direct communication above these rings with the VE PA VA" vv ri rv Pig. 99.— Development of the portal circulation of the human embryo of about three and a half weeks (Marshall, after His) : PA, pancreas; TI, intestines ; TS, stomach; WD, bile-duct ; VA, left allantoic vein ; VA', right allantoic vein ; VA", anterior detached portions of the allantoic veins ; VE, ductus venosus ; VO, portal vein ; VV, vitelline vein ; VV, portions of sinus annulares which disappear ; W, liver. sinus venosus becomes lost, and, at the same time portions of the remaining parts of the vitelline veins become interrupted, while a new capillary system appears within the hepatic tissue, which has meanwhile surrounded the vessels, and provides communication between the veins themselves. Those portions of the vitelline vessels that pass from the upper venous ring to the capillary network are known as the venae advehentes : they become the branches of the portal vein ; those portions which pass from the capillary network to the sinus venosus, forming new relations, are the vence revehentes and they become the hepatic veins. The vitelline veins at their lower communication become com- pletely fused and receive veins from the intestinal tract, thus forming the main portal trunk. The allantoic veins after the establishment of the placental circulation are known as the umbilical veins, of which for a time there are two. They fuse within the allantoic stalk, but remain as distinct vessels within the embryo, running within the lateral walls, for a much longer period. During the fourth week the connection of the allantoic veins with the sinus venosus is lost, and shortly afterward the right vein becomes much smaller than its fellow, and filially undergoes atrophy. The much larger left allantoic or PHYSIOLOGY OF PREGNANCY. 113 umbilical vein joins the primitive portal vein just as this vessel enters the hepatic tissue. The early condition of the placental circulation for a time is such that all blood returning by the allantoic vein must traverse the capillary network of the liver in order to gain access to the heart, since both vitelline and allantoic veins have lost their direct communication with the sinus venosus. After a time, however, the liver is no longer capable of giving passage to the rapidly increasing volume of the placental circulation, and then a direct com- munication is established between the portal vein and the right hepatic vein. This new passage is the ductus venosus, by which the greater part of the blood is carried to the heart without traversing the hepatic substance. The systemic veins arise partly from the primary venous trunks and partly as new vessels. The ducts of Cuvier receive the primitive jugular veins above and the cardinal veins below. The primitive jugulars later become the permanent external jugulars, the internal jugulars being formed as new trunks. The Cuvierian ducts, which undergo change of direction and lengthening, take a position almost vertical, becoming the superior vence cavce, of which there are at first two. The development of the heart induces the disappearance of the greater part of the left superior cava, the proximal end, however, remaining as the insignificant coronary sinus which directly opens into the right auricle. With the atrophy of the left caval trunk a new transverse communication is necessitated to convey the blood from the left side to the remaining and enlarging superior cavse. This need is supplied by the formation of the transverse jugular, which later becomes the greater part of the left innominate vein. The fate of the once important posterior cardinal veins is linked with the history of the AVolffian bodies, whose venous outlet these veins largely are. With the atrophy of the Wolffian bodies the cardinal veins become less important, their final fate being partial disappearance and partial persistence as the azygos veins of adult anatomy. The inferior vena- cava presents a complicated development, for the details of which we are largely indebted to the recent investigations of Hochstetter. The inferior cava is developed partly as an independant trunk, and partly depends upon the appropriation of already existing veins. A new vessel is formed from the proximal end of the ductus venosus, from the point where that canal joins the hepatic veins, downward as far as the superior mesenteric artery, when it divides into two branches which join the primitive cardinals. This new vessel contributes the hepatic portion of the inferior vena cava. The further course of the latter vessel, as well as of the right common iliac vein, is provided for by the enlargement and extension of the lower part of the right primitive cardinal vein, that of the opposite disappearing. The external iliacs and the greater part of the left common iliac vein are new vessels. 7. Development of the Digestive Tract.— The formation of the digestive tube consists essentially in the folding off, closure, and isolation of that part 114 AMERICAN TEXT-BOOK OF OBSTETRICS. of the yolk-sac immediately in contact with the axial portions of the ento- derm. This differentiation is effected by the ventral extension and approxi- mation of the widely expanded splanchnopleure, which, bending together (Fig. 100), gradually closes to form the primitive gut — at first freely opening into the yolk-sac, finally completely isolated from the latter except through the communication maintained by the narrow umbilical duct. By the fifteenth day the gut has become defined to such extent that three parts are distinguishable — the fore-gut, the mid-gut, and the hind-gut. The fore-gut, which includes the cephalic third of the tube, gives rise to the phar- ynx, the esophagus, and the stomach, the latter organ early appearing as a fusiform enlargement of the primitive canal. The anterior end of the fore- gut reaches as far forward as the marked cephalic flexure opposite the mid- brain, and at first is separated from the primitive oral invagination, or sto- Fig. 100.— Transverse section of a sixteen and a half day sheep embryo (Bonnet). matodceum (Fig. 101, a, b), by a septum consisting of the opposed ectodermic and entodermic layers. After the rupture of this partition, which happens during the fifteenth day, the primitive pharynx and oral cavity are directly continuous. A series of four diverticula extend between the visceral arches, and constitute the pharyngeal pouches ox inner visceral furrows (Fig. 106; PI. 16). These evaginations of the pharyngeal lining are of interest, since the first pouch gives rise to the Eustachian tube and the tympanic cavity, the third pouch to the early epithelial thymus body, and the fourth pouch to the lateral por- tions of the early thyroid body. From the ventral surface of the fore-gut, at the end of its pharyngeal division, there grows out the diverticulum, which gives rise to the respiratory tube and the epithelial parts of the pul- monary tissues. PHYSIOLOGY OF PREGNANCY. 115 The mid-gut, at first in free communication with the yolk-sac through the wide yolk-stalk, gradually becomes tubular and elongated, forming a narrow V-shaped loop whose straight and almost parallel limbs are attached behind to the dorsal wall of the body-cavity, above to the terminal part of the fore-gut at the stomach, and below to the hind-gut (Fig. 102). The apex of the loop receives the reduced yolk-stalk or umbilical duct, thereby becoming attached A B Fig. 101.— Reconstructions of human embryo of about fifteen days (His) : acv, men, pcv, anterior, mid- dle, and posterior primary brain- vesicles ; ov, ot, optic and otic vesicles ; s(, septum between primitive oral cavity and head-gut; pg, primitive gut; v, la, ventricular and aortic segments of heart; a', aortic arch ; va, da, ventral and dorsal aortse ; I, liver ; hg, hind-gut ; nc, notochord ; s, somites ; sr, sinus reuniens ; vv, vitelline veins ; uv, ua, umbilical veins and arteries ; al, allantois. to the ventral body-wall. The mid-gut gives rise to the entire small intestine and to the greater part of the large intestine. The liver and the pancreas are formed as diverticula and outgrowths from the lumen and the epithelial lining of the duodenal portion of the mid-gut. The hind-gut soon loses its individuality and contributes the lower segment of the large intestine. In its primitive condition the hind-gut 11(3 AMERICAN TEXT-BOOK OF OBSTETRICS. includes that portion of the gut-tract lying behind the open mid-gut and ter- minating blindly in the sharply flexed caudal pole of the embryo ; the greatly k-±z. Fig. 102.— Intestinal canal of human embryo of six weeks (Toldt). Vitelline duct. Fig. 103. — Digestive tract of human embryo of the sixth week (Toldt) : arrangement of primitive visceral peritoneum. dilated closed end of the tube constitutes the cloaca, the common receptacle for a time of the excretions of both the alimentary and the urinary tracts. A Lung. Stomach. B I 'iteiUne duct Fig. 104.— A, alimentary tract of human embryo of thirty-two days. B, alimentary tract of human embryo of thirty-five days (His). The lumen of the allantoic sac, surrounded by the tissue of the allantoic stalk, extends from the ventral aspect of this space. At a later period communi- cation with the exterior is established by the formation of the anal orifice. The external position of this opening is indicated by the anal invagination of the ectoderm or proctodeum. PHYSIOLOGY OF PREGNANCY. 117 During the early part of the fourth week the intestinal tube, composed of its several characteristic segments, lies in the sagittal plane attached to the dorsal wall of the body-cavity by the straight primitive mesentery (Fig. 103). A few days later a period of rapid growth is inaugurated, the intestinal tube increasing in length with far greater rapidity than the abdominal cavity expands. In consequence of this inequality in growth the small intestines become twisted and coiled, while the large gut takes up a position in front or ventrally, and above the turns of the smaller tube. During the fifth week (Fig. 104) the esophagus elongates and the stomach acquires its characteristic form as well as an obliquely transverse position, its Fig. 105— A, outline of alimentary canal of human embryo of twenty-eight days (His) : pb, pituitary fossa ; tg, tongue ; Ix, primitive larynx ; o, esophagus ; tr, trachea ; Ig, lung ; s, stomach ; p, pancreas ; hd, hepatic duct ; vd, vitelline duct ; al, allantois ; hg, hind-gut ; Wd, Wolffian duct ; k, kidney. B, outline of alimentary canal of human embryo of thirty-five days (His) : pb, pituitary fossa; tg, tongue ; Ix, primi- tive larynx ; o, esophagus ; tr, trachea ; Ig, lung ; s. stomach ; p, pancreas ; hd, hepatic duct ; c, cecum ; cl, cloaca ; k, kidney ; a, anus ; gp, genital eminence ; t, caudal process. former left side becoming directed anteriorly and upward, its former right side looking backward and downward. The cecum for a time is situated high up and in close relation with the transversely placed portion of the large intestine ; later the blind end of this part of the gut descends, owing to the development of an intermediate portion which assumes the position and characteristics of the ascending colon. The cecum for a time is of uniform size ; its further growth, however, is marked by the failure of the apical portion to keep pace with the increase in size of the remaining parts of the gut ; in consequence, that poi'tion which morphologically represents the end of the cecum remains as a narrow tubular attachment connected with the head of the large gut, this appendage constituting the appendix vermiformis — the oldest part of the cecum. 118 A2IERICAN TEXT-BOOK OF OBSTETRICS. The connection of the yolk-stalk or vitelline duct (Fig. 105) with the intes- tinal caDal rapidly becomes less conspicuous, and by the end of the fifth week the yolk-stalk has but slight connection with the gut. The position of the Fig. 106.— Reconstructions of human embryo of about seventeen days (His): ov, optic and ot, otic resides; nc, nc', notochord ; hdg, head-gut; g, mid-gut; hg, hind-gut; vs, vitelline sac; I, liver; v, ta, primitive ventricle and truncus arteriosus; va, da, ventral and dorsal aortse; aa, aortic arches; jv, primi- tive jugular vein ; cc, cardinal vein; dC, duct of Cuvier; uv, ua, umbilical vein and artery; al, allantois; uc, umbilical cord. juncture of the vitelline duct with the intestinal tract varies greatly, but usually corresponds with a point within the small intestine from 40 to 60 centimeters (16 to 24 inches) from the ilio-cecal valve. When the usually atrophic cord is replaced by a tubular recess, the persistent portion of the duct constitutes Meckel's diverticulum, a structure of interest. The vitelline duct may remain pervious throughout its intra-embryonal extent, resulting sometimes in congen- ital umbilical fistula. The ventrally situated intestinal loops for a time extend PHYSIOLOGY OF PREGNANCY. 119 through the umbilical opening into the allantoic stalk, in which, up to the twelfth week, they are normally present ; after the third month, however, the coils are permanently withdrawn into the abdominal cavity. The liver first appears about the fifteenth day as a diverticulum (Fig. 106) from the ventral wall of the fore-gut, surrounded at its end by a thick layer of cells. The organ is rapidly formed, the single diverticulum almost imme- diately dividing into two, which in turn send off secondary and tertiarv sprout- like extensions of solid cell-masses. These cylindrical masses anastomose and form networks of cells throughout the mesodermic tissue assigned to the pro- duction of the liver. The spaces within the rueshworks are occupied by the richly vascular mesodermic tissue which supplies the connective tissue and the contained blood-vessels and bile-ducts. The pancreas (Fig. 105) and the salivary glands are developed as solid outgrowths from the epithelium of the digestive tract. The cylindrical cell- masses at first are slender, solid, and rather club-shaped at their free ends. The} 7 later acquire a lumen and expand into the characteristic compartments of a racemose gland. 8. Respiratory Tract. — The respiratory tract is closely related in its devel- opment with the digestive canal, since it is formed by a direct evagination from the ventral wall of the lower portion of the primitive pharynx. The primitive trachea grows downward for some distance parallel with the esophagus, and then divides into branches which correspond to the primary and secondary bronchi (Figs. 104, 105) ; subsequently each of these undergoes repeated dichotomous -division, the resulting twigs in turn giving rise to smaller branches until the ultimate compartments of the pulmonary tissue are developed. The smaller primary bronchioles are solid cylinders at first, their lumina appearing later. The entodermic portion of the respiratory tract, directly derived from that of the primary digestive tube, forms the epithelial parts of the organs, the con- nective tissues and vascular constituents of the same being products of the mesodermic tracts into which extend the epithelial masses. 9. Development of the G-enito-urinary Organs. — The early stages of the human embryo, as well as of other mammals, mark the appearance of the paired Wolffian bodies and the Wolffian ducts, which for a time repre- sent a functionating excretory apparatus (PI. 16), the ancestor of the per- manent kidneys. The Wolffian duct appears about the fifteenth day as a longitudinal cell- mass extending throughout the posterior half of the embryo. The duct is formed by the evagination and isolation of portions of the mesothelial lining of the body-cavity, the resulting cylindrical cell-mass forming a cord that extends at first to the surface ectoderm, with which it has temporarily close relations (Fig. 107). These appearances have given rise to the views advanced by several investigators, according to which the Wolffian duct is ectodermic in origin. Careful examinations of suitable preparations show that the relations of the developing Wolffian duct to the ectoderm are only secondary, and that the initial steps in the formation of the duct occur, as stated, as evaginations of 120 AMERICAN TEXT-BOOK OF OBSTETBICS. the niesothelium ; the Wolffian duct therefore is a product of the mesoderm. After a time the blindly terminating distal ends of the ducts sink centrally and acquire a communication with the cloacal expansion of the hind-gut. At first the ducts are solid cylinders ; subsequently they possess a lumen. Fig. 107. — Transverse section of sixteen day sheep embryo (Bonnet): ec, ectoderm; en, entoderm s pm, parietal mesoderm ; vm, visceral mesoderm ; am, amnion ; ams, amniotic sac ; s, s', somites ; a, a', aortse ; nc, notoehord ; n, neural canal ; Wd, Wolffian duct ; Wb, Wolffian body. Some days later, usually about the eighteenth day, the Wolffian bodies appear as a series of short cylinders (Fig. 108) which form as buds from the mesothelium of the body-cavity entirely independently of the development of the Wolffian duct. These rods of cells at first are solid ; during the fourth week they acquire lumina and become the Wolffian tubules, and later grow toward and join with the Wolffian ducts. The closed ends of the tubules Fig. 108. — Transverse section of seventeen day sheep embryo (Bonnet) : am, amnion; as. amniotic sac; n, neural canal ; s, somite differentiated into muscle-plate: Wd, Wolffian duct; Wb, Wolffian body; pm, parietal mesoderm ; I'm, visceral mesoderm ; a, a, fusing primitive aorta? ; i, intestine. become expanded and then invaginated by the apposition of blood-vessels sent into the bodies from the aorta. The tufted blood-vessels and the invaginated tubule constitute the Malpighian bodies of the Wolffian bodies, the predeces- sors of the similar structures of the permanent kidney. All parts of the Wolffian bodies, therefore, are derived from the mesodermic tissues. Second- ary tubules are formed as outgrowths from the primary ones whose origin has been sketched above. PHYSIOLOGY OF PREGNANCY. 121 The Wolffian bodies increase rapidly during the second month, gaining in size by the growth of the primary tubules and by the formation of new ones. These bodies act for a time as functionating excretory organs, the period of their greatest development being about the eighth week. After this time they undergo retrogressive change, so that by the fifth month the Malpighian bodies liave largely disappeared and the entire organs become atrophic. In view of important differences in growth, functional activity, and mor- phological significance of various parts of the Wolffian body, there are recog- Fig. 109.— Reconstructed human embryo of about twenty-eight days (His): I-IV, brain-vesicles- nc, neural canal ; nch, notochord; ol, olfactory pit; v, au, cardiac ventricle and auricle; va,da, ventral and dorsal aortse ; da', termination of dorsal aorta ; tb, median part of thyroid body ; tr, larynx ; Ig, lung ; s, stomach ; p, pancreas ; i, intestine ; i' , intesto-vitelline duct ; al, allantoic duct ; k, kidney ; ves, left superior vena cava ; cv, cardinal vein ; pv, portal vein ; vas, vena ascendens, collecting blood from umbil- ical and portal veins ; uv, umbilical vein. nized an anterior segment, corresponding with the head-kidney of lower types, always backward in its development in mammals ; a middle segment, which from its relation to the generative organs in their formation may be regarded as the sexual portion of the organ ; and a posterior segment, likewise rudi- mentary in development and in the nature of the organs to which it contributes. The middle segment is of most importance both functionally and morpho- logically : this portion is sometimes designated the mesonephros. The Mullerian Duct. — Coincidently with the formation of the Wolffian 122 AMERICAN TEXT-BOOK OF OBSTETRICS. duct, during the fourth week, an extended ridge of thickened inesotheliuin appears along the outer side of each Wolffian body, from which, however, this ridge is entirely independent. These ridges represent the early condition of the Mullerian ducts, the lumina appearing within the cell-cords about the fifth week. The Mullerian duct ends blindly below, and later possesses an ex- panded, trumpet-shaped anterior end. Its important morphological relations are considered in subsequent paragraphs. The permanent excretory organ, the kidney, and its duct, the ureter, are derived primarily as outgrowths from the lower end of the Wolffian duct (PI. 16, b; Figs. 105, 109). About the fourth week a diverticulum grows from the hinder end of the duct forward and dorsally into a mesodermic area close to and behind the lower end of the Wolffian bod}'. The tube thus formed is the primitive ureter, which extends within the mesodermic tissue, where, after expanding into the immature pelvis, it breaks up into a number of tubes cor- responding with the calices, from which pass epithelial cylinders representing the epithelial portions of the uriniferous tubules. Later the vascular mesoderm contributes the primitive glomeruli, which meet the expanded ends of the tubules and take part in the further development of the Malpighian bodies of the kidney. By the end of the second month the definite character of the renal structure has become established. As the permanent organ increases in size and functional importance the Wolffian body rapidly atrophies, so that by the end of the fourth month its activity as an excretory organ has disappeared, the parts still remaining bearing relations to the sexual apparatus alone. The bladder is the persistent and expanded proximal portion of the allan- toic duct which retains its lumen, while that of the distal segment of the same duct loses its lumen about the fifth week, becoming converted into a solid fibrous cord, the urachus, which stretches from the summit of the urinary blad- der to the umbilicus. The Madder therefore differs from the kidney and the ureter in possessing a lining derived from the entoderm, and in not being entirely of mesodermic origin. The formation of the internal generative organs consists of two distinct developmental processes, the development of the sexual glands and that of their excretory passages. At the end of the first month the mesothelial cover- ing of the Wolffian bodies, along their inner borders, shows an extended area of thickening and proliferation, the resulting elevated bands, the genital ridges, being the earliest traces of the sexual glands. For a short time these glands are of an indifferent type (Fig. 110), the differential characteristics of the two sexes not being manifested, seemingly, for some days ; the primitive male gland then exhibits a disposition to form networks of tortuous anastomosing cell- cords (Fig. Ill), the forerunners of the seminiferous tubules ; the female gland, on the contrary, possesses a larger number of the primitive sexual cells, and evinces a tendency of its elements to arrange themselves into groups in which the larger primitive ova become central figures. Microscopical examination of the sexual primitive glands even at the end of the fifth week is capable of dis- tinguishing the future sex of the being. It is highly probable, as emphasized PHYSIOLOGY OF PREGNANCY. 123 byNagel, that inherent sexual differences exist in the glands from their earliest appearance, and that the recognition of the indifferent stage depends largely upon our imperfect appreciation of these distinctions. The development of the second part of the sexual apparatus, the system of excretory passages, depends upon the ap- propriation and modification of already existing tubes, the tubules of the Wolff- ian body, the Wolffian duct, and the Fig. 110.— Diagram representing the indifferent stage in the development of the generative organs (modified from Allen Thompson). Fig. 111. — Internal generative organs of a male fetus of about fourteen weeks (Waldeyer) : t, tes- ticle ; e, epididymis ; w', Wolffian duct ; w, lower part of Wolffian body : g, gubernaculum testis. Miillerian duct. The fate of these structures varies with sex. In the female (Fig. 112) the Miillerian ducts are most important; they develop into the ovi- Fig. 112.— Diagram illustrating changes taking place in development of female generative organs (modified from Allen Thompson). Fig. 113.— Internal organs of a female fetus of about fourteen weeks (Waldeyer) : o, ovary ; e, epo- ophoron or parovarium ; w\ Wolffian duct; m, Miil- lerian duct ; w, lower part of the Wolffian body. ducts, and, after becoming fused, into the uterus and the vagina, while tlie Wolffian bodies and duct give rise at best to atrophic structures. The Wolff- 124 AMERICAN TEXT-BOOK OF OBSTETRICS. ian body in the female contributes the transverse tubules of the parovarium or epoophoron, the upper part of the Wolffian duct remaining as the head-tube of the same atrophic organ (Fig. 113). When the Wolffian duct persists it con- stitutes Gartner's duct. In the male subject (Fig. 114), on the contrary, the Fig. 114.— Diagram illustrating changes taking place in development of male generative organs (modified from Allen Thompson). Wolffian tubules and the Wolffian duct contribute the important system of excretory tubes represented by the vasa efferentia, the coni vasculosi, the tube of the epididymis, and the vas deferens, while the Miillerian duct is atrophic, its extreme ends alone remaining as the sessile hydatid of Morgagni, closely connected with the globus major of the epididymis, and as the sinus pocularis or uterus masculinus, opening into the prostatic portion of the iu - ethra. The atrophic tubules of the lower segment of the Wolffian body in both sexes contribute rudimentary organs, the paradidymis and the paroophoron respectively, which consist of a few tortuous tubules situated in the epididymis and in the broad ligament near the parovarium. The stalked hydatids of Morgagni, which are common to both sexes, probably represent portions of the atrophic head-kidney and its duct. The External Genitcd Organs. — Until the ninth or tenth week the external genitalia afford no positive information as to sex, since these parts until this time represent a practically indifferent type (Fig. 115). Up to the sixth week the external openings of the gut and of the urinary tract are received within a common cloacal recess whose recto-urogeuital orifice is surmounted by a small conical elevation, the genital tubercle; the lower and posterior surface of this eminence is divided by a furrow, the genital groove, bounded by thickened lips, the genital folds ; outside the latter a less con- spicuous elliptical fold constitutes the genital ridges. The end of the genital tubercle enlarges and forms a knob-like expansion, the primitive glans either of the future penis or of the clitoris. Toward the end of the second month PHYSIOLOGY OF PREGNANCY. 125 the imperfectly formed septum between the rectum and the urinogenital pas- sage reaches perfection, whereby the complete separation between the aliment- ary and gen i to-urinary canals is effected. In the male (Fig. 115, C, E, g) the genital tubercle elongates to form the penis, while the lips of the genital furrow on its under surface unite to form the Fig. 115.— Development of external genital organs of human fetus (Ecker-Zlegler models) : A, B, indif- ferent type, fifth to eighth week : do, cloaca ; I, lower limb ; gt, genital tubercle ; gr, genital ridge ; gf, genital fold ; gg, genital groove. C, E, G, organs of male type : gp, glans penis ; gr, genital ridge ; gf, geni- tal fold : gg, genital groove ; per, perineum ; a, anus ; pr, prepuce ; 8, scrotum ; r, raphe. D, F, H, organs of female type : d, clitoris ; gr, genital ridges ; gf, genital folds ; ag, urinogenital fissure ; per, perineum ; a, anus ; pc, prepuce of clitoris ; l.maj, labia majora ; l.min, labia minora ; v, vestibule ; vag, vagina. penile portion of the urethra ; coincidently, the closure of the edges of the urinogenital passage takes place, the tube thus formed becoming continuous with the anterior part of the urethra just formed. The primitive genital ridges or outer genital folds grow together and eventually form the scrotum, into which the testicles descend shortly before birth. In the female (Fig. 115, D, F, h) the genital tubercle remains relatively small 126 AMERICAN TEXT-BOOK OE OBSTETRICS. and becomes the clitoris ; the genital furrow remains open, the bounding genital folds forming the labia minora or the nyruphse, and the external folds forming the labia majora. At first the clitoris is disproportionately large, but later it becomes overshadowed by the rapidly growing labia. Usually, by the end of Notochord. Somite. Gut entoderm. Fig. 116. — Transverse section of a sixteen and a half day sheep embryo possessing sis somites (Bonnet). the third month the external sexual characteristics of the fetus are established beyond doubt. Imperfect development, especially faulty union, of certain parts of the primitive genitalia produce the conditions which give rise to ap- parent hermaphroditism : true hermaphrodites, while not impossibilities, are Ccil-mass for Wolffian body. M o!f est ol/ Fig. 121.— A, mesial section through brain of a human fetus of two and a half months (His) : eft, cere- bral hemisphere ; o, optic thalamus ; fin, foramen of Monro ; olf, olfactory lobe ; p, pituitary body ; mo, medulla oblongata; eg, corpora quadrigemina ; cb, cerebellum. B, brain of human fetus of three months (His) : ol/, olfactory lobe ; est, corpus striatum ; cq, corpora quadrigemina ; cb, cerebellum ; mo, medulla oblongata. The relative position of the mid-brain, however, undergoes great change, its original situation as the highest part of the entire encephalon being gradually DEVELOPS lafte'JT^m 1 ''^? < ret ;™ st ™ < ; ted > of twenty-six aays, viewed from the left side; magnified 25 diameters u£ 7 &^'\a^Xl%1%ffl£? P0UCheS; r ' th ^^y; ^nchus^/liveY;'^- THE FETUS. Plate 16. Human embryo, same as preceding figure, but taken at a deeper plane (after F. Mall): H, diverticulum contributing the oral portion of the pituitary body; M (above), primitive mouth; 1, •' 3, 4, pharvngca] pouches; B, bronchus; P, pancreas; I, liver; If, B., Wolffian body; II'. I).. Wolffian duct; K, kidney; c, —timunicate ; P, papilliform projection into Tower PHYSIOLOGY OF PREGNANCY. 129 appropriated by the enormously developed cerebral mantle formed by the rapid- growing cerebral hemispheres; in consequence of the covering in of the mid- brain thus effected, the derivatives of this segment, as the corpora quadri- gemina, occupy a position in the base of the adult brain instead of their morphologically normal place. The extent to which the cerebral mantle Fig. 122.— Fetal brain at the beginning of the eighth month (Mihalkovics) : A, superior, B, lateral, C, mesial surface : E, fissure of .Rolando ; pre, precentral fissure ; Sy, Sylvian fissure ; intp, interparietal fissure ; poc, parietooccipital fissure ; ptt, parallel fissure ; callm, calloso-marginal fissure ; unc, uncus ; calc, calca- rine fissure. covers the remaining parts of the encephalon, including the cerebellum, is distinctive of the human brain (Figs. 121, 122). The inter-brain undergoes great differentiation, its derivatives forming numer- ous highly specialized organs, among which are the eyes and the pineal and pituitary bodies. For the complicated details of the development of the various parts of the brain the reader must be referred to the special works on embryology. The following table, however, modified from Hertwig, will serve as a general indication of the genetic relations existing between the more im- portant parts of the encephalon and the primary cerebral segments : Development op the Human Brain. Primary Vesicles. Secondary Vesicles. Floor. Roof. Sides. Cavity. I. Anterior 1. Fore-brain. Anterior perfor- ated spaces ; olfactory lobes. Great cerebral mantle; corpus callosum; fornix. Lateral ventri- cles. " Brain-mantle. brain- vesicle. Inter-brain. Optic chiasm ; tnber cine- reum ; infun- dibulum; cor- pora mammil. Pineal body ; posterior com- missure ; ve- lum interpos- ituni. Optic thalami. Third ven- tricle. II. Middle primary brain- vesicle. 3. Mid-brain. Cerebral pedun- cles ; poste- rior perforated lamina. Corpora quad- rigemina. Geniculate bodies ; brachia. Aqueduct of Syl- vius. B. III. Posterior primary 4. Hind-brain. Pons Varolii. Anterior med- ullary velum ; cerebellum ; posterior med- ullary velum. Superior and middle pe- duncles of cerebellum. Fourth ventri- cle. Brain-stalk. brain- vesicle, 5. After-brain. Medulla oblon- gata. Thin covering of posterior part of fourth ventricle. Inferior pe- duncles of cerebellum. 130 AMERICAN TEXT-BOOK OE OBSTETRICS. The spinal cord is formed primarily by the thickening of the lateral wall of the neural tube, the latter becoming reduced to a narrow passage, later the central canal. At first gray matter alone exists, but with the formation of the nerve-fibres the white tracts appear (Fig. 1 23). The nerve-fibres connected Outer medullary zone Central canal. Notochord. Ventral c Fig. 123.— Transverse section of developing spinal cord of a twenty-two day sheep embryo (Bonnet). with the spinal cord differ in origin according to their function whether they are motor or sensory, the former proceeding as outgrowths from the nerve-cells within the cord, the latter as processes from the cells of the spinal ganglia; these latter centres, in addition to the sensory fibres passing into the cord, send to the periphery fibres by which sensory impressions are conveyed. The sym- pathetic nervous system originates from the spinal ganglia, from which portions are separated as the origin of the sympathetic ganglia. It may therefore be accepted as an axiom that all nerve-fibres are produced as direct outgrowths from pre-existing nerve-cells, and, further, that all portions of the great nervous system may be referred to the primary neural folds. 11. Development of the Organs of Special Sense. — The history of the specialized organs of touch, taste, and smell, as represented by the various forms of tactile nerve-endings, such as the corpuscles of Meissner, Vater, etc., the taste-buds, and the Schneiderian mucous membrane, belongs to a consider- ation of the histogenesis of these structures rather than to a brief outline of salient features in general development ; suffice it here to add that the organs of taste and smell consist essentially of tissue which has become specialized into neuro-epithelium, the perceptive elements consisting of modified epithelial cells bearing close relations to the nerve-fibres. The various forms of tactile corpuscles receive more or less highly developed sheaths from mesodermic tissues. The organs of sight and of hearing, on the contrary, claim greater attention on account of the profound embryological processes instituted in their formation. The development of the eye consists essentially in the formation of two PHYSIOLOGY OF PREGNANCY. 131 ectoderrnic epithelial pouches, the optic vesicle and the lens-sac, around which the adjacent mesoderm differentiates into vascular and fibrous envelopes. The . 111k. fpfy'*. ''. ■ il Fig. 124.— Section through head of ten day rabbit em- bryo, exhibiting primary optic vessel (0) protruding from fore-brain (B) and coming in contact with surface ectoderm (e) ; m, surrounding mesoderm (Piersol). Fig. 125. — Section through developing eye of eleven day rabbit embryo (Piersol) : B, fore-brain connected by stalk with optic vesicle (o), whose anterior wall is partly invagi- nated; I, thickened and de- pressed lens-area. Fig. 126.— Section through developing eye of eleven and a half day rabbit em- bryo (Piersol) : B, fore-brain connected with optic vesicle (o), nearly effaced by apposition of invaginated anterior seg- ment (r) with posterior wall ( p) ; I, lens- sac completely closed and separated from ectoderm; t, tissue within secondary optic cup derived from surrounding mesoderm. first trace of the visual organs appears very early — at the fifteenth day — as the conspicuous optic vesicles (Fig. 128), which are formed as lateral evagina- tions from the hinder part of the ante- rior primary brain-vesicle ; later, when the optic vesicle opens into the cerebral cavity by means of the optic stalk, the latter communicates with the inter- brain. The original optic vesicle soon exhibits indentation of its anterior wall (Fig. 125), the invagination progress- Fig. 127. — Section through developing eye of thirteen day rabbit embryo (Piersol) : e, ectoderm ; I, lens, consisting of anterior nucleated division representing thin front wall of lens-sac, and greatly thickened posterior division completely filling cav- ity of sac by elongated fibres whose nuclei present crescentic zone (z) ; p, posterior pigmented layer ; r, specialized anterior retinal layer; i, point where layers of optic vessels become continuous; n, ex- treme peripheral section of tissue of primitive optic nerve connected with vascular tunic (») occu- pying posterior surface of lens ; m, surrounding mesoderm, which (at t) grows between lens and retina. Fig. 128. — A, brain of two day chick embryo; B, brain of human embryo of three weeks (His) Shows the development of the optic vesicles and brain-vesicles: Jb, fore-brain; ib, inter-brain; on, optic vesicles. ing until the displaced layer comes in contact with the posterior and outer 132 AMERICAN TEXT-BOOK OF OBSTETRICS. undisturbed segment. The cavity of the original vesicle is now represented by the hemispherical cleft between the two layers. The cavity newly formed by the invagination of the primary vesicle becomes the optic cup, and repre- sents the space later occupied by the crystalline lens and the vitreous body. Coincident!}' with the changes of the optic vesicle, the surface ectoderm at first exhibits a depression lined by thickened cells ; this recess or pit rapidly ■ sp md — ais X 4 fj. Fig. 129.— Human embryo of about twenty-eight days (His): I-V, brain-vesicles; /', / 2 , / 3 , /*, cephalic, cervical, dorsal, and lumbar flexures; op, eye; ot, optic vesicle; ol, olfactory pit; mx, md, max- illary and mandibular processes of first visceral arch; sp, sinus precervical ; ft 1 , ft 2 , heart; I, P, limbs; ate, allantoic stalk; eft, villous chorion. deepens and expands, and finally becomes the closed and isolated lens-sac, lying within the mouth of the optic cup, which it largely fills (Fig. 126). The fate of the layers composing the optic cup, briefly stated, is the forma- tion of the various parts of the retinal tract, the outer and posterior layer becoming the characteristic sheet of retinal pigment ; the blood-vessels and the PHYSIOLOGY OF PREGNANCY. 13:2 connective-tissue elements of the retina are secondary ingrowths (Fig. 127). The hinder wall of the lens-sac undergoes great proliferation, growth, and thickening, and eventually fills the entire sac, the lens then continuing as a solid body composed of specialized epithelial elements. The surrounding mesoderm contributes the blood-vessels, the vitreous body, the choroid, and the sclerotic coat, including the iris and the cornea with the exception of the anterior epithelium of the latter, which is ectodermic in origin. The eyelids, which appear toward the end of the second month, are developed as duplicatures of skin above and below the eye ; about the end of the third or the beginning of the fourth month the lids meet and unite, the eyes remaining closed until near the end of gestation, when the lids perma- nently separate. The ear includes several distinct developmental processes, since the genesis of the auditory apparatus of man includes the formation of the external, the middle, and the internal ear. The external ear is closely related to the history of the first outer visceral furrow, the external canal being, with some minor variations, the representa- tive of this cleft, and the expanded parts constituting its pinna, resulting from the fusion and metamorphosis of the auditory tubercles (Fig. 129) sur- rounding the outer end of the visceral furrow. The middle ear is formed by the persistence and further expansion of the first pharyngeal pouch, hence possesses an entodermic lining. The tympanic membrane includes contributions from all three layers, its outer epithelium being ectodermic, its inner epithelium entodermic, and its fibrous tissue meso- dermic, in origin. The internal ear consists of the morphologically older ectodermic portion, which is represented by the complicated membranous labyrinth, and the surrounding mesodermic envelope, which becomes the bony capsule, and the connective-tissue structures included between the osseous and the membra- nous labyrinth. The earliest appearance of the ears takes place about the fifteenth day, when on each side of the hind-brain a depression lined by thickened ectoderm (Fig. 130), the otic pit, is formed. Al- most immediately these pits become converted into sacs, the otic vesicles, by the closure of their mouths, and soon lose all 'onnection with the ectoderm, lying entirely surrounded by meso- dermic tissue some little distance be- neath the free surface. The otic vesicle b i° 0( i-vessei. appears pyriform, that part corresponding with the closed mouth becoming ex- tended ; this elongation soon becomes more pronounced, so that the now some- FiG. ISO.— Section through developing ear of nine and a half day rabbit embryo (Piersol) : e, ectoderm thickened and invaginated to form au- ditory pit (at o* ; m, surrounding still undifferen- tiated mesoderm ; n, lining of neural tube ; i>, 134 AMERICAN TEXT-BOOK OF OBSTETRICS. Fig. 131.— Diagram of fetal circulation before birth ; the arrows indicate the course of the Dloort- current : the colors show the character of the blood carried by the different vessels. PHYSIOLOGY OF PREGNANCY. 135 ?ig. 13:2— Diagram of circulation after birth ; the ductus yen ductus arteriosus are now closed aud no longer transmit foramen ovale, and the af the blood-current. 136 AMERICAN TEXT-BOOK OF OBSTETRICS. what flattened sac presents a conspicuous outgrowth, the recessus labyrinthi (Fig. 133, a). _ The otic vesicle assumes greater irregularity on account of the appearance, during the fifth week, of a blunt diverticulum, anteriorly and ventrally directed, which is the earliest trace of the future membranous cochlea, and, shortly after, of dorsal projections on its outer side, which foreshadow the semicircular canals (Fig. 133, b, c). Before the end of the fifth month, the chief compartment of the vesicle, by this time of considerable size, undergoes Fig. 133.— Development of the membranous labyrinth of the human ear (W. His, Jr.). A, left laby- rinth of embryo of about four weeks, outer side : v, e, vestibular and cochlear portions ; rl, recessus labyrinthi. B, left labyrinth with parts of facial and auditory nerves of embryo of about four and a half weeks : rl, recessus labyrinthi ; sse, psc, esc, superior, posterior, and external semicircular canals; s, sac- cule; c, cochlea; vn,/n, vestibular and facial nerves; vg, eg, gg, vestibular, cochlear, and geniculate gan- glia. C, left labyrinth of embryo of about five weeks, from without and below ; labelling as in preceding figure. subdivision by the formation'of a constricting fold into a dorsal division, the primitive utriculus, and a ventral division, the primitive sacculus. The rudi- mentary semicircular cauals and the primitive cochlear duct open respectively into the utricle and the saccule. The recessus labyrinthi has become mean- while greatly elongated, and its proximal end cleft into diverging tubes at the formation of a septum. These limbs of the recess open into different spaces, one entering into the saccule, the other into the utricle. The permanent arrangement is now established whereby communication between the divisions of the membranous vestibule, the utricle and the sac- cule, is effected only by the indirect passage through the limbs of the ductus cndolymphaticus. The primary otic vesicle thus becomes the complicated membranous labyrinth, and the ectodermic epithelial lining undergoes differ- entiation in the formation of the highly specialized structures, as the organ of Corti and the maculse acusticse, for'the perception of transmitted stimuli. The mesoderm immediately surrounding the membranous labyrinth later undergoes important changes, whereby the tissue next the epithelial structures is converted into the connective tissue enveloping and supporting the delicate PHYSIOLOGY OF PREGNANCY. 137 epithelial labyrinth, while the tissue slightly removed gives rise to the periotic cartilaginous capsule which later is replaced by bone. The important spaces occupied by the perilymph are formed relatively late, since they arise by the breaking down and channelling of the mesoderm surrounding the epithelial tubes. In the cochlea, for example, the ductus cochlearis, with its epithelial lining, represents genetically the oldest part, while the scala vestibuli and the scala tympani are of more recent origin, since they are formed by partial dis- appearance of the mesodermic tissues. 2. Physiology of the Fetus. Nutrition and Growth. — It is evident that the life of the ovum, what- ever its character, whether vertebrate or invertebrate, picean, amphibian, reptilian, avian, or mammalian, can only be maintained when the fundamental necessities of life — adequate supplies of oxygen, water, and suitable nourish- ment — are provided. The ovum and the early embryo being without means of securing these advantages, such provisions must be ensured by the arrangement of the immediate environments, whether these be within the maternal tissues or within the protecting structures of the shell or the surrounding medium. The loss of yolk, which there is good reason for believing the mammalian ovum has suffered during its evolution, is compensated by the nutritive mate- rials supplied to the developing ovum by the adherent discus proligerus, and by the secretions of the oviduct and uterus which are taken into the interior of the egg by osmosis through the zona pellucida and the primitive chorion. The Fetal Circulations. — The earliest circulation, the vitelline (PI. 15), is well established during the third week. The blood passes from the network of the vascular area, by means of the large vitelline or omphalo-mesenteric veins, into the sinus venosus, and then, after mingling with the blood returned by the systemic veins from the body of the embryo, into the auricular segment of the young heart. From the anterior or arterial end of this organ the blood is carried by the truncus arteriosus into the aortic arches, hence into the primitive aortse, a small portion passing into vessels supplying the embryo, while the greater part enters the vitelline arteries and once more gains the vascular area. The development of the allantoic vessels and the placental circulation necessitates additional blood-currents, in the direction of which the now rapidly developing heart and liver exert an important influence. For a time all the blood returning from the placenta passes through the liver before reaching the heart ; later, when the hepatic capillaries can no Jonger accommo- date the entire placental circulation, the ductus venosus is established. During the later months of gestation the so-called " fetal circulation '' (Figs. 131, 132) presents the following details: After purification by the respiratory interchanges carried on within the placenta by association with the maternal circulation, the blood is conveyed by the single umbilical vein to the under sur- face of the liver ; here the current divides, one part joining the venous blood within the portal vein collected from the intestines, and traversing the hepatic 138 AMERICAN TEXT-BOOK OF OBSTETRICS. capillaries to reach the hepatic veins, the other part passing into these vessels directly by means of the ductus venosus. On reaching the inferior cava the arterial placental blood, but slightly contaminated by admixture of the contents of the portal vein, is poured into the stream of venous blood returned by the inferior cava from the lower parts of the body, and is carried into the heart as part of the mixed stream. On entering the right auricle a fold, the Eusta- chian valve, directs the blood brought by the inferior cava across the auricular cavity through the foramen ovale into the left auricle. Mingling with the small quantity of blood returned from the uninflated lungs by the pulmonary veins, the blood-current passes through the auriculo-ventricular opening into the left ventricle, by the contractions of which it is propelled into the aorta, and distributed by the branches of that vessel to all parts of the body. The blood gathered from the head and the upper extremities and returned to the right auricle by means of the superior cava passes directly through the auricle and right auriculo-ventricular orifice into the right ventricle, crossing in its course the blood-stream entering by the inferior cava. The contractions of the right ventricle send the blood thus returned by the superior cava into the pulmonary artery and on to the lungs. These organs, being still unin- flated, are incapable of receiving more than a small part of the blood supplied from the ventricle ; the excess, however, is carried by means of a newly- formed channel, the ductus arteriosus, which extends from the beginning of the left pulmonary artery to the aorta. The blood carried through this canal mingles with that descending the aorta ; on reaching the hypogastric arteries a large part of the current passes to the placenta for oxygenation, only a small proportion of the stream continuing within the systemic arteries for the supply of the lower parts of the trunk and the inferior extremities. It will be noticed that after joining the current within the inferior vena cava the blood circulating within the fetus is nowhere purely arterial, but is always contami- nated by the admixture of blood already distributed to other parts. The distinctive features of the fetal circulation are the ductus venosus, the ductus arteriosus, the foramen ovale, the hypogastric arteries, and the umbili- cal vein. After birth, with the establishment of the respiratory function and the pulmonary circulation, the accessories to the arrangement of the placental blood-current undergo atrophy and largely disappear. While immediately instituted, these changes are not fully effected until some time after birth. Obliteration of the distal parts of the hypogastric arteries first occurs, and is usually completed by the third or the fourth day after birth. The ductus veno- sus and the umbilical vein are generally closed by the end of a week. The duc- tus arteriosus usually closes within a few days, and is completely impervious by the third week after birth. Permanent closure of the foramen ovale is delayed for some time, the blood being excluded from the left auricle by the apposition of the edges of the valve, which are kept in place by the increasing pressure from the left side exerted by the blood returning from the lungs. After a time the edges of the valve coalesce with the margin of the foramen ovale and the opening becomes permanently closed ; not infrequently, how- PHYSIOLOGY OF PREGNANCY. 139 ever, months elapse before the union becomes complete. In case this union is never perfectly effected, a small communication may remain throughout life as a congenital defect, of slight or grave import depending upon the extent of the faulty union. The establishment of the vitelline circulation, the first one of the embryo, marks the introduction of an important nutritive apparatus in animals possessing large yolks, which in them constitute sources of nourishment of great conse- quence. In man and other mammals, however, the appearance of the vitelline circulation must be regarded rather as the expression of formative processes whose usefulness has largely disappeared in consequence of the profound modifications which the diminution of yolk and the greater dependence on the maternal tissues have witnessed. While in mammals the exposure of the fetal blood-stream over the extended walls of the vitelline sac or umbilical vesicle affords an opportunity for a limited exchange of gases, the amount of nutritive materials directly taken up and appropriated by the embryo must be very insignificant. The deficiencies of the vitelline circulation in mammals, however, are com- pensated by the active development of the allantoic vessels and their further specialization into the all-important placental circulation, whereby the respi- ratory and nutritive necessities are secured to the fetus throughout the last two-thirds of gestation. The placental circulation, by means of which the respiratory interchange of gases and the passage of nutritive substances from the maternal blood to that of the fetus is effected, is undoubtedly the principal, and practically the sole, source of those substances necessary to maintain the life of the developing ani- mal. The liquor amnii has long been regarded as an additional source of nutri- tive materials, in view of the fact that this fluid is undoubtedly swallowed by the embryo and taken into its intestinal canal, as shown by its presence, as well as the presence of hairs and epidermal cells at a later stage, within the gut. The composition of this fluid, however, renders it highly improbable that it contributes in any appreciable degree to the nourishment of the fetus, containing as it does nearly 99 per cent, of water. The liquor amnii, never- theless, serves an important purpose in supplying the water necessary for the fetal tissues, since the latter must contain water in excess, according to Preyer, in order to extract the albumen and the salts from the blood brought by the umbilical vein. The fetal placental vessels convey albumen, salts, and water from the mater- nal blood into the circulation of the fetus, as well as the oxygen absorbed by the red blood-cells during their sojourn in close proximity to the sinuses filled with the blood of the mother. The soluble salts probably pass from the maternal blood into the fetal blood by simple osmosis. That the albu- minous substances, however, are so transferred is very doubtful, but the solution of this question, it must be admitted, so far has been unsatisfactory. The ingenious explanation advanced by Rauber, that a physiological transmigration of leucocytes from the maternal tissues into the fetus furnishes the means of 140 AMERICAN TEX1-BOOK OF OBSTETRICS. transportation of particles of albumin, fat, lecithin, and similar substances, lacks confirmation. By some the evidence is regarded as strong that they pass over in the form of soluble peptones. That substances in solution pass from the maternal circulation into that of the fetus has been proved by direct experiments with iodin (Gusserow, Kru- kenberg, Haidlen), salicylic acid (Benicke), and potassium ferrocyanid (Fehl- ing). The investigations of Zweifel demonstrated the free and rapid passage of chloroform administered during parturition from the maternal blood into the umbilical circulation, and, consequently, the highly probable influence of the anesthetic upon the fetus. The result of attempts to introduce substances in a condition of fine division, but not in solution, such as vermilion, India ink, fat, etc., have been negative, the seeming exceptions where such particles were found in the fetal circulation after injection being attributable to injury of the blood-vessels. The migration of formed elements, such as the pathogenic bacteria of anthrax, typhus, etc. or the colorless blood-corpuscles, from the circulation of the mother into the fetal blood is a question about which there is much difference of opinion. Regarding the blood-cells, moreover, the investigations of Sanger point to the improbability of such migration taking place, since in leukemic conditions of either mother or child the blood of the remaining organism may retain its normal proportions. The experiments of Savory and Gusserow have shown that in animals in which the fetus is poisoned by strychnia the poison may pass from the fetal circulation into that of the mother. Certain substances administered to the mother pass into the liquor amnii, as in the case where iodin is given (Krukenberg). That the fetus takes no part in producing this effect is shown by the fact that the drug is found in the liquor amnii even when the product of conception is dead (Haidlen) ; further, that coloration of the amniotic fluid after the injection of sodium sulphindigo- tate into the jugular vein of the mother is unattended by the presence of the substance within either the kidneys or the urine of the fetus (Zuntz). The staining of the maternal tissues composing the decidua by the pigments con- tained within the meconium emphasizes the fact that substances within the liquor amnii may in turn affect the mother. The respiratory and metabolic changes within the fetus are carried on by means of the oxygen taken up from the maternal circulation by the fetal blood-stream in its passage through the placenta, in exchange for the carbonic acid and other products of tissue-change. So long as this interchange of gases takes place without interruption in the placenta, the fetal circulation contains an excess of oxygen, since, notwithstanding the small amount derived from the mother, the quantity of this gas thus obtained more than suffices for the needs of the embryo, and induces a condition of apnea. When the placental circu- lation is interrupted, however, as by compression of the umbilical cord or by premature separation of the placenta, the fetus perishes with all the symptoms of asphyxiation. PHYSIOLOGY OF PREGNANCY. 141 The direct proof of the source of oxygen from the placenta has been sup- plied by the investigations of Cohnstein and Zuntz, who examined the blood of the umbilical vein in sheep, and found it richer in oxygen than that within the umbilical arteries, although the difference between the arterial and the venous blood during intra-uterine life is much less marked than after birth (Halliburton). The spectroscopic analysis of blood from the human umbilical vessels by Zweifel showed the presence of the oxyhemoglobin bands before respiration was established. The consumption of oxygen by the fetus, as measured by the necessities of its own heat-production, is relatively small, since the maintenance of its tem- perature is greatly facilitated by being surrounded by the liquor amnii, the warmth of which is almost equal to that of the fetal blood. The fetus is still further favored by being spared the necessity of taking within its lungs and alimentary tract substances which must be warmed to its own temperature at the expense of its own heat. The presence of the warmed licjuor amnii also prevents caloric loss by either radiation or evaporation. The pre-natal functions of the fetus include limited activity of the kidneys and preparatory exercise of the organs and glands connected with the alimentary tract and the integument. The early excretory apparatus of the embryo is represented by the Wolffian bodies and their ducts and the allantoic. The yellowish fluid collected within the allantoic sac after its secretion by the Wolffian bodies cannot be regarded as urine in the strict sense of the term, since its elaboration long precedes the development of the fetal kidneys. There is, however, a similarity between the usually alkaline allantoic fluid and the later secretion of the fetal kidneys, the fluid often, but not invariably, containing urea, uric acid, the alkaline chlorids, phosphates, and sulphates, as well as iron, calcium carbonate, and allantoid. The early presence of urea and the urates renders it highly prob- able that the decomposition of albumin with oxidation begins at an early period of intra-uterine life, the excreted substances being taken from the still imper- fectly differentiated fetal blood. The question whether the kidneys under normal conditions regularly secrete urine before birth has received much attention and various answers. The weight of evidence undoubtedly establishes the exercise of such function, but exactly the period at which the secretion of urine first takes place is still unde- termined. After the establishment of communication between the bladder and the exterior of the body by the formation of the urethral canal, the urine is discharged, during the later weeks of gestation, into the amniotic fluid, with which it is in part swallowed by the fetus. The coloring matters of the urine are elaborated only in very limited quantities, as shown by the well-known pale tint of the fluid voided by the new-born child. Digestive Tract. — The pre-natal activity of the glands connected with the fetal alimentary tract is a matter of much interest in view of the demands made upon these organs immediately after birth to supply the ferments neces- sary in the process of digestion and assimilation. The inherent difficulties 142 AMERICAN TEXT-BOOK OF OBSTETRICS. attending the investigation of the subject in the human fetus have left our knowledge on many points still far from satisfactory. The saliva of the fetus has received much attention with a view of deter- mining the presence or absence of ptyalin. While the results of the observa- tions by various investigators are contradictory, the positive evidence of the presence of this ferment in the saliva of the new-born obtained by Schiffer is important. This observer demonstrated the unmistakable presence of ptyalin in the salivarv secretion of three new-born children, thus showing that the capability of converting starch into sugar exists in the saliva from birth — a fact the more remarkable when the absence of the opportunity for the exercise of this power is recalled, the character of the early food requiring neither starch nor dextrin. It has been shown that the ptyalin is not elaborated in- differently by the salivary glands, but that its presence is limited to the secre- tion and tissue of the parotid. The relatively tardy development of the labial and other glands of the oral cavity is in accord with the observed slight activity of the secretory function of the mouth of the fetus. The gastric secretions of the new-born have been found to contain pepsin and rennin immediately after birth, pepsin digestion and the power of curdling milk being established within a few hours. The observed differences in the amount of pepsin contained in specimens of the mucous membrane of new- born children probably depend upon the variability in the development of the gastric glands, as pointed out by Sewall. The pancreatic ferments are probably represented before birth by the pres- ence of trypsin, which acts especially upon the proteids, and a fat-splitting ferment (pancreat in, steapsin), but not by amylopsin, which resembles ptyalin in possessing the power of attacking starch. Langendorff demonstrated the presence of trypsin in the pancreas of the fetus at the fifth and sixth month ; Zweifel, that of pancreatin at birth. The large amount of fatty and albu- minous matters in the milk at once suggests the necessity of the early prep- aration of the digestive ferments required for the disposition of these substances. The intestinal secretions at birth differ widely from those of a slightly later period. In this respect the observation of AVerber, showing the relatively larger number of Brunner's glands in the new-born than during later life, is of interest, although the function of the glands within the fetus is not obvious. The liver early develops, and soon becomes the most conspicuous organ connected with the fetal digestive apparatus. Its large size suggests an early activity, which, in fact, observations on mammalian embryos confirm. A sub- stance resembling bile has been found in the small intestines from the third to the fifth month, and later in the large gut ; in this material, from fetuses of the third mouth, Zweifel found the bile-acids and the biliary pigments. The meconium, the contents of the fetal intestinal canal at birth, presents a dark, brownish-green or almost black appearance, and a soft, viscid, pitch- like consistence. Its source has been the subject of interesting investigation, but much relating to its origin still remains to be investigated. The produc- tion of meconium seems chieflv related to the formation of bile, since it is PHYSIOLOGY OF PREGNANCY. 143 absent before this secretion is poured into the intestinal canal, as well as in cases of malformation in which the elaboration of bile is wanting. The view attributing to the swallowed liquor amnii an active role in the formation of the meconium is opposed by the presence of this substance in malformed fetuses in which the possibility of entrance of the amniotic fluid into the intes- tines was precluded. Before the secretion of bile meconium is not present. Hennig observed light yellowish-green meconium in a fetus at the beginning of the fourth month. The beginning of the fifth month usually marks the period from which the meconium is constantly present. This substance, in addition to the bile, consists of the unabsorbed portions of the intestinal mucus and juices, the secretions of the glands of Brunner and of the pancreas, and of the swal- lowed amniotic liquid, together with such remains as leucocytes, intestinal epi- thelium, lanugo, epidermal cells, and fat from the vernix caseosa carried into the gut-tract along with the liquor amnii. The chemical composition of meconium, as ascertained by Zweifel, includes from 20 to 27 per cent, of solids, of which about 1 per cent, is inorganic, the remainder organic ; the amount of fat and fat-acids and of cholesterin is the same — about .75 per cent. The inorganic constituents include the phosphates and sulphates of magnesium and calcium, sodium chlorid, and oxid of iron. The principal organic substances are the more or less changed bile-salts, the unaltered bile-pigments, bilirubin and biliverdin, and mucin. 3. Multiple Conceptions. The fecundation of more than a single ovum, or, as often less accuratelv termed, " multiple pregnancy," is by no means an infrequent occurrence, as the numerous births of two or more children testify. Multiple conceptions may result in the birth of twins, triplets, and, as great rarities, quadruplets ; a number of well-authenticated instances of five children at one time are recorded ; and even an apparently trustworthy case of the birth of six, four boys and two girls, has been reported by Vassalli. The reputed births in excess of this number are apocryphal. The most extensive series examined with a view of determining the rela- tive frequency of multiple conceptions is that studied by G. Veit, which included the records of thirteen million births in Prussia. According to these statistics, twins occur once in 88 births; triplets, once in 7910; aud quad- ruplets, once in 371,126. About a dozen authentic cases of five at a birth are recorded in medical literature (Kaltenbach). The statistics of different countries seemingly point to considerable variations in the frequency of twins; thus, in Bohemia twins occur once in about 60 births, while in France they appear only once in every 100. Recent statistics supplied by the Board of Health of New York and of Philadelphia place the frequency of twin births in these cities at 1 in every 120 births. In accepting such conclusions, how- ever, possible errors arising from differences in the character and completeness of the statistics compared must not be overlooked. 144 AMERICAN TEXT-BOOK OF OBSTETRICS. Of 150,000 twin j>reguancies studied by Veit, in one-third both children ■were boys ; in slightly less than one-third both were girls ; and in the remain- ing third both sexes were represented. Twins are more frequent in multiparas than in primiparse. Individual and inherited tendencies seem also to be factors in the occurrence of multiple conceptions, since plural births sometimes render particular women or certain families conspicuous. Twins usually develop from two distinct ova derived from the same or from different Graafian vesicles, which may be separated widely or which may even be contributed by different ovaries, as shown by the presence and location of the corpora lutea. When derived from a single ovum, the existence of a double germ may be assumed, with, however, the possibility borne in mind that the twins may have arisen as the result of complete fission of a single germ, as emphasized by Ahlfeld in his investigation of the production of double monsters. Twins originating in this manner are termed " homolo- gous" and are characterized by remarkable physical and mental similarity. Of 506 cases of twins, Ahlfeld found but sixty-six proceeding from a single egg. Twins derived from a single ovum are always of the same sex ; those from two ova may be of different or of the same sex. The arrangement of the fetal membranes of twins depends upon the mode of their origin. The decidua vera is always simple ; the deeidua reflexa, on the contrary, is double when the ova become attached to widely separated parts of the uterine wall. The chorion, being primarily derived from the zona pellucida, is single when the twins originate from two germs contained within a single ovum, but double when they arise from separate eggs. The amnion is primarily always double, since this membrane is produced as an out- growth and extension of each embryo. In those cases where twins occupy a common amniotic sac, a secondary fusion of the two originally distinct sacs has occurred by the breaking down and absorption of the septum which for a time separated them. The placenta is at first double, since each fetus forms its own allantois and resulting placental area. When the twins originate from different ova the placenta may remain permanently distinct, but even in such cases fusion of the placental ai*eas eventually takes place. The placental vessels of single-egged twins almost invariably anastomose, so that the placentae become more or less completely fused, the common nutritive area then consisting of three parts, an intermediate, indifferent area being enjoyed in common, in addition to the par- ticular part which ministers especially to each fetus (Hyrtl). The anastomosis of the placental vessels may result in the most profound impressions in those cases where marked differences exist in the development and vigor of the two fetuses, since the circulation of the weaker fetus may be unfavorably influ- enced, even to the extent of reversal (Ahlfeld), by the overpowering force of that of its stronger brother. Disastrous atrophy and the production of an acardia are among the results attributable to such conditions. When one fetus succumbs, the pressure exerted during the growth of the living child gradually reduces the mass of the dead product of conception, until PHYSIOLOGY OF PREGNANCY. 145 finally it is represented by the greatly flattened and attenuated remains impris- oned against the uterine walls, then constituting the " fetus papyraceus " of the teratologist. Conspicuous, and sometimes remarkable, disparity in the perfec- tion of growth and development may exist in twins at birth, the more favored fetus sometimes exceeding the smaller threefold in weight, the difference depend- ing upon the nutritive advantages enjoyed by the one at the expense of its less fortunate fellow. In consequence of this disparity it sometimes, though very rarely, happens that the fully-matured fetus is expelled at term, while the still imperfectly developed fetus is retained for a time within the uterus until its development has progressed farther toward completion, when it in turn is born. Two remarkable cases in which double uteri were present have been recorded by Barker and Generali, where intervals of forty -three and thirty days respec- tively intervened between the births of the two fetuses. It is the occurrence of such cases which is erroneously regarded as a fact in support of the pos- sibility of superfetation. Triplets may originate, it is evident, from a single ovum or from two or three distinct eggs, a frequent arrangement being that one child is derived from a distinct ovum and two from a single ovum. Upon the manner of their origin depend the arrangement and relations of the placenta and mem- branes. Quadruplets may exist as double twins, or they may result from a combination of a single birth with triplets. Plural conceptions, on the one hand, may result from a single coitus, whereby are impregnated ova which have simultaneously been discharged from the sexual gland, prepared for the reception of the male elements ; on the other hand, repeated impregnations may occur after different, though closely following, sexual acts, these resulting in the fecundation of different ova which have been liberated at slightly separated moments, but which belong to the same ovulation. This possibility has received recognition in the term super- fecundation or superimpregnation, by which is understood the fecundation of two ova, belonging to the same period, by different sexual acts. Conspicuous examples of such occurrences are afforded by instances where a negress gives birth to a white and a black child. While the occurrence of superimpregnation is undisputed, superfetation, or the possibility of ova which originate from different ovulation periods, and there- fore liberated at considerable intervals, being impregnated by sexual acts widely separated, is not admissible. While instances of the delayed birth of a second child are adduced in support of the recognition of the possibility of superfeta- tion, the obvious physical impossibilities of the assumed occurrence are unan- swerable objections to the validity of such interpretation. When the rapid and important changes in both the ovum and its environment that follow fecundation are recalled, the impossibility of spermatozoa reaching and im- pregnating an additional ovum on the one hand, and of the ovum, even although fecundated, descending the Fallopian tube to the uterus, on the other hand, is manifest. The cases cited in support of superfetation are all explicable from the well-known facts attending the unequal growth and devel- 10 146 AMERICAN TEXT- BOOK OF OBSTETRICS. opment of twin conceptions, where this disparity results in the delayed deliv- ery of the less favored fetus. Plural births frequently occur before terra, twins being born a few weeks before the end of gestation, quadruplets and quintuplets in the earlier months of pregnancy. 4. Changes in the Maternal Organism Induced by Pregnancy. 1 . Local Changes. — The presence of the fecundated ovum inaugurates a season of increased nutritive energy, which not only effects changes in those organs in immediate relations with the developing fetus, but also induces changes involving the entire organism of the mother during the continuance of pregnancy. The changes thus induced in the general system being discussed in a separate section (p. 154), consideration in the present place will be directed to those changes manifested by the sexual organs and the parts intimately con- nected with the processes of gestation and parturition. The uterus, as may be expected from its especial relation to the developing fetus, early manifests the profound changes which it undergoes ; indeed, the preparatory alterations affecting its mucous lining and vascularity preceding each menstrual epoch must be regarded as the beginning of the cycle of changes that ends only with the return of the organ to its normal condition after the expulsion of the product of conception and the protecting structures. The hypertrophy of the mucous membrane of the uterus and the greatly increased vascular supply which take place coincidently with the liberation of the ripe ovum from the ovary, under usual conditions, are succeeded by the destructive changes giving rise to the phenomena of menstruation. Should impregnation, on the contrary, occur, the hypertrophic processes are continued with increased vigor, and result in the alterations already described in con- nection with the formation of, the decidua (p. 87). The most conspicuous consequence of the changes in the uterus is the not- able increase in the size and weight of this organ. From the insignificant dimensions of the small, rigid virgin uterus, which include a length of 7 cen- timeters (2f inches), a breadth of 4.5 centimeters (If- inches), and a thickness of 2.5 centimeters (1 inch), there is developed a huge flaccid sac which meas- ures at the close of gestation from 37 to 38 centimeters (15^ inches) in length, 26 centimeters (lOf inches) in breadth, and 24.4 centimeters (9f- inches) in thickness, with a circumference at the level of the oviducts of from 70 to 73 centimeters (29 inches). The weight of the virgin uterus is about 40 grams (1^ ounces); that of the uterus at term, about 1000 grams (2 pounds), an increase of twenty-five times taking place. The capacity of the uterus at the close of gestation is between 4000 and 5000 cubic centimeters (from 8 to 10 pints), or over five hundred times that of the virgin organ. The increase in the bulk of the uterus occurring during the earliest months of pregnancy is attributable to the general hypertrophy affecting its walls, and not directly to the developing ovum, since only after the latter completely fills PHYSIOLOGY OF PREGNANCY. 147 the uterine cavity, at the expiration of the fifth month, is the augmented size of the uterus produced by the mechanical distention caused by the rapidly growing: fetus. The enlargement of the uterus, moreover, is not direetlv dependent upon the presence of the ovum, but is due to actual increase of tis- sue, as shown by the fact that the hypertrophy of the organ progresses up to the fourth month in extra-uterine pregnancies, the same as if the ovum were present within the uterine cavity. The hypertrophy of the uterus at first affects equally all parts of the viscus, but later the fundus and the body grow more rapidly than the cervix. The changes which affect the uterine walls consist of thickening of the mucous membrane, increase of the muscular tissue, augmentation of the connective tissue, and enlargement of the blood-vessels, the lymphatics, and the nerves. As a result of these alterations the walls for a time reach a thickness of 1.5 centimeters (-| inch); but this excessive growth is followed by a marked reduction resulting from the distention incident to the later months of preg- nancy, when the extended uterine walls measure but 5 millimeters (-^ inch) in thickness. The increase of the muscular tunic is effected not only by excessive growth of the already existing involuntary muscle-fibres, which increase from ten to eleven times in length and from three to five times in breadth, but also by the formation of new muscular elements which likewise soon acquire the dimen- sions of .5 millimeter in length by .02 millimeter in breadth. The luminaof the uterine blood-vessels are materially increased, the arteries becoming wider and longer — without, however, entirely losing their tortuosity — and the veins dilating into large venous channels, the swims uterini, which penetrate between the muscular fasciculi and which are particularly well devel- oped within the placental area. The walls of the venous canals are intimately united with the surrounding and likewise hypertrophied connective tissue, in consequence of which arrangement the walls of these vessels do not collapse when mutilated, but remain more or less gaping. The lymphatics of the mucosa and the muscular tunic considerably enlarge. The nerves distributed to the uterus also share in the increased growth, especially the ganglion cervi- cale, which more than doubles its usual size. The form of the uterus undergoes a marked series of changes during preg- nancy. During the first three months the pyriform shape is retained ; subse- quently the organ becomes more expanded in its lower segment, and by the fifth month presents a form intermediate between the spherical and the pyri- form, the longest diameter being vertical, and the antero-posterior dimension being greatest just below the middle of the body (Webster). Late in preg- nancy the pyriform or egg shape once more predominates, owing to the dome- like distention of the fundus and the broadening of the lower segment. During the early months all parts of the uterus increase with equal rapidity ; after the fifth month, however, the cervix participates but slightly in compari- son with the rate of growth manifested in the upper part of the organ.. While hypertrophy of the cervix is admitted by all, the extent to which this portion 148 AMERICAN TEXT-BOOK OF OBSTETRICS. of the uterus contributes to the formation of the excessive uterine sac present at the close of pregnancy is a question regarding which authorities greatly differ. It may be stated at once that the older view, that the cervical canal gradually unfolds itself into the uterine cavity as gestation advances, is no longer tenable, since the investigations of Miiller so clearly showed that the cervical canal is but little affected. Regarding the question, however, as to what extent the cervix participates in the production of the uterine sac — whether it retains its integrity throughout the entire canal or contributes a part of its length to the enlarged muscular bag — the solution is less readily at hand. The differences of opinion concerning these points have arisen more from differences in the interpretation of certain anatomical details than in their variation. It is of interest, therefore, to note the structural peculiarities as repeatedly observed in favorable preparations of the uterus at the close of pregnancy or at the beginning of labor. The classical section secured by Braune of a woman who died during the first stage of labor (Fig. 134) shows, Boundary bet^veen upper \_ and lower uterine seg- II ments {Sckroedcr's con- i traction-ring). %%A B ^;i:;:Zr' s'' Iatcd Fig. 134.— Section of the parturient canal at end of the stage of dilatation, from a woman who died during labor (Braune). in addition to the widely dilated os externum, whose still-defined position indicates the juncture of the uterine and vaginal portions of the parturi- ent canal, two annular markings of much interest. The uppermost of these markings is apparent as a distinct ridge completely encircling the uterine sac and separating the thicker and more voluminous upper segment from the more dependent lower part. This projection was described by Bandl as the dilated true os internum, and as defining, consequently, the upper limit of the cervical canal ; by Schroeder the same structure was regarded as a contraction- ring which marks the juncture of the upper contracted and the lower dilated uterine segments. Some distance lower a second ridge, slightly marked PHYSIOLOGY OF PREGNANCY. 149 anteriorly, but more conspicuous on the posterior wall, constitutes Miiller's ring, which Bandl regards as indicating the upper border of that part of the cervical canal which is unaffected until the dilatation of labor takes place. Sehroeder, on the contrary, views this ridge as the true os internum, and the zone included between his contraction-ring above and the one in question below as the inferior segment of the uterus. From the foregoing it is evident that the significance of the zone included between these two rings is the principal question at issue, some authorities regarding it as a part of the true uterine sac, while others consider it to repre- sent the upper part of the cervical canal, that unfolds before the termination of gestation and thereby contributes to the extension of the uterine sac. Ac- cording to the first view, the cervical canal retains its integrity throughout pregnancy ; according to the second, the canal participates to a limited degree in the formation of the fetal receptacle by dilatation of its upper portion toward the close of gestation. While both views claim distinguished names in their support, the weight of evidence seems to lead to the acceptance of the doctrine attributing a limited participation of the cervix in the formation of the uterine sac of pregnancy. The cervix of the uterus of the sexually mature virgin is about equal in length to the body of the organ, and only in women who have borne children is the neck relatively shorter (Kussmaul). During the first three months of pregnancy the cervix partakes equally in the general hypertrophy affecting the uterus (see Fig. 137), and reaches a length of 6 centimeters (2| inches) or more. While it is only from the seventh month that the os internum exhibits a tendency to expand into the adjacent uterine cavity, the forces leading to this unfolding begin their influence very much earlier — in fact, as soon as this portion of the uterus has reached its maximum hypertrophy, or from about the fourth month of gestation. In addition to the effects of the presence of the fetus, the traction exerted by the muscular bands — retractor fibres of Bayer — which pass from the outer layers of the uterus iuto the round and the sacro-uterine ligaments is an important factor in causing the gradual unfold- ing of the cervical canal. The dilated, funnel-shaped cavity contributed by the cervix for a long time retains its flattened plicse and is covered by ciliated columnar epithelium ; its mucosa finally undergoes conversion into, the decidua by changes identical with those taking place in other parts of the uterine mucous membrane. As a result of these changes the cervical canal shortens, and at the close of gestation measures from 3 to 4 centimeters (1^ to 1^- inches). The unfolding of the cervical canal takes place earlier in priini- parse, owing to the greater resistance of the comparatively rigid muscular tis- sue of the body of the uterus, until now unaffected by the changes of preg- nancy. These changes result in a general softening and elasticity of the body of the uterus from the beginning of gestation, the cervix retaining its usual firmness during the earlier months almost unimpaired. Toward the close of pregnancy the vaginal portion of the cervix projects less and less, the seeming shortening being probably due, in part at least, to the swelling and greater 150 AMERICAN TEXT-BOOK OF OBSTETRICS. prominence of the surrounding walls of the vagina as well as to traction exerted by ascending and diverging muscle-fibres. The change of position of the uterus is particularly associated with the rapid growth of the body, but during the early months of gestation this growth results in augmented antero-posterior and lateral diameters rather than in great increase of the longitudinal axis of the organ. In consequence of this increase, together with the increased anteflexion resulting from the additional weight of the hypertrophied tissue, the fundus does not rise above the symphy- sis until the fourth month. The fundus lies usually to the right of the median line, and often is so turned on its long axis that the left side is directed forward. At the fifth month the uterus fills the hypogastrium, from which time on the rise in the position of the fundus is so regular in its progression that under normal conditions this detail furnishes valuable assistance in the estimation of the stage of pregnancy. During the last two weeks of gestation the uterus sinks within the pelvis, the fundus taking a position somewhat lower than before, resting downward and forward from 7 to 8 centimeters (2| to 3^ inches) below the ensiform cartilage. The observations of Webster led this investigator to believe that the sinking of the uterus not infrequently begins long before (sometimes from the fifth month) the last two weeks, the period usually assumed. The position and relations of the full-term uterus alter with the posture of the woman. In the upright position the fundus bends as far forward as the tension of the distended abdominal walls permits, and rests against the anterior parietes. In the recumbent position the uterus lies against the lumbar part of the vertebral column, the fundus approaching the diaphragm above, with the intestinal coils in front and at the sides. On assuming the lateral posture the large, flaccid uterine sac becomes dependent on the corre- sponding side. The relations of the -peritoneum, and the uterus become disturbed in conse- quence of the altered position of the latter and the excessive tension caused by its enormous proportions. The layers of the broad ligaments become gradu- ally separated and the entire structures shortened, in consequence of which the Fallopian tubes and the ovaries are drawn toward the uterus, against which they lie at the close of gestation. The changes in the disposition of the pelvic peritoneum during pregnancy have been by no means definitely determined, and opinions differ as to the forces leading to such alterations as well as to the extent of displacement. Regarding the lateral arrangement, it is evident that the increase in the trans- verse and vertical diameters of the uterus must result in the elevation of the peritoneum on each side of the pelvis to a considerable degree, as conclusively demonstrated by the observations of Barbour and Polk. The arrangement in front and behind, however, is not so clear, and the statements of authorities are conflicting. Polk maintains that the lowest situation of the peritoneum in front and behind the uterus, with the exception of Douglas's pouch, in the non-pregnant condition is indicated by a line passing from the centre of the PHYSIOLOGY OF PREGNANCY. 151 symphysis to the juncture of the third and fourth sacral vertebrae. At the termination of pregnancy, but before the usual sinking of the uterus within the pelvis has occurred, the lowest limit of the peritoneum, according to the same observer, has ascended and is now marked by a line passing from the centre of the symphysis to the sacral promontory. These conclusions are not confirmed by examinations of frozen sections made by Webster, since this author finds the inferior limit of the peritoneal pouches during pregnancy as low as in nullipara?. The changes in the ante- rior relations of the peritoneum of the vesico-uterine fossa, whereby the peri- toneum becomes stripped from the bladder, are usually regarded as due to the elevation of the uterus and to the consequent mechanical effect, which together are also supposed to exert an influence by which the floor of the pouch of Douglas is raised. Webster attributes the stripping of the peritoneum from the bladder, on the contrary, to the drag caused by the gradual sinking of the pelvic floor, since the delicate subserous tissue gives way 7 under the traction, and the peritoneum consequently does not follow the posterior wall of the bladder in its descent. The extent to which the stripping of the serous cover- ing takes place depends largely upon the capacity of the peritoneal folds exist- ing in the non-pregnant condition, as when these are ample less displacement follows than when the traction cannot be met with supplementary tissue. According to Webster, the central portion of the pouch of Douglas at no time during pregnancy becomes elevated ; this author further points out that the sinking of the uterus may be progressive from the middle of pregnancy, resulting in the marked downward displacement of the organ sometimes observed before the end of gestation. The vagina also exhibits changes resulting from the exaggerated nutrition of pregnancy. These changes include greatly; increased vascularity, thickening and softening of its mucous membrane, whose folds become less rigid and con- spicuous, and hypertrophy of the muscular tunic with great dilatation of the blood-vessels. In consequence of the large quantity of blood contained within the less compact tissues, the vaginal surface presents a bluish tint in contrast with the bright red of its usual condition. This change of color is regarded by some as a valuable objective sign of pregnancy. The external genitals likewise participate in the increased hyperemia of the generative tract, the unusual development of the blood-vessels and the lymph- atics inducing a condition characterized by softening and greater infiltration of the tissues, hence the vulva appears particularly prominent. The excessive vascularity of the parts finds expression in the dusky hue and the unusual activity of the sebaceous follicles and the sweat-glands of the labia. The articulations of the pelvis exhibit to a limited degree changes due to pregnancy. These changes are manifested by an unusual softening and vascu- larity of the interarticular cartilage, particularly that of the symphysis, in consequence of which there takes place a certain amount of loosening, attended in some cases with slight movement. Whatever temporary increase in the pel- vic boundary may thus be secured, the gain at best is probably very insignificant. 152 AMERICAN TEXT-BOOK OF OBSTETRICS. Other changes affecting the pelvic floor and the parts closely connected therewith, such as the base of the bladder and the urethral orifice, result from the downward displacement of the structures closing in the outlet of the pelvis. The pelvic-floor projection is progressively increased from 2.5 centimeters (1 inch) in the nullipara to 9.5 centimeters (3f inches) at the end of pregnancy ; the skin-distance from the symphysis to the coccyx is almost doubled. The following table, compiled by Webster, based on the observations of himself and of other observers, displays some of the more important variations induced by pregnancy within the parts in relation to the pelvis : Pelvic-floor projection Skin-distance from coccyx to symphysis Distance of urethral orifice below brim Distance of urethral orifice below symphysis Distance of junction of bladder and urethra below brim Thickness of tissue between pubes and vagina . .... Depth of utcro-vesical pouch below brim Distance of os externum below brim posteriorly .... Distance of os externum below brim anteriorly .... Distance of os internum below brim posteriorly .... Distance of os internum below brim anteriorly .... Nul- Fifth Eighth lipara. Month. Month. Cm. Cm. Cm. 4.1 5.0 13.5 14.0 16.5 6.1 6.7 6.7 0.6 3.2 6.4 7.6 6.3 1.6 2.8 3.5 6.7 6.3 11.1 8.7 6.3 11.1 8.7 5.7 7.9 7.0 5.7 7.9 7.0 The abdominal walls manifest the enormous distention to which they are subjected by the formation of more or less conspicuous lines — the strioz gravi- darum — which are found in over 90 per cent, of pregnant women. These lines appear as reddish or bluish, sometimes lighter, streaks, which are most numerous and well marked during the last months of pregnancy over the lower part of the abdomen, particularly at the sides. They extend as curved or sinuous lines, and they persist for some considerable time after the termina- tion of o-estation, gradually becoming whiter and more cicatricial in appearance. These strife are due to displacements and partial rupture and atrophy of the connective tissue of the deep layer of the greatly distended cutis. They are not peculiar to pregnancy, but may appear even in men whenever the skin is subjected to unusual stretching, as from tumors, ascites, and other causes; furthermore, they are not limited to the abdomen, but in pregnancy are seen on the nates, the thighs, and the breasts. The linea alba also not infrequently becomes broader, and in multipara? the recti muscles are sometimes so widely separated that the mass of the uterus appears between as a median projection. The umbilicus is affected by the increasing bulk of the abdominal contents, and by the fifth month begins to exhibit a diminution in its depths; by the seventh month its depression has become obliterated, and during the remaining weeks it becomes gradually everted until the umbilicus forms a rounded elevation. The mammary glands, coincidently with the changes affecting the genera- tive organs, undergo important alterations during the preparation for their assumption of the stage of functional activity. These changes early induce PHYSIOLOGY OF PREGNANCY, 153 greater general volume of the breasts, depending upon an increase both of the interlobular connective tissue and fat and of the true secreting tissue of the glands. The enlargement of the breasts begins as early as the second month, but it does not become conspicuous until toward the middle of preg- Fig. 135. — Virgin nipple and areola: 1, nipple; 2, areola of nipple. 3, tubercles of Morgagni ; 4, crevice at base nancy. On touch the periphery of the organ presents uneven and knotty masses consisting of the enlarged acini and lobules of the rapid-growing glandular tissue imbedded within the areolar and adipose tissue. The ulti- mate compartments of the secreting structure become earliest enlarged ; couse- Fig. 136. — Nipple and breast of pregnancy : 1, nipple with openings of milk-ducts : 2, primary areola ; 3, glands of Montgomery ; 5, secondary areola ; 6, venous circle of Haller. quently the increase is first noticeable at the periphery, afterward extending along the course of the larger ducts toward the centre of the organ. The dis- tention of the skin due to the augmented volume of the glands is especially marked over the periphery, in which location reddish, bluish, or whitish strise, 154 AMERICAN TEXT-BOOK OF OBSTETRICS. similar to those seen upon the distended abdominal walls, appear as manifes- tations of the unusual tension of the integument. The veins are also enlarged, and show through the tightly drawn skin as a network of blue lines. The nipple shares in the general hypertrophy of the organ, becoming enlarged, more readily erectile, and sensitive. The surrounding rosy areola of the virgin (Fig. 135) is gradually replaced by a more deeply colored area, the tint of which by the middle of pregnancy varies from the slight brownish discol- oration seen in women of light complexion to the dark brown or almost black color seen in brunettes (see PI. 17). The areola by the eighth or the ninth week becomes softer and more elevated than usual, and its sebaceous glands, from one to two dozen in number, greatly enlarge, those at the periphery becoming particularly conspicuous. These modified sebaceous follicles consti- tute the glands of Montgomery (Fig. 136). The mammary areola varies from 2.5 to 4 centimeters (1 to 1^ inches) in diameter, although these dimensions may greatly be exceeded. In the fifth or the sixth month of pregnancy an additional irregularly pigmented area, the so-called " secondary areola," some- times appears (see PI. 17). After the third month of gestation the breasts contain a thin fluid, the colostrum, which may be pressed out of the newly formed glandular tissue. This fluid consists of a thin albuminous medium containing numbers of fat- drops, displaced epithelial cells, and characteristic aggregations known as " colostrum-corpuscles." 2. General Changes. — Pregnancy, while a purely physiological con- dition, creates great and important changes in the maternal organism. These changes pertain to the different systems and organs of the body ; to some more than to others. The general changes in the maternal organism depend to a great extent on the alterations in the blood and in the functional modifications of the nervous system. The pregnant woman has to provide nutriment, to breathe, to maintain blood-circulation, to secrete and to excrete for two individuals — herself and her fetus. All this means that extensive changes in the general system must occur. If these changes are carried to a reasonable extent, health is maintained and the system becomes fortified, as it were, for the coming parturition ; but when these changes are developed to excess, disorders complicating the pregnancy are produced. Changes in the Circulatory System. — Formerly it was supposed that preg- nancy was accompanied by blood-changes like unto plethora, and it was almost universally inferred that the attending symptoms — the headache, the ring- ing in the ears, the flushed face, the cardiac palpitation, and the dyspnea — were the results of these alterations. Consequently it was a very common practice with phvsicians many years ago to bleed pregnant women from one to many times at intervals during the latter months of pregnancy. Enormous quantities of blood were thus extracted by venesection. A wonderful revolu- tion has taken place in the treatment of pregnant women during the past twenty-five years, owing to more rational ideas of the real condition of the circulatory fluid. PHYSIOLOGY OF PREGNANCY. 155 In pregnancy the composition of the blood, which is increased in quantity, is profoundly altered, but not equally in all its constituent parts, as many careful analyses prove. The quantity of blood present before pregnancy would be inadequate to meet the condition of pregnancy. Thus, the blood is increased in its watery elements and white corpuscles, but is made deficient in the element of albumin, is increased materially in the amount of fibrin, and is diminished relatively in the proportion of red corpuscles — conditions of anemia, hydremia, and hyperinosis. This hyperinosis is also augmented after parturition, because at this time large quantities of effete materials are thrown into the circulation. Instead of a blood-change called "plethora" being present, it should be recognized as one of anemia and hydremia orof chlorosis. If called "plethora/' it should be named serous plethora. Individual variations in the quantity and quality of the blood are dependent on many conditions of hygiene and diet ; poor hygiene reduces the blood to marked chlorosis and hydremia. The surrender of the maternal nutritive material to a growing fetus and a devel- oping uterus, to pelvic tissue, and to glands means a great tissue-drain on the maternal circulatory fluid. As these changes in blood-quality are most marked at the close of utero-gestation, the attending phenomena must be those that are most strongly shown. Certain thrombotic affections observed in preg- nancy and after delivery are thus explainable. In place of the blood-supply at this time being improved by bloodletting, it must clearly be evident that venesection is strongly contra-indicated, for it tends further to aggravate the abnormal alteration. To Cazeaux are we indebted for much of our present knowledge of the blood-changes of pregnancy. Certain viscera of the circulatory apparatus are also much modified in size and in function. The heart becomes physiologically hypertrophied — a fact known for many years and determined by numerous observations. This hy- pertrophy is a wise provision of nature to meet the increasing exigencies of the blood-supply in the advancing months of pregnancy. Hypertrophy of the heart is constantly present to a considerable degree, the whole weight of this organ being one-fifth more in the pregnant than in the non-pregnant state. The left ventricle, the propelling part of this organ, is alone affected. This physiological hypertrophy remains during the period of lactation in those who suckle their children, otherwise the organ quickly diminishes in size; hence in women who have borne many children the heart may remain permanently large. Incident to the total blood-supply in pregnant women the maintenance of the circulation demands either greater frequency in the heart-contractions or an increase in the entire quantity of blood entering the left ventricle. The multiplied vascular elements of the pelvic organs also increase the labor thrown on the heart. The pulse does not undergo the usual acceleration when she changes from a horizontal to an erect posture. Disturbances of the circulatory organs are very often seen. The heart of the pregnant woman shares in the nervous irritability of the whole organ- ism — she is then more susceptible to so-called " cardiac nerve-storms." Thus, 156 AMERICAN TEXT-BOOK OF OBSTETRICS. palpitation, while purely sympathetic in the earlier months of gestation, later comes on from the encroachment of the enlarged and enlarging uterus pushing up the diaphragm and embarrassing the heart's action. The blood-changes of anemia and of hydremia may be so great that edema may be observed in the feet and may extend upward to the thighs and the labia majora. Other organs are likewise increased in size. The liver and the spleen are enlarged. The spleen normally increases in size, owing to an important rela- tion to the quantitative change in the circulatory fluid. A fatty degeneration shows itself in both the liver and the spleen in women who have suddenly died after labor. Numerous small yellow spots are seen scattered through the liver — fatty deposits in the hepatic cells. The thyroid gland is increased in size. In women in whom there is a predisposition to this enlargement, preg- nancy may further stimulate the growth and bring about permanent structural changes. The enlargement of this organ is thought to sustain some relation to changes in the heart and the blood-glandular system. Changes in Respiration. — Pressure of the enlarging uterus, through mechanical action, causes changes in the respiratory organs. An upward movement of the diaphragm lessens the longitudinal dimensions of the thorax. Some embarrassment of the respiration follows this decrease, notwithstanding that there is some increase in the breadth of the lower thorax. In the last two weeks of utero-gestation, owing to the limited shortening of the cervix uteri and to the settling down of the fetus in utero, respiration and circulation become easier. The examination of expired air shows some increased activ- ity of the lungs, in excretion the lungs sharing the work of other excretory organs, in disposing of the extra effete products from mother and fetus. As more blood must naturally be provided to nourish the woman and her child during pregnancy, this extra blood must not only be properly circu- lated, but must also be duly purified. The elimination of carbonic-acid gas by respiration is therefore increased in pregnancy. The respiratory organs may be deranged by cough and dyspnea originating from nervous sympathy in the earlier months of pregnancy. In the later months of gestation the derangement is from encroachment of the gravid uterus, interfering with normal respiration. These phenomena are mostly observed when there is twiu pregnancy or dropsy of the amnion. Changes in the Digestive System and in Nutrition. — The pregnant woman provides the nutritive pabulum by which the growing organs are sustained and by which the fetus and its appendages are built up. She must therefore digest more food, form more blood, and increase the activity of the secretory and excretory organs. Very few women escape such troubles of digestion as nausea and vomiting. In the earlier months the appetite is, as a rule, capri- cious. Further along the appetite and the digestion increase in activity, thereby assisting in improving the general nutrition. An increase of weight takes place in normal cases, irrespective of the grow- ing uterus and the ovum. The fetus itself weighs about seven pounds, the PHYSIOLOGY OF PREGNANCY. 157 liquor amnii one pound, the placenta one pound, and the uterus about two pounds. The average gain of the woman amounts to from ten to fifteen pounds in the whole nine months, being greatest in the last two months. This increase is usually not far from one-thirteenth of the whole body- weight, and it is progressive from the beginning to the end of pregnancy, notwithstanding the nausea and vomiting. The adipose tissue increases most in bulk, especially in the latter half of gestation. These deposits are most noticeable iu the mammary glands, in the abdominal parietes, iu the hips, and in the omentum. The whole figure becomes fuller and rounder. All this increase is but so much stored-up poten- tial energy, to be utilized after delivery, when this energy, by the metabolism of the body, assists the mammary function. Rokitansky has spoken of the lamellae of osseous material on the inner sur- face of the skull and the frontal and parietal bones external to the dura mater, called "puerperal osteophytes." These lamellae, which are irregular in shape, consist of calcium carbonate, traces of phosphates, and organic matter. They are not peculiar to pregnaucy. Robert Barnes thought they sustained some relation to the calcareous changes found in the placenta and to the forthcoming milk. The temperature of the body in pregnancy is not materially changed, although, according to some authorities, it is slightly lower in the morning than during the day. Changes in the Skin, the Gait, and the Osseous Elements. — The functional activity of the sebaceous glands, the sweat-glands, and the hair-follicles of the skin is increased by pregnancy. It has been said by Robert Barnes that the growth of the hair is invigorated during pregnancy when prior to ges- tation the hair had been falliug out. Pigmentations are quite generally observed iu spots over the body, the linese albicantes beiug most noticeable. They are also seen about the abdomen, the navel, and on the face. Around the nipples these deposits may be seen in the form of areolae, primary and secondary (see PI. 17). These pigmentations vary much iu extent and in intensitv in different subjects, being more marked in brunettes than in blondes. Seldom do these deposits completely disappear, but they are always less after parturition. It is not unlikely that they are the result of a temporary hypertrophy of the suprarenal capsules. There is also a change in the gait of a pregnant woman. To preserve the centre of gravity of the body the head and shoulders must be thrown back- ward. This action produces a chauge in the gait most noticeable in women of low stature. Owing to the drain on the osseous elements of the blood during pregnancy by the growing fetus, there is always a considerable delay in the union of fractured bones. Changes in the Urine. — Owing to the hydremic condition existing during pregnancy, the urine becomes more abundant and of a lower specific gravity. It is thought that the kidneys become enlarged, which is probably the case. This change in the size of the kiduevs has somewhat to do with the increased 158 AMERICAN TEXT-BOOK OF OBSTETRICS. quantity of urine, but more probably the more active function is attributable to the increased blood-supply and to the increased arterial tension. The urine may be diminished in quantity, be high colored, have a high specific gravity, as a result of dietetic errors, or some inactivity of the bowels or skin. If not indicative of renal disease, it is transient and unattended by symptoms. The quantity of urea excreted is normal usually. There are also qualitative changes in the urine. The chlorids have been found increased, while the phosphates and sulphates are decreased, due to their use in the growth of the fetus. The kiestein pellicle found upon the urine of pregnant women several hours after its excretion has no necessary relation to pregnancy, because it is found on the urine of virgins and on that of men. The glucose found in the urine of many pregnant women in variable quantities has been referred to a pathological increase in the glycogenic func- tion of the liver. Sugar is present in the urine of almost every woman at some period of lactation being influenced much by the character of the diet. Its presence depends on the quantity and quality of the milk, diminishing as the lacteal secretion is suppressed. Glycosuria of pregnancy ranks next to albuminuria in clinical importance. It may develop in every pregnancy, to disappear after parturition. Traces, more or less in quantity, of albumin are found in the urine. Authorities differ as to the frequency of albuminuria in pregnancy. Schroeder savs that the urine of all pregnant women will contain albumin in from 3 to 5 per cent. ; other authors have contended for a much larger percentage (from 20 to 30). Uncpiestionably, albumin is found in the urine of a very large number of pregnant women. No regard being paid to the number of pregnancies, nor to the previous condition of the kidneys, the presence at some time of a trace of albumin will be found in a very large number of cases. The writer, who instituted these examinations in a large clinical experience in hospitals, has found the frequency to be at least 30 per cent., not constantly, but present in some variable quantity at some time in gestation. This frequency must be inquired into with reference to its etiology. In the first place, quite a number of pregnant women have a physiological albumi- nuria. The trace of albumin is then small and of short duration ; there are no tube-casts, and no attending morbid symptoms. Every authority must coin- cide with Mdricke, that albuminuria is relatively commoner during labor than during pregnancy. A prolonged labor is oftener thus accompanied than is a short and easy labor. Albuminuria is often confined exclusively to the period of labor. The occurrence of albuminuria during labor is explained by the theory that the reflex vaso-motor spasm of the renal arteries, resulting from uterine contractions, causes renal anemia. This theory has the support of Tyler Smith, Spiegelberg, and others. Renal albuminuria may appear early in pregnancy, before there is any possible renal venous stagnation from pressure, being the result purely of reflex irritation. "Whv should not this irritation at times be transferred from PHYSIOLOGY OF PREGNANCY. 159 the uterus to the kidneys as well as to the stomach ? Such an explanation must hold good, if albuminuria is present early in pregnancy, the urine having been normal before that time. There is an intimate connection between the nervous ganglia of the pelvis and the nerve-filaments of the kidneys. The hydremic state of the blood incident to pregnancy is at times a cause of albuminuria. An increased arterial tension which exists in pregnancy may be productive of albuminuria. The urine of a pregnant woman may be albuminous from causes not nephritic, yet morbid. Thus, it may be albumin- ous from blood, from mucus, or from pus in the urine, each of which may be cystic, vaginal, or uterine in origin. The prevalence of albuminuria during pregnancy may be classified as fol- lows: (a) Cases in which it was present when conception took place, a chronic Bright's disease of some type, with albuminuria, having existed before preg- nancy ; (6) Cases in which albuminuria from sub-acute or chronic Bright's disease, the result of scarlet fever, etc., had existed years before, and from which disease a recovery seemingly had taken place : at least there was no trace of albumin in the urine at the time of conception ; (c) Cases in which the existing pregnancy or parturition was attended by an albuminuria, it having never existed before. In the first two divisions of the above classification pregnancy aggravated or caused a return of the albumin. In the last division albuminuria started during, and had been clearly attributable to, the condition of pregnancy. Excepting, then, the cases in which the albuminuria has been due to physiological or pathological causes, not nephritic, and not attributable to pregnancy, the author is disposed to think that the estimate made by Schroeder (3-5 per cent.) is not wide of the actual facts. The oldest theory is that albuminuria and kidney disease during pregnancy are due to mechanical pressure of the gravid uterus od the renal blood-ves- sels, especially on the veins. All admit that this mechanical pressure pre- disposes to, if it does not excite, the disease. This doctrine has been ably advocated by Simpson, Carl Brown, and Cazeaux. It is not so much the renal pressure alone as it is the intra-abdominal pressure that so acts. Support of this theory is obtained from the following facts : Albuminuria is more common in the latter half than in the first half of pregnancy. More cases exist among primiparse, in whom there is great ab- dominal pressure from the rigid, unyielding abdominal walls. Albuminuria is greater in twin pregnancy ; it is also common when there is a\ severe pressure from large uterine fibroids or from ovariau cysts. Tight lacing and heavy skirts aggravate the disease. It is less frequent during gestation than during labor, when pressure is greatest ; it diminishes after labor or after the removal of the abdominal tumors. Any cause that brings about renal venous stasis pre- disposes to and excites nephritis. For instance, valvular defects and pul- monary emphysema, as well as pregnancy, may develop true parenchymatous inflammation of the kidneys. No one of all the above theories or facts constitutes a sufficient explanation for all cases. Each fact or theorv may answer for some cases; two or more 160 AMERICAN TEXT-BOOK OF OBSTETRICS. combined afford a better solution for most. All can recognize the influence of intra-abdominal tension with pressure on the vena cava and its branches, especially in primiparous women. The sinking of the fetal head into the true pelvis in the last two weeks of pregnancy, while it improves the respiration and circulation in general, does not relieve the renal venous stasis. While most women feel lighter and freer during these last two weeks, owing to the settling down of the fetus from the shortening of the cervix, the intra- abdominal and pelvic pressure is not diminished. So great is the significance of albuminuria during pregnancy that its pres- ence should always be watched for. Frequent physical, chemical, and micro- scopical examinations of the urine should be made in the latter mouths of pregnancy. If the presence of albumin is but slight, it may be physiological, or, if pathological, no noticeable symptoms may be observed ; but if it is con- siderable and persistent, and if it occurs early in pregnancy, the prognosis is grave. Albuminuria is then a condition full of ill omen, although it is always susceptible of amelioration by well-directed treatment, and in many cases it may entirely be overcome. From a clinical standpoint it is ordinarily presumed that when there is albuminuria there is also uremia to a corresponding degree. Doubtless it is true that when albumin is abnormally excreted by the kidneys there is some retention of urea in the blood, from defective action of the kidneys, but certainly these two functional disorders do not hold the same proportion or relation. There may be much albuminuria and but little uremia, and vice versd. It is the degree of the latter disorder that forebodes evil. The whole line of treatment should be directed toward favoring the elimination from the blood of this poisonous material of urea, with its products. To secure this result it is incumbent upon us to act as potently as we can upon the bowels and the skin — compensator)' organs of the kidneys — and to address our remaining treatment to controlling other symptoms that may arise. Changes in the Nervous System. — The nervous system becomes more impres- sionable in pregnaucy. The emotional susceptibility is markedly increased and the whole character is altered. A woman may become fretful, peevish, irri- table, and at times unreasonable. The most amiable woman may thus be dis- posed when pregnant. She is often depressed in spirits at first, when her general nutrition is impaired from an imperfect appetite or a faulty digestion. Mania may be excited later ou — easily in those who are thus predisposed by inheritance or by actual melancholia. These conditions are among the most troublesome of the various complications of pregnancy. To witness a woman in the process of child-bearing impaired in her mental functions is indeed sad. There are cases, however, in which a sense of well-being takes the place of one of more or less physical debility. A condition of want of mental and physical activity before pregnancy at times becomes changed to one of buoy- ancy and exhilaration. Physically such women are stronger, and mentally they are more active and energetic. No factor enters so much into the causation of this mental cheer and despondency as the psychical — the degree of the desire for an offspring. DIAGNOSIS OF PREGNANCY. 161 II. DIAGNOSIS OF PREGNANCY. 1. Symptoms and Signs of Pregnancy. 1. The Nausea and Vomiting of Pregnancy, called the "Morning- Sickness." — This symptom consists of nausea, accompanied often with vomit- ing or the retching of a glairy fluid, showing itself early in the morning, gen- erally before, at times only after, breakfast. The assumption of the erect posture seemingly excites the disorder. Sometimes it begins very early, within a few days after conception, but usually not until the fourth or the fifth week of pregnancy. Seldom does it persist throughout pregnancy, but generally ceases spontaneously within the fourth month, although it may continue throughout the whole period. In many or in most cases it is comparatively mild, and does not seriously impair the health, its presence being regarded as a favorable omen ; but as there is every degree of seriousness in its nature, it is at times so severe and so long continued that not only are parts of meals vomited, but all foods, of whatever kind, variety, or quantity, are also rejected. Not only may the ingestion of food excite vomiting, but the sight or the smell of food may also give rise to this characteristic nausea. Morning sickness is a sympathetic disorder reflected from the uterus. There is no more satisfactory explanation of the manifestation of these phe- nomena than that they are a reflex irritation of the sympathetic nervous sys- tem, due to expansion of the uterus. The erect posture quickly assumed always increases the congestion of the uterus, and thereby aggravates its irritability. It is aggravated by unpalatable food, by posture, by sexual excitement, and by emotional disturbances. It is most marked in first pregnancies, and in women of highly nervous organization — a fact ever to be considered in the management of this affection. It comes on almost immediately in a few instances ; usually not until the sixth or seventh week of pregnancy. Some irritations of the pelvic organs may produce the same result, viz., uterine dis- placements and inflammation of the peri-uterine organs. Seldom is it com- pletely absent. It is a suspicious or presumptive evidence taken by itself, but when associated with certain other symptoms and signs it becomes a more prob- able symptom of pregnancy. Not necessarily in the regular order of time, but quite generally associated with this morning sickness, there are certain morbid longings for food ; for instance, foods and drink and certain vegetable acids formerly disliked are now desired ; the most unpalatable substances, such as chalk, clay, aud slate-pencils, may be craved ; or there may be a distaste for the usual articles of diet. Other stomach disorders, such as acidity, flatulency, heartburn, and unpleasant eructations, are sometimes noticed. Salivation is a very common accompaniment of the morning sickness when the latter is severe. A constant dribbling of the saliva by day or by night occurs in the earlier months of pregnancy, and its severity aud duration remain for an uncertain period. It has been observed to continue for mouths after the abatement of the nausea aud vomiting. 162 AMERICAN TEXT-BOOK OF OBSTETRICS. Toothache. — Under the above heading may also be included toothache, which at times is a purely functional disorder ; more often it is a symptom of actual caries, arising from alteration of the buccal secretion, dissolving the lime-salts of the enamel of the teeth ; or it may be the result of a morbid determination of the ossific elements of the teeth of the mother to the bones of the growing fetus. 2. Menstrual Suppression. — The second symptom more or less express- ive of the existence of pregnancy is the suppression of the menses. The function of menstruation is almost always suspended throughout the whole period of pregnancy. So reliable is this symptom that the determination of the end of gestation, or the time for the expected parturition, is best obtained by adding from two hundred and seventy-eight to two hundred and eighty days to the date of appearance of the last menstrual flow. But not invariably is menstruation suspended following an impregnation. The most frequent ex- ception to the general rule is found when menstruation returns once only ; then it is usually for a somewhat shorter time and in diminished quantity. The occurrence of a menstrual flow in diminished quantity and for a shorter time in a married woman who has had her menstrual periods regular as to time, quantity, and duration is very significant of a possible pregnancy, and the conception must have occurred several days before this function last appeared. Again, by way of exception to the rule, there are recorded notable instances in which the period of pregnancy was attended by a regular menstruation. The writer recalls in his experience the case of a woman, now living and in health, who never menstruated before marriage, nor during her married life of several vears unless she became pregnant. She had no menstruation the first two years of her married life until pregnant, and there was no return of the menstrual flow until she was agaiu pregnant ; in other words, menstruation in this case was never present except during pregnancy, M'hen it was normal in all regards, havino- thus appeared in three distinct pregnancies. Possibly the periodic hemorrhage in this case was of cervical origin, but no pathological lesion of the uterus could be detected. Menstruation occurring during the first three months of pregnancy, as it does sometimes, though more scantily, may come from the decidual cavity of the uterus, not yet closed, before the decidua vera and the decidua reflexa have become agglutinated ; then there must have been a certain amount of chronic decidual endometritis — a morbid state, of course. As many causes purely pathological — general and local, physical and psychical — induce menstrual suppression, the exact significance or the relative value of this symptom, as an evidence of the existence of pregnancy deserves most careful consideration. For instance, meustrual suppression following months and years of menstruation, normal in all regards, is a very strong sus- picion of pregnancy. Its value as evidence becomes less when it is stopped in a woman whose previous periods have been irregular from any cause. This symptom of menstrual suppression cannot, of course, be present from preg- nancy when the menses are physiologically absent from lactation, or when the DIAGNOSIS OF PREGNANCY. 163 pregnancy occurs before the first menstrual appearance, prior to puberty or after the menopause. So much faith has the popular mind in the presence of this symptom of menstrual suppression as indicative of pregnancy that no small degree of anxiety in looking forward to a pregnancy is often manifested by women. The fear of impregnation in the unmarried after illicit sexual intercourse, the expectation of the same in the newly married, the ever-pres- ent hope of maternity in the sterile woman, and the seeming appearances of pregnancy in some cases of abdominal enlargements, are mental states which may suspend the normal regularity of menstruation. There is what is called " psychical amenorrhea," in which case menstruation is suspended or is delayed from purely psychical causes. While it affects newly-married women who may be anxious to avoid pregnancy, it concerns mostly unmar- ried women who have exposed themselves to the possibility of impregnation. The fear of a possible pregnancy is doubtless sufficient to prevent a normal return of this function. The exceptions of the cessation of menstruation without pregnancy, in seeming good health, and the continuance of this ute- rine function with pregnancy, are very often misleading. All the exceptions above mentioned should be remembered when esti- mating the actual worth of the symptom of menstrual suppression. We should ever bear in mind, however, that the patient's statements are not always to be relied upon. 3. Mammary Changes. — During pregnancy the mammary glands are in immediate sympathy with the growing reproductive organs of the pelvis, con- sequently a genuine physiological hypertrophy commences in these organs from the beginning of gestation. Their glandular structures become larger, fuller, and firmer ; a sensation of weight or of pricking in them is felt by the patient ; the veins, blue in color, become enlarged and more visible. Light- colored, silvery lines are seen radiating over the projecting organs in the last months of pregnancy. The nipples also become enlarged, more elongated, prom- inent, and somewhat erect (Pis. 17, 18). Surrounding the nipple is noticed the areola, which becomes darker in color, and which is most pronounced in bru- nettes (PI. 17). Two or more enlarged moist follicles, varying in size and con- taining sebaceous material, are seen projecting from the surface of the areola. In the fifth or the sixth month there appears a secondary areola (Pis. 17, 18) con- sisting of scattered round spots, appearing as if the color had been discharged as a shower of drops (Montgomery). Thus every structure entering into the composition of the mammary glands is physiologically hypertrophied. These changes begin as early as the second month, and become more pro- nounced as pregnancy proceeds. The two mammary glands are equally enlarged and progressively developed. The secretion of colostrum in the glands enhances the value of these mammary changes indicative of pregnancy, especially if noticed in women who have never before been pregnant. Milk is now and then seen to ooze from the nipples of some women before delivery (PI. 17); in most women a drop or more of colostrum may be squeezed from the nipples after the third month. Instead of the lacteal secretion being pro- 164 AMERICAN TEXT-BOOK OF OBSTETRICS. moted, its suppression in nursing women is very suspicious of another preg- nancy. Milk is secreted at times, though rarely, when there is no pregnancy. Pelvic diseases, such as chronic metritis, rapid-growing fibroids, ovarian cysto- rnata, and false pregnancy, at times induce milk-secretion. In some women the mammary glands display a noticeable physiological activity at each cata- menial epoch — even to a free milk-secretion. Cases are recorded of the presence of milk in the mammary glands of males. These characteristic physiological changes, in their uniformity and progressiveness, mark the distinguishing differences between the mammary changes of pregnancy and those alterations noticed in size and shape of the glands from sympathy with cei'tain pelvic diseases — ovarian and uterine. These mammary changes in structure, color, and function are of little diag- nostic value when considered alone, but when, taken in conjunction with other symptoms they are highly probable evidences, especially in first pregnancies. Owing to the fact that the darkening of the areola in multiparas, and the erectility of the nipple remain more or less prominent, while colostrum may sometimes be present for years after the cessation of lactation, it can be ap- preciated how these signs lose their diagnostic value in women who have borne children. 4. Functional Disturbances of the Bladder. — Functional disturbances of the bladder are quite often noticeable early in pregnancy. As the bladder is somewhat dragged upon by the physiological prolapsus of the uterus in the first mouth (a position rather increased in the second month), and as it is pressed upon during the third month by the increasing normal anteversion, it can be understood why functional disorders of this organ may result. The bladder- capacity is diminished, and in consequence there is an increased frequency of urination. The vesical symptoms tend to diminish in the fourth month, because of the ascent of the" uterus from the pelvic to the abdominal cavity. If retroversion of the uterus existed prior to pregnancy, this backward mal- position is increased, while the uterus is pelvic in position. Because of the increasing size of the organ, with its growing contents, there follows, at times, from retroversion, serious urinary retention. Incontinence of urine more rarely occurs during pregnancy, from coughing or from sneezing, when the bladder is somewhat distended. Some degree of irritability of the bladder is apparent in almost all pregnant women, aud it occurs to an exaggerated degree in neurotic individuals when the pressure of the gravid uterus is more manifest. Kiestein, sometimes present in pregnant women, is a proteiue substance, consisting of triple phosphates, fungi, and infusoria, that forms like a flocculent cloud on the urine kept standing for a few days at a tem- perature of 70° F. It occurs iu the urine from the eighth to the thirty- second week of pregnancy, then disappears. It has practically no diag- nostic value, as it is found in the uriue of non-pregnant women, and at times in that of men. 5. Intrapelvic Signs. — Certain changes in structure take place in the PREGNANCY. Secondary areola uf usual size (in a brunette). Secondary areola, prominently marked (S), with wide primary (P) areola (in a brunette;. Mammary signs of pregnancy in their order (two -thirds life size). PREGNANCY. Plate 18. Elevation of primary areola (E) in profile, o pared with au areola which is not elevated (ci posite photograph). Well-formed, firm breast and nipple (in a brunette). Typical signs in the blonde: F, follicles ; PA, pri- mary areola. Mammary signs of pregnancy. DIAGNOSIS OF PREGNANCY. 165 uterus in the earlier months of pregnancy, when the organ is confined within the true pelvis, before it ascends within the abdominal cavity ; these changes, carefully studied and detected by vaginal touch and by bimanual exami- nation, possess a significance far greater than any of the aforementioned symp- toms. Associated with some of the other symptoms, these changes become extremely probable evidences : (a) Softening and Enlargement of the Cervix Uteri. — These changes, com- pared with the physical conditions of the same parts in the virgin or the never-pregnant woman, will be observed to be quite characteristic — less so in women who have borne children. The cervix uteri softens and enlarges in all directions as the result of the increased blood-supply and the edema of the parts. The lips of the os uteri become patulous and puffy, a condition most noticeable in primiparse. The softening of the infravaginal cervix, beginning below, extends upward. The cervical secretion of mucus, the so-called " cervical plug," is increased. Rapidly growing myomata may likewise soften the cervix. But should the cervix uteri be the seat of some old injury, and a dense cicatricial tissue result, then there will be no appre- ciable softening from pregnancy. The diminished resistance to touch and the increasing width of the tissues seemingly shorten the cervix. These changes, while beginning in the first mouth, are not recognizable until the second month ; from this time they are progressive. Erroneous views as to changes in the cervix uteri during pregnancy existed in years past. It was believed that the cervical canal was greatly shortened to form part of the corporeal cavity, and that toward the last of pregnancy no cervical cavity existed, it having lost one-half its length by the sixth month, and so on, until it was obliterated in the eighth and ninth mouths. These views, long entertained, were in 1826 called in question by Stolz, whose views most modern obstetricians now uphold. Post-mortem examinations made of women in advanced pregnancy — the best proofs — have established the fact that the- cervix maintains its length of 2.5 centimeters (1 inch) or more to the F last days of pregnancy (Fig. 137). Digital exploration through the patulous cervix substantiates this fact. But during the fortnight preceding parturition a genuine broadening of the cer- vix takes place, when the cervical canal is merged into the upper uterine cavity — a result, no doubt, of the incipient uterine contractions preparatory to labor, as pointed out by Matthews Duncan. The broadening of the cervix in the last stage of pregnancy, prior to eight and one-half months, then, is, seemingly, not real until the last fort- night. More or less of these changes remain eveu after parturition ; in other f -Cervix at end of pregnancy (Waldeyer). 166 AMERICAN TEXT-BOOK OF OBSTETRICS. words, the cervix does not completely resume its pristine virgin firmness and smoothness of surface or its original size. While these changes are noticeable from pathological as well as from physiological causes, their value in the diagnosis of pregnancy is only to be relied upon, when associated with other signs and when taken in conjunction with certain other symptoms. (b) The Violet Color of the Vulvar and Vaginal Mucous Membrane. — Dr. Jacquemin of Paris first discovered this sign, and Dr. Chadwick of Boston has fully dwelt upon its diagnostic significance. Inspection reveals its pres- ence, most distinctly on the inner surface of the labia majora and the vaginal mucous membrane of the anterior wall, exposed when the labia are separated. This pigmentation begins in some cases as early as the fourth week. It is of importance in the earlier months of pregnancy, when there is seen the then pale violet color, becoming more bluish as pregnancy advances. But this sign is not of positive value, for it is at times entirely absent in early pregnancy. While arising from a venous stagnation in the vaginal vessels, it may come also from vaginal or uterine congestion due to disease. This sign is valuable often as early as the second month, and in the latter half of pregnancy it is highly diagnostic ; then its recognition possesses great value. (c) Hegar's sign, which has been given to the profession within the lasi decade, possesses a great advantage. In all doubtful conditions of early preg- nancy this sign ought to be searched for. It is to be detected by vaginal touch and by bimanual examination. Its presence implies a change in the consistency of the lower uterine seg- ment. The greatest changes in the uterus must and do take place in the body of this organ — the bed, as it were, for the growing ovum. The neck of the womb is less supplied with blood, and it receives comparatively little of the stimulus of pregnancy. The develop- ment of the cervix is largely completed by the fourth month. During the first six or eight weeks of gestation fig. i3s.-Pregnant uterus of early part of the body of the uterus enlarges, espe- tbird month (Braun's frozen section), with prob- ..... .*"-.. able post-mortem retroversion : d, d, decidua vera. Chilly in its autero-postenor diameter. Bimanual, recto-vaginal, or abdomino- vaginal touch will detect some enlargement in all directions — anterior, pos- terior, and lateral. The lower uterine segment becomes soft, compressible, and pulsating; above there is the projecting or bulging uterine wall, hard and resisting during uterine contraction, boggy or soft during relaxation. The ac- companying illustrations (Figs. 138-140) best elucidate these facts. The uterus in shape has been likened to that of a demijohn, to an old-fashioned fat-bellied DIAGNOSIS OF PREGNANCY. 167 jug, or to a sphere (corpus) resting upon a cylinder (cervix). These altera- tions in consistency, while noticed on the posterior wall by rectal touch, are best detected along the anterior uterine wall by the finger in the vagina with Fig. 139.— Longitudinal section of a nulliparous (a) and of a muciparous (e) uterus : A, cavity of trie cervix and arbor vitae ; C, cavity of the body ; 0, constriction between body and cervix, the os uteri internum : S, wall of body (Tarnier). the outer hand on the abdomen seizing the uterus. The structures of the corporeal wall may become soft and yielding, and may show a contrast with the cervix below. It is true that the sign of bogginess of the body is not always present, and that its presence is simidated somewhat by morbid states, but the peculiar compressibility of the lower segment, together with the bogginess of the body and the changes in shape of the womb, is not simulated by anything else. This enlargement of the uterus, with the change in its shape, size, and consistency, are the most important signs of pregnancy in the earlier weeks. (d) Changed Position of the Uterus. — We must not fail to bear in mind the modification in the positions of the uterus that pregnancy usually produces. Fig. 140.— Frozen section of uterus at two and a half months (Pinard), showing relaxed and thin walls, thickened decidua ; with the clinical findings of Figure 139 it will be seen how the bimanual signs originated. In the first and second months the uterus is somewhat lower, but in the third month it undergoes an increased anteversion, for the reason that the relatively increasing weight of the body of the uterus with its growing contents tilts the upper end of the uterine lever downward and forward. Some anteflexion 168 AMERICAN TEXT-BOOK OF OBSTETRICS. there appears with the actual anteversion. This change in position will be noticed in all cases except those in which pregnancy has occurred in a previously retroverted uterus ; the retroversion is then increased. This statement is made, notwithstanding that some of this anteversion may be apparent, not real, the anteroposterior diameter of the organ being thickened. Hegar's sign, recognized, as it may be, so early as the second month, and the overhanging and softness of the corpus, the changed position of the uterus, and the violet color of the vagina and cervix uteri, while not abso- lutely positive signs, are highly probable evidences when associated with some of the rational symptoms referred to. They possess a diagnostic sig- nificance ever to be watched for and carefully estimated. They are a corn- plexus of physical signs that gives a reasonable diagnostic certainty. 6. Abdominal Changes. — Under this head are included all those changes in size, shape, and appearance of the abdomen that may take place. (a) Enlargement, Size, and Shape of the Abdomen. — At first, during the first six to eight weeks, there is somewhat of a flattening of the abdominal surface, due, doubtless to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and making traction on the urachus, thereby drawing the umbilicus inward. The navel in consequence becomes depressed ; hence the common expression, " A blank before a bank." Later in the fourth month, as the growing uterus rises for proper accommodation in the abdominal cavity, a slight abdominal enlargement will be observed, and the umbilicus is no longer sunken. By the fourth month the fundus uteri has risen about 5 centimeters (2 inches) above the symphysis pubis. The vertical enlargement progresses at the rate of fully two fingers' breadth each four weeks, reaching the umbilicus at the end of the sixth month, and touch- ing the eusiform cartilage at the end of thirty-eight weeks, or eight and a half lunar mouths (PL 19, Fig. 1). The umbilicus for many weeks prior to that time has been protruding. During the last two weeks of utero-gestation the upper portion of the abdominal walls protrudes less and the girth of the woman seems smaller (PI. 19, Fig. 2). The patient feels more comfortable. The cer- vical canal is apparently shortened, the child in utero has sunken, and the pelvic ligaments are relaxed — changes preparatory to the coming parturition. During this time it will be noticed that the enlarging pregnaut womb is symmetrical, smooth in its contour, larger vertically than transversly, and by proper pal- pation it will be felt to contract spontaneously. Twin pregnancies, breech and transverse presentations, some deformities of the fetus, and some obliqui- ties of the pelvis may alter the shape, the size, and the degree of enlargement of the abdomen. (b) Coloration. — On inspection of the abdomen of pregnant women there will be recognized not only the condition of the navel, but also a changed color of the abdominal surface, and the presence of strise, due to distention of the abdomen. The pigmentation may extend from the pubis to the xiphoid cartilao-e — the brown lines. On the sides of the abdominal walls and down the thighs red, blue, or white markings, like cicatrices, may be seen. PEEGNANCY. DIAGNOSIS OF PREGNANCY. 169 (c) Fetal Movements. — Fetal movements are generally visible after the sixth month through the abdominal parietes. 7. Ballottement. — Ballottement is a passive motion of the fetus, consist- ing of the peculiar sensation felt by the examining fingers upon giving the fetus a motion in utero. Vaginal ballottement is usually employed, although abdominal ballottement is also practicable at times, and may be noticed for a longer period of time, even during the beginning of labor. For the ballotte- ment impulse to be perceptible there must be a mobile fetus, not too large, and a sufficient quantity of the liquor amuii to permit the entire fetal displace- ment in utero. The woman stands or reclines during its performance. In the vaginal ballottement the finger is placed within the vagina, anterior to the cervix, the pulp of the finger being applied to the anterior vaginal fornix by a direct brisk motion. The fetus is propelled upward into the uterine cavity, and, falling back by its gravity, an impulse is imparted to the finger against which it falls. Ballottement distinctly noticed is a pathognomonic sign of pregnancy, there being no other condition in which a solid body is found floating in the uterine cavity. The absence of this sign does not preclude the possibility of pregnancy, for different conditions may prevent its being noticed, such as ex- cessive or great diminution in size of the fetus, hydramnios, multiple preg- nancy, some abnormal presentation, or a faulty insertion of the placenta. Vaginal ballottement can sometimes be practised successfully as early as the latter part of the fourth month. It is more easily recognized in the fifth month, is most distinct in the sixth, continues in the seventh, is doubtful in the eighth, and is absent in the ninth mouth. 8. Intermittent Contractions. — As soon as the uterus is developed suf- ficiently to be felt by the hand through the abdominal wall, there may be perceptible intermittent uterine contractions which are constantly going on at intervals of a few minutes throughout pregnancy. Purely independent of volition, they may become valuable, in a diagnostic sense, in corroborating other signs. Uterine contractions are not positive signs, because the uterus undergoes somewhat similar contractions to free itself of clots of blood, of polypoid or fibroid tumors, and of retained secundines, or they may be simu- lated by a distended bladder. The method of procedure for detecting uterine contractions is to grasp the fundus uteri for from five to twenty minutes, with the patient recumbent on her back, the uterus meanwhile being lifted by the right finger per vaginam, the abdominal walls being relaxed by some flexion of the lower limbs. The characteristic hardening will then be felt, the contraction lasting for several minutes. To Braxton Hicks we are indebted for the thorough elucidation of this sign, which is often referred to as " Braxton Hicks' sign of pregnancy." 9. Quickening- and Fetal Movements. — Quickening is the sensation ex- perienced by the mother as the result of active fetal movements. The period when these active movements are felt is quite uncertain. Usually quickening is considered to occur about the middle of preguancy, consequently the time 170 AMERICAN TEXT-BOOK OF OBSTETRICS. of expected parturition is based on this event, but very unreliably. Certain sensations of motion, such as fluttering or pulsating, are sometimes felt by the mother earlier than these active motions. As pregnancy advances these active motions increase in frequency aud become more marked, and toward the last they are seen very generally. When felt or seen by the physician, as can be done after the sixth month, fetal movements constitute a very valuable and positively reliable sign not only of pregnancy, but also of a live child in utero. This sign should never be inferred to exist from the statements of the patient. Supposed fetal movements are frequently felt by the patient, and are thought to be, but are not, evidences of pregnancy ; frequently they are only illusory. These seemingly fetal motions come from the abdominal walls in false preg- nancy or from the intestines in tympanites. Failure to detect fetal movements does not negative pregnancy, for the child may be dead or its motion may not be felt. To detect these movements, place the patient on her back upon a table or a bed, with the thighs flexed and the abdominal walls relaxed. All clothing should be removed from the abdo- men. By palpation and renewed pressure at different parts of the abdomen the active fetal movements may be detected ; better, sometimes, by applying the hands to the abdomen, after first wetting them with cold water to excite a reflex action of the fetus. 10. Uterine Souffle. — This murmur lias been called "placental," because it was thought to be due to the movement of the blood through the placental sinuses ; it has also been named the " abdominal souffle," because it was thought to result from the pressure of the gravid uterus on the abdominal vessels. Neither of these two theories is correct. This placental murmur is doubtless due to the movement of the maternal blood through the uterine blood-vessels ; hence it should be called " uterine souffle." Heard first in the fourth month, on the sides of 'the upper part of the uterus, especially the left side, which for obvious reasons is brought nearer the anterior abdominal wall, the murmur is at all times synchronous with the maternal pulsation. It is very uncertain as to its presence, tone, pitch, duration, and location ; if once heard, it soon leaves, to return at another time or at another place. It is thus usually heard irregularly as to time, place, pitch, and duration until the end of pregnancy. Uterine souffle is no longer regarded as a certain proof of pregnancy. A sound exactly resembling it is not unfrequeutly heard in inter- stitial fibroids of the uterus, and it may be heard when ovarian tumors are present. In the majority of cases of parturition it is heard for the first two or three days in the. lying-in state. 11. Fetal Heart-sounds. — These sounds are a comparatively modern discovery. Mayer of Genoa first heard them in 1818, in examining the abdo- men of a pregnant woman. The fetal heart-sound cannot, as a rule, be heard earlier than the fifth month in utero-gestation. A practised ear may sometimes detect it a few weeks earlier, as in the fourth mouth. As this sound becomes stronger and louder in advancing pregnancy, its detection in the last few months becomes very easy. The sound may, of course, be quite DIAGNOSIS OF PREGNANCY. 171 feeble. If normally vigorous, some non-conducting material, as a tumor, an abnormal quantity of liquor amnii, or very thick abdominal walls, may intervene, impeding its transmission, or there may be a posterior position of the child, thus making it less distinct ; hence the inability to hear the fetal heart-sound ought not to negative a pregnancy. When attempts are made for its detection, the room should be quiet and the patient should be in the dorsal posture, with the head on a pillow and the thighs flexed lightly to Fig 141.— Location and intensity of fetal heart-sounds in the left occipito-anterior position (the four quadrants are indicated by the red lines ; the pose is from Spigelius). the body or extended. The stethoscope ought to be utilized, from motives of modesty, in localizing the sound of the fetal heart. This instrument should be applied to the abdomen below a transverse line passing through the umbili- cus, because the head of the fetus is more often lower thau the breech. Since the occiput in most instances points toward the left side of the maternal pelvis, the fetal heart-sound is most frequently heard with greatest distinctness upon the left lower space of the abdomen (space D, Fig. 141). If not heard in this space, search for it should be made over other spaces (as b, c, a). If 172 AMERICAN TEXT-BOOK OF OBSTETRICS. heard well in regions c, D, the inference is that the head is the lowest part of the fetus, and that the back of the fetus is anterior ; if heard best in regions A, B, it is to be inferred that there is a pelvic presentation. The mean frequency of the pulsations of the fetal heart is about from 130 to 160 to the minute; they are less frequent in large than in small children, and probably are less frequent in males than in females. A temporary variation in their frequency and force is very common. The sound is double and rhythmic, like the ticking of a watch under a pillow, the first sound being more clear and distinct than the second ; then comes a brief pause, when the second sound is heard ; a longer pause follows before the double rhythmic sound is again heard. The above-mentioned frequency indicates that there is no relation of the fetal heart-sound to the pulsations of the mother's heart. These two sounds are perfectly independent. Because of the varying frequency of the fetal heart-sounds, attempts have been made to base some reliable predictions as to the sex of the fetus in %der o ; but experience has proved that but little reliance can be placed on such attempts. In anterior positions of the vertex the tick of the fetal heart is heard with a maximum intensity to the left or to the right of the median line, slightly below the umbilicus ; while in posterior positions of the vertex it is heard in the flanks, rather higher than the umbilicus and less distinctly. The position of the fetal heart-sound in this way is a valuable help in the diagnosis of the positions of the fetus. The sound of a fetal heart well heard when the uterus- is relatively small — too small to accommodate a fetus of five or more mouths' development — should at once create suspicions of an extra-uterine pregnancy. As auscultation with the stethoscope reveals the presence of the uterine souffle and the fetal heart-sound, the practised ear may also detect the funic or umbilical souffle — an intermittent hissing sound synchronous with the fetal heart. It is referable to the umbilical cord. It is heard in but the smallest number of cases, and its causation is conjectural. As a sign of pregnancy it has very little value. There are also heard sounds produced by active movements of the fetus in utero. Fetal movements, for instance, may be heard by the ear instead of being felt by the hand. Their value is significant. 12. Petal Contour. — Inspection of the shape of the abdomen in preg- nancy is also valuable ; a careful, well-trained touch by palpation may detect the size, shape, and presentation and position of the fetus, as well as, at times, the presence of twins in utero. Diagnosis of the Sex of the Fetus. — Almost every pregnant woman is anxious to know the sex of her child in utero, and the physician is very often asked for an expression of an opinion. The determination of this matter, by estimating the rate of the fetal heart- beat — 120 to 140 in the minute — indicating, it is said, the probability of a male, while a quicker beat means a female, is very unreliable. DIAGNOSIS OF PREGNANCY. 173 Relative ages of parents are probably determining factors, in a measure, as is also a relative physical vigor of parents at the time of sexual congress. The theory of the time of fecundation : if early (within a few days before or following menstruation), may imply a female ; if later, a male, has been advocated. All theories are mostly speculative. 13. Mental and Emotional Phenomena. — Pregnancy quite generally modifies the nature — physical, mental, and emotional — of a woman. At times, she is more vigorous, buoyant, and cheerful than in the non-pregnant state. More generally, however, she is more or less irritable, excitable, and fretful. As the physical appetites for food in quantity, quality, and variety are fre- quently changed, so also is the moral sense sometimes seriously deranged. Classification of the Phenomena of Utero-gestation. — The symptoms and signs of pregnancy may now, for convenient study, be classified as to the time of their occurrence. For instance, the nine calendar months of utero- gestation may be divided into three periods, and a classification may be made of the aforesaid phenomena as to these three periods. First Period of Utero-gestation. — This period comprises the first three calendar months — the time during which the gravid uterus is enclosed within the true pelvic cavity. The symptoms are — (1) Menstrual suppression; (2) gastric disorders ; (3) mammary changes ; (4) vesical irritation. The sign's are — (1) Beginning patulousness of the os uteri ; (2) softening of the infra- vaginal cervix, gradually extending higher ; (3) uterus slightly lowered during the first and second months, and anteverted in the third month ; (4) flattening of the abdomen, with increasing depression of the umbilicus, the depression gradually disappearing toward the fourth month ; (5) violet-colored vaginal walls and cervix uteri ; (6) Hegar's sign (compressibility of lower uterine seg- ment), with softened and rounded uterine body. Second Period of Utero-gestation. — This period embraces the fourth, fifth, and sixth months. The signs and symj>toms are — (1) Menses still absent; (2) subsidence of the gastric disturbances ; (3) increasing and progressive development of the mammary signs ; (4) vesical irritation improved ; (5) the uterus higher, ascending into the abdominal cavity ; (6) cervix higher in vagina ; navel no longer depressed ; (7) fundus uteri two fingers' breadth above pubes at the end of the fourth month ; at the umbilicus toward the end of the sixth month; (8) cervix more softened and patulous; (9) fetal active motion (quickening) experienced toward the end of the fourth or in the fifth month; (10) ballottement detected, becoming more distinct; (11) intermit- tent contractions also detected, increasing in force ; (12) uterine souffle audible in the fourth or fifth month; (13) fetal heart-sounds easily detected, usually first in the fifth month. Third Period of Utero-gestation. — This period embraces the seventh, eighth, and ninth months. The signs and symptoms are — (1) Menses continue absent; (2) gastric symptoms slight or only occasional ; (3) further progressive develop- ment of the mammary signs, colostrum sometimes present ; (4) uterus continues to rise in the abdominal cavity, reaching midway between the navel and the ensi- 174 AMERICAN TEXT-BOOK OF OBSTETRICS. form cartilage at the end of the seventh month ; reaching the ensiform car- tilage in the first two weeks of the ninth mouth ; after which period it grad- ually becomes lower; (5) ballottement continues until the eighth month, when it is doubtful ; it is absent in the ninth month ; (6) umbilicus commencing pro- gressively to protrude; (7) vaginal cervix seemingly shortened, more thick- ened, softened, and patulous, getting higher ; (8) fetal movements felt or seen after the sixth month ; (9) in last two weeks the fundus uteri, having reached its maximum height and size, begins to descend, when the cervix undergoes an apparent shortening. Now the cervical lips become thinner. The presenting part of the fetus, having partially entered the pelvic inlet, is more easily detected by vaginal touch. Pressure-symptoms of the chest and the stomach disappear, though edema of the limbs and the genitals may show themselves. Relative Value of the Symptoms and Signs of Pregnancy in Point of Diagnosis. — Very properly we may classify all the symptoms and signs of pregnancy as medical evidence of the presumptive, the probable, and the positive kind. They naturally rank in value inversely in the order named. The presumptive evidences of pregnancy are — (1) Menstrual suppression ; (2) morning sickness ; (2) irritable bladder ; (4) mental and emotional phenomena. The probable evidences are — (1) Mammary changes; (2) the bimanual signs; (3) abdominal changes in size, shape, and color; (4) changes in cer- vix uteri in size, shape, consistency, and color; (5) uterine murmur; (6) intermittent contractions. The positive signs are — (1) Active movements of the fetus ; (2) passive movements of the fetus (ballottement) ; (3) fetal heart-sounds. Differential Diagnosis of Pregnancy. — Nothing can be of greater moment, on the one hand, than a correct diagnosis of pregnancy, and, on the other, of the many conditions simulating pregnancy. Only the inexperienced will say that its recognition is 'an easy matter. There is no common condi- tion of the female human body so often overlooked or mistaken. Not only does a correct estimate of the actual condition concern the patient and her family in a physical, mental, or moral sense, but the professional reputation of the physician is also seriously involved. No error in diagnosis is so fatal to the interests of the patient. Almost every experienced physician could mention instructive and amusing mistakes which have been made. The legal and social relations of some pregnancies possess a deep and painful interest ; therefore let no opinion be expressed in any case until a reasonable certainty can be arrived at, Time may be needed to clear up all doubts. As pregnancy implies a certain variable amount of abdominal enlarge- ment after the fourth month, its existence must necessarily be differen- tiated from the many other conditions, physiological and morbid, that are attended with the same sign. In the differential diagnosis not much diffi- culty need exist after this enlargement is fairly well advanced. Most mis- takes are doubtless made when the gravid uterus is still within the pelvis; there is then often much doubt. There will first be considered the differential diagnosis of pregnancy and the morbid conditions simulating it during the DIAGNOSIS OF PREGNANCY. lib first three months. Just here comes into play the diagnostic value of the sign so forcibly elucidated by Hegar. The peculiar shape of the uterus in the second and third months of pregnancy (see p. 166) is not simulated by anything else. While in a measure resembling subinvolution of the uterus, it is to be remembered that in this morbid condition there is an organic enlarge- ment uniform in all directions. In chronic metritis attended Avith hyperemia, with or without flexion, the uterus is not jug-shaped, and the elasticity and compressibility of its uterine walls are absent. Chronic metritis attended with parenchymatous hyperplasia of the uterine body, shows the uterine walls dense, hard, sensitive to touch, not elastic, doughy, or boggy. An interstitial fibroid in either uterine wall is dense, hard, and uneven. Doubt is apt to pertain to cases of pregnane} 7 associated with chronic retroversion, but then a careful analysis of the presumptive symptoms will always be helpful in dif- ferentiation. A clear study of the physical signs of the cervix and the corpus uteri as to color, size, shape, and consistency are of inestimable value in the first three months. A search for Hegar's and the other bimanual signs ought never to be neglected. Pregnancy may be concealed, feigned, and imagined. These possibilities must be considered and be cleared up. When pregnancy has created material abdominal enlargement, the diagno- sis ought to be differentiated from all other conditions attended by the same sign, such as ascites, ovarian tumor, uterine fibroid, distended bladder, tym- panites, pseudo-cyesis (false pregnancy), enlarged uterus from gas (physo- metra) or from water (hydrometra), retained menses (hematometra), obesity, enlarged abdominal viscera, malignant disease, etc. In differentiating these con- ditions the three positive signs of pregnancy should always be borne in mind. In ascites fluctuation is most distinct ; the resonant note on percussion is always changed in location according to the position of the patient. Cardiac, hepatic, or renal disease can usually be detected as a causative factor of the ascites, and the symptoms of pregnancy are absent. In ovarian tumor a fluctuation of the abdomen is also present, though less distinct ; the abdominal enlargement has come on more slowly and has a peculiar shape: Menstruation is ordinarily present, and the signs — intra- pelvic and abdominal — of pregnancy are entirely absent, The area of duluess and tympanites is not essentially altered by posture. As pregnancy and an ovarian tumor quite often coexist, a constant watch ought to be made for this possibility in every case of an abdominal enlargement. The presence of two tumors of different consistency with an intervening sulcus is quite significant ; when both are present, the uterus itself by a vaginal examination shows enlargement, and there are present the presumptive symptoms of pregnancy, while there are also the signs of an ovarian cyst. A uterine fibroid creates an abdominal enlargement which is more firm, hard, and dense than any of the above-mentioned conditions • it is nodular and very often asymmetrical, is quite slow of growth, and menstruation is not only present, but, as a rule, is also increased in quantity and lengthened in 17(3 AMERICAN TEXT-BOOK OF OBSTETRICS duration. While the uterine murmur may be very well marked, there are present no positive signs of preguaucy. A distended bladder is of comparatively short duration, is attended with much discomfort, is associated with dribbling of the urine, and is quickly relieved by the use of a catheter. Fecal accumulation is dissipated by a copius rectal enema and free catharsis. Tympanitic distention of the abdomen is always very resonant on per- cussion, is variable in size on different days, does not fluctuate, and quickly disappears by proper treatment. Pseudo-cyesis, or false pregnancy, occurs oftenest toward the menopause, and its false appearances are quickly unmasked by the administration of an anesthetic. Obesity shows the abdominal walls soft, doughy, and easily palpated between the fingers of either hand, and there are no intrapelvic signs indicative of pregnancy. Hydrometra and physometra are extremely rare. There is always with them an absence of most of the probable and all the positive signs of preg- nancy. The uterus iu both diseases enlarges more slowly, and never to the extent of an advanced pregnancy. Diagnosis of Extra-uterine Pregnancy. — A judicious differential diagnosis of intra-uterine pregnancy implies a careful consideration of the possible or probable existence of extra-uterine pregnancy. This is especially the fact when the gravid uterus or the extra-uterine sac is still within the true pelvis, for if the diagnosis is the best guide for treatment, now is the time of all others to know the exact condition of affairs. The following symptoms and signs are worthy of most reliance from a diagnostic point of view. When extra- uterine pregnancy exists, there are — ■ 1. The general and reflex 'symptoms of pregnancy ; they have often come on after an uncertain period of sterility. Xausea and vomiting appear aggravated (Wiuckel). 2. Then comes a disordered menstruation, especially metrorrhagia, accom- panied with gushes of blood, and with pelvic pain coincident with the above symptoms of pregnancy. Pains are often very severe, with marked tender- ness within the pelvis. Such symptoms are highly suggestive. 3. There is the presence of a pelvic tumor characterized as a tense cvst, sensitive to touch, actively pulsating. This tumor has a steady and pro- gressive growth. In the first two months it has the size of a pigeon's egg ; in the third month it has the size of a hen's egg ; in the fourth month it has the size of two fists. 4. The os uteri is patulous; the uterus is displaced, but is slightly enlarged and empty. 5. Symptoms No. 2 may be absent until the end of the third month, when suddenly they become severe, with spasmodic pains, followed by the general symptoms of collapse. 6. Expulsion of the decidua, in part or in whole. DIAGNOSIS OF PREGNANCY. 177 Xurnbers 1 and 2 are presumptive symptoms of extra-uterine pregnancv; Xurnbers 3 and 4 are probable signs of extra-uterine pregnancv ; Numbers 5 and 6 are positive signs of extra-uterine pregnancv. Some of the above-mentioned symptoms resemble those of early abortions. In all cases with the history of a supposed abortion, when an intrapelvic mass is then or afterward felt, there should be suspicion of an extra-uterine preg- nancy. In consideration of the possibility or probability of extra-uterine pregnancy, based on the detection of a lateral extra-uterine sac, we are neces- sarily obliged also to exclude in the differentiation a small ovarian tumor, an enlarged ovary, a hydrosalpinx or a pyosalpinx, and pelvic exudates (cellu- lar or peritoneal). A distinct sulcus between the sac or the tumor and the uterus may be a physical sign to guide in the diagnosis. The svmptoms of a severe and overwhelming pain are quite generally manifested bv the end of the third month, because most cases are tubal in some form. These svmptoms are not noticed when the extra-uterine pregnancy is entirelv abdominal. The possibility of mistakes in diagnosis is to be considered with reference to — (a) Retroflexion of the gravid uterus ; (b) pyosalpinx with amenorrhea, or causing abortion; (c) malignant tumors of the abdomen with ascites; (d) normal pregnancy complicated with abdominal tumors ; (e) coincident intra- and extra-uterine pregnancy; (/) pregnancv in a deformed uterus. Diagnosis of Multiple Pregnancy. — Suspicions of a twin pregnancv are rarely excited ; but the presence of multiple pregnancv mav be conjectured from the following data : (a) Very large size of the abdomen ; (6) exaggera- tion of the results of a gravid uterus ; (c) irregularity of abdominal enlarge- ment ; (ro- duced in the bright yellow color of the amniotic liquid and the deep orange staining of the fetus and its appendages. This patient had high fever before delivery and died in septic coma shortly afterward. Acute yellow atrophy with malignant jaundice is due to blood-poisoning from acute septic infec- tion. The prognosis is exceedingly grave, and the treatment of these cases 274 AMERICAN TEXT-BOOK OF OBSTETRICS. consists in the effort to terminate pregnancy promptly, to arouse the secre- tions of the intestinal canal, and to support the patient's strength. The milder form of jaundice during pregnancy may result from impac- tion of feces, catarrh of the bile-ducts, pressure of the pregnant uterus upon the liver, and the physiological hyperemia that the liver shares in common with other abdominal viscera. Failure in excretion by the kidneys in greater or lesser degree is often noted in these cases, and the development of gall- stones is a not infrequent accompaniment. When the disorder is recognized promptly and the gastro-intestinal tract is subjected to proper and efficient treatment, it is possible often to avoid fatal issue. Winter 3UI describes an illustrative case in which a multigravida who had suffered from malarial intoxication was attacked with jaundice. After a violent illness lasting six or eight days, with severe gastric disturbance and vomiting, premature labor occurred, after which the mother recovered. The treatment of this condi- tion is the medicinal treatment appropriate for these cases in the non-pregnant. In well-marked cases premature labor is likely to occur, and in protecting the interests of the mother no effort should be made to avoid it. Gastric ulcer complicating pregnancy has been observed by Robert Koch 311 in 2 patients, each of whom suffered from profuse hematemesis accompanied by abdominal distress. In one, the milder case, pregnancy was interrupted and a living child was born. In the other the patient collapsed after vomiting blood freely, and although she rallied and ultimately recov- ered, her child was stillborn. Appendicitis complicating pregnancy has been well described by Mixter. 312 Premature labor followed the attack, and an abdominal tumor demanded operation. The appendix was found at the lower end of the kiclnev, its position having possibly been altered by the pregnant uterus. Fecal concre- tions were present. Recovery followed the operation. Pinard 313 describes the case of a woman who was said to have had general peritonitis following rupture of the uterus. The patient had been delivered by forceps after a somewhat difficult and tedious labor. Symptoms of gen- eral peritonitis rapidly developed. At the operation an infected appendix containing a fecal calculus was found. The patient did not recover. It is not difficult to understand how general peritonitis occurring after a difficult labor might be mistaken for abdominal infection following rupture of the uterus. Pinard reports 3 cases of appendicitis occurring in early pregnancy, in which abortion and the removal of the appendix were followed by recovery, In one of these cases premature labor occurred. He also describes a case of intestinal occlusion in a pregnant woman, in whom abdominal section revealed inflammation of the appendix to be the cause. The removal of the appendix- was followed by recovery. Appendicitis occurs equally as often among primi- parse as among multiparas, and at all periods of gestation. It is often slow and insidious in development, and may be mistaken for infection resulting from abortion or labor. It is to be treated sursjicallv in all cases. THE PATHOLOGY OF PREGNANCY. 275 Abrahams 314 has collected 11 cases of appendicitis reported by American authors. He adds 4 cases seen by himself. Of these, 1 was mild, occur- ring about the seventh month of gestation, and improved under local applications of ice and with the administration of opium. The second patient, a multipara, suffered from a catarrhal appendicitis during pregnancy for which operation was unnecessary and which continued after the delivery of the child. In the third case the patient was five months pregnant ; opera- tion was decided upon, but the temperature fell to normal and recovery fol- lowed without operation. The fourth case occurred in a pregnant woman who was injured in the right iliac fossa ; she was delivered in spontaneous labor. On the fifth day intense pain developed, with rapid, feeble pulse aud high temperature. Collapse ensued and the patient was revived with diffi- culty by stimulation. She rallied gradually and made a partial recovery. After convalescence she complained of constant pain in the right iliac fossa. Marx 310 reports a case developing after labor and recovering without operation. After convalescence typical attacks occurred, and a diseased appendix was removed. In a second case the appendix was removed when the patient was four months pregnant, and recovery followed without the interruption of pregnancy. When labor came on the patient experienced pain from adhesions, and the child was delivered with forceps. In the third case, when the patient was two and a half months pregnant, a suppurating ovarian dermoid cyst was removed through the abdominal wall. She had a rapid labor, followed by the development of appendicitis, which rapidly grew worse. An abscess and an adherent appendix were found. The patient made a good recovery. The fourth case occurred in a woman seven months pregnant when attacked by appendicitis with vomiting. Operation was per- formed, and the tube and ovary of the affected side were removed with the appendix. This was followed by labor. The patient's convalescence was retarded through the pocketing of pus in the abdomen. Recovery ulti- mately ensued. In the fifth case, in which pregnancy was four and a half months advanced, vomiting occurred. The patient became very ill and had a rapid pulse. Encapsulated abscess was found, with a pus-tract leading down to the vagina. The patient improved, but again became worse and ultimately perished from septic absorption from several abscess cavities. McArthur 316 reports a case occurring in a woman four and a half months pregnant, in whom abscess of the appendix or ruptured tubal abscess was diagnosticated. At operation the abscess was found to have involved the uterus, and was opened and drained without breaking adhesions. The appendix was gangrenous. The abscess was drained by gauze packing, but abortion and death followed from septic infection. Great sensitiveness and flatness existed over the region of the appendix. Labor occurred, and the patient perished from exhaustion. Appendicitis in the mother may result in the conveyance of infection to the umbilical region of the child. Pinard 317 reports the case of a woman, 276 AM ERICA X TEXT-BOOK OF OBSTETRICS. six months pregnant, who died of appendicitis followed by abortion. On making cultures from the umbilical cord the colon bacillus was discovered. Albuminuria and peptonuria are variations in the metabolism of the pregnant patient, and are of interest and importance to the obstetrician. The clinical significance of the presence of serum-albumin in the urine in pregnancy has, after a closer study of the excretions, been found to have been greatly exaggerated. In accordance with the preciseness and the deli- cacy of the tests employed serum-albumin has been found to be present by Schroeder in from 3 to 5 per cent.; by Ingersley, in 4.8 per cent.; by Flaischlen, in 2.6 per cent.; by Meyer, in 5.4 per cent.; whereas Lantos, in an interesting series of observations at Buda-Pest, 3ls found albumin in 1 8 per cent, of pregnant women and in 60 per cent, of those recently delivered. In 39 fatal cases in which the urine had contained albumin, the patients had suffered from neither eclampsia nor nephritis. The kidneys in these cases were very pale and anemic. Lantos is convinced that albuminuria is very common among pregnant women : that it results from reflex irritation of the vasomotor nerves of the renal vessels, and that it has no pathological significance ; it may, however, be of value as a sign of pregnancy in making a differential diagnosis. Peptone has been found in the urine of pregnant women, and it is thought by some to be an evidence of the death of the fetus. Thomson 319 could not observe that peptone was characteristic of the pregnant condition, nor that it is a symptom of the presence of a macerated or a dead fetus. According to his researches, peptone appears intermittently without appreciable cause in the urine during pregnancy and after labor. Koettnitz, 320 who examined the urine in 31 cases of pregnancy, believes that peptone is not a sign of fetal death. Its presence seems to be a physiological phenomenon, becoming pathological only when this substance is found in excess. It has been found in complicated labor, when maceration of the fetus and severe visceral disease of the mother were present. The treatment of albuminuria and peptonuria during pregnancy consists in interfering with pregnancy and observing a rational hygiene. As most pregnant patients eliminate insufficiently, such forms of diet as agree best with the individual case should be enjoined. The peculiarities of the indi- vidual should be studied closely, and the whole range of therapeutic and medical art will frecpiently be taxed to aid the patient in solving the difficult problem of nourishing herself and her unborn child. Many specific treat- ments have been urged for albuminuria ; among them is the treatment by benzoic acid, sometimes combined with potassium bicarbonate. Various purgatives have been given in these cases, the best of these being those that do not introduce a large quantity of potassium salts into the blood of the patient. In general it may be said that the presence of albumin or of pep- tone in the urine of a pregnant patient is not of itself a pathological phe- nomenon, and it is only when the presence of albumin is associated with casts and deficient excretion, as indicated by a deficiency in urea, that the presence of albumin becomes an indication of disease. THE PATHOLOGY OF PREGNANCY. 277 Abnormal conditions of the mouth and teeth during pregnancy may occasion considerable distress and inconvenience to the patient. The gums frequently become abnormally soft, and a condition known as " white caries" is often seen in the teeth. The edges of the gums are thin, pale, somewhat shriveled in appearance, and retracted from the teeth. A prominent ridge along the free border, often of deeper tint than the surrounding membrane, is sometimes observed. In other cases the gums are reddish and are appa- rently softened, exuding a thin fluid or pus from around the neck of the tooth. Such a condition does not inqfly a want of cleanliness, but appears to be a passive congestion and transudation from the tissues. It has been shown by Elliott * 21 and others that this condition of caries in the teeth results from the altered secretions in the oral and buccal cavities. The secretion of saliva is much increased, ptvalin often being absent. Early in the day the saliva is often of acid reaction, and this is thought to have a potent influence upon the development of caries of the teeth. This disorder is sometimes known as "brown caries" when extensive discoloration of the teeth is pres- ent. The margins of cavities in these cases are black. A line of brownish discoloration sometimes occurs upon the upper incisors or the canines ; the enamel is opaque. This form of caries generally begins in the region of the bicuspids of the upper or the lower jaw, and is usually found among patients of the lower classes. Softening of the dentin of the upper bicuspids and molars is sometimes observed, apparently because the bicuspids are the teeth against which fluid is most forcibly ejected in the emesis of pregnancy; they are also in contact with the tongue at rest. General softening of the teeth without actual decay, and loosening of the teeth in their sockets from par- tial absorption of the alveolus, are also observed. White or soft caries often occurs without apparent cause in patients evidently well nourished, and resembles osteomalacia in its pathology. Affections of the nerves of the face and the teeth often accompany the structural conditions mentioned. By some, altered nervous conditions in these parts are referred to pathological conditions in the mucous membrane of the stomach. Occasionally pain in the mouth and teeth is purely reflex from the uterus, as in a case described by Garrettson, in which pain oc- curred in a carious tooth. Its removal brought no relief, but the healing of an ulcerated cervix uteri caused the pain to disappear. The treatment of these conditions consists in giving proper attention to the general state of the patient. Locally, potassium chlorate and potassium bromid are useful when the gums are irritable. Powdered boric acid may be applied to the teeth with a soft brush, or equal parts of charcoal and pre- cipitated chalk may be used for short periods. In reflex pain occurring in sound teeth, a blister applied over the fourth or fifth dorsal vertebra has been of use. Absolute alcohol and collodion may be painted over a tooth attacked by soft caries "When carious cavities occur, they should be filled, care being taken to cause the patient as little distress as possible ; the filling should be of a non-irritating character. When a tooth gives rise to severe suffering 278 AMERICAN TEXT-BOOK OF OBSTETRICS. during pregnancy, there are many reasons for advising its removal — preg- nancy has been interrupted as the result of such distress, and the presence of continued pain has an undoubted influence upon the development of the child. Exophthalmic goiter and simple goiter may develop rapidly during pregnancy, and by the associated changes that occur in the circulation may result disastrously to the fetus. Thus, in a case reported by Haberlin, 322 the rapid development of exophthalmic goiter was accompanied by premature separation of the placenta, with death to the fetus at eight months. The termination of labor was followed by immediate cessation of the develop- ment of the goiter. In severe cases such patients become very nervous, the hands tremble violently, palpitation of the heart and a sense of constriction about the throat are present, and considerable emaciation. Vomiting also is a symptom in well-marked cases. Although palliative treatment may relieve these patients temporarily, if the symptoms are urgent, the removal of the goiter should promptly be undertaken. Abnormal conditions of the blood are not very infrecptent. The normal condition of the blood during pregnancy in ill-nourished women is that of temporary anemia, which soon gives place to a development of physiological plethora and hyperemia. It has been shown by Dudner 323 and others that as soon as the balance of nutrition becomes established a steady increase in the number of corpuscles and the amount of hemoglobin may be observed. Narse 324 found the specific gravity of the blood during pregnancy to be 1025. The amount of fibrin increases, whereas the quantity of salts and hemoglobin diminishes. Winckelmann 323 found that as pregnancy advances the quantity of hemoglobin increases. Schroeder 32c considers anemia in pregnancy as an exception and as a pathological condition; neither he nor Meyer 327 ob- served a great decrease in hemoglobin or in corpuscles. The observations of Ingersleff, 328 Fehling, 329 and Meyer 330 upon the comparative composition of the blood in the pregnant and non-pregnant show that in the former the number of red corpuscles and the amount of hemoglobin is slightly decreased during early pregnancy. Anemia in the pregnant is produced by the same causes that influence the non-pregnant. Its recognition is effected by the same methods of exam- ination and diagnosis employed in the study of internal medicine. The con- dition of anemia complicating pregnancy was early recognized by American phvsicians, whose contributions to the literature of the subject are among the earliest. Cazeaux and the French school ascribe to anemia many of the, disorders of pregnancy. A curious aversion to the treatment of anemia during pregnancy by methods usually employed in the non-pregnant is shown in the records of a malpractice suit reported to the Obstetrical Society of Lon- don, in 1871, by AVoodman, in which a physician was sued for using ammo- niocitrate of iron in the treatment of this condition. It was claimed that he had thus produced abortion. The verdict of the society was in favor of the physician. Gusserow 331 reports 5 cases of extreme anemia in the preg- THE PATHOLOGY OE PREGNANCY. 279 nant state. The eighth month seemed the period most favorable for the development of this complication. Bischoff and Biermer report cases of oligemia and anemia with cachexia about this period. 332 Cameron's excellent description of leukemia during pregnancy 333 includes a case with a marked family history of leukemia. Sanger 334 reports the case of a leukemic mother who bore a healthy child, and also of a healthy mother who gave birth to a leukemic child. Davis 335 reports the case of a multigravida seized with hematogenic jaundice. Examination of the patient's blood revealed the presence of pernicious anemia. The blood of the fetus was found to be normal. Under treatment, her condition improved greatly after delivery. Although it is possible for these patients to bear healthy children, still pregnant women suffering from various forms of anemia and leukemia are subject to dangerous complications as pregnancy advances and as the patho- logical condition of the blood becomes pronounced. Important symptoms are epistaxis, hematemesis, and melanemia, with the development of a pur- puric condition. Laubenberg 336 has drawn attention to the severity of this complication and to the almost inevitable interruption of pregnancy, and he urges the early induction of labor as the duty of the physician. The most serious condition of the blood attacking the pregnant patient is purpura hcemorrhagica. Its occurrence and severity in pregnant women are explained by the sympathy existing between the utero-ovarian and the tegu- mentary systems of the body. This nervous connection is often observed in the skin eruptions that accompany disorders of menstruation. As has been shown by Immermann, the complication is sporadic in pregnant patients, and it occurs without regard to family history or to previous condition. Phillips m collected cases illustrating the absence of a previous history of hemophilia in these patients. In some of them hard work and insufficient nourishment seem to have produced the. disorder. Profound mental dis- turbance has been followed occasionally by this condition. In Phillips' case the child showed no symptoms of purpura, and the mother recovered rapidly after labor. Kaezmarsky M8 reports a case in which severe sacral pain during pregnancy was the earliest symptom. The birth of a dead fetus speedily followed, and the mother perished from hemorrhage. Dohrn reports twin pregnancy with this complication, with severe postpartum hemorrhage and death. Both these patients had previously been healthy. Wernicke, Reck- linghausen, Hanot, and Luzet offer evidence that seems to prove, on the one hand, that the disorder is a form of infection by bacilli ; on the other hand, the cases described by Dohrn m do not point to this condition as causative. The immunity of the fetus in these cases is inexplicable and of interest. Microscopical study made of the blood in this complication by Gibbon dur- ing the height of an attack of purpura showed that the red corpuscles contained numbers of black granules massed together in some of the cells. These bodies increased as the disorder became severe and diminished in con- valescence. The corpuscles numbered over 5,000,000 in a cubic millimeter early in the disease, this number being greatly diminished as the disorder 280 AMERICAN TEXT-BOOK OF OBSTETRICS. progressed. The white corpuscles became excessive, and the hemoglobin fell to 30 per cent., afterward rising to 60 per cent. The treatment of anemia and leukemia complicating pregnancy consists in securing thorough elimination, and in the employment of those forms of treatment found useful in the non-pregnant patient. Osier 340 obtained good results from the persistent use of arsenic, the free use of iron, the inhalation of oxygen, systematic and forced feeding, and, of great importance, the correction of the condition of gastro-intestinal catarrh so often found in these cases. The patient's strength should be conserved in every possible manner. Should purpuric eruption develop with hemorrhages, antiseptic dressings must be applied over these areas ; bichlorid of mercury should not be employed, the susceptibility of anemic pregnant patients to mercurial poisoning being a contra-indication to its use. Bichlorid of mercury should be given in minute closes when a possible syphilitic taint is suspected as a complication. The prompt induction of labor is indicated in cases in which the disorder steadily increases in severity, although this procedure, when the patient is in a critical condition, is useless and unjustifiable. If the induc- tion of labor is decided on, it should be done promptly and while the patient still has sufficient strength to justify the hope of recovery. The influence of pregnancy upon the alkalinity of the blood has been studied by Blumreich. 341 He finds that the difference in the alkalinity of the blood occasioned by pregnancy is less in mankind than in animals. The increased alkalinity is not due especially to an increase in the red blood- corpuscles. This increased alkalinity progresses steadily throughout preg- nancv, and in some cases is accompanied by a low specific gravity. In 4 cases alkalinity diminished markedly after the birth of the child. In contrast with those patients who are pregnant, the low alkalinity in the non-pregnant is very marked. Cardiac disease complicating- pregnancy is not infrequently observed. In those patients who are well nourished slight cardiac lesions frequently remain undetected during pregnancy and give rise to no embarrassment at labor. A physiological hypertrophy of the heart occurring during pregnancy is well described by Larchner, who found hypertrophy of the left ventricle in pregnant women. Other observers assert that this hypertrophy is asso- ciated with dilatation of the right heart. Istria 343 and others maintain that pregnancy often induces endocarditis, and various observers have noted the development of endocarditis after repeated parturition. The most fatal of these lesions in the pregnant patient is mitral stenosis. Marshall i43 and Duckworth demonstrated the remarkable preponderance of this form of heart disease in women. Direct cardiac symptoms are comparatively few, consisting of palpitation, and at times of pain and depression. Bronchial catarrh is generally observed. The want of concurrence between the cardiac systole and the impulse given by the pulse-wave is an interesting and important diagnostic point in these cases. Cases reported by Fritsch, Budin, Macdonald, and Malherbe illustrate the occurrence and fatal termination of THE PATHOLOGY OF PREGNANCY. 281 this disorder. Death occurred as the result of this lesion in 9 out of 14 cases reported by Macdonald. Of 13 cases seen by Porak, 8 proved fatal. In 19 cases observed by Remy 11 were fatal. In double mitral lesion 7 out of 8 of Hart's cases perished. In one-half of the cases recorded pregnancy was interrupted without interference. Half of these patients died and half of them recovered. The predominance of pulmonary symptoms in mitral stenosis should be borne in mind in making a diagnosis and in instituting treatment. While the mortality of pregnancy complicated by mitral stenosis is more than 50 per cent., aortic lesions give a mortality of 23 per cent. Mitral insufficiency is accredited with 13 per cent., whereas in complex lesions of the heart a mortality of 50 per cent, is a conservative estimate. The prognosis for the continuance of pregnancy and for the life of the child is distinctly unfavorable. Mackness 344 reports a case of pregnancy compli- cated by aortic and mitral disease in which labor was induced, and partial recovery ensued. The patient became so prostrated by persistent emesis and paroxysms of oppression during the latter portion of her pregnancy as to require vigorous stimulation. The emesis and paroxysms of oppression were relieved by the administration of amyl nitrite. Merklen 345 reports an illustrative case in which pulmonary tuberculosis was associated with stenosis at the mitral orifice. Dilatation of both sides of the heart was present, with general anasarca and exaggerated pulmonary congestion. Venous stasis in the kidneys was well pronounced. Pulmonary hemorrhage occurred and proved a temporary relief to the patient. Pinard,** 6 in describing valvular heart disease in pregnancy, does not believe that pregnancy in itself predisposes to heart-lesions. In women who have cardiac disease and who become pregnant, compensation is established if the kidneys are sound. In treating these cases absolute rest, milk diet after the fourth month, and infusions of digitalis have been used successfully. If syncope and complications arise, he urges that the uterus be emptied and that the patient be bled. Hemoptysis complicating pregnancy may be due to simple pulmonary congestion in cases of valvular heart disease, or may result from disease of the parenchyma of the lung, most commonly tubercular. Martin U1 describes the case of a patient, four months pregnant, who suffered from obstinate and persistent hemoptysis. There were pulmonary signs of consolidation anteri- orly below the right clavicle. Hemorrhage occurred at about the time when the patient would have menstruated had she not been pregnant. Epistaxis subsequently developed, and later a profuse red rash, resembling that of scarlatina, covered the body. This rash gradually faded, and was not attended by fever or any signs of other complication. Pulmonary symptoms improved slowly, especially under treatment by a succession of blisters upon the chest, which gave marked relief. The patient recovered completely and the pregnancy terminated normally. Hemorrhage from the Uterus. — The fact that profuse hemorrhage from 282 AMERICAN TEXT-BOOK OF OBSTETRICS. the uterus may occur during pregnancy and the patient yet go on to the end of o-estation is well illustrated in a case described by Robertson. 348 His patient was a multigravida who had several hemorrhages so severe as to lead to the belief, on each occasion, that abortion had occurred. Pregnancy continued to a successful termination. Internal uterine hemorrhage is observed as a complication in patients suf- fering from nephritis during pregnancy. Symptoms of shock and acute ane- mia may be present to such an extent that the presence of placenta prsevia has been suspected in these cases. Schauta m reports the case of a woman, aged forty-four, who had borne 9 children, and in whom the occurrence of pro- fuse hemorrhage led to a diagnosis of placenta prsevia. Although the patient was not in labor, the os was dilated sufficiently to ascertain the absence of placenta prsevia. Transfusion by normal salt solution was performed imme- diately, and when the patient rallied, the child, which was dead, was extracted by craniotomy. A large quantity of clotted blood was found in the uterus and vagina. The patient succumbed from the hemorrhage shortly after delivery. The postmortem examination revealed chronic nephritis as the only complication accounting for the condition. Winter observed 3 similar cases in Schroeder's clinic. 3. Acute Infections During Pregnancy. The condition of pregnancy renders the patient peculiarly liable to the rapid development of infective germs. The body of the pregnant woman presents that condition of plethora and hyperemia in the viscera that invites the growth of bacteria. It is not difficult, then, to understand why these complications of pregnancy are among the most severe. First among these disorders may be considered those in which the infection usually gains access to the body through the genital tract. Among such disorders are gonorrhea, syphilis, and cancer. Gonorrhea is by no means an uncommon complication of pregnancy, and in an ignorant woman no intelligent history attracting the attention of the physician to the condition present may be afforded. The complaint of diffi- culty in micturition and of burning and irritant discharge should, however, occasion an examination, when specific vaginitis may be detected. The symptoms and treatment of this disorder in the pregnant are essentially the same as those in the non-pregnant, but the pathology of the condition is more complex and of greater import. Not only may the gonococci infect the mucous membrane of the vagina, and possibly cause abscess of Bartho- lin's glands, with occasional acute inflammation of the rectum and the sur- rounding tissues, but the endometrium also may be attacked, and even the fetus may be infected in utero by the gonorrheal virus. Children have been born with gonorrheal ophthalmia, and under circumstances that precluded the possibility of infection during birth. Such infection, however, is of comparatively slight importance when compared with the clangers arising to the mother from the development and retention of gonorrheal infection in THE PATHOLOGY OF PREGNANCY. 283 the tissues about the uterus and in the tubes and ovaries. The entire genito- urinary tract of the mother is liable to such infection, the consequences of which may not become apparent until some time after delivery. Thus, in the writer's experience a patient perished from the sudden and acute sep- tic infection occasioned by the spontaneous rupture of a small gonorrheal ovarian abscess occurring two weeks after delivery. This patient's puerperal period had apparently been normal, and the infection must have been received before or during pregnancy. The same observer witnessed death from nephritis in which the genito-urinary tract had been the seat of gonorrheal infection during pregnancy. In this case the tubes and ovaries escaped, but the bladder and kidneys showed abundant infective germs. The presence of gonorrhea as a complication of pregnancy should lead to prompt anti- sepsis of as much of the genital tract as is accessible. If the bladder is invaded, it, too, should be subjected to the same thorough antisepsis. At the time of labor all possible precautions should be taken to avoid violence to the uterus or its appendages that may set free retained gonorrheal poison. During the puerperal period the occurrence of septic inflammation in and about the uterus should be treated promptly by intra-uterine antisepsis, or by abdominal incision as soon as possible. It is folly to treat the insidious ravages of gonorrhea in the connective tissue, the peritoneum, and contents of the pelvis occurring after labor by any but prompt surgical measures. Exploratory abdominal incision is far more conservative in these cases than delay. Cumston ^° reviews the literature of the puerperal state as affected bv gonorrhea, and concludes that no definite symptomatology for a gonorrheal process during the puerperal period has been clearly described. Gonorrhea does not appear to produce fever if the process does not extend above the internal os, and some describe cases in which a gonorrheal catarrh of the cervix extended to the endometrium without serious symptoms. If fever does occur, it may take place as early as the third day. Authorities agree that gonorrhea runs a milder course in many cases during the puerperal period than in non-puerperal patients. As regards the result of gonorrhea, a pyosalpinx, if present in one tube only, will not interfere with pregnancy ; sterility is due largely to endometritis or salpingitis. Cumston reports 5 cases of gonorrhea complicating the puerperal period. In 1 patient a mild gonorrhea during pregnancy was followed by fever and exudate in the puer- peral period. Both disappeared, and the child escaped infection. In the second case the patient was infected soon after parturition, and the symptoms subsided after curetting the uterus and applying carbolic acid. The child also escaped. In the third case thrombosis of the veins in both lower extremi- ties occurred, with a mass extending across the pelvis and finally breaking down with high fever. Posterior vaginal colpotomv was performed, liberat- ing thick, yellowish-green pus. Total abdominal hysterectomy was per- formed later for severe pain and rectal symptoms. The patient made a fair recovery. In the fourth case the right knee-joint was swollen and painful, 284 AMERICAN TEXT-BOOK OF OBSTETRICS. and the parametrium was thickened and the uterus retroverted. The patient made a tedious recovery. Syphilitic infection during pregnancy in many cases runs the usual course of this disorder, and in others it assumes peculiar malignancy. Patho- logically speaking, the virulence of syphilitic infection in pregnancy depends not only upon the patient's powers of resistance, but also upon septic germs that may be associated with the bacillus of syphilis. Some of the most malignant types of puerperal sepsis are observed in patients who become syphilitic at conception or during pregnancy. In these patients the syph- ilitic eruption is so masked and exaggerated by the septic element present as to occasion great difficulty in diagnosis. The writer recalls a case of this sort in which close study by Kaposi was necessary to differentiate between an acute syphilitic exanthem and septic infection. Hirigoyen m describes the occurrence of syphilis in 34 patients, who comprised 5 per cent, of the total number of pregnancies under observation. Other statistics seem to indicate that in large cities this percentage is the usual one in pregnancy. The influence which pregnancy exerts upon women already syphilitic has been described by Fournier, who laid down the maxim that a syphilitic woman who becomes pregnant is much more likely to abort than is a preg- nant woman who becomes syphilitic. The duration of the syphilis exercises a very distinct influence upon the prognosis of the pregnancy : the longer the woman has been syphilitic before the pregnancy occurs, provided she has not been subjected to efficient treatment, the graver is the prognosis for the continuance of the pregnancy and the life of the fetus. The prognosis of pregnancy is also very serious the earlier in the pregnancy the infection occurs ; thus, the majority of pregnancies complicated by syphilitic infection occurring during the first four months result in the death of the fetus. When infection occurs from the fourth to the sixth month of pregnancy, 50 per cent, of children are lost. During the last three months of pregnancy the complication of syphilis results in the death of less than half of the children. The general fetal mortality in syphilis is, under the best circum- stances, 75 per cent. The mother's health in pregnancy complicated by syphilis is liable to rapid deterioration if the syphilitic process be acute. The stimulus of preg- nancy seems to facilitate the spread of the poison and the various lesions that arise from it. To be efficient, antisyphilitic treatment should begin as soon as the infection occurs, and the earlier in the pregnancy such treatment is begun, the better are the results obtained. Local treatment of syphilitic lesions complicating pregnancy consists in thorough cleanliness and in the maintenance, so far as possible, of local antisepsis. Ulcers should be dusted with calomel and iodoform ; the parts should be kept thoroughly clean with antiseptic douches, and the discharges from syphilitic patients should be received upon absorbent material, which is then burned. Antisyphilitic medication is to be conducted in accordance with the therapeutics of this disorder in the non-pregnant. Mercury biniodid, mercury bichlorid, calomel, THE PATHOLOGY OF PREGNANCY. 285 gray powder, and the bichlorid hypodermically are all of use. Inunctions with mercurial ointment are found to be advantageous in many cases. In those patients with whom mercury does not agree potassium iodid in combi- nation with iodin may be used to advantage. The following mixture has proved efficacious in a number of cases : Tfy Iodin, gr. iv ; Iodid of potassium, giv; Compound syrup sarsaparilla, siv. Dose. — One teaspoonful after meals. Besnier 352 obtained good results with a pill containing ^ of a grain of mercury bichlorid with T ^ of a grain of extract of opium and -A- of a grain of extract of gentian rubbed up with glycerin. Equally important with the specific treatment of syphilis in pregnancy is the tonic treatment these cases demand. Well-ordered feeding, in which an abundance of fat, as in cod-liver oil or other forms, is included, and the per- sistent administration of iron, arsenic, nux vomica, and such substances as stimulate digestion, are of the greatest importance. The aim of the physician must not be simply to tear down diseased tissue, but to build up that which is sound. The results of such treatment are often most gratifying. The characteristic lesions of syphilis fade with great rapidity in these cases ; the patient, who may have aborted repeatedly, goes on nearly or quite to term, and a fairly well-developed and healthy child is born. On the other hand, neglect or inadequate treatment often results in sad ravages in the mother's tissues, ending very frequently in fetal death. Murray 353 draws attention to the pathology and diagnosis of syphilis during pregnancy and states that he has found inunctions of mercurial oint- ment the most efficient treatment. If seen before the third month, from 40 to 50 per cent, of cases were carried through pregnancy by this means. He drew attention to the fact that the first syphilid may appear ivpou the ton- sils. The child should be treated through the mother's milk and later by inunctions. Cancer complicating pregnancy affects the course of gestation chiefly in its local manifestations in the genital tract. In rare instances multiple sar- comata develop with great rapidity in various portions of the body, termi- nating in death by constitutional infection. In other instances cancer of the uterus by metastasis speedily reduces the patient to a condition of threat- ened collapse, often resulting in constitutional septic infection. In such cases the interruption of pregnancy is probably of little avail for the patient, except in so far as the malignancy of the cancerous process seems less acute if the uterus is emptied. Fehling 3 " 4 observed 5 cases of cancer of the cervix in 3000 cases of preg- nancy. In the early months of pregnancy he urges vaginal extirpation of the uterus, and in the later months Cesarean operation followed by amputa- 286 AMERICAN TEXT-BOOK OF OBSTETRICS. tion of the uterus with removal of the cervix through the vagina. He describes 5 cases treated after this method with as good results as the nature of the disease permits. Reckmann 3: ' 5 describes a method of operation in a case six months advanced and complicated by cancer of the cervix. The cervix was first thoroughly curetted and cauterized, and the broad ligaments were ligated with catgut. The uterus was drawn down, and the cervix was incised so as to split the uterus. The fetus and its appendages were then removed. The uterus was next retroverted and removed in the usual manner. An excellent result followed. Apparent recoveries from cancer sometimes puzzle the physician and lead him to question the accuracy of his diagnosis. Coe 356 reports a very inter- esting case in which a primipara, aged forty-two, had papillomatous disease of the cervix, for which curetting and the application of iron were employed by Reynolds. Microscopical examination of the mass removed resulted in a diagnosis of carcinoma. The patient became pregnant and was seen by Coe when pregnancy was four and a half months advanced, when she objected to the induction of abortion, as she hoped to save the child. When labor came on, a Barnes bag was inserted to soften the cicatricial ring. The head of the child, fortunately, was small, and the child was delivered by forceps. The patient made a good recovery. The uterus underwent perfect involu- tion and a portion of the cervix was excised, and no evidence of cancer found. The patient resumed her occupation. She reported about a year after, when malignant disease of the cervix was plainly evident. Vaginal hysterectomy was performed, and the upper fourth of the vagina also was removed. This patient apparently made a good recovery after the operation. Typhoid infection during pregnancy seriously threatens the mother's convalescence from labor, and frequently results in the death of the fetus. In a case described by Findlay 357 the patient's husband had been ill for some time with typhoid infection. Her pregnancy terminated at about the expected time, labor occurring with a temperature of 103° F. and a pulse of 140. The uterus contracted well, although intestinal peristalsis was active during labor and the patient had diarrhea, which subsided after delivery. ISTo milk was secreted, and the breasts gave no signs of activity. The skin of the child was shriveled, and after a few days it exhibited an eruption with bul- lous spots, the scars of which persisted when the child had reached adult life. Pregnancy is interrupted in these cases by continued high temperature, by hemorrhage in the endometrium or in the membranes of the ovum itself, and by a depressed condition of the maternal circulation, with asphyxiation, of the child. Kaminski, Zulzer, and Scanzoni observed interruption of pregnancy in two-thirds of their cases. The fact that the fetus may become infected by the transmission of the germs of typhoid through the placenta has been demonstrated by Giglio. 358 The latter examined carefully a fetus and its appendages born of a mother suffering from typhoid fever in an epidemic at Palermo. Pregnancy terminated forty-six davs after the begin- ning of the fever. Although the specimen appeared to be normal on casual THE PATHOLOGY OF PREGNANCY. 287 examination, cultures of the maternal blood demonstrated the presence of the typhoid germ, whereas cultures from the milk revealed bacteria closely resembling those obtained from a typhoid non-pregnant patient. The fetus and its appendages also contained typhoid bacilli. Boyd 359 reports a case in which premature labor occurred a week after the fever began. The patient finally succumbed after continued high temperature. The diagnosis of typhoid fever complicating pregnancy presents no espe- cial difficulty. Should the physician see the case during the puerperal period, it must not be mistaken for puerperal sepsis, nor should puerperal sepsis complicated by diarrhea be mistaken for typhoid fever. It will be remembered that in septic cases diarrhea is a not infrequent symptom. The treatment of typhoid fever during pregnancy should be directed to control- ling the temperature and to maintaining the patient's strength. The treat- ment of pyrexia by the bath and pack is especially suitable in these cases. The latter is most efficacious when the very energetic application of cold had a tendency to prostrate the patient. Xo fear need be felt regarding the induction of labor by treatment addressed to controlling the temperature, for it will not be such treatment, but its failure to modify the fever, that will bring about a premature ending of gestation. The fact that in many preg- nant patients suffering from typhoid the stomach is exceedingly irritable will lead the physician to abstain from the administration of drugs by the stomach so far as possible. Le Page 360 reports 8 cases of typhoid infection complicating pregnancy and the puerperal state. In many of these it was impossible, from the clinical phenomena alone, to say that puerperal septic infection was not present. The serum method of diagnosis gave positive results in each case. A number of the cases were found to have come from a locality where typhoid infection was epidemic. Others were sporadic cases whose place of origin could not be discovered. Le Page's paper calls attention to the value of the serum diagnosis in these cases. Erysipelas occurring during pregnancy is infrequent, and it is grave or mild according as it is or is not accompanied by other forms of septic germs. Facial erysipelas may occur in the pregnant patient and give rise to abortion without the development of puerperal sepsis. Such a result, however, is possible only when strict antiseptic precautions have been observed. Ery- sipelas of the genital tract — or of the lower extremities, in which case the infective germ gains ready access to the genital tract — results almost invari- ably in puerperal septic infection. The symptoms of erysipelas complicating pregnancy do not differ essen- tially from those of erysipelas in the non-pregnant patient. The treatment consists in carefully supporting the patient's strength, and in avoiding all unnecessary examinations and manipulations in the genital tract, as interference with this portion of the patient's body adds to the risk of infection. Smith 361 reports the case of a woman, six months pregnant, who injured her knee. Erysipelas developed in the thigh eight days after- 288 AMERICAN TEXT-BOOK OF OBSTETRICS. ward, and was followed by a large abscess burrowing beneath the muscles. Premature labor occurred at seven and a half months. The puerperal period was normal, and the child survived. In a recent case of facial erysipelas under the observation of the writer, the mother suffered but slight incon- venience from the infection, but gestation terminated prematurely, the child surviving. Erysipelas of the face and head seems to affect the fetus in many cases quite as markedly as erysipelas of the pelvic organs. Colin m reports a case of facial erysipelas at eight months' pregnancy. The fetus, prematurely born, showed upon the correspondmg portions of the head and face an edematous red swelling .that gradually faded, followed by descpiamation. Examination of the infiltrated tissues for erysipelas germs gave negative results. The child perished from multiple abscess in the kidneys. A simi- lar condition of the fetus has been described by Runge, Kaltenbach, and Stratz. Measles. — Of about the same relative virulence as erysipelas is the infec- tion of measles attacking the pregnant patient. The symptomatology of this disorder occurring during gestation does not differ essentially from that observed in the non-pregnant. If the bronchitis usually accompanying measles is severe, the incessant cough and movements of the abdominal walls thus occurring greatly increase the probability of abortion. At birth the child may exhibit an anomalous eruption or it may apparently escape. The prognosis of measles complicating pregnancy is to be based upon the severity of the infection, and especially upon the continuance of high temperature. The infection of measles may be transmitted from mother to child, as illustrated by a case reported by Lomer ; 363 the child perished from intestinal catarrh ; the mother recovered. The characteristic eruption appeared on the child's forehead and breast a few hours after birth. Gautier 364 found measles transmitted from mother to fetus in 6 out of 11 cases ; the maternal mor- tality of the 11 cases was 2. Salus 365 has collected 13 cases of measles complicating pregnancy, in which the pregnancy was interrupted in 10. The children born of mothers having measles did not, as a rule, show evidence of the infection, but hemor- rhage has been observed on the maternal aspect of the placenta, bringing about a premature separation and premature labor. On microscopical exam- ination, bleeding was found in the spongy layer of decidua, with great dilatation of the vessels. Jardine 366 reported 2 cases of measles occurring in puerperal women from the Glasgow Maternity Hospital. In 1 the puerperal period was normal until the seventh day, when measles appeared. The source of infection was traced to the house in which the patient lodged before coming to the hospital. In the second case the rash of measles was just beginning to appear in the first stage of labor. Labor was normal, and the child showed no signs of measles two weeks after its birth. He had seen the ease of a child suffering from measles who was placed in bed beside a woman delivered on the day THE PATHOLOGY OF PREGNANCY. 289 previous. The mother escaped, but the new-born child developed measles. In discussion a case was narrated in which a mother nursed a child having measles and scarlatina and herself remained immune. Scarlatina is a serious complication of pregnancy, and its virulence is apparent from the great promptitude with which it affects the fetus in utero. The fact that the germ of scarlatina is morphologically held by many observers to be identical with various forms of septic bacteria renders scar- latinal infection of grave import. An illustrative case is reported by Bal- lantyne and Milligan, 367 in which the infection occurred during the seventh month of pregnancy. Two days later gestation terminated, and the fetus was found to have scarlatina. In 21 cases of scarlatina occurring during pregnancy, Meyer 368 found it impossible to trace the medium of contagion. The incubation period was from three to five days. In 6 out of 21 cases the disease ran a mild course without complications. In 8 cases sepsis occurred, with 2 deaths. The resemblance of puerperal scarlatina to diphtheric infection of wounds was strikingly illustrated in Meyer's complicated cases. The interruption of pregnancy by scarlatina is well illustrated by Remy ; 369 abortion occurred at five months, the patient making an uncomplicated recovery. Variola resembles scarlatina in its infective energy and in the rapid- ity with which it is transmitted to the fetus. It possesses the fortunate distinction, however, of being susceptible to modification by vaccination. Whereas pregnancy renders the mother more liable to the infection of small- pox, in those cases in which variola occurs in women who have formerly been vaccinated the disease runs a comparatively mild and favorable course. \ T aceination should be performed unhesitatingly during pregnancy whenever variola is epidemic. Especial care should be exercised in procuring pure virus, and antiseptic precautions are necessary in performing the vaccination. There is abundant reason to believe that the fetus is protected by such vaccination. Pneumonia occurring during pregnancy is a serious complication for mother and child. The interference with respiration occasioned by the size of the pregnant uterus, and the unfavorable conditions under which the heart labors during pregnancy account in large part for the severity of the complication. Jurgensen, among 2475 women suffering from pneumonia, found 43 who were pregnant. Of this number more than half aborted. As in the other infections, the degree of fever present is of great importance in prognosis. The symptomatology of pneumonia in the pregnant does not differ from that of the disorder in the non-pregnant. It is observed, however, in preg- nant patients that embarrassment of the circulation is very often pi'esent, and that heart failure develops more rapidly than in the non-pregnant. Mann 370 reports the case of a woman, aged forty-two, with typical pneu- monia at eight months' pregnancy. The fetal heart-sounds ceased five days after the initial chill. Shortly after the crisis of the pneumonia the woman 19 290 AMERICAN TEXT-BOOK OF OBSTETRICS. was delivered with the aid of forceps. During labor the patient became cyanotic, and she was allowed to bleed freely from the umbilical cord; although an unfavorable prognosis had been given, the patient made an uninterrupted recovery. In this connection the writer reports the case of a young primigravida, aged twenty, who developed pneumonia when near the end of gestation. A temperature of 103° F. rapidly developed, and an acute pneumonic process, catarrhal in nature, was found over both lungs. The patient's distress and dyspnea steadily increased, and three days after the beginning of the pneumonia the child was expelled with three or four severe labor pains. The child was cyanosed, had fever, and after passing through an attack of pneumonia recovered. (Plates 20, 21.) Although the mother's urgent symptoms were relieved temporarily by labor, she perished of heart failure soon afterward. Examination of her urine during the pneu- monia and before her delivery showed the presence of albumin in appre- ciable quantity, and the proportion of urea was 1.2 per cent. Epithelium from the kidneys, with abundant crystals of oxalate of lime, was found on microscopical examination. The urine contained large quantities of bacteria of various kinds. The treatment of pneumonia complicating pregnancy is similar to that of pneumonia in the non-pregnant. The patient's condition is in no way improved by the induction of labor, and the occurrence of labor should often be made the occasion for depleting the circulation through controllable postpartum hemorrhage. Pneumonia complicating pregnancy offers more opportunities for depletion than does pneumonia in the non-pregnant woman, and symptoms of threatened asphyxia with profound cyanosis should be met promptly by this resource. Cupping gives great relief in these cases, and the hypodermic use of strychnin and atropin has proved of comfort to the patient. The complication is serious in proportion to the extent of lung tissue involved and the tolerance or intolerance displayed by the circulatory apparatus. The jwognosis of pneumonia occurring during pregnancy has been made the subject of study by Wallich, 371 who found that pneumonia interrupts pregnancy in one-third of all cases before the sixth month, and from the sixth to the ninth month in two-thirds of all cases. The maternal mortality varied from 50 to 100 per cent, of recorded cases, whereas the fetal mor- tality was 80 per cent. Cholera occurring during pregnancy well illustrates the severity of a pronounced infection with the pregnant patient. From a series of 10 cases Klautsch 373 describes two stages of the disease — one attended by copious evacuations from the stomach and intestines, the second by a period of intoxication or asphyxia. The patients were taken ill usually at midnight or early in the morning, and when temporary relief from the symptoms of col- lapse had been obtained by the injection of saline fluids, a typhoidal stage frequently developed, with active delirium, followed by deepest coma. 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S3 u — — Vr-~ w _ '/..■_'.'• U kra |m K <. i -•-^ "'K 11 -'• | -" if « h| - _ X >■ ^ | | ' ' w-i i | 1/ 8 -^^ 3 -j u "« »- 5 - --,---, ^ r X ? , • — " =3T ~~r ^s # Mi • E 1 t< . r 2 ^ c M=1 & I 1 ' i-li 4 Jill THE PATHOLOGY OF PREGNANCY. 291 irregular. Hemorrhage into the conjunctivae was often present. The fetus usually perished in these cases during the stage of intoxication. In the first stage of the disease the patients complained that fetal movements were exceedingly violent. It has been shown by Slaviansky, Tipjakoff, and Simmonds that the epithelium of the placenta is extensively diseased, and that hemorrhages and premature separation often occur. In cases in which the fetus died, it was usually expelled at the end of the stage of asphyxia and in the beginning of the typhoidal delirium. Instrumental delivery fre- quently was necessary. Postpartum hemorrhage rarely was observed, and when the mother survived, involution often proceeded promptly. The prognosis for the mother was as favorable as the prognosis in cholera in non-pregnant women. For the fetus the prognosis was exceedingly grave. The treatment of pregnant patients attacked by cholera is the treatment of cholera in the non-pregnant. No attention should be paid to the pregnant condition, other than to complete labor as rapidly as possible when it begins, and to secure good uterine contractions during and after the labor. A more unfavorable view of the prognosis for the mother is given by Galliard. In his cases the lactic acid method of treatment was employed extensively, with negative results. In mild cases a number of his patients recovered. Tetanus in Pregnancy. — Among the acute infections that attack the nervous system of the pregnant patient with great virulence tetanus is the most formidable. From our knowledge of infection it is rendered clear that the tetanus bacillus is the exciting cause of this complication. A predis- posing cause is to be found in the susceptibility that pregnant patients mani- fest during the first three months of this period. Indeed, the first half of gestation shows by far the greater number of cases of this infection. Teta- nus develops usually after some minor manipulation in the early months of pregnancy, and especially when abortion requires interference on the part of the physician. Thus, Vinay 373 in 106 cases found but 1 after craniotomy and 1 after Cesarean section. The infection is one of early pregnancy, and is not usually connected with parturition at term. Patients most likely to be attacked by the tetanus bacillus are multiparas above the average age, and those who have been living in damp and squalid lodgings. The direct conveyance of the infection has been noted by Henricius and by Anion. The latter, while treating a case of tetanus in the husband, infected the wife, who had aborted, during the manual delivery of the placenta. Tetanus is most frequent among pregnant patients in the tropics, where the condition of the soil is favorable to the growth of the infecting germ. An association of tetanus in pregnancy and the puerperal period with endometritis has been pointed out by Markus. 374 The treatment of tetanus in pregnancy is largely prophylactic. Bearing in mind the peculiar susceptibility of pregnant patients, especially during the first months, any minor operation or examination should be conducted with scrupulous antisepsis. When tetanus infection has occurred, but little can be done to save the patient. 292 AMERICAN TEXT-BOOK OF OBSTETRICS. Tetany daring pregnancy is a condition that is commoner than tetanus. It is characterized by tonic spasms beginning in the muscles of the extremi- ties, especially those of the hands. In severe cases spasmodic movements may extend over the entire muscular system. When not artificially pro- duced, the spasms are symmetrical. Attacks of tetany are not accompanied by loss of consciousness. Such seizures are intermittent and of short dura- tion. As a rule, recovery ensues, the spasms gradually becoming less fre- quent. Patients describe a tingling or a numb sensation of the extremity affected as preceding the spasm, and the same sensation follows the cessation of convulsive movements. If the main artery or the nerve of the extremity in which spasmodic movements are observed be compressed, these sensations, followed by spasm, may be induced. The application of cold tends to check the spasms of tetany. The flexor muscles, and especially the interossei in the hands and feet, are oftenest affected. The electrical reaction of the nerves in the affected region is much increased. The patient's general tem- perature is not affected. Any mechanical irritation of the peripheral nerves, such as tapping the trunk of the facial nerve in front of the ear, results in spasm. The disorder is generally sporadic and is rarely epidemic. It is most usually observed in women during the child-bearing period or during menstruation. Of 44 cases, Trousseau found 40 among nursing women. Kussmaul found transient albuminuria present, and Stiel observed glyco- suria. Dakin 375 reports the case of a multigravida of nervous temperament who, in the third month of her fourth gestation, was seized with frequent vomiting during the day. After this condition had persisted for eleven days she developed spasm of various muscles, preceded by numbness. The hands and feet assumed the posture seen in tetany — the flexors in contraction, and the interossei producing extension of the phalanges. The soles of the feet were hollowed by spasmodic extension. The affected muscles were somewhat painful. The condition extended to all the extremities, and vomiting was increased. On the second day of tetany the spasmodic con- dition became so severe as to give rise to intense suffering. The temperature was subnormal. The patient died of asphyxia, produced by spasm of the muscles of respiration, on the third day of the tetany. Trousseau recog- nizes o varieties of tetany, in accordance with the severity of the affection. He rarely observed a fatal result. Meincrt saw 5 cases end in recovery. In 1 of these cases the patient suffered from tetany in successive pregnancies. In 1 of Meinert's cases the thyroid gland was removed. Between the attacks of tetany the patient is to all appearances normal. In non-fatal cases the pregnancy is not interrupted nor is labor influenced, the spasms ceasing as soon as the uterus is emptied or within a few days. In differentiating tetanus from tetany in pregnant patients it is well to remember that in tetanus the spasm begins in the face or the neck and advances centrifugally, with opisthotonos. In tetany the spasm begins in the extremity and advances centripetally, producing the characteristic posture of the extremities. In tetanus the spasm is constant : in tetany it is inter- THE PATHOLOGY OF PREGNANCY. 293 mittent. The great fatality of tetanus and the comparative mildness of tetany are to be kept in mind. Tetanus is most frequent among men, who by virtue of their occupations are exposed to infection from the tetanus bacillus. Tetany is peculiarly common among pregnant "women or women in a depressed and susceptible condition. "With accurate observation the dif- ferential diagnosis between the convulsions of toxemia and those of tetany is not difficult. The treatment of tetany in pregnancy consists in giving the patient such sedatives and anodynes as shall procure sleep. Vomiting or diarrhea requires especial attention, as these induce a condition of debility that favors a fatal issue. Abortion should not be induced in tetany, as the disorder rarely fails to yield under intelligent medication. Thomas 3713 reports the case of a patient seen in the Johns Hopkins Hos- pital in her seventh pregnancy. The attacks of tetany began in the second pregnancy and recurred at the fifth month in each case. They were ushered in with a tired, aching sensation in the hands, the fingers later becoming stiff and clenched, the feet also being stiff and drawn. In severe attacks the pain was intense, and the fingers were so tightly closed that the nails cut through the skin, the arms being stiff and held close to the chest, and the hands blue and swollen. Other muscles of the body were also involved at times. The nerves responded with unusual readiness to both electric cur- rents, and the deep reflexes were exaggerated. The disease had lasted twelve years, during the second half of her pregnancies. The patient was free while nursing a child, but when menstruation reappeared, the disease returned. Thomas has collected 32 cases hitherto reported. Certain poisons, such as chloroform and alcohol, have been said to cause the disorder, and the removal of the thyroid gland may produce it. Child-bearing is known to favor its occurrence. In Weiss' case a goiter was removed entire from a woman four months pregnant, and immediately after the operation tetany appeared. In Gottstein's case tetany developed during pregnancy and was accompanied by hypertrophy of the thyroid gland. This patient improved greatly on transplantation of the thyroid and on the administration of thyroid extract. 4. Accidents and Surgical Operations During Pregnancy. Although the nervous system of the pregnant woman is remarkably sus- ceptible in many ways to reflexes, there is sometimes exhibited a very decided power of tolerance to severe injury or surgical interference. The variability of this resisting power — some patients showing a remarkable tolerance, whereas others display but a feeble power of resistance — depends not only upon the condition of the nervous system in these cases, but also upon the normal or abnormal state of the uterus and its lining membrane. In a woman in perfect health a quite severe injury or a surgical shock may be received without interrupting pregnancy, whereas if the patient possesses an extraordinarily susceptible nervous system or if the endometrium is in a 294 AMERICAN TEXT-BOOK OF OBSTETRICS. diseased condition, interruption is almost inevitable. Accompanying the premature termination of gestation serious hemorrhage, shock, and greatly increased susceptibility to septic infection are observed. Those operations most frequently demanded during pregnancy are surgical procedures undertaken for some condition of the uterus or of its appendages. Thus, carcinoma of the uterus demands the complete extirpation of that organ as soon as the diagnosis is made, irrespective of the existence or the period of gestation. One of two methods of operation may be chosen — extirpation through the vagina when the diseased uterus is small, or the com- plete removal of that organ through the abdominal cavity when its size pre- cludes the possibility of its removal through the vagina. In either instance the prognosis for the recovery of the mother is by no means hopeless if the operation be performed before her strength has been reduced by the develop- ment of cancerous cachexia. It is sometimes possible to combine the two methods of operation, as was done in an interesting case reported by Stocker, 377 in which a multigravida was found to have cancer of the cervix. At the sixth month of pregnancy the cervix was removed through the vagina, and complete extirpation of the uterus was accomplished by opening the abdom- inal cavity. The patient made a good recovery from the operation. Myomotomy and myomectomy during pregnancy are demanded for fibroid tumors complicating the development of the pregnant uterus. The choice of operation will depend upon the size and location of the tumor, and upon the amount of pressure that it exercises or that it will cause upon the growing uterus. Flaischlen 37S found 2 fibroid tumors behind the uterus in the case of a patient three months pregnant : one tumor sprang from the cornu of the uterus, the other from the base. Both tumors were ligated and removed without interruption of pregnancy. The influence of myomatous tumors upon pregnancy has been thoroughly reviewed in Hofmeier's paper. 379 He finds sterility present in 10.8 per cent, of those having such tumors. He believes that sterility in such patients very often is not clue to the presence of a fibroid. He tabulates 19 cases of fibroid complicating pregnancy, and gives the results of their treatment. In general, he does not find the high percentage of complications present in these cases that some have reported. In choosing a method of treatment in labor complicated by fibroid tumor Pobedinsky 3S0 carried out an interesting proce- dure in the clinic at Moscow. The patient was a multipara in labor •who had a fibroid tumor developed in one of the broad ligaments. The child was alive and in good condition. The prospect for preservation of the child, the removal of the tumor, and the preservation of the uterus seemed favorable. Accordingly, abdominal section was performed, the child and its appendages were extracted, and the tumor was then removed from the broad ligament. The parts were joined by deep sutures, and the uterus was closed. The patient made a good recovery, complicated by infiltration of the broad liga- ment from which the tumor had been removed. This gradually disappeared. Leopold 3S1 reports a case of pregnancy complicated by myoma in the THE PATHOLOGY OF PREGNANCY. 295 anterior wall of the uterus. Abdominal incision was performed, and a some- what calcified tumor was removed. This was followed by considerable hem- orrhage, which was checked by incising a portion of the capsule and packing the cavity with iodoform gauze. Twenty-six deep and superficial catgut sutures were required to close the bed of the tumor. Pregnancy continued, and the patient was subsequently delivered at full term in normal labor. Leopold adds a table of 31 cases, with the results in each. When multiple myomata are present and the uterine wall is extensively changed, it is impossible to preserve the uterus, and incision into the uterine wall may be followed by considerable hemorrhage. Pagenstecher 332 reports the case of a primigravida who had multiple myomatous tumors. The effort to remove one that had a pedicle was followed by rupture of the substance of the uterus with free hemorrhage. It was necessary to remove the uterus, leaving a stump of cervix that was freely cauterized. The patient made a good recovery. On examining the tissue removed multiple myomata were present, together with an embryo of six weeks. The disadvantage of treating a pedicle outside the peritoneum is exemplified in a case reported by Werder. 383 He had removed a subperitoneal uterine fibroid with a short, thick pedicle by the extraperitoneal application of the elastic ligature. A sinus remained at the lower angle of the abdominal wound. Pregnancy occurred, and at the end of the fourth month hemorrhage took place through the abdominal fistula, which had become considerably larger. This recurred at irregular intervals, causing anemia. Labor was three weeks premature, and a living but poorly developed child was delivered by forceps. The placenta was adherent immediately under the abdominal fistula and required manual separation. The patient recovered. The abdominal fistula closed very slowly, and on several occasions menstruation occurred through the fistula. Amputation of the pregnant uterus is an operation performed in con- tracted pelvis. It may be performed at any period of gestation when the interests of the patient demand hysterectomy. The method of procedure best adapted to such cases is abdominal incision, ligation of the ovarian and uterine arteries, and amputation of the uterus, leaving a short stump to close the vagina, and stitching the peritoneum over the surface of the stump. Tumors of the ovary are justly considered serious complications of pregnancy. Dsirne 384 collected 135 cases in which pregnancy was compli- cated by tumor of the ovary. He finds that the gravity of this complica- tion disappears as pregnancy advances. In this complication there is rarely any reason for delay in removing such a tumor by abdominal incision. Puncture of an ovarian cyst and the artificial interruption of pregnancy are to be avoided : they are to be considered only in the light of procedures adapted to an unforeseen emergency. The preferable time for operation in such cases is before the fourth month of gestation. The fetus is less likely to be lost when operation is performed in the third or the fourth month. This complication demands operative treatment, and no period of pregnancy contraindicates ovariotomy. Double ovariotomy during pregnancy may be 296 AMERICAN TEXT-BOOK OF OBSTETRICS. performed successfully, as exemplified by Polaillon. 385 His patient, aged twenty-three, had a large ovarian cyst upon one side and a diseased ovary upon the other. Her general condition at the time of operation was not promising, and numerous adhesions complicated the removal of the tumor. Operation was performed in the third month of gestation. Pregnancy con- tinued, and terminated in normal delivery with a healthy child. The patient's pulse and temperature showed little reaction following operation. Kreutz- man 3S6 reports 2 cases in which ovarian tumors were successfully removed from pregnant patients without interrupting gestation. One of these women, who was in her second pregnancy, had gone two weeks over time. She had a laroe cyst in the left ovary, the pedicle of which had recently become twisted, the contents of the tumor being tinged with blood. The theory that advocates removal of tumors of the ovary during preg- nancy as soon as their presence is ascertained has much to commend it. Isirne 3S7 has collected 23 operations without a death. The prognosis is best for the mother in the second, third, and fourth months of gestation, and for the child in the third and fourth months. The dangers that pregnancy adds to the presence of the tumor are rapid growth and torsion of the pedicle. Kreutzmann 388 removed, at the second month of pregnancy, a multilocular ovarian cyst of the left side whose pedicle was twisted about half from out- side to inside. This condition had evinced no symptoms and was not diag- nosticated before the operation. Had the tumor been allowed to remain as pregnancy continued, gangrene of the cyst must have supervened. That tapping is one of the worst methods of treatment is well illustrated by a case reported by King. 3 * 9 The patient had been in labor for some time, and the pelvis was filled by a tumor that prevented the descent of the head. The tumor was punctured through the rectum ; fluid escaped, and a dead child was spontaneously expelled. The patient made an apparent recovery. Six weeks after parturition she was again admitted to the hospital with a large abdominal tumor. Fever and emaciation were present, and the diag- nosis of pulmonary disease had been made. During the examination the tumor burst into the rectum, and about a gallon of offensive yellow pus was removed. The cavity w-as drained, and the patient recovered. The tumor undoubtedly became infected at the time of the rectal puncture, and the patient's recovery is remarkable. This case is in distinct contrast to the excellent results of abdominal section with entire removal of the tumor. That an ovarian tumor may contain the encysted remains of tubal gesta- tion is illustrated by Rosenwasser's case. 390 This patient had had a ruptured ectopic gestation with hematoma, and, in addition, a tumor that distended the rectovaginal pouch, and was found upon aspiration to be an ovarian cyst. On abdominal section the tumor was removed and also the contents, the ectopic fetus. The patient made an excellent recovery. Affections of the Fallopian tubes may call for operative interference during pregnancy. The prognosis in these cases is equally as good as that of operation for the removal of ovarian tumors, and the reasons for prompt THE PATHOLOGY OF PREGNANCY. 297 interference are quite as cogent. In hematosalpinx it is often impossible to make a differential diagnosis between this condition and ectopic gestation. This fact is well illustrated in the exjjerience of Doran, 391 who removed both tubes and ovaries from a patient who had suffered from attacks of violent pelvic pain at various intervals. One tube had ruptured, allowing the free escape of blood ; the tube contained a structure in the midst of a clot resem- bling an aborted ovum. It is probable that double ectopic gestation existed. The patient made an uninterrupted recovery. Accidents and Injuries. — As regards tolerance to general accidents and injuries during pregnancy, American observers have noted the remarkable tolerance displayed by negro women under such circumstances. Thus Tif- fany 392 reports the case of a negro woman who fell, striking the abdomen violently against the edge of a tub. Peritonitis with retention of urine fol- lowed. With careful treatment, however, the patient recovered without the interruption of pregnancy. Stab-wounds of the abdomen occurring during the pregnant period, but without interrupting gestation, are reported by Belin, 393 in whose patient a considerable portion of the epiploon protruded from the wound. Sloughing ensued, but the patient made a good recovery. Richard m describes the case of a pregnant woman who fell, lacerating the abdominal wall near the umbilicus. A mass of intestine as large as a man's head protruded. The woman was at term, and normal labor, from which the patient recovered, ensued soon after. Harris 395 describes the case of a woman six months pregnant whose abdomen was torn open by the horn of a bull. Although omentum and intestine protruded, pregnancy was uninter- rupted. The viscera were replaced, and the wound was closed by suture. A similar case in which a lacerated wound of the abdominal wall 5 inches long was made is reported by Corey. 396 In this case the pregnancy had reached the third month. The patient went two hundred and two days longer and had a normal labor. Obstruction of the intestine demanding abdominal section is described by Rydygier, 397 who operated upon a patient in the sixth month of gestation who showed symptoms of strangulation for seven days. Recovery ensued without abortion. In fractures in pregnant women retarded union is reported by Petit 39S and others. An interesting operation for stone in the bladder upon a patient eight months pregnant is reported by Keelan. 399 The calculus, which weighed 12J- ounces, was successfully removed without the interruption of pregnancy. Gunshot wounds not penetrating the uterus do not commonly interrupt gestation. A remarkable instance is cited by Prozowsky. 400 The patient was wounded in many places by pieces of lead pipe fired from a gun but a few feet distant. So far as gestation was concerned, neither she nor her child suffered from the accident. A pistol-shot wound of the lung occurring during pregnancy, followed by hemorrhage and shock, is reported by Ban- croft. 401 A healthy child was born at term. A remarkable case is described by Lihotzky, 402 which illustrates the fact 298 AMERICAN TEXT-BOOK OF OBSTETRICS. that the changes occurring in pregnancy may bring into active irritation a foreign body that had previously been inert; he describes the case of a patient perishing from rapid peritonitis in the eighth month of pregnancy. At the autopsy the duodenum was found perforated by a spoon that the patient had swallowed two and a half years previously — an occurrence almost forgotten. The remarkable tolerance shown by the pregnant woman to direct injury from mechanical causes is illustrated in a case reported by Milner. 403 The woman, who was in the sixth month of pregnane}', was accidentally shot through the abdominal cavity and the lower part of the thorax, the missile penetrating the central tendon of the diaphragm and lodging in the lung. Localized pneumonia and peritonitis seemed to limit the injury, the wound draining through the lungs by very free expectoration. Recovery ensued, the patient giving birth to a healthy child sixteen weeks later. Direct mechanical injury may rupture the pregnant uterus, usually result- ing in the death of the patient. It is interesting to observe that the mem- branes may remain unruptured in these cases, thus obscuring the diagnosis of rupture of the uterus. Neugebauer 404 describes a case of suicide in which a primigravida threw herself from the third story of a house upon a stone pavement ; the immediate cause of death was fracture of the skull. The uterus ruptured, and the fetus in its unbroken membranes was found among the mother's intestines. The patient's pelvis also sustained serious injury. That pregnant women can sustain terrible injury complicated by erysip- elas and still go on to term is illustrated by a case reported in the Prager medic inische Wochenschrift, 1881, No. 6. A woman in the eighth month of pregnancy, while working in a brickyard, was buried beneath a mass of earth and rock. A terrible gash was cut through the scalp, and many , bruises and lacerated wounds were sustained. Erysipelas attacked the wounds of the scalp, and the patient was very ill for a time. She did not, however, miscarry, but bore a healthy child at term. Fancon 40S describes the case of a woman who sustained an injury to the knee requiring drainage. She was attacked by erysipelas, which spread over the entire body save the genital organs and the head and neck. Pregnancy was uninterrupted and recovery ensued. Operations upon the rectum in pregnant patients are to be avoided if possible. It has been shown by Tiffany i0b that such operations are usually followed by abortion or miscarriage. On the contrary, as shown by Tiffany, 407 a diseased kidney may be removed from a pregnant patient with complete success. Whereas major operations seem to be well borne by pregnant women, minor surgical procedures of an irritant character are sometimes attended by disastrous results. Thus, Fancon observed in the clinic at Strasburg a case in which cauterization over the ankle-joint was practised for a neglected sprain. Abortion followed, complicated by septic infection necessitating amputation. The patient finally succumbed. Pregnant women often sur- THE PATHOLOGY OF PREGNANCY. 299 vive burns without the interruption of gestation if the pregnancy is not far advanced and the burn is not severe. Hunt 408 reports a case of extensive burn in the ninth month of pregnancy that seems to have affected the fetus directly, for the child was born dead and blistered over an area corresponding with the burns upon its mother's body. Curiously enough, cases are reported in which pregnant women have suffered from abscess of the breast, the abscess being opened, curetted, and drained without interrupting pregnancy, although interfering with the breasts usually results in profound disturbance of the uterus. Pregnancy is no contraindication to excision of the cancerous breast, as illustrated in a case reported by Pilcher. 409 Parasitic growths of the abdominal cavity requiring abdominal section have been treated by sur- gical interference during pregnancy with success. Amputation for crushing injury and severe blows has been borne by pregnant patients and recovery has ensued. A remarkable case is reported by Fancon, in which a pregnant woman jumped from a second-story window without interrupting the gesta- tion. Amputation at the hip-joint during pregnancy has been successfully performed by Keen. 410 The operation was performed for malignant disease of the femur. The patient, who was five months pregnant, had been living in the tropics. She made a good recovery after the oj>eration, having no symptoms of abortion during her convalescence. In deciding upon operations upon pregnant patients care should be taken that the various excretory organs of the body be placed in the best possible condition. All unnecessary shock is carefully to be avoided, as is also hem- orrhage. Although a hemorrhage does not seem to produce abortion, it is dangerous, because it renders the patient more susceptible to septic infection. Fractures unite poorly in pregnant patients, and the application of cauter- izing agents should not be practised during pregnancy. Major operations on the abdominal contents are especially well borne. Pregnancy does not contraindicate operation for diseased conditions of the uterus, the tubes, or the ovaries, provided the fetal sac is not opened. A striking instance of the benefit that pregnant patients sometimes receive from operative interference is shown by those cases of osteomalacia during pregnancy greatly benefited by oSphorectomy. A good example of this is the case described byRasch: 411 the patient, a multigravida, aged forty-one years, suffered from osteomalacia, which continued after the birth of her twins. As the condition continued to grow worse, the tubes and ovaries were removed, when the patient immediately began to improve, and was subsecpiently able to walk. The almost incredible power of resistance that the pregnant uterus dis- plays to interference is well illustrated by a case reported by Vickery : 412 this patient was subjected to medication and operative interference to empty the uterus ; it was supposed that incomplete abortion occurred, and her physician curetted the uterus and applied tincture of iodin, followed by injections of hot water. Notwithstanding this treatment pregnancy con- tinued. 300 AMERICAN TEXT-BOOK OF OBSTETRICS. The prognosis of pregnancy complicated by tumors in cases subjected to operation must be considered as decidedly favorable. Gerdes 413 gives an interesting account of 16 cases of pregnancy complicated by abdominal tumors; out of the 16 cases 4 perished. All the cases were treated by operation, many of them in the most radical manner. 5. Diseases of the Ovum. A. Amnion. Hydramnios (Hvdramnion; Polyhydramnios; Dropsy of the Amnion). — This is the condition in which the liquor amnii is in excess of the normal quantity, which at the end of pregnancy averages between one and two pints. The range of variation is considerable, and it is impossible to state definitely the frequency of moderate degrees of increase, especially in advanced gesta- tion. Neither can it be stated how much fluid is necessary to produce well- marked disturbances. Undoubtedly the uterus and abdomen will tolerate in one woman what could not be borne without marked disturbance in another. The amount of fluid noted in different cases varies from two to twenty-five quarts. Associations. — Hydramnios is more frequent in multipara? than in primi- parse. It often occurs in twin pregnancies, especially those of uniovular development. It has been found in anemic and weakly women ; in those with dropsical conditions ; in tuberculosis, diabetes, and syphilis (Winckel). In a number of instances diseases of the placenta and membranes have been described ; in some cases, edema of cord and placenta. Frequently fetal anasarca, ascites, anencephalus, or spina bifida is present. It is important, however, to note that in a large number of cases (44 per cent., according to Bar) no maternal or fetal peculiarity can be found. Pathology. — The origin of the excessive fluid is not at all definitely known. Theoretically it may be due to oversecretion, imperfect absorption, or to a combination of these. It may be derived from maternal or fetal sources or from both combined. That the normal liquor amnii is mainly of maternal origin seems now well established. Zuntz'" experiment of injecting sodium sulphindigolate into the veins of a pregnant rabbit, producing thereby blue coloration of the amniotic fluid, but not of the fetal kidneys, points strongly in this direction. The contribution of the fetal kidneys has always been believed to be important, but Schaller's experiments greatly discredit this belief. He administered phloridzin to pregnant women and tested the liquor amnii at various periods for sugar. As the glycosuria therebv caused is produced mainly in the kidneys, it was possible to estimate the activity of the fetal kidneys. These results were as follows : 1. There is no regular secretion and periodic excretion of urine by the fetus even at the end of pregnancy. 2. Fetal renal functional activity begins only when the process of labor THE PATHOLOGY OF PREGNANCY. 301 induces changes in the fetal circulation. Even during labor it is exceptional that the fetus urinates into the amniotic cavity. 3. The fetal kidneys functionate much more slowly than those of the adult. In the light of these researches it is extremely probable that in hydram- nios the increased fluid is most frequently maternal in origin. Certain it is that dropsical conditions in the mother are apt to be associated with excess. Fehling has noted that the more hydremic the maternal blood, the more abundant is the amniotic fluid. Indeed, it is not improbable that an important factor in explaining normal differences in the quantity of liquor amnii in pregnancy is a variation in the hydremic condition of the maternal blood. As to the relative influence of overproduction and deficient absorption, nothing can be said, since we do not know the relationship between normal production and absorption. A. R. Simpson thinks that another important factor is loss of tone in the uterine wall. This suggestion is certainly worthy of much consideration in view of the frequency of hydramnios in multipara?, especially in those who have borne several children, and in multiple pregnancies. Many believe that the increased fluid may be derived from the following sources : (a) Altered States of the Circulation. — Some have noted the persistence of the early subamniotic vasa propria of Jungbluth in certain cases of hydram- nios, and have believed the increased fluid to have arisen by exosmosis from them. This is altogether unlikely, because in most cases of hydramnios no such vessels are found. Then it is known that vascularization of the con- nective tissue of the amnion may be found without any hydramnios. (6) Others believe that any conditions which can raise blood-pressure in the umbilical vein and vessels of the villi may cause hydramnios. Thus, it has been noted in some cases of lesion of the fetal heart, with tumors in the fetus obstructing the circulation, in abnormal conditions of the cord, e.g., marked torsion, etc. Brindeau has reported a case occurring at the fifth month where there was sarcoma of one fetal kidney. The umbilical vein was dilated, and, when fluid was injected into it, transudation was observed ; the fetus was ascitic and the placenta very large. It is to be noted, however, that these con- ditions often exist without any hydramnios ; consequently it is impossible to have any accurate knowledge of their importance as causal factors. (c) Excessive Fetal Urination. — That abnormal activity of the fetal kid- neys may sometimes lead to hydramnios is possible, though in no way proved. As has already been stated, the fetus probably does not normally excrete urine in utero until the process of labor begins. Why this function should prematurely develop (if, indeed, it does), leading to an excessive quantity of liquor amnii, is altogether uncertain. (d) The fetal skin may occasionally be the source of hydramnios. This view is pure hypothesis, and is based upon the very rare finding of hydram- 302 AMERICAN TEXT-BOOK OF OBSTETRICS. nios along with a thickened and folded condition of fetal skin. Budin has also noted a case in which there were abundant nevi. These fetal changes may, however, have been in no way connected with the production of the in- creased amniotic fluid. (e) Alterations in the amnion are stated to be an occasional cause. Some think that inflammation of the membrane may possibly explain the produc- tion of acute hydramnios. A few observers have described fissures between the amniotic cells in cer- tain cases, through which they believe the fluid entered the amniotic sac. The relationship to twin pregnancy is of interest. The greater fre- quency in uniovular development has been noted. Where two amniotic sacs are present, there is usually a considerable disproportion in the sizes of the fetuses. Hydramnios occurs in the sac containing the larger fetus. In the latter, hypertrophy of various organs may often be found, especially in the heart; also in the kidneys, liver, or spleen. It is believed by many that the cardiac hypertrophy causes abnormal activity of the kidneys, thus leading to hy- dramnios ; but this is not proved. Sometimes, though rarely, both amniotic sacs may contain an excessive quantity, even though one fetus is not much larger than the other. Hydram- nios may also be found where there is only one amniotic sac. Physical Signs and Symptoms. — The disease, rarely, may develop rapidly. Usually the accumulation of fluid takes place slowly. In the great majority of cases the onset is noted after the fifth month. The uterus is larger than it is at the corresponding period in normal pregnancy, and generally stands at a higher level. Its wall is tenser than normal. Fetal parts are more difficult to palpate, and the heart may not be so often found. Fluctuation is usually easily obtained. It is of great importance to note that the normal variations in the consist- ence of the uterine wall may be absent for long periods. Hardening may not be felt at all in a series of examinations or may be very slightly marked. In acutely developed hydramnios there may be much distress and pain in the abdomen. Vomiting and other reflex disturbances are present. In the ordinary chronic case marked trouble usually develops in ad- vanced pregnancy, though there are many variations in the degree to which patients may be affected. There are gastro-intestinal disorders, difficulty in respiration, frequency or irregularity of cardiac action as a result of the pres- sure of the large uterus. There may be weakness in the body and legs and inability to move about with ease. Avarices and edema of the lower limbs, vulva, and abdominal Avail may develop. The urine may become scanty and albuminous. Ascites may develop. The abdominal wall is greatly thinned and the linea alba markedly stretched, so that the recti are widely separated. Differential Diagnosis. — In the early months the condition may be mis- taken for pregnancy with hydatidiform degeneration of the chorion. Flue- THE PATHOLOGY OF PREGNANCY. 303 tuation is not present in the latter condition, which sooner or later leads to escape of blood from the cervix along with the characteristic vesicles. When the swelling is large, the condition may readily be mistaken for ovarian or parovarian tumor. Repeated examinations should be made in order to determine especially the presence of a fetus, and the other signs of preg- nancy. Ascitic distention of the abdomen, especially if associated with tubercular or malignant masses, may simulate hydramnios, the swellings sometimes simulating fetal parts. A distended bladder along with pregnancy may lead to a diagnosis of hydramnios. Twin pregnancy may sometimes be distinguished with difficulty from it. Prognosis. — In about 50 per cent, of cases pregnancy ends prematurely. The fetus is often born dead, sometimes shrivelled or macerated or mal- formed. Out of thirty-three cases, McClintock noted nine dead-born ; of the rest which were born alive, ten died within a few hours. The nature of the influence of hydramnios on the fetus is not known. Influence on Labor. — In the advanced months labor is usually slow, the pains being weak. Malpresentations and malpositions are frequent. Sudden escape of much liquor amnii may lead to complete inertia of the uterus. Rupture of the uterus has been noted in several cases. In the third stage the placenta is slow in being expelled, and on account of uterine weakness, there is great risk of hemorrhage. The danger of infection is also greater than in a normal case. Treatment. — There is no known method of preventing the increase of liquor amnii. In cases where the patient is fairly comfortable no interference is necessary. A well-fitting binder may relieve abdominal distress some- what. When the mother's health is much affected in marked cases, it is advisable to draw off some of the liquor amnii with a small trocar, the mem- branes being punctured, if possible, above the level of the os internum. Rarely, this procedure is followed by improvement without the occurrence of premature labor. Generally, however, the latter is induced. The via- bility of the fetus is not to be considered in cases where the mother's condi- tion is distressing. When labor takes place, the mother must be attended with great care. When dilatation of the cervix is well advanced, a quantity of amniotic fluid should be drawn off slowly with a fine trocar. If dilatation is very slow, it may be promoted by artificial means. Delivery of the child by forceps or version may be indicated. In the third stage, artificial removal of the placenta may be necessary. The uterus should be packed with gauze for twenty-four hours to stimulate the organ and to prevent bleeding, and large doses of ergot may be administered. Oligohydramnios. — This is the condition in which there is a deficient quantity of liquor amnii. Nothing is known as to its etiology. A few cases have been described in which oligohydramnios in late pregnancy has been associated with absence of one or both fetal kidneys or with imperforate urethra. Gusserow and others believe that such cases are proof that the fetal 304 AMERICAN TEXT- BOOK OF OBSTETRICS. kidneys contribute largely to the liquor amnii. The fetus is often mal- formed as a result, probably, of abnormal pressure. Imperfect nutrition of parts, resulting in ulceration, has been noted. Amniotic Adhesions. — Bands of various shapes and sizes are sometimes found, passing from fetus to amnion, generally where oligohydramnios also exists. They are non-vascular. It is believed that they arise in early embryonic life, as a result of deficiency in the liquor amnii, the surface of the fetus being thereby allowed to come into contact with the amnion, union occurring at one or more points. As the ovum develops, the joined areas stretch. Sometimes the bands break across, remaining attached by their ends to fetus or amnion. They may cause damage to the fetus. The um- bilical cord may become twisted in one and the life of the fetus endangered. Parts of the fetus may atrophy from constriction by a band ; even amputa- tion of a limb may be brought about. Various malformations may be produced — e.g., eventration, anencephalus, encephalocele, etc. Several cases have been described in which localized destruction of the skin resulted from the traction of an adhesion, an appearance like an ulcer being produced. The child when born may show this recently formed or partly cicatrized. Other Variations in the Liquor Amnii. — The fluid varies considerably in color and consistence. Early it is usually dull grayish white ; in the late months it is greenish, the wdiole depending upon the amount of meconium in it. In consistence it may be limpid and thin, or thick and syrupy. The odor is usually only slight, but it may sometimes be distinct and unpleasant. When the fetus is macerated or decomposition has set in, the liquor is usually very dark colored and may have a bad odor. B. Chorion. Hydatidiform Degeneration (Vesicular Mole ; Hydatid Mole ; Cystic Mole ; Uterine Hydatid ; Dropsy of the Villi ; Myxoma Chorii Multiplex). — This condition is one in which swellings develop on the chorionic villi, varying in size from a millet-seed to a grape. They may occur at the ends of the villi, or several enlargements may form on a villus resembling a chain of beads. Sometimes the swelling is elongated and bean-like, a considerable extent of villus being affected. The swelling is caused by a localized hyper- trophy of the normal mucoid tissue which forms the core of the villus. On microscopic examination the outer covering shows the cells of the Langhans layer and the outer layer of syncytium, the cells being thinner and more flattened than normal, owing to stretching. They tend to be separated from one another and in large swellings may disappear, remains of the syncytium onlv being left. The interior consists of delicate branching mucoid cells and of fluid between them, the relative abundance of these varying in different cases. In some swellings the consistence may be gelatinous ; in others watery, a cystic condition being developed. The fluid contains abundant mucin and some albumin. It is generally THE PATHOLOGY OF PREGNANCY. 305 pale in color, but sometimes may have a reddish tinge, due to the presence of blood. The capillaries of the villi are usually obliterated. The swellings on the ends of the villi attached to the decidua extend into the uterine wall as they Decidual cells Patch of decidua serotina. Fig. 149.— Fleshy mole (after Fothergill). Section showing the uterine surface of a placenta retained five months. Decidual cells are seen spreading from the patch of original decidua. enlarge and may penetrate its entire musculature. Rarely, the peritoneal covering may be perforated. Several specimens have been described in which the reflexa was perforated, the swellings lying in the space between it and the vera. In well-marked Fig. 150.— Fleshy mole (after Fothergill). a, amniotic surface ; b, uterine surface. cases the whole mass of the chorion may reach the size of a cocoanut, weigh- ing several pounds. Sometimes hydramnios is also present. The disease usually begins in the early weeks of pregnancy. It may affect both chorion frondosum and lseve, in part or entirely. In some cases only the former or latter may be affected partially or completely. The ovum 306 AMERICAN TEXT-BOOK OF OBSTETRICS. when expelled from the uterus presents, therefore, different appearances in different cases. The effect on the embryo also varies considerably. If the disease be extensive, particularly if the chorion frondosum be affected, the embryo dies and disappears. When only a small part is affected, its life may not be endangered, and it may reach full time. In twin pregnancy the degeneration may be present in one ovum and absent in the other. Etiology. — The cause of the condition is unknown. There is no proof whatever of the view held by many that it is due to endometritis. Several cases of recurrence in the same women have been reported. Results. — Early expulsion of the degenerated ovum may occur, usually between the third and sixth months. In cases where the fetus has not been affected, owing to the small amount of degeneration, pregnancy may reach term. A few cases have been reported in which the mole has not been expelled, even where the embryo has disappeared, but has remained in utero several weeks beyond the period of normal pregnancy. In some instances it has been described as being partially expelled, the rest remaining in the uterus for years. In some cases hemorrhage may be so excessive as to endanger the patient's life ; during expulsion of a mole this danger is great. Occa- sionally the contractile power of the uterus may be considerably weakened ; intraperitoneal bleeding may be marked as a result of perforation of its wall by the mole. If all the vesicles are not expelled, subinvolution of the uterus results, and decomposition may take place in the portions left behind. In recent years it has been shown by different workers that remains of a vesicular mole may give rise to one form of the disease known as " decidu- oma malignum." Metastatic growths tend to develop in the vulva, lungs, and other parts, in which there may be reproductions of the molar structure. Symptoms and Physical Signs. — In the earlier stage there is no indication of the change. In a well-marked case it is usual to note that the uterus increases more rapidly than in normal pregnancy. Thus, at the third month the organ maybe as large as though it contained a fourth or fifth month ovum. Very often hemorrhage occurs. It may be sudden and pi*ofuse, or may escape in driblets — either as pure blood or as serum. When intermittent, the intervals may be long or short. Occasionally the vesicular masses are expelled with the blood, resembling " white currants in red currant juice." As a result of the loss of blood patients often become very much debilitated. When rapid increase of the uterus takes place, excessive vomiting has been noted in a few cases. On bimanual examination, when the condition is well marked the uterus has a firm, somewhat doughy, boggy feeling, its outline being occasionally irregular. Sometimes the cystic masses can be palpated through the abdom- inal wall or rectum. The usual auscultatory phenomena of pregnancy are generally wanting. Ballottement is absent. THE PATHOLOGY OF PREGNANCY. 307 In cases where the mole ceases to develop and is not expelled from the uterus, the latter is smaller than it should be for the period of pregnancy represented. Thus, though nine months have elapsed since conception, the uterus may only be as high as the umbilicus. Differential Diagnosis. — The diagnosis may be very difficult in some stages. Thus the rapid increase in size may simulate hydramnios. When early hemorrhages occur, ordinary abortion may be suspected. Sometimes vesicular mole is mistaken for a uterine neoplasm. When, after hemorrhages, expulsion does not take place, the diagnosis of missed abortion may be made. It is interesting to note that true hydatid development, due to the echino- coccus, may very rarely be found in utero. Its nature is characterized by the presence of echinococcus heads and booklets. Treatment. — When the diagnosis is established, the uterus should be emp- tied. This is best carried out as follows : If the cervix is patulous, it and the vagina should be firmly tamponed and the patient placed in bed. When the cervix is closed, it should be partly dilated artificially, in order that the gauze may be inserted. If, after twelve or fourteen hours, the mole is expelled, the patient should be anesthetized and the uterine cavity carefully explored with one or two fingers, all vesicles remaining in it being carefully removed. The uterus should then be packed for twenty-four hours. If the mole be not expelled by uterine efforts, dilatation of the cervix should be car- ried out and the mole removed with the fingers. A curet is inadvisable on account of the risk of perforating the uterine wall at some thinned portion. When vesicles are firmly united to the uterine wall, no force should be em- ployed in trying to detach them. It is best to remove those which easily come away and to curet the uterus after a week or two. Myxoma Diffusum. — Very rarely a mucoid hypertrophy may be found in that portion of the chorion from which the villi spring. It maybe spread over a large area, forming a gelatinous layer, under the amnion, three to five millimeters thick. Myxoma Fibrosum. — Occasionally a fibroid thickening of the chorion is found either in the subamniotic layer or in the villi. It is found usually in advanced pregnancy. C. Placenta. Anomalies. — At term the shed placenta is a rounded disc, weighing about a pound. Its average diameter is about seven inches ; its thickness varies from three-quarters of an inch to an inch, being greatest near the middle. In some cases the thickness is fairly even in all parts ; in others it varies considerably in different parts. There may be marked Assuring in some cases and a complete absence in others. The size of the placenta also varies considerably, the largest development being found in uniovular twin cases. There are many variations as regards shape. Thus, it may be rounded, 308 AM ERICA N TEXT-BOOK OF OBSTETRICS. oval, ovoid, reniform, crescentic, regularly or irregularly lobed. One or more detached portions may exist — placenta succenturiata. The latter may be related to maternal blood, just like the main part of the placenta. Rarely the detached portion may be as large as that to which the cord is attached, explaining what is sometimes described as a double placenta with a single fetus. In such a condition the cord may end in the membranes between the placental portions, its vessels going to each. Sometimes the villi of the detached part are functionless. Such have been named "placenta spuria." A r ery rarely the placenta may extend around the uterus in a ring-like manner, similar to the condition found in some mammalia. Sometimes it has a gap in its substance — " placenta fenestrata" The cord may have a central, lateral, or marginal insertion. In the latter instance the appearance is often compared to a battledore. Rarely it may be inserted into the membranes, its vessels running in the chorion to the placenta — celamentous insertion. Myxomatous Degeneration. — This change has been described in connec- tion with hvdatidiform changes in the chorion. The effect on the fetus depends mainly on the amount of change in the villi. Calcareous Deposits. — Occasionally small portions of calcareous material are found on the maternal surface of the placenta. They may be in the decidua, attached to the ends of the villi, or sometimes in the substance of the latter. Their causation is unknown. Edema. — The placenta is sometimes swollen and edematous. The causes are probably both maternal and fetal, but are not well understood. It has been noted with obstructive conditions in fetal circulation. Fibrous Degeneration. — This change in the stroma of the chorionic membrane and villi is a very common one in the advanced stages of normal pregnancy, and there is no evidence that it is any indication of a diseased process. The delicate mucoid stroma of the early weeks gradually changes into a dense structure, in many parts resembling connective-tissue sclerosis. There is a relatively large quantity of the matrix in proportion to the nuclei. Many cells are shrivelled and lie in spaces. In many of the vessels great thickening of the intima is found. Remains of the early mucoid tissue are only to be found usually in some of the small (latest formed) villi. In many of the villi attached to the decidua the disappearance of the covering epithelium may make the connective tissue of the stroma appear to be continuous with that of the decidua, and it may be difficult in some instances to distinguish between them. Fatty Degeneration. — This has been described as occurring when the nutrition of the villi is interfered with, frequently in connection with fibrous changes in the villi, and following death of the fetus where the placenta is not immediately expelled. Inflammation. — The relation of the placenta to inflammation is not at all well understood. Much of the work published dealing with diseased condi- PREGNANCY. Plate 22. Anomalies of the Placenta: i, placenta with irregular lobes; 2, placenta in two unequal lobes; 3, irregular placenta; 4, small accessory placenta; 5, placenta succenturlata ; 6, "battledore" placenta, oval ; 7, placenla with velamentous attachment of cord ; 8, placenta with two equal lobes. THE PATHOLOGY OF PREGNANCY. 309 tions is worthless because it has been done when the true nature of the placenta was not correctly known. As regards the very small portion of placental tissue of maternal origin, viz., the decidua to which the villi are attached, there is no doubt that occa- sionally it may be affected along with the rest of the mucosa in an inflamma- tory process often termed " deciduitis." That the change may spread to the attached villi is undoubtedly possible. As to inflammation in the main tissue of the placenta, which is entirely of fetal origin, we know little. Fraenkel has shown that such a process is not infrequent in syphilis. He has described the infiltration of villi with inflammatory products, resulting in hypertrophies and distortions. Syphilis. — "While the influence of syphilis in its various forms on the life of the ovum has been well described from the clinical point of view, we are as yet in want of correspondingly accurate data regarding the pathologic changes accompanying its different manifestations. This is largely due to the rarity of specimens of the pregnant uteri removed from syphilitic women. The ovum alone is often enough obtained, but no complete account of the pathology can be given until the condition of the uterus has been carefully studied. It is of extreme importance to ascer- tain whether the vessels and other tissues of the maternal mucosa are affected in all forms of the disease, or only in certain cases ; whether local maternal changes are necessarily preliminary to fetal changes ; which of the fetal structures are most prone to be affected, and what are the variations related to the different kinds of syphilitic infection. At present, it is sufficient to state that inflammatory changes and gummatous formations have been described in the decidual tissue. Endarteritis has also been noted. In the chorionic membrane and villi chronic thickening, due to inflammatory prod- ucts, may easily be demonstrated. Infarcts in the placenta are common. When numerous and of old standing they lead to the destruction of many portions of the placenta, which are recognized as whitish or yellowish firm areas. Thrombosis in the intervillous space may also occur, the thrombi when of long standing becoming organized, the resulting fibrous tissue com- pressing and destroying many villi. Cysts. — These are occasionally found especially near the fetal surface of the placenta. Some are believed to arise from a localized myomatous degen- eration of the chorion, others from the degeneration of infarcts and hemor- rhages. Tumors. — The myxomatous and fibromyxomatous swellings have already been noted. Occasionally a single large swelling occurs of combined fibrous and myxomatous nature. Sometimes the swelling may consist mainly of angiomatous structure, the tumor being, therefore, a fibromyxoma telangi- ectodes. These forms probably arise in the chorion. Albert has collected a number of these cases, and has pointed out the frequency of abnormal- ities in connection with the pregnancy — e. g., hydramnios, hemorrhages, premature emptying of the uterus. Certain tumors described as fibromata 310 AMERICAN TEXT-BOOK OF OBSTETRICS. are probably merely organized blood-clots or thromboses. In this connec- tion deciduoma malignum may be mentioned, as the new growth usually develops in connection with placental remains. In some cases the disease probably begins before the birth of the ovum. Tuberculosis. — The effects of tuberculous infection on the placenta are not fully known. Local lesions have been noted in the decidua and in the chorion. In cases in which the mother shows distinct tuberculosis else- where tubercle bacilli may be found in the fetal tissues, though no changes exist in the placenta. Placental Infarcts and Apoplexies. — The frequent occurrence in the placenta of localized areas of pale dense tissue has been noted by many ob- servers, and different views have been advanced to explain their formation. Perhaps the most widely held opinion is that which regards them as due to hemorrhages in the placenta. In the light of recent work it would appear that this explanation is not correct. Indeed, true apoplexies or localized extravasations of maternal blood are very rare. Williams, one of the most recent workers in this subject, supports the view originally advanced by Ackermann that the primary cause of infarct formation is to be found in the thickening of vessels in the villi, mainly in the inner wall. As a result, he states there is a coagulation-necrosis of por- tions of the villi just beneath the syncytium, with subsequent formation of canalized fibrin. As the process advances the syncytium degenerates and is changed into canalized fibrin. This is followed by the coagulation of the blood in the intervillous space, which results in the matting together of groups of villi by masses of fibrin. In the advanced stages the stroma of the villi degenerates, so that it resembles the fibrin around it. Moderate degrees of infarct formation' are not to be regarded as pathologic, being frequently found in normal cases, but are probably due to senile changes in the chorion. There is no doubt that diminution of caliber of the vessels of the chorion is a normal change toward the end of pregnancy, owing to thicken- ing of the intima. The endothelium is swollen in some parts and prolifer- ated in others, while often an appearance like hyaline degeneration is noted. These infarcts are for the most part white or yellow in color ; they vary in size from small dots to large portions of the placenta. They may be found next the amniotic surface in the substance of the placenta, or at the maternal surface ; frequently they are situated at the edge. Sometimes they are found as a thick band running around the fetal surface at some distance from the, edge. In the latter condition the placenta is often termed placenta mar- ginata. In some cases this ring-like band is found half an inch or more internal to the edge. Rarely pinkish infarcts are noted, and still more rarely bright-red or dark plum-colored masses are found. Occasionally white infarcts are found, termed by Eden " non-fibrinous." These are an agglom- eration of villi not bound together with fibrin. Marked infarct-forma- tion may be noted in various diseased conditions of the mother, particularly 1HE PATHOLOGY OF PREGNANCY. 311 where there is albuminuria. They may be found in syphilitic cases, though they are not particularly characteristic of this condition. D. Umbilical Coed. Anomalies. — -The cord presents many peculiarities of development. It may be abnormally long — sometimes measuring five or six feet. It may be very short — being four or five inches in length. The latter condition is to be distinguished from relative shortness, an artificial production due to excess of convolutions around the fetus, or to adhesions to the amnion or amniotic bands. The cord may sometimes not enter the placenta, but may end in the membranes at various distances from its edge, the vessels separating and run- ning in the chorion to the villi. The Whartonian jelly of the cord may be very irregularly distributed ; in some parts it may be almost entirely absent, so that the diameter of the cord is much diminished. Sometimes the cord may contain two veins and one artery, or one vein and one artery ; sometimes two cords pass to one placenta. Torsion. — The vessels in the cord are variously related to one another ; usually the arteries are coiled around the vein, running from right to left, causing a twisted appearance ; sometimes they run from left to right ; some- times they run parallel almost the whole length of the cord, very few turns existing. Some variations are probably natural, but many cases occur in which marked torsion of the whole cord on its longitudinal axis is due to move- ments of the fetus. In most cases the torsion is most evident near the fetus. Occasionally the turns are so numerous as to make the cord resemble a coil of wire spring. In one case noted by Schauta, three hundred and eighty twists were counted. Edema and cystic changes have been found with marked torsion. Great narrowing of the cord and partial or complete oblit- eration of its vessels may also be brought about. Convolution. — The cord may be arranged in various ways in relation, to the fetus. Frequently it passes from the umbilicus up over the chest, around the neck, and down in front of the other shoulder. Occasionally it is coiled once or several times around the neck, body, or limbs. The largest number of turns around the body yet described is nine. Extra convolutions are almost always associated with abnormal length of cord. Division of the soft tissues of the neck has been rarely noted as the result of coiling ; amputation of a limb has been more frequently described. Direct strangulation of the child is very rare. As regards labor, Bruttau, of Dorpat, where convolution of the cord is frequently observed, points out that stillborn children are not more frequent than in cases where convolutions are absent. Though a larger percentage are born more or less asphyxiated, there is more risk of pressure on the cord in primiparse. The greatest risk exists where there is dystocia of some form. Excessive convolution may 312 AMERICAN TEXT-BOOK OF OBSTETRICS. cause delay in labor when the free portion of the cord is thereby made very short. Knots of the Cord. — Occasionally the cord may be knotted as a result of the movements of the fetus in utero during pregnancy ; sometimes it may occur during labor. Generally, only one knot is formed, but there may be more. In the case of twins in a single amniotic sac there may be marked twisting or knotting of the cords. In the great majority of instances no damage results to the fetus from the presence of these knots, since they are usually loose. Very rarely is the circulation interfered with. The Whartonian jelly may be displaced where the folds of the knots cross, in cases where they are of some duration. Sometimes a condition of the cord exists to which the term " false knot" has been given, to distinguish it from the above-described " true knot." It con- sists of a projection along the course of the cord, due to a localized accumu- lation of Whartonian jelly, or to a sharp bend or curve in one of the vessels. Changes in the Vessels. — The alterations associated with maternal and fetal diseases have not been well established. Winckel and Swieciki have pointed out the frequency of narrowing of the vessels from changes in the intima and outer wall in syphilis, heart and kidney diseases of the mother, and in other affections. The vein or the arteries, or both, may be affected. Torsion may lead to a partial or complete stenosis of the vessels. Vari- cose enlargements occasionally occur ; rupture has been described. Hernia. — Sometimes, at birth, the fetal abdominal viscera lie in a hernial extension into the cord. Otherwise the fetus may be healthy, but frequently some other abnormality exists — e.g., imperforate anus, malformations of outer genitals, etc. The hernia varies in size. It may contain only small intestine, but, in some cases, large intestine, stomach, liver, and other viscera. Swellings of the Cord. — These are rare. Cysts are sometimes found ; blood effusions ; myxomata ; telangiectatic myxofibromata. 6. Premature Expulsion of the Uterine Contents. Abortion ; Miscarriage. Definition. — By many the term abortion is applied to expulsion of the ovum during the first three months ; miscarriage, to expulsion during the second three months ; premature labor, to expulsion during the last three months. Others use the first two terms synonymously, referring to expulsion of the ovum before viability of the fetus ; in the great majority of cases this - takes place in the twenty-eighth week. In this section the latter definition is employed. Frequency. — No accurate statement can be made regarding the frequency of premature emptying of the uterus. Statistics given by different authori- ties vary considerably. Thirty-seven per cent, of all child-bearing women are said to abort at least once before the age of thirty-one, and after this the percentage is higher. Probably many very early pregnancies terminate THE PATHOLOGY OF PREGNANCY. 313 without being recognized as an abortion, the attendant hemorrhage being regarded as a menstrual disturbance. Abortion is much less frequent during the first than during succeeding pregnancies. The third and fourth months are those in which it is most apt to take place. Very often the date of its occurrence is that corresponding to a menstrual period. Etiology. — The causes of abortion are very numerous, being all condi- tions which set up uterine action. They are often classified as maternal, fetal, and paternal ; but it is impossible to arrange them into distinct divi- sions, assigning to each a definite form of action. In many cases more than one factor is in operation, and it is often impossible to state which is the most important determining cause. Thus, there are many maternal condi- tions in which abortion occurs, in which the causal factors may be a high febrile state, poisons circulating in the blood which may cause death of the fetus, intra-uterine hemorrhages causing fetal death or stimulating the uterus to contraction. Speaking generally as regards the mother, conditions which are associated with high temperature, extreme exhaustion, nervous shock, accumulation of poisons in the blood, hemorrhages in the decidua or in the attached fetal structures, or which lead to mechanical interference with the normal devel- opment of the pregnant uterus, are among the most important causes leading to abortion. Among such conditions are: (1) The acute infectious diseases, syphilis, tuberculosis ; (2) various diseases of the nervous, urinary, circula- tory, respiratory, and alimentary systems ; (3) various inflammations, dis- placements, and neoplasms of the uterus and other pelvic structures ; (4) all forms of mental shock and emotional excitement ; (5) traumatism, e. g., dancing, riding, falls, passage of foreign bodies into the uterus, etc. As regards the ovum, there are many factors which lead to abortion, either by causing death of the fetus or by stimulating the uterine muscle directly. Such are diseases and abnormalities of the chorion, amnion, or cord — hydramnios ; sudden escape of liquor amnii ; diseases or malforma- tions of the fetus causing its death. The paternal influences causing abortion are not well understood. Syph- ilis is the best known. Tuberculosis and some other conditions markedly affecting health are believed in some cases to induce premature emptying of the uterus. Advanced age or extreme youth is thought to act in the same way. Symptoms. — Signs of Abortion.— -These vary greatly. The chief clinical phenomena are: (1) Pains in the pelvis; (2) hemorrhage; (3) expulsion of part or the whole of the ovum and decidual tissue. In some cases the uterine contents may be expelled suddenly without the previous occurrence of any of the above symptoms. As an illustration may be mentioned the case of a woman who passed a three months' ovum while in the middle of a dance, without any warning whatever. In some cases pain is entirely absent ; in others there may be little or no bleeding before the ovum is expelled. Sometimes only blood-serum escapes ; sometimes the liquor amnii first gushes out. 314 AMERICAN TEXT-BOOK OF OBSTETRICS. Very frequently paiu is early felt in the sacral region as a continuous aching. Often, intermittent labor-like pains are present. Fulness and weight in the pelvis and frequency of micturition may be noted. Bleeding may precede pains, may be noticed synchronously, or may follow them. The blood may pass in driblets or as a profuse flow. It may collect in the vagina and form large clots ; or it may be retained in the uterus, distending it and increasing the pain. Clotting may occur in the cervix, only blood-serum escaping. Sometimes bleeding takes place only at night when the patient lies down, ceasing when she walks about. This is probably due to the sink- ing down of the reflexa and ovum, acting as a plug to the internal os while the woman is in the erect posture. The duration of an abortion varies greatly. As just stated, it may take place in a very few seconds, so far as the woman's subjective knowledge is concerned. Ordinarily it lasts over a period of several hours. In some Fig. 151.— Ovum imbedded in blood-clot (Ahlfeld). cases the phenomena may extend over several days, being more or less constant or intermittent in character. When the abortion is not complete, certain effects may be produced which may be evident months or years afterward. On physical examination, in the early stages of abortion, the enlarged uterus may be palpated. When pregnancy is advanced only two or three weeks, it is impossible to be certain as to the degree of enlargement. Usu- ally variations in its consistence — alternate hardening and softening — may be distinguished. Very early no dilatation of the cervix may be felt, even though blood be escaping from it. Later it is more or less patulous, so that a finger may readily be introduced, and presenting portions of decidua, ovum, or blood-clot may be felt (see Figs. 152, 153). Mechanism of Abortion. — Berry Hart has pointed out that in many cases in which a complete abortion is expelled there may be a definite mech- THE PATHOLOGY OF PREGNANCY. 315 anism, which he terras " normal." Of this there are two varieties : First, that in which expansion of the lower uterine segment is accompanied by a separation of the decidua vera from below upward, the whole mass expelled consisting of the outer portion of the vera and serotina, reflexa, and contained ovum ; second, that in which, as the vera gets separated, the reflexa and M it.' v \ ffV7 ,r ? Wn i a. V s ."-: Pig. 152.— Frozen section of the uterus, showing placenta and partially detached membranes (Freund). superficial part of the serotina, with the contained ovum, are driven down into the cervix, the vera following afterward as the abortion proceeds. As regards the separation-plane in the case of a complete abortion, my researches show that it passes mainly through the compact layer of the sero- tina and vera in the middle or outer part ; in certain areas the whole compact layer and bits of the spongy layer may be shed. It is exceptional to find any considerable quantity of the latter removed. 316 AMERICAN TEXT-] 10 OK OF OBSTETRICS. Probably the majority of abortions do not occur in this normal manner; very often the uterine contents come away in successive portions, the expul- sion often being only partial. In these abnormal cases sometimes every- thing may escape except the vera. The reflexa along with the superficial f, V Fig. 153.— Frozen section of the uterus, showing retained membranes iFreund). part of the serotina and the contained ovum may easily be mistaken for a complete abortion on superficial examination. In some cases parts only of the vera may be left ; in other cases parts or the whole of the serotina may be left along with attached villi and more or less of the reflexa. Sometimes the reflexa may be broken off at its junction with the serotina THE PATHOLOGY OF PREGNANCY. 317 and expelled with or without the amniotic sac and its contents. Sometimes the fetus alone or the entire ovum may be expelled through the reflexa, the decidual structures being expelled partly or entirely at a later date. Occa- sionally the entire amnion and its contents may alone be expelled. Varieties. — Different terms are employed to describe the various stages in which abortions are met with clinically. Threatened Abortion. — This condition is one in which there are symptoms pointing to the commencement of expulsion of the uterine contents. As already indicated, these vary in different cases. Ordinarily there are pelvic pains, with or without hemorrhage, and with little or no dilatation of cervix. In many cases of early pregnancy the threatening occurs at the time cor- responding to a menstrual period. Inevitable Abortion. — This is the condition in which the threatening symp- toms have become more marked and persistent, so that all hope of preventing the abortion must be given up. In this stage usually the cervix is dilated, so that a finger may be introduced. Often, however, it cannot be passed through the internal os. Expulsion of portions of the decidua vera is generally 2'egarded as a sign of inevitable abortion ; but this is not always the case, for occasionally this may take place in a threatening abortion, pregnancy continuing afterward. Complete Abortion. — This is the condition in which everything which should be expelled escapes from the uterus. The constituents of the com- plete abortion have already been described. Incomplete Abortion. — In this condition there are left in the uterus de- cidual tissue, fetal structures, or parts of both. The variations which occur have previously been noted. Habitual abortion is the term applied to the repeated occurrence of abor- tion in the same woman. In some instances pregnancy may be interrupted successively at the same period ; in other cases, however, the time is variable. Hissed Abortion. — Occasionally a fetus may die in uiero and no abortion occur ; in some cases no threatening even taking place at the time of fetal death. The uterus may retain its contents for weeks or months. This may happen to twin pregnancies as well as to single ones. Sometimes both ova may perish, sometimes only one. The latter may be the case even when both fetuses lie in one amniotic cavity. When exjndsion finally does occur, the uterine contents present various appearances in different cases. Some- times the fetus is preserved in a shriveled condition, wrapped up in the membranes and placenta, the liquor amnii having been absorbed or pre- viously expelled. The term "blighted ovum" is applied to this condition. In other instances the ovum and decidual tissues are largely altered by hemorrhagic effusions, forming a mass termed the carneous, fleshy, or sarcous mole, or molar abortion. The fetus may be entirely or partially absorbed ; sometimes only a small part of the umbilical cord may be recognized. The villi in these masses are found in various stages of degeneration, similar to those already described in placental infarcts. The blood may be found in all 318 AMERICAN TEXT-BOOK OF OBSTETRICS. stages from the recently effused red clot to the well-advanced, organized, pale fibrin mass. In some early abortions may be noticed hemorrhagic effusions in the decidua and chorion, forming bulgings into the amniotic cavity. To this appearance Breus has given the name of " tuberose subchorionic hematoma of the decidua." When an immediate abortion does not occur as the result of this condition, a carneous mole usually develops. The clinical history in cases of missed abortion varies. Usually after a period of amenorrhea, during which various signs and symptoms of preg- nancy are present, there is hemorrhage from the uterus and perhaps some of the other signs of abortion (often believed to be, by the patient, an actual Fig. 154. — Tuberose subchorionic hematoma of the decidua (Webster), a, Amniotic surface of early abortion-sac ; 6, embryo ; c, large blood-clot in decidua forming a bulging in amniotic cavity ; d, small blood-clots. abortion), and afterward another period of amenorrhea, lasting for weeks or months until the mass is expelled from the uterus. Instead of a second period of amenorrhea, there may be irregular dis- charges of blood. Occasionally, putrefactive changes may occur and a fetid discharge result. Sometimes septic infection may occur. During this latter period the uterus may diminish somewhat in size, thereafter remaining in a stationary degree of enlargement, or it may become slowly and progressively larger owing to a succession of fresh hemorrhages in the ovum. The length of time that a missed abortion may remain in the uterus is not definitely known, and accurate observations are wanting. The subject, is of considerable importance from the medicolegal point of view, as was recently shown in the well-known trial in London, " Ivitsou vs. Playfair." Dr. Playfair removed from a woman on February 23, 1894, a piece of tissue left after an abortion which was regarded by him as of recent origin. The THE PATHOLOGY OF PREGNANCY. 319 woman maintained that it was a portion of the product of a conception which had occurred at least eighteen months previously, being part of a blighted ovum retained in the uterus from October, 1892, when the threatening of an abortion had occurred resulting in the death of the fetus. No difficulty should exist in the determination of the probable age of an abortion. If the chorionic tissue be of recent origin, well-formed villi with preserved epithelium can be made out, whereas in missed abortion of some duration characteristic alterations can be made out. These are : gradual dis- appearance of the fetal epithelium, amniotic and chorionic, fibrin formation in the blood of the intervillous spaces, gradual invasion of the fibrin by con- nective tissue of decidual type. Fothergill believes that these decidual cells gradually absorb the fibrin and the remains of epithelial cells. Thus, the connective-tissue cores of the villi tend to be surrounded by decidual tissue, the whole forming a firm mass. To it Hartman and Toupet have applied the name " deciduoma benignum." Prognosis. — Loss of the mother's life rarely accompanies spontaneous abortion. Yet a fatal result may sometimes take place from hemorrhage or rupture of the uterus ; sometimes it may be due to an acute or chronic infec- tive process. Deciduoma malign urn may develop in connection with abor- tion, causing death. In many cases results follow which do not prove fatal, but lead to much ill health. These are mainly associated with incomplete abortions, which may lead to protracted loss of blood, to the development of a fibrin polypus, to subinvolution of the uterus with hypertrophied and congested mucosa, and, in cases of infection, to various forms of pelvic and systemic disturbances. Complete abortion may be followed by ill health, due to great loss of blood or to the results of septic infection. A rapid succession of abortions usually leads to deterioration of the system from one or more of the above causes. Many women injure themselves by regarding an abortion as a matter of no importance. They either refuse to cease from the ordinary routine of their life, or, if they go to bed, rise too soon and work too early. As a con- sequence, protracted weakness, subinvolution, displacements, etc., are apt to result. In criminal abortion the risks to the mother are enormously increased, owing to the unskilful use of instruments, to the lack of aseptic measures, or, when drugs are employed, to their destructive effects on the system. Differential Diagnosis. — There are difficulties of diagnosis in connection with the different varieties of abortion. A threatened abortion may simulate a number of conditions, and vice versa. The most important point in mak- ing a diagnosis is to determine whether or not pregnancy exists. To do this is often impossible, especially in the early weeks. Consequently there is often much uncertainty in diagnosing abortion. In women who have irregular menstruation, a flow of blood coming on after several weeks of amenorrhea, mav be mistaken for abortion. The 320 AMERICAN TEXT- BO OK OF OBSTETRICS. error is more easily made when the flow is accompanied with uterine pains of a labor-like character. The case may be more complicated when there is some uterine enlargement, such as may be due to inflammation or new growth of the uterus, and when some of the reflex signs and symptoms of pregnancy are present. Sometimes there may be pelvic pain and loss of blood due to some con- dition outside of the uterus altogether — e. g., vaginal new growths, hemor- rhoids, etc. Haultain has described an interesting case in which a clot in the bladder caused dilatation of the sjfliincter urethra?, thus allowing blood to escape, a threatened abortion being closely simulated. A uterine hemorrhage occurring in the course of an ectopic pregnancy is often mistaken for an abortion ; sometimes with serious results. In some cases of pregnancy there is, in the early months, an escape of blood from the uterus before the space between vera and reflexa is obliterated. It may occur in successive gestations in the same woman. Usually such a case is regarded as a threatened abortion. The fact of threatened abortion being established, it is often difficult to decide whether or not it is inevitable. If the bleeding be profuse, or if, under treatment, it ceases and begins again ; if uterine contractions are fre- quent and strong, and continue in spite of treatment ; if the cervix be dilated so that a finger may feel parts of the ovum or decidua bulging into the cer- vical canal ; if the amniotic cavity be ruptured, or the fetus be dead, the abortion must be regarded as inevitable in the great majority of cases. Occasionally, however, the physician makes a mistake and is surprised to find that abortion does not occur, even though the symptoms have been so marked as to lead him to believe it inevitable. Cases have been recorded in which even the amniotic cavity has been ruptured and yet pregnancy has continued to full time. W^itji regard to the condition of the fetus, it is to be noted that in the first three or four months it is impossible to know when it has died. Usually this occurrence is soon followed by emptying of the uterus, but in a few cases this does not follow, and it is then found that there is gradual disappearance of the various reflex sympathetic symptoms and signs of pregnancy. In the early months the latter may be very slight in certain cases, and their disappearance may therefore be unrecognizable. When au abortion has occurred, it is very important to decide whether it has been complete or incomplete. It is possible to give a positive diagnosis only when the physician is able to examine what has been passed from the uterus ; in the great majority of cases he is unable to do this. If he cannot decide in this way, he may gain information either by examining the interior of the organ under anesthesia or by watching the clinical phenomena for some time after the abortion. The first method is satisfactory in a certain measure; but it is impossible to be accurate, especially with regard to determining whether the vera has separated or not. Whenever doubt exists, the uterus should be curetted. THE PATHOLOGY OF PREGNANCY. 321 The second method is fairly satisfactory, though it subjects the patients to risks. If an abortion be incomplete, the uterus does not remain so firm and small as after complete expulsion ; the lochial discharge is usually more profuse, the loss of blood more marked and remaining continuous or inter- mittent for days and weeks, the patient being in a depressed state of health. A complete abortion may itself be easily mistaken for other conditions, and vice versa. Thus, a period of amenorrhea followed by a loss of blood, which may continue intermittently afterward, with excessive leukorrhea and generally weakness, may be due to inflammatory conditions of the uterus, retroversion, mucous or fibroid polypi, or other conditions. Sometimes these diseased states may reflexly set up some of the well-known signs and symptoms of pregnancy. When a fibrinous polypus has formed after an incomplete abortion, it may easily be mistaken for a true neoplasm, simple or malignant. When putrefactive changes take place in the remains of an incomplete abortion, the signs and symptoms may closely simulate those of malignant disease or of a sloughing fibroid. Missed abortion may often be very difficult to diagnose. Sometimes it is regarded as a second pregnancy, an abortion having been thought to occur when only a threatening has taken place. Generally, the pregnancy is regarded as continuing satisfactorily, following upon a threatened interrup- tion. The observation of a few weeks, however, shows that the uterus is not developing in a normal manner. In some cases the diagnosis of new growth of the uterus is made. This is particularly apt to be made if hemorrhages occur, if the finger introduced into the cervix feels a mass in the cavity, or if putrefaction has begun in utero leading to a foul-smelling discharge. Treatment. — Prophylactic. — When a woman has aborted once or several times, the most careful examination should be made, and treatmeut carried out before she becomes j^regnant again. If her health be much run down, an effort should be made to restore it. If there be a syphilitic taint, the parents should be subjected to a long course of antisvpbilitic remedies before pregnancy is allowed to occur again. Diseased conditions in the pelvis should be treated. Thus, a retroverted uterus may require to be replaced and supported by a pessary. Sometimes the removal of adhesions by operation may be necessary. A tumor may require to be taken away. If there be chronic inflammation in the uterus, it should be reduced. After an abor- tion has occurred at least a year (in syphilitic cases longer) should elapse before pregnancy is allowed to take place again. AVhen the woman falls pregnant, she must take particular care of herself, avoiding excitement and fatigue, and paying attention to the digestive tract. She should rest in bed during the times corresponding to menstrual periods, not rising even to urinate or defecate. Coitus during pregnancy should be prohibited, especially in the first half. Purgatives must be avoided. Iron and other tonics need be given only when the system requires them. The administration of potassium chlorate, as 21 322 AMERICAN TEXT-BOOK OF OBSTETRICS. recommended by Simpson, is thought by many to exercise a beneficial influ- ence. The correction of pelvic disorders may be necessary. Threatened Abortion. — The patient must be kept absolutely at rest in bed. For defecation and urination a bedpan should be used. If the bowels do not move naturally, laxatives should not be given ; it is best that the bowels should remain quiet for a few days. The diet should be simple, light, and non-stimulating. Opium or morphin should be administered. At first if uterine contractions are marked, a hypodermic injection (J gr.) of the latter may be given, followed in four hours by a rectal suppository (J gr.). This may be repeated every four or five hours until uterine contractions are quieted. Then the quantity may be continuously diminished. In some cases the drug may be continued several days. To obtain a movement of the bowels a glycerin and olive oil enema should be used. Viburnum pru- nifolium (fluid extract) given by the month in half drachm or drachm doses every six or eight hours is used by many physicians as an accessory to the morphin. Chloral and bromid are also used. When the treatment is satisfactory, the pains and hemorrhage gradually disappear. The woman should then not be allowed to rise, hut should be kept at rest a week or more. When she gets up she should be very careful to avoid all strain, fatigue, excitement, and worry, and should lie down in the middle of the day for an hour or two during the succeeding few weeks. At the succeeding periods corresponding to her menstruation she should spend a few days in bed. Inevitable Abortion. — There is some difference of opinion as to the best method of conducting an abortion case. Should nature be allowed to act, or should artificial means be always adopted ? There is no doubt that artificial cleaning out of the uterus, under proper aseptic precautions, is a most satis- factory procedure, but it is best not to employ this method unless conditions are suitable to a perfect technic. Very often the patient will not allow it to be employed. The carelessness of women in regard to the conduct of abortion is much to be deprecated ; on the part of the physician it is unpar- donable. The recklessness with which many practitioners carry out surgical interference without any regard to asepsis is the cause of much calamity. In a number of cases the uterus may be entirely emptied if the patient be left at rest in bed, and no interference may be necessary. If, however, it be feared that the vagina is not aseptic by reason of digital examination, recent coitus, or some diseased condition, it is best to make use of antiseptic agen- cies in order to prevent infection. These may be applied in the form of s frequent antiseptic vaginal douches. In cases in which hemorrhage is exces- sive it is best, after cleansing the vagina, to tampon the latter firmly with antiseptic or aseptic gauze. In cases also in which the abortion proceeds slowly a tampon is advisable. It acts both as a stimulant of uterine contrac- tion and as a mechanical obstruction to bleeding. It must be noted that in pregnancies later than the fourth month bleeding may goon in utero in some cases even though a firm vaginal tampon be in position. To avoid this it is THE PATHOLOGY OF PREGNANCY. 323 well to allow the liquor amnii to escape by puncturing the amnion, and then to introduce the gauze into the uterus before tamponing the vagina. The plug may be removed in ten or twelve hours, when the complete abortion-mass may often be found in the vagina. If this is not the case, another tampon may be introduced for twelve hours longer. If, however, the uterus be not emp- tied, the patient may be anesthetized and the mass removed with fingers and curet. A hot intra-uterine douche is then given, and the patient kept at rest for ten or twelve days. Many advise the use of ergot in order to promote expulsion and to check hemorrhage. In our opinion this is an unnecessary procedure. In diminishing the hemorrhage of abortion it is not so satisfac- tory as the vaginal tampon, and the large doses necessary are very apt to contract the uterus to such an extent that the os internum will not allow the uterine contents to pass through easily. If the drug be used at all, it should be given only in small doses to improve the tone of the uterine musculature, in cases in which it acts feebly, without producing violent contractions. Quinin is also recommended for this purpose. In Complete Abortion. — When the uterus has spontaneously emptied itself, the patient should be kept in bed and treated as she would be after labor, not being allowed to rise before the tenth day. If there is reason to suspect that the vagina is septic, warm antiseptic douches should be given twice daily for at least a week. When much blood has been lost, or the uterus does not contract well, ergot may be given for a few days. Intra-uterine douching is necessary only when blood-clots tend to accumulate above the os internum, or when there is evidence of intra-uterine infection ; it should be carried out only by means of a double catheter. Sometimes such profuse hemorrhage may occur after a complete abortion as to require an intra-uterine or a vaginal tampon for twenty-four hours or more. In Incomplete Abortion. — The ordinary practice of administering ergot when the uterus is incompletely emptied cannot be too strongly condemned. Though bleeding may be checked for a time, the woman is left in a condition very favorable to the development of aftei'-troubles — e. g., recurrent hemor- rhage, subinvolution, acute or chronic infective processes. An incomplete abortion-mass is a foreign body which should be removed from the uterus. There is some difference of opinion as to whether this should apply to a non- separated and retained decidua vera. As nature's method in spontaneous abortion produces exfoliation and delivery of the superficial vera, discussion is surely needless. There is no doubt that retention of a considerable por- tion of the vera may lead to after-troubles in many cases. Removal of the uterine contents should be carried out as a surgical opera- tion with the strictest attention to technic. The patient should be anes- thetized and placed in the lithotomy position. The vulva and vagina should be thoroughly cleansed, the bladder and rectum having been emptied. The cervix, held by a volsella, should be dilated with a series of graduated dilata- tions, until one or two fingers can be introduced into the cavity of the uterus. The other hand presses down the uterus through the abdominal wall while 321 AMERICAN TEXT-BOOK OF OBSTETRICS. the intra-uterioe fingers explore the cavity, separating the abortion-remains from the wall. These portions may be removed in some eases by the fingers ; when this is impossible, the curet-forceps may be employed. Small shreds may be washed out with a stream of water. When it is impossible to separate all the tissue from the wall with the fingers, a curet or curet-forceps may be employed. In some cases, in which the cervix contracts even after dilatation has been carried out, these instru- ments alone can be used. In the fifth or sixth month, when the fetus is of considerable size, if contraction of the cervix is very marked, it is best to dilate as much as possible, and then to introduce a Barnes bag. After twelve or fourteen hours, if the abortion has not occurred, the uterus may then be more easily emptied. The after-treatment is the same as that already described. In Missed Abortion. — When this condition is diagnosed, the uterus should be emptied. Sometimes the vaginal tampon may stimulate the uterus to con- traction. In other cases the introduction of a Barnes bag into the cervix for a few hours may be necessary. Sometimes dilatation may be carried out, so that the uterine contents may be removed by fingers, curet, and curet-forceps. In every instance the uterus should be carefully explored to insure that nothing be left behind. 7. Extra-uterine Pregnancy. History. — Extra-uterine pregnancy from the standpoint of its etiology, pathology, and operative treatment has provoked such numerous discus- sions and called forth so many valuable essays within the past fifteen or twenty years that the historical side of the subject has received but little attention. From this one-sided view the impression has arisen in the minds of many practical men that this anomalous form of gestation was almost, if not quite, unknown even to our immediate predecessors. A little study of the medical literature of the past four centuries, however, brings to light many classical descriptions of well-recognized eases of extra-uterine pregnancy. Israel Spaeh, in his extensive gynecological work, published in 1597, figures a lithopedion drawn in situ upon a full-length cut of a woman with the belly laid open. He dedicated to this calcified fetus, which he regarded as a "reversion," the following curious epigram, in allusion to the classical myth that after the flood the world was repopulated by the two survivors, Deucalion and Pyrrha, who walked over the earth casting behind them stones which, on striking the ground, became people. Roughly translated from the Latin, this quaint epigram reads as follows : "Deucalion cast stones behind him and thus fashioned our tender race from the hard marble. How comes it that now-a-days by a reversal of things the tender body of a little babe has limbs nearer akin to stone?" We find many of the earliest writers mentioning this form of fetation as a curiosity, but offering no explanation as to its cause. One of the first and THE PATHOLOGY OF PREGNANCY. 325 most natural suggestions was that the fetus had died in utero, and afterward had become displaced into the abdominal cavity, where it excited suppuration and thus was finally discharged. An important discussion was called forth in 1669 by the case of Beuedict Vassal, a surgeon in Corrari, Italy. The great obstetrician Mauriceau's draw- ing (Fig. 155) of the specimen obtained shortly after the autopsy is remark- ably clear, and it well supports his judgment that this was not a tubal preg- nancy as asserted. His description of the case is well worth quoting even at this day : translated freely, it is as follows : " History of a woman in whose abdomen there was found, after death, a small fetus about 2 J inches long, together with a great quantity of coagulated blood. "The history of this case deserves to be carefully considered to decide whether the fetus, as believed by many, was generated in the ejaculatorv ves- sel, called the tube of the womb. On the sixth of January, 1669, in the village Corrari, I saw in the hands of a surgeon named Benedict Vassal a uterus which he had removed a short time before from the body of a woman aged thirty-two, who had died after three days of the most agonizing pains in the stomach, from which she had fallen into frequent fainting spells and the most violent convulsions. This woman had borne eleven children at term, but in her twelfth pregnancy, at about two and a half months, the womb dilated in the direction of the right horn, and, unable to withstand this disten- tion, ruptured. The fetus was expelled into the abdomen, and was found with a great quantity of coagulated blood among the intestines of the mother. Many physicians, surgeons, and naturalists betook themselves to this surgeon to see the uterus which was exhibited by him as a prodigy, as he insisted that the fetus was formed in the ejaculatory vessel, which Fallopius calls 'the trum- pet of the womb.' They accepted at once, without further investigation, that this was just as the said surgeon claimed, and that this case confirmed stories of a like nature narrated by Riolanus. However, I examined the parts of the uterus most carefully and minutely, and it was evident to me that those who accepted this opinion had been led into error ; for this reason, at that time I made a drawing of the womb as it then appeared, and this is a more faithful and accurate reproduction than that which this surgeon had engraved upon copper after a month had elapsed, as the uterus then retained almost nothing of its primitive form, and was spoiled by the handling of a thousand men or more who had seen the uterus, pulled it, disturbed it, and turned it inside out that they might examine it, " Many have adduced this case to prove to us that the testes " [ovaries] " of women are full of little ova which at the moment of coitus free them- selves and emerge from the body proper of the testes, whence they are borne into the uterus through the tube, to serve for the generation of the fetus. They claim that one of these so-called ova had by chance remained in the tube of this woman, instead of passing forward into the uterus, and that this was the cause of her death. 326 AMERICAN TEXT-BOOK OF OBSTETRICS. "Regner de Graaf among others holds this opinion, for the confirmation of which lie brings forward the figure of this uterus, which the surgeon of whom I have spoken had already given to the public; as one finds it on the 260th page of his book on the ' Generative Organs of Women.' Any one Fig. 155. — Case of extra-uterine pregnancy figured by Mauriceau, redrawn, but practically unchanged. The fetus is here shown attached to the sac, which was not the case in his figure. The distinct neck between the sac and the uterus is evident ; the round ligament comes out of the under surface of the sac more toward its outer pole. The relations of a normal uterus are indicated by Mauriceau in dotted lines. who will examine, carefully and without prejudice, the following figure, which is most faithful and faultless, and at the same time look into our reasons, will find that we have given another demonstration which we believe to be the true explanation." Mauriceau with great insight then cites the anatomical relation of the round ligaments to the body of the uterus as substantiating his view of the case. He says, " Behold how clearly I demonstrate that this part in which the child was contained was a portion of the body proper of the womb, and not the tuba uteri na, and this because the round ligament is constantly attached directly to the lateral wall of the body of the womb, called the cornu, and at this place it becomes fused with the substance of the womb. It is therefore certain that the part where the ligament ended (Fig. 155), and at which it was strongly attached on the right side, where the malformation existed, was a portion of the womb itself; consequently the child was engen- dered in a part of the womb that was elongated." It is interesting in this connection to note that Mauriceau, in this differen- tial diagnosis, anticipated some of the results of our latest investigations con- cerning the differences between tubal, cornual, and interstitial pregnancy and pregnancy in a rudimentary horn. From the above it is evident that Mauri- THE PATHOLOGY OF PREGNANCY. 327 ceau was positive that impregnation had not occurred in the Fallopian tube, but in one cornu of the uterus, and that the ovum had developed as a hernia from the uterus. I find that Regner de Graaf, just as Mauriceau states, accepted the view of Vassal, and in his description of the Fallopian tube reports the case and reproduces the figure from the copper plate which Mauri- ceau condemns. De Graaf believed that this was a case substantiating his own theory regarding the function of the ovaries and the Fallopian tube. He Fig. 156. — Reduced figure of Deutsch's case of abdominal pregnancy (an account of which was published in 1799 with life-size copper-plate engravings). says, "We judge that the tubes called Fallopian in women and in every kind of female are true vasa deferentia, or, if you prefer, oviducts, inasmuch as the ova are transmitted through them to the uterus." He further says, " The tube or horn [Fallopian tube] of the womb is dilated and affected by semen corrupted there and seeking an outlet ; but it is remarkable that the male semen should reach that point and that a fetus should have been conceived there, as is proved by histories." De Graaf believed that the ova were fertilized in the ovaries and that they were then carried downward into the uterus, where they remained until the full term of gestation was completed. He does not offer any explanation of the arrest and development of the ovum in the tube ; on the contrary, he dis- tinctly states that he does not know why it occurs. He recognized, however, the dangers of this anomalous pregnancy, as indicated by the following state- 328 AMERICAN TEXT-BOOK OF OBSTETRICS. ruent : "The ovum already fertilized is detained in its transit in the tubes, and by its increase in size brings death to the mother." In his critical remarks upon Vassal's case he says : " And from this our opinion it is not difficult to explain how a fetus occasionally develops in the abdominal cavity among the intestines, inasmuch as the ova already impregnated fall from the testes" [ovaries] " outside the cavity of the tubes and are nourished by the neigh- boring parts." From these references to the earlier literature it will be seen that ectopic gestation was clearly recognized, its symptoms graphically described, and the theories advanced those that are accepted by many writers of the present day. Numerous other contributions are found in the literature of this subject, following De Graaf and Mauriceau, one of the most interesting being figured in the obstetrical work of Peter Dionis of Paris, published in the early part of the eighteenth century. Even so early as 1741, Bianchi constructed an elaborate classification of the forms of extra-uterine pregnancy, which was simplified by Boehmer in 1752, who described three forms — "gestatio ovarica," "gestatio tubaria," and "ges- tatio abdominalis." From the time of Boehmer a period of forty-nine years intervened in which this classification remained practically unchanged. In 1801, Schmidt described the interstitial form of ectopic gestation, and with this addition Boehmer's classification must practically be accepted even at the present clay, with the exception of a primary abdominal form. Etiology. — No entirely satisfactory conclusions have yet been reached regarding the cause of this anomalous form of pregnancy. Among many theories none have been demonstrated. One great difficulty lies in the fact that it has not yet been determined at what point in the female genital tract normal impregnation of the ovum takes place, and until this question is settled the primary question, t whether extra-uterine fetation is an abnormal ectopic impregnation or is simply a detained impregnated ovum, must remain unanswered. Many claim that the seat of coalescence of the male and the female elements is normally in the Fallopian tube. If this claim is admitted, it can readily be seen how a variety of causes might operate to detain the ovum in the tube, where it may continue to develop extra-uterine. Chief among the causes ascribed a few years ago, at the revival of this subject, was the loss of the tubal ciliated epithelium, which would manifestly conspire to prevent the ovum from being carried on down into the uterus ; other causes cited have been flexions of the tube, dilatations and diverticula, constrictions from inflam- matory changes, and polypi in the tube, closing its lumen like a valve. While a variety of causes may operate, it is most probable, from the frequencv with which old inflammatory disease is found coexisting on the other side, that most cases of tubal gestation arise from ileus of the tube, resulting in an inability to transmit the contents of the tube, due to adhesions. An important cause, operating in cases where the pregnancy is toward the outer end of the tube, is the presence of a diverticulum, as pointed out bv J. W. Williams and others. THE PATHOLOGY OF PREGNANCY. 329 Classification : Primary Forms. — The primary forms of extra-uterine preg- . nancy are classified as follows : Tubo-uterine or interstitial. 1. Tubal: [ Y^u' 2. Ovarian. Ampullar. [_ Fimbria tubo-ovarica. Secondary forms are derived from the primary, as follows : , x -n * ( Uterine ; M u „ (1 ( Tubo-ovarian ; (a) From the I g d „' (o) From the I Abdomina , interstitial : | Abdomimih ampullar : | BrQad ^^ (6) From the f Abdominal ; (d) From the J Abdominal ; isthmial : \ Broad ligament. ovarian : ( Tubo-ovarian. In tubal pregnancy, when the fertilized ovum develops out near the fimbri- ated extremity of the tube it is called ampullar ; at the inner portion of the tube it is called isthmial; while in that part of the tube which traverses the uterine wall it is designated interstitial or tubo-uterine. It is in the latter form that the term extra-uterine pregnancy becomes a misnomer, as the conception is not, strictly speaking, extra-uterine, being enclosed in the wall of the uterus, although outside its cavity. For this reason Mr. Tait suggested the term ectopic gestation. Many writers, more pi'actical than scientific, misled by Mr. Tait's dogmatism, go so far as to hold that there is but one form of ectopic gestation — namely, the tubal — and so able a pathologist as Bland Sutton gives them countenance by his denial of the ovarian and abdominal forms, as he considers the cases which have been reported do not sufficiently demonstrate their existence. Xo criticism, however, has yet succeeded in destroying the claims of cases of Leopold, Patenko, and Martin, which we must accept as primarily ovarian. In Leopold's case the patient was operated upon for a pelvic tumor of twenty-five years' standing that proved to be an ovarian tumor containing a lithopedion. In the walls of the tumor ovarian stroma was clearly demonstrated. Patenko's case is even more striking. The right ovary was the size of a hen's egg, and it contained a cyst with smooth walls in which was found a yellow body, the size of a hazel-nut, composed of cylindrical and flat bones. These bones, which were submitted to a careful microscopical examination, were found to be fetal in origin and not the product of a dermoid cyst. The enveloping wall contained corpora lutea and follicles. The tube of the affected side had no adventitious connection with the ovary, and its fimbriated extremity was entirely free, although the internal ostium was closed and some of the fimbria? were gone. Opponents of the theory of ovarian pregnancy take exception to this case, claiming that the gestation was primarily tubal, and that a so-called " tubal abortion " had occurred into the ovary, and that later the ovary and the tube had become detached from each other ! Martin of Berlin reports two cases which he believes are examjjles of undoubted primary ovarian pregnancy. In these cases the gestation-sac was situated entirely within the ovary, the fimbriated extremity of the tube being intact. As an explanation of ovarian pregnancy Martin advances the very 330 AMERICAN TEXT-BOOK OF OBSTETRICS. natural suggestion that the spermatozoon finds its way through the fimbriated extremity of the tube into one of the small recently-ruptured cysts so fre- quently found on the surface of the ovary, and that it there coalesces with the ovum. Too few observations have yet been made to prove the possibility of pri- mary abdominal pregnancy, although the case of Schlectendahl is difficult to explain upon any other hypothesis. In this case a fetus measuring 15 centi- meters (6 inches) in length was found attached to the abdominal wall near the spleen in a woman who had died of hemorrhage. The gestation-sac was sur- rounded by adherent intestines, and the uterus and appendages appealed nor- mal. For the present, however, only two primary forms of ectopic gestation — tubal and ovarian — can positively be accepted. Practically, as Taifc insisted, tubal pregnancy is the only primary form found. ■--. ■ s ■■<:■ Fig. 157.— Prof. August Martin's case of ovarian pregnancy. The intact tube is seen lying above the ovarian sac containing the fetal envelopes. Secondary Forms. — The secondary forms of ectopic pregnancy are derived from the primary. The tubo-uterine or interstitial pregnancy may rupture into the uterus and be followed immediately by expulsion of the fetus, or it may go on to full term and be delivered in the natural way. This mode of termination, unfortunately, is rarer than two other possibilities — namely, rup- ture into the abdominal cavity or rupture into the broad ligament. In the isthmial form of tubal pregnancy the rupture occurs either into the abdominal cavity, thus forming a secondary abdominal pregnancy, or into the broad" ligament, forming extra-peritoneal, broad-ligament pregnancy. The ampullar form of tubal pregnancy gives rise to secondary tubo-ovarian, abdominal, or broad-ligament pregnancy. Tubal Pregnancy. — In the first week after fecundation of the ovum the tube begins to thicken, due chiefly to vascularization without hypertrophy of the muscular fibres. In this respect the tubal envelope differs in its develop- THE PATHOLOGY OF PREGNANCY. 331 ment from that of the uterine muscle in normal pregnancy. In the latter case there is hypertrophy of the individual muscle-fibres to eleven times their length in a normal non-pregnant uterus ; the connective tissue, peritoneal covering, blood-vessels, and lymphatics being also increased by hypertrophy and hyperplasia, so that at full term the uterus weighs two pounds instead of two ounces, the weight of a virginal uterus. The thickening in the pregnant Fallopian tube is due to excessive vascularization with but slight increase in the tissue-elements. As the pregnancy progresses the wall of the tube becomes thinned and stretched until in some cases it appears as a thin transparent mem- brane composed only of an attenuated stratum of muscle covered with peritoneum. The development of the fetal membranes derived from the ovum, with the exception of the placenta, is the same as in intra-uterine pregnancy. Nor- mally, the placenta is derived about equally from the decidua serotina of the uterus and the chorion frondosum of the ovum. In tubal pregnancy Bland Sutton holds that the placenta is largely fetal in its origin. As the embryo increases in size and the walls of the tube become stretched, the plica? in the mucous membrane lose their characteristic appearance and are gradually smoothed out. During the first four to six weeks the abdominal ostium of the tube becomes hermetically sealed. Until the fetal membranes are well formed the life of the fetus is in constant jeopardy, as the chorionic villi have but a feeble hold upon their points of attachment to the tube and may easily be dislodged. This termination is most favorable from the first to the third week of the pregnancy, and it may be so harmless as to give rise to no serious discomfort. An apoplectic ovum thus detached appears as a lump of coagulum, and unless carefully examined its true character may be overlooked. Such bodies, known as " tubal moles," are always products of an ectopic preg- nancy. As the pregnancy advances the formation of the tubal mole is attended with much greater danger, as the accompanying hemorrhage often causes rupture of the tube, followed by rapid death of the mother. These moles, if recent in origin, contain the embryo and its mem- branes. The essential diagnostic point is the discovery of chorionic villi or of the embryo itself. If extruded into the abdominal cavity or into the broad ligament the mole loses its characteristic appearance and soon becomes envel- oped in a yellowish coat of fibrin, and there may be such complete disinte- gration of the fetal tissues as entirely to obliterate its embryonic characteristics. The villi, however, are most persistent, and they may be found after the other evidences of their origin have disappeared. These villi have the same appear- ance under the microscope as those of normal pregnancy. If the ovum continues to grow, the point at which the placenta is attached is of the greatest importance to the mother, as upon this largely depends her chance for life in case of rupture. If the placenta is implanted on the superior wall of the tube, the mother is in constant peril, as rupture here may be fol- lowed by frightful hemorrhage, the lacerated or detached placenta having no counter-pressure to control its bleeding, as is the case when it is attached to 332 AMERICA X TEXT-BOOK OF OBSTETRICS. the floor of the tube. For this reason many surgeons claim that this termi- nation is invariably fatal. If the placenta is implanted on the floor of the tube, the chances of rupture are not necessarily decreased, but the dangers attending this accident are far less to the mother. In this position the pla- centa is pushed downward against the resisting pelvic floor, insinuating itself between the layers of the broad ligament. If the embryo is extruded through the upper wall of the tube, the placenta may still retain a firm attachment and only slight hemorrhage follow, and the immediate clanger be escaped in this way. Occasionally the ovum is lightly attached in the ampullar extremity of the tube, and is extruded into the abdominal cavity without rupture of the tubal walls. This extrusion is known as a "tubal abortion." As evidence of this the fimbriated extremity of the tube is found enlarged and patulous, and there is free blood in the abdominal cavity, in which the tubal mole may be found if the abortion is recent. Tubo-uterine or Interstitial Gestation. — The history of the embryonic development in this type of ectopic gestation differs from the tubal proper on account of its difference in envi- ronment. Here the muscular fibres of the uterus undergo the same changes as in normal preg- nancy. Rupture is almost inev- itable, but it does not occur so early as in the tubal variety, on account of the greater thickness of the walls surrounding the ges- tation-sac. Hecker collected twenty-six cases in which rupture occurred before the sixth month. The fetus occasionally escapes into the uterus, and it is either ex- pelled at once or it goes on to regular term and is born in the natural way. Rupture occurs most frequently into the abdom- inal cavity, and in such cases the hemorrhage is profuse and usually terminates the patient's life in a short time. Interstitial pregnancy is rarely recognized before rupture. Rupture of the Sac. — The time of rupture of the sac depends upon its location and, to a certain extent, upon the attachment of the placenta. In tubal pregnancv primary rupture occurs usually between the second and the fourteenth week. When the placenta is implanted on the floor of the tube, the probability is that the rupture will not take place so early as when it is situated on the superior wall. The causes of rupture are thinning of the walls of the tubes beyond the limits of elasticity, hemorrhage into the sac, traumatism, and gradual enlargement of the embryo. If the patient survive the primary rup- Fig. 15S.— Diagram showing pelvic hematocele poste- rior to the uterus, which is crowded forward with the bladder behind the symphysis pubis, while the rectum is compressed behind against the sacrum (Skene). THE PATHOLOGY OF PREGNANCY. 333 ture, the fetus may still continue to develop, either burrowing downward between the layers of the broad ligament or growing upward into the peri- toneal cavity among the intestines. The injury to the placenta is much less when it is situated on the pelvic floor, as the displacement is not so marked, the hemorrhage is not so profuse, and consecpiently the lives of the fetus and the mother are in less jeopardy at the time of rupture. If blood is poured into the peritoneal cavity, it will usually be absorbed ; if the collection of blood occurs between the layers of the broad ligament, it constitutes pelvic hematocele (Fig. 158). When the fetus becomes intra-ligamentary and con- tinues its development in that position, it is known as broad-ligament gesta- tion. After the twelfth week the sac is liable to secondary rupture at any time up to term. Here again the situation of the placenta is of the same importance in the prognosis as in the primary rupture. Fig. 159.— Ruptured left tubal pregnancy, fetus still attached and lying within the pelvis. Hydrosal- pinx and adhesions on the right side. Uterus displaced toward the right by the sac : u is the fundus uteri ; r, the rectum ; (, the right closed tube ; /, the fetus ; and s, the ruptured extra-uterine sac. The Fetus. — The question as to the possibility of life for the fetus is influ- enced by the location of the pregnancy. In the tubal variety the most favor- able attachment of the placenta is on the floor of the Fallopian tube, as there may be slight if any disturbance of the fetal circulation if the rupture be in the superior wall of the tube, when the child may go on to full term (Figs. 159, 160). Even, however, if the ectopic fetus be delivered alive, it is often deformed and puny and rarely lives more than a few days. For this reason its life should be but little regarded in the treatment of ectopic gestation. The disposal which nature makes of the fetus in case the mother survives the rupture is also of considerable interest. The dead embryo lying free in the abdominal cavity may be completely absorbed up to the second month ; after that period it either undergoes mummification, calcification, or is con- verted into adipocere, or decomposes. Mummification is analogous to the change which bodies undergo in a dry atmosphere. A mummified fetus in its general appearance closely resembles bodies found in arid regions buried in 334 [3IEBICAN TEXT- BOOK OF OBSTETRICS. dry soil or in sand or exposed to the air. The fluid constituents of the extra- uterine gestation are absorbed, and the soft tissues become leathery or parch- ment like. In other cases the fatty elements are converted into adipocere or into ammoniacal soap in the presence of ammonia formed by the decom- position of the tissues. Either the mummified or the adipocere fetus may still undergo further change and become partially or wholly calcified. This pro- cess is not entirely confined to the superficial parts, as there have been described a number of specimens which exhibited the saponaceous or the mummification process on the exterior while the internal organs were calcified. A fetus which has undergone calcification is known as a lithopedion. The fetal mass may remain indefinitely in the abdominal cavity without giving rise to any discomfort to the mother. Cases are reported in which Fig. 160.— Cornual pregnancy. In this case rupture occurred in the right undeveloped cornu of a bicornute uterus (from a specimen presented to the writer by Dr. Watson of Baltimore). such bodies have stayed for ten and fifteen years, in one instance for fifty-four years, in the pelvis without giving rise to serious trouble. On account of the close anatomical relation between the gestation-sac and the rectum and intestines a slight rupture of the intervening walls may occur at any time, or a diapedesis may take place and pyogenic organisms gain access into the sac and induce suppuration. The fetus is then converted into a putrid mass, which may be discharged into the rectum, the vagina, or the bladder. Occasionally the sup- purating mass ruptures at some point on the anterior abdominal wall even so high as the umbilicus. The latter termination is frequently noted in the older medical literature. Symptoms. — All the symptoms characteristic of normal pregnancy may be present. Frequently, however, the subjective symptoms are entirely absent, and the patient may be quite unconscious of her condition. The increase in THE PATHOLOGY OF PREGNANCY. 335 the areolar circle around the nipple and other mammary changes, the gastric disturbance, pain on the affected side, associated with amenorrhea, are the most characteristic symptoms. Too much stress, however, must not be laid upon the absence of the menstrual flow, as it is subject to the greatest variations. In some cases instead of amenorrhea there will be profuse metrostaxis with the expulsion of small bits of decidua. It is of importance not to confuse the decidua of ectopic pregnancy with that of membranous dysmenorrhea. In the latter condition the decidua is usually expelled in small pieces and rarely as a cast of the interior of the uterus. When floated out in water numerous delicate velamentous processes are seen. This membrane is rarely more than one or two lines in thickness, and it is usually very friable. The decidua of ectopic pregnancy is much thicker, varying from 5 to 20 millimeters (^- to finch); it is much less fri- able, the uterine surface being covered with a thick, shaggy, villous coat, and instead of small bits it is usually expelled in large pieces or as a complete cast of the interior of the uterus. Pain is variable, in some cases being almost constant, in other cases absent. The character of the pain before rupture may be sharp and lancinating, or there may be dull and heavy aching. The statement of the patient that she considers herself pregnant is of some value, as that ill-defined sense upon which she bases her opinion may be the only subjective indication of her condition. The appearance of the external geni- talia may be the same as in normal pregnancy. Under these circumstances the vaginal mucous membrane appears purplish in hue, the cervix is soft, the os uteri is usually closed with a plug of mucus, and the uterus, instead of its pyriform shape, is now globular and enlarged to the size of a one-month pregnancy. If an examination be made before rupture, the Fallopian tube of one side will be found enlarged, and if far advanced the uterus will be forced from its position in the median line by the growth of the tumor. If the pregnancy is advanced to the third or the fourth month, a circumscribed tumor, well defined as an area of dulness on the anterior abdominal wall, may be outlined by percussion. Vaginal examination reveals this tumor lateral and posterior to the uterus, with a well-marked sulcus between it and the uterus. Unfortunately, it is only in the rarer instances that a physician is called before rupture occurs, when, unless he is a skilful specialist, the prob- abilities are that ectopic gestation will not be suspected. The growth of the tumor may give rise to pressure-symptoms, such as constipation and dysuria, but the} - are of little special significance, as any pelvic tumor may be attended with similar disturbances. Rupture. — The symptoms of rupture are very characteristic, and they usually are so definite as to cause little doubt in diagnosis. A patient pre- viously healthy or only slightly complaining is suddenly seized with severe abdominal pains, sharp or lancinating, cutting or agonizing. The attack in many instances cannot be ascribed to external violence or to undue exertion on the part of the patient, as she may be in the midst of light household work, 336 AMEBIC AX TEXT-BOOK OF OBSTETBICS. or walking on the street, or even be in bed when the rupture occurs. Previous to the attack she may have had no discomfort or only the slight disturbances of pregnancy. If the hemorrhage is extensive she may fall unconscious as if struck a blow. The pulse, at first rapid, soon becomes almost or quite imper- ceptible ; the respiration is quickened, then becomes jerky, and finally the air- hunger so characteristic of severe hemorrhage becomes pronounced ; vertigo, nausea, and vomiting are present. The symptoms soon merge into those of profound shock, the extremities being cold and clammy, the skin pale, the conjunctiva? pearly, and the lines about the mouth drawn. If the patient is conscious and is able to talk, she will usually complain of intense abdominal pain. Death may follow soon after intraperitoneal rupture, or it may be delaved for a dav or even longer. In some instances the bleeding ceases for a short time and is followed by gradual improvement in symptoms, but it again begins a few hours or some days later, and the patient survives only a few minutes. In extraperitoneal hemorrhage from rupture into the broad ligament the symptoms may not be so urgent. The initial attack in both instances is simi- lar, as the peculiar sharp pain at the onset is due to rupture of the tube. The blood as it accumulates usually checks the hemorrhage by its own pressure, and the patient may have no further trouble. If the embryo dies at the time of primary rupture into the broad ligament, no further discomfort is felt, as a rule, as a harmless hematocele is all that remains. Unfortunately, in many instances this is not the termination, and the fetus continues to develop, and sooner or later a secondary rupture occurs, attended by the same symptoms as the primary rupture. In the rarer cases, which go on for nine months, labor-like pains come on and closelv simulate those of normal parturition. These pains may continue for hours or even for davs, and then cease. The escape of blood and of por- tions of the decidua occurs in a majority of cases at this time, and may mis- lead the attending physician into the diagnosis of abortion if the constitutional symptoms are not urgent. The subjective symptoms of pregnancy are almost alwavs present in such advanced cases. The fetal movements may have been so much on one side as to call the mother's attention to this phenomenon. The fetal heart-sounds are distinct, being heard with unusual clearness. In cases surviving the rupture the sharp labor-like pains gradually sub- side, the secretion in the breasts disappears, the tumor decreases rapidly in size, and as soon as the patient recovers from the shock and loss of blood she may regain her health. It is in these cases that absorption or one of the other changes that render the fetal body innocuous takes place. Infection of the incarcerated fetal mass may occur at any time, even years after the death of the embryo, followed by a train of symptoms similar to those attending pus- formation from other causes. Diagnosis. — The history, if carefully reviewed, often directs attention strongly toward ectopic gestation. The pregnancy usually occurs in a mul- tipara some vears after the birth of the last child, although it may follow THE PATHOLOGY OF PREGNANCY. 337 shortly. There may have been an intervening attack of acute inflammation of the tube or of pelvic peritonitis. This is strongly insisted upon by those who advocate the theory that tubal gestation is due to an old inflammatory process which has changed the normal histology of the tube. A characteristic history is as follows : A woman who has borne one or more children, after an interval of from five to twenty years of sterility observes symptoms of another pregnancy. Her menses, which have been regular, cease, and the morning nausea, pain in the breasts, darkening of the areola, and other symptoms characteristic of her former pregnancies appear. In addition to these symptoms, she has in one ovarian region dull pain, at times so severe as to cause her to seek the advice of her phy- sician. This pain may continue until it culminates in the acute paroxysms caused by rupture, or it may cease, and not be noticed again until the rupture occurs. The most characteristic symptom of all is the sudden sharp pain of Fig. 161.— Diagrammatic sketch showing relations of an unruptured sac (s) to uterus (u), round ligament (ri), and bladder (6). The numerous adhesions are suggestive as to the etiology. the rupture. If followed by a marked anemia it is still more decisive. The bimanual examination, taken in conjunction with this history, points with absolute certainty to the nature of the pregnancy, and the diagnosis is com- paratively simple. In the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. In the normal uterine pregnancy, as the embryo develops the uterus is dis- tended equally in all directions, but occasionally the ovum develops in one corner, distending the uterus on that side, which may prove misleading. In pregnancy occurring in the rudimentary horn of a bicornute uterus the symp- toms are so nearly alike that a differential diagnosis is not likely to be made. Kussmaul collected thirteen cases of pregnancy in rudimentary coruna, the majority of which had been reported as tubal pregnancies. If an exploratory section be performed in these doubtful cases, the anatomical points insisted upon by Mauriceau are of the greatest value in making a differential diagnosis. 338 AMERICAN TEXT-BOOK OF OBSTETRICS. They are as follows : In cornual pregnancy the round ligament is situated anterior to the outer side of the gestation-sac. In tubal pregnancy the round ligament is situated on the uterine side (Figs. 160, 161). Pregnancy occurring in one horn of a well-developed bicornute uterus may go to term and give rise to no untoward symptoms. A pregnant uterus devi- ated to one side by a myoma may be mistaken for ectopic gestation. The diag- nosis, however, can usually be made if the examination is conducted under anesthesia, as it will be found that the tumor varies its position with that of the enlarged uterus, and is directly continuous with it, in addition to being densely hard. The question of interstitial pregnane}' naturally arises in these cases, and if the character of the tumor cannot be recognized at the first exam- ination, the patient's symptoms should be observed carefully, and she should be examined again later to decide whether there is any increase in the size of the suspected tumor. If there is a perceptible increase, the probabilities are that it is interstitial pregnancy. An adherent retroverted gravid uterus may also give rise to misleading symptoms, such as sharp pains, obstinate constipation, pelvic pressure, dysuria, etc., but it is readily differentiated by a bimanual rectal examination, if necessary drawing the uterus down with traction for- ceps so that the fundus may readily be palpated. Ovarian tumors and enlargements of the Fallopian tubes, associated with intra-uterine pregnancy, may cause confusion, especially if the tumor lateral to the uterus gives rise to sharp pain, as may occur in pyosalpinx. In such instances the question of a twin pregnancy, one intra-uterine and the other extra-uterine, must be considered. As fever accompanies pyosal- pinx in the majority of cases, it must carefully be considered in the differ- ential diagnosis. If it be impossible to arrive at definite conclusions con- cerning the suspected mass, and the life of the patient seems in peril, an exploratory celiotomy is justifiable, otherwise expectancy is the safer course. Occasionally a pedunculated ovarian cyst becomes strangulated by axial rota- tion : such an accident is accompanied by pain, vomiting, rapid pulse, and other constitutional disturbance, at times amounting to profound shock. Kup- ture of an ovarian cyst may also be difficult to differentiate from the rupture of an ectopic gestation-sac; in such cases the history and the vaginal examina- tion will clear up the diagnosis. To summarize briefly, it may be said that the diagnosis of ectopic gesta- tion depends upon the following cardinal points : 1. A history of probable pregnancy. 2. Paroxysmal pains, usually located on one or the other side of the pelvis. 3. Irregular metrostaxis. 4. The expulsion of bits of decidua. 5. Coincident enlargement of the uterus and softening of the cervix and discoloration of the vagina. 6. Tumor lateral or posterior to uterus and indirectly connected with it, uterus moderately or not at all enlarged. 7. Changes in the breast. 8. Anemia. THE PATHOLOGY OF PREGNANCY. 339 The diagnosis of ectopic gestation after the death of the fetus is largely dependent upon the clinical history; if this be deficient, the diagnosis is fre- quently impossible, especially if there has been a long interval between the rupture and the time when the patient consults the physician. If the fetus has undergone calcification, it may be felt as a hard mass, but even this is not conclusive, as a calcified myoma may present similar characteristics. Treatment. — From the operative standpoint it is best to divide ectopic pregnancy into the following periods : 1. Before rupture; 2, at the time of rupture ; 3, after rupture; and 4, after calcification, saponification, mummification, or suppuration of the fetus has occurred. 1. Before Rupture. — The electrical treatment, so much advocated a few Fig. 162.— Diagram of intraperitoneal rupture of tubal pregnancy. Free blood in Douglas's cul-de-sac and among the intestines (Dickinson) : S, symphysis ; R, rectum. years since for the destruction of the fetus, while valuable in its day as pio- neer work, has deservedly fallen into disrepute, because of its uncertainty in terminating the fetal life and of its dangers to the mother through subsequent inflammation. The injections of fluids into the sac for the same purpose is so utterly foreign to present ideas of treatment that it is only mentioned to be condemned. The proper course to pursue is the removal of the affected tube. Precipitate operation, however, is not advisable, as the diagnosis should be as accurate as possible before resorting to radical measures. Cases with a history suggestive of ectopic gestation and a mass lateral to the uterus detected by vaginal examination should be operated upon without hesitation. A cer- tain proportion of such cases will prove to be pyosalpinx or hydrosalpinx, but an error is not serious, as in either instance operation is indicated. The 340 AMERICAN TENT-BOOK OF OBSTETRICS. utmost care must be taken not to rupture the thin-walled sac by the pressure of the hands during an examination. 2. At the Time of Rupture. — If called at the time of rupture, the surgeon must operate immediately. While the surgeon is making his preparations the patient should be elevated with the hips high in the bed, to throw the blood as much as possible into the upper part of the body. She should receive at once an infusion of a quart of normal saline solution under the breasts. I prefer to do this with the two caunulse of Sweetnam, of Toronto, by which both breasts are injected at one time. Hypodermics of strychnin should be given every half hour, at first -^ and after that ^ of a grain. A hot stim- ulating rectal enema containing coffee and about 30 grains of carbonate of ammonia is of value. I would also in a bad case firmly bandage the four limbs, so as to keep what little blood was left in the body. Hot bags or bottles will also aid in keeping up the vitality. Preparation for Opera- tion. — The chances for re- covery following operation in extra-uterine pregnancy depend upon the careful observation of all the de- tails of antiseptic and asep- tic technique. For this reason a precipitate opera- tion is always attended with greater danger, as of necessity care in details must be sacrificed. The surgeon should alwavs have a complete set of abdominal instruments and accessories sterilized and packed ready for use. If the operation is hurried, select a well- lighted room or provide a portable electric light ; remove all unnecessary fur- niture, dampen the floor to prevent dust rising, but do not disturb the curtains and other hangings further than is absolutely necessary. A common kitchen table can be turned into an operating-table, with a chair inclined against one end, upon which the patient's feet may rest. Cover the table with a folded blanket, lav upon this an ovariotomy drainage cushion, and place a small pillow at the head. As it may be necessary to irrigate, a douche-bag should be suspended in a convenient position near to, and about 4 feet above the level of, the table. Two smaller tables are required for the instruments and dressings, and three or four chairs for the wash-basins and sponge-dishes. A room thus hastily improvised serves admirably for an operating-room. An abundance of boiled water is necessary. Directions should be given immediately after deciding to operate concerning the preparation of the water. A wash-boiler or other large tin vessel must be scalded thoroughly, and be Fig. 163.— Dr. Peck's ease (Youngstown, Ohio) of extra-uterine pregnancy in the third month ; operation at time of rupture ; recovery. THE PATHOLOGY OF PREGNANCY. 341 partially filled with water which is allowed to boil for an hour if possible. It is best to let the water cool to 110° F., but if time is pressing pure cold water from a well or a hydrant may be used for reducing it to proper tem- perature. This method of cooling the water, however, is not advisable except under stringent necessity. Great care must be observed by the physician in disinfecting his hands : they should be scrubbed thoroughly with a nail-brush with soap and water, followed in succession by immersion in permanganate of potassium (hot sat. sol.) and oxalic acid (hot sat. sol.). A quart of each of these solutions is sufficient. Or, better still, he should scrub his hands rapidly and then put on a pair of sterilized rubber gloves. The nurse and assistants aiding him should also wear gloves. The patient, under anesthesia, is then transferred to the operating-table and is rapidly prepared for abdominal section. The anterior and lateral surfaces of the abdomen are thoroughly washed with soap and water, followed by alcohol, then by ether, and finally by bichlorid solution (1 : 1000). As it may be necessary to open the sac through the vagina, this passage should be washed thoroughly with soap and water, fol- lowed by bichlorid solution (1 : 1000) and an iodoform pack. All dressings, towels, and gauze to be used in immediate proximity to the field of operation are best provided by the surgeon, who should always carry them among his accessories, as the sterilization of these articles cannot be entrusted to an untrained person. Instruments are taken from their sterilized envelope and placed on towels or in trays. 77ie Operation. — The patient is put on the table with the pelvis elevated, about a foot above the level ; the abdomen is then opened freely in the median line; if there has been much hemorrhage, the clots should be turned out, exposing the ovarian and uterine arteries, which ai - e caught either with for- ceps or between the fingers. If on attempting to clear the pelvis of clots fresh blood wells up, no further time should be lost in attempts to expose the bleeding points, but the operator must introduce his hand into the pelvis, grasp the uterine and ovarian arteries, and then apply hemostatic forceps, guided by the sense of touch alone. Having controlled the active hemor- rhage, he must then carefully cleanse the abdomen of clots, preserving the debris as he does so, in order to discover the embryo or the tubal mole. If the pregnancy is in the first or second month, the radical operation consists of a simple salpingo-oophorectomy of the diseased side. If the ovary is easily isolated, the uterine tube alone should be removed. In the case of a young woman in whom the opposite uterine tube was diseased or had been removed, I would be willing even to empty the tube and ligate the nearest large vessels and close the abdomen with an iodoform gauze drain, in the hope that with complete recovery she might still be able to pass through a normal pregnancy. If, however, the term is farther advanced and the pla- centa is extensively attached to surrounding structures, the uterus, the blad- der, the intestines, and pelvic walls, the operation is not so simple, and calls for good judgment to determine how r best to deal with the placenta. It is exceed- 342 AMERICAN TEXT-BOOK OF OBSTETRICS. i'.igly hazardous to attempt the forcible removal of a placenta which is firmly attached, as the hemorrhage following its dislodgement may be so extensive as to defy control. In such cases it is best to leave the placenta in situ, for to attempt its removal would take away any chance the patient has for life in her condition of shock and exsanguiuation. In an extreme case no means further than those necessary to save life at the time of operation should be undertaken, as the essential principle is first to control hemorrhage, leaving subsidiary conditions for subsequent consid- eration. If the placenta is attached exclusively to the floor of the tube or the pelvis, its blood-supply may be derived from numerous vessels, and an attempt to control these by ligation would be impossible. The best course to pursue in such cases is to check the hemorrhage, tie and cut the cord close to its placental origin, and leave the placenta undisturbed. Drainage should not be employed in these cases, because of the increased danger of sepsis. The proper treatment is to close the abdomen completely, and after the patient has recovered a second operation may be performed for the removal of the placenta if it causes untoward symptoms. The greatest care in aseptic and antiseptic details should be observed, as upon the absence of infection depends the patient's chance for recovery when the placenta is not removed. If the operation is aseptic, the prognosis is good, and the placenta may atrophy and give no further trouble. If, however, the wound is infected, suppuration of the placental mass may occur, terminating in general peri- tonitis or in a pelvic abscess. Often in the course of an oj)eration the pla- centa becomes detached and may be removed with the fetus. In all cases in which the operation follows the death of the fetus by some days or weeks the placenta is held by only the slightest attachment or it may lie free in the gestation-sac. It is for this reason that the operation is more favorable at such a time, as the dangers, of hemorrhage are greatly decreased. In some cases, especially those in which there is a temporary cessation of the bleeding, the slightest disturbance of the sac after the abdominal cavity is opened causes a renewal of the hemorrhage. Bold surgical measures are then demanded : the operator should sweep his hand rapidly around the ectopic sac, loosening the adhesions, after which the sac is delivered from its bed of adhesions. The points of bleeding can then be reached and con- trolled by forceps. In case there is extensive oozing on the floor of the pelvis after the removal of the placenta, which it is difficult or impossible to control by liga- tures, a strip of iodoform gauze should be packed firmly clown upon the bleeding points. When there is much fluid and many clots are scat- tered throughout the abdominal cavity, free irrigation with sterilized normal salt solution (6 per cent.) at a temperature of 110° F. should be employed ; 3 or 4 liters (3 or 4 cpiiarts) of the solution may be necessary to cleanse the cavity. There is no danger from the distribution of this material in the abdomen by irrigation, as the ectopic product is usually sterile. In all ectopic cases that undergo operation the opposite tube and ovary THE PATHOLOGY OF PREGNANCY. 343 should closely be examined, and if seriously diseased, their extirpation is demanded : to allow a diseased tube and ovary to remain, which can be of little if any further functional value, would only subject the patient to the dangers of a subsequent ectopic pregnancy or to the discomfort and pain due to adherent appendages. In most cases, however, the tube alone is affected and the ovary is only accidentally involved in the adhesions. 3. Some Days or Weeks after Rupture. — Cases are not usually submitted to operation at the time of rupture, as by the time the surgeon is called the patient is either recovering or is dead from extensive hemorrhage. In a certain proportion of cases the patient, although feeling the sharp pain accompanying the rupture and being compelled to keep to her bed for a day or so on account of weakness, does not call her physician, as she considers it only a trifling matter associated with her pregnancy. There occur undoubt- edly a considerable number of cases like the latter in which the death of the fetus occurs at the time of rupture and no further symptoms are observed, and the patient makes a perfect recovery. It is for this reason that a statis- tical table compiled for the purpose of ascertaining the rate of mortality in extra-uterine pregnancies due to rupture is fallacious. The life of the fetus must not influence the determination to operate, and under no circumstances should operation be delayed on account of sentiment in its behalf. As the dangers of operation greatly increase as the pregnancy advances toward term, on account of the development of the placenta increasing the dangers of hemorrhage, the earliest date possible should be selected for opera- tion. A free incision should be made in the central line of the abdomen. If the pregnancy is in the early weeks, the operation may be no more difficult than a salpingo-oophorectomy for pyosalpinx or for hydrosalpinx. The dan- ger of hemorrhage, however, from the broad ligament is somewhat greater than in the ordinary salpingo-oophorectomy, on account of the increased vas- cularity of the tube, and great care should be exercised in placing the ligatures so that they will control all blood-vessels. The transfixion needle should not be employed for this purpose, as the subsequent shrinkage of tissue following the removal of the vascular tube is liable 'to dislodge the ligature, as more tissue is usually included, and a larger size of silk is employed, than when the ligament is tied off in small sections. The pregnant tube when the ligatures are laid should be lifted well out of its bed with a medium-sized curved needle armed with a carrier. The medium-sized silk suture is the best in this loca- tion, as it stands sufficient strain easily to control hemorrhage, and yet does not strangulate the tissues en masse. Each suture should overlap, in an imbri- cated manner, the one placed immediately before it ; thus no vessels can pos- sibly escape ligation. If pregnancy is further advanced and adhesions have formed between the gestation-sac and the adjacent viscera or the pelvic floor, or if it is a broad-, ligament gestation with the placenta firmly implanted on the pelvic floor, the operation becomes one of the most difficult in abdominal surgery. The adhe- 344 AMERICAN TEXT- BO OK OF OBSTETRICS. sions should be dissected off carefully, all bleeding points should promptly be ligated, and the sac should be enucleated in the ordinary manner. Drainage should not be used if it can possibly be avoided; only persistent oozing which cannot be controlled by ligatures justifies its employment, as the dangers of infection are greatly increased by leaving the abdominal cavity open. The fact that particles of clots and other debris are scattered throughout the abdominal cavity does not render drainage necessary, as such material is innocuous if the field has been kept aseptic, and it will give no trouble if the wound is hermetically sealed. In densely adherent or broad-ligament cases enucleation of the sac is often impossible, and other measures must be resorted to for the relief of the patient. The treatment of the ectopic sac then becomes a question of great importance, as the adhesions to neighboring viscera or to- the pelvic floor may be so extensive as to preclude its removal, as the danger of hem- orrhage following its enucleation is too great in such cases. This question should usually be decided after the abdomen is opened. The extent of adhe- sions and the vascularity of the sac and adjacent tissue should be noted care- fully, and if of such a degree as to contraindicate removal, the next measure, that of making an extraperitoneal opening, must be resorted to. Treatment by Vaginal Opening and Drainage. — In early extra-uterine pregnancies, in which a rupture has occurred several weeks or more before the surgeon has seen the case, a valuable method of treatment, applicable to a large percentage of cases, is the making of a free vaginal opening into the sac, the evacuation of the sac, and free drainage with iodoform gauze. This method of treatment is suitable only where a bimanual examination reveals a well-defined mass low down in the pelvis, easily reached through the vagina, in a case in which the history shows that the rupture has occurred several weeks previously. t While this method of treatment may be adopted with some hesitation in the cases just described, it is pre-eminently the best way to handle those extra-uterine pregnancies in which there are elevation of temperature and much local tenderness and evidence of incipient suppuration of the sac. In these latter cases the vaginal' route is often far less dangerous, when the patient is emaciated and very ill, and entails none of the dangers, while obviating most of the risks, of the abdominal route, and at the same time yielding a perfectly satisfactory result in the final outcome. When such a method of treatment is adopted, the operator should hold himself in readiness to open up the abdomen at once and to expose and control the cardinal vessels in the event of such an accident as an excessive hemorrhage. I have had to do this twice before the patient left the operat- ing-room, and both patients recovered. One of my colleagues lost a life from hemorrhage following an attempted vaginal evacuation. The method of performing the operation is as follows : The anatomical relations of the sac are carefully studied first ; then, with the middle finger in the rectum and the index-finger in the vagina, resting on the prominent THE PATHOLOGY OF PREGNANCY. 345 portion of the sac behind the cervix, the operator thrusts a pair of sharp- pointed scissors through the posterior fornix of the vagina into the sac, taking care to follow the axis of the pelvis, and not to transfix the bowel with the point of the scissors. The moment the sac is opened there is an escape of blood. The operator then takes the largest sized dilator and stretches the wound as widely as possible until it is big enough to admit three fingers. The cavity is then emptied of all its blood, and the laminated clots are drawn out by the fingers until the pelvis is ft-eed of its burden. The irrigation must not be used unless it is perfectly evident that there is no com- munication with the abdominal cavity above. If the sac has been a suppu- rating one, the cavity would next be best washed out with a formalin solution (1 : 500). The next step is to fill the cavity loosely with a washed-out iodoform gauze drain. The drain may be left in for six or seven days or longer, so long as the discharge l'emains pure and sweet and there is no evidence of any pent-up suppuration. With the gradual withdrawal of the drain the sac collapses, and finally it closes completely. Evacuation of an Extraperitoneal Gestation-sac. — The point of opening depends entirely upon the location of the sac : if it is situated low in the pelvis and is of easy access through the vagina, unquestionably the best method of procedure is to evacuate the contents of the sac into that canal and establish free drainage. The best method of opening the sac is as follows : After carefully examining the pelvic mass and deciding where the accessible point for opening is — usually in the fornix — the operator thrusts a pair of medium-sized sharp scissors, guided by the index finger of the vaginal hand, into the sac, and withdraws them partially open ; this is followed by larger scissors, which are also withdrawn in the same manner. AYhile doing this it is usually best for the operator to have his assistant press the sac gently down- ward through the abdominal incision. After evacuating the embryonic debris with the fingers or with placental forceps, the sac should be irrigated freely with sterilized water or with a very weak bichlorid solution (1 : 20,000), fol- lowed by warm water. After cleansing the sac thoroughly it can be packed with iodoform gauze, care being taken to leave a free opening for subse- quent discharge. The greatest care must be observed in passing from the abdominal to the vaginal operation, as to make a vaginal examination followed by the manip- ulation necessary to evacuate the sac by the vagina, and then to close the abdomen without the most careful disinfection of the hands, would be an unpardonable mistake. It is usually best for the operator to entrust the closure of the abdomen to his assistant. If the sac, instead of being in close relation with the vaginal fornix, is found to be pushed up above the uterus, and is situated nearer the anterior abdominal wall, the vaginal method of treatment is not advisable, as there may be an intervening space communi- cating with the general peritoneal cavity between the ectopic sac and the vagi- nal fornix, making it both difficult and dangerous to reach the sac. In these cases it may be necessary to stitch the sac to the abdominal wound, and then 346 AMERICAN TEXT-BOOK OF OBSTETRICS. to make an extraperitoneal opening into it. As a rule, however, the sac will be attached by close adhesions to the abdominal wall above Poupart's liga- ment, and should be opened in this region. The sac should be washed out freely as in the vaginal method, and be packed with gauze. The after-treatment in these cases is often of great importance, as the sac fills up very slowly and there is constant purulent discharge. The opening must not be allowed to close. As a rule, the gauze which is inserted at the time of operation should be withdrawn one piece at a time. After the removal of the last piece, usually about the second or third day, fresh gauze should be inserted, the cavity being first freely irrigated with some mild fluid, such as boracic-acid solution (semi-saturated). 4. Operation after the Fetus has undergone Mummification, Calcification, Saponification, or Suppuration. — The fetus may remain for years in any one of these conditions, except that of suppuration, without injury to the mother's health. Soon after the death of an ectopic fetus the liquor amnii is absorbed, the placental circulation ceases, and the vascular connection between the fetus and the mother is broken. The liquid portion of the ectopic product is grad- ually absorbed, leaving in many instances the fetus isolated in its sac as an in- nocuous body. In such cases operation should not be performed so long as the patient's health remains good, but on the first indication of constitutional dis- turbance, especially if febrile in character, celiotomy for the removal of the foreign body should promptly be resorted to. If suppuration occurs and the pus-sac opens into the rectum, the vagina, the bladder, or externally through the abdominal wall, the fistula should be enlarged and the fetal debris be removed. The sac should then be irrigated frequently until it fills with gran- ulation tissue. These sinuses heal with difficulty, and they may be persistent. 8. Diseases of the Fetus. Of the many diseases that may attack the fetus in utero, some cause its death and expulsion, others influence its growth and development in varying degrees, while others run their course during intra-uterine existence and end in recovery. A mortality of 20 per cent, is a low estimate of the death-rate of intra-uterine existence. Hereditary influences, particularly noticeable when either or both parents are subjects of disease of the nervous s}'stem or of chronic disorders of nutrition, furnish a large number of fetal deaths; such affections are epilepsy, chorea, inebriety, diabetes, cancer, nephritis, phthisis, and, especially, syphilis. Certain infectious diseases are directly transmitted to the fetus ; continued high elevation of temperature in the mother, blood surcharged with vai-ious poisons, alterations in the maternal blood pressure, diseases of the uterus or its appendages ; mechanical disturb- ances or injuries, are important causes of fetal morbidity and mortality. Heredity. — It is as difficult to explain satisfactorily and scientifically heredity as it is to solve the mystery of life itself. The unmistakable evi- dences of heredity in physical resemblance, in mental and even moral char- acteristics, as shown frequently between parent and offspring, are best THE PATHOLOGY OF PREGNANCY. :>A1 explained by the mechanical theory generally accepted by physiologists. Fertilization means the union of a definite quantity of nuclein or chromatin of the spermatic particle with a similar quantity of the same substance in the ovule. From the moment those substances unite, endowed as they are with potential vital characteristics of the individuals whence they originated, we can as readily believe that potentiality for disease will characterize the prod- uct of conception as we can and do believe, what we often see, the inheri- tance of physical, mental, and moral attributes. The actual and ultimate pathologic changes thus occurring in the morpho- logic elements that unite to produce a new entity, we certainly do not, and, perhaps, never can know. We must certainly accept as reasonable hereditary influences which lower vitality, predispose to, or actually produce, disease during and after intra-uterine life. Inebriety. — Nicloux* asserts that in intemperate women enough alcohol reaches the fetal circulation to produce a chronic intoxication or congenital alcoholism, which expresses itself in various nervous derangements. The investigations of Sullivan, f who carefully studied the history of the offspring of chronic drunkards, show that the death-rate of the infants of inebriate mothers was nearly two and a half times that of the infants of sober women of the same stock. A decrease of vitality in the successive children of the alcoholic family was also noted. Thus, in one family the three first-born children were healthy, the fourth exhibited defective intelligence, the fifth was an epileptic idiot, the sixth was dead born, and the seventh pregnancy ended in abortion. Sober paternit) r had little influence when maternal in- ebriety was present, and might almost be neglected in an estimate of the vitality of the offspring. Conception during drunkenness had a distinct influence, as was shown by the fact that of the 7 cases in which the condition was noted, in 6 the children died in convulsions in the first month of life, and in the seventh case the child was still-born. Of the children of drunken mothers that survived their infancy, 4.1 per cent, were epileptics. The records of the hospitals for the insane, the histories of epileptics, of crimi- nals, and of degenerates show conclusively the frightful heritage of inebriety. Statistics of fetal death from this cause alone are practically impossible to obtain, because other diseases are so frequently associated with inebriety, whose baneful influence on fetal growth and development is well known. Infections of the Fetus. — Syphilis. — Syphilitic infection of the fetus is the most important, because the most common and serious, disease that affects the product of conception. Habitual premature expulsion of the fetus is almost always due to syphilis. Abortion, premature labor, still-births at term, and death during the early months of infantile life can very frequently be traced to syphilitic infection, the period at which death occurs being dependent upon the time when infection of the product of conception has occurred and upon the virulence of the infection. The infection may be from the father, the spermatic particle endowing the ovum with all the pos- * L' Obstetrique, March 15, 1900. t Am. Year-Book Med. and Surg., 1901. 348 AMERICAN TEXT-BOOK OF OBSTETRICS. sible pathologic changes induced by syphilis. The mother of a syphilitic product of conception, being originally free from syphilitic infection, may or may not exhibit the evidences of syphilis. Most syphilographers agree that such a mother acquires either the disease or an apparent immunity against it. Thus are explained the occurrence of secondary symptoms in a pregnant woman who has never had a primary sore and Codes' law, that a nursing mother never acquires syphilis from her own syphilitic child. When the mother is syphilitic at the time of conception, the ovum is diseased, and prema- ture expulsion of the fetus is the rule. Should the mother acquire syphilis after conception, the clangers to the ovum from infection are greater the ear- lier in the pregnancy the infection occurs. When one or both parents are, or have been, syphilitic, there is no time limit after which the danger of fetal infection has passed, although it is rare for syphilis to appear in the infant when the infected parent has shown no signs of the disease for a period of four years (Founder). Diagnosis. — -There are no signs by which fetal syphilis can be determined until the expulsion of the ovum. The history of recently acquired syphilis in either parent would indicate the immediate administration of antisyphilitic remedies. In those cases where the fetus has escaped death and is born at term it may be apparently healthy, and the signs of congenital syphilis do not appear until several weeks or months have elapsed. Diagnosis of Congenital Syphilis in the Living Infant. — The syphilitic infant, frequently prematurely born, is wasted, wrinkled, and has the charac- teristic " old-man " or wizened appearance. The abdomen is much enlarged, and through the overstretched abdominal wall the enlarged liver and spleen are readily palpable. An associated ascites is frequently present. Snuffles due to a persistent coryza is one of the earliest symptoms. The discharges from the nose are acrid, often causing excoriations and fissures of the lips. Ulceration of the nasal bones may occur. The mucous membranes of the larynx may be seriously inflamed, or even ulcerated, and produce a character- istic hoarseness. The earliest, skin affection is a roseola, especially marked, as are other syphilitic eruptions, upon tin- palms and soles. Erythematous patches, maculopapular, pemphigoid, vesicular, and pustular eruptions soon follow. Condylomata about the anus, the vulva, the groin, and in other folds of the skin may be present. Enlargement of the liver, of the spleen, and of the thymus gland are readily discovered. Often there is a marked tendency to hemorrhages from the mucous membranes. Tenderness and swelling of the long bones due to osteitis or osteochondritis, cyanosis, and ascites resulting from syphilitic changes in the liver are manifested as the disease exhibits its characteristic signs and symptoms. Diagnosis of Congenital Syphilis after Death of the Infant. — The pathologic changes are similar to those in the adult, all the tissues of the body being involved. The most characteristic change is a cellular infiltration with hyperplasia of the connective, tissue in all the organs and in any portion of the body. The organs which furnish the best evidence for diagnosis are the THE PATHOLOGY OF PREGNANCY. 349 long bones, the lungs, the liver, spleen, and thymus. Upon making section of the long bones at the junction of the diaphysis and epiphysis, instead of finding a normally clear, narrow, and sharp line of demarcation between cartilage and bone, Weger * has demonstrated a broad, yellow, jagged line in syphilitic infants, shown by the microscope to be a premature attempt at ossification which has ended in fatty degeneration, necrosis, and suppuration. Other observers have carefully studied this sign, and it is believed to be pathognomonic of syphilis. The evidences of syphilis to be found in the lungs are, in the order of their frequency : (a) interstitial or fibroid pneumonia ; [b) gummata ; and (c) white hepatization or white pneumonia, a peculiar catarrhal inflammation. In the fibroid pneumonia the alveoli and blood-vessels are seen to be compressed by a dense overgrowth of connective tissue. The air-spaces are thus encroached upon, but not wholly obliterated ; the lung substance is dark red. When some air has entered the lung during imperfect respiration, a cut- off portion will be partly submerged when placed in water, but will not sink. When gummata are on the pleura or scattered through the lung substance, they will be recognized as yellow indurations. The white pneumonia produces marked enlargement of the lungs, showing the imprint of the ribs and a yellow-white color due to wide-spread fatty degeneration. The alveoli are filled with fatty epithelial cells, showing that air could not enter the lungs and that the function of respiration had never been established. The enlargement of the liver in syphilitic infants is also due to excessive growth of connective tissue. Gummata are also frequently found scattered throughout the organ. The liver of a healthy infant should constitute about one-thirtieth part of the body weight; in a syphilitic infant, Ruge| has shown that this proportion is exceeded, in some cases amounting to one-eighth of the infant's weight. A similar excess in the weight of the spleen is also observed, and the thymus gland is much enlarged. Treatment. — The treatment of fetal syphilis consists in thorough antisvph- ilitic treatment of the pai-ents. Should the prospective father be known to be syphilitic, he should be subjected to vigorous treatment before and after marriage, and in the event of his wife's conception, whether she be svphilitic or not, she also should receive treatment throughout the pregnancv. Should the woman be a syphilitic, treatment before and throughout pregnancv is required. Mercury and iodid of potassium should be given, and when it is desired to administer them to the woman without her knowledge, they may be given in a laxative, such as cascara sagrada. From a study of 32 cases Etienne found that in cases where the mother received no treatment the fetal mortality was 95.5 per cent. Every obstetrician of experience has observed very different results when the mother has been subjected to careful treatment before and during pregnancy, the child in such instances being born healthv and not showing throughout its life any traces of syphilis. Typhoid Fever. — In typhoid fever the effect of the disease upon the fetus * Virchorts Archiv, Bd. i., S. 305. fZeits.f. Geburtsh., Bd. i. 350 AMERICAN TEXT-BOOK OF OBSTETRICS. is especially fatal. The percentage of cases in which premature expulsion takes place varies from 65 to 75 per cent, according to different authors. The causes of the premature expulsion are supposed to be clue to the high temperature, changes in the blood, and insufficient oxygenation of the blood as it passes through the lungs. Cases are recorded in which the bacilli of typhoid fever have been found in the internal organs — i. e., lungs, kidneys, and spleen of the fetus after premature expulsion. Septicemia. — Intra-uterine septic infection has been denied by many, but we have sufficient evidence * in recorded cases to confirm its occurrence. Pus-organisms have been found in the fetus of a mother suffering with septic infection, and well-formed collections of pus have been found in the fetus at birth. It is rare, but undoubtedly does occur. Malaria. — There seems to be no longer any doubt of the intra-uterine transmission of malaria. Children have been born with the pathologic changes produced by malaria — i. e., enlarged spleen and pigment granules in the blood and tissues. Playfair says that the disturbance caused by the chill is felt by the mother as her child in ufero passes through this particular stage of the disease. Numerous cases are recorded in which malaria has manifested itself directly after birth. Malaria rarely terminates pregnancy, though this has taken place. Its presence in the mother, however, lias an injurious influence on the growth and development of the fetus. The administration of quinin in as large doses as necessary is indicated. No fear need be appre- hended of causing an abortion or premature labor through its administration. Variola. — That variola occurs in intra-uterine life is beyond dispute. The susceptibility of the fetus, however, varies greatly ; in the majority of cases the fetus is not affected. The manifestations in the fetus are not always synchronous with those occurring in the mother, and are not always similar in character. A case is recorded of a mother who had been exposed to small- pox ; she had no signs of the disease, and was apparently in good health, and wave birth to a child with pustules on it. Again, a mother who had only had varioloid gave birth to a child with the scars of small-pox on it. In rare instances vaccination of the mother has protected the fetus. Abortion takes place in about 50 per cent, of the cases of pregnancy complicated by variola. In the severer and hemorrhagic forms it is almost inevitable. Measles. — The transmission of measles from mother to fetus is rare, but several well-authenticated cases are recorded in which children were born in the different stages of the disease. In those instances in which it occurred in children a few hours or days after birth it would appear from the length of , the period of incubation that the infection took place in utero. The prog- nosis is grave, both as regards the mother and fetus, and especially if the maternal infection takes place at or near the time of labor. Scarlet Fever. — The occurrence of scarlet fever in intra-uterine life is rare, but several well-authenticated cases are on record in which the children were born with the eruption upon them. Should the mother become infected * Centralblalt f. Gyn., 1S85, p. 200. THE PATHOLOGY OF PREGNANCY. 351 during pregnancy the fetus is usually infected also, but this is not invariably the ride. The prognosis is grave for botli mother and fetus, esjjecially if the maternal infection takes place near the end of pregnancy. Erysipelas. — Lebedeff * has presented conclusive evidence of the trans- mission of erysipelas from mother to fetus. In his case the coccus was found in the subcutaneous tissues of the child. Cultures were made, and rabbits which were inoculated with them contracted the disease. No cocci were found in the placenta or cord. Erysipelas is likely to interrupt pregnancy. The mother infected in the puerperal state may transmit it to her new-born child. The gravity of the prognosis is increased by the pregnancy. Tuberculosis. — Tuberculosis may be di recti}' transmitted from mother to fetus, but it is an extremely rare occurrence, as the fetus is very persistent in its resistance to infection by the bacillus. The possibility of its transmission in this manner has been the subject of thorough investigation. Ballinger, Davaine, and Wolff have expressed their disbelief in intra-uterine trans- mission, while Keating, Jacobi, and others have presented cases in which there was undoubtedly transmission from the human mother to the fetus in utero. Johne discovered tubercle bacilli in a still-born calf, and the placenta has also been found to contain the bacilli of tuberculosis. The children born of a mother suffering from tuberculosis are weak, puny, and predisposed to pulmonary disease. Cholera. — It is very doubtful whether cholera can be transmitted to the fetus in utero. Abortion nearly always takes place, due to asphyxiation from changes in the maternal blood. Should the child be born alive, it usually survives but a few days. Recurrent Fever. — Cases of congenital recurrent fever are recorded. Albrecht f reported a case in which he found the spirilla of recurrent fever. 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Kreutzman : Occidental Medical Times, August, 1892. 387. Isirne : Archiv fiir Gynakologie, Bd. xlii., H. 3. 388. Kreutzmann : American Journal of Obstet- rics, August, 1892. 389. King: American Journal of Obstetrics, July, 1893. 390. Eosenwasser : American Journal of Obstetrics, December. 1893. 391. Doran : Transactions London Obstetrical So- ciety, 1891, vol. xxxiii., p. 112. 392. Tiffany: Transactions American Surgical Association, 1888, vol. vi. 393. Belin : Bulletin Medical du Nord, 1878, vol. xvii. REFERENCE LIST. 567 394. Richard: Bulletin Medical du Nord, 1878, vol. xvii. 395. Harris : American Journal of Obstetrics, vol. xx., p. 673. 396. Corey: American Practitioner, September, 1878. 397. Bydygier : Proceedings Congress German Sur- geons, 1867, No. 12. 398. Petit: Thesis, 1876. 399. Keelau : British Medical Journal, 18S7, p. 825. 400. Prozowsky : Vrach, St. Petersburg, 1879, No. 6. 401. Bancroft : Medical and Surgical Reporter, 1876, vol. xxxiv. 402. Lihotzkv: Centralblatt fur Gyniikologie, 1892, No. 24, S. 4S9. 403. Milner : Medical News, vol. lxi., pp. 243, 244. 404. Neugebauer: Centralblatt fur Gyniikologie. 1890, S. 88. 405. Fancou : Journal des Sciences Medicates de Lille, 18S3, S. 241. 406. Tiffany: Transactions Medical and Chirurgi- cal Faculty of Maryland, April, 1S81. 407. Tiffany : Medical News, April 16, 1S87. 408. Hunt: American Journal of the Medical Sci- ences, vol. lxxxi., p. 186. 409. Flicker: Provincial Medical Society, Kings Co., 1879, vol. iii. 410. Keen : Medical News, March 26, 1892. 411. Basch : Zeitschrift fur Geburtshiilfe und Gyniikologie, Bd. xxv., H. 2. 412. Vickery : Boston Medical and Surgical Jour- nal, 1890. p. 413. 413. Gerdes: Centralblatt fiir Gyniikologie, 1890, No. 45. III. LABOR, [. THE PHYSIOLOGY OF LABOR* Definitions. — Labor is the process by which the ovum is separated from the maternal organism and extruded or extracted. The term normal labor (eutocia) may be restricted to labors with normal factors that are terminated by the natural forces, or it may be narrowed down to include only vertex presenta- tions in anterior positions under right conditions. Dystocia, or difficult labor, includes all forms of abnormal or complicated delivery near term. Premature labor refers to the untimely birth of a fetus which has reached the period of viability — that is, a state of sufficient development to live independently of the mother. Miscarriage, or immature delivery, is usually restricted to the expulsion of the fetus from the third month until viability, although it is often used as a synonym of abortion, and is the lay term for that mishap, the word " abortion" to the layman denoting criminal intent. The term abortion is reserved by the obstetrician for the expulsion of the ovum in the first three months. Causes of Onset of Labor. — What constitutes maturity or ripeness we do not know, and in the indefiniteness of our knowledge " we refer the matter to a law of the organism — a law the cause of which we do not know." The termination of pregnancy is due to some combination of conditions, no one of which, singly, will account for the occurrence of labor at two hundred and eighty days after the date of appearance of the last menstrual period. Briefly stated, the chief factors are — 1. Increasing irritability, with strengthening intermittent contractions. 2. Changes in the decidua — loosening, thinning, and thrombosis. 3. Excess of C0 2 and lessened oxygen in the placental blood acting on the motor centre for the uterus in the medulla. 4. Increasing tension on fully-developed muscular walls. 5. Stronger fetal movements in more confined space. 6. Partial relaxation of the cervix. 7. Menstrual periodicity (tenth period). 8. Habit and heredity. 9. Exciting causes — exercise, strain, emotion. 1. A steadily increasing irritability is probably the rule during gestation. At certain menstrual epochs, such as the second, third, and seventh, it is especially marked, and there is evident disturbance both of the neighboring nerves and of uterine ganglia in the first and last trimesters. Intermittent contractions occur regularly in the non-gravid uterus. They * The superior figures (') occurring throughout the text of this section refer to the bibliog- raphy given on page 391. 368 THE PHYSIOLOGY OF LABOR. 369 are distinct from the very beginning of pregnancy, they steadily gain in strength during its progress, and at its end rhythmical hardening and prominence may always be detected. The dividing-line between contractions and true labor-pains is not easily drawn, but as soon as the ovum becomes a foreign body by beginning separation more vigorous action is ensured. 2. The changes in the decidua are well epitomized by Lusk :' " The re- searches of Friedlander, Kundrat, Engelmaun. and Leopold have demon- strated that the decidua vera of pregnancy is distinguishable into an outer dense, membranous stratum, composed of large cells resembling pavement epi- thelia, probably metamorphosed cylindrical cells, and an — in appearance — underlying meshwork, formed from the walls of the enlarged decidual glands. It is in this spongy layer that the separation of the decidua takes place, the fundi of the glands persisting even after the expulsion of the ovum. By many a fatty degeneration of the cells of the decidua has been observed toward the end of pregnancy, but Leopold, Dohrn, and Langhans have shown that this is not of constant occurrence. The trabecular which enclose the spaces of the network diminish in size with the advance of pregnancy. Thus, while they measure at the fourth month about -^ of an inch in thickness, they become gradually reduced in the subsequent months to 2S 1 00 of an inch — a change which materially facilitates the peeling off of the decidual surface. " From the fourth month onward large-sized cells make their appearance in the serotina, especially in the neighborhood of thin-walled vessels. The largest of the so-called giant-cells contain sometimes as many as forty nuclei. Though a physiological product, they resemble for the most part the so-called specific cancer-cells of the older writers. They are of special obstetrical inter- est from the fact, observed by Friedlander and confirmed by Leopold, 2 that they penetrate the uterine sinuses from the eighth month, and lead to coagula- tion of the blood and to the' formation of young connective tissue, by means of which a portion of the venous sinuses becomes obliterated before labor begins. The subtraction of these vessels from the circulation tends to increase the amount of the venous blood in the intervillous spaces of the placenta." 3. Brown-Sequard found by experiment that an excess of C0 2 circulating in the blood of a gravid animal excited uterine contractions, and he claimed that this excess of the gas was the proximate cause of labor. His theory lacks conclusiveness, however, because it does not explain why the CO, postpones its irritant action until the end of the ninth month. Leopold believes that the excess of C0 2 in the placental blood is the result of venous hyperemia of the placenta, produced by the spontaneous thrombosis in the veins of the placental site at the end of pregnancy, while Hasse credits it to certain changes in the circulation of the fetus — chiefly in the crossing blood-currents of the right auricle and shrinkage of the ductus venosus and arteriosus. Spiegelberg teaches that at maturity the fetus requires some new substance not supplied by the placenta, and that it dies (as in extra-uterine pregnancy) if it does not obtain it, while chemical substances no longer required accumulate in the blood and act as irritants to the special nervous centres. 370 AMERICAN TEXT-BOOK OF OBSTETRICS. 4. Power in 1819 called especial atteution to over-distention of the uterus as a causative factor in labor ; it can admirably be demonstrated by analogy. As the over-loaded stomach or the rectum rejects its burden, so the over-dis- tended uterus rebels and expels its contents by the contractions of labor when the mouth of the organ begins to be stretched. The occurrence of premature labor in hydramnion and multiple pregnancy sustains this theory, but, on the other hand, it does not account for labor-pains in extra-uterine pregnancy. The extensibility of the uterine wall has a limit, and when this is reached the ovum in its growth presses more and more upon the internal os. This pressure excites a special set of nerves and brings about uterine contractions, just as the contact of the drop of urine at the neck of the distended urinary bladder ex- cites contraction and evacuation of that orgau. A theory of this nature brings up the question of the innervation of the uterus. Through what set or sets of nerves does the uterus receive its motor impulses during labor? The nerve-supply is largely from the hypogastric and ovarian plexuses of the sympathetic system. The cervical ganglion receives, in addition to its extensive connections with the sympathetic, filaments from the second, third, and fourth sacral nerves. But Lusk and Jacquemart report cases of successful labor in patients suffering with paralysis of the lower ex- tremities, retention of urine, and incontinence of feces — a state of affairs which would lead one to discount the importance of the role played by the filaments from the sacral nerves. Ou the other hand, the experiments of Schlesinger 3 argue against the exclusive source of motor-supply resting with the sympa- thetic, for he was able to elicit reflex movements of the uterus by stimulation after severing all the branches of the aortic plexus. Whether he may not have overlooked some of the slender nerve-filaments in cutting the branches of the aortic plexus is a question worthy of consideration, and the possibility of such an error detracts fronj the value of his experiments and the weight of the conclusions to be drawn from tliem. The uterine ganglia have a certain independence of action, such as the cardiac ganglia possess, since rhythmic con- tractions by both may be kept up after separation. 4 Brandt has shown that massage of no part of the pelvic contents will produce contraction in the non- gravid uterus so rapidly as manipulation of the (supravaginal) cervix, and the writer has demonstrated this for the early weeks of pregnancy. 5 Whatever the channels of nerve-force may be, there has been proved to ex- ist in the medulla oblongata a motor centre for contraction of the uterus that may be excited to action by C0 2 in the blood, by anemia, and perhaps by the toxic substances retained in the blood of one suffering from nephritis. At full term something stimulates this centre to activity, with a complex, co-ordinated set of muscular contractions as the resultant. Moreover, it is supposed by Schatz that the uterus possesses au inhibitory centre which is active throughout pregnancy, but which for some reason ceases to act at term. 6. A diminished resistance in the lower birth-canal is to be noted. The cervix is fully softened, the pelvic floor is edematous and relaxed, and the uterus and its contents often sink low in the pelvis. THE PHYSIOLOGY OF LABOR. 371 7. The theory advanced by Tyler Smith to the effect that the tenth period of ovarian excitement incites the nervous apparatus of the uterus to activity is of some force, since pregnancy is often interrupted at menstrual epochs ; but it is open to the same objection as that just mentioned, for it does not make plain why the ninth or eleventh period fails to effect the same result. More- over, single ovariotomy has beeu performed many times, and double ovariotomy a few times, during pregnancy, without perceptibly influencing its course. 8. Many multipara? follow the same rule in a series of pregnancies. In other cases great variations are seen. 9. Finally, with all things ready, an unimportant, perhaps accidental, occurrence, such as slight increase in intra-abdominal pressure from walking, stair-climbing, coughing, or straining at stool, as well as any mental irritation (anxiety, care, anger), may be the exciting cause. We have been dealing, then, with determining causes, factors in a phe- nomenon, none of which can establish a claim to be considered singly and absolutely causative. Winckel sums up by saying that labor is the total of several causes which may enter into different combinations to accomplish the same result. Lusk takes substantially the same ground, and Barnes observes that the determining causes act synergetically, not singly. The fetus is mature, ready to undertake the complex acts of respiration and digestion ; the imperceptible uterine contractions of several weeks have loos- ened the attachments of the decidua, whose trabecular have grown much thin- ner and capable of easy rupture ; the uterus by distention, perhaps by increas- ing pressure of the fetus on the internal os, has grown very irritable, the lusty inmate augmenting this condition by the force and frequency of its movements. The maternal blood contains an increased quantity of C0 2 ; venous thromboses in the uterine wall near the serotina and in the serotina itself obstruct the cir- culation and cause stasis of the maternal blood returning from the placenta ; the cervix uteri becomes soft and dilatable ; the advent of the teuth menstrual date, with increased congestion and irritability of all the generative organs as a consequence, adds fuel to the pile ; the unknown factor deposits the spark at the centre of uterine contraction in the medulla, and labor begins. The Phenomena of Normal Labor. The physiology of the processes concerned in the expulsion of the fetus includes a study of the action of the uterine walls, the uterine ligaments, the abdominal muscles, and the vagina ; the changes induced by labor in the cervix, in the lower uterine segment, and in the body of the uterus ; the variations in the presenting pouch of membranes; and the character of the liquor amnii, the formation of the caput succedaneum, and the changes in the pelvic floor. Then the clinical character of the three stages of labor will be considered, leaving questions of mechanism and management for later sections. Uterine Contractions. — The uterine contractions of labor go by the name of "pains" in all languages, including the speech of the scientist, because of the suffering inseparably associated with them. The cause of this suffering 372 AMERICAN TEXT-BOOK OF OBSTETRICS. is the compression of the uterine nerves between the contracting muscular fibres, the tension of the external os and lower uterine segment, the stretching of the uterine ligaments, and the pressure of f he advancing fetus on the nerves of the vagina, the vulva, and the neighboring structures. Moreover, hyper- emia of the lower end of the spinal cord and its envelopes is probably in part responsible for the distress. The location of the pain is, at first, in the lumbo-sacral region, and later in the abdomen or down the thighs. The most severe degree of pain is felt at the vulva as the head passes. The onset of the contraction is more rapid than the decline. The pain begins suddenly a few seconds after the beginning of the contraction — as may be seen by the bulging forward of the fundus or as felt by the examining hand — reaches and retains for a few seconds its acme of intensity, and then gradually subsides. If each pain be divided into periods of increase, acme, and decrease, the acme will occupy the greatest length of time of the three divisions, the total duration of a pain being about oue minute. The suffering is commonly more severe in very young or in elderly primiparse than in those in the prime of physical life. Susceptibility to pain, and general vigor, have much to do with the amount of anguish experienced, it being among serene women and dull-witted and sturdy-limbed hospital patients that we oftenest see quiet labors. Painless deliveries have been reported, but they are rare. The muscular fibre of the uterus is non-striated, and the contractions, as in all organs of like histological structure, are peristaltic, involuntary, and inter- mittent. Contractions sweep over the uterus in a peristaltic wave, probably travelling from the opening of the Fallopian tubes down to the cervix, reaching a swift acme, and subsiding within twenty or thirty seconds. Waves in both directions have been observed in the uteri of some of the lower animals. Though mainly controlled by,the sympathetic system of nerves, and hence inde- pendent of the will, the pains are nevertheless influenced to some extent bv the brain — a fact demonstrated by the effect of fright or of excitement in retarding or even in stopping labor. The pains last from thirty to ninety seconds, and the peristaltic action from twenty to thirty seconds ; the interval is about thirty minutes at first, whereas at the end of labor it is but two to three minutes, and nearly disappears as the head emerges. Symmetrical pains often occur in groups, followed by shorter or almost abortive pains. As to the force exerted, the pressure during the height of a pain never exceeds 100 millimeters (4 inches) of mercury, the average being 60 millimeters (2§ inches ; Schatz). Leaman measured the force with which the head advanced (not the force with which it was propelled), and found a high pressure to be five pounds. Forceps was required where it did not exceed two and a half pounds. 6 The force of the pain remains about the same during the entire labor, or it may increase by a fourth, and this with no regard to weariness on the part of the patient. The force does not increase with the resistance offered, but the pains simply become more frequent and last longer. The type of the pains is nearly constant in the same patient (Schatz). THE PHYSIOLOGY OF LABOR. \ V Fig. 169.— Palpation of the cervix before la- bor. The two rings are shown, with the finger-tip touching what may be called clinically the " in- ternal os " (one-half natural size). The amount of force exerted by the pains is supposed to range between seven- teen and eighty pounds. Our methods of measuring, however, are defective, Duncan and Poppel, who studied the force required to rupture the mem- branes, found that in easy cases it was hardly more than the weight of the child, and only in severe cases did it rise to fifty pounds. Schatz 7 passed a rubber bag into the uterus during labor and connected it with a gauge, register- ing fifty-five pounds as the maximum. An obstetrician knows that all the mus- cular power he possesses is sometimes insufficient to prevent rapid expulsion of the head. The changes in shape in the uterus during contraction are marked. In the quiescent state it rests against the spinal column, ovoid in shape, the transverse exceeding the antero-posterior diameter. During contraction these diameters be- come about equal, the uterus assumes an ovoid or somewhat cylindrical form, and by means of this increase of the antero-posterior diameter and the con- tractile action of the broad and round ligaments the fundus is forced forward against the abdominal wall. At the same time the uterus becomes longer at the expense of the lower uterine seg- ment and the cervix (Fig. 239, p. 475). Action of the Ligaments. — The uterine ligaments — the round ligaments, the lower part of the broad ligaments, and the utero-sacral bands — contain much muscular tissue which is directly continuous with that of the uterine wall. Contraction of this muscular tissue occurs with each pain, and serves to fix or to steady the uterus in position at the brim, and to assist in lifting and holding it at an angle favorable for expulsion of the fetus (Fig. 214, p. 438). Action of the Abdominal Muscles. — Xext to the uterine contractions the force of the abdominal muscles is the important expulsive agent. "We include all those muscles that fix the thorax and pelvis or narrow the abdom- inal cavity. The mechanical problems involved are omitted here, as they are discussed in the section on Mechanism of Labor, page 438. The action l>\\-i 'lining diiattitii of internal os. Further dilatation of internal os. Complete effacement of internal os, zvitk sharp external os. Fig. 170.— Diagram showing the sensation to the examining finger of widening and efface- ment of the internal os during dilatation of the cervix, and the knife-like edge of the external os (one-half natural size). 374 AMERICAN TEXT-BOOK OF OBSTETRICS. Fig. 171.— Section of cervix at term (Wal- deyer). The irregular blotted black marks with- in the cervical canal, running to the membranes, denote mucous membrane of cervix ; the de- cidua runs in a wavy line beneath the mem- branes. on the part of the woman is voluntary at first, but becomes less so as labor advances, as shown by her inability to withhold strong pressure at the time when the pelvic floor is endangered. Such assistance to the uterus is not absolutely necessary, for labor may be accomplished in the absence of the action of these external forces, as in paralysis ; but when the head lies in the pocket formed by the curve of the sacrum and the partly stretched pelvic floor, having to turn nearly a right angle in its course, the power brought to bear by the abdominal muscles is of very great moment. From the atrophy of the trunk-muscles due to corset-wearing, failure of force at this crisis often calls for forceps extraction. The uterus is raised by the round ligaments so that abdominal pressure acts to better advantage. The uterus is compressed from all sides, is supported by the pelvic walls, and is arrested in attempts to slip downward by the utero- sacral and broad ligaments and the sacral curve, while its contents are pressed out. The increased tension on all the contents of the trunk sends blood to the extremities and flushes the face of the patient. Be- low the pelvic brim the tension is not brought to bear, and conges- tion produces edema and softening of the cervix and pelvic floor. At times the child is expelled with considerable force by means of this added power, and the uterus may even be inverted by these efforts Action of the Vagina. advancing head. When, Fig. 172.— Cervix of multipara at beginning of labor; the internal os is at the edge of the crater (froEen section, Winter). f the external muscular structures. — At first the vagina opposes some obstacle to the lowever, a large circumference has passed, any onward motion may receive slight aid from contractions of the vagina. Figure 188 (p. 387) shows how the vaginal walls are smoothly fitted to the child even after the exit of the head has greatly distended the passage. Changes in the Cervix during- Labor. — Although palpation of the exter- nal surface of the cervix may give the impression of a smooth expanse of stretched rubber around the opening, yet when the finger is passed within the cervical canal as far as the membranes, is hooked forward, and then slowly withdrawn, one detects two well-defined rings with a 1- to 2-inch (3.5- to 5- centimeter) passage between them, and finds that this passage has yielding side THE PHYSIOLOGY OF LABOR. 375 Rectum. Fig. 173.— Cervix of five and a half months' primipara in dilatation period, with marked irregularity in progress of dilatation of posterior and anterior lips, the posterior being nearly flattened (Winter ; frozen section, five-eighths natural size). Compare widening funnel or crater with Figure 169. walls (Figs. 169, 170, 177). Whether this inner ring be the true internal os, or only the upper limit of the vaginal portion of the cervix, we may be allowed to call it, for clinical pur- poses, the internal os, since we desire to study its be- havior during the dilatation stage. At the beginning of labor in the primipara the cervix is barely passable by the finger-tip. Dilatation of the internal os occurs first, and it may open rather widely before the external os begins to gape (Fig. 170). In this case the cervix thins out to a flat ring over the watch-glass membranes, and the external os may form a sharp, parchment-like edge as the internal os merges with the lower uterine segment and the membranes or the presenting part is applied directly to the external os. At other times the two rings draw back in less marked succession (Figs. 172, 173). In mul- tipara, the more open canal freely admits the finger dur- ing the last month, and the condition is suggestive of labor begun. But an inner edge may always be distin- guished (Fig. 173) until the early labor-pains s or the threatening preliminary pains begin. The effect of such early pains in com- mencing the dilatation of the cervix in certain cases is shown in Figure 178. In multipara? labor is likely to pull back the whole cervix bodily, but with some thinning and with a somewhat irregular edge. Gradually the circle widens until it merges imperceptibly into the uterine wall, leaving, as a rule, to represent the external os, a slightly raised encircling ring on the wall of the curved birth-tube 3 millimeters (-^ inch) in thickness, located against the back of the symphysis in front and halfway up the sacrum behind (Figs. 134, 188). The wall of the cervix is then 2 millimeters (-g 3 ^- inch) in thick- ness, and the cervix is said to be effaced. The anterior lip may be nipped between the bony ring (pelvis) and the ball of bone (fetal head) and become Fig. 174.— Dilating cervix of eight months' primipara, with pronounced thinning of posterior lip (Winter : frozen section, two-thirds natural size). 376 AMERICAN TEXT-BOOK OF OBSTETRICS. elongated and edematous, even to the extent of appearing at the vulva dur- ing delivery or of hanging without it afterward. In patients with contracted inlets the external os often remains at or near the brim after full dilatation. The dilatation is estimated either by guessing at the coin which it seems to resemble in size, or by stating the inches of its diameter, or the number of fingers which the elastic ring will admit. Although the cervix may not be found greatly dilated, it may be dilatable to a large size, as determined by the introduction of four fingers or the whole hand. The common error of the Fig. 175.— Cervix compressed between the bead and the pelvic floor, at the beginning of labor in a Vl-para (Barbour, one-third natural size). The cervix extends from the tuberosity up to the right-hand a; the vagina is shown, and also the ureter and the base of the broad ligament; the area on the side not covered with peritoneum being the shaded space (a, a, a). beginner is to believe that the cervix is much more widely opened than it is in fact. He is sometimes deceived into thinking the cervix has gone by the exceed- ing thinness of the tissue stretched taut over the head (Figs. 173, 216 ; p. 435), or, again, by the softness of the yielding edges. The cervix may remain in a stationary and partly dilated condition for hours, or, in rare cases, for days. It may close after partial dilatation — even from the size of three fingers. The mechanical, factors effecting dilatation are discussed on pages 474-480. The active agents are : (1) Contraction of the longitudinal fibres of the uterine THE PHYSIOLOGY OF LABOR. 377 body, pulling the cervix up over the ovum ; (2) hydrostatic pressure of the bag of waters ; (3) wedge-action of the presenting part ; (4) softening of the cervix. During a contraction there is high tension in all the uterine blood-ves- sels; the unsupported vessels — those of the cervix — become engorged, and the lymphatic interspaces are infiltrated with serum and loosened; thereby the force of cohesion is lessened. Were it not so, the elastic cervix would close down on the shoulders after the passage of the head. " Indeed, the conditions of an elastic tube are not infrequently realized in versions where an attempt is made to extract the fetus through an imperfectly dilated os; in which case, after the disengagement of the shoulders, the cervix is apt to close upon the neck and arrest the delivery of the after-coming head. That this complication does not happen as a rule is due to the fact that in natural labors the mechan- ical expansion is associated with certain organic changes which render the cer- vix soft and distensible, and which at the same time diminish its retractility." 9 To bring the cervix to a circle of a diameter of 5 centimeters (2 inches) frequently demands two-thirds of the total time required for full dilatation. Irregular dilatation is not infrequent, wherein the posterior lip is further effaced than the anterior, or inversely, but the former is more common. From the frozen sections, the first process would seem to be constant in occurrence and most marked in character (Fig. 173). Location of the Orifice. — The internal os is found at the beginning of labor and in frozen sections 6.3 centimeters (2^ inches) below the brim, being a little lower than in the nullipara. 10 The cervix may point backward, and, when there is much difficulty in reaching it far up toward the promontory, one may be obliged to hook the anterior lip downward with the finger in suc- cessive sections until the external os can be caught (Fig. 64, p. 81, Vol. II.). A cervix by excessive distance from the vulva may inform ns of false labor- pains, point to a contracted pelvis or to an abnormal presentation. The cervix may be found with the head packed into it, pressing it downward against the pelvic floor and toward the vulvar opening (Fig. 175). Changes in the Lower Uterine Segment. — The two beliefs concerning this portion of the uterus can only be summarized. Schroeder and his school teach that the lower uterine segment is that part of the wall of the body of the uterus (Fig. 176) extending from the contraction-ring above — the level at which the peritoneum is found firmly adherent — to the internal os below; that it is constituted of more loosely adherent muscular layers than the wall higher up ; and that it is relatively passive during labor. By its anatomical structure and by the epithelial covering of its mucous membrane the lower uterine segment is differentiated from the cervix in both the pregnant and the puerperal uterus. In pregnancy the internal os may be found by its forming the upper end of the closed cervical canal. With this point the denser structure, with its con- nective-tissue appearance, the character of mucous membrane and its junction with the decidua above, and the upper limit of the arbor vitas, usually coincide. The lower segment differs distinctly from the upper, to which it belongs 378 AMERICAN TEXT-BOOK OF OBSTETRICS. anatomically, in possessing loosely connected muscular layers which are easily separated, whereas the rest of the body of the uterus is made up of inseparably interlaced bundles which can only be dissected from one another, even in the thinnest layers, by destroying the structure (Hofmeier). 11 " The physiological behavior of the lower uterine segment during labor is essentially passive, as opposed to the remaining portion of the uterus, which is sharply contrasted with it by contractions." The difference between the two is palpable, after vigorous uterine contractions, to the hand within the cavity, the ring being occasionally detected by the hand without as well. The term " contraction- ring," though firmly seated, should yield, in the writer's opinion, to the more correct " retraction-ring," which is self-explanatory. The cervix aver- ages 4 cm. (1 1 inches) from external to internal os, and the retraction-ring stands about 6 cm. (21 inches) above the internal os. The writer has given precedence to the views of those investigators who believe that the cervix remains unchanged until the beginning of labor. Only Taylor, Muller, Sehroeder, Hofmeier, Waldeyer, et al. LOWER UTERINE SEGMENT. CERVIX (synonymous lower uierin ment). Fig. 170.— Diagram illustrating the two teachings anent the lower uterine segment and the cervix. On the left side an internal os has been added for the sake of clearness, although in the frozen sections of women with full dilatation it is rarely apparent macroscopically (one-third natural size). the briefest outline, however, of the voluminous controversy 12 can be given, and the opposite side stated. The older theory held that toward the end of pregnancy the upper portion of the cervix was expanded and drawn up to form part of the general uterine cavity, leaving only the small vaginal por- tion of the cervix below. Braun, whose section is given in Figure 134, believes that the semicircular ledge with the large vein (Kranzvene) is the in- ternal os, 10 to 11 centimeters (4 inches) above the external os; Bandl confirms this. He now believes, 13 with Kustner, that in first labors the mucous mem- brane of the dilated portion of the cervix — the lower uterine segment — becomes torn or stripped off', and subsequently there is formed upon the denuded surface THE PHYSIOLOGY OF LABOR. 379 Closely interwoven layers. a new membrane not distinguishable from that of the corpus, which in future pregnancies is capable of forming a decidua. Bayer 14 concludes that "the ex- cessively thin decidua of the lower uterine segment passes into cervical mucous membrane on the posterior wall of that segment, and that the lower uterine segment and suftravaginal cervix are one and the same thing. It envelops the presenting part during labor, it is thinned out, distended, paralyzed, while the thick, contractile muscle-mass of the corpus lies above, where the phenomena of contraction occur with their expul- sive effect upon the uterine contents." Practically, the lower uterine seg- ment interests us as the common seat of rupture of the uterus. During long labors, or where obstruction is asso- ciated with vigorous contractions, ex- Retraction-ring. treme thinning occurs at this level, and in such cases the retraction-ring can sometimes be felt as a band or ridge in the vicinity of the navel to serve as a danger-signal. The thickness of the lower uterine segment was measured by the writer on such of the frozen sections as would ad- mit of study. In 5 cases at the eighth and ninth months of pregnancy the average thickness of the wall was 6 mil- limeters Q- inch), the extremes being 5 and 10 millimeters (^ to ^ inch). In 5 cases in the stage of dilatation the average thickness was 3.6 millimeters (■^ inch), the extremes being 2 and 5 millimeters ( -^ to T 3 g- inch). In 6 cases in the expulsion stage the average thickness was 3.5 millimeters (^ inch), the extremes being 2 and 7 millimeters (yg- and -^ inch plus). The remarkable thing in this series is that there are so many instances where a measurement close to 2 mi I i meters (Jg- inch) was found, in some sections of the wall, either in the first or the second stage — namely, in seven different patients. Thus we may say that be/ore labor the wall of the lower uterine segment is 6 millimeters (^ inch) thick, and during labor 3.5 millimeters (\ inch). Anterior and poste- rior walls are rarely equal in thickness, but the sections are nearly equally divided on thinner anterior or thinner posterior walls. Changes in the Body of the Uterus. — Thickening of the wall of the upper uterine segment is a somewhat constant factor. It is especially marked Fig. 177.— Section of the wall of the pregnant uterus (Hofmeier). The difference in texture be- tween cervix and lower uterine segment, accord- ing to Hofmeier, is clearly shown, as well as the loose-meshed and close-meshed muscle-layers of the upper and lower uterine segments. 380 AMERICAN TEXT- BOOK OF OBSTETRICS. in long or obstructed labors (Figs. 134, 191, 291). The average thickness of the uterine wall at term is the same as during the early dilatation stage, as measured on eight frozen sections — namely, 7 millimeters (\ inch). Toward Fig. 178.— Demonstration of retraction-ring (Hofmeier). A multipara who has been in vigorous labor several hours, is found with the head well above the inlet ; A, on examining between pains, the finger finds no upper limit to the cervix, but, following along the inner aspect of the relaxed anterior wall of the uterus to two or three fingers' breadth above the upper border of the symphysis, it encounters the prom- inence of a ring of feeble tension ; B, when a contraction starts, the ring becomes more prominent and tense. It is only after the bag of forewaters becomes tense in its turn that the portion of uterine wall below the ring (the lower uterine segment) loses its flabbiuess and that one is conscious of the formation of a second ring, the internal os, about 4 cm. (1*4 inches) above the external os. the close of the expulsion stage it is, on five sections, from 9 to 18 millime- ters (| to | inch), averaging 1 centimeter (-§ inch). Fig. 179.— Form of membranes during dilata- tion, watch-glass (Varnier) : the presenting part is large and fills the cervix (one-sixth natural size). Fig. 180.— Form of membranes with less effi- cient filling of cervix and pelvis, and larger quan- tity of fore-w-aters (modified from Varnier). Bag of "Waters — Forewaters. — Through the dilating cervix the fetal envelopes are felt, growing tense during the pains or just before the sensation of suffering comes. The ovum is being peeled off the lower uterine segment THE PHYSIOLOGY OF LABOR. 381 and protruded. We note the amount of tension, the shape of the protrud- ing sac, and its volume, and, later, the location of the tear. The tension is usually intermittent, as above stated. At times we detect a permanent tension and look out for hydramnion or twins. The shape of the sac depends on the shape or size of the presenting part, the elasticity of the membranes, and the amount of liquor amnii. It may be (1) Flat ; (2) watch-glass — this is usual with vertex presentations (Fig. 179) ; (3) hemispherical — it may bulge full and round (Fig. 1 80) ; (4) glove- finger — it may be elongated in shape when the cervix is narrow and the pre- senting part does not fill it, as in knee or shoulder presentations (Fig. 181); Fig. 181.— Glove-finger form where the presenting part is small (modified from Varnier). Fig. 182. — Fear-shaped pouch seen with some cases of macerated fetus (modified from Varnier). (5) pear-shaped (Fig. 1 82), as where the fetus is dead and macerated ; 15 (6) double, as with twins — but very rarely. The membranes are slightly permeable under pressure (Pinard), and at times the amnion will leak into the chorion, giving a double pouch. The amnion is most elastic, and, if the chorion is torn, may stretch to the vulva. The cervix and lower uterine segment are pushed sidewise by the elastic bag. The chorion often separates from the decidua. The attachment of the membranes until the beginning of labor runs down to the internal os ; during dilatation to the retraction-ring. In normal cases 16 the coverings of fetal origin are not separated, maternal and fetal membranes parting at the level of the lower pole. In certain cases before rupture the chorion and amnion may already be separated throughout or far up on the cord. Normally the membranes give way on full dilatation of the cervix when pressing on the pelvic floor. At times rupture occurs days or hours before labor, from low implantation of the placenta. 17 In Poullet's case the mem- branes gave way six days, and in that of Matthews Duncan forty-five days, before labor. A copious discharge of fluid that has collected between the ovum and the uterus and due to a catarrhal endometritis, called " hydrorrhcea gravidarum," may deceive one into believing that the amniotic sac is emptv. 382 AMERICAN TEXT- BO OK OF OBSTETRICS. A more common cause of error is the gushing of odorless hysterical urine. At times rupture is delayed until the membranes bulge through the vulva. In rare instances the child is born enveloped completely in the unbroken sac ; this is the " caul." The chorion usually gives way first, having a firmer attachment, as the amnion can loosen over most of its surface and slip downward and out. The seat of rupture may not correspond with the opening of the cervix. If it is on the side wall, the waters may leak more slowly, but this slow flow of the fore-waters is not very often seen, although discharge of the hind-waters in jets, as the presenting part recedes from its tight fit in the cervix during a contraction, may simulate it. Frequent gushes of so-called " liquor amnii " are often only urine. After rupture the waters may come away with a forcible gush or may leak slowly. On examination after delivery the position of JpLACENm- V <\ 2^ ■ffmRANtr- Fig. ISo.— Placenta and membranes after delivery, to show how the relation of the opening to the placenta indicates the site of the latter: I., lateral implantation ; II., fundal implantation; III., placenta previa marginalis. the tear in the membranes shows the location of the placenta in the uterus (Fig. 183). An opening opposite the after-birth would denote implantation in the fundus ; a tear close to the margin of the placenta would indicate pla- centa prsevia ; and one of the intermediate degrees is also shown. Character of the Liquor Amnii. — Ordinarily the waters have a slightly turbid, yellowish color. At times the amniotic fluid is thick with greenish or brownish meconium, due, perhaps, to undue pressure on the child, and some- times indicative of danger, except in breech presentations. Flakes of skin and a muddy consistency suggest a macerated fetus. Bright blood in any quantity within the membranes indicates premature separation of the placenta with leakage into the amniotic sac, but is very rare. Formation of the Caput Succedaneum. — The caput succedaneum is an edematous swelling that develops on the presenting part of the child as the cervix expands. The cervix makes pressure all over the presenting part dur- ing uterine contractions, except at one spot, and here serous infiltration develops a dough}' prominence. The size of this swelling varies with the duration of THE PHYSIOLOGY OF LABOR. 383 the labor. If it occurs on the face, the grotesque disfigurement alarms the family, but the swelling subsides in a day. The scrotum may assume large dimensions in breech labors. On the scalp the position of the edema serves to indicate the position in which the head enters the pelvis, provided too long delay in the lower birth-canal has not occurred. The tumor is located on that end of the head and that side of the head opposite in name to the position. Fig. 184.— Location of the caput suceedaneurn, and its indication of the original position of a vertex presentation. Thus in the left occipito-anterior position it is found to the right posteriorly ; in right occipito-posterior, to the left and front (Fig. 184). Clinical, Course of Labor. Signs of Beginning Labor. — From eight to fourteen days before labor " sinking" or " lightening" occurs in a considerable number of patients. The uterus drops lower, the fundus falls forward, the head engages or descends to lie on the pelvic floor (Fig. 175). and as a consequence the patient experiences a sense of relief, breathes more freely, digests better, and has looser waistbands. This may never occur in a given patient, or it may happen two days or four weeks before delivery. In half the primigravidas Bruhl examined he found the greatest circumference of the head beneath the brim at the end of preg- nancy where the inlet was roomy, whereas in only one-third of the multi- gravidse was this condition seen, owing to the laxer state of the abdominal wall after first pregnancies. On the other hand, irritability of the bladder and venous obstruction in the legs or the labia, with more difficulty in walk- ing, may result from the intrapelvic pressure. At the time of subsidence the intermittent contractions may begin to be painful, so that labor is supposed to 384 AMERICAS TEXT-BOOK OF OBSTETRICS. be under way, the pains often being grouped in certain parts of the day or night, and being most commonly seen among multipara?. Late in pregnancy the vagina and the vulva are relaxed, a glairy mucus lubricating them and facilitating internal pelvic measurement and examination. The only certain method of determining whether labor is under way is by digital exploration of the cervix. By passing the finger within the cervix and hooking it forward we may determine whether the internal os is widening or disappearing (Fig. 169), and the whole tubular canal of the cervix is being thinned and drawn up ; for we must remember that in over-distention of the uterus, as in cases of hydramnion or twins, or in the relaxed state of some multiparous uteri, or where there has been wide laceration, the cervix gapes in the last month, and that a low position of the fetus flattens the cervix between the head and the pelvic floor (Fig. 175). Fig. 1S5— Pelvic floor before distention (modified from a frozen section by Braun and Zweifel, one- third natural size) : the edema and thickening seem excessive, but Webster's measurements show that this floor is rather thinner than the average. We are warned that labor is actually under way by the following signs : 1. Irritability of the bladder and the rectum becoming more marked than before, micturition being particularly affected. 2. The "show" — an escape of blood-streaked mucus, due to slight lacera- tions of the cervix. This sign is not constant. 3. Expulsion of the mucus plug from the cervix — a sign not often detected. 4. Increased secretion. Both cervical and vaginal mucus is poured out in THE PHYSIOLOGY OF LABOR. 385 such a manner that when the passages seem soaked and softened with free mucilaginous discharge we may expect to find cervical dilatation making good progress. 5. Rhythmical uterine pains. The most conclusive symptom of beginning labor is the occurrence of regularly recurring pains, with lessening intervals and increasing force, and the most conclusive sign is that stated above — namely, beginning dilatation of the cervix. Stages of Labor. — The first stage, better called the dilatation stage, ends with the complete canalization of the utero-cervical zone. The second stage, the stage of expulsion, ends with the birth of the child. The third or placental stage ends with complete evacuation and lasting retraction of the uterus. 18 The First Stage, or the Dilatation Stage. — When labor is fairly started the contractions of the uterus assume a certain regularity, characterized by decreas- Fig. 186.— Fully-distended pelvic floor (over one-third life size). iug intervals and by increasing force and painfulness. Occurring at first about every half-hour and only slightly discomforting, with some sense of pressure, the contractions gradually run closer together until, toward the end of dilatation, they give but momentary intervals of relief. The pain is located as a rule in the sacral region, and later extends to the lower abdomen or down the thighs. The patient is restless, standing, sitting, moving, tossing, wringing her hands, seizing on a support, calling for pressure against the sacrum, or begging for re- lief. Her outcry is involuntary, high-pitched, or apologetic, an impatient pro- test, or a plaint. She can be persuaded with difficulty that any progress is being made by such colic, seemingly futile. Her cries are not like those of the second stage, which is marked by a transition to the groan or grunt of effort as she closes the glottis and strives to expel the child. The maternal pulse increases in frequency during a uterine contraction, while the fetal pulse is retarded at the acme of the pain. The temperature in normal labor rarely 386 AMERICAN TEXT-BOOK OF OBSTETRICS. rises 1° F. Urine is freely secreted during this stage, and attacks of shiver- ing or vomiting may occur toward its end. With each pain the cervix grows tense, the border becoming sharp and the membranes protruding, to retreat again as the edges relax. Gradually yielding and softening, with abundant mucus-secretion, the retreating edges permit the membranes to rest broadly on the pelvic floor. When the opening measures 7.6 centimeters (3 inches) the bag of waters usually gives way and the "fore- waters "escape, clear or milky, with particles of vernix caseosum, while the bulk of the amniotic fluid is held back by the ball-valve action of the head. After a pause pains recur and the head descends, and the rim of the cervix is pushed back against the pelvic walls until its edges are hardly perceptible, the cervix being flattened against and practically continuous with the vaginal walls. Tlie duration of the stage of dilatation varies from two hours to several (2>}ln labor, flilly distended Fig. 187 —Diagram of the pelvic floor before and during the process of thinning or stretching. It will be seen that the structure is thinned rather than driven forward (one-third natural size). days. In the primipara twenty-four hours is not uncommon, and the length increases with the patient's age, averaging over thirty hours at forty years (Decterlin). To give a figure for the student to remember, we say that the average duration in the primipara is fifteen hours, in the multipara eight hours. The Second Stage, or the Stage of Expulsion. — We are not here concerned with the mechanism, which will be treated later (p. 480). The patient has a fully-dilated cervix, ruptured membranes, and a fetal head resting on the pelvic floor. The character of the pain changes ; it is no longer teasing and inefficient ; the impulse to drive out the great mass that presses toward the outlet -brings about an effort by the diaphragm and abdominal muscles THE PHYSIOLOGY OF LABOR. 387 with closed glottis ; steadying herself or pulling hard on sheet or assistant, she strains to bring all her strength to bear ; instinctively, as in the savage races, she takes the semi-recumbent posture that brings the uterus upright ; and her outcry is the groan of great effort or the moan of ended exertion. With each pain the pelvic floor bulges and then recedes ; the vulva gapes Fig. 188.— Pelvic floor after the escape of the head (one-third natural size) ■ constructed from the Zweifel frozen section to show the pushing forward of the anterior vulvar commissure also, and the remarkable way in which the child is packed into the birth-canal. The passage of this head through the pelvic cavity might well result in rupture of the uterus. and the head appears ; the parts behind the outlet grow thinner and more dangerously tense ; the acme of suffering has arrived. As the head protrudes through the opening the pains grow stormy, and, reckless of injury, the mother drives out the torturing obstruction. The fourchette slips back over the face and is snugly applied to the neck or shoulder (Fig. 188). Now occurs a pause of from one to five minutes. The child may grow dusky, or may attempt 388 AMERICAN TEXT-BOOK OF OBSTETRICS. to breathe, thus drawing into the air-passages fluids taken into the mouth. Usually the next pain expels the trunk, which is followed by a gush of liquor arunii, with some blood. Tlie duration of the expulsion stage varies from ten minutes to six hours. In prirniparse the average is two hours, in multipara? one hour. Changes in the Pelvic Floor. — The pelvic floor is the fleshy diaphragm dovetailed into the bony outlet of the pelvis. It is about 5 centimeters (2 inches) in thickness, concave above and covered with peritoneum, and convex in shape on its lower skin-surface. Between these surfaces lie fascia?, muscles, connective tissue, and fat, named in the order of their physiological importance. Through the floor run three slits, the urethra, the vagina, and the rectum-anus. The axes of these openings are oblique (Fig. 187), so that direct pressure from above Fig. 189.— Pelvic floor seen in axial coronal section ; one-third actual size (modified from Hart). tends to close the openings by pressing their walls together. Ordinarily their capacity for distention is limited, but the remarkable character of the pelvic floor is that, whereas the chief function of this unique structure is to form a solid and unbroken support for the organs above it under all conditions of strain, at certain moments it must, without injury, efface itself, and open up to the size of its entire length and breadth. We shall consider the changes that bring about this result. Hart, studying frozen sections mainly, 19 observed that the vaginal slit divides the structure into an anterior part, which he named the pubic segment, triangu- lar in shape, composed of retropubic fat, bladder, urethra, ami anterior vaginal wall, attached (loosely) to the pubes ; and a much larger and stronger posterior part, the sacral segment, between the rear vaginal wall and the posterior bony wall, including the anus and part of the rectum. Symington 20 considers that THE PHYSIOLOGY OF LABOR. 389 the rectum and bladder and the upper vagina, like the uterus, should not be regarded as parts of the floor, but as organs resting upon it. Webster 21 holds that the bladder is imbedded in the pelvic floor, and that the vagina and cervix are parts of it, together with the rectum from the coccyx down. In the illustra- tion (Fig. 189), for obvious reasons, the bladder and cervix have been omitted. Late in pregnancy the changes that belong to the pelvic floor are relaxation from edema, moderate increase in thickness, and a low droop or " bulging downward." All these changes favor the stretching that is to come. The main- tenance of its former axis by the vagina, its distance from the symphysis, the shape of the pelvic floor at this time, and the low position before it is opened up into an oblique hernial canal are shown in Figures 185, 187, and 189. During labor, in the dilatation stage the parts anterior to the vagina are restrained from being driven down by the upward traction of the longitudinal fibres of the uterus on the anterior lip of the cervix, to which the bladder is attached. As the os is drawn up the bladder and urethra are somewhat elevated, the former coming to lie at the back and partly above the pubes, flatly com- pressed against the bone, together with the urethra, by the descending head. The utero-vesical pouch of peritoneum is stripped upward from the bladder (Webster), and the urethra is not elongated. The parts posterior to the vagina, composing the sacral segment, are of more clinical interest. The change in position here is rather a pushing backward than a driving downward, and is accompanied with excessive thinning. The centre of the perineal skin-surface, and with it the important tendinous centre of the perineum, is only driven down in the long axis of the body 2.5 cen- timeters (1 inch), while the 5-centimeter (2-inch) perineal pyramid is atten- uated to 4 or even to 2 millimeters (^ or ^ inch).* The sacral segment is moderately elongated. From the tip of the sacrum to the posterior commis- sure before labor is about 16.6 centimeters (6^ inches). During full stretching by the head the Varnier section measures 19 centimeters (7-j inches), and the writer's hospital measurements averaged 18 centimeters (7£ inches). The sphincter ani gapes a little over an inch (Hart), and assumes the form of a D laid on its side (thus, o), while the anus is displaced backward (Fig. 187, A, A, a). The figures may be summarized as follows : — Centimeters. Inches. Thickness of the pelvic floor in front of the anus, in nullipara (Webster) ... 3.3 1J " " at term, before stretching 7 2J " " moderately distended 2.5 1 " " fully distended 3 J Projection of pelvic floor, in nullipara 2.5 1 " " at term, before stretching 7 2| " " at greatest distention 9 3| " " on twelfth day of puerperium 2.5 1 Length of perineal body, from fourchette to anus, in nullipara 3.3 \\ " " after complete dilatation by the head .6.5 2J * The figures used in this discussion are drawn in a certain degree from Webster and Varnier, but are mainly based on an independent study of eighteen frozen sections that range from the eighth month to the middle of the expulsion stage, and are corrected by a number of lead-tape tracings of the pelvic floor during labor. 390 AMERICAN TEXT-BOOK OF OBSTETRICS. The Third Stage of Labor, or the Placental Stage. — The processes whereby the placenta is separated and expelled and retraction of the uterus is secured are given on page 490. Clinically we note that the fundus is hardened by firm uterine contraction, and is located above the brim, but below the level of the navel. Blood trickles in small quantity from the vagina during the pause, the total blood-loss in a labor averaging less than 500 grams (18 ounces). After a rest rhythmic uterine activity is renewed, and the placenta comes away, fol- lowed by the membranes, and the corpus is found to have but half the former breadth and to be halfway to the navel. Very moderate stimuli — such as fric- tion, nursing, a douche of hot water — will now produce good contraction, whereas strong excitors may have failed while the uterus was distended. The average duration of the -placental stage is from twenty to thirty min- utes. The placenta may follow the child at once, or it may remain two hours. After that time the case belongs under the head of Pathology. Duration of Labor. — The length of labor varies within very wide limits, and our definite statements of averages do not claim exactness. The exact hour of the onset of labor is often impossible to fix. Labor is usually longer in the primipara than in the pluripara, on account of the greater resistance of the soft parts during the first delivery. It is longer, as a rule, in the very young and in the elderly primipara, and in the stout than in women of slighter build. Spiegelberg's 506 cases are commonly quoted, wherein the three stages in the primipara are averaged respectively at fifteen hours, two hours, and half an hour, with a total of about seventeen hours, while the multipara is listed at eight, one, and one-half, the total being given as eleven hours. Many of the text-books are non-committal. The majority, however, estimate the duration of labor in the multipara at eight hours — not varying greatly from Spiegel- berg's figures in other respects. Table of Averctge Duration of Stages of Labor in Hours. Primipara Multipara Spiegelberg 22 states that labor most frequently begins between 10 and 12 o'clock in the evening, and the end of labor occurs twice as often between 9 p. M. and 9 A. M. as in the other twelve hours. AVest 23 found, in 2019 cases, 40 per cent, delivered between 11 p.m. and 7 a.m., and the most favored time is between midnight and three in the morning. A larger number of rapid labors are said to occur in summer than in winter (107 : 100). THE CONDUCT OF NORMAL LABOR. 391 REFERENCE LIST. 1. Lusk: Midwifery, 1892, p. 124. 2. Archivfiir Oyndkoloyie, Bd. xi. p. 49. 3. Wiener medicinische Jahrbuch, 1872, 1873. 4. Cohnstein : Archiv fur Oyndkoloyie, Bd. xviii. p. 394. 5. New York Journal of Gynecology and Ob- stetrics, June, 1892, and November, 1893. 6. Parvin : Obstetrics, 1890, p. 362. 7. Cenlralblatl fib- Oyndkoloyie, 1884, p. 648, and 1S85, p. 625. 8. Winter: Zwei Medianschn., Berlin, 1889. 9. Lusk: Midwifery, 1892, p. 13S. 10. Barbour and Webster: Edinburgh Lab. Re- ports, vol. ii., 1890, p. 31. 11. Schroeder : Schwangere unci Kreissende Ute- rus, 1SS6. 12. A clear epitome with partial bibliography is given in Jaggard's section of Hirst's American System of Obstetrics, p. 333. 13. Archivfiir Oyndkoloyie, Band xv. 14. " Zur Phys. u. Path, morphol. d. Gebar- mutter," Gyn. Klinik, 1885, p. 398. 15. Ribemont-Dessaignes-Lepage: Precis d' 06- stetrique, 1894, p. 332, 16. Pinard and Varnier: Anatomic Obstetricale. 17. Precis d' Obstetrique, p. 335. 18. Jewett: Outlines of Obstetrics, Saunders, Philadelphia, 1894, p. 109. 19. Structural Anatomy of the Pelvic Floor, Edinburgh, 1880. 20. Edinburgh Medical Journal, March, 1889. 21. Researches in Female Pelvic Anatomy, 1892. 22. Lehrbuch, 1891, p. 147 ; Monatsschrift fur Oeburtshiilfe, 1868, p. 279. 23. American Medical Journal, 1854. II. THE CONDUCT OF NORMAL LABOR. 1. Antisepsis. Nowhere do we find more striking proofs of the value of the antiseptic system than is shown in the diminished puerperal mortality and morbidity in hospitals since the introduction of antisepsis into obstetric practice. Before the advent of Listerism the usual death-rate from childbed fever in lying-in hospitals was from 2 to 10 per cent., and in so-called " epidemics" this limit was often exceeded. In the women who survived, feverless childbeds were comparatively infrequent. Under antiseptic methods the mortality from sepsis in well-managed institutions is less than 1 in 200, and the morbidity does not exceed 10 per cent. A few examples will suffice to show what is possible under the present perfected system of aseptic obstetrics. Professors Groth, Netzel, and Sonders of Stockholm report 1 17,862 births under their direction (1880-89), with 1 death in 344, or .29 per cent. In Copenhagen (1888-89), in 1218 hospital deliveries the death-rate was .24 per cent. Slawiansky 2 tabulates the results of 176,646 deliveries in fifty-three hospitals of Russia (1881-89), showing a morbidity of 8.57 and a mortality of .38 percent. Leopold 3 records 3089 cases (from May, 1885, to May, 1887) without a death from septic infection. The Boston Lying-in Hospital (1891) recorded 550 deliveries with no death from septic causes. In 1892 there were 515 confinements with but 1 fatal case from septicemia — a mortality of less than 0.1 per cent, for the 1 Verhandlungen des X. Internationalen Med. Cony., B. 111. 2 Ibid. 3 Deutsche med. Wochenschrift, vol. xiii. No. 25. 392 AMERICAN TEXT-BOOK OF OBSTETRICS. two years. 1 In the Sloane Maternity, New York City, there has been thus far but 1 septic death in 3000 deliveries. 2 In the New York Maternity Hospital 957 women were delivered during the three years ending Oct. 1, 1893, without a death from sepsis. 3 W hile in pre-antiseptic times the puerperal mortality was many times greater in public institutions than in private practice, to-day the pauper delivered in a hospital is exposed to less risk than are the well-to-do classes who are confined in their own homes. Insurance reports show that of all deaths in women between the ages of nineteen and twenty-nine more than 18 per cent., and between twenty-nine and thirty-nine years more than 13 per cent., are due to puerperal causes. From 65 to 75 per cent, of puerperal deaths are attributable to sepsis. It is fair to assume that these statistics have to do almost wholly with a class who are delivered outside of hospitals. This indicates a mortality that is truly appalling, especially when one reflects that it falls upon women in the prime of life and usefulness, and is the result of a preventable disease. Yet the disastrous effects of puerperal infection are not represented by the mortalitv alone. Thousands of invalid mothers owe their impaired health to the milder grades of sepsis in childbed. No stronger evidence could be offered than is afforded by the foregoing facts of the need for improvement in the obstetric methods of the general practitioner. Obstetric antisepsis dates from 1847. To Ignatius P. Semmelweis, a young Hungarian who at that time held the position of assistant in the lying-in department of the Vienna General Hospital, belongs the credit of first demon- strating its efficacy. • The obstetric service of the hospital was divided into two sections, in one of which instruction was given to midwives, in the other to medical students. It was with the latter that Semmelweis was connected. The students in this department were at the same time actively engaged in the pur- suit of practical anatomy and pathology. The women were delivered by students who for a considerable portion of their time were occupied with the operations of the dead-house and the dissecting-room. They took no precau- tions to cleanse themselves except to wash their hands with soap and water, and they made examinations ad libitum. The death-rate was excessive, reach- ing nearly 10 per cent, of the women delivered. Horrified at this frightful mortality, Semmelweis bent his energies to find- ing the cause. He was struck with the fact that in the midwives' clinic the death-rate was little more than 3 in every 100 women confined. The records showed also that women delivered before admission nearly all escaped. It appeared, too, that prolonged labors in the students' clinic were almost invari- ably followed by death, while in the midwives' section the length of the labor made little difference in the mortality. During the time that Semmelweis was engaged in his investigations Prof. Kolletsehka, one of his associates, lost his life by a dissection-wound. The symptoms of his colleague's illness were 1 Communication to the writer from Dr. Charles M. C4reen, Sept.. 1893. 2 Personal letter from Prof. J. W. McLane, Oct., 1S93. 3 Personal communication from Dr. Robert A. Murray, Oct., 1893. THE CONDUCT OF NORMAL LABOR. 393 entirely similar to those of the fatal malady which was raging in his own wards. Impressed with the identity of the two diseases, it dawned upon him that the cause of the deadly scourge was to be found in the infected hands of the students who attended the labors. In May, 1847, he established the order that students before taking charge of a labor case should wash their hands in chlorin-water or in a solution of chlorinated lime, and he restricted the number of examinations. The result was an immediate fall in the death-rate. In six months it had dropped from nine or ten to three per hundred, and in the second year of the new regime it did not exceed 1.5 per cent.' Soon after its introduction into surgery by Sir Joseph Lister in 1866 anti- sepsis began to gain a permanent foothold in obstetrics. First adopted in 1870 by Stadfeldt of Copenhagen, it was taken up by the principal maternities of Europe, and to-day, with many improvements in the technique, it is univer- sally practised in the lying-in hospitals of the world. Practical Rules for Disinfection. Instruments, Utensils, and Dressings. — The most efficient of all germicidal agents is heat. For instruments, utensils, sutures, and dressings that will not be injured by high temperatures heat affords the best means of disinfection. Either of three methods, dry heat, boiling, or steaming, may be employed. Dry Heat. — For most utensils exposure in an oven is a convenient and effective method of sterilizing. It is necessary that the temperature reach 284° F. For greater accuracy in regulating the temperature a thermom- eter specially made for the purpose may be used. As some time will be required to bring the instruments to the necessary degree of heat, the exposure should be maintained for at least fifteen minutes to ensure proper sterilization. Boiling. — The best method of sterilizing most instruments is boiling them ten minutes in water. The addition of 1.5 per cent, of washing soda to the water helps to remove greasy matter, tends to prevent steel instruments from rusting, and increases its germicidal action. The soda should, if possible, be chemically pure. This method has the advantage that it is available in any household. All that is needed is a vessel large enough to hold the necessary instruments and appliances, and a range fire, gas stove, or even a large alcohol lamp. In emergency no more elaborate apparatus is required than a common dish-pan. Place in it the instruments, silk or silk-w r orm sutures, sponge compresses, and other materials to be sterilized, cover them with w r ater, and boil for the requisite length of time. Turn off the water, and the pan serves as an aseptic instrument-tray. Steaming.— Sterilization by steam requires special apparatus. Numerous appliances are to be had for the purpose, one of the most economical of which is the Arnold steam-cooker. This process is available for practically 1 For many of these facts the writer is indebted to an address by C. T. Cullingworth, M. D., F. E. C. P., entitled Puerperal Fever a Preventable Disease. — . 394 AMERICAN TEXT-BOOK OF OBSTETRICS. all dressings, and utensils not too bulky to be contained in the sterilizer. It is well to place the articles to be sterilized in a wire basket or a cloth bag in which they may be lowered into the steam-chamber. This facilitates hand- ling. The time required for sterilization is from ten minutes to an hour, according to the bulk and character of the materials. Dressings need the longest exposure. In the labor ward of a hospital a steam-sterilizer may be kept in opera- tion during the labor, and compresses, sutures, dressings, etc., may be taken direct from the steam-chamber as they are wanted for use. Chemical Antiseptics. — Among the chemical agents most commonly em- ployed for obstetric antisepsis are the mercuric chlorid dissolved in water, in strength of from 1 : 2000 to 1 : 500, the mercuric iodid in similar propor- tion, the peroxid of hydrogen (15-volume solution), the liquor soda; chloratre diluted with 9 volumes of water, a 2 per cent, creolin mixture (in water), and a 2 to 5 per cent, solution of carbolic acid. The order in which they are named is substantially that of their germicidal potency. The practical efficiency of mercuric chlorid (corrosive sublimate) is greatly increased by the addition to the solution of five parts of hydrochloric, tar- taric, or acetic acid for each part of the sublimate, since in neutral solutions of that salt the mercury is precipitated as an albuminate on contact with blood or with other albuminous liquids. The acid, moreover, serves to protect the solution against impairment of strength by contact with the alkaline fluids of the tissues. The mercuric chlorid is decomposed by alkalies. The mercuric iodid (biniodid of mercury) requires the addition of an equal weight of the iodid of potassium to render it freely soluble. With this salt no acid is required. Neutral solutions of the mercuric iodid yield no precipitate with albumin. The chlorated-soda solution, the peroxid of hydrogen, and the creolin mixture have the advantage of being practically non-poisonous, and they are therefore more suitable to be trusted to the nurse than are the mer- curial preparations. The Obstetrician. — The obstetrician should be clean ; especially must his hands be clean, and he should wear clean clothing. It is well to avoid eon- tact with pathological material and, so far as possible, with other sources of wound-infection. It is impossible to lay down rules which alone will make an aseptic prac- titioner. The obstetrician must be possessed of an aseptic instinct, and this is a matter which comes of training and a keen appreciation of the possible sources and modes of infection. During attendance upon a labor the obstetrician should wear a fresh- laundered gown or a clean apron large enough to prevent contact of his hands with his clothing. His hands and forearms are to be cleansed thor- oughly and disinfected before the first examination, and before each subse- quent contact with the genitals if they have in the meantime touched any- thing that is not aseptic. Hand Disinfection. — Furbringer Method. — For the disinfection of the THE CONDUCT OF NORMAL LABOR. 395 hands the following method, which is substantially that of Fiirbringer, is recommended : 1. Keep the nails cut short and clean them dry. 2. Brush the hands and forearms systematically for five or ten minutes with a hand-brush, with soap and water as hot as can be borne. Special care must be taken to brush thoroughly the nails, the finger-tips, and the sides of the fingers. The water should be changed two or three times, and the scrubbing completed in running water. 3. Soak well with alcohol (80 per cent.) and, before it evaporates, 4. Immerse for five minutes in a hot solution of mercuric chlorid (1 : 2000 to 1 : 500), or in a 3 per cent, solution of carbolic acid. The foregoing technic, even without the alcohol, though it does not meet the requirements of laboratory tests, will be found satisfactory from the clinical standpoint, if faithfully carried out. Undoubtedly, the most essential step in the process is the soap-and-water scrubbing. It not only removes the greater part of the offending material, but it is also indispensable to the proper action of the antiseptic solution. The latter can penetrate the skin only after the oily matter has been removed and after the skin is thoroughly wet. The use of alcohol helps the action of the chemical solution by dehydrating the skin and rendering it hygroscopic, thus favoring penetration of the solution. It is to some extent also a solvent for fat. When summoned to a case of labor immediately after a septic contact, besides the usual care in disinfection, the obstetrician should wear sterilized rubber gloves. Lacking gloves, it is often possible to manage the birth even without direct contact with the genitals of the patient, the required manip- ulations being conducted through the intervention of a sterilized towel well saturated with the antiseptic solution. Permanganate Method. — AVelch, of the Johns Hopkins Hospital at Bal- timore, recommends the following procedure, which is known as the perman- ganate method. By it the hands, it is claimed, may be rendered practically sterile to culture tests. This, however, is true only of the surface of the skin and that only for a period of not many minutes. The serins always present in the deeper layers of the cuticle are not destroyed and they soon gain access to the surface. 1. The nails are cut short and carefully cleaned. 2. The hands and forearms are scrubbed for five minutes with soap and water. The brush before using is sterilized by steam, and the water, which is as hot as can be borne, is frequently changed. The soap is rinsed off with plain water. 3. The hands are next immersed in a warm solution of permanganate of potassium until of a deej) brown color. The solution is best made with dis- tilled, or at least boiled, water and it should be saturated. 4. The hands are next held in a warm saturated solution of oxalic acid in boiled water until the permanganate stain is entirely discharged. 5. After rinsing in sterilized water the hands are immersed for two min- utes or more in a 1 : 500 mercuric-chlorid solution. 396 AMERICAN TEXT-BOOK OF OBSTETRICS. The most effectual safeguard against infection by the hands is afforded by the use of rubber gloves which have been boiled in normal salt solution for fifteen minutes. The hands are prepared, before putting on the gloves, with the same care as when no gloves are used. This is necessary for the reason that the gloves may be torn and the hand partially exposed. The Nurse. — The nurse should be no less careful than the obstetrician in the observance of all antiseptic details. The Patient. — In hospital practice the patient has a bath and a change of clothing at the onset of labor. In all cases before the first internal examina- tion the abdomen, the thighs, and the vulva are cleansed by the nursewith soap and warm water. The soapy water is rinsed off and the parts are well bathed with the antiseptic solution. It is a useful precaution to cover the limbs of the patient, when she takes the 'bed, with a pair of muslin leggings fresh from the sterilizer. The leggings should be closed below, so as completely to envelop the feet. In addition to this, the patient and the entire cot may be covered with a sterilized gauze sheet. During the first stage a vulvar dress- ing saturated with Thiersch's solution may be worn. Similar precautions are not all practicable in private practice, nor are they all necessary. The change of clothing, the preliminary cleansing and disinfec- tion of the external genitals and adjacent surfaces, and the aseptic cleanliness of everything that comes in contact with the birth-canal must always be insisted upon. The utility of prophylactic vaginal douches is a question which has pro- voked much discussion. Steffeck l recommends vaginal irrigation during labor with mercuric-chlorid solution at intervals of two hours, rubbing the antisep- tic well into the mucous membrane with the fingers. Doderlein 2 advises scrubbing the vagina with a preparation of creoliu and mollin, followed by a ten-minutes' douching with the creolin solution. Hofmeier 3 favors preliminary disinfection, especially in maternity hospitals where students are allowed to examine the patients during labor. He concludes, from a comparison of the records of the Wiirzburg clinic with the published statistics of other like institutions, that, with preliminary disinfection and the careful observation of all possible antiseptic precautions, instruction by means of examinations during labor does not necessarily increase the danger of infect- ing the patient. He further contends that thorough disinfection of the birth- canal is not a source of danger to the mother, as has been claimed, but that it results in a diminished puerperal morbidity and mortality. Frommel 4 reports over five hundred cases in which vaginal injections of the corrosive-sublimate solution (1 : 2000) were employed, and where in many abnormal cases from sixty to seventy examinations were made during the patient's stay in the hospital, the clinic being open to about one hundred students, and being also used for the training of midwives. In this number 1 " Ueber Disinfection des Weiblichen Genital Canals," Zeitschrift fiir Qeburtshtilfe, vol. xv. p. 395. 2 " Disinfection des Geburts-Canal," Archiv fur Gynakologie, vol. xxxiv. 111. 3 Deutsche med. Wochensehrift, 1891, No. 49. * Ibid., 1892, No. 10. THE CONDUCT OF NORMAL LABOR. 397 of patients there were two cases of sepsis whose infection was traceable to his clinic. The morbidity-rate was from 5.5 to 7.5 per cent. In another series of cases, where external disinfection alone was practised, the morbidity rose to 11.1 per cent. Mermann ' reports the results of seven hundred cases without the employ- ment of vaginal douches for preliminary disinfection. He records a morbidity- rate of 6 per cent., with no deaths from septic infection. In the last two hun- dred births there were two cases of mild ophthalmia, and in all less than ten of conjunctivitis among the children. Mermann omits internal examinations whenever practicable, observing the progress of the labor by abdominal palpa- tion and auscultation. Leopold and Goldberg 2 publish the statistics of several thousand deliveries with and without the employment of vaginal disinfection. Their tables show the best results where the vaginal douches were not used. They recommend the employment of abdominal palpation as a means of noting the progress of labor, and the restriction of vaginal examinations to cases of dystocia, except when necessary to confirm a diagnosis made by the abdominal method. They advise douches in operative cases and in all others where previous infection is suspected. Fischel in an experience of 880 births at the Prague Maternity lost nine women from sepsis with the employment of preliminary disinfection. After stopping the use of the irrigations, in a series of 933 cases there were but two deaths due to infection, and a year later, in 521 women delivei'ed, there were no deaths from that cause. The safer course, at least for general use, is undoubtedly the restriction of internal examinations as much as practicable, and of the prelimiuary vaginal douche to cases in which the secretions are pathological. In the presence of purulent gonorrheal discharges both the vaginal and cervical canal, as well as the vulva, ought to be cleansed carefully with soap and water and gentle fric- tion with the fingers, and subsequently flushed well with the antiseptic solution. In extreme cases the disinfection may be repeated at intervals of two or three hours during the labor. This is required not only in the interests of asepsis for the mother, but as a prophylactic against ophthalmia in the child. Mer- curials, however, are not suitable for the purpose, owing to the danger of mercurial intoxication. Mercury has been found in the stools after a single vaginal irrigation. Some of the non-toxic disinfectants, such as crcolin, peroxid of hydrogen, or the chlorinated -soda solution, are to be recommended. Antisepsis in the Use of the Catheter. — Should the patient require to be catheterized after labor, care will obviously be needed to prevent infection of the vaginal wounds and abrasions. But this is not all. Cystitis of the vesical neck frequently results from infectious material carried into the bladder during the use of the catheter. So common is this accident that patients who have repeatedly been catheterized by the nurse, even with ordinary precautions, very rarely escape some degree of vesical irritation, and they often suffer from severe inflammation of the bladder or of the vesical neck. Pyelitis even may 1 Centralblatt fiir Gyndkologie, 1892, No. 99. 2 Deutsche med. Wochenschrift, 1S92, No. 13. 398 AMERICAN TEXT-BOOK OF OBSTETRICS. result by extension of the septic process from the vesical mucosa through the ureters. The strictest asepsis must therefore be observed in catheterizing the bladder. The instrument should be boiled for fifteen minutes in water con- taining 1J per cent, of sodium carbonate immediately before using, and this is possible even with soft-rubber catheters without material injury to the instrument. It should then be handled only with hands that have pre- viously been sterilized. The patient lies upon the back with the knees drawn apart. The labia are to be held apart, either by the patient herself or by an assistant, so as to expose completely the meatus urethrae, and so held until the instrument is passed. The meatus, the vestibule, and all the surrounding surfaces are to be cleansed with soap and water, and subsequently to be washed with the disinfectant solution. The catheter, well lubricated with sterilized vaselin, is then passed with clean hands, the parts being fully exposed to the eye. Precautions must be used to prevent urine from trickling over the wounded surfaces or into the vagina as the instrument is withdrawn. The catheter, after using, should be cleansed carefully with water. Care must be taken that irritating chemical antiseptics are not carried into the urethra upon the catheter; otherwise a troublesome urethritis may result. 2. Management of Normal Labor. Essential to the proper management of childbirth is a watchful super- vision of the health and habits of the patient throughout pregnancy, and a previous knowledge, so far as possible, of the conditions to be dealt with in each case during labor. Next to Listeriau cleanliness, nothing is destined to do more for improved results in obstetrics than the practice, now happily growing with obstetricians, of studying their cases before labor. It is desirable, therefore, that the pregnant woman be under the observation of her phvsician from an early period of gestation, and especially if the experience be her first. Much-needed information and advice may be im- parted with reference to the hygienic requirements of pregnancy. Knowledge may be gained of conditions likely to complicate the parturient or puerperal process, and much may often be done to fortify the health and strength of the patient. Dystocia, if it cannot be prevented, is more successfully managed with the aid derived from previous knowledge and preparation. Even when all is normal, both patient and physician are amply repaid for their pains by the increased confidence with which the result of labor is awaited. The patient should be advised with reference to the selection of her nurse. Instructions will be needed pertaining to the care of the nipples. She should be directed to cleanse them daily during the last month or two of pregnancy, and, if they are very small or sunken, to draw them out with the fingers. This manipulation also helps to inure them to nursing. Daily inunction of vaselin or of fresh cocoa-butter during the same period keeps them supple, and is a better preparation for suckling than the use of astrin- gents so commonly practised. THE CONDUCT OF NORMAL LABOR. 399 Especially important is it that the functions of the kidneys be watched. During the last one or two months before labor the urine should be examined weekly. Examinations at least once monthly are advisable from the first. If albumin is found, the microscopic study of the urine will best reveal the character and extent of the structural changes in the kidneys. In general, the best evidence of the manner in which these organs are performing their functions is afforded by occasional quantitative tests for urea. The patient should be instructed to measure the urine at short intervals during the later months. The average quantity in twenty-four hours should not fall short of 3 pints. The specific gravity should be noted. Obstetric Examination. In the later months it is the duty of the physician to make a preliminary obstetric examination. The most suitable time is usually about the end of the eighth month. The object is to determine the position and presentation of the child, the relative size of head and pelvis, and the possible presence of patho- logical conditions that may complicate the mechanism of labor. It is to be assumed that full information has already been obtained, at the time of engag- ing to attend the patient in confinement, with reference to her obstetric history, including the number of previous pregnancies, term labors, and miscarriages, all important facts pertaining to the character of the pregnancies, labors, and childbed periods, and particulars relating to the course of the present pregnancy. In hospitals it is the rule to make an external and an internal examination. In private practice an internal examination, while always desirable, need not in all cases be insisted upon. Usually all that is necessary to know may be determined by the external methods. In the presence of pelvic deformity, and in all cases in which for any reason the external examination is not satis- factory, exploration of the pelvic cavity should not be omitted. It is essentia] that the bladder and the rectum be empty. The patient lies upon a bed or a lounge, covered with a sheet and with the limbs outstretched. Her clothing is to be loosened and the skirts drawn above the abdomen. The necessary manipulations are conducted under the sheet or through it, without exposure of the patient. In this manner the abdominal examination and the external measurements of the pelvis may be made without causing discomfort or giving offense. The hands of the examiner are first bathed in warm water to render the skin soft and the toucli more acute. This precaution, too, helps to prevent reflex contractions of the abdominal and the uterine muscles, which are more likely to occur when the hands are applied cold to the abdomen. The examination should be methodical. Errors of diagnosis are more fre- quently the result of carelessness than of ignorance. Success here, as in most other undertakings, depends upon a capacity for taking pains. All manipula- tions are to be conducted gently, and need never cause the slightest pain, except rarely when deep pressure is required to map out the lower fetal pole. A defi- nite order of procedure is recommended in accordance with the following scheme : 400 AMERICAN TEXT-BOOK OF OBSTETRICS. 1. Diagnosis of the Fetal Presentation and Position. Location of the Dorsal Plane and Small Parts. — The situation of the dorsal plane and small parts of the fetus may, as a rule, easily be made out by palpat- ing the abdomen. The palmar surfaces of the finger-tips are applied with light intermitting touches (Fig. 190). Beginning at the lower part of the abdomen, a narrow zone is palpated entirely across from one side of the tumor to the other. The palpation is repeated over a similar area just above the first, and so on until the entire surface of the tumor has been explored. Usually the situation of the fetus will be learned by the first touches. It presents to the examining fingers the feel of a solid body, while elsewhere over the tumor only fluid is felt. The location of the child may more readily be made out by placing one hand flat upon the middle section of the abdomen and pressing firmly back- ward (Fig. 191). The liquor amnii is thus displaced to one side and the child to the other, where it can more easily be palpated. af abdomen for locating dorsal plane and photograph). 1 parts of fetus (from The child's back is identified by the length and breadth of the resisting plane which is offered to the examining touch, and by the absence of a sulcus between it and the fetal head. The side of the child presents a narrower 1 The photographs for this article were made by Dr. H. F. Jewett. THE CONDUCT OF NORMAL LABOR. 401 piane than the back, and a distinct sulcus separates it from the head. The examination of the dorsum is facilitated by applying one hand over the upper fetal pole and pressing downward in the axis of the uterus. The back of the child is thus rendered more convex, and is thrust outward toward the abdomi- nal wall within easier reach of the examining hand. The small parts are usually felt as nodules which glide about under the touch : they are best identified by circular, rubbing motions ; sometimes a fetal member may be mapped out through its whole extent. Except in the case of twins, where there are usually arms and legs in various directions, finding the small parts in one section of the abdomen confirms the location of the dorsal plane in the opposite region. Thus, small parts on the right indicate a left dorsal position, and conversely. Small parts few and hard to find point to an Fig. 191.— Depressing abdominal walls in locating dorsal plane of fetus in abdominal examination r displacing child to that side of the uterus toward which its back lies, liquor amnii to the other side (from a photograph). anterior position of the child's back ; small parts numerous and found near the middle section of the abdomen usually mean a dorso-posterior position of the fetus. Examination of the Lower Fetal Pole, — Facing the mother's feet, place the hands flat upon the abdomen over the lower segment of the uterus (PI. 23). 40:2 AMERICAN TEXT-BOOK OF OBSTETRICS. With the hands resting upon the sides of the tumor, their palmar Fig. 192.— Locating cephalic prominence by palpation with both hands. The hand sinks deeper in the pelvis at the side on which the occiput lies (Leopold). surfaces nearly facing each other and the finger-tips 1 or 2 inches above Fig. 193. — Examination of upper fetal pole, showing relation of examining hands to fetal parts (Leopold) the level of the pubes, maintaining firm pressure, the finger-tips are gently CONDUCT OP NORMAL LABOR. Examination Befoee Labor : Examination of lower fetal pole (from a photograph). THE CONDUCT OF NORMAL LABOR, 403 thrust downward into the brim of the pelvis. The pelvic excavation is then explored to learn if it contains the presenting fetal part. If it is filled before labor, the presenting part is the vertex. No other fetal part sinks into the lesser pelvis until labor begins, and even this sinking very rarely occurs except in primiparse. In the latter the fetal head is normally always in the pelvic brim. During labor either pole, whether the woman has previously borne children or not, should be found in the lesser pelvis. The head when it lies above the lesser pelvis is not usually so accessible to palpation as when in the excavation. A useful maneuvre for locating the head, if it is not readily found by direct palpation, is to place the hands in the usual position over the sides of the lower uterine seg- ment and proceed as for external ballottement, bringing the hands more and more nearly together until the head is found. The head will be recognized as a solid globular body which can be tossed from one hand to the other. The cephalic extremity is distinguished from the breech by its greater mobility when it lies above the excavation, by its hardness and globular shape, and by the presence of a sulcus between it and the fetal trunk. The breech alone, is smaller, with the inferior extremities larger than the head. It lacks the hard and globular character of the head, and presents no sulcus between itself and the trunk. An imperfect ballottement of the head is frequently obtainable when it lies in the lower segment of the uterus above the pelvic iulet. Cephalic Prominence. — When the head is in the excavation one side of the brim will be found more completely filled than the other (Fig. 192). This is due to the fact that the occiput sinks deeper into the pelvic cavity than the sinci- put. On one side the frontal portion of the head, on the other side the nape of the neck, occupies the pelvic brim. That side of the cephalic tumor which is the more prominent, therefore, is the sinciput. Cephalic prominence to the right indicates a left, to the left indicates a right, fetal position. The situation of the greater prominence will be observed in the course of the palpation above described. It may also be made out by arching the hand across the abdo- men immediately above the pubes (PI. 24; Fig. 196). The cephalic promi- nence will be found most marked in oceipito- posterior positions. Location of the Anterior Shoulder in Vertex Presentation. — The anterior shoulder may usually be found as follows : While the hands are still held upon the abdomen over the sides of the fetal head, move them upward toward the fundus without relaxing the pressure. The first obstacle they encounter is the anterior shoulder, which may more fully be identified by map- ping it out with the fingers of one hand. Steadying the fetal mass by gentle pressure with the other hand over the breech facilitates the examination. Finding the anterior shoulder within 1 or 2 inches of the median line indi- cates an anterior, and several inches from the median line a posterior, position of the fetus. In left positions the shoulder lies to the left, in right positions to the right, of the median line (Fig. 195). 404 AMERICAN TEXT-BOOK OF OBSTETRICS. Examination of the Upper Fetal Pole. — The examiner next faces the mother's face and places his hands over the sides of the fundus (Figs. 193, 194). The fundal pole of the fetus is then examined by palpation. The head is differentiated from the breech by the characters already Fig. 194. — Examination of upper fetal pole (from a photograph). mentioned and by a more pronounced ballottement than is usually pos- sible when the head presents. By reason of its smooth, globular shape, and especially of its flexible attachment to the trunk, the head is very movable, rebounding distinctly under the touch when in the roomy upper uterine segment. Location of the Fetal Heart-tones. — The stethoscope may or may not be used, according to the usual habit of the examiner. The point at which to listen first is directly over the supposed location of the upper part of the child's back. Failing here, the entire surface of the tumor may be searched. The heart-sounds are usually heard over an area of about 3 inches in diameter, but, since they are sometimes more widely diffused, it is important to locate the point of greatest intensity. The point upon the abdomen at which they are most intense is termed the focus of auscultation. As a rule, this point overlies the fetal heart. Exceptionally, the sounds are most dis- CONDUCT OF NORMAL LABOE. Examination Before Labor : Locating the cephalic prominence by arching the hand across the supra- pubic region (from a photograph). THE CONDUCT OF NORMAL LABOR. -405 tinctly heard at some remote point, owing to firmer contact of the fetus with Fig. 195.— Mapping out the anterior shoulder (from a photograph). the uterine wall at that point. Their location usually serves to distinguish left from right, and anterior from posterior, positions. In a posterior posi- FiG. 196.— Method of locating the cephalic prominence by arching the hand across the suprapubic region. tion the heart, if heard at all, is found far back over one side of the abdo- men : frequently the cardiac sounds are quite indistinct ; rarely they are wholly inaudible. 406 AMERICAN TEXT-BOOK OF OBSTETRICS. For the diagnosis of presentation the situation of the fetal heart is of limited value in women who have borne children. Since the position of the heart is nearly midway between the extremities of the fetal ovoid, the mere inversion of the long axis of the child makes little difference in the location of the heart-sounds. In primiparse, in whom the presenting pole sinks into the excavation in vertex, and rides above it in breech, presentation, the level at which the heart-tones are heard is of some value in determining the pres- entation. In first pregnancies this level will usually be found below the umbilicus in cephalic, and above it in breech, presentation. The Location of the Fetal Movements must be taken on the statement of the mother, which statement as an aid to diagnosis is liable to the usual fal- lacies of subjective signs. It may have some weight, however, in deciding in what part of the uterus the feet lie. Importance of the Abdominal Examination for the Diagnosis of the Fetal Presentation and Position. — With all the facts clearly made out it will readily be seen that the abdominal examination is of more value for the diagnosis of presentation and position of the fetus than the vaginal touch. Every physi- cian, therefore, should familiarize himself with the technique of abdominal palpation and auscultation in its application to obstetric practice. It is within the power of every obstetrician to become expert in obstetric diagnosis by the abdomen. While the facilities afforded by a hospital service are of great advantage, they are by no means indispensable if proper use be made of the opportunities which even the general practitioner has at his command. Pathological Conditions. After determining the presentation and position of the fetus, the abdomen is next to be examined for the possible existence of fetal or maternal anom- alies that may complicate the, labor. A pendulous abdomen in a first pregnancy should suggest the possibility of pelvic deformity. It not infrequently occurs, however, in multiparas in whom the pelvis is normal, and it may retard the labor by hindering the engagement of the presenting pole. Hydramnion is recognized by the increased size and permanent tension of the uterine tumor, by preternatural mobility of the fetus, and by the pres- ence usually of suprapubic edema. The entire abdomen is explored for the possible presence of pathological growths of the pelvic or abdominal organs. Often the location of the placenta may be made out by palpation over the abdomen, except when its implantation is mainly upon the posterior wall of the uterus. Its convex edge presents a resisting ring, and the palpation of fetal parts is partially obscured within the placental area. The diagnosis of vicious insertion of the placenta is therefore sometimes possible by abdomi- nal examination. A hydrocephalic head of a size sufficient to give rise to difficulty in delivery ought to be recognized by external palpation. Its size may be determined THE CONDUCT OF NORMAL LABOR. 407 more accurately by measurements taken with calipers through the abdominal walls, and by trying whether it can be crowded into the excavation. In twin pregnancies, as in hydramnion, the abdominal tumor is usually large and persistently tense, and there is suprapubic edema. Indeed, multiple pregnancies are generally associated with excess of liquor amnii. Single feta- Fig. 197.— Relative location of the posterior superior iliac spines and spine of last lumbar vertebra. The latter is the second vertebral above the level of the iliac spines (after the Ariadne). tion with hydramnion is distinguished from plural pregnancy by the greater mobility of the fetus in the former. There is a larger number of small parts in plural than in single fetation, and they are more widely distributed. Two dorsal planes and more than two fetal poles may sometimes be made out. One head in the excavation and one in the upper uterine segment or in one iliac fossa make the diagnosis of twins. Two fetal poles more than 12 inches apart cannot belong to the same child. The most conclusive evidence of double fetation is the detection at the same time of two fetal heart-beats of different rates. Palpation in multiple pregnancy is generally rendered difficult by the per- manent tension of the uterine tumor. 2. External Measurements of the Pelvis. In primiparse, and in multipara; in whom the previous obstetric history gives rise to suspicion of pelvic contraction, the external diameters of the 408 AMERICAN TEXT- BOOK OF OBSTETRICS pelvis should be measured. Three measurements are usually sufficient — namely, the external conjugate, the interspinal, and the intercristal. Of these measurements the most important is the external conjugate (PI. 25). This diameter is measured from the depression (Fig. 197) just below the spine of the last lumbar vertebra to a point on the pubic surface in front of the upper part of the symphysis. It may safely be assumed that the pelvis is ample when this diameter exceeds 8 inches (20.3 centimeters), and that it is contracted at the brim when the diameter falls below that limit, Q>\ inches (about 16 centimeters). Contraction in other diameters must be excluded. An interspinal equal to or greater than the intercristal diameter indicates flattening of the pelvis ; when both are small, there is general contraction. 3. Vaginal Examixatiox. Before examining per vaginam the obstetrician's hands and the external genitals of the patient are to be cleansed with the same care that is observed during labor. Promontory Fig. 198. — Manual method of measuring the diagonal conjugate. In parous women the pelvic floor and the cervix are examined for injuries inflicted during previous labors. In all cases the diagonal conjugate and the antero-posterior and bisischial diameters at the outlet should carefully be measured and the width and curvature of the sacrum be noted. The method of measuring the diagonal conjugate is shown in Figure 198 and Plate 26. With the patient in the lithotomy position, two fingers of the examining hand are CONDUCT OF XORMAL LAEOE. Elate 25. Measuring the external conjugate: the black dots show the points from which the measurements are taken (from a photograph). CONDUCT OF NORMAL LABOR. Plate 26. Manual method of measuring the diagonal conjugate : p, promontory ; p, B, perineal body dis- placed backward. THE CONDUCT OF NORMAL LABOR. 409 passed into the vagina, and the tip of the second finger is made to rest by its outer margin against the most prominent part of the sacro- vertebral angle. The point at which the edge of the subpubic ligament cuts the radial border of the examining hand is marked by a finger-nail with the other hand. The distance between the points of contact is the value of the diagonal conjugate. To find the true conjugate the amount to be subtracted from the diagonal is usually J. to J inch, according to the depth and inclination of the symphysis. The diameters of the cavity and the transverse diameter at the brim are esti- mated by palpating the walls of the pelvis. The examining hand is to be used wet with the antiseptic solution. If any other lubricant is required, glycerin or vaselin sterilized by heat, or glycerin biniodized or sublimated (1 : 500), may be employed. The Lying-in Room. In private practice the patient is generally confined in the room which she is to occupy during convalescence. The choice of room is not a matter of indifference. One of the first requisites of health at all times is pure air, and this should not be denied the patient at a time when the need of oxygen is greater than usual, owing to the severe muscular activity of labor and to the increased tissue-waste of the puerperium. If possible, therefore, a com- modious room, one which permits of constant ventilation, should be selected. In cold weather an open fire is an efficient aid to ventilation, and it adds greatly to the cheerfulness of the lying-in chamber. A sunny exposure is desirable. Dust-laden hangings are especially objec- tionable, yet it is neither necessary nor best to so far dismantle the room as to make it cheerless. Ordinary cleanliness is usually sufficient. On no condition should the confinement be conducted in an apartment recently occupied by. a patient with erysipelas, childbed fever, suppurating wounds, or other diseases which are recognized sources of possible sepsis, except after systematic cleansing and disinfection. The management of the patient at the close of labor is simplified if a sep- arate cot be provided for the confinement, tiie patient being transferred to the bed at the close of the labor. The Nurse's Preparations. — An orderly nurse will have ready, conve- niently near the bed, a small table (Fig. 199) properly equipped with such appliances as the doctor will need for use during the labor. The table should be covered neatly with one or two sterilized towels, and be supplied with a wash-basin, a hand-brush, soap and hot water, an antiseptic solution, scissors, a ligature for the navel, and a suitable lubricant for the hands. The utensils, the ligature, and the lubricant should be sterilized. The nurse should also provide plenty of aseptic sheets and towels, two dozen sterilized gauze serviettes, 18 inches square, for use at the close of labor in examining or suturing pelvic floor injuries, one or two pieces of unbleached muslin for abdominal binders, a half yard in width by one and a quarter yard in length, one or two surgically clean rubber sheets large 410 AMERICAN TENT-BOOK OF OBSTETRICS. enough to cover the entire width of the bed, plenty of muslin sheets, a rug or oil-cloth to protect the carpet beside the bed, safety-pins of convenient size for pinning the binder, a fountain syringe, a suitable bed-pan, a slop jar, a supply of hot and cold water, a package of sterile cotton for the navel dressing, a blanket for wrapping the child, and the child's clothing. Before sterilizing, towels, sheets, serviettes, etc., are packed in small bundles, each enveloped in a sheet or towel securely pinned. Each package is opened only as its contents are required for use. Preparation of the Bed. — The patient should lie upon a firm mattress. It is customary to protect the bed by means of a rubber sheet, which should be large enough to cover the entire width of the bed and the greater part of its Fig. 199.— Table equipped with basins, brushes, antiseptics, etc., for the physician's use. length. Over this rubber covering is spread a muslin sheet, the two cover- ings being pinned fast to the mattress. These spreads are covered with a second rubber overlaid with a bed-sheet. The latter coverings are withdrawn after labor, leaving the bed clean and protected by the first rubber and its muslin covering. Two or three fresh-laundered sheets, each folded to four thicknesses, may be placed upon the bed in position to receive the discharges. In place of the sheets a good absorbent dressing is a pad specially made for the purpose. It consists of a cheese-cloth sack or bag, which is filled with jute, absorbent cotton, cotton waste, or other absorbent material that has previ- ously been prepared and sterilized. The sack requires to be from 1\ to 3 feet THE CONDUCT OF NORMAL LABOR. 411 square and 3 or 4 inches thick. The pad is best sterilized by steaming for an hour shortly before use. If a separate cot is used for the confinement, it is to be equipped in the manner above described. An excellent substitute for the absorbent pad is the Kelly rubber-pad, now commonly employed in gynecological operations. It is to be sterilized before using. It is unnecessary to say that the entire dressing of the bed should be clean in the surgical sense. Tlie Patient. — The patient should be directed to receive a bath at the beginning of labor and to make an entire change of linen. She will usually prefer to be dressed in her night-clothing, over which, during the first stage, she may wear a loose wrapper. A napkin or a pad kept wet with Thiersch's solution and worn over the vulva during this stage is a useful antiseptic measure. The Obstetric Bag. — It is recommended that the obstetric bag be large enough to contain all the instruments and other surgical appliances that may be needed in ordinary labors. The equipment should comprise obstetric for- ceps ; a Davidson syringe ; a hypodermic syringe ; a glass uterine douche- tube ; a soft-rubber catheter ; a soft-rubber tube with bulb attached for aspi- rating mucus from the child's throat in case of asphyxia ; a half-dozen needles, Fig. 200.— Schultze's pelvimeter. about 2 inches in length and straight or slightly curved, for suturing the perineum ; a few short curved needles, an inch to an inch and a quarter in length, for use in the vagina; a needle forceps; a knife for episiotomy ; steril- ized sutures of catgut, silkworm-gut, and of silk ; one or two hand-brushes ; a yard or two of plain aseptic gauze for possible use in post-partum hemor- rhage ; a set of Barnes' bags ; and a Schultze or Collyer pelvimeter (Fig. 200). The additional instruments that will frequently be of service are a Sims speculum, one or two sponge-holding forceps, a volsella, and a large curette. A small spring-balance will be useful when it is desirable for scientific or other reasons to know the weight of the child. 412 AMERICAN TEXT-BOOK OF OBSTETRICS. The bag should also be supplied with two or three ounces of chloroform, twice as much ether, a few ounces of carbolic acid, and a drachm or two of chloral. Mercurial antiseptics and also obstetric emergents, such as morphin, elaterin, digitalis, ergot, and veratrum viride, are most conveniently carried in tablet form. 4. Anesthesia. Of anesthesia in obstetrics for the usual surgical indications little need be said. The employment of anesthetics in obstetric operations is governed by the well-established usages of surgical practice. By obstetric anesthesia is understood something entirely distinct and apart from surgical anesthesia. It is intended to diminish, not to abolish, pain. Its object is merely to mitigate the severer sufferings of ordinary labor, not to cause complete insensibility. To what extent anesthetic agents may be used to advantage in a simple labor is a question that calls for the exercise of tact and judgment. ' That, on the one hand, obstetric analgesia accomplishes a distinct gain, in so far as it spares the patient the exhausting effects of severe pain and prolonged nervous tension, cannot be doubted ; nor has the obstetrician any more pleasing duty than to save the needless sufferings of childbed. On the other hand, except in moderate doses and during the most active period of labor, anesthetics are lia- ble to impede the progress of the birth. The careless and long-continued use of these agents, especially in excessive quantities, is fraught with serious dan- ger to the patient. Their abuse is doubtless at times an unrecognized factor in grave and even fatal accidents of childbed. These objections obtain more especially against chloroform. With reference to the influence of anesthetics upon the strength and the frequency of the uterine contractions we have some recent observations from Donhoff. 1 He administered chloroform, in various degrees, to five parturients, studying the effect upon the pains with the aid of a tokodynamometer. Even under small doses the labor was retarded. In eight observations the muscu- lar pressure sank nearly to one-half that present before the administration, and the strength of the uterine contractions was not fully restored for several minutes after the inhalations were stopped. That the use of anesthetics during labor predisposes, in some degree, to relaxation of the uterus in the third stage, as claimed by Lusk and others, is abundantly exemplified in the writer's experience. The foregoing facts, while they do not forbid the employment of obstetric anesthesia, call for the exercise of caution in its use. When required for no other purpose then to mitigate the sufferings of the patient, anesthetics should be reserved until the latter part of the second stage, and even then they may be withheld so long as the pains are well borne. Their employment is per- missible at an earlier period in the labor when required to subdue great 1 Archiv fur Gyn., Band xlii, 12. THE CONDUCT OF NORMAL LABOR. 413 nervousness and excitement or to relieve pains of extreme and unusual severity. In exceptional cases these agents may act to accelerate the labor by counteracting the inhibitory effect of pain upon the uterine contractions. In the third stage of labor the uses of anesthetics are chiefly surgical. When anesthesia is required to the surgical degree, it must not be assumed that the obstetric patient enjoys any special immunity from the usual dangers of anesthetics. The relative safety of obstetric anesthesia lies not in any peculiarity of the subject, but in the mode of administration, the limited dosage, the slow and gradual inhalation, and the intermittent use of the drug, during the pains only. Under complete anesthesia the parturient woman is exposed to the same dangers as are other patients. In cases in which an operation ordinarily requiring anesthetics must be performed, neither disease of the heart, of the lungs, nor of the kidneys, nor the exhaustion of the third stage forbids their use. These conditions, how- ever, necessitate increased caution in their administration. In cardiac dis- ease, even in lesions of the myocardium, anesthetics lessen the danger by subduing the reflexes. Choice of Anesthetics. — For mere obstetric analgesia chloroform is gen- erally preferred. It has the advantage of being pleasanter than ether and is less bulky to carry. The latter agent seems to be growing in favor, however, for obstetric use, and it is claimed to be no less manageable than its rival, chloroform, for partial anesthesia. Hirst thinks analgesia is even more promptly produced by ether than by chloroform. The satisfactory use of ether for this purpose, however, depends upon its proper administration. It must be given very gradually in quantities of a few drops with each inspira- tion. The difference in the safety of the two agents is insignificant when used in the obstetric method. When complete insensibility is required for surgical interference, chloro- form should, as a rule, give place to ether. The general mortality of chloro- form when pushed to the surgical degree is four or five times greater than that of ether. Of the two agents, chloroform is the more potent and its effects persist longer after inhalation stops. Ether, since it is used in larger quantities, is more irritant to the air-passages than is chloroform ; hence the former agent should be replaced by chloroform in inflammation of the air- passages, especially if it be acute. Ether is generally believed to be more dangerous in nephritis than is chloroform, but this question is not fully set- tled. Owing to the tendency of the former agent to produce high arterial tension, it is dangerous in marked atheroma. Method of Administration. — The patient is prepared for anesthesia by loosening the clothing, by lowering the head, and by attention to such other precautions as are commonly observed in surgical practice. To protect the skin from the irritating effects of the chloroform vapor the lips, nose, and chin may be smeared with vaselin or with glycerin. A towel spread in one thickness over the head, and lifted by the middle six or seven inches so' as to form a large air-chamber about the face (Fig. 201), makes a suitable inhaler. 414 AMERICAN TEXT-BOOK OF OBSTETRICS, An Esmarch mask is also a convenient apparatus for administering the anes- thetic in the lying-in room. On the first premonition of a coming pain the inhaler is placed over the face of the patient, and the anesthetic is dropped upon it opposite the month. With chloroform, one drop or, at the most, 2 drops should be let fall at each breath. In case ether is used, 3 or 4 drops with each inspiration will suffice. When sufficient effect is not obtained in this manner, the jjatient may be requested to breathe rapidly as the pain is coming on. For convenience in graduating the administration a bottle specially con- structed for the purpose may be used, or a dropping-bottle may be improvised by cutting a longitudinal slot in the side of the stopper (Fig. 201). The foregoing methods of administration ensure abundant dilution of the anesthetic vapors with air and a safe and gradual development of anesthesia Fig. 201— Method of i chloroform with the towel inhaler : the illustration represents the towel as transparent (from a photograph). with the least possible quantity of the drug. The inhaler should be removed on the approach of unconsciousness, and should always be withheld in the intervals between the pains. During the severer pains at the acme of ex- pulsion the inhalation may usually be pushed nearly or quite to the surgical degree. Other Anesthetic Agents. — An agent of great value as a partial substitute for the anesthetic vapors is chloral. It is particularly useful for alleviating the pains of the first stage when they are not well borne. From 45 to 60 grains may be given in doses of 15 grains repeated every twenty minutes. The total quantity should not exceed a drachm. Under the full close the THE CONDUCT OF N0B3IAL LABOR. 415 patient usually bears the pains with little complaint, and sleeps quietly in the intervals. Chloral in the quantity mentioned has no inhibitory effect upon the uterine contractions. In disease of the heart, either organic or functional, the wisdom of its employment is questionable, owing to its depressant effect. It is said by some authorities to be unsafe to give chloroform to a patient who is already under the influence of chloral. The coal-tar analgesics relieve the pains of labor, but they also tend to cause uterine inertia. The hydrochlorate of cocain applied to the cervix and vagina has proved of little service, its action being merely superficial. It is especially objection- able on the ground that it necessitates interference within the passages. From an eighth to a quarter grain of the sulphate of morphin, admin- istered hypodermatieally, as a rule acts kindly in unusually painful labors, but it is rarely to be recommended in strictly normal conditions. Examination during the Labor. The first duty of the obstetrician on reaching his patient in response to her summons is to satisfy himself that she is, as she assumes, actually in labor. The beginning pains, however, are not necessarily to be taken as evidence that active labor is near at hand. Painful uterine contractions are sometimes expe- rienced at intervals for days before the birth. Rarely, after they are fully established, they may wholly cease for hours. Inquiry is made for the usual phenomena of beginning labor, the time when the pains began, and their character, strength, and frequency. Most distinctive of labor is the rhythmical character of the pains and the contraction of the uterus during the pains as felt by the hand laid upon the abdomen. The first uterine contractions of childbirth frequently give rise to little more than a sense of pressure in the sacral and the lumbar region. As the labor progresses they are felt in front over the lower abdomen, and finally radiate down the thighs. If the labor is in actual progress, a systematic external and internal examination is to be made. The general object and method are substantiallv the same as in the preliminary examination, with the addition of certain details which pertain especially to the labor. The abdominal examination aims to determine whether the child is living, what is the presentation and position, the quality and frequency of the fetal pulse, how far the head has descended in the pelvis, the presence of anomalies that may complicate the birth. The relative size of the head and pelvis can be estimated by observing how far the head has sunk or can be made to sink into the excavation. In doubtful cases measurements of the head may be taken with calipers through the abdominal wall. Distention of the bladder is recognized by palpation over the suprapubic region. The diagnosis of presentation and position by abdominal palpation is not usually so readily made at this time as before labor, but in most cases it offers no special difficulty. The character of the fetal heart-sounds affords im- portant information as to the prognosis for the child, and they should fre- 416 AMERICAN TEXT-BOOK OF OBSTETRICS. quently be listened to throughout labor. A fetal pulse-rate much above or below the normal range, or a pulse which grows progressively weaker, indi- cates danger to the child. When a systematic preliminary examination has been made, little additional information remains to be gained by examining internally after labor begins. For the detection of possible complications that may have developed at the onset of labor, such as prolapse of the cord or of a fetal member, as well as for more precise information of the stage of progress, a vaginal examination is usually desirable, even though the obstetrician be expert in abdominal palpation. Before examining internally the nurse is directed to cleanse the abdomen, the vulva, and the inner surfaces of the thighs with soap and water, and finally with an antiseptic solution ; meantime the obstetrician prepares his hands and forearms. The object of this examination is to learn — (1), the condition of the vulva and the degree of resistance it will be likely to offer as the head descends; (2), whether the vagina is well lubricated by the secretions, and the presence or ab- sence of obstruction ; (3), the condition of the cervix, how far dilated, whether dilatable as judged by the extent of softening and thinning; (4), the size and protrusion of the bag of waters ; and (5), the presentation and position of the child in confirmation of the abdominal examination. Vertex presentations are recognized by the hardness and the globular shape of the cranial portion of the head and by tracing the sutures and fontanelles. As the anatomical characters of the presenting part are often somewhat obscured by the caput succedaneum, the examination must be made with care, using firm pressure and searching as far as the fingers can reach. In other than vertex presentations still greater pains will generally be needed to identify the presenting prfrt. During the vaginal examination the hardness of the child's head should be taken into account as an important element in the prognosis. The position is determined by finding in which quadrant of the pelvis the small fontanelle lies. This is best located by first tracing the sagittal suture. (For diagnostic signs of other than vertex presentation the reader is referred to the chapter treating of those presentations.) The examiner will learn whether the membranes are still intact, and how far they protrude during a pain, and will make sure that a loop of the cord has not prolapsed into the bag of waters. It is perhaps unnecessary to say that in this part of the examination care will be needed lest the membranes be prematurely ruptured. To the question which is invariably asked, " How long will the labor last?'' a guarded answer must be given. Definite predictions are seldom possible at the beginning of labor. The prognosis, so far as it can be estimated, must be based on the capacity of the pelvis, the strength and the frequency of the pains, the extent of dilatation and the dilatability of the cervix, the position, size, and hardness of the head, and the degree of descent. When nothing abnormal has been discovered, assurance should be given accordingly. THE CONDUCT OF NORMAL LAB OH. 417 Management op the First Stage. During the first stage of labor the patient ought not, as a rule, to be con- fined to the bed until dilatation is well advanced. She is usually more com- fortable if allowed the liberty of the room, and the pains are thereby pro- moted. Much walking is not advisable, however, before the head has engaged ; it may favor prolapse of the cord or of the small parts, and may hinder engage- ment. If the membranes rupture or if the pains assume unusual intensity, the patient must be kept in a reclining posture upon the bed or a lounge. Malpositions are often capable of correction by postural methods, the woman being required to lie upon the side toward which that part of the head points that is to lead the descent. For example, in a right occipito- posterior position the patient should lie upon the right side, and in a left pos- terior position of the occiput upon the left side. The clothing should be loose, and be limited to a wrapper and the under- clothing. If the physician in his first examination has satisfied himself of the absence of complications, the vaginal examination will rarely need to be repeated until after the rupture of the membranes. When the protruding bag breaks before the head is engaged, it is well to make sure that a loop of the cord has not been swept down with the gush of waters. If the first stage is unduly retarded, a careful digital exploration by the vagina may be needed to learn the cause of delay. The physician's first visit should be prolonged sufficiently to form some estimate of the probable rapidity of the labor and of the length of time before his attendance will again be required. On departing all needed instructions should be left with the nurse. The patient is to be allowed such food and drink as may be necessary, to be warned against voluntary expulsive efforts, and is usually to remain out of bed until the pains are severe. The lower bowel should be cleared and the bladder frequently evacuated. During this stage it is a general rule for the physician not to remain with the patient until the os has reached the size of a silver dollar. Even after his continuous presence at the house is required, he will better, in most cases, absent himself from the room, except when his attentions are needed by the patient. Throughout the labor idle bystanders should, as a rule, be excluded from the lying-in chamber. The presence of the husband is a matter to be left to himself and the patient. Both the maternal and the fetal pulse should occasionally be counted. All manipulations within the passages for the purpose of accelerating the labor in normal cases are scrupulously to be avoided. Rarely when the anterior lip of the cervix is caught over the occiput, and apparently retards the progress of the labor, it may be hooked forward during a pain until it retracts above the head. This is a practice, however, that is very liable to abuse. 418 AMERICAN TEXT-BOOK OF OBSTETRICS. Management op the Second Stage. In the second stage of labor, as in the first, so long as all is normal the duties of the obstetrician are few and simple. From the time dila- tation is nearly complete the patient must not, as a rule, be allowed to leave her bed, not even for evacuations of the bladder or the bowels. She is to be dressed in the usual night-clothing, which the nurse will keep well tucked under the arms, beyond the reach of soiling. A folded sheet hung like a skirt from the hips still further conduces to cleanliness. When the pains are feeble, their intensity may be increased by requiring the patient to move about in bed or even to assume for a time a sitting or a half-sitting posture. The uterine expulsive efforts should be reinforced by the voluntary muscles. Direct the patient to " hold the breath and bear down with the pains." Most women during the expulsive pains instinctively brace their feet and catch the hands of the nearest bystander to assist the straining effort by pull- ing. Except in precipitate labor this practice is to be encouraged. A sheet rolled into a loose rope and fastened by one end to the foot of the bed makes a convenient and efficient sling for the purpose. An abdominal binder is frequently useful in helping the progress of labor during the second stage, particularly in multipara? having lax abdominal walls. The distressing sacral pains so common in the expulsive stage of labor may be relieved in some degree by pressure over the painful region. For this pur- pose the nurse, taking position on the bed behind the patient as she lies upon the side, supports the back by pressing firmly against the sacrum with the palms of the hands during the pains. Cramps in the lower limbs are best overcome by powerfully contracting the antagonistic muscles. In case of cramps in the calf of the leg, for example, the patient should forcibly flex the foot and hold it so until the muscular spasm subsides. Rupture of the Membranes. — When the bag of membranes does not burst spontaneously by the time it reaches the pelvic floor, it should be ruptured by the obstetrician. Care must first be taken to see that a loop of the cord has not slipped down beside the head, as that condition of things would seriously be complicated by the escape of the waters. It is not usually difficult to tear the sac with the finger-nail during a pain. Failing by this method, a sharp- pointed scissors, previously sterilized, may be used. A convenient instrument for the purpose, generally to be found in the lying-in room, is a coarse hairpin. It is first straightened and then well flamed. This perforator is passed on the finger-tip as a guard and a guide, and the bag of membrane is punctured while tense during a pain. Obstetric Position. — As a rule, the posture of the patient should be left largely to her own choice. Occasional changes relieve fatigue. In simple slow labor the pains are promoted by permitting her to move about in bed and now and then to take a sitting position. Until the head reaches the pelvic floor a half-sitting posture is the most favorable, since the THE CONDUCT OF NORMAL LABOR. 419 propelling force thus acts most effectively in the Hue of descent. At the perineal stage the lateral position with the body flexed, which position is most advantageous for the obstetrician, is at the same time advisable from the standpoint of the mechanism. The lower end of the sacrum is tilted back- ward, and some advantage, perhaps, may be derived from the fact that gravity acts more nearly in the axis of expulsiou. Frequency of Vaginal Examination. — Vaginal examinations should be as infrequent as possible. There is seldom occasion in normal conditions for more than one or two internal examinations, at the most, during the expulsive stage. The descent of the head may be followed by palpating over the lower abdomen until the occiput has reached the floor of the pelvis. From that time the progress of the descent may be noted by the touch through the pelvic floor, and during the last moments of expulsion by ocular inspec- tion. All that the obstetrician needs to know in normal cases can usually be learned by abdominal palpation and auscultation. Frequent vaginal exam- inations expose the patient to possible infection despite all other care in the matter of subjective asepsis. Particularly is this the case when the manipulation extends into the lower uterine segment. Prevention of Injuries to the Pelvic Floor. — The frequency of pelvic-floor lacerations in term deliveries in general practice may fairly be estimated at about 35 per cent, in first, and 10 per cent, in subsequent, labors. In little less than half this number the injury must be regarded as unavoidable, except by substituting incisions. In strictly normal conditions the muscular structures of the pelvic floor relax slowly under the pressure of the gradually advancing head and escape intact. The fourchette, however, is frequently torn in first births. In relatively small vulvovaginal outlets and in rigidity of the structures from whatever cause the parts will generally be lacerated during the expulsion of the head, notwithstanding the most skilful efforts of the obstetrician. The order in which the tissues give way is fascia, muscle, mucous mem- brane, skin. Accordingly, a laceration may occur subcutaneously, the tear being confined to the muscles and fascia and no breach of continuity appear- ing to the eye. Numerous procedures have been proposed for the prevention of perineal injuries during delivery. The discussion in this place of the various methods that have been upheld by obstetric writers would serve no useful purpose. Most of them must be regarded as irrational and useless, if not even mis- chievous. When we reflect that the cause of the tear is undue strain upon the resisting girdle through which the head passes at the moment of expulsion, it is plain that any measure to be of value in preventing the injuries in question must do one or both of two things : It must act to promote the relaxation |-,l AMERICAN TEXT-BOOK OF OBSTETRICS. and extensibility of the pelvic floor, or to lessen the tension to which it is subjected during the birth, or both. The former object is best accomplished by the slow and gradual delivery of the head, permitting time for the tissues to stretch ; the latter, by so regulating the expulsion of the head as to keep its smallest circumference in the grasp of the resisting girdle and the propel- ling power directed in the axis of the outlet. The rate of descent is perfectly at command of the obstetrician. The expulsive force of the abdominal muscles may sometimes be suspended by requiring the patient to breathe rapidly during the pains. This, however, is not always possible. The action of the abdominal muscles is at this stage frequently involuntary and wholly beyond the patient's control. Most effect- THE CONDUCT OF NORMAL LABOR. 421 nal for the regulation of the expelling powers is the use of anesthetics. Chloroform or ether should be given at this period on the appearance of the slightest danger of laceration. By the judicious use of the anesthetic the strength and frequency of the pains and the rapidity of expulsion may be regulated at will. The advance of the head, however, can still further be controlled by pres- sure with the thumb and finger held constantly upon the occiput. With the thumb applied to the head immediately in front of the tense border of the perineum, and with two fingers resting upon the occiput, the rate of descent may easily be watched and regulated. To keep the tension of the vulva at a minimum, the long axis of the cephalic cylinder must be kept at a right angle with the plane of the outlet of the soft parts Too rapid extension of the head must be prevented. The forehead should not be permitted to pass the perineum until the occiput is fully expelled and the nape of the neck rests in the subpubic arch. Moreover, to guard against too great strain upon the pelvic floor, the direction of expulsion must be regulated by crowding the head well up in the pubic arch, especially at the time when the equator of the head passes the vulvar ring. The expelling force is thus directed in the axis of the outlet, and the least possible downward thrust is exerted upon the pelvic floor. The foregoing manipulations are best conducted with the patient in the left lateral position. In first labors, therefore, and in others in which the perineum is liable to be torn, the patient should, as a rule, be placed upon the left side, with the buttocks close to the edge of the bed, as soon as the head has reached the floor of the pelvis. There is rarely danger of laceration until after the occipital pole appears in the vulvar fissure. Up to this point usually the progress of the perineal stage, when not over-rapid, may be noted by the touch alone. With the finger upon the perineum just behind the posterior vulvar commissure the occiput can be felt through the soft parts some time before it begins to distend the perineum, and the rate of descent can be observed as accurately as by passing the finger within the passages. From the moment the occiput appears in the vulvar orifice the parts ought to be under ocular inspection. The vaginal discharges are occasionally washed away with a cloth which is kept lying in a warm antiseptic solution. The tension of the resisting ring may be tested by now and then passing the finger within the vaginal orifice during a pain. The head is allowed to advance during a pain until the perineal edge becomes as tense as is deemed safe. Its further progress is then arrested by direct pressure with the fingers in the line of descent (Fia;. 203\ Until about FiG.203- . ' pulsion of the head with to be expelled, driven, down with the pains, it recedes the fingers of one hand in the intervals, and by this to-and-fro movement the asainst the occiput - pelvic floor is moulded as it were to the required degree of distention. When the bregma appears at the edge of the perineum, the head no longer recedes between the pains and is on the verge of expulsion. During the 422 AMERICAN TEXT-BOOK OF OBSTETRICS. passage of the equator of the head extension must be prevented by upward pressure in the axis of expulsion with the thumb placed upon the sinciput close to the perineum, the fingers resting upon the occiput. The sinciput must not be permitted to advance faster than the occiput. If required for the better control, both hands may be used (Fig. 204). A favorite method for managing the expulsion of the head is the fol- lowing : The patient lying upon the left side close to the edge of the bed, the operator, sitting behind her, grasps the head with the fingers of the right hand placed just in front of the fourchette, while the left hand, passed over the abdomen and between the thighs of the mother, seizes the occiput (Fig. 202). This procedure gives easy command of the birth of the head, yet oifers no important advantage over simpler methods. The writer prefers to this the manipulation shown in Figure 204. As a rule, in first labors a half hour or more from the time the pelvic floor begins to be distended will be required before the head can safely be allowed to pass. In subsequent births a shorter time will usually suffice. While the procedures just described are to be recommended to the general exclusion of other methods, there is no objection to the use of gentle pressure THE CONDUCT OF NORMAL LABOR. 423 applied to the head through the lateral aspects of the pelvic floor. For this purpose the hand may be laid flat upon the bulging soft parts with the thumb extending aloDg the right, and the fingers parallel with the left, labium. The hand should rest lightly upon the median thinned-out portion of the perineum, the pressure being applied mainly to each side of it. It must be borne in mind, however, that the object is to regulate the expulsion of the head, not to support the perineum. Much compression of the tense pelvic floor, especially its thinned-out median portion, between the child's head and the obstetrician's hand, must tend rather to increase than to diminish the danger of rupture. If the patient lies upon the back during the perineal stage, it will be found more convenient to regulate the expulsion by the thumb placed upon the occi- put and the first two fingers upon the head in front of the frenulum. The introduction of the finger into the rectum for the purpose of shelling out the head, even when practised between the pains, is more likely, as a rule, to cause than to prevent laceration by too precipitate delivery. It is difficult to understand how the tendency to rupture can be diminished by drawing the perineum forward with the finger in the rectum, as advised by Goodell. As Garrigues has pointed out, an elastic ring encircling a cylinder is subjected to less tension when at a right angle to the cylinder than when oblique. Moreover, interference within the rectum, however practised, is hardly consistent with the requirements of aseptic obstetrics. Episiotomy. — No method yields better results for the ultimate integrity of the perineum than episiotomy rightly timed and properly executed. The ultimate condition of the pelvic floor after episiotomy correctly performed is even better than after many natural deliveries in which the parts escape rup- ture. The tonicity of the structures frequently remains as perfect as in the non-parous woman. The success of the incisions in preventing laceration depends, as already intimated, upon so timing them as wholly to anticipate the tearing, and upon carefully adjusting the location and direction of the cuts. This apparently simple procedure, therefore, is one in which even the accomplished obstetrician may find room for the exercise of skill. The only instrument required, in addition to what is carried in the usual obstetric outfit, is a blunt-pointed tenotomy knife. When laceration seems inevitable or even probable, the cordlike ring, which can be felt about half an inch above the tense border of the vulva by examination during a pain, should be divided. Locating the resisting girdle by the finger, the knife is passed flatwise between the head and the vaginal wall. The edge of the knife is then turned outward and the ring incised. The operation is repeated on the opposite side. The length of the incision should be about one inch, its depth a quarter-inch, and its location about one-third way from the posterior to the anterior commissure when the parts are on the stretch. The structures involved in the incision when made in this manner are unimportant. They consist usually of the skin, fascia, and probably the bulbo-cavernous muscle. 424 AMERICAN TEXT-BOOK OF OBSTETRICS. Most essential is it that the cuts be made parallel with the long axis of the mother's body, not with the vaginal axis. The cuts will then be found on examination after labor to run parallel with the outlet of the birth-canal. If the knife be held in line with the axis of the vulvo-vaginal outlet as the latter appears at the time of incision, its point will be liable to invade the very struc- tures the operation aims to save ; the pos- terior ends of the incisions will be found after delivery much nearer the median line than was intended, and the trans- versus perinei and other important struc- tures will possibly be divided. This result is well shown in the accompany- ing illustrations by Dr. R. L. Dickin- son ' (Figs. 205, 206). If preferred, the resisting ring may be divided with scissors. After labor the cuts should immediately be reuuited with stitches. A running or an inter- rupted suture with fine catgut best an- swers the purpose. The wounds may .y (sketch, just after be closed generally without waiting for the delivery of the placenta, thus saving the necessity for renewing the anesthesia. During the suturiug the patient may lie on the back or on the side opposite the one being repaired. Management of the Cord. — The moment the head is born a finger is slipped within the passages to ascertain if the cord is coiled about the child's neck. When so found, the loop or loops should be drawn down one by one over the head. Should the coil be so taut that it cannot be brought down— an accident that must be extremely rare— the cord may be tied at two points, and be cut between the two ligatures and the trunk promptly delivered. Delivery of the Trunk. — The head should now be held in the hand to keep it in the axis of expulsion. Contrary to the usual teaching, the writer prefers to deliver the posterior shoulder first. While the anterior shoulder lies behind the symphysis the finger is passed over the dorsal aspect of the posterior shoul- der and is slipped into the axilla. The posterior shoulder is then folded for- ward and is cautiously lifted over the perineum. Except in emergency calling for immediate delivery in the interest of mother or child, the expulsion of the trunk is left to nature. It is not good practice to drag the child out of the uterus. The uterus should be compelled to expel it. The presence of the trunk and the extremities stimulates contrac- 1 " The Direction of the Incision in Episiotomy," Trans. Am. Gyn. Soc, 1892. delivery, from nature, R. L. Dickinson) : A, direc- tion of incision faulty, pointing toward the pos- terior vaginal wall : B, correct line of incision, running parallel with the axis of the vulvar opening. THE CONDUCT OF NORMAL LABOR. 425 tions, and time is permitted for retraction. When necessary the expulsion of the trunk may be hastened by the use of friction over the uterus. The frequency with which perineal injuries occur during the delivery of Fig. 206. — Episiotomy (R. L. Dickinson). Direction of incision : The black line shows the direction which the incision should have, as it appears after delivery, in line with the axis of the vulvo-vaginal outlet; the dotted line illustrates a faulty incision, dipping into the middle section of the pelvic floor. the shoulders is probably exaggerated. It is easy to attribute to the shoulders a rupture which had occurred undiscovered during the birth of the head. On the expulsion of the head the face should be bathed, and the skin about the eyes should carefully be cleansed and thoroughly dried as a pre- ventive against ophthalmia. Mucus in the pharynx should quickly be removed by the finger covered with a piece of soft wet muslin or by the use of a soft-rubber tube with an aspirating bulb attached. Ligation of the Cord. — The time for tying the cord is by no means a mat- ter of indifference. Systematic observations have shown that the child gains from 1 to 3 ounces of blood by delaying the ligation for several minutes after birth ; that in cases thus treated the children are notably more robust than when immediate ligation has been practised, and that the usual loss of weight during the first few days of infancy is diminished. This post-natal transfusion of blood is a fact of no little importance, especially in prematurely born and anemic or puny children. According to Budin and Ribemont, it is mainly the result of thoracic aspiration. Schiicking, Porak, and Fritsch, however, attribute it chiefly to the pres- sure exerted upon the placenta by the uterine contraction and retraction. Caviglia, who has recently restudied the subject, 1 supports the latter opinion. He calls attention to the fact that since there is frequently a diminution 1 Nouvelles Arch. d'Obstet. et de Gyn.,.\il. Annee, Nos. 11, 12, et viii. Annee, Nos. 1, 2. 426 AMERICAN TEXT-BOOK OF OBSTETRICS. of the weight of the child in the first moments after birth from relaxation of the uterus, too early ligation of the cord exposes the new-born infant to the loss not only of reserve blood, but also to a part of its own. Still later observations sustain the views of Budin and Eibemont. Since the child's heart may be endangered by forcing too much blood into the circulation, compression of the uterus should not be practised before the cord is tied. Iu certain emergencies immediate ligation may be necessary, owing to con- ditions of the mother requiring the obstetrician's entire attention. In case of well-developed, vigorous infants the rule of late ligation loses much of its importance. The practice now usually observed is to tie the cord after notable pulsation has ceased and the respiration is full}- established. In case of twins the cord should always be ligated on the maternal as well as on the fetal side, owing to the possible existence of a vascular connection between the two placentas. A suitable material for the ligature is narrow linen bobbin. For greater security against hemorrhage a rubber elastic band may be used. It is perhaps needless to say that the material should be surgically clean. It may be left in the antiseptic solution until wanted. The common practice is to tie from one and a half to three inches away from the umbilicus. For this rule, in the absence of a navel-cord hernia, there is apparently no better reason than custom. It is in the interest of an aseptic healing of the navel wound to reduce to a minimum the amount of necrotic material in the stump. The ligature should therefore generally be placed not more than half an iuch from the cutaneous line. It is to be tied as tightly as it can be drawn, with care to put no strain on the umbilical insertion. Before tying, the cord, except it be already thin, should be pinched firmly between the thumb and finger at the point to be ligated. This procedure is better than stripping, which is liable to do violence to the navel. The cord is divided within a quarter-inch of the ligature. It is cut with clean scissors while held in the hollow of the hand to guard against injuring the child. A bit of cheese-cloth pressed a few times against the cut end of the stump will show whether the vessels are securely tied. It is a common practice to place a second ligature a short distance from the first to control the maternal end of the cord. This promotes cleanliness and, it is gener- ally believed, favors the placental expulsion. The latter claim, however, is doubtful. The writer omits the second ligature. Management of the Third Stage. Not the least important duties of the obstetrician in the conduct of natural labor fall in the third stage. Upon the skill and attention given to this jieriod the immediate safety of the woman and the rapidity and completeness of her recovery will often in great measure depend. The chief dangers of this stage are those which grow out of a relaxed condition of the uterus — hemorrhage, THE CONDUCT OF NORMAL LABOR. 427 embolism, and the retention of clots favoring sepsis and subinvolution. The management of the third stage is therefore mainly addressed to uterine con- traction and retraction. From the moment the head is born the uterus should constantly be watched, with the hand held flat upon the abdomen over the fun- dus, until evacuation is complete and the uterine globe as hard as a cricket-ball. After the expulsion of the child the patient is placed on her back. The nurse, if she is competent, may be trusted to hold the fundus, at least while the phy- Fig. 207.— CrediS's method of expressing the ] sions (photographed sician is occupied with other duties. The hand is to be held quietly upon the abdomen so long as the uterus retains its normal consistence. Should the con- tractions be feeble, they may be stimulated by gentle friction. This stimulation is best practised by moving the lax abdominal walls over the uterus with a cir- cular motion of the hand. More active interference is seldom required in nor- mal cases. Marked flabbiness of the uterine tumor and indistinctness of out- line call for more energetic measures to provoke contraction. When the placenta is not expelled after a reasonable time, resort should be had to the method of Crede, as follows : A half hour after the termination of the second stage is allowed for the detachment of the after-birth. If at the expiration of that time the placenta is still undelivered, friction is applied to the uterus until a vigorous contraction is induced. The hand is then placed in such position upon the abdomen that the fundus rests in the hollow of the hand with the thumb in front and the four fingers behind (Fig. 207). At the 428 AMERICAN TEXT-BOOK OF OBSTETRICS. height of the contraction the uterus is compressed and thrust downward in the direction of the pelvic axis. If not at once successful, the process is repeated at short intervals until the object is gained. Until recently Crede advocated much earlier interference. Shortly before his death he recommended waiting thirty minutes. His procedure is now generally adopted. The expectant plan still advocated by certain authorities is open to the objection that the placenta may be retained for hours, during which the patient is exposed to the danger of hemorrhage and is deprived of much-needed repose. Traction upon the cord while the after-birth lies in the upper uterine seg- ment is inconsistent with the normal mechanism of placental expulsion. When the placenta has passed into the lower segment of the uterus or the vagina, no harm will be clone by gently pulling the cord to assist the delivery. As the placenta is extruded the membranes are gradually detached from the uterus, care being taken that no fragments are torn off and left behind. To prevent this the placenta is caught in the hand as soon as it passes the vulva, and if the membranes are not already free they should be twisted into a rope by turning the placenta over, and the twisting continued until the separation is complete. Should a strip of membrane accidentally be left in the passages, it may be removed, if in the vagina or hanging from the cervix, by grasping it with the fingers and gently drawing it away, or by seizing it with sterilized catch-forceps and twisting it off. Fragments of membranes remain- ing wholly in the uterine cavity above the cervix are, as a rule, better left to be expelled with the lochial discharge unless they give rise to hemorrhage. Placenta and membranes must be examined carefully to see if they are com- plete. Possible anomalies of the after-birth or the cord may also be looked for. To make sure that both amnion and chorion are entire the membranes are best examined by transmitted light. The duties of the obstetrician, even in strictly normal labor, are by no means ended with the delivery of the after-birth. The third stage is not com- plete until uterine retraction is fully established. For at least a half-hour after the placenta comes away the uterus is to be watched with the hand upon the abdomen, using friction if necessary to provoke contraction. It is a useful precaution to give a half-drachm of the fluid extract of ergot at the close of labor if the uterus is not firmly contracted. Its use is proper only after evacuation of placenta, membranes, and clots. Its action is most prompt and certain when injected subcutaneously. One or two doses may be left with the patient with instructions that they be taken in the event of flow- ing too freely. The use of a moderate dose of ergot at the close of labor is not only harmless, but it is also entirely in keeping with the objects of treatment at this period. It limits the clanger of hemorrhage, and by dimin- ishing the blood-supply it promotes involution. It tends to close the gates against infection, to guard against the retention of blood-clots in uterine cavity, and therefore it lessens the tendency to after-pains and to putrid accumulations in the uterus. Repair of Laceeatioxs. — Cervical laeerations should be sutured at the THE CONDUCT OF NORMAL LABOR. 429 close of labor in case they give rise to much hemorrhage. In the absence of troublesome bleeding the advantage of the primary suture is doubtful. The method of operating is as follows. No anesthetic is required. The cervix is most readily brought down within easy reach when the patient is on the back. She may lie across the bed with the hips close to its edge, or still better on a firm table. If necessary, the perineum may be retracted with a large Sims speculum. The anterior vaginal wall may be held up out of the way with a retractor, if required. The cervix is drawn well down with a volsella. The lips of the wound are most conveniently held in contact with a single volsella, one hook being caught in each lip near the lower end of the tear. The first suture should be passed just above the upper angle of the laceration and tied. This suture, if properly placed, controls the bleeding. The other sutures are then applied as in the secondary operation. The mate- rial may be waxed silk or silver wire. The former is recommended as being more manageable, and it has, in the writer's experience, proved entirely satis- factory when well saturated with paraffin wax. Lacerations of the pelvic floor in general practice probably occur in not less than 35 per cent, of first and in about 10 per cent, of subsequent labors. This percentage of injuries, however, is capable of considerable reduction under proper management of the per- ineal stage of the birth. In skilfully conducted labors the proportion of lac- erations should scarcely exceed 15 per cent. In case of relatively small vulvo- vaginal orifice, narrow pubic arch, un- usual rigidity of the pelvic floor, breech extraction, and other rapid deliveries, notable injuries are inevi- table in a large proportion of cases. The type of laceration most fre- quently encountered is one that runs nearly in the median line of the super- ficial structures and to one side of it in the vagina (Fig. 208). Sometimes the wound presents the shape of a Y with one arm to either side of the median line. Time for Repair. — Unless the con- dition of the patient at the close of labor is such as to forbid — and this is very rarely the case — lacerations of the pelvic floor should immediately be sutured. Yet perfect union may be obtained by operating at any time within twenty-four hours. The suturing may generally be done with complete success even after so long a period as a week if for any reason it has previously been neglected. When performed Fig. 208— Laceration of the pelvic floor, extending halfway to the rectum and running toward the right vaginal sulcus (from a sketch at the close of labor by Robert L. Dickinson, M. D.). 430 AMERICAN TEXT-BOOK OF OBSTETRICS. thus late the wound-surfaces may first be vivified by rubbing them with a fold of cheese-cloth, aud then made smooth by trimming with scissors. The writer has frequently repaired lacerations while waiting for the delivery of the placenta. This practice saves time, and generally, too, the renewal of the anesthesia. It is not to be advised in extensive and compli- cated injuries. Suture Material. — For most uses silkworm-gut is recommended. Catgut is theoretically objectionable for surface work, owing to its tendency when partially exposed to decompose and to lead septic material into the needle- track ; yet in practice chromated catgut answers well, especially within the vagina. Needles. — For use in the external and more accessible portion of the wound the needle should be straight or be slightly curved and about 2 inches in length. For suturing tears high up in the vagina a needle as much shorter as the depth of the wound will permit, and having a more pronounced curve, may more conveniently be used. Needles of the Hagedorn pattern will be found satisfactory. Method. — An anesthetic is usually necessary. Ether is to be preferred here, as usual for surgical anesthesia. Small tears may be repaired under cocain anesthesia if for any reason it is desirable to avoid the use of the general anesthetic. Cocain is most effective when injected at several points in the lips of the wound. Not more than a grain at most can safely be used in this manner, and the solution should be rendered sterile by boiling. Many women, however, suffer very little pain from the introduction of sutures, since the tissues have largely lost their sensitiveness by the pressure and contusion received during labor. If care is taken to plunge the needle quickly through the skin-margin at the moment the greatest amount of pain is produced, lacerations not very extensive may be sutured without anesthesia. The patient lies in the lithotomy position, crosswise of the bed, with the hips close to the edge of the latter, or upon a table. The knees are held by assistants or by some of the numerous appliances commonly employed for the purpose in gynecological practice. The sheet sling of Dr. Dickinson has the advantage of being always available. One of the chief difficulties in determining the extent and character of the laceration arises from the continuous flow of blood over the parts, obscuring the view. It is generally advisable, therefore, to pack the vagina above the wound with sterile gauze, care being taken to remove it after the operation. Loose tags of tissue which might become necrotic should be trimmed off with scissors. The type of laceration most frequently met with, as previously stated, runs up one or both sides of the vaginal orifice. The aim must be to re- establish completely the normal relations of the injured structures. The sutures may be applied from the skin-surface when the depth of the wound thus included in each suture would not exceed an inch. The sutures are placed at intervals of half an inch, beginning at the posterior angle of the THE CONDUCT OF NORMAL LABOR. 431 wound, nearest the anus. Enter the needle ivpon the skin close to the edge of the wound. Give it a large circular sweep, and let it emerge in the wound well down at the bottom of the tear; then pass it symmetrically through the opposite lip in reversed direction, entering at the bottom of the laceration and emerging on the skin surface at the edge of the wound. Care must be taken to avoid entering the rectum. The course of the suture should be such that when tied the loop shall be nearly circular. Each stitch after insertion is temporarily tightened as if for tying, to see that it has sweep enough to hold the wound-surfaces in contact throughout the entire depth of the laceration. As the threads are placed, one by one, the ends are loosely knotted together or are held with catch-forceps until all are ready to be tied permanently. The gauze packing is then removed, and the wound is cleared of clots. The sutures are tied in the order of insertion. They must be drawn tight enough barely to coapt, but not to constrict, the parts. If the sutures are of non-absorbable material, the ends may be left about an inch in length to facilitate removal. If the sphincter ani is torn, the ends are to be brought together by two or three buried sutures of catgut. In complete laceration of the sphincter the muscle-ends tend to retract deeply in the tissues. In these cases by close inspection a pocket or depression may be detected in the wound-surface on either side of the median line. This depression marks the location of the retracted end of the torn sphincter. The end of the muscle is to be caught up with a tenaculum and drawn well out as the suture is passed on either side. One or two tension sutures of silkworm-gut are introduced through the skin and passed directly through the sphincter on each side of the tear just without the buried coaptation sutures of catgut. Care must be taken to have no dead space above the sphincter. Tears involving the vagina are best sutured on the vaginal surface nearly or quite down to the region of the hymen. These stitches are passed at a right angle to the vaginal axis. The rest of the wound is then sutured from the skin-surface as already described, the plane of each of the latter sutures being nearly at a right angle to that of the skin. Complete teal's, extending into the rectum, may be stitched on the vaginal, the perineal, and the rectal surfaces. Owing to the difficulty of removing silk from the rectum, rectal sutures should be of catgut. They should include little more than the mucous membrane of the bowel. The rectal side of the laceration is closed first, the knots being tied in the rectum, resting upon its mucous membrane, and the remaining wound is sutured on either the perineal, the vaginal, or both surfaces as may be found most expedient. When the rent does not extend up the rectum too far, in addition to the last interrupted sutures tied in the rectum, which coapt the torn ends of the sphincter, a reinforcing stitch will be useful passed in the following manner : While a tenaculum is used to draw out one retracted end of the muscle, the suture is passed through this end of the muscle, and continues its course upward, buried along the edge of the rectal rent, to the apex of the rent ; the needle now emerges, and is again 432 AMERICAN TEXT-BOOK OF OBSTETRICS. buried along the other margin of the rectal rent, and is carefully passed through the other end of the torn sphincter, while a tenaculum draws out this retracted end of the muscle. In deep tears of any kind the tiered suture is a good one. Beginning at one end of the wound, a layer of the torn structures at the bottom of the laceration is closed with a running catgut suture ; this is repeated in a plane next above the first, and so on until the wound is entirely closed. The right and the wrong methods of suturing are shown in Figures 209 to 211. After-care. — There is no necessity, as a rule, for tying the patient's knees together. The sensitive- ness of the parts will be a sufficient safeguard against injurious strain upon the sutures by sepa- rating the limbs, and the patient will be much more comfortable without the leg-binder. Retention of urine frequently results, owing to the reflex disturbance caused by the perineal suture, especially when the latter comes close to the rectum. While injurious distention of the bladder must not be permitted, the catheter should be withheld if possible. Whether the bladder is emptied volun- tarily or otherwise, urine must not be permitted to trickle into the vagina or over the suture-line. The bowels are to be kept open, as in other cases, after the second day. Non-absorbable sutures are re- moved on the eighth or the ninth day. Toilet of the Patient. — The child is received in two or three thicknesses of flannel, is well wrapped, and is laid in a warm place. The nurse then turns her attention to the mother : soiled portions of her body are to be cleansed, best with an antiseptic solution ; her linen, if necessary, is changed ; and all blood-stained articles are" removed from the bed. For bathing the genitals a piece of fresh-boiled cheese-cloth or towelling is to be used instead of a sponge. Sea-sponges should be banished from the lying-in room. New sponges are difficult to clean, and the ordinary household article is dangerously filthy. Vulvar Dressing. — After cleansing, the vulva is covered with an aseptic dressing. A fresh-laundered napkin is suitable, or a lochial guard specially made for the purpose may be employed. These guards are made of absorbent cotton, of cotton waste, or of prepared jute enveloped in cheese-cloth. Suit- able dimensions are about 10 inches long, 4 inches wide, and 2 inches thick. Tail-pieces are attached to the guards for fastening to the binder. The guards are burned after using. These dressings are best sterilized by steaming imme- diately before use. Flowing steam is most effective. They are not employed as occlusion dressings. Their object is rather to promote the cleanliness of the external parts, thus limiting the danger of infecting the passages from the prox- FiG. 209.— Laceration like that shown in Figure 208, with sutures properly placed ready for tying. CONDUCT OF NORMAL LABOR. 1. Abdominal binder and breast-binder in place (from a photograpb). 2. Breast-binder in place (from a photograph). THE CONDUCT OF NORMAL LABOR. 433 imity of decomposing discharges. The use of some non-irritant antiseptic like boric acid, bismuth powder, or iodoform helps to retard putrefactive changes. One rubber sheet should be left in place under the linen for four or five days. ■_- 6 Fig. 210.— A, faulty method of suture, falling short of the bottom of wound and not catching all the musele-ends : a, before tying ; b, after tying. The latter figure shows dead space at the bottom of wound after tying; perineal body only partially restored. B, suture improperly placed: a, before tying; b, after tying. The suture (a) has too little lateral sweep, and it does not include the ends of all the retracted muscle-fibres at the sides of the wound ; b shows the result, the pelvic floor being imperfectly restored. A draw-sheet placed under the patient's hips is a convenient dressing for pro- tecting the bed. The draw-sheet consists of a common muslin sheet folded to four thicknesses. It is replaced by a fresh one as often as soiled. Instead of the draw-sheet an aseptic pad similar to the labor-pad, but thinner and smaller, may be preferred. Abdominal Binder. — The abdominal binder is useful to steady the uterus, and it promotes the comfort of the patient, especially when the abdominal walls Fig. 211.— Shows full sweep of a properly placed suture : a, before tying; 6, after tying. Even though the tear runs in different planes at different depths, the muscle-ends are held in apposition throughout the entire depth of the wound. are very lax. The usual material is a piece of unbleached muslin 1 \ yards in length and about 18 inches in width. This gives width enough to reach from the ensiform to a point below the trochanters (PI. 27, Fig. 1). Unless the binder overreaches these bony prominences it is liable to slip up, and in a few hours is reduced to a mere rope around the body. Binders ready made with gores to fit the body offer no advantage. The pinning of the binder should 434 AMERICAN TEXT-BOOK OF OBSTETRICS. begin at the lower border, and at the first application should be fairly tight. If the uterus shows aDy tendency to relaxation, three folded towels, used as compresses, may be placed on the abdomen under the bandage, one on either side of the uterus and one immediately above it. The binder may be dis- pensed with after one or two weeks. Before leaving, the physician takes final note of the pulse and the general condition of the mother, and gives full instructions to the nurse for the gen- eral care of both patients. III. THE MECHANISM OF LABOR. Labor is a natural process, and it is the province of the accoucheur to restrict himself to watching the processes of nature so long as they are normal and efficient, and to interfere with them only when they become disturbed or inefficient. He is at his best when he is able to compel the faulty efforts of natural labor into a normal course, and he makes a comparative failure when- ever he is obliged to substitute for the acts of nature the relatively crude process of an artificial delivery. An ability to restore the normal by making trifling alterations in the mechanical conditions presupposes, however, a most accurate knowledge of the details of the mechanism which governs the usual course of labor, and of the alterations in them which determine the advent of any deviation from the normal. When, moreover, it is remembered that obstetric operations are but efforts to direct an extraneous force into an accu- rate imitation of the processes of nature, it becomes evident that the first essential to success in obstetrics is the possession of a far-reaching knowledge of the mechanism of labor in its several varieties. Any intelligent study of obstetrical mechanism must, however, be preceded by a comprehension of the technical terms used in describing it, and of the several classifications by which labor is commonly subdivided into varieties. It is further necessary that the student should possess an accurate knowledge of the shape and dimensions of the obstetric canal, and of the fetus which is to pass through it. He is then in a position to acquire an intelligent under- standing of the principles which underlie the mechanism of all the forms of labor, under the head of a description of its commonest variety, and so easily goes on to understand the modifications in the mechanism that follow upon the alterations in the conditions in the other varieties. Attitude of the Fetus. — By the attitude of the fetus is meant the posi- tion its parts assume in ulero in relation to one another, in contradistinction to any relation they may bear to the maternal parts. During the earlier months of pregnancy the uterine cavity is nearly spherical in shape, and it is then so large in proportion to the fetus that its walls are rarely in contact with the embryo. The fetus hangs freely in the uterine cavity, being suspended by the umbilical cord, with its head usually somewhat lower than its pelvis and its limbs in a somewhat extended posi- THE MECHANISM OF LABOR. 435 tion (Fig. 212). As pregnancy progresses the size of the fetus increases more rapidly than that of the uterus, until in normal cases at term the adaptation Fig. 212.— Relation between the size of the uterus and the fetus at fifth month (fetus one-sixth natural size). between the two is sufficiently close to make any extended movements of the fetal limbs difficult or impossible. The attitude which the child then assumes Fig. 213.— Adaptation between the uterus and the fetus at term, in vertex presentations (one-sixth nat- ural size). is that represented in Figure 213, which is readily seen to be the most com- pact attitude in which the child can be arranged. Presentation. — The word j))'esentation is used to define the relation which the long axis of the child bears to the long axis of the uterus, aud the dif- ferent presentations are distinguished from one another by the use of adjec- tives which refer to the part of the child that is to enter the pelvis first in a given case. The several presentations which may occur are cephalic presen- tations — that is, presentations of the vertex, of the brow, and of the face; pres- entations of the pelvic extremity, which are subdivided into breech and foot- ling presentations ; aud transverse presentations, under which are included presentations of the hip, of the trunk, and of the shoulder. 436 AMERICAN TEXT-BOOK OF OBSTETRICS. Position. — In obstetric use the word position is restricted to a meaning in which it is used to define the relation that the dorsum of the child bears to the dorsum of the mother during its passage through the pelvic canal. Each presentation is subdivided into positions according as the dorsum of the child is directed anteriorly or posteriorly and toward the right or the left side of the mother. Thus we recognize under each presentation four positions, according to whether the part which gives the name to the position is directed left- anteriorly, right-anteriorly, right-posteriorly, or left-posteriorly ; for example, vertex presentation, occipito-left-anterior, breech presentation, sacro-right- posterior. Classification of Labor. Presentations. — The presentations are first of all roughly divided into longitudinal and oblique presentations. The longitudinal presentations are those in which the long axis of the fetus is in correspondence with the long axis of the uterus ; the oblique presentations are those in which there is a considerable angle between the two axes. The longitudinal jwesentations are, then, those in which either the cephalic or the pelvic end of the fetus is found at the inlet of the pelvis at the begin- ning of labor — that is, all the variations of cephalic and pelvic presentations. The oblique or transverse presentations include all those in which any por- tion of the fetus other than the head or the breech is found at the pelvic brim. Head presentations are divided into those of the vertex, of the brow, and of the face. Pelvic presentations are divided into breech presentations, in which both thighs are flexed upon the abdomen when the nates of the fetus enter the mother's pelvis, and footling presentations, in which one or both legs are extended and enter in advance of the infant's pelvis. Transverse presentations include presentations of the hip, of the trunk, and of the shoulder; among these presentations those of the shoulder are by far the commonest and most important. It is also convenient to classify the presentations of the fetus in two other ways, in accordance with the results which may be expected to accrue from their occurrence — namely, into normal and abnormal, natural and unnatural, presentations. Normal and Abnormal Presentations. — A presentation of the vertex occurs in about 97 per cent, of all labors, and, both from its frequency and from the favorable character of its results, is considered to be the only normal presentation, all others being classified as abnormal. Natural and Unnatural Presentations. — Natural presentations are those in which the conditions are such that they may be expected to terminate, in a large proportion of cases, in delivery by natural or unaided labor. Unnatural presentations are those in which the shape of the presenting part of the fetus is so ill-adapted to the pelvic canal that the labor can ordinarily be terminated onlv bv the intervention of the obstetric art, natural delivery being possible onlv when the pelvis is exceptionally large and when the fetus is at the same THE MECHANISM OF LABOR. 437 time immature or exceptionally small. Vertex, face, and breech presentations are classified as natural ; brow and transverse presentations are classified as unnatural. Position. — A division of the presentations into varieties in accordance with the obstetrical positions is a matter of the utmost practical importance, as the mechanism and treatment of labor, and, indeed the prognosis, are often radi- cally different in the several positions of a given presentation. For conven- ience the most prominent point on the dorsal side of the presenting part is selected for the denomination of the position in eacli presentation,* in accord- ance with the relation it bears to a cross-section of the inlet at the beginning of labor. Vertex. — Vertex presentations are thus divided into positions in accordance with the quarter of the pelvis in which the occiput is found at the beginning of labor. We recognize in vertex presentations four positions : Occipito-left- anterior ; occipito-right-anterior ; occipito-right-posterior ; and occipito-left- posterior.f Face. — In face presentations the position is named from the position of the chin. The positions are inento-left-anterior, mento-right-anterior, mento-right- posterior, and mento-left-posterior. Broiv. — In brow presentations the positions are somewhat unsatisfactorilv classified from the position of the occipital end of the head, as — brow, occipito- left-anterior ; brow, occipito-right-anterior ; brow, occipito-right-posterior ; and brow, occipito-left-posterior. Breech. — In breech presentations the names of the positions are determined by the situation of the sacrum, as — sacro-left-anterior, sacro-right-anterior, sacro-right-posterior, and sacro-left-posterior. Transverse. — In shoulder presentations the positions are named from the situation of the presenting scapula, as — scapular-left-anterior, scapular-right- anterior, scapular-right-posterior, and scapular-left-posterior. For convenience the names of the various positions have long been desig- nated by a conventional set of abbreviations, which are commonly used with- out the name of the presentation, that being included by implication. The abbreviations now in general use are those which were determined upon by the last International Medical Congress in its session at Washington, D. C. Thev are as follows : Occipito-left-anterior, O. L. A. ; occipito-right-anterior, O. D.JA. ; occipito-right-posterior, O. D. P. ; occipito-left-posterior, O. L. P. ; Mento-left- anterior, etc., M. L. A., etc. ; sacro-left-anterior, etc., S.L. A., etc. ; scapular-left- anterior, etc., So. L. A., etc. * Except in face presentations, in which case the chin is chosen on account of its promi- nence in the mechanism of this variety of labor. t The older obstetricians were accustomed to recognize four other varieties, in which the occiput was respectively directly posterior, directly anterior, left transverse, and right trans- verse. It is now held, however, that these positions do not occur, under normal conditions, in normal pelves. Since they are only found in some varieties of deformed pelves and in some other pathological conditions, their consideration is now commonly relegated to the domain of pathology. + Dextro. 438 AMERICAN TEXT-BOOK OF OBSTETRICS. Anatomy of the Pelvis. The anatomy of the bones and the soft parts which together make up the pelvis is described in detail in another portion of this work, but for the com- prehension of the mechanism of labor it is necessary to add to the anatomical description a discussion of the shape and dimensions of the parturient canal as a whole, before its mechanical relation to the fetus which is to pass through it can intelligently be discussed. The parturient canal (Fig. 214) may be divided, for purposes of descrip- tion, into three parts — the suprapelvic, the pelvic, and the infrapelvic portions. Fig. 1U— The parturient canal : av, axis ofuterus ; at, plane of inlet ; rf, retraction-ring ; 10, internal os ; eo, external os (one-third natural size). The suprapelvic or abdominal portion of the parturient canal is made up of the uterine cavity and the large or false pelvis. This portion of the pelvis is classified with the uterine cavity on account of the similarity of their functions ; that is, the obstetric function of the large pelvis is simply that of affording a resting-place to the lower portion of the child during the whole or THE MECHANISM OF LABOR. 439 the greater portion of pregnancy, and of guiding the presenting part to the inlet at the beginning of labor. The •pelvic portion of the parturient canal consists of the small or true pelvis. The infrapelvic portion is made up of the soft parts lying below the pelvic bones, which parts, though small and inconspicuous in the non-parturient state, are stretched out during labor into a tubular canal which considerably prolongs the parturient canal, and completes the curve of its lower portion, known as the curve of Carus. An adequate comprehension of the shape and the mechanical functions of the parturient canal in its entirety will best be attained by postponing the description of the canal as a whole until its subdivisions and component parts have been described in detail. Suprapelvic Portions. — Uterine Cavity. — The uterus at term is a hollow, ovate-shaped viscus, whose cavity, although anatomically a part of the par- turient canal, is, from a mechanical standpoint, less a part of the passage than the engine by which the passenger is to be propelled. The function of the uterus as the source of the propulsive power by which labor is accom- plished will be discussed later. Its function as a portion of the canal requires no special description. Fake Pelvis. — The false or large pelvis is that portion of the pelvis lying above the linea terminal is. It is composed of the lumbar vertebrae, the upper surfaces of the lateral processes of the first sacral vertebra, and the squamous portions of the iliac bones, and functionally it is completed by the lower portions of the anterior abdominal muscles and their attachments to the horizontal rami of the pubic bones. The whole thus forms a funnel whose sloping walls terminate in the inlet of the true pelvis, and are admirably suited to their office of directing the presenting part into the pelvis in the initial stage of labor. Apart from this point, the chief practical value of the false pelvis is in the light which alterations of its shape or of its dimensions throw upon the diagnosis of pelvic deformities. To be in a position to detect any departure from the normal shape of the pelvis, it is especially important to be familiar with the normal shape of the iliac crests and with the normal curve of the linea terminalis. Although the crests of the ilia are classically described as presenting an S- curve, it must be remembered that only one portion of this curve — namely, that which possesses an anterior concavity — enters into the formation of the basin of the false pelvis ; the other portion of the curve is entirely without the pelvis, and is utilized solely for the attachment of the sacro-iliac ligaments and the erector spina? muscles. The shape of the anterior portion of this curve is such that the greatest distance between the crests is normally 2.5 centi- meters (about an inch) more than the distance between the anterior superior spi- nous processes, the distance between the crests being normallv 25 centimeters (about 10 inches), and that between the spines 22.5 centimeters (about 9 inches).* Under normal circumstances the anterior portion of the linea terminalis * These dimensions are found to be somewhat variable among different races. The figures given are believed to be approximately correct for American women. 440 AMERICAN TEXT-BOOK OF OBSTETRICS. presents a uniform curve with an internal concavity, and there is but little, if any, projection of the crest of the pubes in or about the median line. Pelvic Portion. — The true or small pelvis comprises all that portion of the pelvis lying below the linea terminalis, and it is divided into three portions — the superior strait or inlet, the inferior strait or outlet, and the excavation. It is formed by the sacrum, the coccyx, the lower portion of the ilia, the ischia, and the pubes. These boues taken together form a deep basin-shaped cavity, whose posterior wall is formed by the sacrum and coccyx and is Fig. 215.— Pelvis seen from above, showing the decrease in the transverse diameter from above downward (one-third natural size). sharply curved with an anterior concavity. The anterior wall is formed by the svmphysis, and is short and nearly straight. The lateral walls, which are formed by the lower portions of the ilia, the ischia, and parts of the descend- ing rami of the pubes, are irregular in outline and slope gently inward, so that the transverse diameter of the pelvis is markedly less at their lower than at their upper extremities (Fig. 215). At its upper and lower limits, which are known as the superior and inferior straits (Fig. 216), the dimensions of the pelvis are much less than in the inter- vening space, called the " excavation." An accurate knowledge of this por- tion of the parturient canal is of the greatest importance, and on account of its complexity is most easily given by separate descriptions of the excavation and of each of the straits, after which description it will be easy to include that of the pelvis as a whole in the general description of the parturient canal that follows at the end of this section. The superior strait is bounded by the promontory and the anterior surface of the first sacral vertebra, the linea terminalis, and the pubic crests. The shape of the inlet or superior strait of the pelvis varies considerably in accord- ance with the point of view selected, but if the eye of the observer is placed in the probable position of the axis of the child at term, it will be seen that the shape of the inlet is approximately circular (Fig. 215). THE MECHANISM OF LABOR. 441 It must be remembered that the presence of the soft parts somewhat alters Fig. 216.— Lateral view of the pelvis, showing superior and inferior straits (one-third natural size). the shape of the brim. The importance of this fact, however, is lessened by Fig. 217.— Pelvis seen from above, showing diameters of brim (one-third natural size). the fact that the vessels, the connective tissues, and the rectum, as well as the 442 AMERICAN TEXT-BOOK OF OBSTETRICS. psoas-iliacus muscles, which together form the only important soft parts in the inlet, are concentrated in the sacro-iliac notches, where the space is already most abundant and where its decrease is of least importance. The dimensions of each of the straits are determined by measuring the antero-posterior, the transverse, and the two oblique diameters. The antero- posterior, or, as it is more commonly termed, the conjugate, diameter of the superior strait (Fig. 217) extends from the upper border of the symphysis pubis to the promontory of the sacrum ; its normal length is 11.5 centimeters (4i inches). A little less than half an inch from the upper border of the symphysis pubis is found a point which, owing to the thickness of the pubic bone, is decidedly nearer to the promontory than the upper border itself. From the promontory to this point the distance is 11 centimeters (about 4J inches), and this is called the "obstetrical" diameter or true conjugate. The greatest transverse diameter of the superior strait averages 13.5 centi- meters (5| inches) in length ; this is the diameter referred to whenever the transverse diameter of the superior strait is mentioned. This diameter lies, however, so far back in the pelvis — that is, so near the promontory (Fig. 217) — that it can never be occupied by any of the diameters of the fetal head. The transverse diameter, which could, in fact, be occupied by the fetal head, lies some distance anterior to this, and is so much shorter as to be of little importance, being, in fact, less than are the oblique diameters. In point of fact, the head never enters a normal pelvis transversely, and the transverse diameter is therefore measured merely as a means of comparing one pelvis with another. The oblique diameters extend from the ilio-pectineal eminences to the sacro- iliac articulations ; their length is 12.75 centimeters (about 5 inches). Since the terms right and left oblique diameter are differently used by different author- ities, it seems best to distinguish these diameters as the first and second oblique diameters of the inlet, in accordance with the frequency of their importance in the mechanism of labor; the first being that which extends from the left ilio-pectineal eminence to the right sacro-iliac synchondrosis. The inferior strait is bounded by the subpubic ligament, the descending rami of the pubes, the rami, tuberosities, and spines of the ischia, the sacro- sciatic ligaments, and the coccyx. Its shape, when looked at in the direction of its axis, is that of a lozenge whose anterior sides are formed of the pubic and ischiatic rami, while the posterior are made up of the sacro-sciatie liga- ments.* When looked at from a point somewhat anterior to the line of its axis, it is seen to present a roughly triangular shape ; but when we remember that the sacro-sciatic ligaments become very distensible during labor, and that the softening of the sacro-iliac and sacro-coccygeal articulations that occurs * Owing to the projection downward of the tuberosities of the ischia, it will be seen that the surface of the inferior strait is bent upon itself to form an external convexity (Fig. 218). For practical purposes it is, however, convenient to neglect this bend, and to deal with the inferior strait as though it did, in truth, lie in a plane between the tip of the coccyx and the subpubic ligament. THE MECHANISM OF LABOR. 443 during pregnancy permits of a considerable movement of these bones upon each other, it will be seen that when the soft parts of the inferior strait are Fig. 218.— Lateral view of the pelvis, showing external convexity of the inferior strait. distended by the head, its aspect from either position will be that of an ovate or egg-shaped orifice (Fig. 219). The antero-posterior diameter of the inferior strait extends from the lower border of the symphysis to the extremity of the coccyx. Its length in the non-parturient state is 9 centimeters (about 3J inches), but when the move- Fig. 219.— View of distended outlet. The dotted lines show the possible position of the sacro-sciatic ligament and the consequent increase in the transverse diameter during extreme distention. ments of distention spoken of above are fully effected, the length of this diam- eter is increased to 11 centimeters (4-f inches), or perhaps even to 12 centime- ters (4| inches). The transverse diameter, which is drawn between the inner borders of the tuberosities, measures 11 centimeters (4| inches), and it is 'the only unyield- 444 AMERICAN TEXT-BOOK OF OBSTETRICS. ing diameter of the inferior strait. The divergent direction of the tuberosities makes it possible, however, for the transverse diameter of the head to corre- spond with a much wider transverse diameter of the outlet whenever the con- ditions of the case permit the parietal protuberances to occupy a position pos- terior to the tuberosities (Fig. 219). The oblique diameters are manifestly rendered unimportant by the uncer- tainty as to their length, the result of the elasticity of the sacro-sciatic ligaments. The excavation, which is bounded by the inferior and superior straits, com- prises all that portion of the pelvis lying between them. The backward curve of the bodies of the sacral vertebrae and the straightness and shortness of the anterior wall of the pelvis render the excavation much more roomy in an Fig. 220.— Diagram showing a division of the lateral wall of the excavation into seetio with their mechanical functions. i in accordance antero-posterior direction than is either of the straits, and this increase of space is, of course, greatest in the middle portion of the excavation. The oblique diameters are correspondingly increased for the same reason, and, indeed, in the middle of the excavation they are often longer than any of the diameters of a small fetal head — a fact which is sometimes of import- ance in the mechanism of posterior positions of the vertex and of presentations of the face. If the transverse diameters of the excavation were similarly ample, this portion of the pelvis would be devoid of obstetrical interest ; but this is far from true. The transverse diameter of the excavation is at one point the smallest and also one of the most rigid diameters of the whole pelvis, and the importance of the anatomy of the lateral walls of the excavation is so great that its comprehension is the key-note to the whole subject of obstetrical mech- anism. The anatomy of the lateral walls is so difficult of description that it THE MECHANISM OF LABOR. 445 is possible to comprehend it only by means of a subdivision of the lateral walls of the excavation into three parts (Fig. 220) : An upper portion (A, Fig. 220), which is roughly triangular in shape ; a second portion (B), which lies below and in front of the first; and a third portion (C), which lies below and behind the first. Portion A is composed throughout of unyielding bone. In its upper part its surface is smooth and very uniformly curved. The transverse diameter of the pelvis at this point is the ample transverse diameter of the superior strait. The oblique lines drawn through the anterior edge of this portion upon one side of the pelvis and through the posterior edge of the corresponding portion upon the other side are likewise ample, and, indeed, vary but little from this same length (5^ inches). In its lower part portion A of the lateral wall inclines inward to its termination in the rigid ischial spines, between the points of which the smallest diameter of the pelvis is found — a diameter so small as to be practically impassable by the biparietal and suboccipito-bregmatic diameters of a full-sized head. Portion B of the lateral walls of the excavation has but little rigid bone in its composition. The ileo-pubic ramus Avhich forms its upper portion is as smoothly and uniformly curved as the rest of the brim of the pelvis. Its middle part is made up mainly of the membranous coverings of the foramen ovale, that are covered by the obturator muscle, and at the time of term, like all the other ligaments and fascial coverings of the pelvis, are more elastic than in the non-parturient state. When these muscles and fasciffi are put upon the stretch by the pressure of the pre- senting part during its descent, their recession converts portion B of the lateral wall into a shallow spiral groove, with bony edges and a soft floor, which deepens as it descends and turns forward. The ischio-pubic ramus, which forms the floor of the lower part of portion B, is here so curved (lat- erally outward) as to lend itself readily to the continuation of this groove. Portion C has a bony edge composed of the posterior border of the ischium and the lateral edge of the sacrum and coccyx, but it is made up mainly of the very elastic sacro-sciatic ligaments and the pyramidal muscle. When these ligaments and muscles are put upon the stretch during the descent of the head, portion Oof the lateral wall is converted, like portion B, into a spiral groove which deepens as it descends and turns forward. When the rigidity of portion A and the yielding nature of portions B and C are considered in connection with the fact that even in the bony pelvis the foramen ovale and the sacro-sciatic notches are regions of recession separated from each other by the projecting ischial spines, it will be seen that when distended by pressure from within, the lateral walls of the excavation may be considered as consisting, for mechanical purposes, of two deep grooves separated from each other by a prominent ridge of unyielding bone (Fig. 221). The anterior of these grooves pursues a spiral course downward and forward from the anterior end of the oblique diameter at the brim, to end under the pubic arch at the inferior strait. The posterior groove pursues a similar 446 AMEBICAX TEXT-BOOK OF OBSTETRICS. spiral course downward and forward from the posterior end of the other oblique diameter at the brim, to end in the same point at the outlet. Fig. 221.— Sections of the pelvis, showing the lateral grooves and the bony ridge which separates them : A, sagittal section. The lines b, c, d, e, indicate the horizontal planes through which the cross-sections b, c, d, e, are taken. The shaded portions of the figure indicate the spiral grooves, the depth of the groove being deepest where the shading is darkest. B, cross-section, showing the nearly-uniform curve of the unbroken bony circumference of the superior strait. C, cross-section, showing the bony ischium (A, Fig. 220) separating the distensible foramen ovale (B, Fig. 220) and sacro-sciatic notch (C, Fig. 220). D, cross-section through the ischial spines, which here emphasize deflection inward of the bony ridge (A, Fig. 220). E, cross-section near the inferior strait. The posterior half is distensible, and in the anterior half the bony descending ramus of the pubes curves outwardly to continue the curve formed by the yielding tissues which cover in the foramen ovale, as seen in the sections C and D. The oblique diameters drawn toward the bottom of the anterior groove THE MECHANISM OF LABOR. 447 upon one side and the bottom of the posterior groove upon the other side are throughout the pelvis ample for the passage of any of the diameters of the fetal head except the occipito-frontal and the occij>ito-mental. Should any rounded body be started at the upper end of either of these grooves, and be forced downward by a vis-a-tergo under the influence of a constant intrapelvic pressure, it must necessarily follow the path of least resistance — that is, the course of the groove in which it started — to end its course under the pubic arch at the outlet. The importance of these considerations will be apparent when the section on the Mechanism of the Second Stage of Labor is reached. Infrapelvic Portion. —When the soft parts below the inferior strait are distended by the head, they include a hood-shaped space of considerable size, bounded upon its upper border by the edge of the pubic arch, the tuberosities of the ischia, and the lower edge of the sacro-sciatic ligaments, and upon its other or inferior border by the orifice of the distended vagina. Its anterior wall is from a quarter to half an inch in length. Its posterior wall, when fully distended, is from 6 to 10 centimeters (2J to 4 inches) in length. When the head has wholly escaped from the inferior strait it occupies an elastic canal composed wholly of soft parts and having but one mechanical function — an elasticity which keeps the head constantly in contact with the edge of the pubic arch. The Parturient Canal as a "Whole. — The parturient canal (Fig. 214) con- sists functionally of two portions, an ovate reservoir formed by the uterine cavity and the false pelvis, and a curved passage which extends downward and forward from the lower opening of the reservoir. This passage possesses an irregularly cylindrical shape which has classically been likened to the curve of a ram's horn. The anterior wall is much shorter than the posterior. If both the anterior and posterior walls are divided into an equal number of equal parts, and planes are drawn between each pair of these points (Fig. 222), a curved line passing through the centre of each of these planes forms what is known as the axis of the pelvic canal; if this curved line is continued forward, it will reach the abdomen of the mother at about the situation of the umbilicus in the non-parturient state. This prolongation of the pelvic axis is known as the curve of Cams. The centre of any body passing through the pelvic canal must travel through a path closely approximate to this curved axis. Were the pelvic canal exactly cylindrical and the fetal head exactly spherical, the mechanism of labor would be limited to an observation of the above-related fact; but in reality the irreg- ularities in the contour of the pelvic canal and the corresponding irregularities in the shape of the fetal head are matters of the greatest importance. It will be remembered that although the transverse diameter of the superior strait is nominally the greatest, yet the rapid convergence of the ilio-pectineal lines as they stretch forward renders the length of the practicable transverse diameter in fact less than that of the oblique diameters, so that any ovate body presented to the inlet of the pelvis will tend to enter the brim in the oblique diameter. At the inferior strait the transverse diameter is the narrowest of the whole 448 A3IEBICAN TEXT-BOOK OF OBSTETRICS. pelvis, and, since the oblique diameters at the moment of delivery are shorter than the distended conjugate, any ovate body which attempts to pass the outlet will do so most readily if its long diameter corresponds with the antero-posterior diameter of the inferior strait. It is therefore evident that the process of Sagittal section of the pelvis, showing the pelvic axis and the curve of Cams. labor will most easity be accomplished by the occurrence of a rotation of the longest diameter of the presenting parts from an oblique position at the supe- rior straight to an antero-posterior position at the outlet ; and, in point of fact, the mechanical relations which lead up to this rotation lie at the bottom of the whole subject of the mechanism of labor. It is to be noted that when the woman is in the erect position the axis of the superior strait* forms an angle of about 30° with the horizon; that in the same position of the woman the axis of the inferior strait is directed downward and a little forward; and that the axis of the vaginal outlet of the distended parturient canal looks almost directly forward and but very slightly downward (Fig. 222). Differences between the Male and the Female Pelvis. — It is important that the obstetrician should clearly understand the normal characteristics of the female pelvis in contradistinction to those of the masculine form, because the approaches to a masculine type — which are not uncommon and may occur * A line drawn from the centre of the superior strait in a direction perpendicular to its plane. THE MECHANISM OF LABOR. 449 in any portion of the pelvis — are not unimportant as a cause of dystocia and of alterations in the mechanism of labor. The differences between the male and the female pelvis will be rendered most easily familiar by the use of a series of figures showing respectively the shapes of the superior strait, of the Fig. 223.— Male pelvis viewed in the axis of the brim. antero-posterior curve of the sacrum and the pubic arch, and of the inferior strait in the masculine and feminine types. Superior Strait. — In the male the sacrum is narrow, the promontory en- croaches deeply into the brim, the iliac crests are comparatively erect, and the interior concavity of the anterior portion of the ilio-pectineal line is but little Fig. 224.— Female pelvis viewed in the axis of the brim. marked (Fig. 223). The shape of the inlet is thus angular and strongly cor- date as compared with that of the female pelvis (Fig. 224). Antero-posterior Section of the Pelvis. — In the male the sacrum is lono- and 29 450 AMEBIC AX TEXT-BOOK OE OBSTETBICS. its upper portion is nearly straight, while the lower part of this bone and its continuation, the coccyx, are bent sharply forward. The symphysis and the adjacent portions of the descending rami are long and erect. (Fig. 227). In the Fig. 225.— Male pelvis seen from the front. female (Fig. 228) the sacrum is shorter, its general direction is more distinctly downward and backward, its upper portion is much more concave from above downward, and the antero- posterior curve is throughout more uniform than in Fig. 226.— Female pelvis seen from the front (one-third natural size). the male. The symphysis is short, and the wider pubic arch, shortly to be spoken of, decreases the importance of the descending rami in the formation of the anterior wall. Inferior Strait. — In the male (Fig. 225) the angle of the pubic arch meas- THE MECHANISM OF LABOR. 451 ures from 75° to 80°. The anterior wall of the pelvis — that is, the dis- tance between the symphysis and the tuberosities — is long as compared with the pelvis of the female (Fig. 226), in which pelvis the sides of the pubic arch form an angle of from 90° to 100°, and the entire depth of the pelvis is much diminished. The backward recession of the tip of the sacrum and the coccyx, together with the increased distance between the tuberosities, greatly Fig. 227.— Diagrammatic anteroposterior section of male pelvis. 223. —Diagrammatic antero-posterio of female pelvis. increases the size of the inferior strait in the female (Fig. 224) as compared with the male (Fig. 223). There is a greater relative distance between the acetabula, and their surfaces are directed somewhat obliquely to the front. This situation of the acetabula is decidedly unfavorable to the function of the hip-joints in locomotion, and it accounts for the greater proximity of the knees in women and for the characteristic difference between their gait and that of men, whose pelvic bones are designed for locomotion alone. The Fetus. The head of the new-born child is, proportionately to its body, so much larger than that of the adult, and the body is proportionately so much the more compressible, that the head is in most cases the only part of the body that affords any considerable mechanical obstacle to the passage of the fetus through the parturient canal. From its comparative incompressibility it is, moreover, the part which most nearly retains its normal shape throughout labor, and it is therefore in the passage of the head that the mechanical pro- cesses of labor are most plainly marked and most important. From the foregoing considerations it is at once apparent that a thorough familiarity with the dimensions and shape of the fetal head and with the changes it undergoes during labor is a necessary preliminary to the compre- hension of the principles of obstetric mechanism. Some familiarity with the 452 AMERICAN TEXT-BOOK OF OBSTETRICS. shape and dimensions of the remainder of the fetus in the attitude it ordi- narily assumes, though less often of importance, is nevertheless essential. The Fetal Head. — The head is obstetrically divided into two portions, the face and the cranium. The face is much smaller in proportion to the cranium than that of the adult, and is of but little importance in normal labors. It is, however, well to remember that the face is made up of the most solid and incompressible bones which enter into the composition of the head, and that its configuration is altered but little, if at all, by the processes of labor. The cranium or brain-case is to be divided for purposes of description into two portions, the base and the vault of the skull. The base is formed by the basilar portion of the occipital bone, the petrous portions of the temporal bones, the sphenoid and ethmoid, and the orbital processes of the frontal bones. These bones, even at birth, are firmly united, and they form a com- paratively small but almost totally incompressible mass. The vault is made up of the parietal bones and the squamous portions of the occipital, temporal, and frontal bones. These bones are all wide, flat, and slightly curved. The squamous portion of the occipital bone is attached to the basilar portion by a band of fibro-eartilaginous tissue which permits of quite free motion between the two portions. All the bones of the vault are united at their edges by membranous commissures formed of the dura mater and the unossified external periosteum. The vault of the cranium, though much larger than the base of the skull, differs from the base in its possession of compressibility and of a marked capacity for alteration of shape under the moulding influences of the constant pressure of labor. It must be remembered, however, that different heads present very different degrees of ossification at the time of birth, and, indeed, vary widely, from cases in which the flat bones are so slightly ossified as readily to be bent by the pressure of the finger, and in which the mem- branous intervals are extremely wide and well marked, up to cases in which the ossification and union of the bones are so far advanced as to reduce the compressibility of the skull to a min- imum of small practical value. The Sutures and the Fontanelles. — The membranous lines of union between the contiguous bones of the vault are known as sutures, and at the points where more than two bones meet these sutures commonly widen out to mem- branous spaces known as fontanelles (Fig. 229). The sutures are distinguished by the following names: That between the frontal bones is the frontal; that between the frontal and parietal bones is the coronal; that between the parie- tals is the sagittal; and that which separates the squamous portions of the occipital from the two parietals is the lambdoidal suture. At the point where the frontal and parietal bones come together the frontal, Fig. 229.— Diagrams of the fontanelles : A, ante^ rior; B, posterior; C, lateral. THE MECHANISM OF LABOR. 453 sagittal, and coronal sutures meet in a membranous space or fontanelle which is rhomboidal in shape and is ordinarily of considerable extent. This space is known as the anterior or large fontanelle, and sometimes as the bregma (PI. 28, Fig. 2). Of its four sides, the two anterior are usually the longer, and when this difference is well marked the resulting fontanelle may more properly be said to assume the shape of an Indian arrow-head (Fig. 229, a). The junction of the sagittal and lambdoidal sutures at the point where the occipital and parietal bones meet forms a small triangular space, known as the posterior occipital, or small fontanelle (PI. 28, Fig. 3). In well-ossified heads this space is frequently small or wanting, and the posterior fontanelle is then represented only by the junction of the three sutures. It is to be remembered, moreover, that when the bones are closely crowded together by the pressure of severe labor, either fontanelle, however well marked, may be partially or wholly effaced for the time by an overlapping of the edges of the bones which bound it. Exceptionally, a locally defective ossification along the edges of the bones may result in the production of either Wormian bones or false fontanelles, both of which are most common in the course of the sagittal suture, and which may result in considerable confusion of diagnosis if the possibility of their existence is not borne in mind.* Dimensions of the Fetal Head. — The size of the fetal head at term varies greatly with the size of the individual fetus, but, however great this variation ma}' be, the relative proportions between the different parts of the head remain approximately constant, and for the sake of clearness it is usual, in the discussion of general principles, to ignore this variation of size and to use as the basis of argument the dimensions of the average head. The diam- eters that have been found most useful in the description of the head are as follows : The anteroposterior diameters — the occipito-mental, the occipito- frontal, the suboccipito-bregmatic ; the transverse diameters — the biparietal, the bitemporal, and the bimastoid ; the vertical diameters — the fronto-mental and the cervico-bregmatic. Anteroposterior Diameters. — The occipito-mental diameter (PI. 28, Fig. 1) is drawn from the chin to the most distant portion of the occiput. The occipito- frontal (PI. 28, Fig. 1) is drawn from the point of union of the supraorbital ridges to that portion of the occiput which is most distant from them. The suboccipito-bregmatic (PI. 28, Fig. 1) is drawn from the point of junction between the occiput and the neck to the centre of the anterior fontanelle. Transverse Diameters. — The biparietal diameter (PI. 28, Figs. 2, 4) is drawn from the apices of the biparietal protuberances — namely, through that portion * It is well to bear in mind, in addition to the anterior and posterior fontanelles, the occa- sional existence of a third, the lateral fontanelle. This fontanelle is present only in poorly-ossi- fied heads, and when present is found at the junction of the occipital, parietal, and temporal bones, near the base of the mastoid process and behind the ear. The lateral fontanelle may sometimes be mistaken for the bregma unless carefully observed. It is four-sided, but is irregu- lar in shape (Fig. 229, c). It may be said that the mastoid process feels like the side of a large canine tooth imbedded in the temporal bone. It is usually recognizable, and it is sometimes a valuable point in the diagnosis of this region of the skull. 454 AMERICAN TEXT-BOOK OF OBSTETRICS. of the skull at which the lateral surfaces are most widely distant from each other ; the bitemporal (PI. 28, Figs. 2, 4) extends transversely between the most distant portions of the coronal sutures ; the bimastoid extends between the mastoid processes at the base of the skull. To these diameters is some- times added a less important diameter, that lying between the base of the zygomatic processes, the bizygomatic. Vertical Diameters. — The fronto-mental diameter (PL 28, Figs. 1, 4) extends from the chin to the upper part of the forehead ; in the absence of any dis- tinctive point of origin at its upper extremity, as well as from its small size, it is of but little importance. The cervico-bregmatic (PI. 28, Fig. 1) is drawn between the junction of the neck and the chin arid the centre of the anterior fontanelle. The lengths of the several diameters, as obtained by Tarnier and Chan- treuil, are given as follows: Centimeters. Inches. Occipitomental diameter 13 = 5J- Occipito-frontal " 11.5 = 4J- Suboccipito-bregmatic diameter 9.5 = 3J Biparietal diameter 9.5 = 3f Bitemporal diameter 8 = 3} Bimastoid diameter 7.5 = 3 Fronto-mental diameter 8 = Z\ Cervico-bregmatic diameter 9.5 = 3| These diameters may be divided into classes in two ways: (1) by their com- pressibility, and (2) by the degree of difficulty with which they may be expected to pass the pelvis. The compressibility of the fetal head as a whole is not only a very variable factor, but the different parts of the same head vary widely in both the ease and the safety with which compression can be applied to them. The biparietal and bitemporal diameters are safely and easily compressible. The suboccipito-bregmatic, oceipito-frontal, and occipito-mental diameters are almost equally compressible, but the degree of danger to the fetus that com- pression of these diameters involves is vastly greater than is the case with the biparietal and bitemporal diameters ; and with oblique compression the degree of danger increases as the direction of the force approaches to the antero-posterior diameters. The bimastoid and bizygomatic diameters are for practical purposes totally incompressible. The Relative Value of the Diameters of the Head as Compared with the Diameters of the Pelvis. — It will be observed that the lengths of the suboccipito-bregmatic and biparietal diameters are nearly equal, so that a cross- section of the head through these diameters (Fig. 230, a) is very nearly circu- lar ; and from this fact and from their size this cross-section is capable of pass- ing any diameter of the pelvis* when presented to it in any obstetrical posi- tion. Since this is the cross-section which is always presented to the pelvis by well-flexed heads, the study of position would be of little importance if the ex- istence of flexion could always be depended upon and if the remainder of the * Except that between the spines and the ischia. LABOR. IS Occipihi-fFonl % \. -7 k 4> &F J' ,o c Occiput ^ llparietal : \ S ft 5 iparietal y cnb3pn- Ver Tex Bitemporal 8cm3i/.in> Dosterior sM-'FontaniHe Occipital Protuberance Fetal Head : 1. Fetal skull seen from the side ; 2. Fetal skull seen from above : 3. Fetal skull seen from behind; 4. Fetal skull seen from in front-showing sutures, fontanelles, and diameters. THE MECJTAXJSM OF LABOR. 455 head could be neglected ; but two factors in labor equally contribute to render this cross-section of the head by no means the only one which must be con- sidered. In the first place, we must be prepared to consider the mechanism of brow and face cases, and, in addition, those cases of vertex labor in which the flexion of the head is, from one cause or another, imperfect ; and, moreover even in the best vertex labor good flexion is seldom attained in the early stages Fig. 230— Diameters of the fetal head: A, cross-section of the fetal head through the suboccipito- bregmatic and biparietal diameters ; B, eross-section of the fetal head through the bi parietal and occipito- frontal diameters; C, cross-section of the fetal head through the biparietal and occipito-mental diam- eters ; D, cross-section of the fetal head through the suboccipito-frontal and bitemporal diameters. of engagement at the brim. Secondly, even when good flexion is present and this circular cross-section is in the inferior strait or excavation, the brim is occupied by the frontal portion of the head in combination with the neck — a by no means unimportant factor in the mechanism of even the most normal cases. It is therefore important to remember the shape and dimensions of the cross-sections, which include, first, the biparietal and occipitofrontal diameters (Fig. 230, b) ; second, the biparietal and occipito-mental diameters (Fig. 230, c) ; third, that which cuts the head and neck through what might be called the " suboccipito-frontal" diameter* and the bitemporal diameter (Fig. 230, d). If the diameters of these cross-sections be compared with those of the pelvis, it will be seen that all the transverse diameters are capable of an easy passage through any of the diameters of the pelvis. The occipito-frontal and sub- occipito-frontal are too large to pass any of the conventional f diameters except the oblique diameters at the superior strait and the distensible antero-posterior * Approximately the cervico-bregmatic plus the thickness of the neck. t Those which have names. 456 AMERICAN TEXT-BOOK OF OBSTETRICS. diameters of the inferior strait ; while the occipito-mental is too large even for these, and may consequently be regarded as an impracticable or impossible diameter. A careful remembrance of the relative values of these diameters will be found of great service in the comprehension of normal labor, and of still more value in understanding abnormal labor. The Articulations between the Head and the Spinal Column. — The articulations by which the head is joined to the trunk are, it will be remem- bered, the occipito-atlantoid, the atlanto-axial, and those between the other cervical vertebrae. The occipito-atlantoid articulation admits of but little motion except that of extension and flexion, while even that motion, when carried to extremes, is greatly assisted by a similar movement in the other cervical articulations. So, too, the rotatory movement which alone is possible in the atlanto-axial joint is greatly assisted by the movements in the other articulations of the neck. The capacity for lateral flexion resides wholly in the intervertebral articulations and is limited by their ligaments. Rotation of the head to either side is safely possible only through an arc of about 90° ; that is, when the chin of the fetus is in the plane of the shoulders the limit of safety in rotation has been reached. Antero-posterior flexion is limited only by contact between the chin and the breast. Extension can be carried to a point at which the occiput rests against the back of the neck and the chin is in a line with its anterior surface. The Fetal Body. — The compressibility of the fetal trunk renders impossible and worthless any statement of the absolute length of the diameters which the fetal body presents to the pelvis during labor; but the relative lengths of the transverse and antero-posterior diameters as compared with each other is of importance, and is constant in at least two parts of the trunk — namely, in the regions of the shoulders and the hips. The transverse diameter in both these regions is always longer than the antero-posterior diameter. The Shoulders. — The relation of the shoulders of the infant to the mechan- ism of labor is somewhat altered by their movability. The shoulders may be jjresented to any portion of the pelvis in one of two positions : First, they may enter together, with the line of the clavicles approximately at right angles to the spine — that is, in the position ordinarily assumed by adults. Second, one shoulder may be elevated and the other depressed, so that the one enters in advance of the other, both clavicles being still approximately in the same line, but this line now forming an oblique angle with that of the vertebral column. In the second, which is the usual and normal position, the transverse diameter never loses its superiority of length over the antero-posterior diameter. When both shoulders enter together, this superiority of the transverse diam- eter is always rendered somewhat less marked by the occurrence of a simul- taneous forced depression of" both clavicles, and is occasionally so much diminished as to lead to interruptions of the mechanism by which the delivery of the shoulders is normally accomplished. The Hips. — The pelvic bones of the infant are sufficiently rigid to prevent THE MECHANISM OF LABOR. 457 any considerable moulding of the breech, and the transverse diameter of the hips is always considerably greater than the antero-posterior diameter of the same portion of the body. The Trunk. — The intermediate portions of the infant's trunk are so soft and compressible that its diameters are totally inconstant. The shape of the cross- section of the trunk corresponds with the shape of that portion of the pelvis in which it lies, and even the presence of the limbs in juxtaposition with it makes but little difference, since its softness permits the limbs, under the pres- sure of labor, to indent it at any point. Diagnosis, Frequency, and Prognosis of the Several Varieties of Labor. Diagnosis.* — In obstetric diagnosis we are furnished with two methods of examination of almost equal importance — namely, examination of the abdomen and examination of the vagina — which must be described separately. The abdominal examination must be subdivided into inspection, palpation, and auscultation. In the use of this method of examination it is best for the beginner to ignore the possibility of O. L. P. and O. D. A., on account of their great infrequency and of the excessive complications that an effort at their recognition would involve. The value which the individual obstetrician places upon an abdominal examination is generally proportionate to the experience he has enjoyed. The beginner should be urged to avail himself of every opportunity for practising this method, for, while he will find in his early practice many cases in which the obesity of the patient or the rigidity of the abdominal muscles and uterus renders abdominal palpation of no value, a large number in which the exam- ination is inconclusive, and only a few in which he can attain a clear diagnosis by this means, yet as his experience enlarges the first class will steadily decrease in number and the latter two will increase proportionately, if he is faithful in practising palpation upon every case that comes under his charge; and the value which attaches to facility in making a diagnosis by this means in many difficult operative cases can be appreciated only by those who possess it. It is certainly a fact that to the experienced hand abdominal palpation yields results fully as valuable as those which can be obtained by digital examination per vaginam, and that there are but few cases in which repeated examinations during the progress of labor will fail to establish a diagnosis by palpation and auscultation alone. Abdominal Inspection. — Inspection is mainly valuable as affording a hint of the existence of transverse presentations and of multiple pregnancy. Abdominal Palpation. — Palpation is the most important part of the abdominal examination; it should be performed onlv in the intervals between * Although the methods which must be used in making the diagnosis of presentation and position are indicated in another part of this work, such a diagnosis is so essential to the mechanical management of labor that it seems wise to repeat in brief the technique of the several methods of examination in this section. 458 AMERICAN TEXT-BOOK OF OBSTETRICS. the pains, all pressure of the hand being intermitted with the appearance of each contraction. The physician should stand by the patient's side facing toward her head, and should apply the pain: of each hand flat against the cor- responding side of the uterus. Throughout the examination it is all-important that the motions of the hand should be slow and gentle, any quick or jerky impulse being almost certain to result in rigidity of the abdominal walls and the uterus, thus frustrating the purpose of the examination. Every effort should be made to divert the attention of the patient, to soothe her fears, and to assure her that the examination will uot be painful. It not infrequently happens that the first attempt will be a total failure, while the second will yield satisfactory results owing to the changed mental condition of the patient. Diagnosis of Presentation by Palpation. — The finger-tips of each hand should be pressed with a gradual and gentle motion downward behind the symphysis pubis in search of the fetal head (Fig. 231), which in cephalic pres- Fig. 231.— Diagnosis of presentation by palpation. entations is almost always to be felt in this situation as a marked transverse check to the examining hand. In this examination care should be taken to note on which side the head is most plainly perceived, since with a well-flexed head the frontal extremity is much the more easily reached, with the partially extended head but little difference is to be noticed, and in face presentations the occiput is much the more distinct. The fundus should then be palpated carefully as a further means of excluding the possibility of a breech presentation. The head may be dis- tinguished from the breech at the fundus by its greater size and mobility, by its rounded contour as opposed to the tapering form of the smaller breech, and by an easily distinguished sulcus which corresponds with the neck of the child ; but the best evidence of the presence of the breech at the fundus THE MECHANISM OF LABOR. 459 is always the recognition of a head presentation by deep palpation behind the symphysis. Differential Diagnosis of Presentations by Palpation. — Cephalic Presenta- tions. — The most distinctive sign of head presentations is to be found in the recognition of the head by deep palpation behind the symphysis. The diag- nosis should then be checked by ascertaining the absence of the signs charac- teristic of the head at the fundus. Pelvic Presentations. — In breech presentations the obstetrician's attention is generally first arrested by the absence of the transverse check to the fingers, due to the presence of the head, on deep palpation behind the symphysis. He should then be able to recognize the presence of the head at the fundus by the signs just enumerated. Transverse Presentations. — In transverse presentations the long axis of the child is felt to be transverse. The differential diagnosis between the head and the breech is always of importance, and is to be made by the signs enu- merated above as characteristic of the head. Diagnosis of Position by Palpation. — The hands should be placed along the sides of the uterus and should make gentle but deep pressure toward each other (Fig. 232) — that is, with the uterus and child directly between their Fig. 232.— Diagnosis of position by palpation. palms — in the effort to estimate the relative resistance afforded by the right and left sides of the uterus, the flat, firm back of the child usually presenting a resistance to pressure that is markedly greater than that of the yielding abdomen and the movable limbs. The differing resistances having been estimated, the fingers should be applied to the sides of the uterus, not with the tips deeply indented into the abdomen, but with their whole palmar surface pressed firmly against the 4(30 AMERICAN TEXT-BOOK OF OBSTETRICS. uterus ; the hands should then be moved gently up and down along the uterine wall in an endeavor to recognize the irregularities due to the presence of the fetal limbs. During this search it is necessary to guard against the error of mistaking either of the round ligaments for the fetal members. These ligaments, which at term are of nearly the size of the adult finger, extend obliquely from the cornua of the uterus downward, outward, and forward to the pelvic brim. They may be recognized by their situation and by the pain of which the patient invariably complains when they are rolled about under the fingers. The existence of small subperitoneal fibroids is another possible source of error. With thin and flaccid abdominal walls it is sometimes possi- ble by this method to recognize the fetal limbs with the utmost distinctness, but in the majority of cases an irregularity in the contour of the fetus is all that can be hoped for. By palpation, then, we can hope to distinguish not only the presentation, but also the position, since the latter must correspond with the quarter of the pelvis in which the fetal back is found. Owing to the infrequency of O. D. A. and O. L. P. positions, it is generally safe to call all cases in which the back of the child is found toward the left, O. L. A., and those in which it is found toward the right of the mother, O. IX P. Abdominal Auscultation. — Auscultation of the fetal heart gives confirm- atory evidence about the presentation and position, informs us of the condi- tion of the child, and is the most important sign in the recognition of multiple pi-egnancy. In vertex presentations the heart is most plainly heard over the back of the child and below the mother's umbilicus ; * in breech presentations the heart is heard over the back, but its greatest intensity is generally above the mother's umbilicus ; while in presentations of the face it is most readily heard over that portion of the uterus which corresponds with the chest of the child, but is again below the umbilicus. In transverse presentations the heart is usually plainly audible when the back is anterior, but is often found with difficulty in the posterior varieties, and is of comparatively little value in the diagnosis of position. In interpreting the evidence of position furnished by the situation of the fetal heart it must not be forgotten that, owing to the fact that sound is better con- ducted by solids than by liquids, the exact situation of the fetal heart-sounds corresponds with that portion of the back or chest which happens at the moment to be in contact with the uterine wall ; the situation of the fetal heart-sound, therefore, may vary temporarily with the position of the mother, as one or the other shoulder rests against her soft parts, or it may temporarily be absent (especially when the patient lies upon her back), owing to the intervention of the liquor amnii between the fetal chest and the physician's ear. * Owing to the oblique position which the shoulders normally occupy, the dividing-line between the right and the left position of the heart-sounds in this and in all longitudinal pres- entations should be that drawn between the umbilicus and the right anterior superior spine of the ilium rather than the median line of the body. THE MECHANISM OF LABOR. 461 In addition to the value of auscultation in the diagnosis of position, its importance in the recognition of the condition of the fetus can hardly be over- estimated, any fatigue of importance being quickly shown by alteration of the rate and regularity of the heart-sounds. In addition to the fetal heart-sounds, the so-called "uterine" or "placental souffle" is generally heard as a soft blowing sound synchronous with the mother's pulse ; this sound is of no practical value. Summary of Diagnostic Signs furnished by the Abdominal Exami- nation. — At the conclusion of the abdominal examination its results should be summed up and a diagnosis be made by some such mental process as the following : The first process of palpation, described on page 459, enables one to deter- mine whether the presentation is cephalic, pelvic, or transverse, and this result is checked by the position of the fetal heart as obtained by auscultation ; that is, in cephalic presentations the heart is found below the umbilicus, in breech presentations above it, and in transverse presentations a little toward that side of the abdomen to which the head is directed. The position is determined by the situation of the fetal back, as established by the second method of palpation, described on page 459, and by the position of the fetal heart, which position should correspond with that of the fetal back.* If the presentation is either breech or transverse, no further determination is necessary, or indeed possible, by the abdominal examination; but if the pres- entation is cephalic, it is both necessary and possible to determine whether it is a presentation of the vertex, the brow, or the face. In vertex presentations the end of the head that corresponds with the fetal abdomen — that is, the face — is found at a higher level than the opposite or occipital end, and the fetal heart is heard over the back. In face presentations the end of the child's head that corresponds with the abdomen — that is, the face — is palpated less readily than the dorsal (occipital) end of the head, and the heart is heard over the front of the child.! In brow presentations both ends of the head are easily reached by palpation. The heart is usually heard over the back. Vaginal Examination. — Technique of the Examination. — In obstetric work it is usually best to avail one's self of the extra length of the middle finger by employing two fingers for all examinations, except in those cases in which the extremely narrow vulva of a primipara makes the introduction of the second finger painful to the patient. Most American obstetricians prefer to * Except in face presentations (see p. 509. f It will be perceived that the distinction between vertex and face presentations by abdom- inal examination is likely to be difficult, since in a left anterior position of either presentation the most accessible end of the head will be found in the right posterior quarter, while in both presentations the heart is left anterior ; the only distinction is to be found in the position of the fetal limbs as compared with the heart, and in the perception of the greater size and more rounded contour of the occiput as opposed to the face; but the great infrequency of face pres- entations and the ease with which they are distinguished on vaginal examination make this source of error a matter of small importance. 462 AMERICAN TEXT-BOOK OF OBSTETRICS. examine the patient when in the left lateral decubitus, but it is well to accustom one's self to examining in all positions, not only in the interest of the patient's comfort and convenience, but also because it is often possible by changing the decubitus to reach a portion of the child that has before been unattainable. The vulva being aseptic, the hand, having been thoroughly disinfected and anointed with an aseptic lubricant, should be introduced under the bed-clothes, which should be so held up by the other hand as to protect them from contact with the examining fingers ; these should be placed against the genital cleft, and be swept gently forward until they find the entrance of the vulva and come in contact with the fourchette, friction against the vestibule and clitoris being carefully avoided in the process. As the examining finger enters the vagina it should note successively the size of the vulvar orifice, the position of the coccyx, the shape of the sacrum,* and the condition of the rectum — whether full or empty. These points having been ascertained, the finger should be passed upward into the posterior fornix, and be swept forward over the soft and yielding vault of the vagina in the effort to find the external os, which is usually situated in the median line and near the centre of the pelvis. In case of failure to find the os readily, the field of the pelvis should be quartered systematically by the examining finger, much after the fashion employed by a pointer dog in searching a field for game. If the cervix be not yet taken up, it is recognized as a rounded prominence, on the summit of which is found the orifice of the os if the patient be a primipara ; in multiparas the lacerated and ragged condition of the cervix frequently makes the external os indistinguishable from an early stage of labor, but the finger in such cases may usually be passed into the cervical canal, and will then recognize the presence of the internal os. If the cervix has been wholly taken up, the os is best recognized by passing the finger through it and into the space between the cervix, and the presenting part.f The physician's ability to reach the upper portions of the pelvis is more dependent upon the position in which his hand is held than upon the length of his fingers. When he desires to reach the upper and posterior parts of the pelvis, his hand should be held in the position indicated in Figure 233, the perineum being strongly retracted by the pressure of the web between the second and third fingers. When the object sought for lies nearer the anterior wall of the pelvis, the position of the hand should be altered by rotation of the forearm into the position represented in Figure 234. The upper border of the second finger is now pressed firmly against the edge of the pubic arch, and the pulp of the finger is directed anteriorly. * The writer strongly recommends the practice of roughly measuring the conjugate diameter by reaching upward for the promontory of the sacrum, as a routine measure, at the conclusion of the first examination in each case, and he believes that many operative difficulties may be avoided by this simple procedure. I Unless this precaution of hooking the finger about the edge of the os be observed, the beginner is liable to mistake a fold of the vaginal wall, or in breech presentations the anus, for the os uteri, both of which mistakes have been made by medical students in the presence of the writer. THE MECHANISM OF LABOR. 463 The os having been reached, the finger should note its size, the thickness of its edge, and its consistency, whether hard or soft, and by very gentle stretch- ing should endeavor to ascertain its degree of dilatabilitv ; in this last maneu- vre it is necessary to employ the greatest gentleness in order to avoid the inex- Fig. 233.— Positon of the hand in digital examinat along the posterior wall of the pelvis. disable accident of a manual laceration of the os during examination. The characteristically different sensations yielded to the finger by the smooth and velvety cervix, the rough but slippery membranes, and the hairy scalp is a matter with which it is important to become familiar, for it is easy to recognize t<:: - ■ j IR^^s "V ^ Fig. 234.— Position of the band in digital < if the fetus along the anterior wall of the pelvis. these differences if the physician has trained himself to observe them in even a comparatively small number of cases, and the possession of this facultv may at some time preserve him from the dangerous or even fatal error of making an application of the forceps to the intact membranes or over an undilated cervix. If the cervix is thin, it may be possible to recognize the presenting part 464 AMERICAN TEXT-BOOK OF OBSTETRICS. through its substance; but in ordinary cases it is necessary to introduce the finger through the os in order to distinguish between the different parts of the child. The finger should be passed up until it comes in contact with the pre- senting part, and it should then seek systematically for marks by which the character of this part can be determined. The presence of the head is to be determined by the perception of one or more sutures ; that of the face, by the presence of the mouth and nose ;* that of the breech, by the recognition of the spinous processes of the sacrum, the genitals, and the anus. The tuberos- ities of the ischia and the pubic arch are also easily recognizable. The shoulder presents no very distinctive marks, and the diagnosis of a transverse presenta- tion is not easily made by vaginal examination during the early stages of labor unless a hand and an arm are prolapsed, but it should always have been recognized by abdominal palpation before the vaginal examination is made. The various distinctive marks of each of the presentations must be sought for, and the diagnosis is to be made in accordance with those found to be present. The diagnosis of presentation by vaginal examination, though ordinarily easy, is sometimes difficult when the presenting part is still high in the pelvis. It would be supposed, a priori, that the distinction between the hard head and the yielding breech could be made in- all cases with the greatest ease, but a considerable experience in the superintendence of students has convinced the writer that this point of consistency is a most unsafe and unsatisfactory guide, and some personal experiences have led him to adopt the rule of never permitting himself to diagnose a head unless it is possible to recognize at least one suture, nor to commit himself to the diagnosis of a breech without inserting the examining finger into the anus and recognizing the presence of the coccyx. Summary of Signs of each Presentation. — Vertex Presentations. — In vertex presentations the finger should first recognize the convergence of the lambdoidal and sagittal sutures forming the small fontanelle. The finger should then pass along the sagittal suture until it reaches the large fontanelle and recognizes the four sutures which enter it. It should next search for the ears, the mastoid processes, and the lateral fontanelles, all of which may usually be found by following the lambdoidal sutures to their terminations. The ear is always recognizable, the mastoid and the lateral fontanelles are less constantly conspicuous, and all these marks are usually less easilv reached upon the posterior than upon the anterior side. The ear, when reached, always points toward the occipital end of the head, unless, as sometimes happens, it is folded forward against the scalp — a fact which is easily recognized if the finger is passed backward and forward a few times across the ear. With a well-flexed head the posterior fontanelle is lower in the pelvis than is the bregma, and the upper and posterior part of the ear is generally the more easily accessible. When the head is somewhat extended the fontanelles are upon about the same level in the pelvis, and the anterior edge of the ear is most easily reached. With extreme extension of a vertex presentation the * Care must be taken not to mistake the supraorbital ridges of a face presentation for the suboccipital ridges of a well-flexed vertex presentation. THE MECHANISM OF LABOR. 465 eyebrows are not infrequently accessible (see Brow Presentations). The diag- nosis of position in vertex presentations is made by ascertaining the position of the occiput ; this is obtained, first, by comparing the positions of the small and large fontanelles in the pelvis, and, second, by observing the direction in which the flaps of the ears point. Broiv Presentations. — When the extension is so extreme that the small fontanelle is reached with difficulty and the supraorbital ridges and the bridge of the nose are well below the brim of the pelvis, the presentation is that of a brow. By very high examination the mouth can occasionally be touched in brow presentations. The position »is named after the position of the small fontanelle, but care should be taken to check the diagnosis by an independent observation of the position of the root of the nose, which should, of course, be in the opposite quarter of the pelvis. Face Presentations. — When the supraorbital ridges are found upon one side of the pelvis and the point of the chin upon the other, the presentation is a face. Before the diagnosis is considered assured the fingers should recognize, in addition to the chin and the supraorbital ridges, the mouth, the nostrils, the eyes, and the root of the nose in their proper positions; and it is even well to adopt the precaution of always inserting the finger into the mouth and ascer- taining the presence of the maxillary processes and the tongue, which can be mistaken for nothing else. The position is indicated by the position of the chin, and should be checked by an observation of the position of the frontal suture. Breech Presentations. — In breech presentations we must distinguish, during the vaginal examination, between presentations of the whole breech and foot- ling presentations. In presentations of the whole breech the finger should recognize the spinous processes of the sacrum, the anus, and the genital cleft. In boys the scrotum often becomes enormously distended, and this may lead to confusion if the possibility of the fact is not borne in mind. When a breech presentation is found, the finger should always be inserted into the anus, and be made to recognize the tip of the coccyx, the tuberosities of the ischium, and the pubic arch. The position is named, as has been said, after the position of the sacrum, and it is most easily determined by finding the position of the tip of the coccyx of the fetus by rectal examination. In foot- ling presentations one or both ankles or feet protrude through the os. Presentation of a Hand or a Foot. — If the membranes be ruptured, a pre- senting hand or a foot may easily be drawn outside the vulva and be recognized by the eye ; if this be impossible, it may easily be differentiated by the touch through the membranes by observation of the following points : The foot is to be distinguished from the hand by the presence of the malleoli and of the prominence of the heel, and by the facts that the great toe is of equal or greater length than the others and is placed in the same plane with them ; while the hand is recognized by the absence of the heel, by the fact that it can be placed in direct continuation of the line of the limb to which it is attached, and that the thumb is shorter than the fingers and can be opposed 466 A3IEBICAJX TEXT-BOOK OF OBSTETRICS. to them. The importance of avoiding rupture of the membranes in such presentations is, however, so great that it is usually best to trust to the results of external palpation. Presentations of the Knee and the Elbow. — The knee may sometimes be dis- tinguished from the elbow by the presence of the patella ; but, since the latter is small and not always easy of recognition, it is best to distinguish between these two joints by following the course of the limb to its termination in a hand or a foot as the case may be. Transverse Presentations. — The shoulder is liable to be mistaken only for the breech, from which it may be distinguished by the presence of but one limb in place of the two which are attached to the pelvis, and by recognition of the smooth ridge of the scapula as opposed to the rough spines of the sacrum ; recognition of the clavicle and the ribs will also assist the diagnosis ; but the recognition of a shoulder by vaginal examination is extremely diffi- cult, and the existence of the presentation is practically ascertained, in the majority of cases, by external palpation, without assistance from vaginal examination. In presentations of the hand it is sometimes possible to make a diagnosis of position by observation of the hand alone ; to this end it is first necessary to determine which hand of the fetus presents, this being best ascertained by attempting to shake bands with the presenting part, the right hand of the fetus coming into position to shake hands with the right hand of the physician, and the left with the left. If the presenting hand be turned by rotation of the forearm into forced supination, the thumb points to the side on which lies the fetal head, and the back of the hand corresponds with the back of the fetus ; but in actual practice the attitude of the child so seldom corresponds exactly to any one of the four classical positions that this evidence is of comparatively slight value, and is only to be used as confirmatory of the results of palpation. Frequency. — The vertex presents in about 97 per cent, of all labors, the breech presents in about 2 per cent., and the remaining 1 per cent, is made up of brow, face, and transverse presentations, the latter two being the move frequent. Prognosis. — Vertex Presentations. — In vertex presentations the prognosis for both mother and child is better than in any other variety of labor. It varies, however, to some slight degree with the position, being better in ante- rior than in posterior positions, on account of the somewhat longer and more difficult labors which are to be expected, as will be seen, in the latter. Face Presentations. — In face presentations the prognosis, though not neces- sarily bad, is always worse for both mother and child than in vertex cases ; for. although a minority of face labors are terminated with safety and rapid- ity by the efforts of nature, yet in those cases in which an arrest occurs, and in which art must step in, the delivery is often difficult. The prog- nosis for the mother is that of the operation indicated, but in the opera- tive delivery of face cases the dangers to the fetus are always peculiarly great. THE MECHANISM OF LABOR. 467 Brow Presentations. — In brow presentations the prognosis for both patients is that of the operation by which the case is delivered. It is therefore neces- sarily worse than that of vertex presentations. Breech Presentations. — In breech presentations the prognosis for the mother is only altered from the normal by the fact that the rapid extraction of the after-coming head and arms that is very frequently necessary is attended by a considerably increased liability to perineal and cervical lacerations. The prognosis for the child is always bad, especially among primiparse or with women who for any other reason have rigid soft jjarts. Transverse Presentations. — Transverse presentations must always be termi- nated by art, and the prognosis varies with the period of labor at which inter- ference is undertaken. In uncomplicated transverse presentations an early version is usually easy, and the prognosis for both patients is therefore good. In neglected cases the operation is always difficult, and the prognosis for both patients is bad. 1. Vertex Presentations. Frequency of Cephalic Presentations. — At the end of pregnancy the cephalic end of the child presents in about 97 per cent, of all cases. In 97,871 births in private practice Spiegelberg found head presentations in over 97 per cent. In 23,000 cases confined in Guy's Hospital Lying-in Charity the percentage of head presentations was 96.9. Premature delivery and stillbirth of the fetus decrease greatly the proportion of head pres- entations. Thus, Collins found that head presentations occurred in 97 per cent, of living children among about 16,000 deliveries at term, and in only about 80 per cent, among 500 births of putrid fetuses. Churchill found that at seven months only 83 per cent, of living and 53 per cent, of dead children are born by cephalic presentation. DuBois found 83 to be the percentage for living children and 45 for dead children at the same period. It is found that during the latter months of pregnancy changes in the presenting pole of the fetus occur once or more in from 35 to 40 per cent, of all cases. The change from a pelvic or a transverse presentation to a cephalic, however, is very much commoner than the loss of a cephalic presentation. The latter would therefore seem to be the position of more stable equilibrium, and it will be found that these observations — namely, the decreased percentage of head presentations among premature and stillborn children, and the greater stability of head presentation as compared with any other — have an important bearing upon the etiology of the presentations. Relative Frequency of the Four Positions. — In about 75 per cent, of all cephalic presentations the occiput is found upon the left side of the mother, and in more than 73 per cent, of this 75 per cent, the position is anterior — that is, O. L. A. In the remaining 25 per cent, the occiput is of course directed to the right side of the mother, but the determination of the relative frequency of right anterior and right posterior positions is not so easily de- termined, there being gi'eat differences of opinion upon this point among 468 AMERICAN TEXT-BOOK OF OBSTETRICS. different observers, the key to this difference of opinion being probably found in their adoption of different periods of labor for the determination of the position. In a large proportion of those cases in which the occiput is to the right and somewhat anterior at the very beginning of labor — that is, before the head is even pressed into the superior strait — the position becomes right pos- terior as soon as engagement occurs. It is probable that some observers have classified such cases as O. D. A., and others as O. D. P. Again, the enormous majority of right posterior positions become right anterior by rotation during the second stage of labor. An observer who made his diagnosis only during the latter part of the second stage would class all such cases as anterior posi- tions. It is certainly a fact that the vast majority of right positions are right posterior positions at the time when the greatest diameter of the head occupies the superior strait ; and if this period of labor be selected as the time when the position should be determined, it is safe to say that nearly 75 per cent, of all cases are primarily O. L. A., and almost 20 per cent, are primarily O. D. P. Of the small remainder, almost 4 per cent, are primarily O. D. A., and but a little over 1 per cent, are O. L. P. Etiology of Presentations. — Three conditions have been urged as chiefly contributing to the frequency of cephalic presentations, and it seems probable that the true cause must be found in a combination of all three conditions, which probably vary in their importance in individual cases. These three causes are — first, the effect of gravity ; second, the easier adaptation of the fetus to the uterine cavity in head presentations; and third, the effect of active movements on the part of the fetus. In estimating the relative importance of these factors in the etiology of head presentations, it is evident that to attain the truth it is necessary to reach a conclusion which will explain the results of clinical observation recorded above, and which will make evident not only the reasons for the great prepon- derance of cephalic presentations of the fetus, but also for its variability in accordance with the period of delivery and the condition of the fetus. The Influence of Gravity. — It has been found by experiment that if a re- cently-dead fetus at term be immersed in a saline fluid of the specific gravity of the liquor amnii, it tends, under the influence of gravity, to assume an oblique position, with the head lower than the breech and the right side lower than the left. This fact is explained by Matthews Duncan, who has shown that the specific gravity of the fetal head is greater than that of the decapitated trunk, and that the greater specific gravity of the right side is clue to the enormous relative size of the liver in the new-born child. It is evident, then, other conditions being equal, that we may expect, in a preponderance of cases, to find the head and right shoulder of the fetus in that portion of the uterus which is horizontally lowest in the ordinary positions of the mother. The ordinary positions of the mother may be considered in this connection to be three — the vertical position of the trunk, the horizontal position in a dorsal decubitus, and the horizontal position in a lateral decubitus. "When THE MECHANISM OF LABOR. 469 the trunk is erect the anterior uterine wall is inclined to the horizon at an angle of about 35°, and the lowest portion of the uterine cavity is to be found in the neighborhood of the pubes. Most pregnant women are in this position — that is, either standing or sitting— for about two-thirds of the twenty- four hours, and it is consequently the most important of the three positions in this connection. In this position of the mother the child would tend to assume, under the influence of gravity, precisely the position in which it is usually found — that is, a vertex presentation, O. L. A. — and in the absence of disturbing elements it will be in this relation to the mother about two-thirds of the time. When the woman lies upon her back the posterior uterine wall is inclined to the horizon at an angle of about 55°, and the lowest portion of the uterus is in the neighborhood of the promontory. Thus, in this position also the influence of gravity tends to maintain a cephalic presentation.* When the woman lies upon her side the lowest point of the uterine cavity is usually near the fundus and toward the side upon which she reclines, f In this position, then, the influence of gravity would be exerted against the maintenance of a cephalic presentation ; and since the lateral decubitus is maintained by most pregnant women for the greater part of that third of their time which is spent in bed, it is evident that the influence of gravity would not, by itself, be a sufficient cause for the appearance of a cephalic presentation in so large a number as ninety-seven out of every one hundred labors ; but since, from the influence of gravity alone, it is probable that the head would maintain, other influences being excluded, a cephalic presentation during the greater part of the time, it is fair to assume that this furnishes a predisposition toward the existence of a cephalic presentation in any given case. When, moreover, we investigate the relation of this factor to the varia- tion in percentages due to premature births and stillbirths, we find its influ- ence so entirely in accord with the results of clinical observation as to add still further proof of its importance. Thus, Dr. Duncan found that when a child dies in utero before labor, the specific gravity of its head is less than that of a living child, and the body, when uncontrolled, often actually floats head uppermost in a saline fluid. Again, it is highly probable that the rela- tive difference between the specific gravity of the head and that of the body is less among premature than among full-term children, since we know that the proportionate development of the brain and the cranial bones, in compari- son with that of the body, is much less during the early months of pregnancy than it becomes at term. It may with propriety be conceded that the greater specific gravity of the cephalic pole of the fetus is a predisposing cause of head presentations, and it only remains to be determined whether the other causes are sufficient to main- tain this position when once established. * Though with the back of the fetus toward the back of the mother (see Etiology of Posi- tion, p. 472). t When the woman lies upon her right side the influence of gravity tends to turn the back of the child forward, and when she lies upon her left side tends to turn it backward. 470 AMERICAN TEXT-BOOK OF OBSTETRICS. Adaptation between Fetus and Uterus. — It is usual to consider the uterus as a flaccid mass which readily moulds itself to the shape of its contents or its surroundings ; but when we remember that during each contraction the uterus straightens itself and tends to assume a definite form, and that, moreover, there is undoubtedly a process of slight rhythmic contraction goiug on through- out the whole of the latter part of pregnancy, it is evident that the uterus must be regarded as a body which has, to some extent at least, a definite, in- trinsic shape. It has, moreover, been determined by post-mortem examina- tions that this shape is one which alters, and alters in a definite direction, during the development of the uterus. At and for some time before the fifth month the uterine cavity is nearly spherical (Fig. 235), and is very large as compared with the still small and undeveloped fetus ; but from this time on the cavity becomes progressively Fig. 235. ^-Relative size of the fetus and the uterine Fig. 23fi.— Adaptation between the uterus and the cavity at the fifth month. > fetus at term in vertex presentation. more and more pyriform, until toward the end of pregnancy it assumes the definitely pyriform shape shown in Figure 236. The uterine cavity, at term and under normal conditions, is but little larger than the fetus. It is, moreover, evident, on comparing the shape of the fetus in its ordinary attitude with the shape of the uterus at term, that in head presentations (Fig. 236) the fetus and the uterus are extremely well adapted to each other, but that in breech (Fig. 237) or in transverse presentations one portion of the uterine muscle is subjected to an undue a-mount of tension, while other por- tions are unduly relaxed; therefore any change from the cephalic to either a breech or a transverse presentation will be opposed by the contractile power* of that portion of the uterine muscle that would be overstretched in the new presentations ; that is, we may assume that the shape and contractility of the uterine walls tend to preserve a cephalic presentation when this is once well established, and that the rhythmical contractions would probably tend to re- establish it when lost. It is safe to assume, then, that the shape of the uterus may be considered an important factor in preserving a cephalic presentation THE MECHANISM OF LABOR. 471 Fig. 237.— Adaptation between the fetus and the uterus at term in breech presentation. First, that cephalic presentations pre- when this has once been established by the influence of gravity, and that its insensible contractions furnish an influence of importance in re-establishing a head presentation when this has been lost. Influence of the Fetal Movements. — Since the fetal movements are accidental and independent of any volitional impulse, it is probable that their occurrence would be insufficient to effect any con- siderable change in the relation of the fetus to the uterus unless in an ex- tremely relaxed condition of the uterine and abdominal walls, and that even in such uteri the change would be likely to occur only when the position of the mother added the influence of gravity to the effect of fetal movements. It is evident that even in such cases the operation of the same causes would probably tend to a speedy assumption of the cephalic presentation. Conclusions. — Tt is now necessary to consider how far the conditions just enumerated explain the observed facts quoted at the beginning of this section : ponderate in the proportion of 97 to 3; second, that this preponderance is much decreased by both premature deliveries and stillbirths ; third, that the change from a pelvic or a transverse presentation into a cephalic is very much more common than the loss of a cephalic presentation ; and fourth, that both abnormal presentations and changes of presentation are much commoiverV among multipara and when the quantity of liquor amnii is large. >// First. — The existence of a condition, the influence of gravity, that tends to establish a cephalic presentation, and that is operative for two-thirds of the time, in combination with other conditions which render any other presentation unstable, and which are operative all the time, is, in the absence of anything which favors any other presentation, sufficient to account for almost any per- centage of preponderance of cephalic presentations. Second and Third. — In the middle of pregnancy the shape of the uterine cavity is nearly spherical and its size is greatest as compared with that of the fetus ; the latter is but little developed and the presentations are totally un- certain. During the sixth and seventh months the conditions approach nearer to those observed at term ; but even in the eighth and ninth months the differ- ence in the specific gravity of the cephalic and pelvic ends of the infant is less marked than at term ; the pyriform shape of the uterus is less strongly marked, and the adaptation between the uterus and the fetus is less close ; that is, all the factors which we have been considering as important in the production of the preponderance of cephalic presentations have less value than at term. We find by observation that at these periods the preponderance of 472 AMERICAN TEXT-BOOK OF OBSTETRICS. cephalic presentations is correspondingly decreased, and that spontaneous changes of presentation are correspondingly much more frequent than at the end of pregnancy; we are, then, justified in our belief in the importance of these factors. Fourth. — These considerations are in full accord with the observed fact that both abnormal presentations and changes of presentation occur most frequently in multiparas with relaxed uterine and abdominal walls, and are but rarely seen in the more rigid condition of the muscles that is characteristic of first pregnancies. So, too, it is fully established that these changes and abnormal presentations occur much more frequently when the quantity of liquor amnii is relatively so great that the uterus tends through distention to acquire a more nearly spherical shape, and when the limbs of the fetus are accorded much greater freedom of movement. As a result, it seems safe to assume that the influence of the relatively greater specific gravity of the cephalic pole of the fetus is the predisposing cause, and that this, together with the intrinsic shape of the uterine cavity and the influence of the movements of the fetus, are the maintaining causes of the great preponderance of cephalic presentations. Etiology of Position. — It has already been observed (p. 469) that in the erect posture of the trunk, usually assumed by the woman for two-thirds of the twenty-four hours, the influence of gravity tends to the production of an O. L. A. position, and in the remaining one-third of the twenty-four hours the influence of gravity varies with the decubitus which the woman assumes in bed. Therefore it may safely be assumed that any conservative factors which appear late and tend to fix the child in any position in which they find it are more likely to find it O. L. A. than in any other position. Such a factor is to be found in the shape of the superior strait. The presence of the rectum in the left ilio-sacral notch renders the second oblique diameter of the pelvis less ample than the first, so that if the oblique cross-section of the head that is ordinarily presented to the pelvis at the inlet rests with its long diam- eter in correspondence with the second oblique diameter at the brim, the head is less easily accommodated than if it is presented to the first oblique diameter. It will, then, as the adaptation becomes progressively tighter and tighter, tend to remain in the first oblique diameter for longer periods than in the second ; that is, it will be dislodged with difficulty from the first oblique diameter, and with ease from the second by any slight cause ; and since the influence of gravity tends during the greater part of the time to turn the occiput forward, a head which occupies either an O. D. A. or an O. L. P. position will tend to, become O. L. A. rather than anything else. The maintenance of an O. D. P. position is, moreover, rendered comparatively unlikely from the fact that the shape of the head is less well adapted to that of the pelvis in this position Changes of position are, in fact, extremely frequent until within the last few weeks before delivery, and the position, moreover, is never finally determined until the head engages at the brim. Diagnosis. — On abdominal examination the head is found at the inlet ; the THE MECHANISM OF LABOR. 473 fetal limbs and the most accessible end of the head are found on one side of the abdomen, and the heart on the other. On vaginal examination the finger should recognize the small fontanelle on one side of the pelvis, and by follow- ing the sagittal suture should find the large fontanelle on the other. The ears should always, and the mastoids and lateral fontanelles should usually, be felt at the ends of the lambdoidal sutures. Prognosis. — The prognosis for both mother and child is better than in any other variety of labor. A. Mechanism of the First Stage of Labor. It is customary to divide labor into three stages. The first stage comprises the time occupied in the dilatation of the os ; the second, that expended in the descent and expulsion of the child ; while the third is occupied by the birth of the placenta. For purposes of description it is well to consider the three stages as being sharply divided from one another, but it must be remembered that clinically the division between the first and second stages is often difficult and indefinite, since the final stages of dilatation are not infrequently accomplished only during the descent of the head ; and for clinical purposes it is well to define the end of the first stage as occurring whenever the os is fully dilated or dilat- able, it being understood that the expression " fully dilatable" refers to a con- dition in which the os, though still imperfectly dilated, has become so soft and elastic as not to offer any efficient obstacle to the descent of the presenting part. To understand exactly the mechanism of labor it is necessary to discuss first the forces by which the process is accomplished, and next the manner in which each force acts during the different stages of labor. The forces by which labor is effected are those produced by the contraction of the uterine and abdominal muscles, together with such influence as can be effected by the weight of the child and the waters. The uterine muscle acts in two ways: first, by diminishing the intra-uterine area and thus creating a general intra-uterine fluid-pressure due to the contrac- tion of the uterus upon the fluid contents of the unruptured ovum ; second, by the force of direct contact between the breech and the fundus of t\w. uterus whenever a rupture of the membranes and the consequent escape of the waters permit this contact to occur. Direct contact may also occasionally occur, as will be seen later, before the rupture of the membranes. The abdominal muscles when set into voluntary contraction reinforce both forms of action of the uterine muscle. When the uterine muscle is in direct contact with the breech, the abdominal muscles, lying in close contact with the uterus, add their force to that which the uterus itself exerts against the child ; when the child is protected from contact with the uterine walls by the presence of a quantity of liquor amnii, the contraction of the abdominal muscles again adds itself to that of the uterine wall, and thus adds its increment to the general intra-uterine fluid-pressure. The force of gravity is inactive in many positions of the mother, and is at most an increment of but small importance. 474 AMERICAN TEXT-BOOK OF OBSTETRICS. B-&, In considering the manner in which the above-mentioned forces are employed in effecting the dilatation of the os during the first stage of labor, it is neces- sary to consider several variations which may occur in the mechanical con- ditions. When the waters are abundant and the membranes persist unbroken throughout the first stage, the dilatation is usually accomplished by the action of the membranes only. This may be considered the normal mechanism of dilatation, and must be described first, after which it will be proper to take up the various conditions in which, from one cause or another, the membranes cease to act their proper part, and the dilatation must be accomplished by the pressure of the fetal head against the cervix. Normal Mechanism of Dilatation. — In the first instance — that is, when the waters are abundant and the membranes are intact — the position of the fetus is unaffected by the intra-uterine fluid-pressure. It is an axiom in phys- ics that fluid-pressures, however pro- duced, are invariably equal and oppo- site in all directions, from which it fal- lows that, the pressures A (Fig. 238) being equal and opposite to the pres- sures jB, the child will be unmoved by the uterine contraction. Similarly, the fluid-pressure upon any one portion of the uterine wall being equal to that ex- erted upon any other portion of equal area, there would be no effect, even upon the shape of the uterus, if its entire surface contracted at once and it' its walls were of uniform strength throughout. The initial stages of dila- tation of the os are in reality to be referred to the fact that the lower uterine segment possesses less muscular strength than the upper part of the uterus, and to the character of the uterine contractions. Neglecting for the moment the latter factor, and limiting the discussion to the effect of the different strengths of the upper and lower uterine segments, we shall see that the contraction of the more powerful upper part of the uterus forces the less powerful lower portion open, notwithstanding its efforts at contraction. The total force exerted by the uterine contractions results in the application of a uniform centrifugal pressure upon all portions of the containing wall. The amount of this pressure upon any given unit of surface — as, for example, a square inch — will, of necessity, be equal to the average force exerted by the same superficial extent of the uterine wall ; hence it follows that at any portion of the viscus where the strength of the wall is greater than the average the contracting centripetal force will tend to overcome the resulting centrifugal Fig. 238.— Diagram illustrating the absence of alteration in the attitude of a child by the action of opposite and equal fluid-pressures. THE MECHANISM OF LABOR. 475 force, and the. result will be a decrease in the extent of the uterine walls at that point. Similarly, at any point where the strength of the uterine wall is below the average the expanding centrifugal force of the fluid-pressure will be greater than the centripetal force of the contracting muscles, and at such points, therefore, the expanding force of the fluid-pressure will tend to over- come the contracting force of the uterine muscles, and there will be a conse- quent increase in the area of those portions of the uterine wall. Xow, the lower uterine segment is by all odds weaker than any other portion of the uterus ; it therefore tends to expand during the contraction from the action of the general intra-uterine fluid-pressure. The circular portion of the uterine area, which is opposite to the lumen of the vagina, is, moreover, unsupported by the general intra-abdominal pressure and by the force of the tonicity of the abdominal muscles that is exerted upon all the other portions of the uterus — a fact which, by decreasing the centripetal force, still further increases the surplus of the centrifugal element at this point. As a matter of fact, at the beginning of labor the first influence of the uterine contractions is seen in the assumption by the lower uterine segment of a more expanded shape, such as shown by the dotted outline in Figure 239. Moreover, since at one point in the lower uterine segment the cohesion of its substance is still further lessened by the existence of a solution of continuity, the lumen of the os uteri, it is evident that there will be a still more marked tendency to expansion at this weakest spot, resulting in a tendency to dilatation of the os. To these considerations must be added the effect of the peculiar composition of the uterine muscle and of the peculiar character of its contractions. It is essential to remember that this highly composite muscle is made up of inter- lacing fibres, whose action may mechanically be divided into one set of longitudinal and one of circular stresses ; that is, if the action of those fibres having an oblique direction be resolved, as is physically allowable and proper, into their longitudinal and transverse resultants, the action of the whole will be found precisely equal to that which would be exerted by two hypothetical sets of fibres, of which the first and most powerful set directly encircle the ute- rus in horizontal zones, while the second and less powerful set extend upward through the margin of the os, cross the fundus, and thence pass down to reach the margins of the os at points opposite to their origins. If a uterine muscle so composed were set into action, it will be seen that, Fig. 239.— Diagrams showing the diminution of the upper uterine segment and the expansion of the lower segment during each contraction. 476 AMERICAN TEXT-BOOK OF OBSTETRICS. from a mechanical standpoint, the circular fibres surrounding the os would by their contraction tend to keep it closed, while the longitudinal fibres, acting in opposition to these, would by their contraction tend to open the os by drawing its margins apart over the contained ovum. This conception, though some- what more simple than the actual auatomical fact, is mechanically essentially coi-rect ; but, since the circular stresses are the more powerful, it is evident that this arrangement cannot result in the dilatation of the os unless compli- cated by the presence of some additional factor. This factor is found in the circumstance that the contractions of the uterine muscles, like those of all the hollow viscera of the body, are peristaltic, and that the rhythmic contraction of the uterus begins at the fundus and passes gradually down to the cervix. Each contraction of a given part of the uterus is preceded and followed by a relaxation ; but since, from the interlaced arrangement of the fibres of the uterus, the contraction of any portion of its surface necessarily exerts a longi- tudinal strain, it will be found that the outward stress upon the margius of the os remains nearly constant, while its circular contraction is intermittent; it is probable that the initial dilatation of the os is largely due to the constancy of the longitudinal and the intermittency of the circular strain ; that is, the first gains in dilatation are made at moments when the uterine muscles of the lower uterine segment and the cervix are relaxed, but when the general fluid- pressure is maintained by contractions of the upper portions of the uterus. As the iuterual os and the upper portion of the cervix dilate under the action of these forces, a new mechanism comes into play through the elasticity of the membranes, which bulge through the circle of the os and enable the intra-uterine fluid-pressure to take direct effect upon its margins. As this process continues the internal os becomes effaced, the cervix is shortened and Fig. 240. — Diagram illustrating the dilatation of the os by the membranes. If the application of the fluid-pressure to the os (at right angles to the surface of the membranes at this point) is repre- sented by the direction of the arrow, and the amount of the force by the length of the diagonal line which continues the arrow, the amount of force that is applicable to the dilatation of the os is represented by the length of the line A. Fig. 241.— Diagram illustrating the dilata- tion of the os by the membranes. All the con- ditions are identical with those of Figure 237, ex- cept that the membranes have a greater con- vexity ; the direction of the arrow is therefore more oblique, and the force efficient for dila- tation, represented by the line A, is greatly in- creased. disappears, and finally the external os itself is in direct contact with the mem- branes and begins to receive directly the effect of the longitudinal stresses. As the external os dilates the membranes again bulge forward into its lumeu, and the force of the fluid-pressure becomes directly active upon its margins. The force so exerted is directly proportional to the convexity of the membranes, and increases as the convexity increases — a fact which is explainable by well- THE MECHANISM OF LABOR. 477 known physical laws as follows : The force of fluid-pressure, in addition to being opposite and equal at all points, is always exerted at right angles to any surface against which it is applied. If it is necessary to ascertain what portion of the force is exerted in any given direction, it is only necessary to break up the internal force into its elements by the construction of a parallelo- gram of forces, such as is described in all elementary treatises on mechanics and illustrated in Figures 240 and 241. Figure 240 exhibits the influence of the general intra-uterine fluid-pressure when the conditions of the case allow but a slight convexity to the unsupported portions of the membranes. The expan- sive element of the fluid-pressure is here represented by the line A, while in Figure 241, where the convexity of the unsupported membranes is much greater, the expansive element of the force will be represented by the length of the much longer line A: from this it follows that, other things being equal, the rapidity of dilatation will be proportional to the degree to which the mem- branes project through the os. As will be seen later, the same considerations are equally applicable to the action of the head in producing dilatation after the rupture of the membranes. The familiar clinical fact that the closing stages of dilatation are usually much more rapid than the beginning stages is fully explained by the foregoing considerations, taken in connection -with the equally familiar fact that the contractions of the uterus tend normally to become stronger and stronger throughout the process of labor. In the more normal form of the mechanism of the first stage — that is, so long as the membranes remain intact — the progress of the first stage of labor is dependent mainly upon the first form of force which the uterine muscle is capable of exerting— that is, the force of the general intra-uterine fluid-pres- sure — and the membranes are the dilating agent. The second form of force, that of the direct pressure of the uterine muscle against the child, is under these circumstances inoperative, while the fact that the voluntary muscles of the abdominal walls are but seldom brought into play by the patient reduces the action of the remaining or auxiliary forces, in this form of the mechanism of the first stage, to the small reinforcement of the general intra-uterine fluid-pressure, which is due to the general intra- abdominal pressure constantly exerted by the tonicity of these muscles. Mechanism of Dilatation of the Os after Rupture of the Membranes, with Partial or Complete Escape of the Waters. — Partial Escape. — After the rupture of the membranes the liquor amnii tends to drain away until its escape is stopped by the contact of the presenting part with the margins of the os (Fig. 242). Iu this condition the presenting part forms with the circle of the os a ball-valve ; the geueral intra-uterine pressure is concentrated upon its upper surface, and its descent is opposed only by the comparatively feeble resistance of the cervix. When this condition occurs the portions of the fetus that correspond with arrows marked A' and B' are still affected by pres- sures which are opposite and exactly equal to the propelling force exerted upon the portions which correspond with the arrows A and £, but the propel- ling force represented by the arrow C is opposed only by the resistance of the 478 AMERICAN TEXT-BOOK OF OBSTETRICS. unsupported cervical and vaginal tissues, against which the head is pressed by a force equal to the effect of the intra-uteriue fluid-pressure upon an area Fig. 242.— Diagram illustrating the manner in which the general intra-uterine fluid-pressure becomes propulsive after the rupture of the membranes. Fig. 243.— Diagram illustrating the dilatation of the os by the head. The total force is again repre- sented by the oblique line, and the force which is ap- plicable for dilatation is represented by the line A. equal to the transverse area of that zone of the uterus where the head first comes in contact with the walls — that is, the surface R to R'. From the comparative rigidity of the spherical head it can exert but little direct expansive force upon the margins of the os during the early stages of dilatation (Fig. 243) — a fact which ex- plains admirably the relatively slow progress of dilatation after early rup- ture of the membranes. When, how- ever, the os has so far dilated as nearly to admit the greatest circumference of the head, its action is that of a slightly tapering wedge, by which almost the whole power of the propelling force is transmitted into an outward pressure of the margins of the os, and which must compel an extremely rapid com- pletion of the dilatation * (Fig. 244). It will be seen that in this second form of the mechanism of the first stage the force employed is still that of the general intra-uterine fluid-pressure, but that the dilating agent is now the head. * It will be seen that this fact is an adequate explanation of the greater frequency of laceration of the cervix when a rupture of the membranes results in the completion of the dilatation by the direct pressure of the rigid head. Fig. 244.— Diagram illustrating the dilatation of the os by the head. The total force is repre- sented by the oblique line, and the force applic- able for dilatation is represented by the line A. THE MECHANISM OF LABOR. 479 After Complete Escape * of the Waters. — The escape of any considerable quantity of the waters usually results in contraction of the uterus sufficient to permit of firm contact between the fundus and the breech of the child. The force of this contact is then transmitted to the head through the vertebral column of the fetus. At first sight it seems unlikely that any considerable force could be transmitted through so flexible a rod as the vertebral column of an unborn child. This transmission is, however, rendered possible by the following conditions : It is an observed fact that during a contraction the long diameter of the uterus, far from being decreased, is actually lengthened. This phenomenon is due to the superior strain of the circular stresses, which by their greater force decrease the antero-posterior diameter of the uterus and thereby f increase its length (Figs. 245, 246) ; the lateral uterine walls, at the Fig. 245.— Diagram illustrating the alteration in the shape of a cross-section of a uterus during its contractions. The heavy line represents the non-contracted, the dotted line the contracted, uterus (compare Fig. 243). Fig. 246.— Diagram illustrating the alteration in the shape of a sagittal section of the uterus during its contractions. The heavy line repre- sents the non-contracted, the dotted line the con- tracted, uterus. same time, come into strong contact with the surface of the fetal body, and so straighten out the child, thus increasing the violence of the contact between the breech and the fundus, and affording a firm supporting surface which pre- vents any bending of the vertebra?, and converts the backbone for the moment into a mechanically rigid rod which is fully capable of the transmission of force. AVhen this form of mechanism obtains, the head acts as the dilating wedge, and the second form of force, that furnished by direct contact between the breech and the fundus, is alone active. Mechanism of Dilatation of the Os with Originally Scanty Waters. — It occasionally happens that the waters are originally so scanty in amount as to permit direct contact between the breech and the fundus to occur early in the first stage. Under these circumstances the head is brought into close contact with the os at the beginning of labor. The mechanical conditions are now closely similar to those which obtain after the escape of the waters, with the single exception that if the membz-anes are tough and inelastic their tension may somewhat impede the progress of the head. * This term, though conventional, is inaccurate, as there is almost always some liquor left in the uterus. ■f The ovum being incompressible. 480 AMERICAN TEXT-BOOK OF OBSTETRICS. Mechanism of Dilatation with Undue Elasticity of the Membranes. — If the membranes are unusually elas- tic, it may sometimes happen that after the formation of a considerable pouch of membranes in advance of the head, the volume of the uterine contents may be lessened sufficiently to permit the head itself to be brought into close contact with the margins of the os, by the force of a perhaps temporary direct contact between the breech and the fundus. In this position, if the head is in contact with the entire mar- gin of the os, in forms with it a ball- valve by which the "fore-waters" are entirely cut off from the uterine con- tents. The pressure, C (Fig. 247), is now opposed only by the elasticity of the membranes and of the vaginal tissues. The general fluid-pressure is no longer exerted against the margins of the os, and the conditions are mechanically sim- ilar to those illustrated in Figure 242. Fig. 247.— Diagram illustrating the formation of a ball-valve by contact between the head and the edges of the os. The waters behind the head are exposed to the general intra-uterine fluid- pressure, while the fluid-pressure in advance of the head is only created by the elasticity of the fetal membranes. B. Mechanism of the Second Stage of Labor in Vertex Presentations, O. L. A. The second stage of labor is commonly divided into three sub-stages: The descent and expulsiou of the head ; external restitution ; and the delivery of the trunk. The adaptation between the normal head and the pelvis is so close that for the accomplishment of the descent and expulsion of the head there is required the occurrence of a set of somewhat complicated movements which are, in fact, essentially one single complex motion. This motion consists of three elements : (1) The descent of the head through the pelvis ; (2) a change from the partially extended position which the head normally occupies at the beginning of labor to one of complete flexion ; and (3) lateral rotation of the head within the canal, from the oblique position which the suboccipito-bregmatic diameter occupies at the brim to the antero-posterior position in which it emerges from the outlet. Although it is necessary in discussing this motion to describe its components separately, it must not be forgotten that no one of its parts can proceed to its accomplishment without the coexistence of the others. Thus, descent can be accomplished only during the existence of flexion, while flexion is produced only by the act of descent. So, too, the final stage of descent, Known as expulsion, is normally impossible without rotation, while rotation occurs only during the descent of a fully-flexed head. The most intelligible THE MECHANISM OF LABOR. 481 way of describing these highly complex phenomena is by a chronological study of the mechanical conditions which occur and succeed each other during the stage of descent and expulsion. Descent. — It is necessary, in describing the mechanism of the second stage, to begin by considering the action of the forces by which the mechanism of this stage is effected. So long as the fetus is exposed on all sides to contact with the liquor amnii, the contractions of the uterine and abdominal muscles can produce no effect upon it other than that of subjecting it to a uniform fluid-pressure, equal and opposite in all directions. In point of fact, the mech- anism of descent does not begin until the presenting part is cut off from the liquor amnii by coming into apposition with the edges of the os. As was implied in the last section, this contact may happen in either of two ways : First : When the mechanism of the first stage is such that the head comes into close contact with the margins of the os before any considerable quantity of the liquor amnii has escaped from the uterus, it forms with the os a ball- valve (Figs. 244 and 247) by which the remaining part of the waters is retained within the uterus ; and the occiu'rence of descent is then the result of the action of the intra-uterine fluid-pressure. This is the normal — that is, the most usual and the most favorable — mechanism of descent. Second : When close contact between the head and the os does not occur until after the complete escape of the waters, the uterine muscle contracts upon the child, and the force of the circular stresses is lost so far as the pro- duction of descent is concerned, but the breech and the fundus of the uterus come into contact with each other, and the force of the longitudinal stresses is tli us still available. This second form of the mechanism of the second stage is commonly called a " dry labor," and such labors are, with reason, much dreaded by obstetricians, because the loss of the powerful circular stresses usually leads to a protracted second stage. * Normal Mechanism of Descent. — The portion of the head that is without the uterus (E, 72', Fig. 242) is opposed only by the resistance of the vaginal tissues. Every other portion of the fetus is exposed to the general intra-uterine fluid-pressure. If it is remembered that fluid-pressures are always equal and opposite, it will be seen that the forces A and B are directly neutralized by the forces A' and B', and that the force C is opposed only by the comparatively trifling resistance of the vaginal tissues. This force (C) is then practically unopposed, and is therefore efficient for descent. Mechanism of Descent in Dry Labors. — When the escape of the waters has permitted the uterus to contract upon the child, the advance of the present- ing part is opposed only by the vaginal tissues, and is favored by the force of all the longitudinal stresses of the uterine muscle ;f but unless the descent progresses rapidly a localized contraction, due to the unopposed action of the circular stresses, leads to a lessening of the calibre of the uterine canal at any point where the diameter of the child is small — for example, the neck (Fig. 248) — and the descent of the child is then further opposed by the fact * Consult Mechanism of Descent in Dry Labors for other factors of delay. t And by the auxiliary efforts of the abdominal muscles. 482 AMERICAN TEXT- BOOK OF OBSTETRICS. that the shoulders must be made to dilate this ring — that is, to overcome the tonic contraction of the circular stresses. In dry labors, then, the force of the circular stresses is not only lost as a factor in the production of descent, but may sometimes also be opposed to it. Flexion. — At first sight it would seem that the only result to be expected in either case would be the occurrence of descent, and that as the head is normally somewhat extended at the beginning of labor, this descent would oppose to the pelvic diameters the always difficult and frequently impossible occipitofrontal diameter. A somewhat more careful examination will demon- strate, however, that the propelling and opposing forces are already so dis- posed upon the head as to favor, from the start, the occurrence of flexion, and that the first movement of descent will, under normal circumstances, tend to bring to the brim the much smaller suboceipito-bregmatic diameter. To this end two factors contribute : first and most important, the articulation of the 1 ' i 1 ■/ x&. ■s^ Fig. 248.— Constriction-ring about the neck of the child Fig. 249.— Diagram of head lever, (one-sixth natural size). vertebral column to the skull at a point much nearer to the occipital than to the frontal end of the head ; second, the mechanical effects of the irregular shape of the skull. Unequal Lengths of the Ends of the Head. — The effects of the excentric position of the occipito-atlantoid articulation must be investigated separately for each of the three forms of force that may be active — that is, for the force of gravity, the general fluid-pressure, and the force of direct contact with the uterine muscle. Force of Gravity. — Whenever the force of gravity is active, it is evi- dent that the weight of the body will be transmitted to the skull through the occipito-atlantoid articulation. If the fetal head is supposed, at the begin- ning of this motion, to occupy a position midway between extension and flexion, the occipital and sincipital ends of the head, marked o and F respect- ively (Fig. 249), will rest against the uterine walls, while the force A is applied at the occipito-atlantoid articulation. Since the force is applied nearer to the THE MECHANISM OF LABOR. 4S3 occipital end of the head, it is evident that a greater amount of impulse will be communicated to the occiput; and since the resistances are of necessity equal, the occiput will tend to advance more rapidly ; but advauce of the occiput with relative delay of the sinciput is, in effect, flexion. The head, in fact, becomes a lever of the third class, in which the pressure of the resist- ances applied to the longer end is more effective in delaying progress than the equal pressure applied to the shorter end of the lever. It is further to be noticed that as flexion progresses the relation between the lengths of these arms is so altered as to make them progressively more unequal, so that, as the head flexes, the point at which the pressure of the resistance is applied to the occipital end of the head becomes progressively nearer to the vertebral articulation. General Intro-uterine Fluid-pressure. — If Figure 250 represents the situ- ation of the child at the end of the first stage, we see that the forces A and B are applied directly and with equal c force to the ends of the head ; but it is evident that the pressure (C) exerted upon the breech of the infant will be transmitted to the head more readily by the vertebral column than by the soft tissues of the trunk, and that a large portion of this force (C) must therefore be concentrated on the con- dyles. So far as this force (C) is con- cerned, the argument used in explain- ing the production of flexion by the influence of gravity applies, then, with equal force to this condition. Direct Contact between the Breech and the Fundus. — The whole effect of a direct pressure upon the breech by the fundus will be applied to the condyles of the occiput, and, the resistances upon the occiput and sinciput being of neces- sity equal, while the opposing forces are concentrated at a point much nearer the occiput, it is evident that the occipital end of the head will tend to advauce more rapidly than the frontal end ; but advance of the occiput with relative or absolute delay of the sinciput of course results in flexion. Irregular Shape of the Fetal Skull. — The occurrence of flexion is like- wise aided by the second factor referred to above, the irregular shape of the skull. As will be seen by analysis of the opposing forces exerted at R and R' (Fig. 251), if the effect of the equal resistances at R and R' be represented by the length of the equal lines S and S' drawn perpendicular to the surface of the skull at these points (the direction in which these resistances must, according Fig. 250.— Diagram illustrating the application of a preponderance of the intra-uterine fluid- pressure to the occipital end of the head. It is evident from the condition of the head lever (see Fig. 249) that the sinciput is exposed to the force B, plus a small proportion of the force C, while the occiput receives the force A, plus the greater part of the force C. 484 AMERICAN TEXT-BOOK OF OBSTETRICS. to well-known mechanical laws, be exerted), the construction of the parallel- ogram of forces shows that the line T (whose length represents the portion of the resistance R which is exerted in direct opposition to descent) is much greater than that of the line T' (which represents the efficient proportion of the resistance -R'). From this it is evident that the occipital end of the head is exposed not only to greater force from above, but also to less resistance from below, while the sincipital end is opposed by greater resistance and receives a less amount of propulsive power — conditions which can only result in a more rapid advance of the occiput. As soon as partial flexion has been accomplished a second effect of the irregular shape of the head comes into play, and there must be accorded such importance as is due to it. Figure 252 represents a partially-flexed head Fig. 251.— Diagram illustrating the influence of Fig. 252. —Diagram illustrating the second- the irregular shape of the skull in producing flexion, ary effect of the irregular shape of the head in by the construction of the parallelogram of forces. promoting flexion after partial flexion has It is seen that the force which dilates the sinciput, once been produced, represented by the line T, is greater than the force which dilates the occiput, represented by the line T, which represents the sinciput. engaged in the elastic canal formed by the lower uterine segment and the vagina.* The forces A and B, due to the constriction of the elastic canal in which the head lies, and acting necessarily at right angles to the surface of contact, will then form a pair of equal but not opposite forces — in mechanical language "a couple" — the effect of which is to rotate the head upon a trans- verse axis at C, thus increasing its flexion. It will be noticed that all these causes of flexion f are dependent for their existence on the presence of resistances acting in opposition to the vis-a-tergo which urges the head downward, and it necessarily follows from this fact that flexion occurs most rapidly and becomes most marked when the resistances are best developed — a theoretical consideration which is in thorough accord with the observed fact that there is often a temporary loss of flexion in the excavation, where the space is the greatest; that is, that flexion is generally better marked while the head is experiencing the well-developed resistances of * The fact that the vaginal walls possess at the end of pregnancy intrinsic muscles of con- siderable development, though too often wholly neglected in the consideration of the mechan- ism of labor, is, notwithstanding, an element in the production of flexion that must not be forgotten. f Except the last and least important. THE MECHANISM OF LABOR. 485 the superior strait than in the excavation, where the resistances are less. So, too, flexion again increases when the head reaches the inferior strait. Flexion is, in fact, normally more marked in this part of the pelvis than in any other ; but here another factor comes into play. We have previously seen flexiou produced by the action of the propelling forces against resistances which were exerted with approximately equal force on both the occiput and the sinciput ; but when the head reaches the inferior strait its occipital end rapidly frees itself from the pressure of the bones, and is opposed only by the resistances of the soft parts of the pelvic floor, while the sinciput is still exposed to the firm resistance of the bony sacrum. It is evident that when the greater pressure is exerted on the longer arm of the lever extreme flexion is a necessary result. The mechanical explanation is thus in complete agreement with the clinical fact that the deeper is the engage- ment of the head, the more marked is the tendency to flexion and the greater is the certainty of its accomplishment- Rotation. — The movements of descent and flexion make up the whole mechanism of the earlier part of the second stage of labor ; but another factor — rotation — is necessary to its completion. The mechanism of rotation is, unfortunately, extremely difficult of com- prehension ; and, as nothing is more difficult than to teach mechanical prob- lems involving the use of three dimensions without the aid of models, the student will be wise if he supplements the words and figures of any written description by a constant inspection of the dried pelvis and by the results of the intrapelvic touch in actual clinical work. A complete comprehension of the mechanism of rotation is seldom acquired in any other way. The student must, at all events, grasp the fundamental fact that it does occur, and must always occur, before expulsion can take place. The head enters obliquely because the oblique diameters are the largest at the superior strait, but it must emerge in an antero-posterior position — that is, with the sagittal suture opposed to the antero-posterior diameter of the outlet — because the antero-posterior diameter is the largest at the outlet. The movement by which the oblique position at the brim is converted into an antero-posterior position at the outlet is known obstetrically as rotation. To understand the mechanism of rotation it is necessary to remember, first, that with good flexion (without which rotation does not occur) the occipital end of the head is on a lower level than the sincipital ; that is, the occiput receives the pressure of the lower portion of the anterior part of one lateral wall, while the sinciput receives the pressure of the iqiper portion of rhe pos- terior part of the other lateral wall. Secondly, it is necessary to remember accurately the shape, depth, and direction of the spiral grooves described on page 446 (Fig. 221). Thirdly, it must not be forgotten that whenever oue end of the head executes a movement of rotation, its other end must, of course, move simultaneously in the opposite direction. As the head enters, O. L. A., in the usual position of moderate flexion at the brim, the occiput is necessarilv in contact with the upper part of the anterior groove upon the left side of the 486 AMERICAN TEXT-BOOK OF OBSTETBICS. pelvis ; though the groove is here shallow, the occiput is unable to move away from it, because the bregmatic region lies at this time in the deep sacro- Cervix dilated, head on posterior vaginal wall. Pelvic floor, with rectun Fig. 253.— A vertical transverse section of the pelvis (one-third natural size). Position of the head In the inferior strait after complete rotation. The tuberosities of the ischia prevent any further rotary movement, while further descent is opposed only by the soft parts. iliac notch on the right side. As descent goes on the occiput enters the anterior groove more fully — that is, it reaches the point at which the groove Fig. 254.— Forward motion of the head during the stage of expulsion under the influence of the forward thrust of the sacrum and the pelvic floor (one-sixth natural size). is too deep to permit an easy escape of the occiput from its guidance — and by the time the occiput approaches the point where the groove turns forward, and THE MECHANISM OF LABOR. 487 where it must itself turn forward to avoid the pressure of the projecting iliac spiue, the suboccipito-frontal diameter is in the brim and the sinciput is in the sacro-iliac notch. With the next movement of descent the sinciput slips below the promontory and is in contact with the upper and shallow part of the pos- terior groove on the right side. The occipitofrontal diameter now occupies the extremely large oblique diameter of the excavation, and the posterior edge of the groove in which the sinciput lies is here so ill marked that, with the great space aiforded by the oblique diameter of the excavation, it would be an extremely easy matter for the sinciput to slip backward into the hollow of the sacrum if any force tending in this direction were applied. This force is, in fact, applied as a result of the tendency of the occiput to turn forward along the course of the anterior groove of the left side,* under the impulse furnished by the pressure of the projecting iliac spine against the posterior surface of the occipital end of the head. But when the sinciput has once slipped backward in this way into the hollow of the sacrum, there is nothing left to prevent the occiput from turning still farther forward, until, as it reaches the median line, it receives the thrust of the other side of the pelvis, and is steadied in its (^ Fig. 255.— Head during distention of the pelvic floor after rotation, with beginning extension (Smellie). median position by its reception of equal pressures on each side from the descending rami of the pubes and the tuberosities of the ischium. Expulsion. — The parietal bosses now lie in contact with the tuberosities of the ischium. The narrow bitemporal diameter corresponds with the narrow transverse diameter of the pelvis between the iliac spines. The sinciput is * It will be remembered that when the occiput turns forward the sinciput must of necessity turn backward. 488 AMERICAN TEXT-BOOK OF OBSTETRICS. still in contact with the lower portion of the sacrum, and the occiput, though steadied on both sides by the bones, finds its descent opposed only by the yield- ing tissues of the vaginal outlet (Fig. 253). Under these circumstances (p. 482) the propelling force from above concentrates itself upon the occiput until the perineum is fully distended. The occipital end of the head is then freed from the resistances, while the whole bregmatic region and the sinciput form a rigid slanting surface which is opposed to the slanting surface furnished by the sacrum and the perineal tissues (Fig. 254). As a consequence the driving force of the uterine pressure is converted by the shunt of these shelving surfaces into a forward thrust, under the influence of which the head, as a whole, moves forward until its progress is arrested by contact of the nape of the neck with the anterior pelvic wall. The large fontauelle is now at the fourchette, the whole of the occipital half of the head is free from pressure, while the fore- head is still exposed to the driving force of the uterine muscle above * and to the forward shuntof the posterior pelvic wall. The necessary result is a forward mo- tion of the head with arrest of the neck ; that is, the head extends, the bregma, the forehead, and the face successively pass the fourchette, and the head is expelled by extension (Figs. 254 and 255). It is then a convenient mnemonic that in normal labor the head descends in flexion and is expelled by extension. The time occupied by the latter stages of the expulsion of the head — that is, the time between the first ajapearance of the hairless forehead and the com- pletion of the expulsion — is usually very brief. This rapid motion of descent is usually followed by a period of inaction, which is due to the fact that the decrease in the volume of the uterine contents has been so great as to exhaust the contractile power of the uterine fibres, and to render progress impossible until after the occurrence of the peculiar phenomenon known as retraction. Retraction of the Uterus. — It is well known that the amount of shortening- possible to any given muscular fibre is very definitely limited, and it is believed that the extreme shortening of the uter- ine muscle as a whole that is observed during labor is rendered possible by a process of rearrangement of the rela- tions of the fibres of the uterine muscle to one another, known as retraction. The way in which this process is ef- fected is not definitely and scientifically known, but the conception generally ac- cepted as a working hypothesis is that the cells of the uterine muscle not only shorten, but rearrange themselves upon one another in some such way as that diagrammatically represented by Figure 256, A and B. When retraction has once taken place it is usually permanent, and the distinction between contrac- tion and retraction, whatever it may mean pathologically, is therefore clinically * As transmitted to it b_v the fluid pressure. Fig. 25C— Diagrams representing the hypothet- ical relations between the uterine fibres in unre- tracted and retracted uteri : A, arrangement of the uterine fibres in the unretracted uterus; B, ar- rangement of the uterine fibres in the retracted uterus. THE MECHANISM OF LABOR. 489 one which it is important to understand and to bear in mind. In the descrip- tion of the mechanism of labor it is necessary to remember that the fact of retraction is an established entity, notwithstanding the unestablished position of the hypothesis upon which its existence rests. When, after the expulsion of the head, retraction of the uterine fibres has been effected, the rhythmic contractions again set in and the process of expul- sion of the body begins. Expulsion of the Body : Rotation of the Shoulders. — The shoulders having entered the pelvis during the expulsion of the head, they are usually born with the next few succeeding pains. The head having entered in the first oblique diameter, it is evident that the shoulders, which normally lie at right angles to the antero-posterior diameters of the head, will normally enter the pelvis in the second oblique diameter. As the shoulders are driven down by the pains, the anterior shoulder follows the curved line of least resistance, previously travelled by the occiput, while the posterior shoulder follows the path of the sinciput. The anterior shoulder thus rotates to the arch, and the transverse axis of the shoulders occupies the antero-posterior diameter of the outlet. Restitidion of the Head. — The head, being now free from pressure, tends to retain or reassume its natural relation to the shoulders, and thus as they assume an antero-posterior diameter the already expelled, head undergoes an external rotation by which the occiput is carried to a position opposite the left, and the sinciput to one opposite the right, buttock of the mother. This process is known as the external rotation or restitution of the head. The shoulders are, however, so small and soft as compared with the head that the mechanism of their rotation is not infrequently faulty or irregular. It may, moreover, happen that at the time of their entrance the action of the intrinsic muscles of the child may have so turned the body that the transverse axis of the shoulders lies at an acute angle to the antero-posterior axis of the head. The small and soft shoulders may from this cause enter the pelvis in the transverse, or even in approximately the first oblique, diameter. The shoulder which should normally have been the posterior may thus become the anterior, and in this way lead to such an excessive external rotation of the head that the occiput swings around to the right buttock of the mother. This faulty process is com- monly known as super-rotation. Exptdsion of the Shoulders. — The shoulders being retained in the antero-posterior diameter by the pressure of the tuberosities, the posterior shoulder receives the forward shunt of the pelvic floor, which, together with the curvature of the body necessary to admit of the passage of the curved pelvis, jams the anterior shoulder against the symphysis pubis in such a way (Fig. 257) that the posterior shoulder sweeps forward over the perineum and is the first to reach the vulva. As the body is urged onward the perineum retracts, the anterior shoulder appears from beneath the arch, the shoulders emerge from the vulva, following the direction of the curve of Cams (Fig. 222), and the remainder of the body rapidly follows in the same path. During the process of expulsion the arms normally remain crossed upon the chest in the 490 AMERICAN TEXT-BOOK OF OBSTETRICS. usual attitude of the fetus, but they are not infrequently held back by the fric- tion of the pelvic wall, and are thus forced into a position of partial exten- sion in which the forearms lie across the abdomen. The mechanism of the second stage in O. D. A. positions differs from that Fig. 2o7.— Expulsion of the shoulders. of O. L. A. only in the substitution of the word right for the word left throughout the description. C. Mechanism and Management of the Third Stage of Labor. Mechanism of the Third Stage of Labor. — After the expulsion of the child the uterus shuts down upon the placenta, and there is usually a period of from five to ten minutes during which little or no contraction is apparent, this interval being again occupied by the process of retraction of the uterine fibres. The first active contractions of the uterus after the expulsion of the child necessarily lessen the area of the uterine surface over which the placenta is attached, and thus in part or jn whole separate the placenta from the uterine wall ; during the next relaxation blood escapes from the torn sinuses in the placental site, and the mechanism by which the placenta is expelled depends upon the escape or non-escape of this blood from the uterus. If the first retraction is sufficient completely to detach the placenta, but does not succeed in expelling it, any blood which may be effused will usually find its way to the external world by dissection of the membranes from the uterine wall ; during the next few contractions the uterus will be able to shut down upon the placenta, and will compel it, by the force of direct contact, to pass through the os edgewise and in the most compact possible form — that is, in the shape shown in Figure 258, in which the thin cake-like placenta is seen to have been folded upon itself in a roughly fusiform shape. When, however, the attachment of the placenta is too firm to permit an immediate separation, or when, as probably more frequently happens, the con- traction of the fundus is more energetic than that of the lower portion of the uterus, so that only the upper portion of the placenta is detached, the relaxation following each contraction will be accompanied by an effusion of blood which is confined behind the placenta. The upper part of the placenta will then be THE MECHANISM OF LABOR. 491 forced downward, and as the detachment proceeds the position of the placenta will be so far altered that its fetal surface presents at the os, the uterine cavity behind it being occupied by a mass of blood (Fig. 259). When this occurs, Fig. 258.— The more favorable mechanism of expulsion of the placenta (Varnier). the placenta presents in so much more bulky a form that it is usually expelled so slowly and with so much difficulty that the process is not completed until the effused mass of blood attains sufficient size to redistend the uterus slightly, Fig. 259.— The less favorable of the common methods of expulsion of the placenta (Varnier). and thus permit of the occurrence of more forcible coutractions. The placenta is then expelled, not by the force of direct contact, but by an iutra-uterine fluid-pressure exerted through the mass of effused blood. This second form of the mechanism of the third stage of labor, though essentially normal, is much the less easy and favorable for the patient; although the amount of blood lost is not usually sufficient to effect any perceptible altera- tion in her pulse. In either mechanism the elastic and collapsible nature of the membranes renders them less likely than the placenta to be thoroughly detached, and as the latter emerges through the hole in the membranes that corresponds with the os they are necessarily inverted, and, becoming detached by the traction due to the advance of the placenta, follow after it in a loose mass. 492 AMERICAN TEXT-BOOK OF OBSTETRICS. Management of the Third Stage of Labor.* — The inquiry naturally arises: How far is it within the power of the obstetrician to favor or to compel the occurrence of the mechanism first described ? To this inquiry it may be answered that the maintenance of a careful watch upon the uterus by constant touch of the fundus through the abdominal wall, aud the institution of rapid but light friction with the fingers upon the fundus during the first contraction, usually so far increase its duration and force as often to effect the complete separation of the placenta. Moreover, if this friction is persisted in through- out the succeeding period of relaxation, it will usually maintain sufficient con- traction to prevent any considerable effusion, and secure separation during the first or the immediately succeeding pains. This most essential portion of the method of Crede should therefore uniformly be adopted. The second and less favorable mechanism is probably safer for the patient than any manual method of removal of the placenta, but in case a delay in the third stage, notwithstanding the adoption of Creole's method of expulsion, should require the introduction of the hand, a digital intra-uterine exami- nation should first be made, and if the placenta is found to present in the way shown in Figure 259, an effort should be made to reach the edge of the pla- centa with the finger. It may then be possible to draw the edge of the after- birth into the os, and thus permit its ready expulsion without the complete introduction of the hand. D. Mechanism and Management of the Posterior Positions of Vertex Presentations. Mechanism of Right-posterior Positions. — In the right-posterior posi- tions of vertex presentations the head always enters the pelvis O. D. P. ; it should invariably enter the inferior strait in a right-anterior position ; but the process by which this rotation is accomplished is, unfortunately, so deli- cately balanced that it is always liable to a failure, and this, if it occurs, necessarily results in a persistence of the posterior position, which, though not incompatible with a natural delivery, is attended by greatly increased risks to both mother and child. We have to consider, then, first, the entrance of the head into the pelvis in posterior positions; secondly, the normal mechanism of the subsequent delivery by rotation; and thirdly, the (abnormal) mechanism of the delivery of a persist- ently posterior occiput. Labor in posterior positions is usually longer and more difficult than in anterior positions, for two reasons : first, because the entrance of the head into the pelvis is more difficult; and second, because, even under the most favorable circumstances, labor is sure to be lengthened by the more extended rotation of the occiput that is necessary to its completion. The difficult entrance of the head at the brim in occipito-posterior positions is due to the existence of two factors, one of which is physiological, while the other is mechauical. The physiological factor is to be found in an irregular * For the management of the first and second stages of normal labor, see page -J 17. THE MECIIAXISM OF LABOR. 493 and imperfect action of the pains, that characterizes the first stage of labor in a large proportion of posterior positions. The exact cause of this well-marked feature of such cases is unknown. Probably it is a reflex phenomenon due to pressure, from the mechanical mal-adaptation shortly to be spoken of; but it is a fact that a long first stage, which is due to irregular, variable, and ineffective pains, is always suggestive of a posterior position. The mechanical factor is due to the irregular shapes of the fetal head and the pelvic brim. If parallel diameters are drawn across the pelvic brim (Fig. '260). the one (a) from the i-ight side of the sacral promontory to the right ilio- Fig. 260.— Adaptation between the fetal head and the brim of the pelvis in anterior positions of the occiput. pectineal eminence, and the other (b) from the left sacro-iliac notch to the pubes, it will be seen that when the head enters O. L. A., the wide biparietal diameter of the head corresponds with the greater space afforded by B, the longer of these diameters ; while the lesser bitemporal diameter is in corre- spondence with A, the shorter of these parallel diameters. The entrance of the head is therefore mechanically easy in anterior posi- tions ; but, conversely, when the head enters O. D. P., its wide biparietal diameter is opposed to the narrow oblique space between the promontory and the ilio-pectineal eminence of the right side, while the narrow biparietal diameter is loosely fitted into the wide space afforded by the anterior portion of the pelvis (Fig. 261). Two factors of difficulty are thus produced : first, the widest portion of the fetal head finds itself in apposition with a narrow portion of the pelvis, and therefore requires a powerful driving impulse to force it through the brim ; second, this retarded widest portion of the head is situated on the occipital end of the head lever, while the sincipital end is almost free. This situation, therefore, always tends toward a too rapid descent of the sinciput — that is, toward the production of extension — but the degree 494 AMERICAN TEXT-BOOK OF OBSTETRICS. of extension produced varies with the relative sizes of the pelvis and the head. If the disproportion between the biparietal diameter of the head aud the portion of the pelvis in which it finds itself (that is, A, Fig. 261) is not extremely great, the production of an extension sufficient to cause a light pressure of the forehead against the pubes may be enough to equalize the Fig. 261.— Adaptation between the fetal head and the brim of the pelvis in posterior positions of the occiput. resistances at the opposite ends of the cephalic lever, and may thus permit the greater propulsive force applied to the occiput (see page 483) to accomplish its descent while the sinciput is, still above the brim. The head in this case will enter the excavation in a fairly well flexed condition. If the disproportion between the occiput and the posterior portion of the pelvis is more extreme, the process of extension will continue until the occipito- frontal diameter occupies the first oblique diameter of the brim. The head may then pass the brim, after long labor, in an extended position ;* it may be arrested at the brim by becoming a brow presentation, or it may exceptionally be converted into a face presentation. Passage of the Excavation. — After its escape from the superior strait the head occupies the first oblique diameter of the excavation O. D. P., aud the accomplishment or non-accomplishment of the remainder of the labor by the normal mechanism of rotation depends wholly on the degree of flexion present. Rotation in Well-flexed Right-posterior Positions. — When the occiput enters the excavation — that is, passes below the promontory — while the sinciput is still delayed in or above the brim, it occupies for the moment so roomy a posi- * It will be remembered that the occipito-frontal diameter is too large to pass even the oblique diameters at the brim with ease. THE MECHANISM OF LABOR. 495 tion that it is enabled to descend rapidly almost to the floor of the pelvis, while the sinciput, delayed by the pressure of the anterior pelvic wall, makes but slight progress. The occiput then lies between the sacrum and the right ischium, in the hollow made by the recession of the elastic sacro-sciatic lig- aments — that is, in the deeper portion of the posterior groove of the right side of the pelvis — while the sinciput is pressed against the smooth and uniform surface of the upper part of the anterior portion of the lateral wall on the left side. As descent goes on the occiput follows the posterior groove forward under the pressure of the unyielding bony edge of the sacrum, which presses against its posterior surface ; this motion is unopposed by the sinciput, which in thoroughly well flexed heads is still so high in the pelvis that it is free to turn backward over the smooth bony surface of the upper portion of the lateral wall (portion A, Fig. 220, a and B, Fig. 221). Rotation thus pro- gresses smoothly, and usually rapidly, until the occiput' reaches the spot at which the posterior and anterior grooves of the right side join, and thus assumes an anterior position. The sinciput, which has by this time become well pos- terior, now lies in the upper portion of the posterior groove of the left side. The head is now in an O. D. A. position in the lower portion of the pelvis, Fig. 262.— Diagram illustrating the possible reproduction of flexion in partly extended posterior posi- tions of the occiput. The force of rotation is represented by the arrow a; the portion of that force which is applicable to flexion, by the line b. and the remainder of the mechanism, including restitution, is exactly similar to that which would have obtained in an originally O. D. A. position (see pp. 480-490). Mechanism of Rotation when the Head enters Poorly Flexed in Right-pos- terior Positions. — When more marked, but not extreme, extension occurs across the brim before the passage of the occiput, the release of the latter, as be- fore, permits it to make a rapid descent until it is arrested by contact with 496 AMERICAN TEXT-BOOK OF OBSTETRICS. the pelvic floor ; but at the time when the occiput begins to feel the forward impulse of the deep lower portion of the posterior groove of the right pelvic wall the sinciput is not, as before, in contact with the smooth surface of por- tion a of the left lateral wall, but has, on the contrary, already entered the upper portion of the anterior groove on that side. Under these circumstances rotation may exceptionally be accomplished. When this does happen the mechanism is as follows : As the occiput is urged forward, the posterior side of the sinciput is pressed firmly against the slightly rising edge of the upper portion of the anterior groove, and under favorable circumstances this increased pressure may result in flexion of the head in the manner illustrated in Figure 262, which is a horizontal section of the pelvis through the spot where the sinciput impinges against the lateral wall. The rotation force due to the for- ward motion of the occiput urges the sinciput backward in the direction of the force represented by the arrow A. If upon this arrow we construct the parallelogram of forces, we see that by the shunt of the shelving surfaces of the sinciput and the pelvic wall there is produced a small pressure (b) upon the sinciput that tends directly to flexion, and that may, under favorable cir- cumstances, actually produce flexion to a degree sufficient to permit the sinciput to slip by on to the smooth surface of portion A (Fig. 220). The sinciput is free to then glide back into the posterior groove as the occiput moves forward, and the mechanism of rotation described above goes on as before. This process, however, is mechanically so extremely difficult that it can occur only under the most favorable conditions — that is, when the adaptation is easy, when the pains are powerful, and, most important of all, when the loss of flexion is so extremely slight that but a slight change is needed to restore it. Mechanism of Rotation when the. Head enters Unflexed in Posterior Posi- tions : the Mechanism of the Passage of the Excavation in Persistent Right-pos- terior Positions. — When the head passes the brim so far extended that the sinciput is as low, or nearly as low, in the pelvis as the occiput, the forehead reaches the deeper portion of the anterior groove at about the same time that the occiput reaches the deeper portion of the posterior groove. Both ends of the head are then urged to rotate forward by the forward trend of their re- spective grooves ; since neither one can rotate forward unless the other turns back, there results a dead-lock which can be broken only by the intervention of art — that is, by a manual or an instrumental flexion of the head. In rare cases, however, this dead-lock may be avoided by the occurrence of a second and abnormal mechanism, by which the occiput is rotated directly backward into the hollow of the sacrum. This rotation can occur only when the adaptation between the head and the pelvis is exceptionally easy, when the sacrum is exceptionally hollow, and when its lateral concavity is but little marked. The occurrence of a backward rotation is then due to the fact that the posterior edge of the anterior groove, formed by the ischiatic spine, is more prominent than the corresponding portion of the posterior groove, formed by the edge of the sacrum. If, under these circumstances, THE MECHANISM OF LABOR. 49* the occiput ami the sinciput are at equal depths iu the pelvis, it results that the sinciput is more firmly fixed in the anterior groove than is the occiput in the posterior ; and if the adaptation is exceptionally easy or the lower portion of the sacrum is wanting iu prominence, the occiput may be able to escape from the posterior groove and turn backward over the sacrum as the sinciput rotates forward. This escape of the occiput into the hollow of the sacrum usually so far diminishes the pressure on the occiput as to permit of its rapid advance, while the descent of the sinciput is still delayed by the normal resistances of the anterior wall of the pelvis. The rapid descent of the occi- put as compared with the sinciput thus re-establishes flexion, with the head in a directly occipito-posterior position. Expulsion of the head in a persist- ently posterior position by the natural forces or by the aid of forceps is then possible, though the conditions are much less favorable than when the occiput is rotated forward, as may be seen by reference to Figure 263. On comparing Fig. 263.— Expulsion of the head in persistently posterior positions of the occiput ; mechanism of face to pubes delivery. Figure 263 with Figure 254 it will be seen that when the occiput is anterior the curved axis of the child's head and body corresponds with the curved axis of the pelvis, but that when the occiput is posterior these curves are reversed upon each other, and that to effect the delivery iu this position the uterine forces must alter the shape of the child by elongating the occiput, by com- pressing the sinciput, and by producing an exaggerated flexion uutil the normal curve of the fetal axis is reversed. Although the fetal head is surprisingly tolerant of the excessive compression necessary for this change of shape, the process always results in the stillbirth of a large proportion of the children ; while the prominence of the occiput, even after the most extreme moulding, always exposes the soft tissues of the pelvic floor to a degree of tension that almost invariably results in deep laceration of these structures during the stage of expulsion. The expulsion of a persistent occiput posterior, more- over, always requires, in addition to lax adaptation, the presence of very 498 AMERICAN TEXT-BOOK OF OBSTETRICS. powerful uterine contractions or the application of powerful traction by the forceps ; and even when these conditions are present the process is a long one. The head remains on the perineum until the processes of the change in its shaj^e and the production of extreme flexion are sufficiently far advanced to per- mit the occiput to travel downward along the median line of the posterior wall under the influence of the pressure from above. The region of the small fonta- nelle finally appears at the vulva, and the perineum retracts, or, more com- monly, tears across the occiput to the base of the neck. The occipital end of the head is then free from pressure, while the sincipital end is still exposed to the driving force of the uterine contractions. The excess of pressure upon the sincipital end of the head then causes extension, by which the forehead, the eyes, the nose, and the chin successively appear under the arch, while the occiput swings backward, and the head is born by extension (Fig. 263). Restitution. — During the expulsion of the head the shoulders enter in the second oblique diameter, and the rotation of the left (the anterior) shoulder to Tig. 264.— Occipito-posterior position, with the head beginning to distend the pelvic floor (Smellie). the arch produces an external restitution to the right, in accordance with the general law that external rotation or restitution restores the head to its origi- nal position. Abnormal or so-called " super-rotation" is, however, of especially common occurrence in these cases. Summary. — In reviewing the mechanism of posterior positions it is at once apparent that the whole key to the situation is to be found in the degree of flexion presented — that the better the flexion the more certain and the more rapid is the execution of the normal and most favorable mechanism. It is an THE MECHANISM OF LABOR. 499 established fact in practice that in the comparatively few cases in which good flexion is established at the start and maintained to the end, posterior labor is hardly less favorable than anterior ; and that the degree of difficulty increases as the degree and persistence of flexion decrease, until we reach the fact that when flexion is lost and is not promptly restored by art, posterior positions invariably yield long, difficult, and exhausting labors for the mother, and a large proportion of stillbirths among the children. It may safely be said that there is no variety of labor in which easily-avoided ill results are so commonly incurred as in posterior positions of the vertex ; and there is certainly no sub- ject in obstetrics that better deserves the attention of the student than the means of detecting extension and of preserving or re-establishing flexion in these cases. Mechanism of Left-posterior Positions. — Of the mechanism of O. L. P. positions it is only necessary to say that it differs from that of O. D. P. posi- tions simply in the substitution of one side of the pelvis for the other, and in the fact that failure of rotation is more common in left positions. Management of Labor in Posterior Positions of the Vertex. — Prophy- laxis. — Since posterior labor is so much less favorable than anterior, it is evi- dent that every effort should be made to prevent the occurrence of posterior positions, or, when they do occur, to convert them into anterior positions before the occurrence of labor or during its early stages. We are, fortunately, able to effect this end in the great majority of cases, provided the position is diagnosticated before the ruptui'e of the membranes or the engagement of the head. For this reason, if for no other, the obstetrician should in every case endeavor to ascertain the position of the fetus by making an abdominal pal- pation some days before the advent of labor. If a posterior position is dis- covered at this time, it is usually possible to' rectify it by postural treatment of the patient. If the patient is placed in the knee-chest position, the anterior wall and the fundus are the lowest portions of the uterus. So long as the patient remains in this position there is a tendency for the child to sag away from the brim under the influence of gravity ; and since the recession of the head from the brim leaves the child free to turn upon its own axis, while the presence of the spinal column makes the dorsal side the heavier, there is also a tendency toward a rotation of the fetus as a whole until its dorsum is in apposition to the anterior wall of the uterus. The woman should in such cases be instructed to assume the knee-chest posture several times daily during the last few weeks of pregnancy, to remain as long in this position as is possible without fatigue, and, on relinquishing it, to recline on the right side for a short time before rising, in the hope that as the child's head again settles down against the brim it may become fixed in an anterior position. The enlarged abdomen of the gravida at term may prevent the assumption of the true geuu-pectoral position and compel her to adopt the knee-elbow atti- tude ; but in either event it is essential that the abdomen should be free from 500 AMERICAN TEXT-BOOK OF OBSTETRICS. pressure against either the bed or the thighs of the patient ; that is, the thighs should be vertical (Fig. 265). The postural treatment is especially powerful when instituted before any labor-pains have occurred. If this treatment is conscientiously carried out for several davs, the physician will almost surely find the position anterior when summoned to the patient in labor. Even if the patient is not seen until labor is present, it is still worth while to adopt a postural treatment so long as the membranes are unruptured and the head is unengaged. The patient ^ ^ should then be encouraged to maintain ^j/\^ this position so long as her strength permits, or until a vaginal examination B without alteration of her attitude dem- -~s>^~^ onstrates the fact that rotation has occurred. She should then be placed ^j^ in the latero-proue position upon the c =-^- ^ =a — side to which the occiput is directed, Fig. 265-Correct (A) and incorrect (B and aQ( \ should remain ill that position C) methods of assuming the genu-pectoral posi- ., , , , . „ , ■■ . , tion until the head is firmly engaged m the new position. Should the head, after once becoming anterior, show any tendency to revert to the posterior position, it mav even be wise to rupture the membranes in order to prevent any such reversion. Should the postural treatment fail, no special treatment is necessary until after the rupture of the membranes has occurred ; but both before and after rupture frequent examinations are to be advised, in order to detect early any tendency to the production of marked extension. Passage of the Superior Stf-'ait. — In the majority of cases the head in pos- terior positions passes the superior strait by the natural efforts only after some delay, and often only after the occurrence of some extension and of considerable moulding of the head. The attitude of the phvsician should be determined by the degree of exten- sion presented. When the extension is not extreme, he should not be alarmed by a failure of progress, but should avoid interference, and expect the best results so long as the condition of both patients remains good. When extension becomes so extreme that the eyebrows are below the brim of the pelvis, there is but little prospect that the head will pass the superior strait by the natural efforts, aud unless active progress is present it is wise, after a single hour has passed without alteration of the condition, to abandon the expectant method of treatment and resort at once to the operative treatment of a high arrest of the posterior occiput. Operative treatment at the superior strait subdivides itself into the operative re-establishmeut of flexion and the delivery through the superior strait of the flexed but arrested head. Operative Flexion. — If, at the time when operative flexion becomes neces- THE MECHANISM OF LABOR. 501 sary, the membranes are still intact, it may occasionally be possible to raise the forehead by making' pressure upon it with two ringers placed within the cervix, the woman being in the laterally recumbent or knee-chest position, in order to afford the assistance of gravity to the efforts of the accoucheur. Since it is impossible, however, to obtain complete flexion of the head in this way, and since the extension is almost certain to recur if no further change is made, it is essential that the head as a whole should be freed from the brim by pres- sure upon the vertex, after flexion has been secured, in the hope that on its en- trance it may be better situated, and may thus be able to maintain its flexion. Should extension again recur, it is best to etherize the patient, introduce the hand into the vagina, and dilate the os manually to a degree sufficient to permit the passage of the half hand within the uterus. Should the membranes be ruptured at the time when interference is decided upon, this must usually be the first maneuvre. When sufficient dilatation has been attained, the half hand should be passed within the os until the fingers cover the forehead, which should then be pressed gently upward until complete flexion has been secured and the head has been freed from the brim. The hand should then be withdrawn, the fingers placed as high upon the forehead as possible in order to maintain flexion, and the head forced into the brim by external pres- sure. The ether should be removed, and the fingers should maintain pressure upon the sincipital portion of the head until a firm engagement in a flexed position has been effected by the efforts of the uterus. Should extension be- come re-established, an operative delivery of the head is necessary. Operative Delivery of a High Arrest of the Posterior Occiput. — If extension is present, flexion should be established by the introduction of the half hand. Three methods of delivery are then possible : The child ma}' at once be turned, the head may be rotated manually and forceps applied to the anterior occiput, or forceps may be used while the occiput is still posterior. The latter method is to be recommended only when the other methods are, for one reason or another, contra-indicated or impossible, and the choice ordi- narily rests between the procedures of a manual rotation of the occiput to the front with a subsequent application of the forceps, and version. Manual rotation and the application of forceps is a difficult, and version in normal pelves is an easy, operation. The head after manual rotation not infrequently returns to its original position during the manipulations incident to the application of the blades, and in any event it is necessary to applv the forceps to the head when freely movable above the brim, which operation is always difficult. The writer believes, however, that after the forceps has successfully been applied to the head in an anterior position, an extraction with it is less dangerous to the soft parts of the mother than is the extraction of an after-coming head ; the forceps operation should therefore, in his opinion, be chosen by those who are thoroughly skilful in the use of the instrument, but the primary performance of version should be elected by operators of small experience. Should manual rotation and the use of forceps be decided upon, the whole 502 AMERICAN TEXT-BOOK OF OBSTETRICS. hand should be passed into the uterus and the head be raised gently until the whole surface of the hand can be applied to the forehead, the fingers lying over the face of the child ; whereupon the hand and the forearm of the operator should be rotated with the head until the occiput is well anterior to, and even, if possible, to the left of, the median line. During the introduction of the hand careful counter-pressure must be made at the fundus by an assistant or by the other hand of the operator, and during the rotation the external hand must be used to promote the rotation of the trunk. The rotation should always be slow and be procured with the utmost gentleness. Unless the rotation of the trunk accompanies that of the body, the head will return to its original position as soon as it is free from pressure. In difficult cases it may occasionally be per- missible to apply the internal fingers to the shoulder of the child to promote this rotation. The whole mauenvre is frequently so difficult that, unless the waters have been but recently evacuated, it should not be attempted until a fair experience in version has furnished the operator with some adroitness in intra- uterine manipulations. After rotation has been effected the head should be urged into the brim by counter-pressure upon the fundus, and it should be maintained in position by gentle abdominal pressure ujdou the head itself, from the hands of an assistant, while the forceps application is made. The forceps should be applied, if pos- sible, to the sides of the head, and, as in all high operations, the use of an axis-traction instrument is to be recommended. If version is decided upon, the head should be flexed before it is raised, as this always requires less force than an attempt to raise the extended head. If version is absolutely contra-indicated and manual rotation fails, an attempt should be made to bring the head through the superior strait by the application of forceps without alteration of the position ; but as a preliminary even to this operation an extended head should gently be flexed. In the use of forceps while the occiput is still posterior, it is inadvisable to make any attempt to apply the blades to the sides of the head, as the position of the parietal bosses in the narrow space between the ilio-pectineal eminence and the promoutory makes it extremely difficult to adjust the forceps to the ends of the biparietal diameter. Even when it is so adjusted a very slight forward inclination of the line of traction may cause the forceps to slip forward along the head to the temporal region. In this position the forceps is extremely likely to slip from the head altogether ; even if the forceps holds its position, the sole and necessary result of traction is a reproduction of the extension, which, of course, results in an arrest, or at least requires the use of increased and unnecessary force. The blades should therefore be applied to the sides of the' pelvis, where they will take an oblique grip upon the head. This application is always very difficult, and the operation too frequently results in a fracture of the skull or in the birth of a stillborn child from cranial compression. As soon as the head has passed the brim the forceps should be removed, and if necessary reapplied in the manner shortly to be recommended for the oper- ative treatment of the low head in posterior positions. THE MECHANISM OF LABOR. 503 Management of the Passage of the Excavation in Posterior Positions. — Flexion. — As was said in the discussion of the mechanism of posterior posi- tions, the maintenance of complete flexion is the first and most essential con- dition of the progress of the head through the excavation. It follows that the maintenance of flexion when possible, and its re-establishment when it has been lost, must demand throughout the case the most careful attention from the obstetrician. When the adaptation is easy and good flexion is present from the start, descent and rotation to an anterior position are sometimes so quickly performed that no assistance is needed ; but in a large proportion of cases the head enters the excavation in a condition of partial extension, and in such cases an early adoption of certain very simple measures frequently makes the difference between difficult and easy labors. The various expedients which may be used to promote or to re-establish flexion form, then, the first and most important division of the treatment of the low head in posterior positions; but, since it not infrequently happens that even a well-flexed head fails to rotate from over- tightness of adaptation, from relative inefficiency of the pains, or from minor variations in the shape of the head and the pelvis, it is necessary to add thereto a second division, which consists of the expedients that may be employed to favor or to produce rotation during extraction, whenever, from any cause, a well-flexed head is arrested in a posterior position in the excavation. Maintenance of Flexion. — Unless progress goes on with unusual rapidity, the maintenance of flexion by counter-pressure should be undertaken as soon as the head has entered the excavation and the forehead is within easy reach. As soon as the degree of descent permits, the fingers should be placed against the frontal bones as far forward of the large fontanelle as the pelvic space allows, and any further descent of the sinciput should be retarded by a maintenance of pressure against the forehead throughout the whole of each pain until the occur- rence of rotation carries the frontal bones backward and out of the reach of the fingers. In this process a simple retardation of the descent of the sinciput is all that is to be aimed at or desired, since flexion is supposed to be already present, and its maintenance is all that is needed. This maintenance of flex- ion, which is usually easy, is always a very much more simple matter than is an attempt to raise the forehead by pressure after extension has once occurred. If this precaution is carefully observed from the start, loss of flexion is extremely rare, and a recourse to the more heroic methods required for its re-establishment may usually be avoided. Re-establishment of Flexion. — When extension occurs, it must be reduced before any further progress is possible. Flexion may be re-established either by pushing the sinciput up, by drawing the occiput down, or by a combination of both methods. The forehead may occasionally be made to recede by pres- sure upon the frontal bones with the fingers ; it should then be held in position until the uterine efforts have effected complete flexion by descent of the occiput, and until rotation has occurred. This method, the simplest and safest, is, how- ever, possible only in very easy cases. 504 AMERICAN TEXT-BOOK OF OBSTETRICS. It is occasionally possible to reinforce this method by hooking the fingers of the hand around the occiput, and thus drawing down upon the occiput with one hand while the sinciput is pressed up by the other hand. This method is possible only when the extended head is very low and the soft tissues of the outlet are very lax ; in the majority of cases in which extension has fully been established it is necessary to resort to instrumental methods. The vectis (Fig. 266), which was the precursor of the forceps, was originally used to promote the descent of the head by the application of leverage motions to the sides of the head in alternation. The vectis is never used to-day except for the reduction of exten- sion, and, in the opinion of the writer, cannot be recommended even for this purpose, since, in the first place, its efficiency depends on its possession of an exaggerated cephalic curve which renders its intro- duction difficult, and, in the second place, it can rarely be prevented from slipping, without the use of a degree of force which exposes both the vagina of the mother and the scalp of the child to serious risks of laceration. If employed, the vectis is passed around the occiput and is used to draw it down, while the delay of the sinciput is entrusted to the friction of the pelvic walls or to counter-pressure by fig. 266.-The vectis. the fingers. For this purpose the hand of an assist- ant must be utilized, since the employment of the vectis always requires both hands; that is, while one hand makes traction on the handle of the vectis, the fingers of the other hand must always be placed between the vagina and the instrument to protect the tissues from laceration. , Reversed Forceps. — A far better operation, when manual efforts at flexion have failed, is to be found in the application of reversed forceps. This opera- tion is in reality a mere extension of the ancient principle that the tips of the forceps should always be directed toward the leading point on the presenting part ; but when the forceps is applied to an extended head in a posterior posi- tion with the tips directed posteriorly, its grasp is directed so far toward the occipital end that the instrument is almost certain to slip after flexion has occurred. It is therefore important to remember that this application should be utilized only for the production of flexion, that during each traction the fingers of the unemployed hand should carefully note the motions of the , head, and that as soon as flexion has been established the blades should be removed, if necessary being reapplied for the delivery of the head in the manner recommended for the delivery of a well-flexed head in posterior positions. Technique of the Application of Reversed Forceps. — The forceps should be placed outside the vulva, in the position in which they are to lie when applied to the head — that is, with the transverse axis of the blades at right angles to THE MECHANISM OF LABOR. 505 the sagittal suture, and with the tips directed backward. If the lock is of the ordinary form, the handle of that blade which would be the left in the ordinary position should be held in the right hand, and, under the guidance of two fingers of the left hand, should be inserted into the vagina and passed into position as near as possible to the occipital end of the head (Fig. 267). Fig. 267.— The application of reversed forceps. The arrow indicates the effect of the forceps in pro- moting the descent of the occiput while the sinciput is delayed by friction against the anterior pelvic wall. The other blade should be adjusted to correspond with its fellow, and simple traction upon the handles should be made in the direction of the handles, all leverage motions being avoided. The force of the instrument is then directed against the occipital end of the head alone ; the sinciput is delayed by the friction of the pelvic walls, while the occiput descends under the force of traction, and flexion results. As soon as the small fontanelle has been brought to the centre of the pelvis — that is, when the head has been flexed — the forceps should be removed and the process of rotation be entrusted to nature, since lacerations of the vagina are far less often produced when rotation is effected by the uterine force than when it is procured by instrumental means; unless, indeed, the condition of the patient necessitates an immediate delivery. Low Forceps in Well-flexed Heads in Posterior Positions. — When rotation fails notwithstanding the presence of good flexion — that is, when a well-flexed head is delayed in a posterior position until the signs of exhaustion occur — tin's failure is usually the result of a relative want of vis-a-tergo, which must be compensated for by the substitution of the vis-a-fronte of the forceps ; but it is the first essential to success in this operation that the instrument should be so applied that its presence in the vagina offers no impediment to the rota- tion of the head. If in this position of the head the forceps is applied to the sides of the pelvis, its oblique grasp upon the forehead and the occiput will almost certainly prevent rotation ; while, even if it is applied to the sides of the head, it is liable to cause extension and consequent delay, with laceration 506 AMERICAN TEXT-BOOK OF OBSTETRICS. of the perineum, and frequently the death of the fetus, unless special precau- tions are taken to ensure its grasping the occiput. So long as the occiput is distinctly posterior to the transverse line of the pelvis, the forceps should be applied to the sides of the head with the concavity of the pelvic curve toward the forehead — that is, with the tips anterior ; but care should be taken during the application of the blades to keep the handles well raised, or, to use a better expression, to direct the tips far backward into the pelvis, iu order to ensure their grasping the occiput and thus promoting rather than retarding flexion during the tractions. The tractions should be directed as far backward as the perineum will allow, at least until rotation has occurred ; since it is sometimes difficult to secure this line of traction in the ordinary position of the hands, it is often well, in the extraction of posterior positions, to place the left hand upon the shanks of the instrument near the vulva, and with that hand draw backward while the right hand steadies the extreme end of the handles. It must not be forgotten that the maintenance of flexion and the conse- quent production of rotation are essential objects of this first application, since descent is dependent on them. The ^traduction of forced rotation by a rotative movement of the handles of the forceps is so extremely dangerous to the soft parts of the mother as to be permissible to uone but the most experienced operators. The operator who has really acquired sufficient skill to justify such a maneuvre will infallibly have acquired so active an impression of its dangers as to use it with the most Fig. 26S.— Lateral motion of the handles of the curved forceps during the rotation of a posterior posi- tion of the head : A, position of the handles when first applied ; B, position of the handles after partial rotation has occurred. extreme care ; but, though an active rotation force is not permissible, it is always proper, and indeed necessary to success, that the operator should avoid preventing rotation. He should know exactly the motion the handles will make during the rotation of the head, as that occurs under the guidance of the pelvic grooves, and he should be constantly on the watch to promote and favor this motion. Iu this connection it must be remembered that when rotation occurs it will be in the axis of the blades and not in that of the handles, so that as the blades rotate their handles will move in a laterally circular direction such as is illustrated in Figure 268. If a good pair of straight forceps is at hand, it THE MECHANISM OF LABOR. 507 is much the better instrument for low operations in posterior positions, since with it no such lateral motion of the handles occurs, and the avoidance of the necessity of watching for it greatly simplifies the operation. At the conclusion of each traction the handles of the forceps should be sep- arated slightly, since, if this is done, the head not infrecpiiently rotates to an anterior position within the blades. This maneuvre is especially useful when the original application of the forceps has been slightly inaccurate, and the head is, in consequence, not grasped exactly on its sides. A careful digital examination should always be made at the conclusion of each traction, in order to note exactly the mechanism which is going on, to become aware of rotation as soon as it occurs, and to detect any tendency to extension which may have followed a faulty application of the forceps. As soon as the position is slightly anterior, or even when it becomes trans- verse, the forceps should be removed and reapplied to the sides of the head, but this time with the concavity of the pelvic curve toward the occiput, since any further rotation with the blades in the former position would carry them into the position of the reversed forceps, in which the grasp is unsatisfactory and the danger of laceration is great from the too close apjDroach of the tips to the posterior wall of the vagina. The tractions should again be intermittent, rotation of the forceps with the head should be favored, and the compression should be intermitted during the intervals between the tractions, to permit the head to rotate within the blades. When the head has reached the O. D. A. position the forceps should again be removed, and reapplied in the ordinary way, unless the application is at that time wholly unsatisfactory. The operation as a whole is vastly more difficult than is an extraction in an anterior position. Delivery in Persistently Posterior Positions. — When, from any cause, the proper maintenance of flexion has been neglected, and the occiput has settled into the hollow of the sacrum — that is, where it has become directly posterior — a delivery " face to pubes " is all that can be hoped for. Under these circumstances delivery by the natural efforts necessarily implies the presence of an unusually powerful and active uterus. It is necessary for the pains to force the head into extreme flexion, to mould it into a much-changed shape, and to distend the soft tissues to an extreme degree ; and the vis-a-tergo of the uterus must usually be reinforced, before the process is completed, by the vis-a- fronte of the forceps. The first duty of the obstetrician is to establish an extreme flexion by pressure on the forehead with the fingers ; it will then be maintained by nature if the uterus is powerful enough to effect an unaided delivery. In this case an attempt to preserve the perineum by keeping the occiput well forward against the pubes is his ouly other duty ; and as the necessary change in the shape of the head is to be most safely effected by slow moulding — that is, during a long second stage — he should be patient and loath to interfere ; indeed, in these cases the use of the forceps is never warranted unless the signs of exhaustion of one or the other patient are clearly present and increasing and progress has ceased. 508 AMERICAN TEXT-BOOK OF OBSTETRICS. If the forceps must be used, it should be applied to the sides of the head, aud the extraction should be effected by means of the so-called " pump-handle traction." The tractions should at first be directed well backward until the perineum distends, in order to draw the occiput downward along the posterior pelvic wall, and then should sweep forward, in order to draw it forward over the pelvic floor to the vulva and the arch of the pubes. These tractions should be gentle and intermittent, in order to encourage a slow moulding of the head,* and the forward direction should be maintained until the small fontanelle appears at the fourchette and the perineum retracts along the neck. The handles of the forceps should then be moved backward, but without inter- mission of the traction, in order to favor the appearance of the face from under the pubic arch by extension as in natural labor. 2. Face Presentations. Frequency. — A face presentation is not a very common anomaly. Pinard found 320 face cases out of 81,711 deliveries at the Paris Maternite — a fre- quency of about 1 iu 250. At Guy's Hospital Lying-in Charity, London, there was a frequency of 1 in 276, or .36 per cent, out of 23,591 cases of labor. Churchill analyzed about 250,000 cases, and found that face presen- tations averaged 1 iu 231. Collins at the Dublin Rotunda found the fre- quency to be 1 in 497. Spiegelberg thought that in Germany it was 1 in 324. Relative Frequency of the Positions. — M. L. A. is but very slightly more frequent than M. D. P. M. D. A. and M. L. P. are very rarely seen. Etiology. — Face presentations are, of course, produced by the extension of vertex presentations at or just before the beginning of labor, and every face presentation has therefore passed through the stage of brow before becoming a face presentation. Many factors may contribute to the production of this ex- tension, and it is probable that the etiology of the anomaly varies widely in different cases. It may be originated by an abnormal shape of the head, by an obliquity or abnormality of the uterus, by small tumors in or about the pelvic brim, by a deformity of the pelvis, or by an over-tight adaptation between the head and the brim in a posterior position of the vertex. Undue Length of the Hind-head. — Any abnormal prominence of the occi- put necessarily lengthens the short arm of the cephalic lever, and therefore tends to the production of extension. The presence of such an anomaly would undoubtedly predispose to a face presentation, and cases have been reported in which it was apparently the sole cause ; but in the majority of face cases the head is found to be of normal shape after the moulding of labor has passed away, and was therefore probably normal at the beginning of labor. Obliquity or Abnormality of the Uterus.. — An obliquity of the uterine axis by which the fundus is inclined to the side on which lies the back of the child tends to roll the condyles to the opposite side of the pelvis by altering the * Since the chief danger in this operation is that of inhibiting the life of the fetus by com- pression of its skull against the pubes, it is well to have the fetal heart watched by an assistant, and to regulate the force of the tractions by the effect produced upon its beat. THE MECHANISM OF LABOR. 509 Fig. 269.— Manner in which an obliquity of the uterine axis may produce a face presentation. direction of the uterine force (Fig. 269), in which the condyles are urged (in the direction of the arrow) by the uterus, and thus produces extension. Again, any irregularity in the contour of the uterine wall on the side to which the occiput is directed — for example, a cicatrix or a localized tonic constriction — may delay its progress and so pro- duce extension. Small Tumors in the Brim.— A. tu- mor which impedes the advance of the occiput, but does not interfere with the sinciput, may be the cause of a face presentation. Pelvic Deformities. — The minor grades of flattened pelvis in which moderate extension at the brim is nor- mally present (see Dystocia) are a fre- quent cause of face presentations. Tight Adaptation in the Posterior Positions of Vertex Presentations. — We have seen (p. 493) that there is a marked tendency to the production of extension at the brim in O. D. P. and O. L. P. positions. That this is a frequent cause of face presentation is shown by the fact that, although an O. D. P. occurs but about once in every four vertex labors, the results of its extension — that is, an M. L. A. — make up nearly one-half of all face labors. Diagnosis. — On abdominal examination the fetal limbs, the heart,* and the least accessible portion of the head are found on the same side. On vagi- nal examination with the finger, the pointed chin, the mouth with its maxillary processes and the tongue, the nostrils, the bridge of the nose, the eyes, and the supraorbital ridges should be found and recognized. The position is deter- mined by the position of the chin. Prognosis. — The prognosis in face presentations for both mother and child is always somewhat worse than in vertex labor, but it varies greatly in accord- ance with the position of the chin, the prognosis of anterior positions being vastly better than that of posterior positions. The mortality of face presenta- tions varies also between extremely wide limits, in accordance with the varia- tions in the adaptation between the head and the pelvis, and more especially with the degree of ossification of the fetal head. When the chin is anterior, when the adaptation between the head and the pelvis is moderately easy, and the fetal head is so soft as to permit of an easv production of the necessary change of shape, face labor is apt to be rapid. The prognosis for the mother is then unaltered from that of good normal labor, and the prognosis for the child is but little worse ; but this statement is true only -when the conditions are such that there is rapid progress throughout the * In face presentations the heart is heard over the ventral side of the chest. 510 AMERICAN TEXT-BOOK OF OBSTETRICS. second stage : with the supervention of any delay the prognosis for the child becomes decidedly poor, while at the same time the mother's prospects are rendered less good by the risks of laceration during rotation that are always involved in a difficult or operative delivery of the face. In posterior positions of the chin the prognosis for the child is always poor, since under the most favorable circumstances it is necessarily exposed to the utmost danger, both from the marked compression of the cranium against the symphysis that invariably occurs and from the great tension upon the tissues of the neck that is implied in the extreme extension necessary to excite rotation in posterior positions of the face. With any but the most extremely favorable conditions the prognosis for the child in posterior positions of the face is almost necessarily fatal, while that for the mother is complicated by the proba- bility of extensive lacerations. In the large majority of such cases rotation fails, and the child's case is then practically hopeless, since no instance has yet been recorded iu which the child's life was preserved duriug the extraction of a persistently posterior position of the face. Mechanism and Management of Face Presentations. Mechanism of Pace Presentations. — Iu the mechanism of face presenta- tions the chin plays the same ?'6k that the occiput does in vertex labor. Rotation is as necessary to expulsion in the one case as in the other, and the occurrence of rotation depends on the fact that under normal conditions the chin enters more deeply into the pelvis than the most prominent point upon the other side of the head, which in this case is that portion of the forehead immediately anterior to the bregma. This deeper entrance of the chin is in face presenta- tion secured only by the existence of complete extension, and extension is even more important to progress dur- ing the second stage of face labor than is flexiou during the second stage of vertex labor. Mechanism of Face Presentations, 31. L. A. — Fully-developed face pres- entations at the beginning of labor are comparatively rare. The face commonly starts as a vertex, passes through the stage of a brow while still unengaged, and becomes a face presentation only during the passage of the brim. By .reference to Figure 270, which represents the position of the head during the passage of the brim by a face presentation, it will be seen that after the point of the chin has passed the pelvic brim the ventral side of the head and the neck is so shaped as to offer but little opportunity for the engendering of friction against the pelvic wall, while the -Presentation of the face at the pelvic brim. THE MECHANISM OF LABOR. 511 shape of the projecting forehead and bregmatic region is such as to ensure firm pressure between them and that part of the pelvis opposite. The posi- tion of the head brings its articulation with the spinal column far out to the Fig. 271.— Face presentation at outlet after rotation (Smellie). ventral side of the head, and we have then the pressure of the propelling force concentrated far out to one side in the head, while the resisting force of friction against the pelvic walls is exerted almost wholly upon the other side ; hence good extension is the rule in face labor. The existence of complete extension, Fig. 272.— Configuration of the fetal head after its delivery as a face presentation. .—Configuration of the fetal head after its delivery as a vertex presentation. however, places so great a strain upon the tissues of the neck that its produc- tion is usually accomplished slowly ; and the diameter which must occupy the brim as the head descends — namely, the cervico-bregmatic (Fig. 270)— is so 512 AMERICAN TEXT-BOOK OF OBSTETRICS. large that with reasonably tight adaptation the descent of the face is usually accomplished at the expense of considerable moulding of the head (Fig. 272). The cervico-bregmatic diameter of the head is so far behind the leading point, the chin, that by the time the head is free from the superior strait — that is, when this great diameter passes it — the chin is already deep in the pelvis, and, indeed, by this time occupies the deepest portion of the ante- rior groove of the left lateral wall. At this point there is often a temporary dead-lock, since the great elongation of the head may still leave the region of the sagittal suture in the sacro-iliac notch, where it is prevented by the promontory from turning backward, although the chin is being urged strongly forward by the lower portion of the anterior groove. Rotation can then occur only when the propelling force is sufficiently strong to crowd the chin downward to the lowest possible point, and may even require a further lateral moulding of the head under the pressure of the promontory against the projecting occiput. As soon as the occiput slips under the promontory rotation promptly occurs. The chin swings under the pubic arch (Fig. 271), and the mouth, the nose, the eyes, and the forehead successively appear at the fourchette. When the angle of the jaw rests against the descending rami of the pubes, the chin and the face become wholly freed from pressure, while the occiput is still exposed to the propelling power of the uterine force from above.* The chin then sweeps upward, and as the occiput continues to progress, the bregma, the small fontauelle, and the occiput successively appear at the fourchette, and the head emerges by flexion. The mechanism of face labor is, then, extension, descent, rotation, and birth by flexion. Restitution carries the chin to the side to which it was originally directed during the expulsion of the shoulders. The mechanism of 31. D. A. labor is, of course, similar to that of M. L. A. The Mechanism of Posterior Face Presentations. M. D. P. — The chin enters the posterior groove at the brim, and should travel forward along its course ; but even when extension is complete the production of so extensive a rotation as is necessary to bring the chin to the front is rendered extremely difficult by the marked obstacle afforded to its performance by the resistance of the very prominent bregmatic region, which, notwithstanding its size (Fig. 274), must be made to travel backward along the whole left lateral surface of the brim — a motion possible only when the propelling forces are sufficiently powerful and the head is sufficiently soft to permit the production of a very extreme degree of moulding of the head. When rotation has once carried the chin into an anterior position, the mechanism, of course, is that of a primary M. D. A. No separate description of the M. L. P. mechanism need be given. Management of Pace Presentations. — Management of Face Presentations at the Brim. — The measures which must be considered in the management of face presentations when detected while the child is still in or above the brim are as follows : The case may be left to nature; an attempt may be made to raise the * Through the intrauterine fluid pressure. THE MECHANISM OF LABOR. 513 chin, and so restore a vertex presentation by manual flexion of the head, after which it may be left to nature or be delivered by the forceps ; forceps may be applied to the face as such, or the case may at once be delivered by version. Natural Labor. — The first expedient, that of leaving the case to the care of nature, is applicable only under one set of circumstances. When the chin Fig. 274.— Posterior position of the face deeply engaged in the pelvis (Smellie). is anterior ; when the woman is a multipara who has had a succession of easy labors ; when the accoucheur is able to satisfy himself by a thorough examina- tion that the soft parts are soft and dilatable, that the pelvis is ample, and that the child is small, the latter point having been determined not only by palpation of the abdomen, but also by palpation of the head with the half hand introduced into the vagina ; when the uterus is powerful and the pains are frequent ; and, finally, when no pathological complication is present, — it is often wise to adopt a conservative policy ; but the consequences of delay are so serious even in anterior positions of the face, and the prediction of an easy labor is always so difficult, that the obstetrician should feel that in making this prediction and adopting a policy of inaction he is taking a veiy grave responsibility. When the chin is posterior, or when, in anterior positions, the couditions are anything but the most favorable, it should be the rule that the detection of a face pres- entation at the brim is to be followed by immediate interference. Interference at the Brim. — The choice of methods rests between manual flexion of the head into a vertex presentation, version, and the application of forceps to the face. The choice between version and the production of a head presentation by manual flexion rests mainly on the position of the chin. If the chin is pos- terior, flexion of the head will result in the production of an anterior position 33 514 AMERICAN TEXT-BOOK OF OBSTETRICS. of the vertex — the most favorable position for a subsequent delivery by nature or for an extraction by the forceps ; if the chin is anterior, flexion can produce only the unfavorable posterior position of the vertex. In posterior positions of the chin manual flexion should ordinarily be the first expedient, and the head, when flexed, should be urged into the brim by external pressure with the hand, in the hope that it may become engaged in this position under the influence of the pains, after which the case should, of course, be left to nature ; but if an engagement does not follow promptly, it is best to apply forceps at once, since the conditions which originally produced the face presentation may usually be relied upon to reproduce it. If the manual reproduction of a vertex presentation proves difficult or impossible, the attempt should be abandoned and version be performed. If the chin is anterior, flexion of the head would result in the production of a posterior position of the vertex ; and since, as has been seen, posterior positions of the vertex at the brim are frequently best treated, when interference is necessary, by a resort to version, it follows that in anterior positions of the chin, when interference is necessary, a primary version is the operation of choice. When in such cases a version is contra-indicated, the choice lies between an application of the forceps to the face and a manual flexion iuto a poste- rior position of the vertex, to be followed by an attempt at a manual rota- tion of the occiput to the front and the application of forceps. If the conditions are such as to render this latter operation possible, it is generally preferable to the use of forceps to the face ; but since the conditions which contra-indicate version very generally render manual rotation of the head diffi- cult or impossible, it will sometimes be necessary to resort in such cases to the use of forceps to the face. The use of forceps to the face at the brim is always a difficult operation. The delivery of the child through the brim without injury to either mother or child can be accomplished only by the utmost accuracy in the adjustment of the blades ; and even in anterior positions the prognosis is serious. The use of forceps to the face high is, then, never permissible to any but a thoroughly skilled operator, and even in such hands it should be reserved for a last resort. In posterior positions the forceps is never permissible, and it should be forbid- den both from its inherent difficulties and because success in the passage of the brim can only result in the production of that very dangerous condition, a posterior position of the face within the excavation. Management of Face Presentations, Low. — Chin Anterior. — When a face presentation has been allowed to x pass^]ieLrim or has not been discovered until s it is within the excavation, its prog^ss showM be watched with great care, and the utmost pains must be taken to nSaintai/ complete extension throughout the second stage. A constant watch over^tne processes of nature must be main- tained, since any considerable delay is attended by great danger to the life of the child, from the likelihood that an interruption of its cerebral circulation may occur as a result of the extreme tension necessarily put upon the vessels of the neck or of their compression against the sides of the pelvis. THE MECHANISM OF LABOR. 515 It follows from these dangers that even moderate delay furnishes a sufficient indication for the use of low forceps in face presentations. Complete exten- sion, as has been said, is of the utmost importance, and, fortunately, may easily be maintained by pressure with the fingers upon the under surface of the lower jaw. Should interference become necessary, it is absolutely important that the forceps should be applied to the sides of the cranium, and with the tips so far posterior as to be entirely clear of the neck. In anterior positions, if this necessity be borne in mind, the application of forceps is easy, and the extraction of the child ordinarily presents no great difficulties ; but it must not be for- gotten that pressure upon the tissues of the neck by the tips of the blades must almost invariably result in loss of the child. Chin Posterior. — As has been said, the face should never be allowed to enter the pelvis chin posterior. If this abnormality is not discovered until it has occurred, the patient should at once be etherized, the hand be introduced, and the possibility of raising the head above the brim should be tested. If this is possible without grave risk to the mother, it should at once be done, and the face dealt with according to the principles already outlined for the operative treatment of the face high (p. 513). If elevation of the head proves impossible, the obstetrician should content himself with the maintenance of extreme extension by traction upon the chin in combination with a constant attempt to promote rotation by drawing the chin forward with the fingers. This process should be persisted in so long as there is, in his judgment, any possibility of rotation. When this prospect becomes hopeless, forceps may be applied and an attempt be made to extract the face as a persistently posterior chin presentation. Any attempt at rotation by the forceps must be forbidden, both because of the grave danger of provoking extensive lacerations of the mother that neces- sarily attends this maneuvre, and because any slipping of the blades upon the child or any oblique application of the forceps would necessarily involve com- pression of the vessels of the fetal neck, and therefore the loss of the fetus. A straight forceps should be used if it is at hand. It should be applied care- fully to the sides of the head and with the tips well anterior, so that the grasp of the blades may be wholly upon the cranial vault. The tractions should be directed slightly backward until the perineum is thoroughly upon the stretch, then forward and upward until the chin emerges, and then well downward, that the occiput may emerge under the arch and the head be born by flexion. Since lacerations of the pelvic floor are inevitable in this operation, and since every possible advantage must be taken, the perineum should be incised by deep lat- eral incisions as a preliminary measure. This process has not yet been successful in the extraction of a living child ; but since it has never, so far as known, been adopted while the child was in good condition, and as it has several times succeeded in extracting dead but uninjured children, it deserves a more extended trial whenever a child in this position is still in fairly good condition. If the child's vitality is already seri- ously compromised, its chances of life are so small that the prospect of preserv- 516 AMERICAN TEXT- BOOK OF OBSTETRICS. ing the mother's soft tissues would, in the judgment of most obstetricians, justify the choice of craniotomy.* 3. Brow Presentations. Frequency. — As face cases have usually, if not invariably, passed through the stage of brow in the process of their conversion from a vertex presentation, temporary presentations of the brow must be at least as frequent as those of the face ; but if only those brow presentations which remain such until altered by the obstetrician are included in the list, the frequency becomes less — pro- bably not more than 1 in 1500 labors. Relative Frequency of the Positions. — Brow O. L. A. and brow O. D. P. are almost equally frequent. The others are much less common. Etiology. — Brow presentations are due to the same causes that produce presentations of the face (p. 508), but it is of course a fact that if the process of extension is arrested in the stage of brow, it implies a greater obstacle to the progress of the head than where nature is able to develop a face presentation. Diagnosis. — On abdominal examination the two ends of the head are found at about the same level, and the heart is usually heard over the back. On vaginal examination the small fontanelle is found at one end of the field, the large fontanelle in its centre, and the supraorbital ridges on the other side. Prognosis. — Siuce at term and with a normal head the spontaneous delivery of an unchanged brow presentation is possible only after a degree of prolonga- tion of labor that is disapproved by modern obstetrics, the prognosis of per- sistent brow presentations for both mother and child is that of the operation chosen. It should be remembered, however, that when nature changes the brow to a face the prognosis becomes that of a face presentation. Mechanism and Management of Brow Presentations. Mechanism of Presentations of the Brow. — Anterior Position of the Brow {that is, brow 0. D. P. and brow 0. L. P.). — In the rare cases in which a pres- entation of the brow succeeds in enter- ing the pelvis, this possibility is due to the fact that the moulding of the head has progressed until the occipito-mental diameter has become sufficiently small to pass the oblique at the brim, and this change is compensated for by a corre- sponding increase in the occipito-frontal Fig. 275.— Configuration of the fetal head after its i- *" /-n. nr -_ N rru delivery as a brow presentation. diameter (Fig. 2/5). The increase in the length of this diameter necessarily carries the forehead much deeper into the pelvis than any other part of the * Since the above was written the great success of symphysiotomy has led most obstetricians to believe that a division of the symphysis should precede all applications of the forceps to a persistently posterior position of the face. THE MECHANISM OF LABOR. 517 head, so that m anterior jrositions of the brow the projecting forehead engages in the anterior groove of the lateral pelvic wall as soon as the brim has been passed, and reaches its deeper part by the time the occiput escapes from the sacro-iliac notch and enters the shallow upper part of the posterior groove of the opposite pelvic wall. If the conditions are so exceptionally favorable as to permit of the expul- sion of an unchanged brow presentation, the forehead moves forward aloug the course of the anterior groove, while the occiput, beiug still in the shallow upper part of the posterior groove of the opposite side, moves back into the hollow of the sacrum ; the root of the nose comes to the pubic arch, and the progress of the anterior portion of the head is then arrested, while the occiput travels down along the posterior wall of the pelvis and across the perineum. The nose and the chin then appear beneath the pubic arch, and the head in anterior positions of the brow is thus expelled by extension. External rota- tion, of course, carries the occiput to the side to which it was originally directed. Posterior Positions of the Brow (that is, brow 0. L. A. and brow 0. D. A.). — Should an unchanged posterior position of the brow succeed in passing the brim, the forehead would enter the posterior groove and the occiput would lie against the shallow portion of the anterior groove. If the case went on to delivery, the rotation of the forehead along the posterior groove would be similar to that of the occiput in occipito-posterior positions of the vertex ; but when the enormous difficulties incident to the expulsion of the brow under the most favorable circumstances are increased by the inherent difficulties always attached to rotation in posterior positions, the sum-total of the obstacle becomes so great that a delivery is almost unknown, and it may be laid down as a practi- cal rule that posterior positions of the brow always become arrested. Management of Brow Presentations : Management at the Brim. — When a brow presentation is detected at the brim, we may deal with it by any one of the four following methods : the case may be left to the care of nature ; the brow may be converted into a vertex by manual flexion ; the brow may be changed into a face by manual extension ; or the case may be delivered by immediate version. The choice between these methods of treatment depends primarily on the position, but in posterior positions of the brow — that is, when the occiput is anterior — the indications are considerably modified by the pres- ence of excessive moulding of the presenting part. Anterior Positions of the Brow. — The class of cases which should be left to the care of nature is extremely limited, and includes only those few cases of anterior positions of the brow which, when detected, are rapidly changing into anterior positions of the face, and in which the conditions of the case are such that, if the face becomes established, its progress is certain to be rapid and easy. Flexion of such a brow would produce a posterior position of the vertex, and there is then but little hope of a spontaneous delivery of the uew presentation, since the marked tendency to extension which always character- izes the posterior positions of the vertex would almost certainly reproduce the 518 AMERICAN TEXT-BOOK OF OBSTETRICS. brow, while if an operative delivery is to be undertaken, version is the opera- tion of election in posterior positions of the vertex. It follows that version is the operation of choice in anterior positions of the brow (see Management of Face Presentations at the Brim, p. 512). All other anterior positions of the brow should be dealt with by immediate version as the operation of choice, the production of a vertex by manual flex- ion being ruled out for the following reasons : In freeing a partially-engaged brow from the brim of the pelvis as a pre- liminary to version, it is essential that the first effort at raising the head should be directed against the forehead, since a preliminary flexion of the head re- places the long occipito-mental diameter by the shorter occipito-frontal diam- eter, and the subsequent elevation of the head therefore exposes the tissues of the mother to far less risk than would be involved in an attempt to force the extended occipito-mental diameter bodily upward. Moderate flexion is, more- over, an important element to success in the subsequent manipulations of the version, since its production minimizes the obstacle offered by the projecting sinciput. When in anterior positions of the brow which promise a difficult delivery an attempt at version fails, a manual extension of the brow to an anterior posi- tion of the face, to be followed by forceps, is the only alternative to craniotomy, unless the condition of the child warrants a resort to one of the major cutting operations (see The Use of Forceps to the Face at the Brim, p. 514). When the brow presents in a posterior position — that is, with the occiput anterior and with the head unmoulded — its treatment by manual flexion results in the production of an anterior position of the vertex, and a manual flexion is therefore in these cases the operation of choice. After the re-establishment of flexion the head should be held in position by the hands for a few pains ; but, unless its engagement occurs promptly, it is usually best to resort to an immediate application of the forceps, since it may fairly be presumed that the conditions which originally led to the loss of flexion are still present, and will probably reproduce the extension if the case is left to itself. In this position of the brow a manual extension is contra-indicated, since it could only result in the production of a posterior variety of the face, which in itself is so danger- ous that it demands an immediate version. If, therefore, in these cases a manual flexion is ruled out, version should again be selected as the operation of second choice. When the brow presents in a posterior jjosition — that is, with the occiput anterior and with the head already much moulded — the operation of manual restoration of the vertex must be ruled out in the interest of the child, for the following reasons: First, if a marked change of shape is apparent at the time the presentation is detected, the restoration of a vertex presentation by a manual flexion of the head presents great difficulty; moreover, the conditions are so much altered by the change in shape of the head that its re-extension into a brow will almost certainly occur as soon as the pains reappear or the forceps is applied. Second, a vertex delivery involves so extensive a re- THE MECHANISM OF LABOR. 519 moulding of the head to its original shape as to expose the child to great risk of danger from cerebral hemorrhage ; while the delivery of a much-moulded brow by version — that is, by the extraction of the after-coming head — results in but little change in shape, and is therefore much the safer for the child. Version is, then, the only operation which should be considered in these cases. The operative treatment of brow presentations, high, may be summarized as follows : In anterior positions, version is the operation of choice. In the posterior positions of unmoulded brows a manual flexion to au anterior posi- tion of the vertex and a subsequent application of forceps to the head should be preferred ; this failing, version should be the second choice.* In the pos- terior positions of much-moulded heads version should be selected. A high application of forceps to the brow is ordinarily more dangerous to the mother than a craniotomy, and but little more hopeful for the child. The abdominal operations would be indicated only in the interests of the child, and would usually be contra-indicated by the fact that the vitality of the child is usually considerably lowered by the time the ordinary operations have become impossible. Management of Brow Presentations after their Entrance into the Pelvis. — Since the brow never enters the pelvis until after an excessive moulding has been produced, and since the adaptation is then always so close that anv alteration of the presentation is impossible, it is unnecessary to discuss in this connection any other problem than the delivery of the brow as such excessively moulded and closely adapted to the pelvic cavity. If the sinciput is anterior, the forceps should be applied to the sides of the head with the concavity of its pelvic curve anterior, and the mechanism of the natural delivery of a persistent brow should be imitated. The tractions should be directed downward and backward until the root of the nose engages at the arch, and their direction should then gradually be moved forward and upward until the occiput sweeps forward over the perineum, then downward asjaiu to permit the emergence of the face ; but the chance of extracting a living child in this way is so small, and the risk to the mother's tissues is so extremely great, that the application is never permissible unless the child is in fairly good condition. If its vitality is already seriously lesseued, it is probably the best practice to deliver by craniotomy. Such cases are, fortunately, almost never seen during the life of the child, and perhaps never at term. If the brow has entered the pelvis with the sinciput posterior, and the child is still alive, a very cautious attempt to promote rotation by the forceps might be justifiable ; but success would be extremely unlikely, and a resort to crani- otomy would almost certainly be necessary. This condition, however, is so extremely rare that it is almost unnecessary to refer to it. * An extension to a face and a subsequent rotation of the chin to the front are occasionally possible, but this operation is always difficult, and should not be attempted by operators of small experience. 520 AMERICAN TEXT-BOOK OF OBSTETRICS. 4. Pelvic Presentations. Pelvic presentations are commonly divided into breech, knee, and footling presentations ; but knee and footling presentations are so similar in every respect to those of the whole breech that it is convenient to treat them as sub- variations. Frequency. — Pelvic presentations occur in about 1 in 30 labors when mis- carriages and premature labors are included. Among labors at term, however, their frequency falls to about 1 in 60 cases. Thus, Pinard found among 100,000 cases 3301 pelvic presentations, but on excluding the premature cases the proportion fell to 1 in 62. Among pelvic presentations about 60 per cent, are presentations of the breech. Etiology. — Pelvic presentations are produced by the failure of the condi- tions which ordinarily ensure the existence of cephalic presentations (see p. 468). They are, then, especially frequent among premature and macerated children, when the liquor amnii is excessive and wdien the uterine and abdom- inal walls are very lax. They are the rule in hydrocephalus, and one out of every four twins is a breech child. In deformed pelves, too, in which the head is unlikely to become fixed at the inlet during the last weeks of preg- nancy, breech presentations become more frequent. S. D. A. and S. L. P. — that is, the two positions in which the loug diameter of the breech occupies the first oblique diameter of the inlet — are much more common than S. L. A. and S. D. P. Knee and footling presentations are probably always secondary, and are due to an active movement of the fetal limbs. Diagnosis. — On abdominal examination the head is found at the fundus and its absence is noted at the brim; the heart is heard above the umbilicus. On vaginal examination in presentations of the breech the presenting part is at first high and is reached with difficulty. The finger recognizes the vulva or the scrotum and penis, as the case may be, the anus, and the sacral spines. On rectal examination of the fetus the coccyx, the tuberosities of the ilia, and the pubic arch are easily recognizable. The position is best determined by the position of the coccyx as ascertained by a rectal examination. In knee and footling cases the prolapsed extremity is recognized by its anatomical characters (see p. 465). Prognosis. — The prognosis for the mother in breech presentations is only altered from the normal by the frequency with which rapid extractions are necessary, and by the fact that in such extractions there is a greatly increased risk of laceration. The prognosis for the child is alwavs poor, the mortality running as high as 10 per cent, in skilled hands. The prognosis for both patients is worse when the mother's soft parts are rigid — for example, in primiparse. Mechanism and Management of Breech Presentations. Mechanism of Breech Presentations. — Normal Mechanism. — In breech presentations the first stage is ordinarily abnormally slow. If the membranes THE MECHANISM OF LABOR. 52] are intact, the dilatation of the os is performed by them as in head presenta- tions, and every care should be taken to preserve their integrity until the os is fully dilated. This precaution is of special importance in breech presenta- tions, since, although the small and tapering breech is not ill-adapted to the dilatation of the os, the breech, when considered as a dilating wedge, labors under the disadvantage that its small size renders its passage through the cervix an inefficient preparation of the soft parts for the passage of the larger and harder head ; extensive lacerations of the cervix are therefore frequent whenever the preparation of the cervix has been entrusted to the breech. When the resistance of the cervix has been overcome, the comparatively small and soft breech naturally enters the pelvis easily, as the bitrochanteric diameter, the greatest diameter of the breech, is less than any of the diam- eters of the brim. The bitrochanteric diameter enters in one or the other oblique diameter, and is then crowded downward into the pelvis until the pos- terior hip impinges on the pelvic floor, when, uuder the forward shunt of this portion of the posterior wall of the pel- vis, the breech as a whole bends for- ward by a lateral inflection of the trunk (Fig. 276). This movement engages the anterior hip in the deep portion of the anterior groove of that side of the pelvis to which it is directed, and as the anterior hip rotates forward the posterior hip slips back into the groove of the sacrum. The lateral inflection becomes well marked, the anterior buttock appears at the vulva, and as the trunk is driven more deeply into the pelvis by the uterine contractions the anterior hip becomes fixed at the pubic arch, and the posterior hip swings forward until the posterior buttock and trochanter appear successively from under the fourchette. As the posterior half of the breech emerges the perineum retracts upward along the child's pelvis, and, all pressure being thus removed from the pos- terior surface of the breech, the inflection is released and the trunk of the child is permitted to straighten itself again, thus releasing the anterior hip from its position of pressure against the pubic arch ; the whole trunk then moves downward through the pelvis, and only such moderate lateral inflection as is necessary to accommodate the trunk to the course of the pelvic bones still persists. When the legs remain, as they should, in their normal position of flexion, the escape of the knees from the vulva releases the lower extrem- ities. At about the time the umbilicus appears at the vulva the shoulders enter the brim, their transverse axis lying in the oblique diameter. If the arms remain in their normal position — that is, crossed over the breast — the anterior Fig. 276. — Lateral inflection of the trunk during expulsion of the breech. 522 AMERICAN TEXT-BOOK OF OBSTETRICS. shoulder rotates to the arch and is delayed by fixation against its inner surface, while the posterior shoulder and elbow pass the vulva. The escape of the posterior shoulder so diminishes the size of that portion of the body occupy- ing the outlet as to permit the anterior shoulder to escape from the arch and emerge from beneath it. The pressure of the uterus upon the longer arm of the cephalic lever should, under normal conditions, preserve the flexion of the head. In this condition the chin and the face necessarily enter the pelvis first, the suboccipito-frontal and suboccipito-bregmatic diameters occupying one of the oblique diameters of the superior strait. Since, at the time the head engages at the superior strait, the shoulders have already rotated into a position in which the bis- acromial diameter occupies the antero-posterior diameter of the outlet, the head approaches the superior strait in a transverse diameter, but the recession of the posterior portion of the lateral wall of the pelvis at the brim, as it approaches the sacro-iliac notch, causes the face and the forehead, the first portion of the head entering the pelvis, to swing backward into a posterior position. The after-coming head thus normally enters in an occipito-anterior position. As the head enters the excavation the sinciput is so much lower in the pelvis than the occipital end of the head that it swings along the course of the posterior groove until it slips into the median Hue upon the pelvic floor, the occiput which is still exposed to the smooth bony surface of the brim, at the same time l'otating to the median line in front. The face appears, followed by the forehead, at the vulva, the perineum retracts over the bregmatic region, and the head is born, still in a state of flexion. Abnormal Mechanism of Breech Presentations. — The frequent occurrence of abnormalities in breech presentations is to be accounted for by the ease with which the legs, the arms, and the head may become extended by friction against the pelvic wall. The descent of the legs and the arms should normally be accomplished pari passu with that of the body through the transmission of the uterine force to their upper surfaces by the liquor amnii ; but in a large pro- portion of cases the cervix has still sufficient resiliency to contract tightly upon the fetal trunk after the legs have passed the cervix. The upper surface of the legs is then cut off from the pressure of the liquor amnii, while their descent is still opposed by an undiminished friction against the pelvic walls ; again, they may be detained by being themselves caught in the grasp of the cervix, while the body continues to descend ; or, finally, they may have been placed in an extended position by the action of their intrinsic muscles. As a result, it not infrequently occurs that the legs become extended against the body during the descent of the breech. Under these circumstances it occasionally happens that the legs are sufficiently closely applied to the child to act as rigid splints to its trunk, thus causing arrest by preventing the lateral inflection necessary to the passage of the trunk. An arrest due to this cause usually necessitates a resort to operative interference. The re-contraction of the cervix upon the body may also result in an exten- sion of the arms upward during the descent of the shoulders, until they lie along THE MECHANISM OF LABOR. 523 the sides of the head. The shoulders then enter the pelvis normally, but their further progress is arrested by the fact that, unless the child be small or the pelvis be unusually ample, the head and the arms form too bulky a mass to enter the pelvis together easily, and the interference of the obstetrician is again required. Even though the legs and the arms maintain their normal relations to the trunk, the passage of the head may be arrested by extension. Under normal circumstances the sinciput is driven into the pelvis, because the pressure of the liquor amnii upon the forehead is usually sufficient to overcome the resistance of the face against the pelvic walls, and there is nothing, there- fore, to disturb the original relation of flexion of the head upon the chest ; but if the attendant is injudicious enough to make traction, or if the already delivered portion of the trunk is unsupported, its weight, under the influence of gravity, is transmitted to the head through the occipito-atlantoid articulation, and a traction is thus initiated which is exerted solely against the occipital end of the head. The result is au abnormally rapid descent of the occiput. If this descent occurs before the head enters the superior strait, it may cause sufficient extension to result in the entrance of the occipito-mental or the occipito-frontal diameter into the superior strait, and thus produce an arrest of the head in this portion of the pelvis. If the influence of gravity only becomes active after the entrance of the forehead into the pelvis, no more than a partial extension is likely to result, but this partial extension brings the occiput into the deeper portion of the anterior groove of one lateral wall, while the sinciput rests in the posterior groove of the opposite wall. Rotation of the forehead forward is thus prevented, and there results a dead-lock which can only be broken up when a rapid descent of the forehead — that is, the restoration of flexion — is secured by operative influence. Still another abnormality occasionally occurs. When the child is small or the pelvis is exceptionally ample — in other words, when the adaptation between the child and the pelvis is abnormally easy — the shoulders may enter the brim in the transverse diameter. If the back of the child is anterior, this produces no modification of the mechanism ; the shoulders become oblique, and finally antero-posterior, during their passage through the lower part of the pelvis, the head enters with the sinciput posterior, and the birth goes on normally. If, however, the shoulders enter the superior strait transversely in a posterior position of the breech, the face and the forehead usually become engaged in the anterior portion of the pelvis before rotation of the shoulders can occur. If, under these circumstances, the flexion of the head is thoroughly well marked, the forehead passes along down the course of the anterior groove, the face appears under the arch while the neck retracts the perineum, and, if the pains are of the very best, the forehead may be urged down under the arch and the head be born in flexion. The successful conduct of this form of mechanism by the forces of nature is, however, rare. It often happens that the projecting chin, the mouth, or the nose catches upon the upper border of the pubic bones. The sincipital end of the head is then delayed, extension results, the head jams across the brim by 524 AMERICAN TEXT-BOOK OF OBSTETRICS. the occipitomental or the occipitofrontal diameter, and an absolute arrest usually follows. Delivery by the efforts of nature then almost never occurs, and is only possible when the adaptation is so easy that the uterus is able to drive the occiput through the brim, while the chin slips upward and forward over the horizontal ramus of the pubes in order to make room for it. If this happy release of the chin happens, complete extension follows, the occiput appears under the fourchette, and the head is born in extension. This move- ment of extension is, however, usually accomplished only by traction on the body or by the application of the forceps ; even then it is likely to involve so much delay that the preservation of the life of the child is unlikely. Management of Breech Presentations. — Nothing more thoroughly tests the skill and judgment of the obstetrician than his management of a breech presentation. Upon the one hand, it is of the first importance that he should remain inactive so long as the natural jtrocesses are progressing satisfactorily. Upon the other hand, he must be prompt to foresee the appearance of danger to the child, and to interfere as soon as this danger is manifest. He cannot be warned too strongly to avoid premature interference, since the use of trac- tion instantly disarranges the delicate balauce by which the normal attitude of the child is maintained. As before stated, the maintenance of flexion in natu- ral breech labor is clue to the facts that the legs, arms, and forehead are driven down by the action of the intra-uterine-fluid pressure upon their upper sur- faces, and that this pressure is more than sufficient to overcome the friction of the pelvic walls against the lower surfaces of these parts ; but when traction is made upon the breech, the additional force thus supplied is distributed to the members only through the knees, the shoulders, and the occipito-atlantoid articulation respectively, while the very fact of its application — that is, the promotion of a more rapid descent — increases the force of friction exerted against the feet, the hands, and the forehead. Traction is then almost invari- ably followed by extension of the legs, the arms, and the head, with all its inherent difficulties. AVhen, however, interference is demanded, speed in extracting the arms and head is essential. After the scapula? appear, five minutes are an average time within which the mouth should be brought to the vulva. He who interferes in a breech delivery should feel that unless unusual good fortune attends his efforts he is likely to be confronted by the necessity of a manual delivery of each and every portion of the child's anatomy as these por- tions successively approach the pelvis. Even in the most skilled hands this process is attended by much more danger to the child than is involved in a natural delivery. Since natural delivery is ordinarily possible only when complete flexion is maintained, since a single traction is likely to produce extension, and since, when extension has once occurred, delivery is ordinarily possible only by the immediate adoption and subsequent prosecution of an operative extraction, it becomes evident how important it is that the obstetrician should remain abso- lutelv inactive unless there arise circumstances which show him that nature is THE MECHANISM OF LABOR. 525 likely to fail — that is, that the best chances for the child have been lost, and that the second best must be taken ; for if it be true, upon the one hand, that a prompt natural delivery is safer for both mother and child than the best operative interference, it is equally true, upon the other hand, that when nature fails in promptness the only hope for the child and the best prospect for the mother is to be secured by the immediate performance of an operative delivery. Management of Normal Breech Labor. — In breech labor the obstetrician's duty, so long as progress is normally rapid, is reduced to the following details : It is wise never to conduct a breech labor without one skilled assistant, if such a person can be obtained. This assistant should give the ether if this is required, and should be ready to apply suprapubic pressure to the head if a rapid extraction becomes necessary. When delivery is imminent the woman should be placed in the lithotomy position, since there is never any certainty that interference may not become necessary at any moment. It is also well to put the patient slightly under the influence of ether as soon as the delivery is thought to be near at hand, since, if interference is indicated, it is rendered greatly easier by anesthesia, and because a partial anesthesia can be raised to the surgical degree with much less loss of time than is necessary to produce unconsciousness in a totally unetherized patient. From the time the breech enters the pelvis the fetal heart should be care- fully watched, since there is always danger of compression of the cord, and for this reason auy irregularity of the fetal heart is sufficient cause for inter- ference. As soon as the cord can be reached its pulsations will keep the obstetrician informed of the condition of the child. As soon as the buttocks emerge from the vulva they should be wrapped in a warm sterilized cloth ;* the attendant should do his utmost to relieve the perineum from undue strain by pressing the hips and the pelvis of the child into close contact with the arch ; and even after the delivery of the hips he should continue to support the breech in an elevated position for the same rea- son. When the knees appear he should reduce the bulk of the presenting part by flexing out the legs. As soon as the umbilicus is within reach of the finger he should gently draw down a loop of the cord, to avoid the danger of undue tension upon the cord or upon the umbilicus during the subsequent descent of the body. The hips and the body should still be held constantly forward toward the mother's abdomen, in the curve of Cams, iu order that the rota- tion and expulsion of the head may not be interfered with by the weight of the body; but no traction should be made during this process. As the elbows appear the forearms should be drawn out, and if the fetal body is sufficiently elevated the head should follow without delay. f Rapid Extraction of the Breech when Arrested High. — When a breech is arrested at the superior strait until the signs of exhaustion of one or the other * Warm in order to lessen the danger of a premature respiration, sterile on account of its contact with the vulva. f For the procedure of extracting the head and arms low, see page 530. 526 AMERICAN TEXT-BOOK OF OBSTETRICS. patient appear, or when a rapid delivery becomes necessary by reason of some condition which threatens the life of mother or child, five methods of securing descent are applicable : Traction may be made upon the anterior groin with the finger, the fillet, or the blunt hook ; forceps may be applied to the breech ; or the hand may be inserted into the uterus, and be made to bring down a leg for use as a handle by which to make traction. Of these methods, the use of finger iu the groin is always preferable when its employment is possible, but iu high arrest of the breech the finger seldom has sufficient power to secure descent; and if the breech is but slightly engaged in the brim at the time interference becomes necessary, the introduc- tion of the hand to bringdown a leg is ordinarily the method which should be chosen when the finger iu the groin fails. If the breech is already so far engaged as to render this maueuvre difficult or dangerous, the cautious employment of the blunt hook or the fillet is permissible. An operator of practised skill may succeed by the forceps, but the application of this instru- ment to the breech at the superior strait is not to be recommended to begin- ners. The Use of the Finger. — In applying this method the half baud should be passed iuto the vagina, the forefinger be hooked into the groin in any manner convenient to the operator, and traction be made downward and backward in the axis of the superior strait. Care should be taken to direct the line of traction rather toward that side of the pelvis to which the back of the child is directed, in order to lessen the dan- ger of snapping the femur (Fig. 277). The Blunt ^HooL— Both the fillet and the blunt hook can usually be ap- plied to the groin, without special diffi- culty, in any portion of the pelvis, and Fig. 277.— Proper (A) and improper (B) directions i ,1 j? • i r • l a? j. - c of traction upon the thigh.* both furnish fairly effective means of traction ; both instruments, however, labor under the disadvantage of subjecting the tissues of the child to great risk of injury, the blunt hook, when skilfully used, being perhaps the less danger- ous. The hook should be passed, under the guidance of the finger, between the anterior hip of the child and the pubic bones until it can be so rotated that its point passes between the child's thigh and abdomen. The finger should then be passed between the thighs and be brought into contact with the point of the hook, which should then be settled downward by gentle traction until its curve fits snugly into the flexure of the groin. The shank of the hook should then be grasped by the hand to which the finger belongs (Fig. 278), and traction should be made with the other hand, the finger lying in contact with the * Though represented with the fillet, this Figure illustrates equally the manner of employ- ing the fillet, the blunt hook, or the finger. THE MECHANISM OF LABOR. 527 point of the hook throughout the extraction, in order to protect the soft parts from injury as far as possible. The line of traction should be directed toward the side on which the sacrum lies, in order to avoid fracture of the thigh. Fig. 278.— Method of grasping the blunt hook. The Fillet. — The fillet may be made of a piece of broad tape, preferably linen on account of its greater strength, or of a wide strip torn from a silk handkerchief; the best fillet known, however, is that made by passing a stout cord through a piece of rubber tubing about three-eighths of an inch in diameter. The fillet may occasionally be passed through the groin by the un- aided fingers, but in high arrest it is seldom possible to succeed in adjusting it by this method. Several instruments have been devised for the special purpose of placing the fillet, but their place can be filled equally well by a piece of string and a large English webbing catheter. The disinfected catheter should be threaded with a double loop of disinfected string or of narrow bobbin, and with its stilette, should then be bent to the shape of the blunt hook (Fig. 279). The catheter should be passed into the groin in the manner directed for the use of the blunt hook, and the finger should ■ draw clown the projecting loop of string until the end of the fillet can be passed through it, when, by the removal of the catheter, the fillet is placed in posi- tion in the groin. The same precaution as to the direction of the line of trac- tion must be observed with the fillet as that recommended for the blunt hook and the finger. The Use of Forceps. — If the forceps is used in high arrest of the breech, its application is similar to that which is to be described under low arrest (p. 528), although it is much more difficult. The Extraction of a Leg. — In the introduction of the hand into the litems to bring down a leg, the breech should be pressed back gently through the brim before any attempt is made to pass the hand. The utmost gentleness should be observed throughout this maneuvre, and undue tension on the utero- vaginal attachments should be avoided bv a careful maintenance of counter- Fig. 279.— Use of the catheter as a porte-fillet. 528 AMERICAN TEXT-BOOK OF OBSTETRICS. pressure against the fundus with the other hand. The operator should always be careful to ascertain the position of the cord, to avoid the production of an unnecessary prolapse. If the foot is within reach, it should be seized and gently drawn out from the os. He should seize the anterior leg whenever that is accessible, as the line of traction on the anterior leg can be kept nearly in the axis of the inlet, while a pull on the rear leg brings the anterior but- took to a sitting position on the brim. If the legs are extended across the chest, two fingers should be placed along the crest of the tibia, and be used to so flex the leg that the foot passes down the median line of the child's abdomen until it reaches a position in which it can be seized and with- drawn. When the foot appears at the vulva, the leg should be wrapped in a towel which has been dipped in a warm solution of corrosive sublimate, and traction should be made upon it in a line which should at first be directed as far back- ward as the perineum allows, in order to pull, so far as possible, in the axis of the superior strait. As the breech descends the line of traction should swing forward, until, when the hips clear the vulva, it is directed nearly vertically upward, the woman being in the lithotomy position. As soon as the knee is well outside the vulva the grasp should be shifted to the thigh, as any pro- longed traction on the lower leg is apt to overstrain the ligaments of the knee-joint, If there is any difficulty in bringing the breech to the vulva, its delivery may be assisted by hooking the forefinger into the other groin as soon as it is within reach ; as the breech distends the perineum it should be drawn well forward, and every effort should be made to prevent a laceration precisely as is done in the delivery of the fore-coming head. When the second knee appears at the vulva, it should be drawn outward along the side of the child and toward its back, until the fingers can reach the leg and release the foot by flexiqn of the leg upon the thigh ; but all pressure upon the shaft of the femur must carefully be avoided, since fracture of the femur during this process is always easy. Care should be taken to bend the knee only in the natural direction. Rapid Extraction of the Breech when Arrested Low. — Low arrest of the breech can usually be overcome by the use of the finger in the groin, which method should always be the first tried. If this method fails, the use of the fillet, or, better, the blunt hook, is decidedly less dangerous to the child in low than in high arrest, the method of applying them being exactly the same ; the forceps is here, however, easy and is almost invariably efficient ; moreover, if due care is exercised, this instrument is far less likely to injure the child than is the blunt hook. Application of the Forceps to the Breech Low. — If the breech lies in an antero-posterior or oblique position, the tip of one blade of the forceps should lie against the upper sacral vertebrae, while that of its fellow should be pressed into the flexor surface of the most easily accessible thigh (Fig. 280), If the position of the hips is transverse, each tip of the forceps should THE MECHANISM OF LABOR. 529 impinge upou a femur just above or beyond the trochanter, which then furnishes a firm hold for the blades (Fig. 281). In making the application the forceps should be placed in an approxi- mately correct position upon the breech, locked, and held lightly in this posi- tion. A hand should then be passed into the vagina until the finger-tips can touch the exact spots at which the tips of the blades should lie; an accurate adjustment is then easily attained by direct movements of the tips of the blades with the internal fingers. The small size of the tapering breech, in comparison with the diameters of any pelvis through which a living child can be ex- tracted, renders it easy to obtain an accuracy in the adjustment of the forceps that is impossible of at- tainment when the forceps is used upon the head. It is this fact which renders the forceps valuable in this connection, since the avoidance of injury to the child and the attainment of a secure grasp of the breech are to be effected only by the adjustment of the tips to exactly the points to which they were directed, and the utmost care must be observed in verifying the position of the forceps before any traction is made. When the operator is sure that the instrument is satis- factorily in position, the handles should be grasped sufficiently tight to ensure a firm pressure, which should then be maintained without intermission until after the delivery of the child. The ordinary forceps is better adapted to this application than any special forms which have yet been devised. When the instrument is used upon the high breech the advantages of axis-traction are perhaps more fully apparent than in any other obstetric operation. Rapid Extraction of the Trunk. — As soon as the legs and the pelvis of the child have cleared the vulva, they should be grasped (through a warm aseptic towel) in the manner shown in Figure 282, in which each thigh is grasped by Fig. 2S0.— Forceps applied to an oblique position of the breech. Fig. 2S1.— Forceps applied to a transverse position of the breech. 530 AMERICAN TEXT-BOOK OF OBSTETRICS. -Method of grasping the thighs during the extraction of the breech. the fingers of one hand, the thumbs of the operator lying along the sacrum ; this grasp should be maintained throughout the extraction, no other grasp being so secure, and any pressure upon the crests of the ilium or upon the ab- domen of the child being dangerous to its bones and abdominal viscera. The line of traction should be directed as far backward as the perineum allows, in order to facilitate the passage of the shoulders through the superior strait, and the back of the child should be kept steadily directed upward — that is, toward the anterior portion of the mother's pelvis — to secure an anterior position of the occiput for the after- coming head. When the umbilicus ap- pears at the vulva a loop of the cord should be drawn downward, as is done during the normal delivery of the breech. Rapid Extraction of the After-coming Head and Arms. — If, by any chance, either arm remains flexed upon the in- fant's chest, it may easily be drawn out when the elbow appears at the vulva ; but in the great majority of cases both arms will be extended beside the head, and their extraction is then more difficult. The method that should be chosen for their release must depend upon the point of the pelvis at which the shoul- ders become arrested. Low Arrest of the Arms and tl\e Head. — In easy extractions it is very often possible to bring the shoulders into sight outside the vulva by simple traction upon the thighs. In such cases it is frequently possible to extract the after- coming head and arms by the very easy and simple maneuvre known as Deventer's method. In this procedure the body of the child is dropped down- ward as soon as the points of the shoulders are in sight ; the feet are grasped with one hand, the fingers of the other hand being pressed upon the upper sur- face of the shoulders, and -the child is drawn vertically downward toward the floor, the mother being in the lithotomy position. Under this traction the occiput appears at the vulva, and the forehead and face follow coincidently with the arms. The mechanism by which this somewhat surprising delivery is accomplished is as follows : The method is applicable only wheu the pelvic space permits the head and the arms to enter the brim together, and both are then contained in the excavation when the shoulders are at the vulva. The arms are then in contact with the elastic sacro-sciatic ligaments, which stretch before them and permit them to lie by the side of the head. The chin is arrested by the pelvic floor ; the head extends, and thus brings the occiput to the vulva. The head is then delivered in extension, and the arms follow THE MECHANISM OF LABOR. 531 (Fig. 283). The original advocates of this method claimed that it rarely if ever tears the perineum, and the writer's experience with it certainly supports this claim. When the conditions permit the head and the arms to euter the pelvis together — that is, when the shoulders can be brought to the vulva by traction upon the thighs — Deven- ter's method, though not the most powerful, is cer- tainly by far the most rapid and easy of all the maneuvres for the release £g^ of the head and the arms, and it should always be j|* given a trial. It is nec- essarily inapplicable when the head and the arms are arrested at the superior strait, tion then only increases the difficulty. Combined Traction on the Face and Shoulders. — If the shoulders appear at the vulva, but Deventer's method fails, the arms must be delivered severally before the head can appeal - . Two fingers should be passed along the upper surface of the most easily accessible arm until their tips rest in the bend of the child's elbow. The elbow should then be urged backward and toward the me- dian line by the fingers, and be swept across the child's face to the vulva, at which the elbow, forearm, and hand appear in the order named. This process should then be repeated with the other arm. Pressure upon the shaft of the humerus should carefully be avoided, since it is certain to suap the bone. The child is then laid astride of one of the operator's fore- arms, and the hand belonging to this forearm is passed into the vagina until its first and second fingers lie upon the canine fossse of the child. The other hand is hooked over the shoulders, the neck being between its first and second fingers, with the finger-tips upon the supraclavicular region (Fig. 284). The hand that is hooked about the shoulders is then used to make traction upon the child, while the internal hand exerts itself to preserve the flexion of the head. The direction of the first tractions should be in the line of the axis of that part of the pelvis in which the child lies, and as the head emerges the line of traction should sweep forward in the curve of Cams until, at the end of the extraction, the body of the child rests upon the other forearm and along the abdomen of the mother (Fig. 285). When the mouth appears at the vulva Fig. 283.— Deventer's method of extraction of the after-coming head and arms. 532 AMERICAN TEXT-BOOK OF OBSTETRICS. and the mouth and pharynx have been cleared out, all hurry ceases, and the Fig. 284.— Delivery of the after-coming head by combined traction on the head and shoulders. operator's efforts should be directed to the preservation of the perineum. But little traction should now be used, aud the hand that was applied to the face should be used to shell out the head by pressure on the forehead through the perineum, or, if necessary, by passing two fin- gers into the rectum. High Arrest of the Arms and Head. — When the adap- tation between the head and the pelvis is not sufficiently easy to permit the simulta- neous entrance of the head and the arms into the pelvis, the arrest of the shoulders at the superior strait may be known by the fact that the child ceases to make progress, under tractions of ordinary strength, at about the time when the tips of the scapulre -Position of the child immediately after the escape -. , . , . of the after-coming head from the vulva. appear at the VUlva. At ttliS THE MECHANISM OF LABOR. 533 point of the extraction it is therefore important to watch for a marked increase of resistance, and when this is observed the tractions should immediately be intermitted, since their continuance only serves to lock the head and the arms securely in the brim, thus rendering the subsequent maneuvres for their release more difficult. The body of the child, in such an event, should be pressed slightly upward, and be rotated until the back is directed to one or the other side of the mother's pelvis. The hips should then be elevated gently toward the mother's abdomen and toward the side to which the back of the child is directed, moderate traction being exerted upon them at the same time. The object of this maneuvre is twofold : first, that space may be afforded for the passage of the hand into the vulva along the abdomen of the child ; secondly, that the posterior shoulder, which is usually the most accessible, may be brought as deeply into the pelvis as possible. The hand of the operator that naturally faces the abdomen of the child should then be passed rapidly into the vulva, with its palm flat against the abdomen and chest, until two fingers can be passed up along the arm of the child and their tips placed in position in the bend of the elbow. Xo pressure upon the arm should be made until this position is reached, but wheu it is attained the elbow should be drawn down across the child's face until the forearm and hand are within easy reach and can be brought to the vulva. If the hand passed along the abdomen fails to reach the elbow, the latter may sometimes be found by seizing the feet in that hand and drawing them gently upward and to the opposite side, so that the hand which before held the feet can be passed along the back of the child close under the pubic arch to the back of the posterior shoulder, and thence along the arm to the elbow, which, however, must, as before, be brought downward across the child's face. The hips of the child should then be swept downwai'd and traction be made upon the thighs, in the hope that the pelvic space may permit the entrance of the head -with the remaining arm, or at least bring the elbow within the reach of the fingers ; if this does not occur, the body of the child should again be pressed backward into the pelvis, and the child be so rotated that the arm which was anterior becomes posterior, when it should be released by the same method that was used in the extraction of the first arm. During this rotation the back of the child should sweep across the front of the mother's pelvis. This rotation may be effected either by grasping and turning the thorax with both hands or by drawing the already extracted arm forward along the side of the pelvis, between the labium and the back of the child. In rotating the child it must always be remembered that the articulations of the neck are so arranged that if the point of the chin be carried beyond the point of the shoulder a dislocation of the atlas upon the axis is the result. For this reason the thorax should be pushed strongly upward whenever an attempt at rotation is made, in order to free the head from the superior strait ; and the hands of the assistant should watch the head from above, that he may warn the operator if it fails to follow the shoulders. In the extraction of the head from the superior strait the method of combined traction upon face and 534 AMERICAN TEXT-BOOK OF OBSTETRICS. shoulders is usually the best, but it should then be reinforced by suprapubic pressure applied in the axis of the brim by the hands of an assistant. Difficult Extraction of the Head and the Arms. — Arrest of an Arm behind the Occiput. — It sometimes happens that the head rotates with the shoulders, but the arm is detained behind the pubes by friction against its walls. In such a case the arm crosses the nape of the neck and, if traction is made, becomes jammed between the occiput and the symphysis. If this accident is discovered before traction has been made, prompt rotation in the reverse direc- tion may unlock the arm, and in this case this reversed rotation should be continued until the arm becomes posterior — that is, through 180° ; but unless the first attempt unlocks the jam, the child will probably be lost, and it is then, perhaps, best to make direct traction upon the arm at the risk of fracturing the humerus, after forewarning those present that this must be the result, and that it is done in the interests of the child. Closure, of a Constriction-ring, or of an Imperfectly dilated Os, about the Neck. — The stricture of the canal formed by either of these conditions may embarrass the release of the arms, but it does not otherwise affect the above- described maneuvre, except that any abrupt or too forcible movements of the hand while within the uterus are even more dangerous in these cases than in others. The extraction of the head from the constricting band is, however, often a matter of great difficulty. Any attempt to overcome this obstruction by force exposes the mother to the most imminent danger of rupture of the uterus; and though steady traction upon the mouth and the shoulders should be given a fair trial, and may effect dilatation in time to save the child, it is in these cases that the application of forceps to the after-coming head is most often indicated. There can be no doubt of the truth of Lusk's observation, that " the forceps will sometimes bring the head rapidly through the cervix when traction upon the feet only serves to drag the uterus to the vulva." Gare should be taken, however, that this rapidity be not so great as in itself to cause a serious laceration. Arrest of the Head, at the Superior Strait by reason of an Unusual Size of the Head. — Most German and American obstetricians believe that the use of combined traction upon the face and the shoulders is the best method to adopt in arrest of the after-coming head at any point in the pelvis, and it should certainly be the first method tried in any given case; but as cases frequently occur in which the head can be delivered with far greater ease by a rapid alter- nation between two or more methods than by the continued use of any one alone, it is for this reason, if for no other,' well to be familiar with all the methods which have been found of value. The Prague Method. — -This maneuvre is often of service in effecting the engagement of the head and its initial descent into the superior strait. This is especially true in certain forms of -contracted pelvis and with operators whose muscular strength is inadequate to the really severe strain which is sometimes imposed upon the internal hand in the use of the combined method at the brim, but it is usually inferior to the combined method after the greatest diam- THE MECHANISM OF LABOR. 535 eter of the head has passed the' superior strait. Like all methods of manual extraction, it is greatly increased in value by the application of proper supra- pubic pressure by an assistant. In executing the Prague method the feet are seized by one hand and the borlv is drawn as far downward as the perineum allows ; the other hand is V Fig. 2S6.— Delivery of the after-coming head by flexion through seizure of lower jaw, and extrusion by means of pressure in axis of brim. then hooked over the shoulders, and traction is made by both hands simul- taneously (Fig. 287). As the head enters the excavation the body is swung rapidly upward, and the remainder of the delivery is accomplished by upward Fig. 287.— Prague method of extracting the after-coming head, superior strait. traction on the feet, while the hand upon the neck promotes flexion by retard- ing the descent of the occiput (Fig. 288). The chief disadvantage of the Prague method lies in the fact that all the force exerted by the operator is expended upon the child's neck, and that the amount of force that can safely h: applied is therefore less than in the combined method. 536 AMERICAN TEXT- BOOK OF OBSTETRICS. Arrest from Extension of the Head. — This condition is rare unless in im- properly conducted extractions, but if, by any clumsiness on the part of the operator, the abdomen of the child has been directed to the front during the liberation of the arms, and the chin is therefore arrested at the symphysis, the Prague method should be used through- out. Iu this case the direction of the first traction should be nearly horizontal (Fig. 289), and as the occiput descends the body of the child should be raised until, wheu the head emerges from the vulva, the line of traction is nearly parallel with the mother's abdomen.* Forceps to the After-coming Head at the Superior Strait. — The use of the forceps is generally believed to be the most powerful and certain means of overcoming difficult cases of high arrest of the after-coming head. This ope- ration is, however, often difficult, and the time occupied in the application of the forceps may be of vital importance to the child. Moreover, there are but few cases in which a skilled operator, aided by efficient suprapubic pressure, fails to deliver by manual extraction ; but as such cases do occasionally occur, the forceps should always be at? hand before the delivery is attempted. If Fig. life— Prague method of extracting the afte coming head, inferior strait. Fig. 28s.— Extraction of after-coming head, chin arrested at symphysis. forceps be used, the body should be raised to a nearly vertical position, and the * If forceps is necessary, the instrument should be applied under the child's body, and should extract by the same mechanism. THE MECHANISM OF LABOR. 537 forceps should be passed into place upon the sides of the head, beneath the abdomen of the child. An axis-traction model should be preferred. Arrest of the Head at the Inferior Strait or on the Perineum. — Cases in which manual extraction by the combined method fails to overcome a low arrest are extremely rare, but if forceps be required the application and extrac- tion are always easy. Arrest of the Head due to Contraction of the Pelvis. — In the ordinary form of contraction the arrest is always, at the brim, and after the head has passed the superior strait the subsequent delivery is easy. A breech presentation should never be allowed to persist as such in ajusto- minor pelvis, but if it has not been corrected the inevitable arrest of the head at the superior strait should be met by extreme flexion and by the application of forceps, followed by craniotomy if not promptly successful. In all flat pelves, and in flat pelves only, the head enters the superior strait in the transverse diameter, and the passage of the strait is most easily effected in a somewhat extended position, in which the biparietal diameter is received by one of the sacro-iliac notches, while the lesser bimastoid diameter is opposed to the contracted conjugate : if, then, the hand, when it is passed into the vagina for combined traction, finds the head transverse, it should allow extension to go on until the face begins to approach the side wall of the pelvis or until the greatest diameter of the head has passed the superior strait; when this has occurred flexion should promptly be restored, and rotation and de- livery will then rapidly follow. In simple fled pelves the application of forceps to the after-coming head is rarely successful after manual extraction has failed, but in pelves of the gen- erally-contracted flat type, if the transverse diameter is markedly diminished, the mechanism approaches that of a normal or justo-minor pelvis, and if the breech presents and efforts at manual extraction of the head fail, the appli- cation of the forceps may be tried. 5. Footling Presentations. Mechanism and Management. — The mechanism of footling presentations is in no way different from that of presentations of the whole breech. The treatment varies only in that in a rapid extraction there can be no question as to the choice of operation. 6. Transverse Presentations. Under transverse presentations are included presentations of any portion of the trunk ; but as all transverse presentations soon change to presentations of the shoulder, it is only necessary to speak of the latter. Frequency. — Transverse presentations occur in from 1 in 150 to 1 in 300 of all cases of labor. Thus, Spiegelberg made the proportion 1 in 180; Churchill, 1 in 252 ; and the Guy's Hospital Reports, 1 in 297 (or .32 per cent, out of 22,980 cases of labor). The positions are of but little importance. Etiology. — Transverse and breech presentations are produced by the same 538 AMERICAN TEXT-BOOK OF OBSTETRICS. causes (see p. 520), but iu transverse presentations the influence of pelvic de- formities is somewhat more important, since, if the head cannot enter the brim, it may slip to one side and permit the shoulder to enter even after labor is well under way. Diagnosis. — On abdominal examination the longest diameter of the uterus is transverse; the head is found in one flank, and the breech in the other. On vaginal examination the finger may be able to recognize the clavicle and the spinous process of the scapula, and to ascertain that there is but one limb attached to the presenting part, but the vaginal diagnosis is apt to be obscure unless an arm is prolapsed. Prognosis. — As the termination of a transverse presentation by natural labor is extremely rare, the prognosis for both mother and child is necessarily that of the operation undertaken. When the abnormality is detected and treated early, the prognosis for both patients should be fairly good, but it becomes worse in proportion to the length of time during which the case is allowed to go on untreated. Mechanism and Management of Transverse Presentations. Mechanism of Transverse Presentations. — Since natural delivery so rarely occurs iu transverse presentations, the later stages of the mechanism by which it is effected are of small practical importance; but, notwithstanding the rarity of its completion, its earlier stages are rendered not unimportant by the fact that success in the delivery of impacted shoulders rests upon a thorough comprehension of the processes by which the impaction was effected, this being, in fact, the first stage of the mechanism of natural delivery in transverse presentations. The process is commonly known as the " spontaneous evolution of the fetus." Any part of the trunk may present at the beginning of labor; but as the fetus is crowded down into the brim, the shoulder inev- itablv enters deepest in persistent transverse presentations, and, since the shoul- der always becomes anterior early in labor, it is only necessaiy to describe the anterior form. In the anterior form the supraclavicular region corresponds, at the time of the entrance of the shoulder, with the anterior end of one oblique diameter at the brim, the lower portion of the thorax lying at the posterior end of the same oblique diameter. The full width of the shoulder enters the pelvis, and this portion of the child is then fixed iu position by contact of the neck with the horizontal ramus of the pubes. Under the influence of the driving power of the uterus above, the lower portion of the thorax is forced more and more deeply into the posterior half of the pelvis by a lateral inflection of the body of the child upon itself. The trunk then dips into the excavation, the true ribs, false ribs, abdomen, and pelvis of the fetus entering in the order named (Fig. 290). If the child is sufficiently flexible and if the uterus is sufficiently powerful to complete the delivery, this process of lateral inflection of the trunk goes on until the pelvis of the child appeal's at the vulva, and with its expul- sion the case is converted by spontaneous evolution into a presentation, or THE MECHANISM OF LABOR. 539 rather au expulsion, of the breech, in which, however, one shoulder is already within the pelvis and one arm is already delivered. A second and very much more rare form of delivery in persistent trans- verse presentations is seen only with immature fetuses, aud it can seldom occur unless maceration is far advanced. In it the prolapsed shoulder is driven forward through the pelvis, the head of the child being crowded into the pel- vis with the body (Fig. 291). The shoulder is the leading point, and it should 290 — Spontaneous evolution, first form rotate to the arch, but when this process is possible the body is always so small and soft that the mechauism is usually but little marked. Management of Transverse Presentations. — The prognosis of sponta- neous evolution is so bad for both child and mother that transverse presenta- tions should never be left to nature, and the question of the treatment is sim- ply the question of the choice of the operation to be adopted. Three opera- tions are applicable to the treatment of transverse presentations in its various stages — the several varieties of version, decapitation, and exenteration, the choice between them depending upon the stage of labor at which the presentation is detected. Version. — If the presentation is detected before any portion of the trunk is deeply engaged, and while the membranes are still unruptured, one or the other of the external versions should be chosen. If the abdomen or the hip presents, pelvic version will usually be the easiest, aud for this reason should generally be preferred ; if the conditions are such as to render cephalic version easy and if the pelvis is normal, cephalic version should be performed. If the shoulder presents, cephalic version should be chosen, except in a flat pelvis, where the shape of the inlet makes a breech presentation the presenta- 540 AMERICAN TEXT-BOOK OF OBSTETRICS. tion of choice. In such cases an external pelvic version would naturally be chosen. If, at the time an operation is undertaken, the shoulder has already entered the pelvis, but the conditions of the case are still such as to permit of version, a bipolar, cephalic, or pelvic version should be performed. If, at the time when interference is decided upon, the membranes are already ruptured, and especially if the shoulder is already well crowded into the pelvis, the external and bipolar methods will usually be impossible, and internal podalic version must be chosen. Internal Podalic Version in Trans- verse Presentations. — This operation differs from internal version in head presentations only in the choice and method of introducing; the hand, in the Fig. 291.— Spontaneous evolution, second and rare form of mechanism, known as birth with double body (one-sixth natural size, redrawn from Kiistner). Fig. 292.— Frozen section of shoulder presen- tation (Chiara): the distortion and the elonga- tion of the neck are noteworthy. frequent occurrence of a prolapsed arm, and in the method of raising an impacted shoulder. In raising the shoulder it is necessary to remember the mechanism of the method by which nature deals with a neglected transverse presentation — that of spontaneous evolution. In this process, as has been said, the trunk enters the pelvis at the brim in an oblique diameter, but as it is forced farther down the shoulder rotates to the front and becomes fixed there, while the thorax and the abdomen are crowded into the posterior portion of the pelvis by flexion upon themselves (Fig. 290). Now, so long as the position is still oblique, and if flexion of the trunk has not begun, the presenting part may easily be raised by pressure upon the shoulder in the axis of the superior strait ; but so soon as the shoulder lias rotated to the front and the thorax has entered the pelvis, it is essential that the process of relieving the impaction should begin by the return of the part which entered last — that is, of that portion of the thorax and the abdomen still lying opposite the sacro-iliac synchondrosis. No pressure must be exerted upon the shoulder itself until the trunk again occupies an oblique position. It will be seen that the process of unlocking the impaction is by a direct reversal of the mechanism of spon- THE MECHANISM OF LABOR. 541 taneous evolution. Of course, during this whole process the most careful counter-pressure must be maintained at the fundus. In simple cases a prolapsed arm may be used as a convenient handle by which to push up the shoulder, and in all cases it is well to begin the opera- Fig. 293.— Direct method of seizing a foot in ver- sion for transverse presentations. Fig. 294.— Direct method of seizing a foot in ver- sion for transverse presentations. tiou by noosing a fillet around the prolapsed wrist. This fillet answers a double purpose: First, it may be used to draw the arm out of the way of the operating hand; second, during the process of extraction slight tractions on the fillet will prevent the extension of that . arm, thus greatly facilitating the delivery ; but care must be taken to remove the noose as soon as possible, for cases are on record in which sloughing of a member has followed the too prolonged or violent use of a fillet. In the search for a foot two methods may be used : The hand that corresponds with the position — that is, left position, left hand — may be passed along the back and over the buttocks to the thigh and leg (Fig. 295), or the hand may be passed across the ab- domen and directly to the feet (Figs. 293, 294). The first, which is the surer way, should, as a rule, be preferred, but the latter method is often the easier, especially in ab- domino-anterior positions. Much has been written on the advantage to be gained by se- lecting the superior foot in version for transverse presentation; but as this view has never obtained much credence outside of England, and asGalabin, one of the latest British authorities, not only disapproves of this practice, but gives a very convincing mechanical proof of the fallacy of the theory which prompted it, Fig. 295.— Method of reaching the foot by first passing the hand around the breech. 542 AMERICAN TEXT-BOOK OF OBSTETRICS. the subject need only be mentioned here. Unless special care be taken to select the superior foot, the lower foot is almost invariably seized. Treatment of Neglected Transverse Presentations. — When a transverse pres- entation has been so long neglected that the release of the shoulder is thought to involve more danger to the mother than it would be justifiable to incur in the interests of the child, or when the child is already moribund or dead, one or the other of the appropriate destructive operations must be undertaken. If the neck is at this time within reach, decapitation should be selected. If the process of spontaneous evolution has gone so far that it would be diffi- cult or impossible to apply the decapitator to the neck, an exenteration should be chosen, and after the abdomen and the thorax have been emptied of their contents the operator must use his judgment as to whether it is safer to break the vertebral column and extract the child still doubled up upon itself, or to draw the fetal pelvis into that of the mother by traction with the fingers from within its cavity. 7. Prolapsed Extremities. Presentation of the Head and a Hand. — When a hand prolapses and enters the pelvis with the head, it is most commonly placed at one end of the bitemporal diameter. Its presence then generally results in delay through the increased size of the presenting part, and it may occasionally interfere with rotation. If the hand is placed against the occipital end of the head, its presence may delay the descent of the occiput and thus produce extension at the brim. This abnormality usually causes a delay sufficient to induce exhaustion on the part of one or the other patient, and thus indicates opera- tive interference ; but if such an indication does not arise, the ultimate result in most cases is that the head slips by the prolapsed arm, after a greater or longer period of delay, and is thus eventually born by a natural labor. Prognosis. — If the presentation is detected early, the prognosis is little dif- ferent from that of normal labor, and even when detected after a moderately long second stage it is influenced by the treatment, and should never be grave. Treatment.— An attempt should be made to push back the prolapsed hand with the fingers, and, if extension has occurred, to restore flexion by pressure upon the forehead with the hand. Should this effort fail, an operative delivery must be resorted to, the choice of operation depending upon the position of the head. If good flexion is present, the forceps should be applied, but care must be taken to introduce the blade between the hand and the head, and great care will be necessary to avoid fracture of the fingers, the hand, or the wrist. If the application fails to do injury, the prognosis of the operation is good, since the tractile force is applied to the head while the hand is still ex- posed to friction against the pelvis ; the head thus always slips past the hand. When marked extension is present, if manual flexion fails or if the head is already much moulded toward the configuration of a brow, internal podalic version should be performed. Presentation of a hand and a foot is decidedly more rare than the above ; its prognosis and treatment are, however, similar. NDEX. Abdomen, hydatid of, in pregnancy, 224 Abdominal auscultation, 460 binder after labor, 433 changes in pregnancy, 168 examination in diagnosis of fetal presenta- tion and position, 406 in labor, 457, 461 muscles in labor, action of, 373 palpation in labor, 457 stalk, 85 walls in pregnancy, changes in, 152 Abnormal presentations, 436 Abortion, 312 cause of, 313 complete, 317 treatment of, 323 diagnosis, differential, 319 duration of, 314 frequency of, 312 habitual 317 incomplete, 317 treatment of, 323 inevitable, 317 treatment of, 322 mechanism of, 314 missed, 317 treatment of, 324 prognosis of, 319 signs of, 313 symptoms of, 313 threatened, 317 treatment of, 322 treatment of, 321 varieties of, 317 Accidents and injuries during pregnancy, 297 and surgical operations during pregnancy, 293 After-care of labor, 432 Albuminuria in pregnancy, 158, 221, 276 treatment of, 276 Alcock's canal, 30 Aleeithal, 78 Allantoic circulation, 104 Allantois, 85 Amnion, S4 diseases of, 300 Amniotic adhesions. 304 Amniotic bands in fetus, 351 Ampullae, 68 Amputation of pregnant uterus, 295 Anemia in pregnancy, 278 treatment of, 280 Anesthesia in labor, 412 Anesthetics in labor, choice of, 413 method of administration, 413 Antisepsis in labor, 391 Appendicitis in pregnancy, 274 Areola, 66 Arteries of fetus, development of, 108 Articulations between fetal head and spinal column, 456 Ascites in pregnancy, 272 Attitude of fetus, 434 Auscultation, abdominal, 460 focus of, 404 Bacteria in genital tract in pregnancy, 213 Bag, obstetric, 411 of waters, 139. See also Liquor Amnii. Ballottement, 169 Bathing in pregnancy, 184 Bed, preparation of, in labor, 410 Beginning labor, signs of, 383 Bimastoid diameter, 453 Binder, abdominal, after labor, 433 Biparietal diameter, 453 Bitemporal diameter, 453 Bladder, female, 41 in pregnancy, 220 functional disturbances of, 164 of fetus, development of, 122 Blastodermic stage, 95 Blastomeres, 7S Blastula, 78 Blighted ovum, 317 Blood-islands of Pander, 105 Body, fetal, 456 Boiling, sterilization by, 393 Brain-case, anatomy of, 452 Brain fetus, development of, 126 Braxton Hick's sign of pregnancy, 169 Breech presentations, 520 management of, 524 mechanism of, 520 543 544 Breech presentations, positions of, 437 prognosis of, 467 Bregma, 453 Broad-ligament pregnancy, 333 Brow presentations, 516 management of, 517 mechanism of, 516 positions of, 437 prognosis of, 467 Bulbi vestibuli, 38 Canax of Xuck, 53 parturient, anatomy of, 43S Cancer in pregnancy, 2S5 of uterus in pregnancy, 191 treatment of, 194 Caput succedaneum, formation of, 382 Cardiac disease in pregnancy, 280 Carunculae myrtiformes, 40 Carus, curve of, 439, 447 Catalepsy in pregnancy, 256 Catheterization after labor, cleanliness in, 397 Caul, 382 Celom, 83 Cephalic presentations, frequency of, 467 Cerebral hemorrhage in pregnancy, 250 thrombosis in pregnancy, 250 Cervical lacerations after labor, repair of, 428 Cervicobregmatic diameter, 453 Cervix, anatomy of, 47 diseased, in pregnancy, treatment of, 185 during labor, changes in, 374 dilatation of, 376 i epithelioma of, in pregnancy, 194 in pregnancy, changes in, 165 Cesarean section in eclampsia, 242 Cholera in fetus, 351 in pregnancy, 290 treatment of, 291 Chorda dorsalis, 82 symptoms of, 254 treatment of, 255 Chorea in pregnancy, 252 Chorion, 86 diseases of, 304 hydatidiform degeneration of, 304 cause of, 306 diagnosis, differential, 307 symptoms of, 306 treatment of, 307 myxoma diffusum of, 307 fibrosum of, 307 Chromatin, 75 ■ 'liromosomes, 75 Circulation, allantoic, 104 fetal, 137 Circulatory system in fetus, development of, ' 104 in pregnancy, changes in, 154 Cleanliness in catheterization after labor, 397 of nurse in labor, 396 of patient in labor, 396 of the obstetrician, 394 Clitoris, 38 Clothing in pregnancy, 184 Coccygeus, 28 Coitus in pregnancy, 184 Colles' fascia, 31 Complete abortion, treatment of, 323 Conceptions, multiple, 143 Conduct of labor, 391 Conjugate diameter of pelvis, 44 Contraction-ring and retraction-ring, differen- tiation, 378 Contractions, intermittent, in pregnancy, 169 Cord, umbilical, 311. See also Umbilical Cord. Cranium of fetus, anatomy of, 452 Crede's method of expulsion of placenta, 427 Curve of Cams, 439, 447 Cystitis in pregnancy, 220 Cysts of placenta, 309 Death, habitual, of fetus, 361 of fetus, 359 diagnosis of, 359 Deeidua, S7 and fetal membranes, infection of, in preg- nancy, 205 hypertrophy of, in pregnancy, 197 Deciduitis, 309 Deciduoma benignum, 319 Deformities and malformations of fetus, 351 of special regions and organs of fetus, 353 Delivery, face to pubes, 507 in persistently posterior positions, 507 of trunk, 424 Descent in dry labor, mechanism of, 481 Diabetes in pregnancy, 257 pathology of, 259 treatment of, 258 Diameter, bimastoid. 453 biparietal, 453 bitemporal, 453 cervico-bregmatie, 453 fronto-mental, 453 occipito-frontal, 453 occipito-mental, 453 suboccipito-bregmatic, 453 Diameters of pelvis and fetal head, relative value of, 454 INDEX. 545 Diet in pregnancy, 183 Digestive system in fetus, development of, 113 physiology of, 141 in pregnancy, changes in, 156 Dilatation of cervix during labor, 376 of os uteri, normal mechanism of, 474 stage of labor, 38-5 duration of, 386 management of, 417 mechanism of, 473 Disinfection of hands, Furbringer's method, 393 permanganate method, 395 practical rules for, 393 Douglas's pouch, 44, 47, 54, 151 Dressing, vulvar, after labor, 432 Dressings, sterilization of, 393 Dry heat, sterilization by, 393 labor, mechanism of descent in, 481 Ductus arteriosus, 138 venosus, 137 Duration of labor, 390 of pregnancy, 179 Ear of fetus, development of, 133 Eclampsia, 237 and epilepsy, diagnosis, differential, 248 cause of, 238 Cesarean section in, 242 disease similar to, 243 mortality from, 242 susceptibility to, 238 symptoms of, 237 treatment of, 240 Ectoderm, 79 Ectopic pregnancy, 324. See also Extra-uterine Pregnancy. Elbow and knee, presentations of, 466 Elephantiasis of labia in pregnancy, 212 Endometritis in pregnancy, 204 treatment of, 204 Entoderm, 79 Epilepsy and eclampsia, diagnosis, differential, 248 in pregnancy, 24S Episiotomy during labor, 423 Epithelioma of cervix in pregnane)', 194 Erysipelas in pregnancy, 287 treatment of, 287 of fetus, 351 Exercise in pregnancy, 183 Expulsion, mechanism of, 4S7 of head, management of, 421 of placenta, method, Crede's, 427 stage of labor, 386 duration of, 388 Expulsion stage of labor in vertex presenta- tions, mechanism of, 480 management of, 418 Extra-uterine pregnancy, 324 after rupture, treatment of, 343 at time of rupture, treatment of, 340 before rupture, treatment of, 339 cause of, 328 diagnosis of, 176, 336 fetus in, 333 history of, 324 operation in, 341 preparation for operation in, 340 primary forms of, 329 rupture in, 335 secondary forms of, 330 symptoms of, 334 treatment of, 339 Eye of fetus, development of, 130 Face of fetus, anatomy of, 452 presentations, 437, 465, 508 management of, 512 mechanism of, 510 positions of, 437 posterior, mechanism of, 512 prognosis of, 466 to pubes delivery, 507 Fallopian tubes, affections of, in pregnancv. 296 False knot, 312 pelvis, anatomy of, 439 Fascia? of pelvis, 29 Female and male pelvis, differences between, 448 bladder, anatomy of, 41 generative organs, anatomy of, 36 physiology of, 70 ureter, anatomy of, 41 urethra, anatomy of, 40 Fetal body, anatomy of, 456 circulation and maternal circulation, rela- tion of, 140 circulations, 137 contour, 172 head, anatomy of, 452 and spinal column, articulations between, 456 dimensions of, 453 sutures of, 452 heart-sounds, 170 membranes and decidua, infection of, in pregnancy, 205 physiology of, 84 movements, 169 influence of, on presentations, 471 54G INDEX. Fetus, amniotic bands in, 351 anatomy of, 451 and uterus in presentations, adaptation between, 470 arteries in, development of, 108 attitude of, 434 bladder in, development of, 122 brain in, development of, 126 changes in structure of, after death, 360 cholera of, 351 circulatory system in, development of, 104 death of, 359 diagnosis of, 359 or life of, diagnosis of, 178 deformities and malformations in, 351 of special regions and organs of, 353 determining length of, 104 development of, 74 external form, 95 in eighth month, 102 in fifth month, 102 in fourth month, 102 in fourth week, 96 in ninth month, 102 in second month, 100 in seventh month, 102 in sixth month, 102 in third month, 101 in third week, 96 in thirteenth and fourteenth days, 95 digestive tract in, development of, 141 physiology of, 141 diseases of, 346 double formations of, 357 ear in, development of, 133 , erysijielas of, 351 excessive development of, 357 eye in, development of, 130 generative organs in, development of, 122 genito-urinary organs in, development of, 119 growth of, 137 habitual death of, 361 heart in, development of, 105 in extra-uterine pregnancy, 333 infections of, 347 kidneys in, before birth, secretion of, 141 life or death of, diagnosis of, 178 liver in, development of, 119 luxations in, 352 malaria of, 350 measles of, 350 metabolic changes in, 140 nervous system in, development of, 126 neural canal of, development of, SI nutrition of, 137 Fetus, pancreas in, development of, 119 papyraceus, 145 physiology of, 137 recurrent fever of, 351 respiratory changes in, 140 tract in, development of, 119 salivary glands in, development of, 119 scarlet lever of, 350 septicemia of, 350 sex of, diagnosis of, 172 small-pox of, 350 special sense organs in, development of, 130 spinal cord in, development of, 126 syphilis of, 347 diagnosis of, 348 treatment of. 349 tuberculosis of, 351 tumors of, 353 typhoid fever of, 349 veins in, development of, 111 yellow fever of, 351 Fibromyomata, 1S8 First stage of labor, 385 duration of, 386 management of, 417 mechanism of, 473 Flexion, mechanism of, 4S2 Focus of auscultation, 404 Fontanelle, anterior, 453 posterior occipital, 453 Fontanelles, 452 Foot and hand, presentation of, 542 presentation of, 465 Footling presentations, management of, 537 mechanism of, 537 Fore-gut, 114 Forewaters, 139. See also Liquor Amrtii. Fractures in utero, 352 Fronto-mental diameter, 453 Funic souffle, 172 Furbringer's method of disinfection of hands, 394 Gait in pregnane}', changes in, 157 Gartner's duct, 62 Gastric ulcer in pregnancy, 274 Gastrula stage, 79 Generative organs, female, anatomy of, 36 physiology of, 70 in fetus, development of, 122 Genital tract, bacteria in, in pregnancy, 213 Genitals, external, in pregnancy, changes in, 151 Genito-urinary organs in fetus, development of, 119 INDEX 547 Glands of Bartholin, 38 of Montgomery, 66 Goiter in pregnancy, 27S Gonorrhea in pregnancy, 282 Gravity, influence of, on presentations, 468 Hand and foot, presentation of, 542 and head, presentation of, 542 presentation of, 465 Hands, sterilization of, 394 Fiirbringer's method, 393 permanganate method, 395 Head and hand, presentation of, 542 diameters of, and diameters of pelvis, rela- tive value of, 454 expulsion of, management of, 421 fetal, anatomy of, 452 and spinal column, articulations be- tween, 456 dimensions of, 453 sutures of, 452 Heart of fetus, development of, 105 Heat, dry, sterilization by, 393 Hegar's sign of pregnancy, 166 Hematuria in pregnancy, 220 Hemoptysis in pregnancy, 281 Hemorrhage in pregnancy, 281 concealed accidental, of pregnancy, 225 diagnosis of, 226 uterine, in pregnancy, 281 Herpes in pregnancy, 248 prognosis of, 249 treatment of, 249 Hind-gut, 115 Hydatid, abdominal, in pregnancy, 224 Hvdatidiform degeneration of chorion, 304 Hydramnion, 300 diagnosis, differential, 302 influence on labor, 303 pathology of, 300 prognosis of, 302 symptoms of, 302 treatment of, 303 Hydrocephalus, 356 Hydrorrhrea gravidarum, 381 Hygiene of pregnancy, 183 Hymen, 39 Hypertrophy of decidua, 197 of uterus, 188 Hysterectomy for myomata of uterus, 190 Hysteria, influence of pregnancy on, 247 in pregnancy, 260 Impregnation and segmentation, 77 Incomplete abortion, treatment of, 323 Inevitable abortion, treatment of, 322 Inferior strait of pelvis, 442 vena cava, 113 Infrapelvic portion of parturient canal, 439 of pelvis, 447 Injuries and accidents during pregnancy, 297 Instruments, sterilization of, 393 Intercourse, sexual, in pregnancy, 184 Intermittent contractions, 169 Interpubic disk, 23 Interstitial pregnancy, 332 rupture of sac in, 332 Intervertebral disk, 25 Intrapelvic signs of pregnancy, 164 Jelly of "Wharton, 95 Kidney of pregnancy, 220 Kidneys in fetus, secretion of, 141 Kiestein in pregnancy, 164 Knee and elbow, presentations of, 466 Labia, elephantiasis of, 212 majora, 37 minora, 37 Labor, 368 abdominal binder after, 433 examination in, 457, 461 muscles in, action of, 373 palpation in, 457 after-care of, 432 and pregnancy, spinal irritations compli- cating, 251 anesthesia in, 412 anesthetics in, choice of, 413 method of administration, 413 antisepsis in, 391 bed in, preparation of, 410 beginning, signs of, 383 catheterization after, cleanliness in, 397 cause of, 36S cervical lacerations after, repair of, 428 cervix during, changes in, 374 dilatation of, 376 classification of, 436 cleanliness of hands during, 394 of nurse during, 396 of patient during, 396 conduct of, 391 course of, 383 date of, prediction of, 181 delivery of trunk in, 424 diagnosis of, 457 frequency and prognosis of, 457 dilatation stage of, 385 duration of, 386 management of, 417 548 INDEX. Labor, dilatation stage of, mechanism of, 473 disinfection in, 393 dry, 481 descent in, mechanism of, 481 duration of, 390 episiotomy during, 423 examination during, 415 expulsion of head in, management of, 121 stage of, 38b' duration of, 388 management of, 418 in vertex presentations, mechan- ism of, 480 external measurements of pelvis in, 407 first stage of, 385 duration of, 386 management of, 417 mechanism of, 473 influence of hydramnion on, 303 lacerations after, repair of, 428 of pelvic floor after, 429 ligaments in action of, 373 location of orifice in, 377 lower uterine segment in, changes in, 377 thickness of, 379 lying-in room in, 409 management of, 398 of cord in, 424 mechanism of, 434 nurse's preparation in, 409 obstetric bag in, 411 examination in, 399 position in, 418 pains, 371 amount of force exerted by, 373 change in shape of uterus during, 373 Ideation of, 372 patient after, toilet of, 432 in, preparation of, 411 pelvic floor during, changes in, 388 prevention of injuries to, 419 physiology of, 368 placental stage of, 390 duration of, 390 management of, 426, 492 mechanism of, 490 position during, 418 rupture of membranes during, 418 second stage of, 3S6 duration of, 388 in vertex presentations, mechan- ism of, 480 management of, 418 stages of, 385 third stage of, 390 duration of, 390 Labor, third stage of, management of, 426, 492 mechanism of, 490 uterus during, changes in, 379 vagina during, action of, 374 vaginal examination in, 408, 461 frequency of, 419 vulvar dressing after, 432 Lacerations after labor, repair of, 418 cervical, after labor, repair of, 428 of pelvic floor after labor, 429 Lactiferous duct, 67 Levator ani, importance of, 27 Ligaments in labor, action of, 373 Ligation of umbilical cord, 425 Liquor amnii, 139 character of, 382 variations in, 304 Lithopedion, 334 Liver, atrophy of, in pregnancy, 273 of fetus, development of, 119 Longitudinal presentations, 436 Luxations in fetus, 352 Lying-in room, 409 Malaria of fetus, 350 Male and female pelvis, differences between 448 pronucleus, 77 Mamma?, anatomy of, 65 blood-vessels of, 69 nerves of, 70 size of, 65 Mammary changes during pregnancy, 163 glands in pregnancy, changes in, 152 treatment of, 1S7 Mammillae, 65 Mania in pregnancy, 260 treatment of, 261 Maternal circulation and fetal circulation, relation of, 140 impressions, 251, 357 organs, changes in, in pregnancy, 146 Measles in pregnane}', 288 t of fetus, 350 Meconium, 142 Meningitis in pregnancy, 251 Menstruation, physiology of, 72 stages of, 72 suppression of, in pregnancy, 162 Mental condition of pregnancy, 173, 185 Mesoderm, 80 Mid-gut, 115 Miscarriage, 312 Missed abortion, 317 treatment of, 324 Moles, tubal, 331 INDEX. 549 Mons veneris, 37 Morning sickness, 101 Morula, 7S Mouth and teeth, diseases of, in pregnancy, 277 treatment of, 277 Mulberry mass, 78 Mullerian ducts, 12L Mailer's ring, 149 Multiple conceptions, 143 pregnancy, diagnosis of, 177 Muscles, abdominal, in labor, action of, 373 Myomata of uterus in pregnancy, 188 hysterectomy for, 190 treatment of, 190 Myomatous tumors, influence upon pregnancy, 294 Myomectomy during pregnancy, 294 Myomotomy during pregnancy, 294 Natural presentations, 436 Nausea and vomiting in diagnosis of preg- nancy, 161 of pregnancy, 261 diagnosis of, 262 treatment of, 266 Nervous system, changes in, in pregnancy, 160 development of, in fetus, 126 disorders of, in pregnancy, 245 poisonings of, in pregnancy, 257 Neuralgia in pregnancy, 245 Normal presentations, 436 Nurse, cleanliness of, in labor, 396 preparation of, in labor, 409 Nutrition, changes in, in pregnancy, 156 Oblique diameters of pelvis, 442 Obstetric antisepsis, 394 bag, 411 diameter of pelvis, 442 examination in labor, 399 position in labor, 418 Obstetrician, cleanliness of, 394 Occipito-frontal diameter, 453 Occipito-mental diameter, 453 Oligohydramnios, 303 Os uteri, dilatation of, normal mechanism of, 474 Osseous elements in pregnancy, changes in, 157 Otic pit, 133 vesicles, 133 Ovarian tumors in pregnancy, 208 Ovaries, 57 Ovariotomy in pregnancy, 208 Ovary, diseased, in pregnancy, 206 Ovary, diseased, in pregnancy, treatment of, 207 tumors of, in pregnancy, 295 Oviducts, 56 ( Ivulation, 70 Ovum, blighted, 317 diseases of, in pregnancy, 300 fertilization of, 74, 77, 180 maturation of, 74 segmentation of, 77 Pains of labor, 371 amount of force exerted by, 373 change in shape of uterus during, 373 location of, 372 Palpation, abdominal, in labor, 457 differential diagnosis of presentation by, 459 in diagnosis of breech presentations, 459 of position, 459 of presentation, 458 of transverse presentations, 459 Pancreas of fetus, development of, 119 Paroophoron, 62 Parovarium, 62 Parturient canal, anatomy of, 438 Patient after labor, toilet of, 432 cleanliness of, in labor, 396 preparation of, in labor, 411 Pelvic floor, anatomy of, 30 changes in, in labor, 388 in pregnancy, 152 lacerations of, after labor, 429 prevention of injuries to, in labor, 419 ligaments, relaxation of, in pregnancy, 228 peritoneum, changes in, in pregnancy, 150 Pelvimeter, Schultze's, 411 Pelvis, anatomy of, 17, 438 articulations of, 22 changes in, in pregnancy, 151 conjugate diameter of, 442 diameter of, and diameters of fetal head, relative value of, 454 dimensions of, 20 excavation of, 440, 444 external measurement of, in labor, 408 fasciae of, 29 in pregnancy, examination of, 186 male and female, differences between, 448 oblique diameters of, 442 obstetrical diameter of, 442 position of, 20 transverse diameters of, 442, 444 Peptonuria in pregnancy, 276 treatment of, 276 Peritonitis in pregnancy, 224 550 INDEX. Permanganate method of sterilizing the hands, 395 Placenta, 87 anomalies of, 307 calcareous deposits in, 308 cysts of, 309 edema of, 308 expulsion of, Crede's method, 427 fatty degeneration of, 308 fibrous degeneration of, 308 inflammation of, 308 myxomatous degeneration of, 308 structure of, 91 syphilis of, 309 tuberculosis of, 310 tumors of, 309 Placental apoplexies, 310 circulation, 139 infarcts, 310 marginata, 310 souffle, 461 stage of labor, 390 duration of, 390 management of, 426, 492 mechanism of, 490 Plethora, loo Pneumonia in pregnancy, 289 prognosis of, 290 treatment of, 290 Polyneuritis in pregnancy, 247 Position and presentation, diagnosis of, 400 definition of, 436 diagnosis of, by palpation, 459 persistently posterior, delivery in, 507 Pouch of Douglas, 44, 47, 54 Pregnancy, 74 abdominal, changes in, 168 examination in, 186 walls in, changes in, 152 accidents and injuries during, 297 and surgical operations during, 293 acute infections in, 282 albuminuria in, 158, 221, 276 treatment of, 276 and labor, spinal irritations in, 251 anemia in, 278 treatment of, 280 appendicitis in, 274 articulations of pelvis in, changes in, 151 ascites in, 272 atrophy of liver in, 273 bathing in, 184 bladder in, functional disturbances of, 164 cancer in, 285 cardiac disease in, 280 catalepsy in, 256 Pregnancy, cerebral hemorrhage in, 250 thrombosis in, 250 cervix in, changes in, 165 cholera in, 290 prognosis of, 291 treatment of, 291 chorea in, 252 symptoms of, 254 treatment of, 255 circulator}' system in, changes in, 154 clothing in, 184 coitus in, 184 cystitis in, 220 death during, 249 diabetes in, 257 pathology of, 259 treatment of, 258 diagnosis of, 161 differential, 174 nausea and vomiting in, 161 diet in, 183 digestive system in, changes in, 156 duration of, 179 eclampsia in, 237. See Eclampsia. endometritis in, 204 treatment of, 204 epilepsy in, 248 and eclampsia in, diagnosis, differen- tial, 248 erysipelas in, 287 treatment of, 287 exercise in, 183 extra-uterine, 324 after rupture, treatment of, 343 at time of rupture, treatment of, 340 before rupture, treatment of, 339 cause of, 328 diagnosis of, 176, 336 evacuation of an extraperitoneal gestation-sac in, 345 fetus in, 333 history of, 324 operation in, 341 preparation for, 340 primary forms of, 329 secondary forms of, 330 symptoms of, 334 treatment of, 339 vaginal opening and drainage in, 344 gait in, changes in, 157 gastric ulcer in, 274 general changes in, 154 genitals, external, in, changes in, 151 goiter in, 278 INDEX. 551 Pregnancy, gonorrhea in, 282 Hegar's sign of, 160 hematuria in, 220 hemoptysis in, 281 hemorrhage of, 225 diagnosis of, 226 herpes in, 248 prognosis of, 249 treatment of, 249 hygiene of, 183 hysteria in, 260 infections, acute, in, 282 injuries and accidents in, 297 intermittent contractions in, 169 interstitial, 332 intrapelvic signs of, 164 kidneys during, 220 kiestein in, 1(34 mammary changes during, 163 glands in, changes in, 152 treatment of, 187 management of, 186 mania in, 260 treatment of, 261 maternal impressions in, 251 organs in, changes in, 146 measles in, 288 meningitis in, 251 menstruation in, suppression of, 162 mental condition of, 173, 185 mouth and teeth in, diseases of, 277 treatment of, 277 multiple, diagnosis of, 177 myomatous tumors in, influence on, 294 myomectomy in, 294 myomotomy in, 294 nausea and vomiting of, 261 diagnosis of, 262 treatment of, 266 nervous system in, changes in, 160 disorder's of, 245 poisonings of, 257 neuralgia in, 245 nutrition in, changes in, 156 osseous elements in, changes in, 157 ovariotomy in, 208 pathology of, 188 pelvic floor in, changes in, 152 pelvis in, examination of, 186 peptonuria in, 276 treatment of, 276 peritonitis in, 224 physiology of, 74 pneumonia in, 289 prognosis of, 290 treatment of, 290 Pregnancy, polyneuritis in, 247 posture and bearing of, 228 prior, diagnosis of, 177 prolongation of, 181 pruritus in, 259 purpura hemorrhagica in, 279 reflex excitability in, 247 renal functions in, care of, 186 respiration in, changes in, 156 rest in, 184 salivation in, 248 salpingitis in, 206 scarlatina in, 289 signs of, 161 skin in, changes in, 157 smallpox in, 289 stomach disorder in, care of, 186 surgical operations and accidents during, 293 symptoms and signs of, 161 value of, 174 syphilitic infection in, 284 tetanus in, 291 treatment of, 291 tetany in, 292 treatment of, 293 toxemia of, 228 diagnosis of, 235 prevention of, 233 treatment of, 235 tubal, 330 tubo-uterine, -332 typhoid fever during, 2S6 diagnosis of, 287 umbilicus in, changes in, 152 urea in, 232 uremia in, 160 urethra in, 220 urinary organs in, disorders of, 220 treatment of, 223 urine in, changes in, 157 toxicity of, 232 uterus and peritoneum in, relations of, 150 in, changed position of, 167 changes in, 146 vagina in, changes in, 151 vaginal mucous membrane in, changes in, 166 vomiting and nausea in diagnosis of, 161 diagnosis of, 262 treatment of, 266 vulvar mucous membrane in, changes in, 166, 168 weight in, increase in, 156 Presentation and position, diagnosis of, 400 definition of, 435 5o2 INDEX. Presentation, diagnosis of, by palpation, 458 differentia], by palpation, 459 examination of lower fetal pole in, 401 of upper fetal pole in, 402, 404 fetal, and position, diagnosis of, 400 location of cephalic prominence in, 403 of fetal heart-tones in, 404 of the dorsal plane and small parts in, 400 of a hand and a foot, 542 or a foot, 465 of the head and a hand, 542 Presentations, 436 abnormal, 430 adaptation between fetus and uterus in, 470 breech, 520 diagnosis by palpation, 459 management of, 524 mechanism of, 520 positions of, 437 prognosis of, 467 brow, 516 management of, 517 mechanism of, 516 positions of, 437 prognosis of, 467 causes of, 468 cephalic, frequency of, 467 face, 508 mechanism of, 510 positions of, 437 posterior, mechanism of, 512 prognosis of, 466 footling, management of, 537 f mechanism of, 537 frequency of, 466 influence of fetal movements on, 471 of gravity on, 468 longitudinal, 436 natural, 436 normal, 436 of elbow and knee, 466 positions of, 437 posterior face, mechanism of, 512 signs of, 464 transverse, 537 diagnosis by palpation, 459 management of, 539 mechanism of, 538 positions of, 437 prognosis of, 467 unnatural, 436 vertex, 467 left posterior positions in, mechanism of, 499 Presentations, vertex, location of anterior shoulder in, 403 positions of, 437 posterior positions in, management of, 499 prognosis of, 466 right posterior positions in, median. ism of, 492 second stage of labor in, mechanism of, 480 Prior pregnancy, diagnosis of, 177 Prolongation of pregnancy, 181 Pruritus in pregnancy, 259 Pseudocyesis, 272 diagnosis of, 273 treatment of, 273 Psychical amenorrhea, 163 Puerperal osteophytes, 157 Purpura hemorrhagica in pregnancy, 279 QTJICKENrjSG, 169 when first noticed, 181 Rauber's cells, 79 Recurrent fever of fetus, 351 Reflex excitability in pregnancy, 247 Respiration, changes in, in pregnancy, 156 Respiratory changes in fetus, 140 tract in fetus, development of, 119 Rest in pregnancy, 184 Retraction-ring and contraction-ring, differen- tiation, 378 Retroversion of gravid uterus, 215 Rotation, mechanism of, 4S5 Rupture of extra-uterine pregnancy, 335 of membranes during labor, 418 of sac in tubo-uterine pregnancy, 332 of uterus in pregnancy, 197 treatment of, 200, 204 tubal, 332 Salivary glands in fetus, development of, 119 Salivation in pregnancy, 248 Salpingitis in pregnancy, 206 Scarlatina in pregnancy, 289 Scarlet fever of fetus, 350 Schultze's pelvimeter, 411 Second stage of labor, 386 duration of, 388 management of, 418 vertex presentations, mechanism of, 480 Segmentation and impregnation, 77 nucleus, 77 physiology of, 77 INDEX. 553 Septicemia of fetus, 350 Sexual intercourse in pregnancy, 184 Show, 384 Signs and symptoms of pregnancy, 161 value of, 174 of beginning labor, 383 Skin in pregnancy, changes in, 157 Smallpox in pregnancy, 2S9 of fetus, 350 Somatopleure, 83 Somites, 82 Souffle, uterine, 461 Space of Ketzius, 30 Spermatids, 76 Sperm-nucleus, 77 Spina bifida, 356 Spinal column and fetal head, articulation between, 456 cord of fetus, development of, 130 irritations in pregnancy and labor, 251 Splanchnopleure, 83 Sterilization by boiling, 393 by dry heat, 393 by steam, 393 of the hands, 394 permanganate method, 395 Stomach disorder iu pregnancy, care of, 186 Strise gravidarum, 152 Suboecipito-bregmatic diameter, 453 Superfetation, 145 Superimpregmtion, 145 Surgical operations and accidents during preg- nancy, 293 Sutures of fetal head, 452 Symphysis pubis, 22 i Symptoms and signs of pregnancy, 161 value of, 174 Syncytium, 91 Syphilis, fetal, 347 diagnosis of, 34S treatment of, 349 of placenta, 309 Syphilitic infection in pregnancy, 2S4 ' TETA2frs in pregnancy, 291 treatment of, 291 Tetany in pregnancy, 292 treatment of, 293 Third stage of labor, 390 duration of, 390 management of, 426, 492 mechanism of, 490 Threatened abortion, treatment of, 322 . Toilet of patient after labor, 432 Toxemia of pregnancy, 228 diagnosis of, 235 Toxemia of pregnancy, prevention of, 233 treatment of, 235 Toxicity of urine in pregnancy, 232 Transverse diameters of pelvis, 442, 444 presentations, 537 management of, 539 mechanism of, 538 positions of, 437 prognosis of, 467 Trophoblast, 90 Trunk, delivery of, 424 of fetal body, 457 Tubal abortion, 332 moles, 331 pregnancy, 330 rupture, 332 Tuberculosis of fetus, 351 Tubo-uterine pregnancy, 332 Tumors, myomatous, influence upon preg- nancy, 294 of fetus, 353 of placenta, 309 ovarian, in pregnancy, 208, 295 Typhoid fever during pregnancy, 286 diagnosis of, 287 of fetus, 349 Ulcer, gastric, in pregnancy, 274 Umbilical cord, 311 anomalies of, 311 constituents of, 94 convolutions of, 311 dimensions of, 94 hernia of, 312 knots of, 312 ligation of, 425 management of, 424 physiology of, 94 structure of, 95 swellings of, 312 torsion of, 311 vessels of, changes in, 312 souffle, 172 Umbilicus, changes in, in pregnancy, 152 Urachus, 122 Uremia in pregnancy, 160 Urethra in pregnancy, 220 Urinary organs in pregnancy, 222 disorders of, treatment of, 223 Urine, changes in, in pregnancy, 1 57 toxicity of, in pregnancy, 232 Uterine contents, premature expulsion of, 312 fibroids, 188 segment, lower, changes in, in labor, 377 souffle, 170, 461 Utero-gestation, periods of, 173 554 IXDEX. Uterus, amputation of, in pregnancy, 295 anatomy of, 45 and appendages, pathological conditions of, 188 and fetus in presentations, adaptation be- tween, 470 and peritoneum in pregnancy, relations of, 150 cancer of, in pregnancy, 191 treatment of, 194 change in position of, in pregnancy, 167 changes in, in pregnancy, 140 during labor, changes in, 379 pains, changes in shape of, 373 dimensions of, 46 displacements of, in pregnancy, 215 hemorrhage from, in pregnancy, 281 hypertrophy of, 1S8 ligaments of, 51 myouiata of, in pregnancy, 188 treatment of, 190 normal position of, 54 retroversion of, in pregnancy, 215 treatment of, 215 rupture of, in pregnancy, 197 treatment of, 200, 204 walls of, structure of, 49 Vagina, action of, in labor, 373 anatomy of, 42 changes in, in pregnancy, 151 diseased states of, in pregnancy, 214 examination of, in labor, 408 Vagina, examination of, in labor, frequency of, 419 in diagnosis of labor, 461 Vaginal mucous membrane in pregnancy, changes in, 166, 168 Vertex presentations, 467 left posterior positions in mechanism of, 499 location of anterior shoulder in, 403 positions of, 437 posterior positions in, management of, 499 prognosis of, 466 right posterior positions in, mechan- ism of, 492 second stage of labor in, mechanism of, 480 Vestibule, 38 Vitelline circulation, 104, 139 Vomiting and nausea in diagnosis of pregnancy, 161 of pregnancy, 261 diagnosis of, 262 treatment of, 266 Vulva disorders of, in pregnancy, 212 Vulvar dressing after labor, 432 Waters, bag of, 380 Weight in pregnancy, increase in, 156 Wolffian bodies, 120 duct, 119 Yellow fever of fetus, 351 SAUNDERS' BOOKS GYNECOLOGY and OBSTETRICS W. B. SAUNDERS & COMPANY 925 WALNUT STREET PHILADELPHIA NEW YORK LONDON Fuller Building, 5th Ave. and 23d St. 9, Henrietta Street, Covent Garden "SAUNDERS" IMPRINT ENSURES SUCCESS." *1*HAT the degree of excellence obtained by the Saunders publications is a high one is evidenced by the fact that in every one of the 190 Medical Colleges in the United States and Canada, Saunders' text-books are used as reci- tation books or books of reference. In the list of recom- mended books published by 172 of these colleges (the other 18 colleges do not publish such lists) Saunders' books are mentioned 2644 times. These figures really mean that in each of the medical colleges in this country an average of 15^ of the teaching books employed are publications issued by W. B. Saunders & Company. A Complete Catalogue of our Publications will be Sent upon Request SAUNDERS' BOOKS ON Penrose's Diseases of Women Fourth Revised Edition A Text-Book of Diseases of Women. By Charles B. Penrose, M. D., Ph. D., formerly Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Oc- tavo volume of 539 pages, with 221 fine original illustrations. Cloth, $375 net - FOUR EDITIONS IN AS MANY YEARS Regularly every year a new edition'of this excellent text-book is called for, and it appears to be in as great favor with physicians as with students. Indeed, this book has taken its place as the ideal work for the general practitioner. The author presents the best teaching of modern gynecology, untrammeled by anti- quated ideas and methods. In every case the most modern and progressive technique is adopted, and the main points are made clear by excellent illustra- tions. The new edition has been carefully revised, much new matter has been added, and a number of new original illustrations have been introduced. In its revised form this volume continues to be an admirable exposition of the present status of gynecologic practice. PERSONAL AND PRESS OPINIONS Howard A. Kelly, M. D.. Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore. " I shall value very highly the copy of Penrose's ' Diseases of Women ' received. I have already recommended it to my class as THE BEST book." E. E. Montgomery, M. D., Professor of Gynecology, Jefferson Medical College, Philadelphia. " The copy of ' A Text-Book of Diseases of Women ' by Penrose, received to-day. I have looked over it and admire it very much. I have no doubt it will have a large sale, as it justly merits." Bristol Medico-Chirurgical Journal " This is an excellent work which goes straight to the mark. . . . The book may be taken as a trustworthy exposition of modern gynecology." GYNECOLOGY AND OBSTETRICS. American Text-Book of Gynecology Second Edition, Thoroughly Revised American Text=Book of Gynecology : Medical and Surgical. By 10 of the leading Gynecologists of America. Edited by J. M. Baldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic. Handsome imperial octavo volume of 718 pages, with 341 illustrations in the text, and 38 colored and half-tone plates. Cloth, $6.00 net; Sheep or Half Morocco, $7.00 net. MEDICAL AND SURGICAL This volume is thoroughly practical in its teachings, and is intended to be a working text-book for physicians and students. Many of the most important subjects are considered from an entirely new standpoint, and are grouped together in a manner somewhat foreign to the accepted custom. In the revised edition of this book much new material has been added and some of the old eliminated or modified. More than forty of the old illustrations have been replaced by new- ones. The portions devoted to plastic work have been so greatly improved as to be practically new. Hysterectomy, both abdominal and vaginal, has been rewritten, and all the descriptions of operative procedures have been carefully revised and fully illustrated. OPINIONS OF THE MEDICAL PRESS The Lancet, London " Contains a large amount of information upon special points in the technique of gyne- cological operations which is not to be found in the ordinary text-book of gynecology." British Medical Journal " The nature of the text may be judged from its authorship ; the distinguished authorities who have compiled this publication have done their work well. This addition to medical literature deserves favorable comment." Boston Medical and Surgical Journal "The most complete exponent of gynecology which we have. No subject seems to have been neglected . . . and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the-matter of illus- trations and plates the book surpasses anything we have seen." SAUNDERS' BOOKS ON GET A • THE NEW THE BEST i\ 111 6 T 1 C & H. STANDARD Illustrated Dictionary Second Edition, Revised The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, and kindred branches; with over ioo new and elaborate tables and many handsome illustrations. By W. A. Newman Dorland, M. D., Editor of " The American Pocket Medical Diction- ary." Large octavo, nearly 800 pages, bound in full flexible leather. Price, $4.50 net ; with thumb index, #5.00 net. Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest Possible Cost TWO LARGE EDITIONS IN LESS THAN EIGHT MONTHS The immediate success of this work is due to the special features that distin- guish it from other books of its kind. It gives a maximum of matter in a mini- mum space and at the lowest possible cost. Though it is practically unabridged, yet by the use of thin bible paper and flexible morocco binding it is only 1 Ss inches thick. The result is a truly luxurious specimen of book-making. In this new edition the book has been thoroughly revised, and upward of one hundred important new terms that have appeared in recent medical literature have been added, thus bringing the book absolutely up to date. The book contains hun- dreds of terms not to be found in any other dictionary, over 100 original tables, and many handsome illustrations, including 24 colored plates. PERSONAL OPINIONS Howard A. Kelly, M. D., Professor of Gynecology, Johns Hopkins University, Baltimore. " Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." Roswell Park, M. D., Professor of Principles and Practice of Surgery and of Clinical Surgery, University of Buffalo. " I must acknowledge my astonishment at seeing how much he has condensed within rela- tively small space. I find nothing to criticize, very much to commend, and was interested in finding some of the new words which are not in other recent dictionaries." GYNECOLOGY AND OBSTETRICS. Garrigues' Diseases of Women Third Edition, Thoroughly Revised A Text-Book of Diseases ot Women. By Henry J. Garrigues, A. M., M. D., Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City. Handsome octavo, 756 pages, with 367 engravings and colored plates. Cloth, $4.50 net; Sheep or Half Morocco, #5.50 net. INCLUDING EMBRYOLOGY AND ANATOMY OF THE GENITALIA The first two editions of this work met with a most appreciative reception by the medical profession both in this country and abroad. In this edition the entire work has been carefully and thoroughly revised, and considerable new matter added, bringing the work precisely down to date. Many new illustrations have been introduced, thus greatly increasing the value of the book both as a text -book and book of reference. In fact, the illustrations form a complete atlas of the embry- ology and anatomy of the female genitalia, besides portraying most accurately numerous pathologic conditions and the various steps in the gynecologic opera- tions detailed. The work is, throughout, practical, theoretical discussions being carefully avoided. PERSONAL AND PRESS OPINIONS Thai. A. Reamy, M. D. Professor of Clinical Gynecology, Medical College of Ohio. " One of the best text-books for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form." Bache Emmet, M. D. Professor of Gynecology in the New York Post-Graduate Medical School. " I think that the profession at large owes you gratitude for having given to the medical world so valuable a treatise. I shall certainly put it forward to my classes as one of the best guides with which I am familiar, not only with which to study, but for constant consultations." American Journal of the Medical Science! " It reflects the large experience of the author, both as a clinician and a teacher, and com- prehends much not ordinarily found in text-books on gynecology. The book is one of the most complete treatises on gynecology that we have, dealing broadly with all phases of the subject." SAUNDERS 1 BOOKS ON Hirst's Text-Book of Obstetrics Third Edition, Thoroughly Revised and Enlarged A Text>Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylvania. Handsome octavo, 8j3 pages, with 704 illustrations, 36 of them in colors. Cloth, $5.00 net ; Sheep or Half Morocco, $6.00 net. MANY BEAUTIFUL ILLUSTRATIONS. 36 IN COLORS Immediately on its publication this work took its place as the leading text-book on the subject. Both in this country and in England it is recognized as the most satisfactorily written and clearly illustrated work on obstetrics in the language. The illustrations form one of the features of the book. These are numerous and are works of art, most of them being original. In this edition the book has been thoroughly revised. New matter has been added to almost every chapter, notably those treating of Diagnosis of Pregnancy, the Pathology of Pregnancy, the Pathology of Labor, and Obstetric Operations. More than fifty new illustra- tions, including three colored plates, have been introduced. OPINIONS OF THE MEDICAL PRESS British Medical Journal "The popularity of American text-books in this country is one of the features of recent years. The popularity is probably chiefly due to the great superiority of their illustrations over those of the English text-books. The illustrations in Dr. Hirst's volume are far more numerous and far better executed, and therefore more instructive, than those commonly found in the works of writers on obstetrics in our own country." Bulletin of Johns Hopkins Hospital "The work is an admirable one in every sense of the word, concisely but comprehensively written." The Medical Record, New York "The illustrations are numerous and are works of art, many of them appearing for the first time. The author's style, though condensed, is singularly clear, so that it is never necessary to re-read a sentence in order to grasp the meaning. As a true model of what a modern text- book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival." GYNECOLOGY AND OBSTETRICS. The American Text-Book of Obstetrics Second Edition, Thoroughly Revised and Enlarged The American Text=Book of Obstetrics. In two volumes. Edited by Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M.D. Two handsome imperial octavo volumes of about 600 pages each; nearly 900 illustrations, including 49 colored and half-tone plates. Per volume: Cloth, $3.50 net; Sheep or Half Morocco, $4.00 net. JUST ISSUED — IN TWO VOLUMES Since the appearance of the first edition of this work many important advances have been made in the science and art of obstetrics. The results of bacteriologic and of chemicobiologic research as applied to the pathology of midwifery ; the wider range of the surgery of pregnancy, labor, and of the puerperal period, embrace new problems in obstetrics. In this new edition, therefore, a thorough and critical revision was required, some of the chapters being entirely rewritten, and others brought up to date by careful scrutiny. A number of new illustrations have been added, and some that appeared in the first edition have been replaced by others of greater excellence. By reason of these extensive additions the new edition has been presented in two volumes, in order to facilitate ease in handling. The price, however, remains unchanged. PERSONAL AND PRESS OPINIONS Alex. J. C. Skene, M. D„ Late Professor of Gynecology, Long Island College Hospital, Brooklyn. " Permit me to say that ' The American Text-Book of Obstetrics ' is the most magnificent medical work that I have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers." Matthew D. Mann, M. D., Professor of Obstetrics and Gynecology in the University of Buffalo. " I like it exceedingly and have recommended the first volume as a text-book for our sophomore class. It is certainly a most excellent work. I know of none better." American Journal of the Medical Sciences " As an authority, as a book of reference, as a ' working book ' for the student or practi- tioner, we commend it because we believe there is no better." SAUNDERS' BOOKS ON Dorland's Modern Obstetrics Modern Obstetrics: General and Operative. By W. A. Newman Dorland, A. M., M. D., Assistant Demonstrator of Obstetrics, Univer- sity of Pennsylvania ; Associate in Gynecology in the Philadelphia Polyclinic. Handsome octavo volume of 797 pages, with 201 illustra- tions. Cloth, $4.00 net. Second Edition, Revised and Greatly Enlarged In this edition the book has been entirely rewritten and very greatly enlarged. Among the new subjects introduced are the surgical treatment of puerperal sepsis, infant mortality, placental transmission of diseases, serum-therapy of puerperal sepsis, etc. By new illustrations the text has been elucidated, and the subject pre- sented in a most instructive and acceptable form. Journal of the American Medical Association " This work deserves commendation, and that it has received what it deserves at the hands of the profession is attested by the fact that a second edition is called for within such a short time. Especially deserving of praise is the chapter on puerperal sepsis." Davis' Obstetric and Gynecologic Nursing Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., M. D., Professor of Obstetrics in the Jefferson Medical College and Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia Hospital. i2mo of 400 pages, illustrated. Buckram, $1.75 net - This volume is designed for the obstetric and gynecologic nurse. Obstetric nursing demands some knowledge of natural pregnancy and of the signs of accidents and diseases which may occur during pregnancy. It also requires knowledge and experience in the care of the patient and child. Gynecologic nursing is really a branch of surgical nursing, and as such requires special instruction and training. This volume presents this information in the most con- venient form. The Lancet, London " Not only nurses, but even newlv qualified medical men. would learn a great deal by a perusal of this book. It is written in a clear and pleasant style, and is a work we can recom- mend." GYNECOLOGY AXD OBSTETRICS. Schaffer and Edgar's Labor and Operative Obstetrics Atlas and Epitome of Labor and Operative Obstetrics. By Dr. O. Schaffer, of Heidelberg. From the Fifth Revised and Enlarged German Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medi- cal School, New York. With 1.4 lithographic plates in colors, 139 other illustrations, and ill pages of text. Cloth, $2.00 net. In Saunders' Hand-Atlas Series. This book presents the act of parturition and the various obstetric operations in a series of easily understood illustrations, accompanied by a text treating the subject from a practical standpoint. The author has added many accurate repre- sentations of manipulations and conditions never before clearly illustrated. American Medicine " The method of presenting obstetric operations is admirable. The drawings, representing original work, have the commendable merit of illustrating instead of confusing. It would be difficult to find one hundred pages in better form or containing more practical points for students or practitioners." Schaffer and Edgar's Obstetric Diagnosis and Treatment Atlas and Epitome of Obstetric Diagnosis and Treatment. By Dr. O. Schaffer, of Heidelberg. From the Second Revised German Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School, N. Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315 pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series. This book treats particularly of obstetric operations, and, besides the wealth of beautiful lithographic illustrations, contains an extensive text of great value. This text deals with the practical, clinical side of the subject. The symptoma- tology and diagnosis are discussed with all necessary fullness, and the indications for treatment are definite and complete. New York Medical Journal "The illustrations are admirably executed, as they are in all of these atlases, and the text can safely be commended, not only as elucidatory of the plates, but as expounding the scien- tific midwifery of to-day." SAUNDERS' BOOKS ON Galbraith's Four Epochs of Woman's Life The Four Epochs of Woman's Life : A Study in Hygiene. By Anna M. Galbraith, M. D., author of " Hygiene and Physical Cul- ture for Women" ; Fellow of the New York Academy of Medicine, etc. With an Introductory Note by John H. Musser, M. D., Professor of Clinical Medicine, University of Pennsylvania i2mo volume of 200 pages. Cloth, $1.25 net. MAIDENHOOD, MARRIAGE. MATERNITY, MENOPAUSE In this instructive work are stated, in a modest, pleasing, and conclusive manner, those truths of which every woman should have a thorough knowledge. Written, as it is, for the laity, the subject is discussed in language readily grasped even by those most unfamiliar with medical subjects. Birmingham Medical Review, England " We do not as a rule care for medical books written for the instruction of the public. But we must admit that the advice in Dr. Galbraith's work is in the main wise and wholesome." American Year-Book Saunders' American Year=Book of Medicine and Surgery. A Yearly Digest of Scientific Progress and Authoritative Opinion in all Branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and foreign authors and inves- tigators. Arranged, with critical editorial comments, by eminent Ameri- can specialists, under the editorial charge of George M. Gould, A.M., M. D. In two volumes : Vol. I. — General Medicine, octavo, 715 pages, illustrated; Vol. II. — General Surgery, octavo, 684 pages, illustrated. Per vol.: Cloth, $3.00 net; Half Morocco, $3.75 net. Sold by Sub- scription. EQUIVALENT TO A POST-GRADUATE COURSE The contents of these volumes is much more than a compilation of data. The extracts are carefully edited and commented upon by eminent specialists, the reader thus obtaining also the invaluable annotations and criticisms of the editors, all leaders in their several specialties. The Year- Book is amply illustrated. The Lancet, London " It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advantage of certain critical commen- taries and expositions . . . proceeding from writers fully qualified to perform these tasks." GYNECOLOGY AND OBSTETRICS. Schaffer and Norris* Gynecology Atlas and Epitome of Gynecology. By Dr. 0. Schaffer, of Heidelberg. From the Second Revised and Enlarged German Edition. Edited, with additions, by Richard C. Norris, A. M., M. D., Gynecolo- gist to Methodist Episcopal and Philadelphia Hospitals. With 207 colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. In Saunders' Hand-Atlas Series. The value of this atlas to the medical student and to the general practitioner will be found not only in the concise explanatory text^ but especially in the illus- trations. The large number of colored plates, reproducing the appearance of fresh specimens, give an accurate mental picture and a knowledge of the changes induced by disease of the pelvic organs that cannot be obtained from mere description. American Journal of the Medical Sciences " Of the illustrations it is difficult to speak in too high terms of approval. They are so clear and true to nature that the accompanying explanations are almost superfluous. We commend it most earnestly." Hirst's Diseases of Women A Text-Book of Diseases of Women. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylvania. Handsome octavo volume of about 800 pages, magnificently illus- trated. In Preparation. This new work of Dr. Hirst's will be on the same lines as his Text-Book of Obstetrics. The wealth of illustrations will be entirely original from photographs and water-colors made especially for this work. Webster's Obstetrics A Text=Book of Obstetrics. By J. Clarence Webster, M. D., F. R. C. P. E., Professor of Obstetrics and Gynecology, Rush Medical College, in affiliation with the University of Chicago, etc. Handsome octavo volume of 900 pages, finely illustrated. In Preparation. This is an entirely new work by an eminent teacher of wide experience. The book will be thoroughly practical and the text magnificently illustrated. SAUNDERS' BOOKS ON American Pocket Dictionary Third Revised Edition The American Pocket Medical Dictionary. Edited by W. A. Newman Dorland, A.M., M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania ; Fellow of the American Academy of Medicine. Over 500 pages. Full leather, limp, with gold edges. $1.00 net ; with patent thumb index, $1.25 net. James W. Holland, M. D.. Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadelphia. " I am struck at once with admiration at the compact size and attractive exterior. I nend it to our students without reserve." Long's Syllabus of Gynecology A Syllabus of Gynecology, arranged in conformity with "American Text-Book of Gynecology." By J. W. Long, M. D., Emeritus Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, #1.00 net. Brooklyn Medical Journal " The book is certainly an admirable resume of what every gynecological student and practitioner should know, and will prove of value." Cragin's Gynecology. Fifth Revised Edition Essentials of Gynecology. By Edwin B. Cragin, M. D., Professor of Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, 200 pages, 62 illustrations. Cloth, $1.00 net. In Saunders' Question- Compend Series. The Medical Record, New York "A handy volume and a distinct improvement on students' compends in general. No author who was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done." Boisliniere's Obstetric Accidents, Emergencies, and Operations Obstetric Accidents, Emergencies, and Operations. By the late L. Ch. Boisliniere, M. D., Emeritus Professor of Ob- stetrics, St. Louis Medical College ; Consulting Physician, St. Louis Female Hospital. 381 pages, illustrated. Cloth, $2.00 net. British Medical Journal " It is clearly and concisely written, and is evidently the work of a teacher and practi- tioner of large experience, its merit lies in the judgment which comes from experience." AshtOn's Obstetrics. Fifth Edition, Revised and Enlarged Essentials of Obstetrics. By W. Easterly Ashton, M. D., Professor of Gynecology in the Medico-Chirurgical College, Phila- delphia. Crown octavo, 252 pages, 75 illustrations. Cloth, $1.00 net. In Saunders' Question- Compend Series. Southern Practitioner "An excellent little volume containing correct and practical knowledge. An admir- able compend, and the best condensation we have seen." COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the -"h-ation of a definite period after the date of borrowing, by " e rules of the Library r by spe^ * : -arian in cha r