J" y- /^ :^' /^ WE \ SCIB3ICES UBRABV f^^-^^ y -^-/v OBSTETRICAL, TABLE. 267 f. •" ■- 1 A -/ * -■ a S " ;u. — to Od >.S§ 3 mS ^=: >,~' li ■~ =S Oi'C aj n > «i- — m S' >" *ii-" « c o E s- a 1' m '^ hfSr J c * g c ^^-^ c ^ a; *" r iJ > ■a S « & •n P<>.i C "'=' o t. «■" — .Z3 .a (B ^ r- - ^ a) N o o a o c3 §!a;5i to o 08 -a 1. t: £ g g SB Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/treatiseonscienc1889play \rE. .. .i er of mer ..CI! I( ing ig P ■ig P ng P. I ^'"l f Z)er?f * mo r. ff' .1 LES, n of L^ Co)u 1 i^C-t'0-«-^-^ >--^^L^^^ a<^^-'''^'^'>^^ ^^^^.^c^-^^-z^^ A TKEATISE THE SCIENCE AND PRACTICE MIDWIFEEY, BY W. S. PLAYFAIR, M,D., LL,D., F.R.C.P., physician-accoucheur' ;4'0 H. I. AND R. H. THE DUCHESS OF EDINBURGH ; PROFESSOR OF OBSTETRIC MEDICINE IN king's COLLEGE; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO king's COLLEGE HOSPITAL; CONSULTING PHYSICIAN TO THE GENERAL LYING-IN HOS- PITAL AND TO THE EVELINA HOSPITAL FOR CHILDREN; LATE PRESIDENT OF THE OBSTETRICAL SOCIETY OF lONDON ; EXAMINER IN MID- WIFERY TO THE UNIVERSITY OF LONDON AND TO THE ROYAL COLLEGE OF PHYSICIANS. FIFTH AMERICAN FROM THE SEVENTH ENGLISH EDITION. WITH NOTES AND ADDITIONS BY EGBERT P. HARRIS, M.D. WITH FIVE PLATES AND TWO HUNDRED AND SEVEN ILLUSTRATIONS. PHILADELPHIA : LEA BROTHERS & CO. 1889. ^6) /8Sf Entered according to Act of Congress, in the year 1889, by LEA BROTHERS & CO., in the OflBce of the Librarian of Congress at Washington. All rights reserved. Westcott a Thomson, William J. Pornan, i'itereolypers and Eleclrotypers, Philada. Printer. PliiUida. EDITOR'S PREFACE TO THE FIFTH AMEEICAN EDITIOK Four years have passed since the last American edition was issued, and this period has worked a revolution in the results attained in sev- eral forms of obstetric surgery : notably is this the case in the Porro- Csesarean operation ; the conservative Csesareau operation ; and the exsective method of treating extra-uterine pregnancy where the foetus is alive and of viable development. The Porro operation has fallen in its rate of mortality since 1884 from 58 to less than 20 per cent. ; and the Conservative or Improved Csesarean, from 45 per cent, to a general average of 20 per cent., and for Continental Europe of 12. The exsective operation named had had but one case prior to 1885, but has now had five without the death of a mother. These facts are not mentioned in the last English edition. Laparo-elytrotomy, which was attracting considerable attention four years ago, has almost ceased to exist, by reason of the diminished death-rate under the improved Csesarean section, which in Germany has been one case lost in eight. Laparo-elytrotomy has therefore not been performed since September 18, 1887. The Editor has brought up the work to date upon these subjects, and their statistical records to the close of the year 1888. All of the American additions, except the article upon the forceps, have been either rewritten or remodelled, and many new and short notes have been added where required. The work has been sufficiently Americanized, upon the points where English and American obstetri- cians differ in opinion and practice, to fit it for the uses of American medical students and obstetricians. All notes and additions have been distinguished by enclosure in brackets [ ]. 329 South 12th Street, Philadelphia, July 11, 1SS9. AUTHOR'S PREFACE TO THE SEVENTH ENGLISH EDITION. The Author has again the satisfaction of presenting to the profes- sion a new edition of his work. Since the last edition has been exhausted in about two years, there are necessarily not many changes to make; still, the whole has been carefully revised, some portions have been re-written, and several new illustrations have been added. The chief change in this edition, however, is that the obstetric nomenclature decided on by a committee appointed at the International Medical Con- gress, held at Washington in 1887, has been introduced. This com- mittee was presided over by Professor A. R. Simpson of Edinburgh, and there can be little doubt that its recommendations will eventually be generally adopted, and will lead to something like uniformity in obstetric description. The Author has hitherto not used letters in describing the various cranial positions and the like, chiefly because he personally thought them rather pedantic and not necessarily leading to simplicity. Now, however, that so authoritative a committee has pro- nounced in their favor, and that there is a reasonable hope of the same letters being employed by writers in various countries, he has thought it advisable to introduce them in brackets, so as to give his readers the opportunity of familiarizing themselves with their use. The Author has once more to express his grateful thanks to Dr. W. Tyrrell Brooks of Oxford, to his colleague Professor Crookshank of King's College, and to Dr. John Phillips, for their valuable assistance. Dr. Brooks has, for the second time, revised the chapters on conception and generation ; Dr. Crookshank has done the same with reference to the bacteriology of puerperal septicaemia ; and Dr. Phillips, as on several previous occasions, has spared the Author much labor by his aid in passing the work through the press. 31 George Street, Hanover Square, January, 1SS9. PREFACE TO THE FIRST EDITION. Those who have studied the progress of Midwifery know that there is no department of medicine in which more has been done of late years, and none in which modern views of practice differ more widely from those prevalent only a short time ago. The Author's object has been to place in the hands of his readers an epitome of the science and practice of midwifery which embodies all recent advances. He is aware that on certain important points he has recommended practice which not long ago would have been considered heterodox in the extreme, and which even now will not meet with general approval. He has, however, the satisfaction of knowing that he has only done* so after very deliberate reflection, and with the profound conviction that such changes are right and that they will stand the test of experience. He has endeavored to dwell especially on the practical part of the subject, so as to make the work a useful guide in this most anxious and responsible branch of the profession. It is admitted by all that emergencies and difficulties arise more often in this than in any other branch of practice ; and there is no part of the j)ractitioner's work which requires more thorough knowledge or greater experience. It is, moreover, a lamentable fact that students generally leave their schools more ignorant of obstetrics than of any other subject. So long as the absurd regulations exist which oblige the lecturer on midwifery to attempt the impossible task of teaching obstet- rics in a short three months' course — an absurdity M'hich has over and over again been pointed out — such must of necessity be the case. This must be the Author's excuse for dwelling on many topics at greater length than some will doubtless think their importance merits, since he desires to place in the hands of his students a work which may in some measure supply the inevitable defects of his lectures. viii rilF.FACK TO TlIK IIIIST F.DITIOS. iNIaiiy (if tlif illii-tratiiiiis arc cdpifd Iroiii ]ii'(\i(iii- aiitliois, while si>nu' arc (iritiiiial. 'V\\v lolKtwiii;^,' (jiinlatinii rroiii the iirdiKv to Tyler Smith's ManiKtl of Ohstdrirx will explain w liy the >(»iiree (»j' ilu- copied wood-cuts has not been in each instance acknowled<::ed : " M'hen I lx.'gan to jniljlish, I determined to n Lalior — Risks to the Mother and ('hild — [Pelvic Exostosis obstructing Delivery] —Mechan- ism of Delivery in Head Presentation : «, in Contracted Brim , /», in Generally- Contracted Pelvis — Diagnosis — External Measurements — Internal Measure- ments-Mode of Estimating the Conjugate Diameter of the Brim — Mode of Diagnosing the Oblique Pelvis — Treatment — The Forceps — Turning — Crani- otomy — The Induction of Premature Labor — Induction of Abortion — [Dan- gers of Casarean Section Overestimated] 382 CONTENTS. XV CHAPTER XIII. HEMORRHAGE BEFORE DELIVERY: PLACENTA PREVIA. PAGE Definition — Causes — Symptoms — Sources and Causes of Ilemorrliage — Prognosis — Treatment- [Braxton Hicks' Bimanual Method of Turning in Placenta Previa] 407 CHAPTER XIV. HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED PLACENTA. Causes and Pathology — Symptoms and Diagnosis — Prognosis — Treatment . . . 418 CHAPTER XV. HEMORRHAGE AFTER DELIVERY'. Its Frequency — Generally a Preventable Accident — Causes — Nature's Method 6t Controlling Hemorrhage — Uterine Contraction — Thrombosis — Secondary Causes of Hemorrhage — Irregular Uterine Contraction — Placental Adhesions — Constitutional, Predisposition to Flooding — Symptoms — Preventive Treat- ment — Curative Treatment — Secondary Treatment — [Hot-water Injections of Uterus] — [Head Lowered and Body Elevated in Fainting from Hemorrhage] — Secondary Post-partum Hemorrhage — Its Causes and Treatment 421 CHAPTER XVI. RUPTURE OF THE UTERUS, ETC. Its Fatality— Seat of Rupture— Causes, Predisposing and Exciting — Symptoms — Prognosis— Treatment; when the Foetus Remains in ittero, when the Fo?tus has Escaped from the Uterus— [Prevot's Supravaginal Amputation of Uterus] — Lacerations of the Cervix — Recapitulation — Lacerations of the Vagina — Vesico- and Recto-vaginal Fistul?e — Their Mode of Formation — Treatment— [Rational Treatment of Rupture of the Uterus] 438 CHAPTER XVII. INVERSION OF THE UTERUS. Division into Acute and Chronic Forms— Description— Symptoms— Diagnosis- Mode of Production — Treatment— [Spontaneous Reposition of the Inverted Uterus] 449 xvi coyrEyrs. PART IV. OBSTETRIC OPERATIONS. CHAPTER I. INDUCTIOX OF PREMATURE LABOR. PAGE History — Objects — May be Performed on account eillier of tlie Mother or Child — Modes of Inducing Labor — Puncture of Meni})ranes — Administration of Oxytocics — Means acting Indirectly on the Uterus — Dilatation of Cervix — Separation of Membranes — Vaginal and Uterine Douches — Introduction of Flexible Cathetei- — [Infantile Mortality after Induction of Premature Labor] 456 CHAPTER IL TURNING. History — Turning by External Manipulation — Object and Nature of the Opera- tion — Cases Suitable for the Operation — Statistics and Dangers — Method of Performance — Cephalic Version — Method of Performance — Podalic Version — Position of Patient — Administration of Antesthetics — Period when the Operation should be Undertaken — Choice of Hand to be Used — Turning l)y Bipolar Method — Turning when the Hand is Introduced into the Uterus — Turning in Abdomino-anterior Positions — Difficult Cases of Arm Presentation — [The Forceps in America] 464 CHAPTER in. THE FORCEPS. Frequent Use of the Forceps in Modern Practice — Description of the Instrument — Tiie Short Forceps — Its Varieties— The Long Forceps — Suitable to all Cases alike — Action of the Instrument— Its Power as a Tractor, Lever, and Com- pressor — Preliminary Consideratif)ns before Operation — U.se of Anaesthetics — Description of the Operation— Low Forceps Operation — High Forceps ( )pera- tion — Possible Dangers of Forceps Delivery — Possible Risks to the Child . . 478 CHAPTER IV. THE VKCTIS— THE FILLET. Nature of the Vectis — Its Use as a Lever or Tractor — Ca.'^es in which it is .Appli- cable — Its Use as a Rectifier of Malpositions— The Fillet — Nature of the Instrument — Objections to its Use 502 CONTENTS. XVll CHAPTER V. OPERATIONS INVOLVING DESTRUCTION OF THE FfETUS. PAGE Their Antiquity and History— Division of Subject — Nature of Instruments Em- ployed—Perforator — Crotchet — Craniotomy Forceps— Cephalotribe — Forceps- saw — Ecraseur — Basilyst — Cases requiring Craniotomy — Metliod of Perfora- tion — Extraction of the Head— Comparative Merits of Cephalotri{)sy and Craniotomy — Extraction by the Craniotomy Forceps — Extraction of the Body — [Meigs' Craniotomy Forceps]— Embryotomy — Decapitation and Eviscera- tion 504 CHAPTER VI. THE C^.SAREAN SECTION-PORRO'S OPERATION-SYMPHYSIOTOMY. History of tlie Operation— [Macduff's Delivery]— Statistics— [Old Caesarean Rec- ords of little Practical Value now]— [Csesarean Section in America] — Re- sults to Mother and Child — Causes Requiring the Operation — [Csesarean Sec- tion under Relative Indications] — Post-mortem Csesarean Section — Causes of Death after the Csesarean Section — [Csesarean Section, causes of Death fol- lowing]— [Csesarean Section performed Prior to Labor] — Preliminary Prepa- rations — [Color-line of Abdomen in Pregnant Women] — Description of the Operation — [Sutures in Csesarean Operations] — Subsequent Management — Porro's Operation— [Porro Operation in Great Britain] — [Porro Statistics] — Substitutes for the Csesarean Section— Symphysiotomy — [Symphysiotomy in Naples] 518 CHAPTER VII. LAPARO-ELYTROTOMY. History — [Statistics of Laparo-elytrotomy] — Nature of the Operation — Advan- tages over the Csesarean Section— Cases Suitable for the Operation — [Laparo- elytrotomy Inadmissible in many Cases of Labor] — Anatomy of the Parts concerned in the Operation — Method of Performance — Subsequent Treatment — [Laparo-elytrotomy performed on Either Side] 534 CHAPTER VIII. THE TRANSFUSION OF BLOOD. History — Nature and Object of the Operation — Use of Blood taken from the Lower Animals — Difficulties from Coagulation of Fibrin — Modes of Obviat- ing them — Immediate Transfusion — Addition of Chemical Agents to prevent Coagulation — Defibrination of the Blood — Statistical Results — Possible Dan- gers of the Operation — Cases suitable for Transfusion — Description of the Operation — Schilfer's Directions for Immediate Transfusion — Effects of Suc- cessful Transfusion — Secondary Effects of Transfusion— [Transfusion with Defibrinated Blood] 539 A VIII COSTEMS. PART V. THE PUE It r E R A L STATE. CHAPTER I. THE PUERPERAL STATE AND ITS MANAGEMENT, PAGE Importance of Studying llie Puerperal State— Tlie Mortality of Childbirih — Alterations in the Blood after Delivery — Condition after Delivery — Nervous Shock — Fall of tlie Pulse— The Secretions and Excretions — Secretion of Milk — Changes in the Uterus after Delivery — The Lochia— The Afler-pains — Management of Women after Delivery — Treatment of Severe After-pains — Diet and Kegimen 551 CHAPTER II. MANAGEMENT OF THE INFANT, LACTATION, ETC. Commencement of Respiration after tlie Birth of the Child — Apparent Death of the Newborn Child — Its Treatment — "Washing and Dressing the Child — Ap- ])lication of the Child to the Breast — Tiie Colostrum and its Properties — Secre- tion of Milk — Importance of Nursing — Selection of a Wet-nurse — [Diet proper for Wet-nurses] — Management of Lactation — Diet and Regimen of Nursing Women — Period of ^Veaning — Disorders of Lactation — Means of Arresting the Secretion of Milk — Defective Secretion of Milk — [Milk-diet for Nursing Mothers] — Depressed Nipples— Fissures and Excoriations of the Nipples — Excessive Flow of Milk — Mammary Abscess— Hand-feeding — Causes of Mor- tality in Hand-feeding — Various Kinds of Milk — Method of Hand-feeding . 562 CHAPTER III. PUERPERAL ECLAMPSIA. Its Doubtful Etiology — Premonitory Symptoms — Symptoms of the Attack — Con- dition between the Attacks — Relation of the Attacks to Labor — Results to Mother and Child — Pathology — Treatment — Obstetric Management — [Urine to be Examined in Eclamptic Cases] 578 CHAPTER IV. PUERPERAL INSANITY. Classification — Proportion of Various Ff)rms — Insanity of Pregnancy — Predis- posing Causes — Period of Pregnancy at whicli it Occurs — Type of Insanity — Prognosis Transient Mania during Delivery — Puerj)eral Insanity (pro|)er) — Type of Insanity — Causes — Theory of its De])endence on a Morbid State of the Blood — Objections to the Theory — Prognosis — Post-n)ortem Signs — Dura- tion — Insanity of Lactation — Type— Symptoms — Of Mania — Of Melancholia — Treatment — (Question of Removal to Asyliun — Treatment during Conva- lescence 587 CONTENTS. XIX CHAPTER V. PUERPERAL SEPTICAEMIA. PAGE Differences of Opinion— Confusion from this Cause — Modern View of tliis Dis- ease — History — Its Mortality in Lying-in Hospitals— Numerous Theories as to its Nature — Theory of Local Origin— Theory of an I']ssential Zymotic Fever — Theory of its Identity with Surgical vSeptiat'inia — Nature of this ^'iew — Channels through whicli Septic Matter may be Absorbed— Character and Origin of Septic Matter often Obscure — Division into Autogenetic and Heterogenetic Cases— Sources of Self-infection — Sources of llelerogenetic Infection— Influence of Cadaveric Poison— Infection from Erysipelas— Infec- tion from other Zymotic Diseases— Infection from Sewer Gas— Ceases illustrat- ing this Mode of Infection— Contagion from other Puerperal Patients— Mode in which the Poison may be Conveyed to the Patient — Conduct of the Prac- titioner in Relation to the Disease— Nature of the Septic Poison— Local Changes resul.ting from the Absorption of Septic Material — Channels through which Systemic Infection is Produced — Pathological Phenomena observed after general Blood Infection — Four Principal Types of Pathological Change — Intense Cases without marked Post-mortem Signs— Cases Characterized by Inflammation of the Serous Membranes— Cases Characterized by the Impac- tion of Infected Emboli and Secondary Inflammation and Abscess — Descrip- tion of the Disease — Duration— Varieties of Symptoms in Different Cases- Symptoms of Local Complications — Treatment 598 CHAPTER VI. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. Puerperal Thrombosis and its Results — Conditions which favor Thrombosis — Con- ditions which favor Coagulation in the Puerperal State — Distinction between Thrombosis and Embolism — Is Primary Thrombosis of the Pulmonary Arteries possible ? — History — Symptoms of Pulmonary Obstruction — Is Recovery pos- sible ? — Causes of Death — Post-mortem Appearances — Treatment — Puerperal Pleuro-pneumonia ; its Causes and Treatment 629 CHAPTER VII. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. Causes — Symptoms — Treatment 6-11 CHAPTER VIII. OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE PUERPERAL STATE. Organic and Functional Causes — Idiopathic Asphyxia — Pulmonary Apoplexy — Cerebral Apoplexy — Syncope — Shock and Exhaustion — Entrance of Air into the Veins G43 XX COyTEXTS. ( HAPTKR L\. PERiniERAL VENOUS THROMBOSIS (SYN.: CKrUAL rHI.ERITIR-PnLEr.MASIA DOI.KNS-ANASARCA SEKOSA-0:DEMA LACTErM-WllITE I,Eubic bones aud forming the upper boundary of the pubic arch. Movements of Pelvic Joints. — The close apposition of the bones of the pelvis might not unreasonably lead to the supposition that no movement took place between its component parts; and this is the opinion which is even yet held by many anatomists. It is tolerably certain, however, that even in the unimpregnated condition there is a certain amount of mobility. I Thus, Zaglas has pointed out" that in man there is a movement in an antero-posterior direction of the sacro-iliac joints which has the effect, in certain positions of the body, of causing the sacrum to project downward to the extent of about a line, thus narrowing the pelvic brim, tilting up the point of the bone, and thereby enlarging the outlet of the pelvis. This movement seems habitually brought into ])\\xy in the act of straining during defeca- tion. During pregnancy in some of the lower animals there is a very marked movement of the pelvic articulations which materially facili- tates the process of ])arturition. This, in the case of the guinea-])ig and cow, has been especially jiointed out by Dr. Matthews Duncan.^ In the former, during labor, the pelvic bones sej^arate from each other to the extent of an inch or more. In the latter the movements are different, for the sym])hysis j)ubis is fixed by bony ankylosis, and is im- movable; but the sacro-iliac joints become swollen during pregnancy, ' Traite d'Accoxichements, p. 11. ^ Manthly Journal of Medical Science, Sept., 1851. ^ Researches m Obstetrics, p. 19. ANATOMY OF THE PELVIS. 39 and extensive movements in an antero-posterior direction take place in them which materially enlarge the pelvic canal during lahor, fit is extremely probable that similar movements take place in women, both in 'the symphysis pubis and in the sacro-iliac joints, although to a less marked extent. | These are particularly well described by Dr. Duncan. They seem to consist chiefly in an ele- vation and depression of the symphysis pubis, either by the ilia moving on the sacrum, or by the sacrum itself undergoing a forward movement on an imaginary transverse axis passing through it, thus lessening the pelvic l)rim to the extent of one or even two lines, and increasing, at the same time, the diameter of the outlet by tilting up the apex of the sacrum. These movements are only an exaggeration of those which Zaglas describes as occurring normally during defecation. The instinctive positions which the parturient woman assumes find an ex[)]anation in these observations. During the first stage of labor, when the head is passing through the brim, she sits or stands or walks about, and in these erect positions the symphysis pubis is depressed and the brim of the pelvis enlarged to its utmost. As the head advances through the cavity of the pelvis she can no longer maintain her erect position, and she lies down and bends her body forward, which has the effect of causing a nutatory motion of the sacrum, with corresponding tilting up of its apex, and an enlargement of the outlet. These movements during parturition are facilitated by the changes which are known to take place in the pelvic articulations during preg- nancy. / The ligaments and cartilages become swollen and softened, and the synovial membranes existing betw^een the articulating siirfaces become greatly augmented in size and distended with fluid.) These changes act by forcing the bones apart, as the swelling of a sponge placed between them might do after it had imbibed moisture. The reality of these alterations receives a clinical illustration from those cases which are far from uncommon in which these changes are carried to so extreme an extent that the power of progression is materially interfered with for a considerable time after delivery. On looking at the pelvis as a whole we are at once struck w^ith its division into the true and false pelvis. The latter portion (all that is above the brim of the pelvis) is of comparatively little obstetric importance, except in giving attachments to the accessory muscles of parturition, and need not be further considered. /The brim of the pel- vis is a heart-shaped opening bounded by the sacrum behind, the linea ilio-pectinea on either side, and the symphysis of the pubes in front.)' All below it forms thgj3ayity, which is bounded by the hollow of the sacrum behind, by the inner surfaces of the innominate bones at the^ , sides and in front, and by the posterior surface of the symphysis pubis.^*^ It is in this part of the pelvis that the changes in direction which the ftetal head undergoes in labor are im]")arted to it. The lower border of this canal or pelvic outlet (Fig. 4) is lozenge-shaped — is bounded by the ischiatic tuberosities on either side, the tip of the coccyx behind, and the under surface of the pubic symphysis in front. Posteriorly to the tuberosities of the ischia the boundaries of the outlet are com- pleted by the sacro-sciatic ligaments. 40 ORdANS CONCERNED IN PARTriUTION. There is a very markcHl clittbrcnco hotwccii the pelvis in llie male aiul the ieniale, and the j)eeuliaiitie.s of the hitter all tend to facilitate the process of j>artiiritiou. In the female pelvis (Fig. 5) all the boues are Fig. 4. Outlet of Pelvis. i lighter m structure, and have the points for muscular attachments iiTUcITTess developed. The^l liac boues are more s})read out, hence the greater breadth which is observed in the female figure, and the peculiar side-to-side movement which all females have in walking. The 'tuber- osities of the ischia are lighter in structure and fartlier ajDart, and the t^ rami o f the pubes also converge at a much less acute ang^e. Tiiis greater breadth of the pubic arch gives one of tlie most easily appreciable points of contrast between the male and the female pelvis : the pubic arch Fig. 5. The Female Pelvis. in the female forms an angle of from 90° to 100°, while in the male ( (Fio-. 6) it averacres from 70° to 75°. The obturator foramina are p more triangular in shape \ "o The whole cavity of t / ity of the female pelvis is wider and less funnel- shaped than in the 'male, the symphysis pubis is not so deep, and, as the promontory of the sacrum does not project so much, the shape of ANAT03IY OF THE PELVIS. 41 <^lie pelvic_brim is_ more oyal tliiin in the male. These differences between the male and female pelvis are probably due to the presence of the female genital organs in the true pelvis, the growth of which Fig. 6. The Male Pelvis. increases its development in width. In proof of this, Schroeder states that in women with congenitally defective internal organs, and in women who have had both ovaries removed early in life, the f)elvis has always more or less of the masculine type. The measurements of the pelvis that are of most importance from an obstetric point of view are taken between various points directly opposite to each other, and are know^n as the diameters of the l)elvis. Those of the true pelvis are the diameters which it is especi- ally important to fix in our memories, and it is customary to describe three in works on obstetrics — the antero-posterio r or conjugate, the Fig. 7. Brim of Pelvis, showing antero-posterior, c. v, oblique, d, and transverse, t, diameters. obliqiie, and the transverse — although of course the measurements may be taken at any opposing points in the circumference of the bones. The antero-posterior (diameter conjucjata vera, c, Y, sacro-pubic) at the brim (Fig. 7) is taken from the (^upper part of the posterior surface of 42 ORG Ays COyCERNED AY PARTVRITIOy. the symphysis pubis to the centre of tlie pioiuoiitory of tlie sacrum;) in the ciivitv, Ironi the centre of the; symphysis piil>is to a correspond- ing point in the hotly of the tliird })iecc of the sacrum; and at the outlet (ct)ccy-pul)ic), from the lower l)order of the symphysis pul>nrto tlie tip of the coccyx. The ohlh^iv (diameter dkujondlis, d), at the' hrnyi, is taken from the sacro-iliac joint on cither side to a point (XTlie brim ctartin ix partviutios. unm, ami it must be rcmciiilx'icd that tlie (lc<;ree ot" inclination varies considerably in the same female at (liU'crenl times, in accordance with the ])osition of the body. Durinjr ])i'('onancy especially the obliijuitv of tlie brim is lessened by the patient throwing herself backward in Planes of the Pelvis, -with Horizon. A B. Horizon. c d. Vertical line. A B I. Anple of inclination of pelvis to horizon, equal to 60°. B I c. Angle of inclination of pelvis to si)inal column, ecjiial to 150°. c I J. Angle of inclination of sacrum to spinal column, equal to 130°. F, F. Axis of pelvic inlet. L M. Mid-plane iu the middle line. N. Lowest point of mid-plane of ischium. order to support more easily the weight of the graviil uterus. The height of the promontory of the sacrum above the ujijier margin of the symphysis jnibis is on au average about 3|- inches, and a line pass- ing horizontally backward from the latter ]>oint would impinge on the junction of the .second and third coccygeal bones. Axes of the Parturient Canal. — Vyy the axis of the pelvis is meant an imaginary line which indicates tlu^ direction which the foetus takes during its expulsion. (The axis of the brim (Fig. 10) is a line 1 1 drawn perpendicular to its plane, which would extend from the unibil- j ' icus to about the a])ex of the coccyx ;) ^hc axis of the outlet of the liouy pelvis intersects this, and extends from the centre of the ]iromontorv of the .«acrum to midway between the tuberosities of the i.schia.) The axis of the entire jielvic canal is re])re.sented by the .sum of the axes of au indcHnite number of jilanes at different levels of the pelvic cavity, which forms an irrcfjular parabolic line, as represented in the accom- panying diagram (Fig. 10, a d). It must be borne in mind, however, that it is not the axis of the bony pelvis alone that is of importance in obstetrics. Wc must always, in ANATOMY OF THE PELVIS. Fig. 10. 46 Axes of the Pelvis. A. Axis of superior plane. b. Axis of niiJ-plane. D. Axis of canal. c. Axis of inferior plane. E. Horizon. considering this subject, remember that the general axis of the parturi- ent canal (Fig. 11) also includes that of the uterine cavity above and of the soft parts below. These are variable in direction according to Fig. 11. Representing General Axis of Parturient Canal, including the Uterine Cavity and Soft Parts. 46 ORGAXS CONCERNED IN PARTrniTION. Fig. 12. circiiin.stan('cs ; aiulfit is (Hily tlic axis (if that |>liysis and the base of the coccyx that is fixed.! The axis of the lower part of the canal will vary accordintji; to the amount of distension oi" the jierinenni during;- labor; but when this is stretched to its ntino>t, just before the expidsion of the head, the axis of the ])lane between the edge of the distended perineum and the lower border of the symphysis looks ncai-lv directly forward. The axis of the uterine cavity oenci-ally corresjionds with that of the pelvic brim, but it may be much altered by abnormal jtositions of the uterus, such as anteversion irom hixity of liie abdelvis of the child (Fi^. 1'3) is less devcli^ied t ransversely and is much less deeph^ curved tliali m tTie adult. The pubes is also much shorter from side to side, and the ]^ul)ie arch is an acute ang le. The result of this narrowness of both the pid)es and sacrum is that the transverse (t) diameter_of thejieh'ic^ brim is shorter instead of longer than the antero-po.sterior (c. v). The sitles of the pelvis have a tendency to jiarallelism, as well as the antero-j)os- terior walls; and this is .stated by Wood to be a ])eculiar characteristic of the infantile pelvi.s. The iliac boues are not sprea d out as in adult Side View of Pelvis. ANATOMY OF THE PELVIS. 47 life, so that the centres of the crests of the ilia are not more distant from each other than the anterior superior spines. Tiie cavity oi' the true pelvis is small, and the tuberosities of the ischia are j)ro[)ortionately nearer to each other than they afterward become; the pelvic viscera are consequently crowded np into the abdominal cavity, which is, for this reason, much more prominent in children than in adults. The bones Fi(i. 13. Pelvis of a Child. are soft and semi -cartilaginous until after the period of puberty, and yield readily to the mechanical influences to which they are subjected ; and the three divisions of the innominate bone remain separate until about the twentieth year. As the child grows older the transverse development of the sacrum increases, and the pelvis begins to assume more and more of the adult shape. The mere growth of the bones, however, is not sufficient to account for the change in the shape of the pelvis, and it has been well shown by Duncan that this is chiefly produced by the pressure to which the bones are subjected during early life. The iliac bones are acted upon by two principal and opposing forces. One is the weight of the body aliove, which acts vertically upon the sacral extremity of the iliac beam through the strong posterior sacro-iliac ligaments, and tends to throw the lower or acetabular ends of the sacro-cotyloid beams outward. This outward displacement, however, is resisted, partly by the junction between the two acetabular ends at the front of the pelvis, but chiefly by the opposing force, which is the upward pressure of the lower ex- tremities through the femurs. Tiie result of these counteracting forces is that the still soft bones bend near their junction with the sacrum, and thus the greater transverse development of the pelvic brim character- istic of adult life is established. In treating the pelvic deformities it will be seen that the same forces applied to diseased and softened bones explain the ])eculiarities of form that they assume. Pelvis in Different Races. — The researches that have been made on the differences of the ]>elvis in different races prove that those are not so great as might have been expected. Joulin pointed out that in all 48 ORCiAys coycKRM:i> l\ rAnrrniTioy. luunan jk'Ivcs the tniiisviTsc (t) diaiuctcr was larger than tho aiitcro- postcrioi- (c. v), \\\\\\v the rovcrsc was the case in all tlie lower animals, even in the higiiest siniia-, Tiiis observation has been more reeentlv confirmed by Von Franqiie,' who has made careful measurements of the pelvis in various races. Jn the pelvis of tlie jijorilla the oval form of the l)rim, resulting from the increased lenirth of the conjugate (c. \) diameter, is very marked. In certain races tliere is so far a tendency to animality of type that the diilerence between the transverse (t) and conjugate (c. v) diameters is much less than in Euro^jean women, but it is not sufficiently marked to enable us to refer any given pelvis to a particular race. Von Franque makes the general observation that the size of the pelvis increases from south to north, but that the conjugate (c. v) diameter increases in projiortion to the transverse (t) in southern races. Soft Parts in Connection -with Pelvis. — In closing the descri])tiou of the pelvis the attention of the student must be directed to the mus- cular and other structures which cover it. It has already been jiointed out that the measurements of the pelvic diameters are considerably lessened by the soft parts, which also influence ])arturition in other ways. Thus, attached to the crests of the ilia arc strong muscles which not only support the enlarged uterus during pregnancy, but are powerful accessory muscles in labor : in the pelvic cavity are the obturator and pyriformis muscles lining it on either side; the pelvic cellular tissue and fascise ; the rectum and bladder ; the vessels and nerv^es, jiressure on which often gives rise to cramps and pains during pregnancy and labor; while beloAv the outlet of the pelvis is closed and its axis directed forward by the numerous muscles forming the floor of the pelvis and perineum. The structures closing the pelvis have been accurately described by Dr. Berry Hart,^ who points out that they form a complete diajihragm stretching from the pelvis to the sacrum, in which are three "faults" or *' slits" formed by the orifices of the urethra, vagina, and rectum. The first of these is a mere capillary slit; the last is closed by a strong muscular sphincter; while the vagina, in a healthy condition, is also a mere slit, with its Avails in accurate ap- posit ion. Hence it follows that none of these apertures impairs the structural efficiency of the pelvic floor or the support it gives to the structures above it. ' Soanzoni's BeitrUge, 1867. ' The Slrudnml Anatomy of the Female Pelvic Floor. THE FEMALE GENERATIVE ORGANS. 49 CHAPTER II. THE FEMALE GENERATIVE ORGANS. The reproductive organs iu the female are conveniently divided, a(!cordiug' to their function, into — 1. The external or copulative organs, which are chiefly concerned in the act of insemination, and are only of secondary importance in parturition : they include all the organs situate externally which form the vulva, and the vagina, which is placed inter- nally and forms the canal of communication between the uterus and the vulva ; 2. The internal or formative organs : they include the ovaries, which are' the most important of all, as being those in which the ovule is formed; the Fallopian tubes , through which the ovule is carried to the uterus ; and the_jiteriis, in which the impregnated ovule is lodged and developed. 1. The external organs consist of — The mons Veneris (Fig. 14, /'), a cushi on of adijjose and fibrous tissue which forms a rounded projection at the upper part of the vulva. It is in relation above with the lower part of the hypogastric region, fi'om which it is often separated by a furrow, and below it is continuous with the labia majora on either side. It lies over the symphysis and horizontal rami of the pubes. After puberty it is covered with hair, /v On its integument are found the o penings of numerous sweat and ^-\ sebaceo us gland s. The labia majora (Fig. 14, a) form two symmetrical sides to the longitudinal aperture of the vulva. They have two surfaces — one ex- ternal, of ordinary integument, covered with hair; and another internal, of smooth mucous membrane, in apposition with the corresponding portion of the opposite labium, and separated from the external sur- face by a free convex border. They ax'e thicker iu front, where they /' run into the mons Veneris, and thinner behind, where they are united, V^ in front of the perineum, by a thin fold of integument called the four-' h chette . which is almost invariably ruptured in the first labor. In the Ky virgin the labia are closely in apposition, and conceal the rest of the generative organs. After childbearing they become more or less sepa- rated from each other, and in the aged tliey waste and the internal nymphse protrude through them. Both their cutaneous and mucous >\ surfaces co ntain a large number of sebaceous glands, opening either \ directly on the surflace or into the hair-follicles. In structure the labia are composed of connective tissue , containing a varying amount of fat, and parallel with their external surface are placed tolerably close plex- uses of elastic tissue , interspersed with regularly arranged smooth mus- cular fibres. These fibres are described by Broca as forming a mem- branous sac, resembling the dartos of the scrotum, to which the labia majora are analogous. Toward its upper and narrower end this sac is continuous with the external inguinal ring, and iu it terminate some of 50 onn.ixs ro.\ri:nxi:i) ix PARTcnrnox. the fibres of the round lij^aim-iit. J'lic aiialoiry with tlic srrotum is lurtlier borne out by the occasional iiernial jirotrusion oi' tlie ovary t into the labium, correspoudiug to the uonuai desceut ol" the testis in J^ the male. ^ Jv/s^Jw C'C^.-A.^-^ cl ^ V-"'^'^^^ r/ The labia minora, or nymphsB (Fig. 14; 6), ai-e two folds of mucous meml)rane, comm('ncin*i- below, on cither side, about the centre ol the iuternal surface of the labium externum; they converge a.s they proceed lUG. 14. External Genitals of Virgin with Diaphragmatic Hymen. (After Sappey.) a. Lubium mnjiis. b. Labium miniiH. c. Prteputium clitoridia. d. Glana clitoridis. e. Vestibule just above urethral orifice. /. Mona Veneris. upward, bifurcating a.s they ajiproach each other. The lower branch of this bifurcation is attached to the clitoris (Fig. 14, c), Avhile the iip])er and larger unites with its fellow of the opposite side and forms a fold round the clitoris, known as its prepuce. The nym])ha> are usually entirely concealed by the labia majora, but after childl)earing and in old age they project somewhat beyond them ; then they lose their delicate pink color and soft texture, and become brown, dry, and like skin in appearance. This is especially the case in some of the negro races, in whom thev form long projecting folds callccl the a])ron. The surfaces of the nymplue are covered with te ssellat ed e})itheliura, THE FEMALE GENERATIVE ORGANS. 51 and over tlieiii arc distributed a large number of vaseulai' papillie, somewhat enlarged at their extremities, and sebaceous glands, which are more numerous on their internal surfaces. The latter secrete an odorous, cheesy matter which lubricates the surface of the vulva and prevents its folds adhering to each other. The nynipha? are composed of trabecuhe of connective tissue containing muscular fibres. The clitoris (Fig. 14, d) is a small erectile tubercle situated about half an inch below the anterioi' commissure of the labia majora. It is the analogue of the penis in the male, and is similar to it in structure, consisting of two corpora cavernosa, separated from each other by a fibrous septum. The crura are covered by the ischio-cavernous muscles, which serve the same purjjose as in the male. It has also a suspensory ligament. The corpora cavernosa are composed of a vascular ])lexus with numerous traversing muscular fibres. The arteries are derived from the internal jnidic artery, which gives a branch, the cavernous, to each half of the organ ; there is also a dorsal artery distributed to the prepuce. According to Gusseubauer, these cavernous arteries pour their blood directly into large veins, and a finer venous plexus near the sur- face receives arterial blood from small arterial branches. By these arrangements the erection of the organ which takes place during sex- ual excitement is favored. The nervous supply 6f the clitoris is large, being derived from the internal pudic nerve, which supplies branches to the corpora cavernosa, and terminates in the glands and prepuce, where Paccinian corpuscles and terminal bulbs are to be found. On this ac- count the clitoris has been supposed by some to be the chief seat of voluptuous sensation in the female. The vestibule (Fig. 14, e) is a triangular space, bounded at its apex by the clitoris, and on either side by the folds of the nymphse. It is smooth, and, unlike the rest of the vulva, is desti tute of seljaceous glands, although there are several groups of muci^^ous^^ands opening on~Tfs surface. At the centre of the base oi flie~triaugle, which is formed by the upper edge of the opening of the vagina, is a prom- inence, distant about an inch from the clitoris, on Avhich is the ori- fice of the urethra. This prominence can be readily made out by the finger, and the depression upon it — leading to the urethra — is of importance as our guide in passing the female catheter. This little operation ought to be performed- without exposing the patient, and it is ?j \^ done in several ways. The easiest is to place the tip of the index'y^ \ ^ finger of the left hand (the patient lying on her back) on the apex of /^ the vestibule, and slij) it gently down until we feel the bulb of the J''^ urethra and the dim[)le of its orifice, which is generally readily found.p," If there is any diflfieultv in finding the orifice, it is well to remember^ that it is placed immediately below the sharp edge of the lower border of the symphysis pubis, which will guide us to it. The catheter (and a male elastic catheter is always the best, especially during labor, when the urethra is apt to be stretched) is then passed under the thigh of the patient, and directed to the orifice of the urethra by the finger of the left hand, which is placed upon it. AVe must be careful that the instrument is really passed into the urethra, and not into the vagina. It is advisable to have a few feet of elastic tubiuo; attached to the end 52 oiiGASs ('ONcerm:i> jy parti rition. of the oathotcr, so tliat tlie uriiu' can l)e j)assc(l into a vessel inider the bed without iiiic()verinrtance from a medico-legal point of view. Sometimes it is so tough as to })revent intercourse alto- gether, and may require division by the knife or scissoi*s before this can be effected ; and at others it rather unfolds than ruptures, so that it may exist even after imj)regnation has been effected, and it has been met with intact in women who have hal)itually led unchaste lives. In a few rare cases it has even formed an ol)stacle to delivery, and has required incision during labor. ' Amrr. Journ. of Ohstetrici, 1880, vol. xiii. p. 265. ■' Hart. op. n't. ^ Biidin, Rechercheji mr P Hymen el rOrijice vugiiuil, 1879. THE FEMALE GENERATIVE ORGANS. 53 The carunculse niyrtiformes arc small fleshy tubercles, varying from two to Ave in number, situated round the orifice of the vagina, and which are generally sui)|)(»scd to be the remains of the ruptured hvmen. Schroeder, however, maintains that they are only formed after childbcaring, in conse(|uence of })arts of the liymen having been destroyed by the injuries received during the passage of the child. Vulvo-vaginal Glands. — Near the posterior })art of. the vaginal orifice, and below the superficial ])erineal fascia, are situated two con- glomerate glands which are the analogues of Cowper's glands in the male. Each of tliese is about the size and shape of an almond, and is contained in a cellular fibrous envelope. Internally they are of a yel- lo\\nsh-white color, and are composed of a number of lobules separated from each other by prolongations of the external envelope. These give origin to separate ducts which unite into a common canal, about half an inch in length, which opens i n fron t of the attached edge of the hymen in virgins, and in married women at the base of one of the carunculee niyrtiformes. According to Huguier, the size of the glands varies much in different women, and they appear to have some connec- tion with the ovary, as he has always found the largest gland to be on the same side as the largest ovary. They secrete a glairy, tenacious flj.iid, which is ejected in jets diu'ing the sexual orgasm, probably through the spasmodic action of the perineal muscles. At other times their secretion serves the purpose of lubricating the vulva, and thus preserves the sensibility of its mucous membrane. Fossa Navicularis. — Immediately behind the hymen, in the unmarried, and between it and the perineum, is a small depression called the fossa navicularis, which disappears after childbearing. The perineum separates the orifice of the vagina from that of the rectum. It is about IJ inches in breadth, and is of great obstetric interest, not only as supporting the internal organs from below, but because of its action in labor. It is largely stretched and distended by the presenting part of the child, and, if unusually tough and unyield- ing, may retard delivery, or it may be torn to a greater or less extent, thus giving rise to various stibsequent troubles. Vascular Supply of the Vulva. — The structures described above together form the vulva, and they are remarkable for their abundant vascular and nervous supply. The former iconstitutes an erectile tissue similar to that which has already been described in the clitoris, and which is especially marked about the bulb of the vestibule (Fig. 15). From this point, and extending on either side of the vagina, there is a well-marked plexus of convoluted veins which, in their distended state, are likened by Dr. Arthur Farre to a filled leech. The erection of the erectile tissue, as well as that of the clitoris, is brought about under excitement, as in the male, by the compression of the efferent veins, by the contraction of the i sch io-cave rn o n s m uscles , and by that of a thin layer of muscular tissues surrounding the orifice of the vagina and described as the constrictor vagina e. The vagina is the canal which forms the communication between the external and internal generative organs, through which the semen passes to reach the uterus, the menses flow, and the fcetus is expelled. Ill v.^-" 54 (jJWASs foycKRyKi) IS rARTrniTioy. ( Kniiiiiily s|K'akiii(ular and pinjcct into the ei)itiielial layer. Unliiraiie, that of" the vagiua seems to be d estitute oi' j^and* ^- Beueath the e])ithelial layer is a sul)n»ucous tissue coiitamin^ a large iiunibcr of e lastic and some imiscular fibres, derived from the muscular walls of the vaf2:ina. These are stroni^ and well developed, especially towai-d the ostium vat[i- n:e, where they are arranged in a circular mass having a si)hinctcr action. They consist of two layers — an internal longitudinal aiid an external circular — with oblique decussating fibres connecting the two. Below they are attached to the isehio-pubie rami, and above they are continuous with the muscular coat of the uterus. (^The muscular tissue^ of the vagina increases in thickness during pregnancy, but to a much] less degree than that of the uterus.) Its vascular an-angements, like those of the vulva, are such as to constitute an erectile tissue. 'Jhe arteries form an intricate network around the tube, and eventually end in a submucous capillary plexus from which twigs pass to supply the paj)ilhe ; these again give origin to venous radicles which unite into meshes freely interlacing with each other and forming a well-marked venous ])lexus. 2. The internal organs of generation consist of the uterus, the Fallojnau tubes, and the ovajies; and in connection with them we have to studv the various ligaments and folds of ijcritoueum which serve to maintain the organs in position, along with certain accessory structures. Phvsiologically, the most important of all the generative organs are the ovaries, in which the ovules are formed and which dominate the entire reproductive life of the female. The Fallopian tubes, which convey the ovule to the uterus, and the uterus itself — whose main function is to receive, nourish, and eventually expel the impregnated product of the ovarv — may be said to be, in fact, accessory to these viscera. Practi- callv, however, as obstetricians, we are chiefiy concerned with the uterus, and may conveniently commence with its description. The uterus is correctly described as a ])yrU()rm_organ, flattened from before backward, consisting of the body with its rounded fundus, anosition ]iartly by being slung by its ligantcnts, which we shall subscfjuently study, and partly by being suj)ported from beloAV by the pelvic cellular tissue and the fleshy column of the vagina. The result is that the uterus, in the healthy female, is a perfectly movable body, altering its ])osition to suit the condition of the surrounding viscera, especially the bladder and rectum, which are subjected to variations of size according to their fulness or emptiness. AVlu'u from anv cause — as, for exam]de, some ])eriuterine inflammation ])rodueing adhesions to the surrounding textures — the mobility of the organ is interfered with, much distress ensues, and if pregnancy sui)er- THE FEMALE (JPJNERATIVE ORGANS. 57 venes more or less serious coiisccjiiciicos may result. Generally speak- ing, the iit(!rus nuiv be said to lie in a line roughly eorresponding with the axis of the p elvic brim, its fundus being pointed ibrward, and its cervix lying in siielTa direction thai a line drawn from it would impinge Fig. 18. Transverse Section of the Body, showing relations of the fundus uteri. TO. Pubes. a a (in front). Remainder of hypogastric arteries, a a (behind). Spermatic vessels and nerves. B. Bladder. L L. Round ligaments. U, Fundus uteri. I t. Fallopian tubes, o o. Ovaries, r. Rec- tum, g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, v. Last lumbar vertebra. on the junction between the sacrum and coccyx. According to some authorities, the uterus in early life is more curved in the anterior direc- tion, and is, in fact, normally in a state of anteflexion. Sappey holds that this is not necessarily the case, but that the amount of anterior curvature depends on the emptiness or fulness of the bladder, on which Transvi Srctinii of rtcrus. the uterus, as it were, moulds itself in the iinimpregnated state. It is believed also that the body of the uterus is very generally twisted some- what obliquely, so that its interior surface looks a little toward the right side, this prol)ably depending on the presence and frequent distension 58 OrxdAyS CONCERNED IN PARTURITION. oi' tliL- rcvliuu in the left side (if the pelvis. '|'lic anter ior sin-l'ace of the uterus is convex, antl is ei)v<'n'(l^ in tin-ee-fonrtlis of its extent by the peritoneum, which is intiinatt'ly aTInerent to it. Px-low the reHec- tion of the nienibrane it is lo(»sely connected by celhihir tissue to the bhulder, so that any downward disphicenient of the uterus (b'afrs the bladder alon*:; with it. The posterior surface is also convex, but more distinctly so tiian the anterior, as may be observed in looking at a transverse section of tiie or<>;an (Fig. 19). It is also covered by ])ei-itoneuin, tlie reflection oi" which on the rectum forms the cavity known as Douglas' pouch. T he fu ndus is the upper extremity of the uterus, lying above the j)oints (Tfentry of the Fallopian tubes. It is onlv slightly I'ounded in tiie virgin, but becomes more decid- etllv and [)ernianently rounded in the woman who has borne chil- dren. Until the period of pul)erty the uterus remains small and unde- veloi)ed (Fig. 20); after that time it reaches the adult size, at which Fig. 20. uterus and Appendages in an Infant. (After Farrc.) it remains until menstruation ceases, when it again atro])hies. If the woman has borne children it always remains lip- g er than in the nullii)ara. In the virgin adult the uterus measures 2\ inches from the orifice to the fundus, ratlier more than half being taken up by tlic cervix. Its greatest breadth is opposite the insertion of the Falloi)ian tubes; its greatest thickness, about 11 or 12 lines, opposite the centre of its body. Its average weight is about 9 or 10 drachms. Indeju'ndently of preg- nancy, the uterus is subject to great alterations of size toward the men- strual period, when, on account of the conge.stion then present, it enlarges, sometimes, it is said, considerably. This fact .should be borne in mind, as this periodical swelling might be taken for an early pregnancy. For the purpose of description the uterus is conveniently divided into 3 X y^ A ' I ^, g^- n THE FEMALE GENERATIVE ORGANS. 59 i\\Q fundus, with its rounded iij)j)cr extremity, sitiuited between the in- sertionir()f the Fall()i)ian tubes ; the Ixxlji, which is bounded above by the insertions of the Fallopian tubes auTT below by the upper extremity of the cervix, and wiiicli is the part chiefly concerned in the rece[)tion and ii^rowth of the ovum; and the cervix, which projects into the va^i^ina and dilates durint;' labor to give passage to the child. The cervix is conical in shape, measuring 11 to 12 lines transversely at the base, and 6 or 7 in the antero-posterior direction ; while at the apex it measures 7 to 8 transversely and 5 antero-posteriorly. It projects about 4 lines into the canal of the vagina, the remainder of the cervix being placed above the reflection of the vaginal mucous membrane. It varies nuicli in form in the virgin and milliparous married Vt'oman and in the woman who has borne children; and the differences are of importance in the diagnosis of pregnancy and uterine disease, /in the virgin it is regu- larly pyramidal in shape. ") At its lower extremity is the opening of the external os uteri, forming a sma.ll circular opening, sometimes difficult to feel, and generally described as giving a sensation to the examining finger like the extremity of the cartilage at the tip of the nose. It is bounded by two lips, the anterior of which is apparently larger on account of the position of the uterus. The surface of the cervix and the borders of the os are very smooth and regular. In women who have borne children these parts become considerably altered. The cervix is no longer conical, but is irregular in form and shoi-tened. The lips of the os uteri become fissured and lobulated, on account of partial lacerations which have occurred during labor. The OS is larger and more irregular in outline, and is sometimes sufficiently patulous to admit the tip of the finger. In old age the cervix atrophies, and after the change of life it not uncommonly entirely disappears, so that the orifice of the os uteri is on a level with the roof of the vagina. The internal surface of the uterus comprises the cavities of the body 'and cervix — the former being rather less than the latter in length in. virgii^^ but about equal in women who have borne children — separated from each other by a constriction forming the u}i|)cr boundary of the cervical canal. The cavity of the body is triangular in shape, the base of the triangle being formed by a line joining the openings of the Fal- lopian tubes, its apex by the upper orifice of the cervix, or internal os, as it is sometimes called. In the vjrgin its boundaries are somewhat convex, projecting inward. After childbearing they become straight or slightly concave. The opposing surfaces of the cavity are always inl contact in the healthy state, or are only separated from each other by aj small quantity of mucous. The cavity of the cervix is s pindle-sh aped or fusiform, narrower above and below at the internal and external os uteri, and somewhat dilated between these two points. It is flattened from before backward, and its opposing surfaces also lie in contact, but not so closely as those of the body. Oii__t]ic nnicon^ lining of the anterior and posterior sur- faces is a prominent ixrpciidicular ridge, with a lesser one at each side, froiii which transverse ridges proceed at more or less acute angles. They have received the name of the arbor vitce. According to Guy on, the perpendicular ridges are not exactly opposite, so that they fit into each GO OliUAS^ COSiJERSED IS rARTUlUTION. other, and servo more completely to iill up the cavity of the cervix, cs- l)eeialiy toward the internal os (Fio-. 21). The a rbor vitte is most dis- tinct in the virgin, and atropliics considerably afterV-irrfdbearing-. Fig. 21. Fig. 22. Portion of Interior of Cervix, enlarged nine diameters. (.Vfter Tyler Smith and Ilassall.) The superior extremity of tlie cervical canal forms a narrow isthmus separating it from the cavity of the body, and measuring about three- eighths of an inch iu diameter. Like the external os, it contracts after the cessation of menstruation, and in old age sometimes becomes entirely obliterated. The uterus is compo.sed of three principal structures — the peritoneal, mu-scular, and mucous coats. The pcritj^uc um forms an investment to the greater part of the organ, extend- ing downward in front to the level of the OS internum, and behind to the top of the vagina, from which ])oints it is reflected upwai'd on the bladder and rectum respectively. At tiie sides the peritoneal invest-/ ment is not so extensive, for a little below the level of the Fallopian tubes the peritoneal folds sc])arate from each other, forming the broad ligaments (to be afterward dc^-^cribcd) ; here it is that the ves.sels and nerves supplying the uterus gain access to it. At the upper jxirt of the organ the peritoneum is so closely adherent to the muscular tissue that it can- not be separated from it ; below, the connection is more loose. The mass <^ Jfuscnlar Fibres of Unimpregnated Uterus (After Farre.) a. Fihrps utiitod hy ronncctive tis.sn('. 6. Separate fibres aiiJ elementary corpusclus. THE FEMALE GENERATIVE ORGANS. 61 of the uterine tissue, botli in the body and cervix, consists of unstriped muscular fibres (Fig. 22), firmly united toilet her by nucleated coiuiective tissue and elastic fibres. The muscular libre-cellsare large and fusiform with very attenuated extremities, generally containing in their centi-eadis- tinct nucleus. These cells, as well as their nuclei, become greatly enlarged during pregnancy (Fig. 23) : according to Strieker, this is only the case Fig. 23. Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) with the muscular fibres which play an important part in the expulsion of the foetus, those of the outermost and innermost layers not sharing in the increase of size.^ In addition to these developed fibres there are, especially near the mucous coat, a number of roundje lemen tar y corpus- cles, which are believed by Dr. Farre^ to be tlie"eTementary form of the muscular fibres, and which he has traced in various intermediate states of development. i^Dr. John Williams^ believes that a great part of the muscular tissue of the uterus — rather more, indeed, than three-fourths I of its thickness — is an integral part of the mucous membrane, analogous (i to the muscularis mucosse of the mucous membrane of the alimentary canal. ] This he describes as being separated from the rest of the muscu- lar tissue by a layer of rather loose connective tissue containing numer- ous vessels. In early foetal life and in the uteri of some of the lower animals this appearance is very distinct ; in the adult female uterus, however, it cannot be readily made out. On examining the uterine tissue in an unimpregnated condition no definite arrangement of its muscular fibres can be made out, and the whole seem blended in inextricable confusion. By observation of their relations when hypertrophied during pregnancy Helie* has shown that they may, speaking roughly, be divided into tliree layers — an ex- ternal ; a middle, chiefly longitudinal ; and an internal, chiefly circular. Into the details of their distribution, as described by him, it is needless to enter at length. Briefly, however, he describes the external layer as arising posteriorly at the junction of the body and cervix, and spreading upward and over the fundus. From this are derived the muscular fibres found in the broad and round ligaments, and more particularly described by Rouget. The middle layer, is made up of strong fasciculi^ * Compamti/ve Histolor/i/, vol. iii. ; Syd. Soc. Trans., p. 477. yP" / ^ The Uterus and its Appeudaxjefs, p. 632. ^ "On the Structure of the Mucous Membrane of the Uterus," Ohsfei. Jown., 1875-76, vol iii. p. 496. * Reeherches sur la Dinposition dcs Fibres mu.'iculaires de I' Uterus, Paris, ] 869. 62 oi^^■.lxs' coycEEXED ly rAirrriiiTioy which run uj)\\ar(l, but decussate and unite will) ladi other in a remarkable manner, so that those whicli are at fii-st su])ertieial become most deeply seated, and rice cer-sd. The nmscular fasciculi which form this coat curve in a circular manner round the large veins, so as to foi-ni a species of muscular canal, throu ,. r. ,1 period. (After Williams.) and re-iormed afresh by proliferation of the cells of the muscular and connective tissues, probably from below upward, the new membrane commencing at the internal os. Hence its appear- ance and structure vary considerably according to the time at which it is examined. The subject, however, will be more particularly studied in connection with menstruation. The mucous membrane of the cervix is much thicker and more trans- parent than that of the body of the uterus, from which it also differs in certain structural peculiarities. The general arrangements of its folds and surface have already been described. The lower half of the mem- brane lining the cavity of tlie cervix, and the whole of that covering its external or vaginal portion, are closely set with a large number of minute filiform or clavate pajiillse (Fig. 27). Their structure is similar to that oT the mucous membrane itself, of which they seem to be merely elevations. They each contain a vascular loop (Fig. 28), and they are believed by Kilian and Farre to be mainly concerned in giving sensi- bility to this part of the generative tract. All over the interior of the cervix, both on the ridges of the mucous membrane and between their folds, are a very large number of mucous follicles consisting of a 64 ORGAXS COSCKliSi:!) IS PAim' I'JTIOS. stnictiirt'lcss hu'IuIjimhc lined with cyljiHlrical cpitlicliiim and inti- inati'ly united with coniu'ctive tissue. Tliey ceji^e at tlie external oriHeo of" tlie cervix, and tliey secrete the thiek, tenacious, and alka- line mucus which is generally lound filling the ccrvitid cavity. The trans[)arent follicles, known as the '^ ocu(<. The I vmjjhatics of the uterus arc large and well developed, and they have recently, and with much probability, been supposed to ])lay an important part in the production of certain puerperal diseases. A more minute knowledge than Ave at present possess of their course and distribution will probably throw nuich light on their influence in this respect. According to the researches of Leopold,' who has studied their minute anatomy carefully, they oi-iginate in lymph-S])aces l)etween the fine l)undles of connective tissue forming the basis of the mucous lining of the uterus. Here they are in intimate contact with the utric- ular glands and the ultimate ramifications of the uterine blood-vessels. As they pass into the muscular tissue they become gradually narrowed into lymph-vessels and spaces, which have a very com})licated arrange- ment, and which eventually unite together in the external nuiscular layer, especially on the sides of the uterus, to form large canals Mhich probably have valves. Immediately under this i)eritoneal covering these lymph-vessels form a large and characteristic network covering the anterior and posterior surfaces of the uterus, and present, in various parts of their course, large ampulla?. They then spread over the Fal- lopian tubes. The lymphatics of the body of the ut(n'us unite with the luml)ar glands, those of the cervix with the jielvic glands. The distribution and arrangement of tlie iieryes of the uterus have been the subject of much controversy. They are derived mainly from the ovarian and hypiogastric plexuses, inosculating freely Mith each other between the folds of the broad ligament, from whicli they enter the nuiscular tissue of the uterus, o;cnerally, but not invariably, follow- ing the course of the arteries. (They are chiefly derived from the sympathetic] but as the hy})ogastric plexus is connected with the sacral iiervesJ it is probable that some fibres from the cerebro-spinal system are ' Arch. J. GyndL, 1873, Bd. vi. Heft 1, S. 1. THE FEMALE GENERATIVE ORGANS. 67 distributed to the cervix. Jt i.s now generally admitted that nervous filaments are distributed to the cervix even as far as the external os, although their existence in this situation has been denied by Jobert and other writers. The ultimate distribution of" the nerves is not yet made out. Polle describes a nerve-filament as entering the papilhe of" the cervical mucous membrane along with the capillary looj), and Franken- hauser says the nerve-fibres surround the muscles of" the uterus in the form of plexuses and terminate in the nuclei of the muscle-cells. Anomalies of the Uterus. — Various abnormal conditions of the uterus and vagina are occasionally met with which it is necessary to mention, as they may have an important practical bearing on parturi- tion. The most frequent of these is the existence of a double, or par- tiallv double, uter us (Fig. 29), similar to that fouud normally in many Fig. 29. Bifid Uterus. (After Farre.) of the lower animals. This abnormality is explained by the develop- ment of the organ during foetal life. The uterus is formed out of structures existing only iu early foetal life, known as the ^Yolfiian bodies. These consist of a number of tubes situated on either side of the vertebral column and opening externally into an excretory duct. Along their external border a hollow canal is formed, termed the canal of Miiller, which, like the excretory ducts, proceeds to the common oloaca of the digestive and urinary organs which then exists. CThe, canal of Miiller unites with its fellow of the opposite side to form the- uterus and Fallopian tubes in the female, and subsequently the central partition at their point of junction disappears. ^ If, however, the prog- ress of development be in any way checked, the central partition may remain. Then we have produced either a complete double uterus or the uterus bicoruis, which is bifid at its upper extremity only ; or a double vagina, each leading to a separate uterus. If pregnancy occur in any of these anomalous uteri — and many such cases are recorded — serious troubles may follow. It may ha]^pen that one horn of the double uterus is not sufficiently large to admit of pregnancy going on to term, and rupture may occur. It is supposed that some cases, presumed to be tubal gestation, were really thus expli- cable. Impregnation may also occur in the two cornua at diftereut G8 ORG Ays CONCERXEJJ jy PMlTmiTION. tinio.<, leading to .supcrluitatuMi. It is, however, quite jjossible that iini)re5j:;nation may oeeiir m~one horn of a bifid uterus, and labor be conij)leted without anytliing unusual being observed. A remarkable case of this sort has been recorded by iJr. Koss of JJrighton,' in which a i)atient miscarried of twins on July IG, 1870, and on October 31, filteen weeks later, she was tlelivered of a healthy child. C'areiul examination showed the existence of a complete double uterus, each side of which had been impregnated. Curiously enough, this patient had formerly given birth to six living children at term, nothing remarkable having been observed in her labors. It can only rarely hapi)en that, under such circumstances, so favorable a result Mill follow, and more or less difficulty and danger may generally be expected. Occasionally the vagina only is double, the uterus being single. Dr. Matthews Duncan has recorded some eases of this kind,^ in which the vaginal se})tum formed an obstacle to the birth of the child, and required division. Fig. 30. Uterus Septus Tniforis. (From Kussmaul, after Gravel.) «. Vagina. 6. Sinple os uteri, c. Partition of ..torus, tl.ick ..Ik.vc- ai.d thir. Ixlow. d d. Eight and Icit ^ merine cavities, e e. Two ridges i.. the posterior wall of the ce.MX. [Double uteri are of several di.stinct types, the extremes of which are the " p.\rtitione(J uterus," where the organ is single without and double within, and the ^^" "completely bifi(l_jiterus,^' where there is a dmible va- gina and cervix with a Y-shaped or double-barrelled body. The for- mer can onlv be diagno.sticated from within, and is rarely discovered until after the second sta^e of a labor has Ijccn completed. In a ca.se reported by Dr. B. F. IWr of Philadelphia the ]>atient bore twins, one fcEtus from' each compartment, the birth of which was followed by two • Lancet, 1S71, vol. ii. p. 188. ' Researches in ObsUtrk.^ i». 443. THE FEMALE GENERATIVE ORGANS. 69 single phicentje at intervals of a quarter of an hour. Where there is only one foetus the uterus develops mainly on one side, and the unoccu- pied one lies much lower than the fundus of the other. Dr. Drysdale of this city discovered one such case by the touch after labor, and no doubt a (direful scrutiny would find that they are less rare than might be presumed. Pregnancy in a uterus nnicornus is apt to terminate fatally by rup- ture, but exceptional cases may occur and the foetus be delivered at term. In one ca.se seen by the writer the development of the abnormal uterus gave rise to much pain and distress for several months, and an extra- uterine pregnancy was regarded as almost certain by the family physi- cian. The child Avas a female of four pounds, and died in three days from an undeveloped duodenum and an imperforate rectum: the coruu was on the right side. — Ed.] Lig-aments of the Uterus. — The various folds of peritoneum which invest the uterus serve to maintain it in position, and they are described ^ as its ligaments. They are the broad , the vesico-uterin e, and sacro- ^terine ligame nts ; theToimd [igiiments are not peritoneal folds like the others. The broad. Hgaments extend from either side of the uterus, where their lamiute are separated from each other, transversely across to the pelvic wall, and thus divide the cavity of the pelvis into two parts, the anterior containing the bladder, the posterior the rectum. Their upper borders are divided into three subsidiary folds, the anterior of which contains the round ligament, the middle the Fallopian tube, and the posterior the ovary. The arrangement has received the name of the aJa vespertilionis, from its fancied resemblance to a bat's wing. Between the folds of the broad ligaments are found the uterine vessels and nerves, and a certain amount of loose cellular tissue continuous with the pelvic Fig. 31. / Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) fiiscifB. Here is situated that peculiar structure called the organ of E,osenmuller, or the parovarinn i (Fig. 31), which is the remains of the Wolffian body and corresponds to the epididymis in the male. This 70 ORGASS COyCERyEl) IS PARTURITION. may best be seen in yonnf;; snbjccts by lioldin^'- up llic Itroad li^nients and Ittokinij; tlin»nAJiTriiITlON. of the uterus at fii-st transversely outward, and tlien downward, back- ward, and inward, so as to rcacli the nei<:;hh(»i IkhkI ol" the ovary. In tne first ])art of" its coui'se it is straight ; aftei-ward it Ix-conics fiexuous and twisted on itself. It is contained in the nj)iH'r part of tTIe^ hroad liu-anicnt, wiiere it may be felt as a hard cord. It commences at the uterus by a narrow opening, admitting only the jKtssage of a bristle, known as ostiinn nierinum. As it pitsses through the muscular walls of the uterus the tube takes a somewhat cin-ved course, and f)j)ens into the uterine cavity by a dilated aj)erture. From its uterine attachment the tube expands gradually until it terminates in its trumjx-t-shaped ex- tremity ; just l)efore its distal end, however, it again contracts slightly. The ovarian end of the tube is surrounded by a number of remarkable fringe-like processes. These consist of longitudinal mend)ranous fim- bria?, surrounding the aperture of the tube like the tentacles of a lH»lyp, varying considerably in number and size and luiving their edges cut and sul)divided. On their iinier surface are found both transverse and lon.gitiitHnaL folds of mucous iiieml)rane continuous with those lining the tube itself (Fig. 33). One of these fimbriie is always larger and Fig. 33. Fallopian Tube laid open. (After Richard.) a, h. Uterine portion of tube, c, d. Plica? of mucous inenibrane. e. Tubo-ovarian ligaments and fringes. /. Ovary, g. Round ligaments. more developed than the rest, and is indirectly united to the surface of the ovary by a fold of peritoneum proceeding from its external surface. Its under surface is grooved so as to form a channel, open below. The function of this fringe-like .structure is to grasp the ovary during the menstrual nisus ; and the fimbria which is attached to the ovary would seem to guide the tentacles to the ovary which they are intended to seize. One or more supplementary .series of Hmbri;e sometimes exi.>^t, which have an a])erture of communication with the canal of the Fallo- pian tube, beyond its ovarian extremity. His has recently shown that the fimbriated extremity of the tube, after running over the upjier part of the ovary, turns down along its free border, .so that its aperture lies THE FEMALE GENERATIVE ORGANS. 73 below it, ready to receive the ovule when ex])elled from the Graafian follicle/ The tubes themselves consist of peritoneal, muscular, and raucous coats. The peritoneum surrounds the tube for three-fourths of its cal- ibre, and comes into contact with the mucous lining; at its fimbriated extremity, the only instance in the body where such junction occurs. The muscula r jcoat is principally com])osed of cjrcu]ar_fi])i-es, with a few longitudinal fibres interspersed. Its nmscular character has been doubted, but Farre had no difficulty in demonstrating the existence of muscular fibres both in the human female and many of the lower ani- mals. According to Robin, the muscular tissue of the Fallopian tubes i is entirely distinct from that of the uterus, from which he describes it as being separated by a distinct cellular septum. The mucous lining is thrown into a number of reinarkable longitudinal folds, each of which contains a dense and vascular fibrous septum wdth small muscular fibres, and is covered with columnar and ci liated epi thelium. The apposition of these produces a series of minute capillary tubes, along which the ovules are propelled, the action of the cilia, which is toward the uterus, apparently favoring their progress. The ovaries are the bodies in which the ovules are formed and from which they are expelled, and the changes going on in them, in connection with the process of ovulation, during the whole period between the establishment of puberty and the cessation of menstru- ation, have an enormous influence on the female economy. Normally, \ the ovaries are two in number ; (in some exceptional cases a supplemen- 1 tary ovary has been discovered,Yor they may be entirely absent. ) They \ are ])laced in the posterior folds of the broad ligaments, usually below I the brim of the pelvis, behind the Fallopian tubes, 'the left in front of. the rectum, fthe right in front of some coils of the small intestine.' J Their situation varies, however, very much under different circum- stances, so that they can scarcely be said to have a fixed and normal position ; most probably, however, as has been recently shown by His,^ » Cthey are normally placed close below the brim of the pelvis, with their long diameters almost vertical, and immediately above the aperture ofl the distal extremity of the Fallopian tubes.^ In pregnancy they ris^ into the abdominal cavity with the enlarging uterus ; and in certain conditions thev are dislocated downward into Douglas' space, where they may be felt through the vagina as rounded and very tender bodies. The folds of the broad ligament, between which the ovaries are l)laced, form for them a kind of loose mesentery. Each of them is united to the upper angle of the uterus by a special ligament called the utero-o yarian. This is a rounded band of organic muscular fibres about an inch jii_len_gth, continuous with the superficial muscular fibres of the posterior wall of the uterus, and attached to the inner extremity of the ovary. It is surrounded by peritoneum, and through it the muscular fibres, which form an important integral part in the structure of the ovaries, are conveyed to them. The ovary is also attached to the/ fimbriated extremity of the Fallopian tube in the maimer already descnbed. ■■1C~ 1 His, Archivfur Anat. unci Phys., 18S1. ' Op. cit. 74 onaAys cosceiiskd is parturition. The ovary is of an irrej^iilar oval sliapc (Fijj. 34), the ujijkt honk-r being convex, the h»\\er — tiiroiiiists of cdlumnar epithelium, differing (tnly from the epithelium lining the Fallopian tubes, with which it is sometimes continuous through the attached fim- bria uniting the tube and the ovary, in being destitute of cilia. Imme- diatelv beneath this coverins; is the dense coat known as the tunica THE FEMALE GENERATIVE ORflANS. 75 albtu/inca, oii account of its wJiitisli color. It consists of short cou- nective-tissue fibres arranged in lamiuse, among whicli are interspersed fusiform muscular fibres. At the point where the vessels, and nerves enter the ovary this membrane is raisetl into a ridge, which is contin- uous M'ith tlie utero-ovarian ligament and is called the hilam. The tunica albuginea is so ultimately blended with the stroma of the ovary as to be inseparable on dissection ; it does not, however, exist as a distinct lamina, but is merely the external part of the pro})er structure of the ovary, in which more dense connective tissue is developed than elsewhere. On making a longitudinal section of the ovary (Fig. 35) it will be seen to be com])oscd of two parts, the more internal of which is of a reddish color from the number of vessels that ramify in it, and is called the medidlarij or Fig. 35. vascular zone; while the external, of a whitish tint, receives the name of the cortical or parenchymatous substance. The former consists of loose connective tissue interspersed with elastic and a considerable number of muscular fibres. Accordino; to Kou^et^ and His,^ the muscular structure forms the greater part of the ovarian stroma. The latter de- scribes it as consisting essentially of inter- Avoven muscular fibres, wdiich he terms the "fusiform tissues," and which he believes to ^"^^^S"^? (Ifter^Far/e.)^*^''^^ be continuous with the muscular layers of the ovarian vessels. The former believes that the muscular fasciculi accompany the vessels in the form of sheaths, as in erectile tissues. Both attribute to the muscular tissues an important influence in the expulsion of the ovules and in the rupture of the Graafian follicles. Waldeyer and other writers, however, do not consider it to be so extensively developed as Rouget and His believe. \^he cortical substance is the more important, as that in which the Graafian follicles and ovules are formed. ) It consists of interlaced fibres of connective tissue containing a large number of nuclei. The muscular fibres of the medullary sub- stance do not seem to penetrate into it in the human female. In it are found the Graafian follicles, which exist in enormous numbers from the earliest periods of life and in all stages of development (Fig. 36). The Graafian Follicles. — According to the researches of Pfliiger, AValdeyer, and other German writers, the Graafian follicles are foi'med iii early foetal life by cylindrical inflections of the epithelial covering of the ovary, which dip into the substance of the gland. These tubular filaments anastomose with each other, and in them are formed the ovules, which are originally the epithelial cells lining the tubes. Por- tions become shut off from the rest of the filaments and form the Graaf- ian follicles. The ovules, on this view, are highly-developed epithelial/ cells, originally derived from the surface of the ovary, and not developed! in its stroma. These tubular filaments disappear shortly after birth, but they have recently been detected by Slavyansky ^ in the ovaries of a ' Journal de Physiol., i, p. 737. ' SchuUze's Arch.f. Mlkroscop. Anat., 1SG5. ^ Annates de Gynec, Feb., 1871. 76 ORa.iys LuycEityKD is rARTuniTios. woman tliirtv years of age. Tliese oUsc rvatioiis have l)eeii iiKwlificd hy Dr. Fouli.^.' lie reeoj^iiizes the ori<;in of the ovules from thegerm-epi- FiG. ?.C,. Section through the Cortical Part of the Ovary. e. Surface epitlieliuin. s n. Ovarian stroiua. 11. Larfie-sized Graafian follicles. 2 2. Middlo-eized ; and 3 3. Small-sized Graafian fcillicles. o. Ovule witliin Graafian follicle, v v. Blood-vosseU in the stroma, g. Cells of the membrana granulosa, (After Turner.) thelium covering the surface of tlie ovary, whicii is itself derived from the AVolflfiau body. He believes all the ovules to be formed from the germ- FlG. Vertical SeClion throiigh the Ovary of the Human Foetus. g g. Gcrm-fpitliflium, witli o o. Developing ovules in it. »». Ovarian stroma containing <•<• c. Fu.siform connective-ti.-isue corpuscles, v v. C^apillarv Iilood-ves.sols. In the centre of the figure an involution of tlic Kerni-ei)ithelium is shown : and at tji.- left lower siile a primordial ovule, with the connective- tissue cor]>uschs arranging themselves rouml it. (.Vfter Koulis.) epithelium eor])u.sclc.< wliicli become imbedded in the .-stroma of the ovary by the outgrowth of processes of vascular connective tissue, fresh gerni- ' PrnreerUnf/.-^ nf the Royal Soc. of Edinb., AytrW, ISTo, and Journ.of Anat. and PIdis., vol. xiii., 1879. THE FEMALE GENERATIVE ORGANS. 77 epithelial corpuscles being constantly produced on the surface of the organ u[) to tlie age of two and a half years, to take the phiceof those already imbedded iu its stroma. He believes the Graafian follicles to be formed by the growth of delicate processes of connective tissue between and around the ovules, but not from tubular inflections of the epithelium covering tlie gland, as described by Waldeyer (Fig. 37). This view is supported by the researches of Balfour,' who arrives at the conclusion that the w^hole egg-containing part of the ovary is really the thickened germinal epithelium, broken up into a kind of meshwork by grow^ths of vascular stroma. According to this theory, Pfliiger's tubular filaments are merely trabeculae of germinal ej^ithelium, modified cells of which become develo])ed into ovules. The greater proportion of the Graafian follicles are only visible with the high powers of the microscope, but those which are approaching maturity are distinctly to be seen by the naked eye. The quantity of these follicles is immense. Foulis estimates that at birth each human ovary contains not less than thirty tliousancl. No fresli_follicles apj)ear to be fori]Qjed_after_birth],^l and as development goes on some only grow, anHnby pressure on the others destroy them. Of those that grow, of course only a few ever reach maturity ; they are scattered through the substance of the ovary, some developing in the stroma, others on the surface of the organ, where they eventually burst, and are discharged into the Fallopian tube. A rijje Graafian follicle has an external investing membrane (Fig. 38)i 3 Diagrammatic Section of Graafian Follicle. 1. Ovum. 2. Membrana granulosa. 3. External membrane of Graafian follicle. 4. Its vessels. 5. Ova- rian stroma. 6. Cavity of Graafian follicle. 7. External covering of ovary. which is generally described as consisting of two distinct layers : the external, or tunica fibrosa, highly vascular and formed of connective tissue; the internal, or tunica propria, composed of young connective tissue, containing a large number of fusiform or stellate cells, and form- ing a basement membrane to the epithelial layer which lies internal to it. These layers, however, appear to be essentially formed of conden.sed ovarian stroma. Within this capsule is the epithelial lining, called the ' F. M. Balfour, "Structure and Development of Vertebrate Ovary," Quarterly Journal of Microscopical Science, vol. xviii., 1878. (/ 78 ORGANS COXCERXED IX rARTriUTfOX. memhnDi" (jrcDtnlot^d, consistin<:; of" coliuiiiiar ('j)itliclial colls, Avliirh, according to Foiilis, are originally ioniicd I'roin tlic nuclei of'tlie fibro- nuclear tissue of the stroma of the ovary, but which, according to \\'al- deyer and Balfour, are formed from the germinal epithelium itself. At one })art of the circumference of the ovisac is situated the ovule, around Avhich the epithelial cells are congregated in greater quantity, constituting the j)ro)ection known as the dis cus pro/if/e n(f>. The remainder ot" the cavity of the follicle is filled v.ith a small (juantity of transj)arent fluid, the liquor fo/iici(li , travcviHid by three or four minute bands, the retinac- ula of Barry,'which are attached to the opposite walls of the follicular cavity, and apparently serve the purpose of suspending the ovule and maintaining it in a pro})er })osition. In many young follicles this cavity does not at first exist, the follicle being entii'ely filled by the ovule. According to Waldeyer, the liquor folliculi is formed by the disintegration of the epithelial cells, the fluid thus producL'd collecting and distending the interior of the follicle. The ovule is attached to some part of the internal surface of the Graafian follicle. It is a rounded vesicle about yytt^^^ ^^ ^^^ ^'^^'^' ^'^ diameter, and is surrounded by a layer of columnar cells, distinct from those of the discus proligerus, in M'hich it lies. It is invested by a transparent elastic membrane, the zona pellucida, or vitelline membrane. In most of the lower animals the zona pellucida is perforated by nume- rous very minute pores, only visible under the highest powers of the microscope ; in others there is a distinct aperture of a larger size, the micropyle, allowing the passage of the spermatozoa into the interior of the ovule. It is possible that similar apertures may exist in the human ovule, but they have not been demonstrated. Within the zona pellucida some embryologists describe a second fine membrane, the existence of which has been denied by Bischoff. The cavity of the ovule is filled with a viscid yellow fluid, the yelk, containing numerous granules. It entirely fills the cavity, to the w^alls of which it is non-adherent. In the centre of the yelk in young, and at some portion of its periph- ery in mature ovules, is situated the germinal vesicle, ^^•hich is a clear circular vesicle, refracting light strongly, and about Jy-th of a line in diameter. It contains a few granules, and a nucleolus, or germinal spot, which is sometimes double. From within outward, therefore, we find — 1. The r/ermma^ spot ; round this 2. The germinal vesicle, contained in i 3. The yelk, which is surrounded by the 4. Zona pellucida, with its layers of columnar epithelial cells. These constitute the ovule. The ovule is contained in f The Graafian follicle, and lies in that part of its epithelial lining called the Discus proligerus, the rest of the follicle being occupied by the liquor folliculi. Round these we have the epithelial lining or membrana gran- ulosa, and the external coat, consisting of the tu7iica propria and tlie tunica fibrosa. The vascular supply of the ovary is complex. The arteries enter at THE FEMALE GENERATIVE ORGANS. 79 the hilum, penetrating the stroma in a spiral curve, and are ultimately distributed in a rich capillary plexus to the follicles. The large veins unite freely M'ith each other, and form a vascular and erectile plexus continuous with that surrounding the uterus, called the bulb of the Fig. 39. Bulb of Ovary. V. Uterus. 0. Ovary and utero-ovarian ligament, r. Fallopian tube. 1. Utero-ovarian vein. 2. Pampin- iform ovarian ple.xus. 3. Commencement of spermatic vein. ovary (Fig. 39). Lymphatics and nerves exist, but their mode of termination is unknown. The Mammary Glands. — To complete the consideration of the generative organs of the female we must study the mammary glands, which secrete the fluid destined to nourish the child. In the human subject they are two i n number, and instead of being placed upon the abdomen, as in most animals, they are situated on either side of the sternum, over the pectorales majora muscles, and extendiCfrom the third// to the sixth ribs, i) This position of the glands is obviously intended to suit the erect position of the female in suckling. They are convex anteriorly, and flattened posteriorly where they rest on the muscles. They vary greatly in size in diiferent subjects, chiefly in proportion to the amount of adipose tissue they contain. In man and in girls previous to puberty they are rudimentary in structure; w^iile in preg- nant women they increase greatly in size, the true glandular structures becoming much hypertrophied. Anomalies in shape and position are sometimes observed. Supplementary mammae, one or more in number, situated on the upper portion of the mammse, are sometimes met with, identical in structure with the normally situated glands ; or, more com- monly, an extra nipple is observed by the side of the normal one. In^r some races, especially the African, the mammae are so large and pendu- lous that the mother is able to suckle her child over her shoulder. The skin covering the gland is soft and supple, and during preg- nancy often becomes covered with fine white lines, while large bine veins may be observed coursing over. (Underneath it is a quautitv of connective tissue, containing a considerable amount of fat, which ex- tends beneath the true glandular structure. This is composed of from ^fiteeu to twenty lobes, each of which is formed of a number of lobules,,; The lobules are produced by the aggregation of the terminal acini in'' which the milk is formed. The acini are minute cul-de-sacs opening into little ducts, which unite with each other until thev form a larse 80 oiiGAys coxrFRxrD tx rARrrniTiox. duct for cacli lobuU' ; tlic diK'ts ol" eiuli lpo.ved to ])rotcct and soften the integument during lactation. Beneath the skin are mus- cular fibres, mixed with connective and elastic tissues, vessels, nerves, and lymphatics. When the nipple is irritated it contracts and hardens, and by .some this is attributed to its erectile properties. The vascular- ity, however, is not grcat,[and it contains no true erectile t issue j the rhardening is, therefore, due to mu.outaneously or, it may be, under the stimulus of sexual excitement. Whether the laceration takes place during, before, or after the menstrual discharge is not yet posi- tively known: from the results of post-morten Qxamination in a num- ber of women who died shortly before or after the jieriod, "NA'illiams believes that (the ovules are expelled before the monthly flow com- |mences.M In order that the ovule may escape, the laceration must, of coui-se^ involve not only the coats of the Graafian follicles, but also the superincumbent structures. Laceration seems to be aided by the growth of the internal layer of ' Proceedings of the Royal Society, 1875. IMah- III. Fig I. ArecavitPy ruptured SMd k(j:>ody ora.afian jfefPiefe', lUst dcv&fopintf' ivito a Corpus tu'rcur Fie. 2. Carpus iuiii^vn ten days affe-v" wiensi'iruah'or d:? ^ Fig. 3. wfiicvi ftiis ne.oer ruptured, Fig 4^. Corpus Pute.uvM> of eFre^'nanoj _ ILLUSTRATIONS OF THE CORPUS LUTEUM, CAFTER DALTON.) "5.-jtu.-fls.f.if,.g'?,.c.. OVULATION AND MENSTRUATION. 83 the follicle, which increases in thickness l)ef()re ru})ture, and assumes a characteristic yellow color from the number of oil-globules it then con- tains. It is also greatly facilitated, if it be not actually produced, by the turgescence of the ovary at each menstrual period, and l)y the con- traction of the muscular fibres in the ovarian stroma. As soon as the rent in the follicular walls is produced, the ovule is discharged, sur- rounded by some of the cells of the membrana granulosa, and is re- ceived into the fimbriated extremity of the Fallopian tube, which grasps the ovary over the site of the rupture. By the vibratile cilia of its epi- thelial lining it is then conducted into the canal of the tube, along Mhicli it is propelled, partly by ciliary action and partly by muscular contraction in the walls of the tube. After the ovule has escaped certain characteristic changes occur in the empty Graafian follicle, which have for their object its cicatrization and obliteration. There are great diiferences in the changes which occur when impregnation has followed the escape of the ovule, and they are then so remarkable that they have been considered certain signs of pregnancy. They are, however, differences of degree rather than of kind. It will be well, however, to discuss them separately. As soon as the ovule is discharged the edges of the rent through which it has escaped become agglutinated by exudation, and the follicle shrinks, as is generally believedTlBy the inherent elasticity of its internal coat, but, according to Robin, who denies the existence of this coat, from compression by the musular fibres of the ovarian stroma. In proportion to the contraction that takes place the inner layer of the follicle, the cells of which have become greatly hypertrophied and loaded with fat- granules previous to rupture, is thrown into laumerQUg, folds (Plate II.| Fig. 2). The greater the amount of contraction the deeper these folds become, giving to a section of the follicle an appearance similar to that of tlie convolutions of the brain (Fig. 41). ^These folds in the human subject are generally of a bright-yellow color, but in some of the mammalia they are of a deep red. j The tint was formerly ascribed by Raciborski to absorption of the coloring matter of the blood-clot contained in the follicular cavity — a theory he has more recently abandoned in favor of the view maintained by Coste, that/it is due to the inherent color of the cells of the lin- ing membrane of the follicle, which, though not well marked in a single cell, becomes very apparent en ma.'^.se.J The ex- istence of a contained blood-clot is also denied by the latter physiologist, except as an unusual pathological condition; and secti he describes the cavity as containing a gelatinous and plastic fluid which be- comes absorbed as contraction advances. (The more recent researches of Dalton,^ however, show the existence of a central blood-clot in the ' " Report on the Corpus Luteum," American Gyncec. Trails., 1877, vol. ii. p. 111. Fig Ovary. sh(i\vin>jf corims luteum three weeks after lueustru- ation. (After Dalton.) 84 ORGANS CONCERNED IN PARTURITION. cavity of the follicle; and he coiisidei'S its occa.sional absence to be cou- ''uected with disturbance or cessation of the menstrual iuuction.j (The Ifolds into which the membrane has been thrown continue to inci'ease in )size, from the proliferation of their cells, until they unite and become [adherent, and eventually till the follicular cavity.'j J>y the time that another Graafian follicle is matured and ready Ibr rupture the diminu- tion has advanced considerably, and the empty ovisac is reduced to a very small size. The cavity is now nearly obliterated, the yellow color of the convolutions is altered into a whitish tint, and on section the cor{)us luteuni has the appearance of a compai-t white stellate cicatrix, which generally disa ppears in less than forty dav s from the j)eriod of rupture. The tissue of the ovary at the site of laceration also shrinks, and this, aidetl by the contraction of the follicle, gives rise to one of those permanent pits or depressions which mark the surface of the adult ovary. Slavyansky' has shown that only a few of the im- mense number of Graafian follicles undergo these alterations. The greater proportion of them seem never to discharge their ovules, but, after increasing in size, undergo retrogressive changes exactly similar in their nature, but to a much less extent, to those which result in the formation of a corpus luteum. The sites of these may afterward be seen as minute striae in the substance of the ovary. \ Should pregnancy occur, all the changes above described take place ; but, inasmuch as the ovary partakes of the stimulus to which all the generative organs are then subjected, they are much more marked and apparent (Plate 11^ Fig. 4). Instead of contracting and disapjjcaring in a few weeks, the corpus luteum continues to grow until the third or fourth month of pregnancy ; the folds of the inner layer of the ovisac become large and fleshy anct permeated by numerous capillaries, and ultimately become so firmly united that the margins of the convolutions thin and disappear, leaving only a firm fleshy yellow mass, averaging from 1 to 1| inches in thickness, which surrounds a central cavity, often containing a whitish fibrillated structure, believed to be the remains of a central blood-clot. This was erroneously supposed by Montgomery to be the inner layer of the follicle itself, and he conceived the yellow sub- stance to be a new formation between it and the external layer ; Avhile Robert Lee thought it was placed external to both the external and internal layers. Between the third and fourth months of jircgnancy, when the corpus luteum has attained its maximum of development (Fig. 42), it forms a firm ])ro)ection on the surface of flic ovary, averaging about one inch in lengtli and I'atlicr more than half an inch in breacltli. After this it conmiences to atrophy (Fig. 4.">), the fat-cells become absorbed, and the capillaries disappear. Cicat rization is not complete until fr om one to two months after delivery. On account of the marked a]-)pcarance of the corpus luteum it was formerly considered to be an infallible sign of pregnancy; and it was distinguished from the corpus luteum of the non-pregnant state by being called a "true" as oj)posed to a "false" corpus luteum. From what has been said, it will be obvious that this designation is essentially > Archil: de Phys., M;ircli, 1874. OVULATIOX AND MEXSJ'RUATIOX. 85 wrong, as the (lifference is one of degree only. (l)alton' ai)plics the term " false corpus liiteum" to a degenerated condition sometimes met with in an unruptured Graafian follicle, consistinj^ in reabsorption of its contents and thickening of its walls (Plate Ilf, Fig. 3).\ It differs Fig. 42. Fig. 43. Corpus Lnteum of the Fourth Month of Pregnancy. (After Dalton.) Corpus Luteum of Pregnancy at Term. (After Dalton.) from the " true " corpus luteum in being deeply seated in the substance of the ovary, in having no central clot, and in being unconnected with a cicatrix on the surface of the ovary. Xor do obstetricians attach by any means the same importance as they did formerly to the presence of the corpus luteum as indicating impregnation ; for, even when well marked, other and more reliable signs of recent delivery, such as enlargement of the uterus, are sure to be present, especially at the time when the corpus luteum has reached its maximum of development ; while after delivery at term it has no longer a sufficiently characteristic ap]:)earauce to be depended on. Menstruation. — By the term menstrucdion (catamenia, periods, etc.) is meant the periodical discharge of blood from the uterus which occurs, in the healthy woman, every lunar month, except during pregnancy and lactation, when it is, as a rule, suspended. The first appearance of menstruation coincides with the establishment of puberty, and the physical changes that accompany it indicate that the female is capable of conception and childbearing, although exceptional cases are recorded in which pregnancy occurred before menstruation had begun. In temf)erate climates it generally commences between the f()ui:teenth and .s ixteent h years, the largest number of cases being met wiTTTTn the fifteenth year. ' This rule is subject to many excejitions, it being by no means very rare for menstruation to become established as early as the tenth or eleventh year or to be delayed until the eighteenth or twentieth. Beyond these physiological limits a few cases are from time to time met with in which it has begun in early infancy or not until a comparatively late period of life. Influence of Climate, Race, etc. — Various accidental circumstances ^ Op. cit., p. 64. ^;8G ORCAXS COXCERXED TX rARTJ'PJTJON. have much to do with its estabhsh incut. As a rule, it occurs souiewhat ca rlk'r iu trop ical, and later in very cold than in temperate, climates. Tile inlhiencc of climate has been unduly exajrgerated. It used to he ot'iicraliy stated that in the Arctic reeriotl of its establishment in the tropics and in temperate countries. Harris' states that among the Hindoos 1 to 2 per cent, menstruate as early as nine years of age ; 3 to 4 jier cent, at ten ; 8 per cent, at eleven ; and 25 per cent, at twelve ; while in Loudon or Paris probably not more than 1 girl in 1000 or 1200 does so at nine years. The converse holds true Mith regard to cold climates, although we are not iu possession of a sufficient number of accurate statistics to draw very reliable conclusions on this point ; but out of 4715 cases, including returns from Denmark, Norway and Sweden, Russia, and Labrador, it Avas found that menstruation was established on an average a year later than in more temperate countries. T^t is probaljle that the mere influence of temjierature has much to do iu producing these differences, but there are other factors the action of ■which must not be overlooked. Raciborski attributes considerable im- portance to the effect of race ; and he has quoted Dr. Webb of Calcutta to the effect that English girls in India, although subjected to the same climatic influence as the Indian races, do not, as a rule, menstruate earl- ier than in England ; Mhile iu Austria girls of the ^Magyar race meu- ^struate considerably later than those of German ])arentage.^ The ^ur- ilQu nding s of girls and their manner of education and living have probably also a marked influence in promoting or retarding its establish- ment. Thus, it will commence earlier in the children of the rich, who are likely to have a highly-developed nervous organization, and are habituated to luxurious living and a premature stimuhition of the mental faculties by novel-reading, society, and the like; while amongst the hard-worked poor or in girls brought up in the countiy it is more likely to begin later. Premature sexual excitement is said also to favor its early appearance, and the influence of this among the factory-girls of Manchester, who are exposed in the course of their work to the tempta- tions arising from the promiscuous mixing of the sexes, has been pointed out by Dr. Clay.* [Precocious Physical "Woinanhood. — We emphasize the term '' physical," because in a mental and moral sense the subjects are for- tunately, with rare exceptions, only children in years and tastes. Pre- » Edin. Med. and Surg. Journ., 1832. ■■' Amer. Journ. of Obstet., 1870-71, vol. iii. p. 611: R. P. Harris, "On Early Pubertv." * Op. cit., p. 227. * Brit. Record oj Obstd. Med., vol. i. OVULATION AND MENSTRUATION. 87 cociously developed girls are, as a rule, of very unusual size for their years, and usually enjoy good health, while precoeity in male children is apt to be associated with senii-idioey and cpile[)sy. Where menstruation begins in the iirst year, the girl may at three or four years of age pre- sent the evidences of puberty in the appearance of pubic and axillary hair, rounded mammae, and a broad pelvis, associated with well-rounded arms and legs and a strength and height much beyond her years. In three children l)orn in this State, these characteristics were marked resj)ectively, at four and a half years, five, and six. The five-year-old girl was a beautifully formed miniature woman, and the one of six was large, fat, and had the developed features of twice her age ; still, she was only a child in tastes, and as such devoted to her dolls and toys. The sexual passion is very rarely a marked characteristic in such subjects, as it is in the other sex, and hence the ability to procreate has rarely been tested ; but occasionally in the lower classes pregnancy has occurred at an early age. The youngest English mother on record was nine years seven months | and nine days old when Mr. Henry Dodd of Billingtou, York, who was present at her birth, delivered her of a seven-pound healthy child, after a labor of six hours, on March 17, 1881. She commenced to menstruate at twelve months, and became pregnant about six weeks before she was nine years old.^ The youngest American mother became such at ten years and thirteen | days, giving birth to a child of seven and three-quarter pounds. She also menstruated at one year, and at the time of her labor was 4 ft. 7 inches in height and weighed 100 pounds. The case was reported by Dr. Rowlett of Kentucky.^ A still younger mother was reported by Schmith more than a century ago. The child began to menstruate at two years, and when eight years and ten months old bore a dead foetus which was thought by its development to have reached its full term. The mother had the mammae and pubes of a girl of seventeen.^ Ed.] Changes Occurring at Puberty. — The first appearance of men- K struation is accompanied by certain well-marked changes in the female system, on the occurrence of which we say that the girl has arrived at the period of puberty. The pubes become covered with hair, the^' breasts enlar ge, the pe lvis assumes its fully-developed form, and the general contour of th^body fills out. The mental CLualitiesalso alter : the girl becomes more shy and retiring, and her whole bearing indicates the change that has taken place. The menstrual discharge is not estab- lished regularly at once. For one or two months there may be only premonitory symptoms — a vague sense of discomfort, pains in the breasts, and a feeling of weight and heat in the back and loins. There then may be a discharge of mucus tinged with blood, or pure blood, and this may not again show itself for several months. Such irregu- larities are of little consequence on the first establishment of the func- tion, and need give rise to no apprehension. Duration. — As a rule, the discharge recurs every twenty-eight days, \} Barnes' Obstetric Medicine and Surgery.'] [^ Tranniilvania Med. Journ., vol. vii. p. 447.] [^ Sue's Essais hidoriques, Paris, 1779, vol. ii. p. 344.] f 88 ORGANS CONCERNED L\ PARTURITION. and with some women with such roj^uhirity that they can foretell its appearance almost to the hour. The rule is, however, subject to very jj;reat variations. It is by no means uncommon, and strictly within the limits ul" health, for it to api)ear every twentieth day, or even with less intcival ; while in other cases as much as six weeks may habitutdly intervene i)etweeu two periods. The period of incurrence mav also vary in the same subject. I am actpiainted with patients who some- times only have twenty-eight days, at others as many as forty-eight days, between their periods, without their health in any way sul!ering. Joulin mentions the case of a lady who only menstruated two or three times in the year, and whose sister had the same jx'culiarity. The duration of the period varies in ditierent women and in the same woman at different times. In this country its average is four or five dm' s. while in France, Dubois and Brierre de Boismont fix eight days as the most usual length. Some women are only unwell for a few hours, while in others the period may last many days beyond the aver- age without being considered abnormal. The quantity of blood lost varies in different women. Hipjxici-ates puts it at oxviij, which, however, is nuich too high an estimate. Arthur Farre thiid formed. * n^ r^jf On mia:Dscopic examination the menstrual fluid exhibits blood-cor-^yr /" pus cles, m ucus-corpuscl es , and a considerable amount of ' Epithel ial scales , the last being the debris of the epithelium lining the uterine cavity. ( According to Virchow, the form of the epithelium often proves j that it comes from the interior of the utricular glands.^ The color of the blood is at first dark, and as the period progresses it generally becomes lighter in tint. In women who are in bad health it is often / very pale. These differences doubtless depend upon the amount of V^jT, mucus mingled with it. The menstrual I blood has always a character- T. vy^ '\ istic faint and heavy qdor^i M'hich is analogous to that which is so dis- ^ ^ tinct in the lower animals during the rut. Raciborski mentions a lady ^ who was so sensitive to this odor that she could always tell to a certainty J when any woman was menstruating. ( It is attributed either to decom- ,- \^ ^, posing mucus mixed with the blood, which, when partially absorbed, may cause the peculiar odor of the breath often perceptible in menstru- ating women, or to the mixture with the fluid of the sebaceous secretion from the glands of the vulva. ') It probably gave rise to the old and prevalent prejudices as to the deleterious properties of menstrual blood, which, it is needless to say, are altogether without foundation. It is now universally admitted that thefsource of the menstrual blood \\ is the mucous membrane lining the interior of the uterus,)for the blood may be seen oozing through the os uteri by means of the speculum and in cases of procidentia uteri; while in cases of inverted uterus it may be actually observed escaping from the exposed mucous membrane and col- lecting in minute drops upon its surface. (^During the menstrual nisus the whole mucous lining becomes congested to such an extent that, in examining the bodies of women who have died during menstruation, it is found to be thicker, jlarger, and thrown into folds, so as to completely fill the uterine cavity. The capillary circulation at this time becomes very marked, and the mucous membrane assumes a deep-red hue, the network of capillaries surrounding the orifices of the utricular glands being especially distinct. These facts have an unquestionable connec- tion with the production of the discharge, but there is much difference of opinion as to the precise mode in which the blood escapes from the^^ vessels. Coste believed that the blood transudes through the coats of the -* capillaries without any laceration of their structure. I Tarr e inclines to the hypothesis that the uterine capillaries terminate by open mouths, the escape of blood through these between the menstrual periods being ]ire- vented by muscular contraction of the uterine walls. Pouchet believed that during each menstrual e])oeh the entire mucous membrane is broken down and cast off in the form of minute shreds, a fresh mucous mem- brane being developed in the interval between two periods. During this process the cajullary network would be laid bare and ruptured, and the escape of blood readily accounted for. Tyler Smith, who adoj>ted this theory, states that he lias frc^quently seen the uterine nuicous mem- brane in women who have died durino- menstruation in a state of disso- 90 ORGANS CONCERNED IX PARTURITION. lutioii, witli the ln'okon looj)s of the capillaries ex[)ose(l. Tlie |>lie- noiueiui atteiuliiiji- the so-ealled inenilmiiioii.s clysineiiorrhd'a, in whieh the mucous membraue is thrown oii' in shreds or as a cast of the uterine cavity — the nature of which Avas first })()inted out by 8inij)S(»n and Oldham — have been suj)posed to corroborate this thc(»ry. This view is, in the main, corroborated by the recent researches of Kni>;elmann,' \\ illiams," and others. (^AN'illiams describes the mucous linintr of the -uterus as undergoing a fatty degeneration before each period, which 'commences near the inner os, and extends over the whole mucous mem- brane and down to the muscular wall. This seems to bring on a certain amount of muscular contraction, which drives the blood into the capil- laries of the mucosa, and these, having become degenerated, readily rupture and jiermit the escape of the blood.) The mucous mendjrane .now rapidly disintegrates, and is cast oii' in shreds with the menstrual discharge, in which masses of epithelial cells may always be detected. Engehiiaun, however, holds that the fatty degeneration is limited to the superficial layers, and that a portion only of the epithelial investment is thrown off. ^Vs soon as the period is over, the formation of a new mucous membrane is begun, Avhich arises either from proliferation of the elements of the muscular coat itself, or from the proliferation of the epithelial cells lining the bases of the uterine glands which remain imbedded in the muscular tissue after the mucous membrane has been thrown off, and at the end of a week the whole uterine cavity is lined l)y a thin mucous membrane. This grows until the advent of another ])eriod, when the same degenerative changes occur unless imjiregnation has taken place, in which case it becomes further developed into the decidua. LoewenthaP believes that the meustral decidua is produced by the imbedding of an ovum in the lining membrane of the uterus, which, if imju'cgnation occurs, is develo])ed into the decidua of preg- nancy. If conception does not take place, the ovum dies, and this is followed by the degeneration and expulsion of the menstrual decidua, accompanied by a flow of blood, which is the menstrual discharge. Theory of Menstruation. — That ^there is an intimate comicction between ovulation and menstruation) is admitted by most physiologists, and it is held by many that the determining cause of the discharge is the periodic maturation of the Graafian follicles. There is abundant evidence of this connection, for we know that when,', at the change of life, the Graafian follicles cease to develop, menstruation is arrested) andi.when the ovaries are removed by operation, of which there are now numerous cases on record, or when they are congenitally absent, men- struation does not generally take ])lace. ) A few cases, however, have been observed in which menstruation contimi(>d after doulile ovari- otomy, or the removal of the ovaries bv Battev's operation, and these have been used as an argument by those ]>hysiologists who doul)t the ovular theory of menstruation. Slavyansky has particularly insisted ou * Amrricfin Journal of Ohs^tetrirs, lS7o-7G, vol. viii. p. 30. * "On tlie Stniftiire of the Mucous Menibrniie of the Uterus," OhMet. Journ., 1875-76, vol. iii. p. 4%. ^ Arch./. Gyn., Bd. xxiv. Hft. 2, S. 1G9: " Eine neue Deutung des Menstruations- Prozess." OVULATION AND MENSTRUATION. 91 such cases, which, however, are probably susceptible of explanation. It may be that the habit of menstruation may continue for a time even after the removal of the ovaries ; and it has not been shown that men- struation has continued permanently after double ovariotomy, although it certainly has occasionally, although quite exceptionally, done so for a time. It is possible, also, that in such cases a small portion of ovarian tissue may have been left unremoved, sufficient to carry on ovulation. Roberts, a traveller quoted by Depaul and Gueniot in their article on menstruation in the Bidiorinaire des Sciences medicales, relates that in certain parts of Central Asia it is the custom to remove both ovaries in young girls who act as guards to the harems. These women, known as "hedjeras," subsequently assume much of the virile type and never menstruate. The same close connection between ovulation and the rut of animals is observed, and supports the conclusion that the rut and menstruation are analogous. The chief difference between ovulation in man and the lower animals is that in the latter the process is not generally accompanied by a sanguineous flow. To this there are excep- tions, for in monkeys there is certainly a discharge analogous to men- struation occurring at intervals. Another point of distinction is that in animals connection never takes place except during the rut, and that it is then only that the female is capable of conception ; while in the human race conception only occurs in the intervals between the periods. This is another argument brought against the ovular theory, because, it is said, if menstruation depend on the rupture of a Graafian follicle and the emission of an ovule, then impregnation should only take place during or immediately after menstruation. iCoste explains this by sup- jiosing that it is the maturation and not the rupture of the follicle which , determines the occurrence of menstruation,' and that the follicle may remain unruptured for a considerable time after it is mature, the escape of the ovule being subsequently determined by some accidental cause, such as sexual excitement. However this may be, there is good reason^ to believe that the susceptibility to conception is greater during the ' menstrual epochs. ^Raciborski belie v^es that in the large proportion of cases impregnation occurs in the first half of the menstrual interN'al or in the few days immediately preceding the appearance of the dischargey There are, however, very numerous exceptions, for in Jewesses, who almost invariably live apart from their husbands for eight days after the cessation of menstruation, impregnation must constantly occur at some other period of the interval, and it is certain that they are not less prolific than other people. This rule with them is very strictly adhered to, as will be seen by the accompanying interesting letter from a medical friend who is a well-known member of that community, and which I have permission to publish.^ This fact is of itself sufficient to disprove 1 10 Bernard Street, Kvsseli, Square, July '21, 1S7:5. My Dear Sir : 1. Tothebest of my knowledge and belief, the law which prohibits sexual intercourse among Jews for seven clear days after the cessation of menstruation is almost univer- sally observed ; the exceptions not being sufficient to vitiate statistics. The law has perhaps fewer exceptions on the Continent — especially Russia and Poland, where the Jewish population is very great — than in England. Even here, however, women wlio observe no other ceremcmial law observe this, and cling to it after everything else is 92 ORGANS CONCERNED IN PARTURITION. the ihcfvv advanced \)\ Dr. Avrard,' lliat iiiipreguatioii is iinj)()s.sil)lt' in llu' latter half oC the ineiistrual interval. This and the other reasotis referred to nndonhtedly throw some donbt on the ovnlar theory, hut they do not seem to be sufficient to justify tiie eonelusion that menstruation is a physiological process altogether independent of the development and maturation of tlie Graafian follicles. All that they can be fairly held to ])rove is that the escape of the ovules may occur independently of menstruation, but the weight of evidence remains strongly in fiivor of the theory which is generally received. Jt should be stated that Lawson Tait attributes considerable influence in menstruation to the Fallopian tubes themselves ; but his views on this point, ba.sed on obser- vations made after the removal of the ovaries for certain morbid con- ditions, cannot yet be taken as proved; and Thornton'^ has related a case in which he removed both tubes, leaving the ovaries intact, in Mhich menstruation subsequently went on as liefore. The cause of the m onthly period icity is quite unknown, and will probably always remain so. Goodman^ has suggested what he ad Is the "cvclieal theory of menstruation," which refei-s the phenomena to a gen- eral condition of the vascular system specially localizing itself in the generative organs, and connected with rhythmical changes in their nerve- centres. It does not seem to me, however, that he has satisfactorily proved the recurrence of the conditions which his ingenious theory assumes. The purpose of the loss of so much blood is also somewhat obscure. To a certain extent it must be considered an accident or com- plication of ovulation produced by the vascular turgescence. ( Isor is it .essential to fecundation, because women often conceive during lactation, 'when menstruation is suspended, or before the function has becoiue 1 established.! It may, however, serve the negative purjiose of relieving the congested uterine capillaries, Avhich are periodically filled with a supply of ])lood for the great growth which takes place when coucep- thrown overboard. There are doubtless many exceptions, especially among the better classes in England, wlio keep only three days after the cessation of the menses. 2. The law is — as you state — that should the discharge last only an liour or so, or should there be onlyone gush or one spot on the linen, the five days during wliich the period viif/lit continue are observed ; to whicli must be superadded the seven clear days — twelve days per mensem in which connection is disallowed. Should any discharge be seen in the intermenstrual period, seven days would have to be kept. Iiut not the five, for such irref/ular discharge. 3. The "bath of purification," which must contain al Iraitt eighty gallons, is used on the last night of the seven clear days. It is not used till after a bath for cleansing purposes; and from the night Mheii such '' i)urifying " bath is used .Jewish women are accustomed to calculate the commencement of pregnancy. That you .should not have heard it is not strange: its mention would be considereil liighly indelicate. 4. .Jewish women reckon their pregnancy to last nine calendar or ten lunar months — 270 to 280 davs. There are no special data on which to reckon aii average, nor do 1 know of anv books on the subject, excej)! some Tahuudic authorities, which 1 \yill look up for you if you desire it. Pray make no apologies for writing to me : any infor- mation I possess is at your service. I am, dear sir, vours very truly. Dr. Plavfair. " A. Asher. p.j^._Tlie biblical foundation for the law of the seven clear days is Leviticus xv. verse 19 till the end of the chapter — especially verse 28. 1 Rrr.de Therap. Med.-Chir., 1867. » Oh.«tef. Trans., 1886, vol. xxviii. p. 41. ^ American Journal of Obstetrics, 1878, vol. xi. ]>. 073. OVULATION AND MENSTRUATION. 93 tion has occurred. Thus immediately before each period the uterus may be cousidered to be placed by the afflux of Ijlood iu a state of preparation for the fuuctiou it may be suddenly called upon to per- form. That the discharge relieves a state of vascular tension which accompanies ovulation is proved by the singular phenomenon of vicari- ous menstruation which is occasionally, though rarely, met with. It occurs in cases in which, from some unexplained cause, the discharge does not escape from the uterine mucous membrane. Under such cir- cumstances a more or less regular escape of blood may take place from other sites. The most common situations are the mucous membranes of the stomach, of the nasal cavities, or of the lungs ; the skin, not un- commonly that of the mammte, probably on account of their intimate sympathetic relation with the uterine organs ; from the surface of an ulcer ; or from hemorrhoids. It is a noteworthy fact that in all these cases the discharge occurs in situations where its external escape can readily take place. This strange deviation of the menstrual discharge mav be taken as a sign of general ill-health, and it is usually met with in delicate young women of highly mobile nervous constitution. It mav, however, begin at puberty, and it has even been observed during the whole sexual life. The recurrence is regular, and always iu connec- tion with the menstrual nisus, although the amount of blood lost is much less than in ordinary menstruation. Cessation of Menstruation. — After a certain time changes occur, showing that the woman is no longer fitted for reproduction ; roeiist ru- ation ceases, Graafian follicles are no longer matured, and the ovaryJ)&;- comes shrivelled and wrinkled on its surface. Analogous alterations take place in the uterus and its appendages. The Fallopian tubes atro- phy, and are not unfrequently obliterated. The uterus decreases in size. The cervix undergoes a remarkable change, which is readily detected on vaginal examination ; the projection of the cervix into the vaginal canal disappears, and the orifice of the os uteri in old women is foimd to be flush with the roof of the vagina. In a large number of cases there is, after the cessation of menstruation, an occlusion l^oth of the external and internal os ; the canal of the cervix between them, however, remains patulous, and is not unfrequently distended with a mucous secretion. The age at which menstruation ceases varies much in different women. In certain cases it may cease at an unusually early age, as between thirty and forty years, or it may continue far beyond the average time, even np to sixty years; and exceptional, though perhaps hardly reliable, instances are recorded iu which it has continued even to eighty or ninety years. These are, however, strange anomalies, which, like cases of unusually ])recocious menstruation, cannot be considered as having any bearing on the general rule. Most cases of so-called protracted menstruation will be found to be really morbid losses of blood depending on malignant or other forms of organic disease, the existence of M^hich, under such cir- cumstances, should always be suspected. In this country menstruation usually ceases between forty and fifty years of age. Raciborski says that the largest number of cases of cessa- tion are met with iu the foi^-sixth year. It is generally said that 94 ORGANS CONCERNED IN PARTURITION. woiiu'ii \\ln» coiiiinciKv t(» iiR'nstniate when xcvy ycjung cease to do so at a comparatively early age, .so that the average duration of the fime- tion is al)out the same in all women, C'azeaux and JiacihorsUi, whose opinion is strengthened by the observations of (Jny in 1500 cases/ think, on the contrary, that the earlier menstruation commences the longer it lasts, early mensturation indicating an excpss of vital energy -which continues during the whole childbearing life. (Climate and other accidental causes d^ ^ n()t seem to have as much effect on the cessation as oil tiie estal)lishment of the functioii^ It docs not api)ear to cease earlier in warm than in temperate climates. The change of life is generally indicated by irregularities in the recurrence of the discharge. It seldom ceases suddenly, but it may be absent for one or more periods, and then occur irregularly; or it may become profuse or scanty until eventually it entirely stops. The popidar notions as to the extreme danger of' the meno})ause are probably much exaggerated, although it is certain that at that time various nervous phenomena are apt to be developed. So far from having a prejudicial effect on the health, how- ever, it is not an uncommon observation to see an hysterical woman, who has been for years a martyr to uterine and other complaints, appar- ently take a new lease of life when her uterine functions have ceased to be in active operation ; and statistical tables aljundantiy prove that the general mortality of the sex is not greater at this than at any other time. ^ cX ' 3Ied. Times and Gaz., 1845. ^iVf PART II. PREGNANCY. CHAPTER I. CONCEPTION AND GENEEATION. Generation in the human female, as in all mammals, requires the congress of the two sexes, in order that the semen, the male ele- ment of generation, may be brought into contact with the ovule, the female element of generation. The semen secreted by the testicle of an adult male is a viscid, opal- escent fluid, forming an emulsion when mixed with water, and having a peculiar faint odor, which is attributed to the secretions which are mixed with it, such as those from the prostate and Cowper's glands. On analysis it is found to be an albuminous fluid, holding in solution various salts, principally phosphates and chlorides, and an animal sub- stance, sperraatin, analogous to fibrin. Examined under a magnify- ing power of from 400 to 500 diameters, it consists of a transparent and homogeneous fluid, in which are floating a certain number of granules and epithelial cells derived from the secretions mixed with it, and^cer- tain characteristic bodies, the spermatozoa, which are developed • from the sperm-cells, and which form its essential constituents. The sperm- cells are those occupying the tubuli seminiferi of the testicle. Several kinds of sperm-cells are described which receive their name from the position they occupy with regard to the lumen of the tubule (Fig. 4-4). The cells which are next to the wall of the tubule are called the outer or lining cells. They are more or less flattened in form, and are situa- ted on a distinct ])asement membrane. Internal to this layer is another, consisting of round cells, the nuclei of which are in a state of prolifera- tion : this is the intermediate layer. Between this and the lumen of the tubule are a number of cells irregular in shape, amongst which are im- bedded the heads of the spermatozoa, the tails of which project into the lumen. The spermatozoa are tliought to arise from the middle or ]>ro- liferating layer in the following manner: the nuclei of the sperm-cells proliferate, and from their subdivisions arise the heads of the sperma- tozoa, the bodies of which originate from the protoplasm of the cells. By the decomposition of the substance in which the heads of the sperm- atozoa are imbedded the contained spermatozoa become liberated and move about freely in the seminal fluid. As seen under the microscope, 95 96 PREGNANCY. the spermatozoa, whirh exist in healthy semen in cnonnDii- numbers, present the a])])t'anince ot" minute jiaitieles not unlike a tadpole in shape. The head is oval and flattened, measuring about Ywk^() "^^ ^" inch in breadth, and attaehed to it i)y a short intermediate j)ortion is a delicate lilamentt)us exjiansion or tail, Avhieh tapers to a point so fine that its termination cannot be seen by the highest powers of the micro- sec »pe. The whole spermatozoon measures from ^^ to -^^ of an iucli in length. The spermatozoa are observed to be in constant Fig. Ai. ^■'-■''^■.:. : ;-■ '^''^r ^ ■' ' c Section of Parts of Three Seminiferous Tubules of the Rat. a. With the spermatozoa least advancedin deTC'loiimeiit. h. More advanced, c. Coiitaininp fully-developed spermatozoa. Between the tubules are eeeii strands of interstitial cells and lymph-spaces. (From a preparation by Mr. A. Frazer.) motion, sometimes very rapid, sometimes more gentle, which is suji- posed to be the means by which they pass ujnvard through the female genital organs. They retain their vitality and power of movement for a considerable time after emission, provided the semen is kept at a tem- perature similar to that of the body. Under such circumstances they have been observed in active motion from forty-eight to seventy-two hours after ejaculation, and they have also been .seen alive in the testicle as long as twenty-four hours after death. In all j)robability they con- tinue active much longer within the generative organs, as many physi- ologists have observal them in full vitality in bitches and rabbits seven or eight days after copulation. (The recent experiments of Haussman, however, show that they lose their power of motion in the human vagina within twelve hours after coitus, although they doubtle.'^s re- tain it longer in the uterus and Fallopian tubes.\ Abundant leucorrheal tlischarges and acrid vaginal secretions destroy their movements, and may thus cause sterility in the female. On account of their mobility, the spermatozoa were long considered to be independent animalcule^ — a view which is by no means exploded, and has been maintained in mod- ern times by Pouchet, Joulin, and other writers, while Coste, Robin, CONCEPTION AND GENERATION. 97 Kolliker, etc. liken their motion to that of ciliated epithelium. There can be uo doubt that the i'ertilizing power of the semen is due to the presence of the s])ermato/oa, althou<>;h some of the older physiologists assigned it to the spermatic fluid. The former view, however, has been conclusively proved by the experiments of Provost and Dumas, who found that on carefully removing the spermatozoa by filtration the semen lost its fecundating properties. Sites of Impregnation. — There has been great difference of opinion as to the i)art of the genital tract in which the spermatozoa and the ovule ct)me into contact, and in which impregnation, therefore, occurs. Sperm- atozoa have been observed in all parts of the female genital organs in animals killed shortly after coitus, especially in the Fallopian tubes, and even on the surftice of the ovary. The phenomena of ovarian gesta- tion, and the fact that fecundation has been proved to occur in certain animals within the ovary, tend to support the idea that it may also occur in the human female before the rupture of the Graafian follicle. In order to do so, however, it is necessary for the spermatozoa to penetrate the proper structure of the follicle and the epithelial covering of the ovary ; and no one has actually seen them doing so. vMost probably the ! contact of the spermatozoa and the ovule occurs very shortly after the rupture of the follicle and in the outer part of the Fallopian tubes^) Coste maintains that unless the ovule is impregnated it very rapidly degenerates after being expelled from the ovary, partly by inherent changes in the ovule itself, and partly because it then soon becomes invested by an albuminous covering which is impermeable to the spermatozoa. He believes, therefore, that impregnation can only occur either on the surface of the ovary or just within the fimbri- ated extremity of the tube. . Mode in "which the Ascent of the Semen is Effected. — The semen is probably carried upward chiefly by the inherent mobility of the spermatozoa. It is believed by some that this is assisted by other agencies : amongst them are mentioned the peristaltic action of the uterus and Fallopian tubes ; a sort of capillary attraction effected when the walls of the uterus are in close contact^ similar to the movement of fluid in minute tubes ; and also the vibratile action of the cilia of the epithelium of the uterine mucous membrane. The action of the latter is extremely doubtful, for they are also supposed to effect the descent of the ovule, and they can hardly act in two opposite ways. The move- ment of the cilia being from within outward, it would certainly oppose rather than favor the progress of the spermatozoa. |(It must, therefore,, be admitted that they ascend chiefly through their own powers of motion.j They certainly have this power to a remarkable extent, for there are numerous cases on record in which impregnation has occurred without penetration, and even when the hymen was quite entire, and in ■which the semen has simply been deposited on the exterior of the vulva : in such cases, which are far from uncommon, the sjiermatozoa must have found their way through the whole length of the vagina. ^It is probable, however, that under ordinary circumstances the passage of the spermatic fluid into the uterus is facilitated by changes which take place in the cervix during the sexual orgasm, in the course of 7 98 rRECNAyCY. Fig. 45. wliicli the OS uteri is said to dilate and dose ap;aiii in a rliytliiuical manner.' ImpregTiation. — The precise method in which the spermatozoa etlecl inipi'ejinati(»ii was lonir a matter of doiiht. Jt is now, however, (crtain tliat they actually ])enetrate the ovule and readi its interior. This has been couclusively proved hy the observations of Barry, Meissner, and others/ who have seen the spermatozoa within the external membrane of the ovule in rabbit.4(Fig. 45). In some of the invertebrata a canal or openinj^ exi.sts in the yjma pellucida through which the sjiCiMuatozoa ])ass. No such aperture has yet been demonstrated in the ovules of manunals, but its existence is far from imjM'obable. According to the ob.sers'ations of Newport, several spermatozoa penetrate the zona j)cllucida and enter the ovule ; and the greater the number that do so the more ,„^^. . . certain fecundation becomes. In the lower 0\Tim of Rabbit containing • i i c • /■ i • i Spermatozoa. animals the iusion ot tlie spermatozoa Avith 1. Zona peiiucuia. 2. The germs, con- the substaucc of the vclk has bccu obscrvcd : sisting of two large cells, several ii,i i-m'i i ■ smaller cells, and spermatozoa. aud although Similar phenomena have not been observed in the human ovum, there is not any doubt but tliat the further development of the ovum is due to the union of the spermatozoon with the female element. Tlie length of time which lapses before the fecundated ovule ari'ives in the cavity of the uterus has not yet been ascertained, and it pi'obably varies under different circumstances. It is known that in the bitch it may remain eight or ten days in the Fallopian tulie, in the guinea-pig three or four. In the human female the ovum has never been discov- ,ered in the cavity of the uterus before the tenth or twdi't h day 'after impregnation. The changes which occur in the human ovule immediately before and after impregnation, and during its progress through the Fallopian tube, are only known to us by analogy, as, of course, it is impossible to study them by actual observation. We are in possession, however, of accu- rate information of what has l)een made out in the lower animals, and it is reasonable to suppose that similar changes occur in man. Imme- diately after the ovule has passed into the Fallopian tube it is found to be surrounded by a layer of granular cells, a portion of the lining membrane 46), and it is thought from observations ^% j^ on the iuvertebrata that they arise from = w^:..^- - the germinal vesicle, the remains of Formation of the " Poiar Giobuie." which give origin to a new nucleus, l. zona pellucida, containing sperma- which is known as the female pronucleus. Se. ^■5.\'ile"poL''giobuie^'''^'"'°^' Those changes occur in all ovules, whether they are impregnated or not, but if the ovule is not fecundated no further alterations occur. Supposing impregnation has taken place by the entrance of a spermatozoon within the zona pellucida of the ovule, a second nucleus is formed by the penetration of the spermato- zoon within the yelk, where it loses its tail and becomes transformed into a granular body, the male pronucleus. After a time the male and female pronuclei approach one another, and finally fuse to form a nss' n ucleu s, and the ovum then receives the name of the blastosphere. or fi rst segmentation-sphere. After this occurs the very peculiar phenom- enon known as the cleavage of the yelk, which results in the formation of the layer of cells from which the foetus is developed. The segmen- tation of the yelk (Fig. 47) occupies in mammals the whole of its sub- stance. In birds the cleavage is confined to a small area of the yelk called the cicatricula or blastoderm. Hence the term holoblastic has been applied to the ova of mammals, meroblastic to those of birds. It divides at first into two halves, and at the same time the new or first segmentation-nucleus becomes constricted in its centre, and separates into two ])ortions, one of Avhich forms a centre for each of the halves into which the yelk has divided. Each of these immediately divides into two, as does its contained portion of the nucleus, and so on in rapid succession until the whole yelk is divided into a number of divisions, each of which consists of a clump of nucleated protoplasm. By these continuous dichotomous divisions the whole yelk is formed into a granular mass, which, from its supposed resemblance to a mul- berry, has been named the iiMnj'qrmbody. AVhen the subdivision of the yelk is completed its separate parts become converted into a number of cells, each of which consists of a mass of granular protoplasm. These cells unite by their edges to form a continuous lining (Fig. 48), 100 PREGNANCY. which, through the expansion of the piprifnrm hmly hy fluid \vhjrh forms in its interior, is rl intended until it forms a lining to the zona pcl- hu'ida. 'J lii> is tlie b hixtoihrinU- lacinbrdiic . fntin wliich the ibutus is developed, iiy this time the ovum has reached the uterus ; and heiore proceeding to consider the further changes which it undergoes it will F'lo. 47. ect Sections of the Ovum of the Rabbit during the Later Stages of Segmentation, showing the formation of the blastodermic vesicle. (After E. v. Benedcu.) a. Section showing the enclosure of entomeres, eii/., by ectomeres, ect., except at oue spot— tne blastopore. h. More advanced stage, in which fluid is beginning to accumulate between the entomeres and ectomeres, the former completely enclosed, c. The fluid has much increased, so that a large space separates entomeres from ectomeres, excei)t at one part ])carance, is at least CONCEPTION AND GENERATION. 101 partially thrown off with the ovum ; on which account it has received the name of the decldua caduca. The decidua consists of two principal portions, which in early preg- nancy are separated from each other by a considerable interspace, which is occupied by mucus. One of these, called tiie d ecidua vera , lines the entire uterine cavity, and is, no doubt, the original mucous lining of the uterus greatly hypertrophied. The second, the dec id ua r ^flexa . is closely applied round the ovum, and it is proljably formed "by the sprouting of the decidua vera around the ovum at the point on which the latter rests, so that it eventually completely surrounds it. As the ovum enlarges the decidua refiexa is necessarily stretched until it comes everywhere in contact with the decidua vera, with which it firmly Fig. 48. Formation of the Blastodermic Membrane from the Cells of the Muriform Body. (After Joulin.) 1. Layer of albuminous material surrounding 2. The zona pell ucida. unites. After the third month of pregnancy true union has occurred, and the two layers of decidua are no longer separate. I The decidua ser- otina, which is described as a third portion, is merely that part of the decidua vera on which the ovum rests, and where the placenta is event- ually developed^ it is characterized by its extreme vascularity, which serves the purpose of supplying nutriment to the fwtus through the capillaries of the foetal placenta. It is needless to refer to the various views w^hich have been held by anatomists as to the structure and formation of the decidua. That taught by John Hunter was long believed to be correct, and down to a recent date it received the adherence of most physiologists. He believed the decidua to be an inflammatory exudation which, on account of the stimulus of pregnancy, was thrown out all over the cavity of the uterus, and soon formed a distinct lining membrane to it. AMien the ovum reached the uterine orifice of the Fallopian tube it found its entrance barred by this new membrane, which accordingly it pushed before it. 102 PREGNANCY. This separated portion formed a covcriii;; to tlio ovmii, and l)ecame the dec'idiia roHcxa, wliih-a fresh cxiidatioii tddk place at that portion of the uterine wall wliicli wa.s thus laid bare, and this became the decidua ser- otina. William Hunter had much more correct views of the deeidna, the accuracy of which was at the time much contested, but which have recently received full recognition, ^lle describes the decidua in his earlier writings as an li^pertropliy of the uterine inucous membrane itself — a view which is now held by all jjliysiologists.) "N^'hen the decidua is lirst formed it is a hollow triangular sac lining the uterine cavity (Fig. 49), and liaviug three openings into it — tho.se Fig. 49. Aborted 0\-um of about Forty Days, showing the triangular shape of the decidua (which is laid open), and the aperture of the Fallopian tube. (After Coste) of the Fallopian tubes at its ujiper angles, and one, corresponding to the internal os uteri, below. If, as is generally the case, it is thick and pulpy, these openings are closed up and can no longer be detected. In earlv pregnancy it is well developed, and continues to grow up tojthe third month of utero-gestation. After that time it commences to atroi)hy, its adhesion with the uterine walls lessens, it becomes thin and transparent, and is ready for expulsion when delivery is etfected. AVhen it is most developed a careful examination of the decidua enables us to detect in it all the elements of the uterine mucous mem- brane greatly hypertro])hied. Its substance chiefly consists of large round or oval nucleated cells and elongated fibres, mixed with the tubular uterine glands, which are much elongated, lined V)y columnar ciliated epithelial cells, and contain a small quantity of milky fluid. According to Friedliinder, the decidau is divisible into two layers : the inner being formed by a proliferation of the corpuscles of the subepi- CONCEPTION AND GENERATION. 103 thelial connective tissue of the mucous membrane ; the deeper, in con- tact witli the uterine walls, out of flattened or compressed gland-ducts. In an early abortion the extremities of these duets may be observed by a lens on the external or uterine surface of the decidua, occupying the summit of minute projections separated from each other by depressions. If these projections be bisected, they will be found to contain little cavities filled with lactescent fluid, Avhich were first described by Mont- gomery of Dublin, and are known as J\Io)itr/omery's cups. They are in fact the dilated canals of the uterine tubular glands. On the inter- nal surface of such an early decidua a number of shallow depressions may be made out, which are the open mouths of these ducts. The decidua vera is highly vascular, and its vascularity persists till after the seventh month of pregnancy; the decidua reflexa is only vas- cular during the early part of pregnancy, depending for its vascularity chiefly on the villi of the chorion, and hence losing this with their atrophy. When the ovum reaches the uterine cavity it soon becomes imbedded in the folds of tiie hypertrophied mucous membrane, which almost entirely fills the uterine cavity. As a rule, it is attached to some point near the opening of a Fallopian tube, the swollen folds of raucous membrane preventing its descent to the lower part of the uterus; in exceptional circumstances, however — as in women who have borne many children and have a more than usually dilated uterine cavity — it may fix itself at a point much nearer the internal os uteri. I According to the now generally accepted opinion of Coste, the mucous i membrane at the base of the ovum soon begins to sprout around it, ■ and gradually extends until it eventually covers the ovum (Figs. 50- 52), and forms the decidua reflexa. Coste describes, under the name Fig. 50. Fig. 51. Fig. 52. Formation of Decidua. (Tlie decidua is colored lilack ; the ovum is rep- resented as engagod be- tween two projecting folds of membrane.) Projectiiiff Folds of Mem- brane growing up around the Ovum. Showing Ovum completely surrounded by the Decidua Reflexa. of the umbilicus, a small depression at the most prominent part of the ovum, which he considers to be the indication of the point where the closure of the decidua reflexa is eftected. There are some objections 104 PREGNANCY. to this theory, for no one lias seen the decidua reflexa incomplete and in the process of formation ; and on examining its external surface — that is, the one farthest from the ovum — its microscopical a])pearance is identical \vitli that of the inner surface of the decidua vera. To meet these tiiHicultics, Weber and (joodsir, whose views have been adopted by Priestley, contended that the decidua rcHcxa is " the ])ri- marv lamina of the mucous membrane, which, when the ovum enters the uterus, separates in two-thirds of its extent from the layei-s beneath it to adhere to the ovum ; the rcmainin()r. At first the li(|iii(l is clear and limpid. As ])rcii.iijincy advances it , becomes more turbid and dense, from the admixtui'c of" c])illiclial debris J derived from the cutaneous surface of the fictus. In some cases, with- /(' out actual disease, it may be dark green in color and thick and tenacious / 1 in consistency. It has a peculiar heavy odor, and it consists chemically of Avater containing albumen, some urea, and various salts, jn-incipally phosphates and chlorides. The source of the lifpior amnii has been much disputed. Some maintain that it is derived chietiy from the fcetus — a view sufficiently disproved by the fact that the liquor amnii continues to increase in amount after the death of the fojtus, Burdach believed that it is secreted by the internal surface of the uterus, and an-ivcs in the cavity of the amnion l)v transudation through the meml)rane. VPriestlev — and this seems the most proi)able hypothesis — thiidends entirely on the mobility of the foetus in the fluid which surrounds it. Some have also supposed that it prevents the foetus in the early montlis of pregnancy from forming adhesions to the amnion. In labor it is of great service by luljricating the passages, but chiefly by forming, with the membranes, a fluid wedge which dilates the circle of the os uteri. In a few rare cases there is a certain amount of limjnd fluid be- tween the chorion and the amnion, separating the two membranes. This is apparently only a more than usually fluid condition of the gelat- inous tissue which naturally exists between the chorion and amnion. Occasionally, after the bag of membranes is felt in lal)or the chorion alone ruj)tures, and the sjnirious liquor amnii is discharged, giving the attendant the impression that the membranes have been ruptured. The chorion is the more external of the truly foetal membranes, althoug-h external to it is the decidua, having a strictlv maternal orisrin. It is a perfectly closed sac, its external surface, in contact with the decidua, l)cing rough and shaggy from the development of villi (Fig. 56), its internal smooth and shining. As the ovum ))asses along the Fallopian tube it receives, as we have seen, an albuminous coating, and t bisj with the zona pellucida, is developed into a temporary structure, th e conceptioj^ and generation. 113 primifirc ch orion . This primitive chorion as tho aiiuiion devolops is reinlorccd by the hiycr of cpihlast coveriniL;' tlu; umbilical vcsick; cx- tenially, which separates it from the subjacent mesoblast and hypoblast, and, together with the epiblastic layer of the false amnion, with which it is coutiuuGUS, passes to the primitive chorion, either combining with this or by ])ressure causing its absorption and disappearance. The membrane thus Jbrnied is called by Turner the subzonal mem- brane, and by Von Baer the aerouH cnrc/ope. From it are developed villi of cellular structure, which at first extend as a ring round the ovum, but eventually cover the whole of its surface. These villi are finger-like projections from the surface of the ovum which are re- ceived into corresponding depressions iu the decidua, with which they soon become so firmly united that they cannot be separated with- out laceration. As the allantois develops, its mesoblastic layer grows into the space between the embryo and subzonal membrane, and in the human subject spreads over the whole of its inner surface, combining with it to form a new membrane, the true or complete chorion. Each villus now receives a separate artery and vein, the former having a branch to each of the subdivisions into which the villus divides. These vessels are encased in a fine connective-tissue sheath from the allantois, which enters the villus along with them and forms a lining to it, described by some as the endochorion, the external epithelial membrane of the villus, derived from the epiblast layer of the blastodermic membrane, being called the exochorion. The artery and vein lie side by side in the centre of the villus, and anastomose at its extremity, each villus thus having a separate circulation. As soon as th.e union of the allantois with the chorion has been effected the villi grow very rapidly, give off branches, which, in their turn, give off secondary branches, and so form root-like processes of great complexity. In the early months of gestation they exist equally over the whole surface of the ovum. As pregnancy advances, however, those which are in contact with the decidua reflexa shrivel up, and by the end of the second month cease to be vascular, being no longer required for the nutrition of the ovum. The chorion and decidua thus come into close contact, being united together by fibrous shreds, which on microscopic examination are found to consist of atrophied villi. The union between the chorion and the decidua reflexa as pregnancy advances becomes so complete that their line of junction cannot be ascertained, and they together with the decidua vera form one mem- brane, which on its inner surface is only separated from the anniion, which has spread over it, by a fine layer of gelatinous tissue. The portion of the chorion which is in relationship to the decidua reflexa is known as the chorion keve, whilst that in contact with the decidua serotina receives the name of the chorion frondosura; and in this portion the villi, instead of dwindling away, increase greatly in size, and eventually develop into the organ by which the foetus is nourished — the placenta. Form of the Placenta. — This important organ serves the pur- pose of supplying nutriment to, and aerating the blood of, the foetus, Ill PREGNANCY. ami (III its integrity the existence of tiie foetus (le[K'n(ls. It is met Mitli in all niaminals, l)ut is very different in form and arrangement in dilli'rent classes. Tims, in the sow, mare, and in tlie eetaeea it is diHused over tiie whole intei-ior of the uterus ; in the rmninants it is divided into a number of sej)arate small masses, .scattered here and there over the entire uterine walls ; while in the carnivora and elephant it i'orms a zone or belt round the uterine cavity, (in the Junnan race, as well as in rodentia, iusectivora, etc., the j)]acenta is ill the form of a ci rcular ma ss, attached generally to s(»me part of i\\^ uterus near the orifices of one ]''alloj)ian tube ; but it may Ije sit-j uated anvMhere in the uterine (avity, even over the internal os uteril The form of placentation in man and the apes is known as the meta- discoidal, whilst in rodentia and insectivora the placentation is discoidal. The metadiscoidal placentation is placed ventrally with regard to the eml)ryo, and the allantois extends over the whole ol" the subzonal mem- brane, whilst in the discoidal variety the placenta is placed dorsally, and the allantois only extends over a jiortiou of the subzonal mem- brane, to the remainder of which the yelk-sac is ajiplied. As it is expelled after delivery with the foetal membranes attached to it, and as the aperture in these corresponds to the os uteri, we can generally determine pretty accurately the situation in which the ])lacenta was placed by examining them after expulsion. The maternal surface of the placenta is somewhat convex', the foetal concave. Its size varies greatly in different cases, and it is usually largest when the child is big, but not necessarily so. Its average diameter is from 6 to 8 inches, its weight from 18 to 24 ounces, but in exceptional cases it has been found to weigh several pounds. Abnormalities of form are not very rare. Thus, the placenta has been found to be divided into distinct parts, a form said by Professor Turner to be normal in cer- tain genera of monkeys, or smaller supplementary placentae (placentce siiccenttiria) may exist round a central mass. These variations of shape are only of imjiortance in consequence of a risk of j^art of the detached placenta being left in the uterus after delivery and giving rise to sej)- tictemia or secondary hemorrhage. The foetal membranes cover the whole foetal surface of the ]>la- centa, being refiet-ted from its edges so as to line the uterine cavity, and being expelled with it after delivery. They also leave it at the insertion of the cord, to which they form a sheath. The cord is gen- erally attached near the centre of the placenta, and from its insertion the umbilical vessels may be seen dividing and radiating over the whole fwtal surface. The maternal surface is rough and divided by numerous sulci, which are best seen if the placenta is rendered convex, so as to resem- ble its condition when attached to the uterus. A careful examination shows that a delicate membrane covers the entire maternal surface, unites the sulci together, and dips down between them. This is, in fact, the cellular layer of the do'cidua serotina, which is separated and expelled with the placenta, the deeper layer remaining attached to the uterus. Numerous small oj^enings may be seen on the surface, which are the apertures of the veins torn off from the uterus, as also those CONCEPTION AND GENERATION. 115 of some arteries, which, after taking several sharp turns, open suddenly into the substance of the organ. As regards the minute structure of the placenta, it is certain that it consists essentially of two distinct portions — one ffietal, consisting of the greatly hypertrophied chorion villi, with their contained vessels, which carry the fcetal blood so as to bring it into intimate relation witli the maternal blood, and thus admit of the necessary changes occurring in it connected with the nutrition of the foetus ; and the other maternal, formed out of the decidua serotina and the maternal blood-vessels. These two portions are in the human female so intimately l)lended as to form the single deciduous organ which is thrown off after delivery. These main facts are admitted by all, but considerable differences of opinion still exist among anatomists as to the precise arrangement of these parts. In the following sketch of the subject I shall describe the views most generally entertained, merely briefly indicating the points which are contested by various authorities. The foetal portion of the placenta consists essentially of the ulti- mate ramifications of the chorion villi, which may be seen on micro- scopic examination in the form of club-shaped digitations, which are given off at every possible angle from tlie stem of a parent trunk, Placental Villus, greatly magnified. (After Joulin.) 1, 2. Placental vessels formiug termiual loops. 3. Chorion tissue, forming external walls of vilhis. 4. Tissue surrounding vessels. just like the branches of a plant. Within the transparent walls of the villi the capillary tubes of the contained vessels may be seen lying distended with blood, and in*e.senting an appearance not unlike loops 116 PREGNANCY. of small intestine. The capillaries are the terminal ramitieations of the umbilical arteries and veins, ^vhich, after reaching the site of the placenta, divide and subdivide until they at last form an immense number of" minute caj)illarv vessels, with their convexities looking toward the maternal portion of the placenta, each terminal looj) being contained in one of the digitations of the chorion villi. Each arte- rial twig is accompanied by a corresjionding venous branch, which unites with it to form the terminal arch or loop (Fig. 60). The fcetal blood is carried through these arterial tM'igs to the villi, where it comes into intimate contact with the maternal blood, in consequence of the anatomical arrangenK-nts ])rcsently to be described ; but tiie two do not directly mix, as the older physiologists believed, for none of the maternal blood escapes when the umbilical cord is cut, nor can the minutest injections through the fo'tal vessels be made to pass into the maternal vascular system, or vice versii. In addition to the lo(>])ed terminations of the umbilical veasels, Farre and Schroeder van der Kolk have described another set of capillary vessels in connection with each villus (Fig. 61). This consists of a very fine network cover- FiG. 61. a. Terminal villus of fcetal tuft, minutely injected, i. Its nucleated non-vascular s^heath. (After Farro.) ing each villus, and very different in appearance from the convolu- ted vessels Iving in its interior, which are the only ones which have been usually described. Dr. Farre believes that these ves.sels only exist in the early months of pregnancy, and that they disappear as pregnancy advances. Priestley ' suggests that they may not be vessels at all, but lym])hatics, which may jiossibly al)Sorb nutrient material from the mother's blood and throw it into the foetal vascular system. The existence of lymphatics or nerves in the ])lacenta, however, has never been demonstrated, and they are believed not to exist. As generally described, the maternal portion of the i)lacenta consists of large cavities or of a single large cavity which contains the maternal ' The Gravid Ulent.% p. 52. CONCEPTION AND GENERATION. 117 blood, and into wliioh tlie villi of the chorion penetrate (Fig. 62). Into this niaternal ])art of" the viscus the curling arteries of the uterus pour their blood, which is collected from it hy the uterine sinuses. The Fig. 62. Diagram representing a Vertical Section of the Placenta. (After Dalton.) a, a. Chorion, h, b. Decidua. c, c, c, c. Orifices of uterine sinuses. villi of the chorion, therefore, are suspended in a sac filled with mater- nal blood, which penetrates freely between them, and with which they are brought into very intimate contact. Dr. John Keid believed that onlv the delicate internal lining of the maternal vessels entered the Fig. 63. Fig. 64. Diacrrnm illustrating the Mode in which a i'hicental Villus derives a covering from the Vascular System of the Mother. (After Priestley.)" a. Vilhis having three terminal digitations pro- jecting into 6. Cavity of the mother's vessel, c. Dotted lines representing coat of vessel. The E.xtremity of a Placental Villus. (After Good.sir.) a. External membrane of villus (the lining mem- brane of va.senlar system of Weber). 6. Kxternal colls of villus derived from decidua. nithelium. In various animals the ])lacentje are more or less specialized from the generalized form, in some to a much greater extent than others. In the human ])laceuta the luaternal vessels have lost their normal cylindrical form, and are dilated into a system of freely' intercommunicating placental sinuses, which are, in fact, mater- nal ca])illarics enormously enlarged, with their walls so ex})anded and thinned out that they cannot l)e recognized as a distinct layer limiting the sinus. Each fa-tal chorion villus projectin<^ into these simises is covered witli a layer of cells distinct from those of the epithelial layer of the villus, and readily stripped from it. These are maternal in their origin, and are derived from the deeidna, which sends prolongations of its tissue into the ]ilacenta. These cells, he believes, form a secreting epithelium which scjiarates from the maternal blood a secretion for the nourishmeut of the foetus, which is, in its turn, absorbeil by the villi of the chorion. A view not very dissimilar to this has been advanced by Professor Ercolani of Bologna, who maintains that the maternal jiortion of the ])lacenta is a new formation, strictly glandular and not vascular in its structure. It is formed, he thinks, by the submucous connective tissue of the deeidna serotina, and it dips down into the placenta and fitrms a sheath to each of the chorion villi, which it sejia rates from the maternal blood. This new glandular structure he describes as secreting a fluid, termed the "uterine milk," which is absorbed by the villi of the chorion, just as the mother's milk is absorbed by the villi of the intes- tines; and it is with this fluid alone that the chorion villi are in direct contact. The sheath thus formed to each villus is doubtless analog<»us to the layer of cells which Goodsir described as encasing each villus, but is attributed to a new structure formed after conception. The existence of the maternal-simis system in the placenta is altoy-cther denied bv anatomists of eminence whose views are worthv of ' Introduction to Human Anatomy, Part 2, and Journ. of Anat. and Plnixiolorpj, 1877, vol. xi. p. 33. CONCEPTION AND GENERATION. 119 careful consideration. Prominent amongst these is Braxton llieks/ who has written an elaborate |)aj)er on the subject. He liolds that tiiere is no evidence to prove tliat the maternal blood is ])oured out into a cavity in which the (chorion villi float, and he believes that the curling arteries, instead of entering the so-called maternal portion of the ])la- centa, terminate in the decidua serotiua. The hyperti-ophied chorion villi at the site of the placenta are firmly attached to the decidual sur- face, into which their ti])s are imbedded. The line of junction between the decidua reflexa and serotina forms a circumferential margin tf), and limits, the placenta. The arrangement of the foetal ])ortion of the pla- centa on this view is very similar to that generally described, but the villi are not surrounded by maternal blood at all, and nothing exists between them unless it be a small quantity of serous fluid. The change in the fVetal blood is effected by endosmosis, and Hicks suggests that the follicles of the decidua may secrete a fluid which is poured into the intervillous spaces for absorption by the villi. Functions of the Placenta. — It will thus be seen that anatomists of repute are still undecided as to important points in the minute anatomy of the placenta, which further investigation will doubtless clear up. The main functions of the organ are, however, sufficiently clear. During the entire period of its existence it fills the important office of both stomach and lungs to the foetus. AVhatever view of the arrangement of the maternal blood-vessels be taken, it is certain that the foetal blood is propelled by the pulsations of the foetal heart into the numberless villi of the chorion, where it is brought into veiy intimate relation with the mother's blood, gives off its carbonic acid, absorbs oxygen, and passes back to the foetus, through the umbilical vein, in a fit state for circulation. The mode of respiration, therefore, in the foetus is analogous to that in fishes, the chorion villi representing the gills, the maternal blood the water in which they float. Nutrition is also effected in the organ, and by absorption through the chorion villi the ])abulum for the nourishment of the foetus is taken up. It also probably serves as an emunctory for the products of excretion in the foetus. Picard found that the blood in the placenta contained an appre- ciably larger quantity of urea than that in other parts of the body, this urea probably being derived from the foetus. Claude Bernard also attributed to it a glycogenic function,^ supposing it to take the place of the f(etal liver until that organ was sufficiently developed. Finally, we find that the temporary character of the placenta is indi- cated by certain degenerative changes which take place in it previous to expulsion. These consist chiefiy in the deposit of calcareous patches on its uterine surface, and in fatty degeneration of the villi and of the decidual layer between the placenta and the uterus. If this degene- ration be carried to excess, as is not unfrequently the case, the ftetus may perish from want of a sufficient number of healthy villi through which its respiration and nuti'ition may be effected. The umbilical cord is the channel of communication between the fcetus and placenta, being attached to the former at the umbilicus, to the latter generally near its centre, but sometimes, as in the battledore ' OhsU Trans., 1873, vol. xiv. p. 149. ' Acad, des Sciences, April, 1859. 120 PREC NANCY. ])l:i('cnta, at its (Hljie. It varies iniicli in k"n<;tli, ineasuriii<; on an avor- iio^v {'n>u\ 1; 21 pounds lias l)oen recently recorde*!.^ Such overthrown children are almost invariably stillborn.^ The average size of male children at birth, as in after life, is some- what greater than that of female. Thus Simpson^ found that out of 100 cases the male children averaged 10 ounces more in weight than the female, and half an inch more in length. [Some mothers of average size invariably bring forth very small children, never having one near an average weight. Such was the case with a lady under my care, whose heaviest male infant, now a vigorous boy of twelve years, weighed 5| pounds. A female child, now a young lady, weighed 3| pouncls ; and another of the same sex, that died at eight months, weighed only 2| pounds. It grew plump, but its lower extremities were deficient in muscular energy. The father of these children is of average height and weight. — Ed.] A newborn child at term is generally covered to a greater or less extent with a greasy, unctuous material, the vcrnix caseosa, which is formed of e^ilhelial^scales and the secretion of the sebaceous glands, and which is said to be of use in labor by lubricating the surface of the child. The head is generally covered with long dark hair, which frequently falls off or clianges in color shortly after birth. Dr. Wiltshire* has called attention to an old observation, that the eyes of all newborn children are of a peculiar dark steel-gray color, and that they do not acquire their permanent tint until some time after l)irtli. The umbilical cord is generally inserted below the centre of the body. The most important part of the foetus from an obstetrical point of view is the head, which requires a separate study, as it is the usual j)resenting part, and the fecility of the labor depends on its accurate adaptation to the maternal passages. Anatomy of the Foetal Head. — The chief anatomical peculiarity of interest in the head of the foetus at term is tliat the bones of the skull, especially of its vertex — which, in the vast majority of cases, has to pass first through the pelvis — are not firmly ossified as in adult life, but are joined loosely together by membrane or cartilage. The result of this is that the skull is capable of being moulded and altered in form to a very considerable extent by the pressure to which it is sul)jected, and thus its ])assage through the pelvis is very greatly focili- tated. This, however, is chiefly the case with the cranium proper, the bones of the face and of the base of the skull being more firmly united. By* this means the delicate structures at the base of the brain are protected from pressure, while the change of form which the skull 1 Brit. Med. Journ., Feb. 1, 1879. '■^ Probably the largest fa4us on record was that of Mrs. Captain Bates, the Nova Scotia giantess, a woman of 7 feet 9 inches, whose linsband is also of gigantic build, reaching 7 feet 7 inches in lieight. This child, born in Ohio, was their second, and was lost in its birth, as no forcejis could be procured of sufficient size to grasp the head. The foetus weighed 284- pomids. and was ;>0 inches in length. Their first infant weighed 18 pounds. \Ve have had children born in this city (Philadelphia) at matu- rity and live that weighed but one pound. The well-remembered " Pincus baby " weighed a pound and an ounce. — Harris, note to 3d American edition. ^^^electcd Oi.^'t. Works, p. 327. * Lancet, February 11, 1871. 124 pnEGXAyry uiulcrgoc'S (liiriiifj lahor inij)lic'at('.s a portion of tlio skull wliore |»res- surc oil tlie fraiiial fontents is least likely to be injurious. The divisions between the bones of the eraniuni are iurther of obstet- ric importance in enabling us to detect the |)r('cise jiosition of the head during labt»r, and an accurate knowledge of them is therefore essen- tial to the obstetrician. ^^'e talk of them as sutures and fontanelleSy the former being the lines of junction between the sej)arate bones, which overlap each other to a greater or less extent during labor; the latter membranous inter- spaces where the sutures join each other. The ])rincij)al sutures are — 1st. ''J'he sdf/itf'il, which separates the two parietal bones, and extends longitudinally backward along the vertex of the head. 2d. Tht'fro)i(fil, which is a continuation of the sagittal, and divides the two halves of the frontal bone, at this time separate from each other. 3d. The corona/, which separates the frontal from the parietal bones, and extends from the squamous portion of the temporal bone across the head to a corresponding point on the o])posite side. And 4th, the lamhdoiilal, which receives its name from its resemblance to the Greek letter J, and separates the occipital from the parietal bones on either side. The fontanelles (Fig. 65) are the membranous Fig. Co. Fig. 66. Anterior aud Po.sterior Fontan- elles. Bi-parietal Dianuttr. Sa;:iual and I.anilidf)idal Sutures, with Poste- rior Fontanelle. interspaces where the sutures join — the anterior and largeV being loz- enge-shaped, and formed by the junction of the frontal, sagittal, and two halves of the coronal sutures. It will be well to note that there are, therefore, four lines of sutures running into it, and four angles, of Avhich the anterior, formed by the frontal suture, is most elongated and well marked. The posterior fontanel le (Fig. 6Q) is formed by the junction of the sagittal suture with the two legs of the lambdoidal. It is, therefore, triangular in sha])e, Mith three lines of suture entering it in three angles, and is much smaller than the anterior fontanello, forminir merely a depression into which the tip of the finger can be placed, while the latter is a hollow as big as a shilling or even THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 125 larger. As it is tlie posterior foiitanellc which is genei-ally lowest, and the one most commonly fijlt during- labor, it is important for the student to familiarize himself with it, and he should lose no oppf)rtunity of studying the sensations imparted to the finger by the sutures and fou- , , "7 ^ taneiles in the head of the child after birth. ,_-^— — "" ' ^-<,j^^ jf^"' '^ ' The Diameters of the Foetal Skull. — For the purpose of under- standing the mechanism of ]al)or, we nmst study the measurements of the foetal head in relation to the cavity through which it has to pass. They are taken from corresponding points opposite to each other, and are known as the diameters of the skull (Fig. 67). Those of most importance are — 1st. The occipito- menf(i/is (o. m), from the occipital Fig. 67. protuberance to the point of the chin, 5.25" to 5.50". 2d. The occipito-frontalis (o. f), from the occiput to the centre of the fore- head, 4.50" to 5". 3d. The sub- occipito-brefjmafica (s. o. b), from a point midway between the occipital ])rotuberance and the margin of the foramen magnum to the centre of the anterior fontanelle, 3.25". 4th. The cervico-bregmatica (c. b), from the anterior margin of the foramen magnum to the centre of the ante- rior fontanelle, 3.75". 5th. Trans- verse or bi-parietalis (bi-p), between the parietal protuberances, 3.75" to 4". 6th. Bi-itemporalls (bi-t), between the ears, 3.50". 7th. Fronto- mental'is (f. m), from the apex of the forehead to the chin, 3.25". The length of these respective diameters, as given by different writers, differs considerably, a fact to be explained by the measurements having been taken at different times — by some just after birth, when the head was altered in shape by the moulding it had undergone ; by others when this had either been slight or after the head had recovered its normal shape. The above measurements may be taken as the average of those of the normally-shaped head, and it is to be noted that the first two are more apt to be modified during labor. The amount of compres- sion and moulding to which the head may be subjected Mathout proving fatal to the fcetus is not certainly known, but it is doubtless very con- siderable. Some interesting examples of the extent to which the head may be altered in shape in difficult labors have been given by Barnes/ M'ho has shown by tracings of the shape of the head taken innnediately after delivery that in protracted labor the occipito-mental (o. m) and occipito-frontal (o. f) diameters may be increased more than an inch in length, while lateral compression may diminish the bi-parietal (bi-p) diameter to the same lengtli as the interauricular. The foetal head is movable on the vertical column to the extent of a quarter of a circle ; and it seems probable that the laxity of the ligaments admits with ' Obd. Trans., 18(30, vol. vii. p. 171. 1 & 2. Diameter occipito-frontalis (o. f). 3 & 4. occipito-mentalis (o. m). 5 & 6. cervico-bregmatica (c. b). 7 & 8. fronto-mentalis (f. m). 126 PREGyAyry. iiii|)unilv a ii;i'catc'r ciivular movciucnt than would 1)C possible in the adult. ( )n takinu' the avc'i'ati:L' of" a lararietes and on the greater quantity of amniotic fluid, by both of which the free mobility of the fa?tus is favored. The facility with which the position of the fcetns in utero can be ascertained by abdominal palpation has not been generally appreciated in obstetric works, aud yet by a little practice it is easy to make it out. Much information of importance can be gained in this way, and it is quite possible, under favorable circumstances, to alter abnormal pres- FiG. 68. Mode of Ascertaining the Position of the Foetus by Palpation. eutations before labor has begun. For the purpose of making this examination the patient should lie at the edge of the bed, with her shoulders slightly raised and the abdomen uncovered. The first obser- ' Mm. f. Geburf., 1865, Bd. xxiv. S. 172; aiul 186G, Bd. xxviii. S. 3(31: " Gebiirts- hiilfliche Studien." 128 PREGNASCY. vation to make is to see if tlie loiifritudinal axis of the uterine tumor (.•orrcspoiuls with that of tlie mother's alKloiiien ; if it does, the presenta- tion must l)e either a head or a breeeli. Jiy spreadinj:: the hands over the uterus (Fig. OS) a greater sense of resistance can be fch, in most cases, on one side than on the otlier, eorresj)on(ling to the back of the child. By striking the tips of the fingers suddenly inward at the fundus, the hard breech can generally be made out, or the head still inore easily if the breech be dow invard. AVhen the uterine wall^ are unusually lax it is often possible to feel the limbs of the cliild. 'These observations can be generally corroborated by anscultati on, ibr in head presentations the fcetal heart can u.-;ually be heard belowThe umbilicus, and in breech cases above it.^ Transversepi'esentations can even more easily be made out by abdominal palpation. 'Here the long axis of the uterine tumor does not corresjjcnd with the long axis of the mother's abdomen, but lies obliquely across it. By pal})ation the rounded mass of the head wni be easily felt in one of the mother's flanks, and the breech in the other, while the fcetal heart is heard pulsating nearer to the side at which the head is detected. Tlie reason why the head presents so frequently has been made the subject of much discussion. The o ldest theor y was, that the head lay over the os uteri as the r esult of ^^^g^ jj^ tion, aiid the influence of gravity, although contested by man^'^ot'stetricians, prominent among whom were Dubois and Simpson, has ])een insisted upon as the chief cause by others. Dr. Duncan being one of the most strenuous advocates of this view. The objections urged against the gravitation theory Avere drawn partlv from the result of exjieriments, and partly from the frequency witli which abnornal presentations occur in premature lal)ors, when the action of gravity cannot be supposed to be susjjended. The experi- ments made by Dubois M-ent to show that when the foetus was suspended in water gravitation caused the shoulders, and not the head, to fall lowest. (He therefore advanced the hypothesis that the position of the fcetus was due to inst inctive move ments which it made to adapt itself to the most comfortable position in which it could lie. It need only be remarked that there is not the slightest evidence of the fcetus possessing any such power.") Simpson proposed a theory which was much more plausible. (He assu/ned that the foetal position was due to reflex movements produced by ]ihysical irritations to which the cutane- ous surface of the foetus is subjected from changes of the mother's position, uterine contractions, and the like. J The absence of these movements, in the case of the death of the tcetus, would readily ex- plain the frequency of mal-presentations under such circumstances. The obvious objection to this theory, complete as it seems to be, is the absence of any proof that such constant extensive reflex movements reallv do occur in utero. Dr. Duncan has very conclusively disposed of the principal objections which have l)een raised against the influence of gravitation, and when an obvious explanation of so simple a kind exists it seems useless to seek farther for another. He has sho-wn that Dubois' experiments did not accurately represent the state of the foetus in utero, and that during the greater part of the day, wiien the woman is upright or lying on lier back, the foetus lies obliquely to the horizon TILE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 129 at an angle of about 30°. The child thus lies, in the former case, on an inclined plane formed by the anterior uterine wall and by the abdomi- nal parietes ; in the latter, by the posterior uterine wall and the vertebral column. Down the inclined plane so formed the force of Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan.) 6, is parallel to the axis of the pregnant uterus and pelvic brim, c, d, e. Is a perpendicular line. centre of gravity of the foetus, d, the centre of flotation. the gravity causes the foetus to slide, and it is only when the woman lies on her side that the foetus is placed horizontally, and is not subjected in the same degree to the action of gravity (Fig. 69). The frequency of mal- presentations in premature labors is explained by Dr. Duncan partly by Fig. 70. Illustrating the Greater Mobility of the Fcetus and the Larger Relative Amount of Liquor Amnii in Early Pregnancy. (After Duncan.) «, 6. Axis of pregnant uterus. h, h. A horizontal line. the fact that the death of the child (^yhich so frequently precedes such cases) alters its centre of gravity, and partly by the greater mobility of the child and the greater relative amount of liquor amnii (Fig. 70). The influence of gravitation is probably p^reatly assisted by the contr ac- 130 PREGNANCY. tjons 9f f lip iitpriT^ wlnVli arc guing on during the greater })art of preg- nancy. The influence of tliese was j)ointc(l out by Dr. Tyler Smith, ■who distinctly showed that the contractions of the uterus preceding delivery exerted a moulding or adapting influence on the fretus and prevented undue alterations of its jjosition. Dr. Hicks proved' that these uterine contractions are of constant occurrence from the earliest period of pregnancy, and there can be little doubt that they must have an important influence on the body contained within the uterus. The whole subject has been recently considered by Pinard,^ who shows that many factors are in action to produce and maintain the usual position of the foetus in utero, which may be either of an active or a j)assive character: the former being chiefly the active movements of the fretus and the contractions of the uterus and the abdominal muscles ; the latter, the form of the uterus and the foetus, the slippery surface of the amnion, pressure of the amniotic fluid, etc. When any of these factor's are at fault mal-presentation is apt to occur. The functions of the fcetus are in the main the same, with differences depending on the situation in which it is placed, as those of the sepa- rate being. It breathes, it is nourished, it forms secretions, and its nervous system acts. The mode in which some of these functions are carried on in intra-uterine life requires separate consideration. Nutrition. — During the early part of jDregnancy, and before the formation of the umbilical vesicle and the allantois, it is certain that nutritive material must be supplied to the ovum by endosmosis through its external envelope. The precise source, however, from which this is obtained is not positively known. By some it is believed to be derived from the granulations of the discus pi-oluierus which surround it as it escapes from the Graafian follicle, ana suTJsequently from the layer of albuminous matter which surrounds the ovum before it reaches the uterus ; while others think it probable that it may come from a special liquid secreted by the interior of the Fallopian tube as the ovum passes along it. As soon as the ovum has reached the uterus there is every reason to believe that the umbilical vesicle is the chief source of nourishment to the embryo through the cnanneTof the omphalo-mesen- teric vessels, which convey matters absorbed from the interior of the vesicle to the intestinal canal of the foetus. At this time the exterior of the ovum is covered by the numerous fine villosities of the primi- tive chorion, which are imbedded in the mucous membrane of the uterus ; and it is thought that they may absorl) materials from the maternal system, which may be either directly absorbed l)y the cnd)rvo or which may serve the purpose of replacing the nutritive matter which has been removed from the umbilical vesicle by tlKMimphalo-mesenteric vessels. This point it is of course impossible to decide. Joulin, how- ever, thinks that these villi probably have no direct influence on the nourishment of the fictus, which is at this time solely eflected by the umbilical vesicle, but that they absorb fluid from the materiial system, which passes through the amnion and fornix the li(|Uor amnii. As soon as the allantois is developed, vascular connnunication between th e foetus and the maternal structures is established , and the temporary ^ Obst. Trans., 1872, vol. xiii. p. 216. Annal. de Gyn., 1878, torn. ix. p. 321. THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 131 i'liiKitiou of the umbilical vesicle is over; that structure, therefore, rapidly atrophies and disappears, and the nutrition of the foetus is now solely carried on by means of the chorion villi , lined as they now are by the vascular endochorion, and chiefly by those which go to form the substance of the placenta. This statement is o})posed to the views of many ])hysiologists, who believe that a certain amount of nutritive material is conveyed to the fnetus through the channel of the liquor amnii, itself derived from the maternal system, which is supposed either to be absorbed through the cutaneous surface of the fetus or carried to the intestinal canal by deglutition. The reasons for assigning to the liquor amnii a nutri- tive function are, however, so slight that it is difficult to believe that it has any apprecialile action in this way. They are based on some questionable observations, such as those of Weydlich, who kept a calf alive for fifteen days by feeding it solely on liquor amnii; and the experiments of Burdach, who found the cutaneous lymphatics engorged in a foetus removed from the amniotic cavity, while those of the intes- tine were empty. The deglutition of the liquor amnii for the purposes of nutrition have been assumed from its occasional detection in the stomach of the foetus, the presence of which may, however, be readily explained by spasmodic efforts at respiration which the foetus undoubt- edly often makes before birth, especially when the placental circulation is in any way interfered with, and during which a certain quantity of fluid would uecessarily be swallowed. The quantity of nutritive material, however, in the liquor amnii is so small — not more than 6 to 9 parts of albumen in 1000 — that it is impossible to conceive how it could have any appreciable influence in nutrition, even if its absorption either by the skin or stomach were susceptible of proof. That the nutrition of the foetus is effected through the placenta is proved by the coaunon observation that whenever the placental circula- tion is arrested, as by disease of its structure, the foetus atrophies and dies. The precise mode, however, in which nutritive materials are absorbed from the maternal blood is still a matter of doubt, and must remain so until the mooted points as to the minute anatomy of the pla- centa are settled. The various theories entertained on this subject by the upholders of the Hunterian doctrine of placental anatomy, and by those who deny the existence of a sinus system, have already been referred to in the chapter on the Anatomy of the Placenta, to which the reader is referred (pp. 114-120). Respiration. — One of the chief functions of the placent a, besides that of nutrition, is the supply of oxvgenated blood to the foetus. ; That this is essential to the vitality of the foetus, and that the placenta is the site of oxygenation, is shown by the fact that whenever the placenta is separated, or the access of the foetal blood to it arrested by compression of the cord, instinctive attempts at inspiration are made, and if aerial respiration cannot be performed the foetus is exjielled asphyxiated. Like the other functions of the foetus during intra-uterine life, that of respiration has been made the subject of numerous more or less inge- nious hypotheses. Thus, many have believed that the foetus absorbed gaseous material from the liquor amnii, which served the purpose of 132 pjiJ':(;yAycy. oxvi;t'Matin<; its l)loo(l — St. Ilihiin; thiiikintr tliat this was effected Iw niimitc opeiiir.trs in its sUiii, JJrcianl aiiiiehi, to whieh tliey believed the licjiior ainiiii j^ained access. Jndependently of the entire want of eviilence of tiie absorption of ga.seou.s materials jjy these channels, the theory is disproved by the fact that the liquor aninii contains no air which is capable of respiratit)n. Serres attributed a sim- ilar finiction to some of the chorion villi, which he believed peneti'ated the utricular Lrhmds of the decidua rcHexa and absorbed ses into the lower extremities, and the adult circulation is established. The changes which take place in the temporary va.scular arrange- ments of the fVetus prior to their complete di.sajjpearance are of .some jiractical interest. TlH3_jiiK^:tji,^.Uit(il'iQsus, as has been .said, collap.ses, chiefly because the nia.ss of blood is drawn to the lung.s, and partlv, ])erhaps, by its own inherent contractility. Its walls are fomxl to be thickened, and its canal clo.ses, fir.st in the centre, and subsequently at its extremitie.s, its aortic end remaining pervious longer on account of the greater pressure of blood from the left side of the heart (Fig. 72). Practical closure occurs within a few days after birth, although Flourens states that it is not completely obliterated until eighteen months or two years have elai)sed.' Accord- ing to Schroeder, its walls unite without the <^<^ formation of any thrombus. The foramen ovale is soon closed by its valve, which con- tracts adhesion with the edges of the a])er- ture, so as effectually to occlude it. Some- times, however, a small canal of connnuni- cation between the two auricles may remain pervious for many months, or even a year and more, without, however, any admixture of blood occurring. A permanently jnitu- lous condition of this a])erture, however, sometimes exists, giving rise to the disea.'^e known as cyanosis. The umbilical ai'teries and veins and the ductus venosus soon also become impermeable, in consequence of concentric hypertrophy of their tissue and collap.se of their walls. The closure of the former is aided by the formation of coagnla in the intei'ior. According to Kobin, a longer time than is n.sually supjio.'^ed elap.'^es before they become com- ])letely elo.sed, the vein remaining pervious until the twentieth or thirtieth day after delivery, the arteries for a month or six weeks. He has al.so flescribed ^ a remarkable contraction of the umbilical ve.'Jsels within their sheaths at the point where they leave the abdomi- nal walls, which takes place within three or four days after birth, and seems to prevent henK)rrhage taking place when the cord is detached. Thc_lr\'er, from its ])roportionately large size, ap]xn-ently jdays an important jiart in the fVctal economy. It is not until about the fifth month of utero-gestation that ita.ssumes its characteristic structure and forms bile, previous to that time its texture being .criod one of its most impoi'tant offices is the formation of sugar, which is found in much larger amount in the foetus than after birth. Sugar is, however, found in the foetal structures 1 Acad, des Sciences, 1854. * Ibid., 1860. Diagram of Heart of Infant. (After Dalton.) 1. Aorta. 2. Pulmonary artery. 3. 3. Piilinonnrj' brandies. 4. Dnrtus arteriosus beconiiug oblite- rated. I THE ANATOMY AND PHYSIOLOGY OF THE FOETUS. 135 long before the development of the liver, especially in the mucous and cutaneous tissues; and it seems probable that these, as well as the jila- centa itself, then fulfil the glycoj^enic function, afterward chiefly per- formed by the liver. The bile is secreted after (Ik; fifth month of [),rcg- nancy, and passes into the intestinal canal, and is subsequently collected inTTie o:all-bladder. By some physiologists it has been supposed that the liver, during intra-uterine life, was the chief seat of depuration of the carbonic acid contained in the venous blood of tlie foetus. It is, however, more generally believed that this is accomplished solely in the placenta. The bile, mixed with the mucous secretion of the intestinal tract, forms the meconi imi which is contained in the intestines of the foetus, and whicli"~collects in them during the whole period of intra- uterine life. It is a thick, tenacious, greenish substance, which is voided soon after birth in considerable quantity. ■U rin e is certainly formed during intra-uterine life, as is proved by the fact, familiar to all accoucheurs, that the bladder is constantly emptied instantly after birth^ It has generally been supposed that the foetus voids its urine into the cavity of the amnion ; and the existence of traces of urea in the liquor amnii, as well as some cases of imperfo- rate urethra in which the bladder was found to be enormously distended, and some cases of congenital hydronephrosis associated with impervious ureters, have been supposed to corroborate this assumption. The ques- tion has been very fully studied by Joulin, who has collected together a large number of instances in which there was imperforate urethra with- out any undue distension of the bladder. He holds, also, that the amount of urea found in the liquor amnii is far too minute to justify the conclusion that the urine of the foetus was habitually passed into it, although a small quantity may, he thinks, escape into it from time to time; and he therefore believes that the urine of the foetus is only secreted regularly and abundantly after birth, and that during intra- uterine life its retention is not likely to give rise to any functional disturbance.^ Function of the Nervous System. — There is no doubt that the nervous system acts to a considerable extent during intra-uterine life, and some authors have even supposed that the foetus was endowed with the power of making instinctive or voluntary movements for the pur- pose of adapting itself to the form of the uterine' cavity. ( Most probably, however, the movements the foetus performs are purel y reflex^ That it responds to a stimulus applied to the cutaneous nerves is proved by the experiments of Tyler Smith, who laid bare the amnion in pregnant rabbits, and found that the foetus moved its limbs when these were irri- tated through it. Pressure on the mother's abdomen, cold applications, and similar stimuli will also produce energetic foetal movements. The gray matter of the brain in the newborn child is, however, quite rudimentary in its structure, and there is no evidence of intelligent action of the nervous system until some time after birth, and, a fortiori, during pregnancy. ^Acad. des Sciences, p. 308. lo6 PREGNANCY. CHAPTER III. PREGNAN'CY. Changes in the Uterus. — As soon as fonooj^tion has takoii place a series ot" remarkable changes commence in the uterus, Avhich progi-ess until the termination of pregnancy, and are well worthy of careful study. They produce those marvellous modifications which effect the transformation of the small undevelojjcd uterus of the non-pregnant state into tlie large and fully-dcN-eloped uterus of pregnancy, and have no parallel in the w'hole animal economy. A knowledge of them is essential for the proper comprehension of the phenomena of labor, and for the diagnosis of j)regnancy which the practitioner is so frequently called upon to make. Excluding the varie- ties of abnormal pregnancy, which "will l)e noticed in another place, we shall here limit ourselves to the consideration of the modifications of the maternal organism which result from simple and natural gestation. The unimpregnated uterus measures 2J inches in length, and weighs about 1 ounce, while at the full term of pregnancy it has so immensely grown as to weigh 24 ounces and measure 12 inches. The growth com- mences as soon as the ovum reaches the uterus, and continues uninter- ruptedlv until deliveiy. In the early months the uterus is contained entirelv in the cavity of the pelvis, and the increase of size is only apparent on vaginal examination, and that with difficulty, ( Before th e t hird month the enlargement is chiefly in the lateral direct ion,) so that the whole body of the uterus assumes more of a -2)herical sha])e than in the non-pregnant state. If an opportunity of examining the gravid wiQYWs poHt-mortem should occur at this time, it will be found to have the f orm of a ST">he re flattened somewhat posteriorly and l)ulging ante- riorly. After the ascent of the organ into the abdomen it develops more in the vertical direction, so that atjerm it has the form of an ovoid, with its large extremity above and its narrow end at the cervix uteri, and its longitudinal axis corresponds to the long diameter of the mother's abdo- men, provided the presentation be either of the head or breech. The autcrioi- surface is now even more distinctly projectino; than before — a fact which is explained by the proximity of the posterior surface to the rigid spinal column behind — while the anterior is in relation with the lax abdominal parietes, which yield readily to pressure, and so allow of the more marked jirominence of the anterior uterine wall. Before the gravid uterus has risen out of the pelvis no ap]>reciable increase in the size of the abdomen is perceptible. 1[ On the contrary, it is an old observation that at this early state of pregnancy the abdomen is flatter_jhan jisiial, on account of the partial descent of the uterus in the pelvic ca^•ity as a result of its increased weight, j As the growth of the (jrgan advances it soon becomes too large to be contained any longer PREGNANCY. 187 within the pelvis, and about tlie middle of the third or the beginning of the fourtli month the fundus rises above the pelvic brim — not sud- denly, as is often erroneously thought, but slowly and gradually — when it may be felt as a smooth rounded swelling. (it is about this time that the movements of the fjetus first become, appreciable to the mother, when " quickeithu/" is said to have taken place.) Toward the end of the fourth month the uterus reaches to about three fingers' breadth above the symphysis pubis. About the fifth month it occupies the hypogastric region, to which it imparts a marked projection, and the alteration in the figure is uow distinctly per- ceptible to visual examination. (About the sixth month it is on a level with, or a little above, the unTOilicusVFig. 73). About the seventh Fig. 73. Relations of the Pregnant Uterus at Sixth Month to the Surrounding Parts. (After Martin.) month it is about two inches above the umbilicus, which is now project- zing and prominent, instead of depressed, as in the non-pregnant state. (During the eighth and ninth months it continues to increase until the summit of the fundus is immediately below the ensiform cartilage/ (Fig. 74). A knowledge of the size of the uterine tumor at various periods of pregnancy, as thus indicated, is of considerable practical im- portance, as forming the only guide by which Aye can estimate the prob- able period of delivery in certain cases in which the usual data for cal- 138 PRKGNANCY. Fig. 74. filiation aiv al)S(_'nt ; as, I'ur L'\aiii[)l(', wlicii tlic patient lias conceived (lurinLi: lactation. e'ur alx)iii a week or more before labor the uterus {»;enerally sinks sonie- what into the pelvic cavity, in conse- quence of the relaxation of the soft parts which precedes delivery, and the ])atient now feels herself smaller and lim it is known as " th e lightenin g before labor." AMiilc the uterus remains in the pel- vis its loniiitudinal axis varies in direc- tion, nmeh in the same M'ay as that of the non-])rei;nant uterus, sometimes be- ing more or less vertical, at othei-s in a state of anteversion or partial retrover- sion. These variations are probably de- pendent on the distension or em])tine&s of the Ijladder, as its state must neces- sarily affect the })osition of the movable organ poised behind it. After the uterus has risen into the abdomen its tendency is to project forward against the abdom- inal wall, which forms its chief support in front. In the erect position the long axis of the uterine tumor cor- resj)onds with the axis of the pelvic brim, forming an agle of about 'M)° with the horizon.) In the semi-recumbent ])Osition, on the other hand, as Duncan^ has pointed out, its direction becomes much more nearly vertical. In women who have borne many children the abdominal parietes no longer afford an efficient support, and the uterus is displace*! anteriorly, the fundus in extreme cases even hanging downward. In addition to this anterior oI)liquity, on account of the projection of the spinal column, the uterus is very generally also displaced laterally, and sometimes to a very marked degree, so that it ma}^ be felt entirely in one flank, instead of in the centre of the abdomen, (in a large pro- portion of cases this lateral deviation is to tlie_ rig ht sid e, and many liypotheses have been ])rought forward to explain this fact, none of them being satisfactory.) Thus, it has been supposed to dej)end on the greater frequency with which women lie on their right side during sleep, on the greater use of the right leg during walking, on the supposed comj)ai-a- tive shortness of the right round ligament which drags the tumor to that side, or on the frequent distension of the rectum on the left side, which prevents the uterus being displaced in that direction. (Jf these, the last is the cause which seems most constantly in ojieration, and most likely to produce the effect. The cervix must obviously adapt itself to the situation of the body of the uterus. (We find, therefore, that in the early months, when the Size of Uterus at Various Periods of Preg- nancy. uterus lies low m the pelvis, it is more readily Avithin reach. ' Researches in Obstetrics, p. 10- After the PREGNANCY. 139 ascent of tlic uterus it is dniwii uj), aiul fVeqiieiitly so much so as to be reached with clillieulty. When tiie uterus is uuich antev(,'rte(l, as is so often tlic case, tiie os is displaced backward, so that it cannot be felt at all by the examining finger. Toward the end of j)regnancy the greater part of the anterior surface of the uterus is in contact with the abdominal wall, its lower ])ortion resting on the posterior surface of the symphysis jiubis. I'he posterior siu'face rests on the spinal colunni, while the small intestines are j)ushed to either side, the large intestines surrounding the uterus like an arch. Chang-es in the Uterine Parietes. — Tlie great distension of the uterus during pregnauey was formerly supposed to be mainly due to the mechanical pressure of the enlarging ovum within it. If this were so, then the uterine walls would be necessarily much thinner than in the non-pregnant state. VTIus is well known not to be the case, and the immense increase in the size of the uterine cavity is to be explained by the h ypertrop hy of its walls.)^ At the full period of pregnancy the thickness of the uterine parietes is generally about the same as that of the non-pregnant uterus, rather more at the placental site, and less in the neighborhood of the cervix.j Their thickness, however, varies in different places, and in some women they are so thin as to admit of the foetal limbs being very readily made out by palpation. (Their density is, however, always much diminished, and, instead of being hard and inelastic, they become soft and yielding to pressure.N This cliange coin- cides with the commencement of pregnancy, of whicn it forms, as recog- nizable in the cervix, one of the earliest diagnostic marks. At a more advanced period it is of value as admitting a certain amount of yielding of the uterine walls to movements of the foetus, thus lessening the chance of their being injured. Bandl has pointed out that during the latter months of pregnancy the lower segment of the uterus, to a dis- 1 tance of from four to six inches above the inner os, is thinner and less vascular than the tissues of the body of the uterus above. This thinner portion is separated from that above it by a ridge, often easily made out when the hand has to be inserted into the uterus after delivery, known as " Bandl's ring." ^ Changes in the Cervix during- Preg-nancy. — A^ery erroneous views have long been taught, in most of our standard works on midwifery, as to the changes which occur in the cervix uteri during pregnancy. It is generally stated that, as pregnancy advances, the cervical cavity is greatly diminished in length, in consequence of its being graduallv drawn up so as to form part of the general cavity of the uterus, so that in the latter months it no longer exists. In almost all midwifery works accurate diagrams are given of this progressive shortening of the cervix (Figs. 75 to 78). The cervix is generally described as having lost one- half of its length at the sixth month, two-thirds at the seventh, and to be entirely obliterated in the eighth and ninth. The correctness of these views were first called in question in recent times by Stoltz in 1826, but Dr. Duncan,^ in an elaborate historical paper on the subject, * XJeher das Verhallen des Uterus und Cervix in der Schtcangerschaft und ivakrend der Ocbiirt, 1876. ^ Researches in Obstetrics. 14U riii:(;yAycy. lias sliown that Stoltz was anticipated hy M'citlnvcli in 1750, and, to a less (k'lrrc'c, l)y Kocdi-rci- and otlicr writers. Tliis oijinion is now i)r('tty gcnc'i-aily adniittcil to be eorreet, and is nplield by Ca/eaux, Arthur Fig. 7") Fig. 76. " l^ Fig. 77. Fig. 7 Supposed Shortening of the Cervix at the Third, .Sixth, Eighth, and Ninth Months of Preg- nancy, as figured in obstetric works. Farre, Duncan, and most modern o])stetric'ians. Indeed, vanous pod- moriem examinations in advanced pregnancy have shown that(f he cavit y of the cervix remains in reality of" its normal length of one iuc-lA and it Fig. 79. Cervix from a Wuman dying in the Eighth Month of Pregnancy. (,.\fier Duncan.) PREGNANCY. 141 can often be measured durini^lifeby the examining finger on account of j its patulous state (Fig. 70). [During the fortm'glit immediately prcr-frl- ' ing delivery^ however, a rcalSshortening or oljlitoratioii of the ccivii'ul cavity takes place, eonnnencing above, until the cervical canal is mei'ged into the uterine cavity ; but this, as Duncan has ])ointed out, seems to I be due to the incipient uterijie contractions which prepare the cervix ' for laborN There is, no doubt, an apparent shortening of the cervix always to be detected during ])rcgnancy, but this is a fallacious and deceptive feeling, due to the softness of the tissue of the cervix, which is exceedingly characteristic of pregnan(y, and \vhich to an experienced finger affords one of its best diagnostic marks. In the non-pregnant state the tissue of the cervix is hard, firm, and inelastic. (W hen conception occ urs, softening begins at the external os, and proceeds gradually and slowly upward until it involves the whole of the cervix^ By the end of the fourth month both lips of the os are thick, soft, and velvety to the touch, giving a sensation likened by Cazeaux to that ]>roduced by pressing on a table through a thick, soft cover. By the sixth month at least one-half of the cervix is thus altered, and by the eighth the whole of it ; and so much so that at this time those unaccustomed to vaginal examination experience some dif- ficulty in distinguishing it from the vaginal walls, (it is this softening, then, which gives rise to the apparent shortening of the cervix so gen- erally described ; and it is an invariable concomitant of pregnancy, except in some rare cases in which there has been antecedent morbid induration and hypertrophic elongation of the cervix. (If, therefore, on I examining a woman supj)osed to l)c advanced in pregnancy, Ave find the cervix to be hard and projecting into the vaginal canal, we may safely conclude that jiregnancy does not exist, j The existence of soften- ing, however, it must be remembered, will noi itself justify an opposite conclusion, as it may be produced, to a very considerable extent, by various pathological conditions of the uterus. At the same time that the tissue of the cervix is softened, its Ga.YJtyjs "\jiiilg.ned and the external os becomes patulous. This change varies considerably in primiparte and multiparse. In the former the external OS often remains closed until the encl of pregnancy ; but even in them it generally becomes more or less patulous after the seventh month, and admits the ti]) of the examining finger. In women who have borne children this change is much more marked. The lips of the external os are in them generally fissured and irregular, from slight lacerations of its tissue in former labors. It is also sufficiently open to admit the tip of the finger, so that in the latter months of pregnancv it is often quite possible to touch the membranes and through them to feel the present- ing part of the child. The remarkable incrense jp size of tl^p uterus during pregnancy is, as we have seen, chiefly to be explained by the growth of its structures, all of which are modified during gestation. The ])eritoneal covering is con- siderably increased, so as still to form a complete covering to t\\v uterus when at its largest size. William Hunter supposed that its extension was effected rather by the unfolding of the layers of the broad ligament 142 PREGXAycy. tliaii l»y i»n)\vtli. Tliat the layers of the l)roai/.( — >o as to measure, accordiu"; to K(")llillains tiicir al)sence during the latter months of gestation by the presence iu the urine at that time of free lactic acid, uhich increases its acidity and prevents the decomposition of the urea into car- bonate of ammonia. He believes that kiestein is ])roduced by the action of free carbonate of annnonia on the phosj)hate of lime contained in the urine, and that this reaction is })reventcd by the excess of acid. Golding Jiii'd believed kiestein to be analogous to casein, to tlie pres- ence of •which he referred it, and he states that he has ibund it in 27 out of 30 cases. Braxton Hicks so far corroborates liis view, and states that the dej^osit of kiestein can be much more abundantly produced if one or tMO teaspoonfuls of rennet be added to the urine, since that substance has the property of coagulating casein. Much less importance, however, is now attached to the presence of kiestein than formerly, since a precisely similar substance is sometimes found in the urine of the non-pregnant, especially in antemic women, and even in the urine of men. Parkes states that it is not of uniform composition, that it is produced by the decom])osition of urea, and consists of the free phosphates, bladder-nuicus, infusoria, and vaginal discharges. Neuge- bauer and Vogel give a similar account of it, and hold that it is of no diagnostic value. That it is of interest as indicating the changes going on in connection with pregnancy is certain ; but inasmuch as it is not of invariable occurrence, and may even exist quite independently of gestation, it is obviously quite undeserving of the extreme importance that has been attached to it. Toward the end of pregnancy suga r may sometimes be detected in the urine, and after delivery and during lactation it exists in considerable abundance; thus out of 35 cases tested in the Simpson Memorial Hos- pital in Edinburgh during the puerperium, it was found in all, the amount varying from 1 to 8 per cent.' Kalten1)ach has shown that this temporary glycosuria is due to the jiresence of milk-sugar in the urine, and that it ceases with the disappearance of milk from the breasts.- This ])hysiological glycosuria nuist be carefully distinguished from true diabetes, which is a grave complication of pregnancy. Albumen is often present during the latei* stages of ])regnancy, and it may be transitory and of eom])aratively little moment, although its j)resence must always be a cause of some anxiety. Leyden bi-lieves that it is most often met with in the second half of a frsf ])regnancy, and it may become chronic, leading to granular atro])hy of the kidneys,'* In some cases it seems to be the result of catarrhal conditions of the blad- der ; in others it is probably caused by undue arterial tension consequent on pregnancy. ' Eflin. Med. Journ., vol. 1881-82, p. 116. ^ Zrii.f. Gebnrl. n. Gijn., 1879, Bd. iv. S. 101 : " Die Lactosurie der Wodinerinnen." ' Deutsche vied. Wocheusch., 1886, Iso. 9. SIGNS AND SYMPTOMS OF PREGNANCY. 147 CHAPTER IV. SIGNS AND SYMPTOMS OF PREGNANCY. In attemptiug to ascertain the presence or absence of pregnancy tlic pi-actitioner has before liim a problem which is often beset with great difficulties, and on the proper solution of which the moral charac- ter of his patient, as well as his own professional reputation, may depend. The patient and her friends can hardly be expected to appre- ciate the fact that it is often far from easy to give a positive opinion on the point -, and it is always advisable to use much caution in the exam- ination, and not to commit ourselves to a positive opinion except on the most certain grounds. This is all the more important because it is just in those cases in which our opinion is most frequently asked that the statements of the patient are of least value, as she is either anxious to conceal the existence of pregnancy, or, if desirous of an affirmative diagnosis, unconsciously colors her statements so as to bias the judg- ment of the examiner. Constant attempts have been made to classify the signs of pregnancy; thus, some divide them into the natural and sensible signs, others into the presumptive, the probable, and the certain. The latter classification, which is that adopted by Montgomery in his classical work on the Signs and Symptoms of Pregnancy, is no doubt the better of the two, if any be required. The simplest Avay of studying the subject, how- ever, is the one, now generally adopted, of considering the signs of pregnancy in the order in which they occur, and attaching to each an estimate of its diagnostic value. Signs of a Fruitful Conception. — From the earliest ages authors have thought that the occurrence of conception might be ascertained by certain obscure signs, such as a peculiar appearance of the eyes, swelling of the neck, or by unusual sensations connected with a fruitful inter- course. All of these, it need hardly be said, are far too uncertain to be of the slightest value. The last is a symptom on which many married women profess themselves able to depend, and one to which Cazeaux is inclined to attach some importance. Cessation of Menstruation. — The first appreciable indication of ])rc'gnancy on which any dependence can be placed is the cessation of the ciistDiuMry inriistrual discharge; and it is of great importance, as loniiiiiw- the (iiily ivliablc guide for calculating the probable period of delivery. In women mIio have been ])reviously iierfectlv regular, in whom there is no morbid cause which is likely to have produced sup- pression, the non-appearance of the catamenia may be taken as strong presumptive evidence of the existence of j^regnancy ; but it can never be more than this, unless verified and strengthened by other signs, niasmuchias there are many conditions besides pregnancy which may lead to its non-appearance. Thus, e xposiir c jo _cold, meutal_gjiiption, 148 PREayANCY. gene ral debi lity, especially \vlien coiineeted with iiiei])ieiil plitluj^is, may all Have this etteet. Mental imjires'^ionsarepeeiiliarly liable to mislead in this respect. It is far from uncommon in newly-married women to find that menstruation ceases for one or more ])eri<»ds, either from the general disturbance of the system connected with the married life or from a desire on the part of the patient to find herself jn-egnant. Also in unmarried women who have subjected themselves to the risk of impregnation mental emotion and alarm often ])roduce the same rcj^uit. \A. further source of uncertainty exists in the fact that in certain ("ases menstruation may go on for one or more periods after conccptioji or even diu'ing tiie whole picLinancy. ] The latter occurrence is certainly of extreme rarity, but one or two instances are recorded by Perfect, Churchill, and other writers of authority, and therefore its })ossibility must be admitted. The former is much less uncommon, and instances of it have probably come under the observation of most practitioners. The explanation is now well understood. ( During the early months of gestation, when the ovum is not yet sufficiently advanced in growth to fill tlie whole uterine cavity, there is a considerable space between the decidua reflexa which surrounds it and the decidua vera lining the ute- \ rine cavity. ) It is from this free surface of the decidua vera that the periodical discharge comes, and there is not only ample surface for it to come from, but a free channel for its esca})e through the os uteri. After the third month the decidua reflexa and the decidua vera blend together and the space between them disappears. Menstruation after this time is, therefore, much more difficult to account for. It is probable that in many supposed cases occasional losses of blood from other sources, such as placenta prsevia, an aljradcd cervix uteri, or a small polypus, have been mistaken for true menstruation. If the discharge really occurs periodically after the third month, it can only come from the canal of the cervix. The. occurrence, however, is so rare that if a woman is menstruating regularly and normally who believes herself to be more than four months advanced in pregnancy, we ai'e justified ipso fad o in negativing her su])position. ( [Menstru ation in a pregnan t woma n ma y be due to the existe nce of a double uteiiLr;, one half of which is emj)ty and free, while the other contains a fnetus. Th^wo halves or compart- ments may be impregnated at dift'erent jiei^^, and give rise to a so-called superfnetation. — Ed.] ) In an uninarried woman all state- ments as to regularity of menstruation are absolutely valueless, for in such cases nothing is more common than for the patient to make false statements for the express pur])ose of dece])tion. ( Conceptioi i may nnfjuesti pnabl y occ ur when men struation is nor- nTallj_al)sent. \ This is far from uncommon in women during TactathmT- wEen the function is in abeyance, and who therefore have no reliable (lata for calculating the true period of their delivery. Authentic cases are also recoi-ded in Avhich young girls have conceived before menstrua- tion is established, and in which pregnancy has occurred after the change of life. Taking all these facts into account, we can only look upon the cessa- tion of menstruation as a fairly presumptive sign of pregnancy in SIGNS AND SYMPTOMS OF PRFMNANCY. 149 woiiun in ulioiii there is no clear reason to account for it, hut one which is undoubtedly of great value in assisting our diagnosis. Shortly after concej)tion various sympathetic disturbances of the sys- tem occur, and it is only very exceptionally that these are not estab- lished. They are generally most developed in women of highly ner- vous temperament ; and they are therefore most marked in patients in the upper classes of society, in whom this class of organization is most common. Morning- Sickness. — Amongst the most frequent of these are various disorders of the gastro-intestinal canal. Nausea or vomiting i s very common ; and as it is generally felt on first rising from the recumbent position, it is popularly known amongst women as the " morning sick- ness."/ It sometimes commences almost immediately after conception, but more frequently not until the srcu nd month, and it rarely lasts after > the fourth mouth) Generally there is nausea rather than actual vomit- ing. The Avoma'n feels sick and unable to eat her breakfast, and often brings up some glairy fluid. In other cases she actually vomits ; and sometimes the sickness is so excessive as to resist all treatment, seriously to affect the patient's health, and even imperil her life. These grave forms of the affection will require separate consideration. Very different opinions have beeu held as to the cause of morning sickness. Dr. Henry Bennet believes that, when at all severe, it is always associated with congestion and inflammation of the cervix uteri. Dr. Graily Hewitt maintains that it depends entirely on the flexion of the uterus, producing irritation of the uterine nerves at the seat of the flexion, and consequent sympathetic vomiting. This theory, when broached at the Obstetrical Society, was received with little favor : it seems to me to be stifficiently disproved by the fact, which I believe to be certain, that more or less nausea is a normal and nearly constant phenomenon in pregnancy, for it is difficult to believe that nearly every pregnant woman has a flexed uterus. U^'he generally received explana- tion is probably the correct one — viz. that nausea as well as other forms of s ympa.thetic disturba,nce depends on the stretching of the uterine fibres by the growing ovum, and consequent irritation of the uterine nerves. It is therefore nwv, and only one, of the numerous reflex phe- nomena naturally accompanying pregnancy. \ It is an old observation that when the sickness of pregnancy is entirely absent, other (and gen- erally more distressing) sympathetic derangements are often met with, such as a tendency to syncope. Dr. Bedford^ has laid especial stress on this point, and maintains that under such circumstances women are peculiarly apt to miscarry. Other derangements of the digestive functions, depending on the same cause, are not uncommon, such as excessive or depraved appetite , the patient showing a craving for strange and even disgusting articles of diet. These cravings may be altogether irresistible, and are popu- larly known as " longings." Of a similar character is the disturbed condition of the bowels frequently observed, leading to constipation, diarrhrfa, and excessive flatulence. Certain glandular sym])ath ies may be developed, one of the most ^ Diseases of Women and Children, p. 551. 150 PREOyA^X'Y. (.'oiuuiuii bciii^ an e xcessive se cretion J roin the .salivaiygltim^'^- A tend- ency to syncope is not uufrefjuent, rarely proceeding to actual fainting, but rather to that sort of jiartial syncope, unattended with complete loss of consciousness, which the older auth<»rs used to call '^ lypotheniia." This often occurs in women wiio show no such tendency at other times, and, when developed to any extent, it forms a very distressing accom- paniment of pregnancy. Toothache is common, and is not rarely asso- ciated with actual caries of the teeth. When any of these j)henomena are carried to excess, it is more than probable that some morbid condi- tion of the uterus exists, whicii increases the local irritation producing them. Mental Peculiarities. — Mental phenomena are very general. An undue degree of despondency, utterly beyond the patient's control, is far from uncommon ; or a change which rendcre the bright and good- tempered woman fractious and irritable ; or even the more fortunate, but less common, change by which a disagreeable disposition becomes \ altered lor the better. All these ])henomena of exalted nervous susceptibility are of but slight diagnostic value. Thev mav be taken as corroborating more cer- tain signs, but nothing more ; and they are chiefly interesting from their tendency to be carried to excess and to produce serious disorders. Mammary Changes. — Certain changes in the manuuje are of early occurrence, dependent, no doubt, on the intimate sympathetic relations at all times existing between them and the uterine organs, but chiefly required for the purpose of preparing for the im])oi"tant function of lactation which on the termination of pregnancy they have to per- form. Generally about the second month of pregnancy the breasts become mcreased in size and tender. As pregnancy advances they become much larger and firmer, and blue veins may be seen coursing over them. The most characteristic changes are about the nip])les and areola?. The nipples become turgid, and are frequently covered with minute branny scales, formed by the desiccation of sero-lactescent fluid oozing from them. The areolae become greatly enlarged and dai'kened from the deposit of pigment (Fig. 80). The extent and degree of this discol- oration vary nuich in different women. In fair women it may i)e so slight as to be hardly a]iprceiable ; while in dark women it is generally exceedingly characteristic, sometimes forming a nearly black circle extending over a great part of the breast. The areola becomes moist as well as dark in appearance, and is somewhat swollen, and a nund)er of small tubercles are developed upon it, forming a circle of projections round the nip])le. These tubercles are descriljcd 1)V Montgomery as being intimately connected with the lactiferous ducts, some of which may occasionally be traced into them and seen to open on their sum- mits. As pregnancy advances they increase in size and number. During the latter months what has been called " the secondary areola " is jiro- duced, and when well marked presents a very characteristic appearance. It consists of a number of miiuite discolored spots all round the outer margin of the areola, where the pigmentation is fainter, and which are generally described as resembling spots from which the color has been SIGNS AND SYMPTOMS OF PREGNANCY. lol discharged by a shower of water-drops. Tin's cliaiioc, like the dai-k- eniiig of the primary areola, is more marked in brunettes. At this period, especially in women whose skin is of fine texture, whitish sil- very streaks are often seen on the breasts. They are produced by the stretching of the cutis vera, and are permanent. By pressure on the l)reasts a small dro]) of serous-looking fluid can very generally be forced out from the nipple, often as early as the third Fig. 80. // \ Appearance of the Areola in Pregnancy. month, and on microscopic examination milk- and colostrum-globules can be seen in it. The diagnostic value of these mammary changes has been variously estimated. When well marked they are considered by Montgomery to be certain signs of pregnancy. To this statement, however, some important limitations must be made. In women who have never borne children they no doubt are so ; for, although various uterine and ova- rian disea.ses produce some darkening of the areola, they certainly never produce the well-marked changes above described. In mnltiparte, however, the areolse remain permanently darkened, and in them these signs are much less reliable. /In first pre ^ ^nanc ies the presence of milk in the breasts may be considered an ahiiost certain sign, and it is one which I have rarely failed to detect even from a comparatively early period. \ It is true that there are authenticated instances of non-pregnant Avomen Slaving an abundant secretion of milk, established from mam- mary irritation. Thus, Baudelocque presented to the Academv of Surgery of Paris a young girl, eight years of age, who had nursed her little brother for more than a month. Dr. Tanner states — I do not know on what authority — that " it is not uncommon in Western Africa for young girls who have never been pregnant to regularlv employ 7 152 pnEayAycY. tlicmsclvos ill inirsiii<2; llic cliiMrcii of (ttlicis, the iii;iiiiiiiii' hcinj; excited to aetion bv the application of the juice of one of the Kuphoihiaceaj." Lacteal secretion Jias even been noticed in the male hreitst. lint these exce})tions to the oem-ral rule are so uncommon as merely to deserve mention as curiosities ; and I have hardly ever been deceived in diair- nosing a first jjregnancy I'rom the })resencc of even the minutest (juantitv of lacteal secretion in the breasts, althoujih even then «»ther ccjrrobo- rative signs should always be sought for. f Jn nmltiparie the presence ot" milk is by no means so valuable, for it is commoli for milk to remain in the mamma^ long after the cessation of lactation, even for several years.) Tyler Smith correctly says that " suj>j)ression of the milk in persons who are nursing and liable to impregnation is a more valuable sign of pregnancy than tlie converse condition." This is an observation I have frequently corroborated. As a diagnostic sign, therefore, the mammary appearances are of great importance in primipane, and when well marked they are seldom likely to deceive. They are specially important when we suspect i)reg- uancy in the immarried, as we can easily make an excuse to look at the breast without ex])laining to the })aticnt the reason ; and a single glance, especially if the patient be dark-complexioned, may so far strengthen our suspicion as to justify a more thorough examination. In married multiparoe they are less to be depended upon. /In connection Avith this subject may be mentioned various irregular deposits of pi gment which are frequently observed. The most connnon is a cl ark'^mx )Avnjsl.i or yijlLawish. Im£. atai'ting from the pubfs and imi- Diug up to the ceiltrc of tlie abdomfiU-^sometimes as far as the umbilicus only, at others forming an irregular ring round the umbilicus and reach- ing to the epigastrium. It is, however, of very uncertain occurrence, being well marked in some women, wiiilc in others it is entirely absent. Patches of darkened skin are often observed about the face, chiefly on the forehead, and this bronzing sometimes gives a very peculiar a])p.car- ance. Joulin states that it only occurs on parts of the face exjioscd to the sun, and that it is therefore most frequently observed in women of the lower orders who are freely ex])oscd to atmospheric influences. These pigmentary changes are of small diagnostic value, and may con- tinue for a considerable time after delivery. [A contusion of the cheek in a pregnant woman will sometimes be followed by a dark-brown spot or liver-mark that may remain several months or less, according to the stage of gestation. We once saw a well-marked instance of this in a lady of Philadel])hia, a young multi])ara. — Ed.] Foetal Movements. — The progressive enlargement of the abdomen; and the size of the gravid uterus at various ]K'rio(ls of ])regnaii(y, as welh as the method of examination by means of abdominal paljiation, have* already been described (j)j). 127 and 137). ' We will now consider the well-known phenomena ])roduced by the movements of the foetus \n virn, which arc m. fhniilinr to all pregnant women. These, no doubt, take \\\\\vv iVoni ilic (arlii^i pci'ind of fa'taL lije at which the muscular ti.>^sue of the fetus is suilicicnlly developed to admit of contraction, but they are not felt l)y the mother until some- where about the sixteenth week of utcro-ge.station, the jirecise period at iiiayS Ai\l) SYML'TOMS OF PREGNANCY. 153 which they arc perceived varyinti: considerably in difFerent cases. The vF. error of" the law on this subject which siip})oses the child not to be alive, ♦ \^ or " quick," until the mother ieels its movements, is well known, and />^ has fVe(juently been ])r()tcsted against by the medical ])r(^fession. The^T so-called nu'ickcniiKi — which certainly is felt very suddenly by some w women — is believed to depend on the rising of tlie uterine tumor suf- ficiently high to perniit of the impulse of the foetus being transmitted to the abdominal walls of the mother, through the sensory nerves of which its movements become appreciable. (The sensation is generally described as being a feeble, fluttering, which M'hcn first felt not unfrccjuently causes unpleasant nervous sensations."^ As the uterus enlarges the movements become more and more distinct, and generally consist of a series of sharp blows or kicks, sometimes quite appreciable to the naked eye and causing distinct projections of the abdominal walls. Their force and frequency will also vary during pregnancy according to circumstances. At times they are very frequent and distressing ; at others the foetus seems to be comparatively quiet, and they may even not be felt for several days in succession, and thus unnecessary fears as to death of the foetus often arise. The state of the mother's health has an undoubted influence upon them. They are said to increase in force after a pro- longed abstinence from food or in certain positions of the body. It is certain that causes interfering with the vitality of the foetus often pro- duce very irregular and tumultuous movements. They can be very readily felt by the accoucheur on palpating the abdomen, and sometimes, in the latter months, so distinctly as to leave no doubt as to the exist- ence of pregnancy. They can also generally be induced by placing one hand on each side of tlie abdomen and applying gentle pressure, which will induce foetal motion that can be easily appreciated. (As a diagnostic sign the existence of foetal movements has always held a high place, but care should be taken in relying on it.^ It is cer- tain that women are themselves very often in error, and fancy they feel the movements of a foetus when none exists, being probably deceived by irregular contractions of the abdominal muscles or flatus within the bowels. They may even involuntarily produce such intra-abdominal movements as may readily deceive the practitioner. Of course, in advanced pregnancy, when the foetal movements are so marked as to be seen as well as felt, a mistake is hardly possible, and they then con- stitute a certain sign. But in such cases there is an abundance of other indications and little room for doubt. In questionable cases and at an early period of pregnancy the fact that movements are not felt must not be taken as a proof of the non-existence of pregnancy, for they may be so feeble as not to be perceptible, or they may be absent for a consider- able period. Braxton Hicks ^ has directed attention to the value, from a diagnostic point of view, of ijitcrmittent contractions ot' tlic utci-ns during prej;- nancy. After the uterus is snlficicMitly large to be felt by palpation, if the hand be placed over it and it be grasped for a time M'ithout using any friction or pressure, it will be observed to distinctly harden in a manner that is quite characteristic. This intermittent contraction occurs 1 Obst. Trans., 1872, vol. xiii. p. 216. 154 iTjyiyAycy. evfiT five or ten luimitts, soiiU'tiiiK'.s <»ftc'iier, rarely at loiij^^er iiittrvals. The I'aet that the uterus did eoutract \n this way had beeu previously described, uiore especially by Tyler Smith, mIio ascribed it to jx-ristaltie action. Jiut it is certain that no one before Dr. Hicks had pointed out the I'act that such contractictns are constant and normal concomitants ot" j)rej;nancy, continuing during the whole period ot" utero-gestation, and forming a ready and reliable means ot" distinguishing the uterine tumor from other abdominal enlargements. Since reading Dr. Hicks' paper I have paid considerable attention to this sigu, which I have never i'ailcd to detect, even in the retroverted gi'avid uterus contained entirely in the pelvic cavity, and I am disposed entirely to agree Avith him as to its great value in diagnosis. If the hand be ke})t steadily on the uterus, its alternate hardening and relaxation can be appreciated with the greatest ease. The advantages which tliis sign has over the foetal move- ments are that it is constant, that it is not liable to be simulated by anythin<>- else, and that it is independent of the life of the child, being equally appreciable when the uterus contains a degenerated ovum or dead fa?tus. The only condition likely to give rise to error is an enlargement of the uterus in consequence of contents other than the results of conception, such as retained menses or a polypus. The histoiy of such cases — wliich are, moreover, of extreme rarity — would easily prevent any mistake. As a corroborative sign of pregnancy, therel'ore, I should give these intermittent contractions a higli i)lace. [In rare instances these intermittent contractions are accomj)anied by a sensation of pain, such as to alarm the patient and give rise to feai-s of a miscarriage ; but it will be found that the uterus gives no evidence of a design to exjiel its contents. In one case attended by the writer the pains lasted three weeks, and finally ceased under an opiate treat- ment, the contractions continuing, but without sensation : the foetus wiis born at maturity. — Ed.] The vaginal signs of pregnancy are of considerable importance in diagnosis. They are chiefly the changes which may be detected in the cervix, and the so-called huUoUement, which depends on the mobility of the fretus in the licpior amnii. Softening of the Cervix. — The alterations in the density and appa- rent length of the cervix have been already described (p. 138), A\'hen pregnancy has advanced l)eyon(l the fifth month the peculiar ve lvety soitness oT ilic <(rvix i- \ ( i y ( haincteristic, and aflbrds a strong corrol> orative sign, but one which it would be unsafe to rely on by itself, inasmuch as very similar alterations may be produced by various causes. AVhcn, however, in a supposed case of jiregnancy advanced beyond the period indicated the cervix is found to l)e elongated, dense, and projecting into the vaginal canal, the non-existence of pregnancy may be safely inferred. (Therefore the negative value of this sign is of more importance than the positive.) In connection with this maybe mentioned a sign of pregnancy to wliich attention has recently been drawn by Hegar.' It consists in a peculiar elasticity of the lower seg- ments of the uterus, made out by vaginal or rectal examination. It may serve to differentiate the pregnant uterus from certain uterine » CenlralbhU fiir Gyndk., 1886, Bd. xi. p. 805. STG2fS AND SYMPTCMS OF PREGNANCY. 15o enlartiXMuents due to tiiinors in those cases in wliicli the diagnosis is donhtl'id. Ballottement, when distinctly made out, is a very valuahle indica- tion of ])rc!j:nancy. It consists in the disphicenient, by the exaniinint^ finoer, of the fetus, which floats up in the liquor anuiii, and falls back ao;ain on the tip of the finger with a slight tap M'hich is exceedingly characteristic. In order to practise it most easily the patient is placed on a couch or bed in a position midway between sitting and lying, by which the ver- tical diameter of the uterine cavity is brought into correspondence with that of the pelvis. Two fingers of the right hand are then passed high up into the vagina in front of the cervix. The uterus being now steadied from without by the left hand, the intravaginal fiugers press the uterine wall suddenly upward, when, if pregnancy exist, the foetus is displaced, and in a moment falls back again, imparting a distinct impulse to the fingers. When easily appreciable it may be considered as a certain sign, for although an auteflexed fundus or a calculus in the bladder may give rise to somewhat similar sensations, the absence of other indications of pregnancy would readily prevent error. Ballotte- ment is practised between the fourth and seventh months. Before the former time the fcetus is too small, M'hile at a later period it is relatively too large and can no longer be easily made to rise upward in the sur- rounding liquor amnii. The absence of ballottement must not be taken as proving the non-existence of pregnancy, for it may be inappreciable from a variety of causes, such as abnormal presentations or the implan- tation of the placenta upon the cervix uteri. Vaginal Pulsation. — There are also some other vaginal signs of pregnancy of secondary consequence. Amongst these is the vagiual pulsation, pointed out by Osiander, r esulting from the enlargement of t he va ginal arteries, which may sometimes be felt beating at an early period. Often this pulsation is very distinct, and at other times it can- not be felt at all, and it is altogether unreliable, as a similar pulsation may be felt in various uterine diseases. Uterine Fluctuation. — Dr. Rasch has drawn atteutiou to a pre- viously undescribed sign which he believes to be of importance in the diagnosis of early i)regnancy.^ It consists in the detectiou of fluctua- tion through the anterior uterine wall, depending on the presence of the liquor amnii. In order to make this out, two fingers of the right hand must be used, as in ballottement, while the uterus is steadied through the abdomen. Dr. Rasch states that by this means the enlarged uterus in pregnancy can easily be distinguished from the enlargement depending on other causes, and that fluctuation can always be felt as early as the second month. If it is associated with suppressed menstruation and darkened areola?, he considers it a certain sign. In order to detect it, however, considerable experience in making vaginal examinations is essential, and it can hardly be dejiended on for general use. A peculiar deep violet hue of the vaginal nuicous meml)rane was relied on by Jacquemin- and Kliige as affording a readily-observed 1 Brit. Med. Jonrn., 1873, vol. ii. p. '2(il. "■ The credit of first drawing attention to this sign of pregnancy is generally given 156 rREG NANCY. iiulii-atiuii ul' j)iv<;naiu'y. In most cases it is well marked ; sometimes, indeetl, the c'luin«i;e of color is very intense, and it evidently dej)ends on the eoii<>estion ])r()dueed by ])ressure of the enlarjicd uterus. Chad- uick has recently rein vest ijiated this si}:;n, and altrihutcs to it a hi^h diaiiiidstic valiu'.' It has been generally stated U) be unreliable, as a similar discoloration is said to be jiroduced by the ])ressnre of larne uterine libroids. This, however, Chadwick declares is not the case. Auscultatory Signs of Pregnancy. — By far the most important sir/- -sc and in the absence of all others, is })erfcctly reliable. The fact that the sounds of the fwtal heart are audilile during advanced pregnancy was first pointed out by Mayor of (Geneva in 1.S18, and the main facts in connection with foetal auscultation were subsequently worked out by Kei'garadec, Nacgele, Evory Kennedy, and other observers. The pulsations first become audible, as a I'ule, in the course of the fifth mon th or about the middle of the fourth month. In exceptional circumstances and by practised observers they have been heard earlier. Depaul believes that he detected them as early as the eleventh week, and Routh has also detected theni at an earlier period by vaginal stethoscopy, which, however, for obvious reasons, cannot be ordinarily employed. Naegele never heard them before the eighteenth week, more generally at the end of the twen- tieth, and for practical purposes the pregnancy must be advanced to the fifth month before we can reasonably expect to detect them. From this period up to term they can almost always be heard, if not at the first ■attemj)t, at least afterward to a certainty, if Ave have the opportunity of making repeated examinations. Accidental circum- stances, such as the presence of an unusual amount of fiatus in the intestines, may deaden the sounds for a time, but not ]iermanently. Dejxiul only failed to hear them in 8 cases out of 0()6 examined during the last three months of pregnancy; and out of 180 cases Avhich Dr. Anderson of Glasgow carefully examined, he oidy iailcd in 12, and in each of these the child was stillborn. They therefore form not only a most certain indication of pregnancy, but of the life of the ftetus also. The sound has always been likened to the double tic-tac (»f a watch heard through a pillow, which it closely resembles. It consists of two beats, se])aratcd by a short interval, the first being the loudest and most distinct, the second being sometimes inaudible. The ra- pidity of the fo'tal ])ulsations forms an imjiortant jueans of distin- guishing them from transmitted maternal ])ulsations, with which they might be confounded. Their average number is stated by Slater, who made numerous observations on this point, to be lo2, but some- to .Tacqiieniier, a distinmiishod I'^rendi ()l)stetriciaii, wlio wrote a work im miulse should always be ascertained before counting the suj)- posed foetal pulsations. If these are found to be 120 or more, while the mother's pulse is only 70 or 80, no mistake is ])0ssible. If the latter is abnormally quickened, greater care may be necessary, but even then the rate of pulsation of each Avill be dissimilar. Braxton Hicks' has pointed out that in tedious labor, when the nuiscular j)owcrs of the mother are exhausted, the muscular subsurrus may produce a sound closely resembling the fretal pulsation ; but error from this source is obviously very imjn-obable. In listening for the fVctal heart-sound the jvatient should be ]ilaced on her back, with the shoulders elevated and the knees flexed. The sur- face of the abdomen should be uncovered, and an oi'dinary stcthoscoj)e em])loycd, the end of which must be pressed firndy on the tumor, so as to depress the abdominal walls. The most absolute stillness is neces- sary, as it is often far from easy to hear the sounds. Sometimes, after failing with the ordinary stethoscope, I have succeeded with the bin- aural, which remarkably intensifies them. When once heard they are most easily counted during a space of five seconds, as on account of » Obsl. Trans., 1874, vol. xv. p. 187. SlOyS AND SYMPTOMS OF PBEGNANCY. 159 their frequency it is not always possible to follow them over a longer period. ANHien the f(otal heart-sounds are heard distinctly, pregnancy may be absolutely and certainly diagnosed. Tiie fact that we do not hear them does not," however, preclude tlie ])0ssibility of gestation, for the frx'tus mav be dead or the sounds temporarily inaudible. Other Sounds heard in Pregnancy. — There are some other sounds heard in auscultation wiiic-h are of very secondary diagnostic value. One of these is the so-called umbUAmlyv J\ndc souffle, which was first pointed out by Evory Kennedy. It consists oif a single blowing murnuu- syn- chronous with the fetal heart-sounds, and most distinctly heard in the immediate vicinity of the point where these are most audible. INIost authors believe it to be produced by pressure on the c ord, either when it is placed between a hard part of the foetus and ihe'ut'erine walls or is twisted round the child's ueck. Schroeder and Hecker detected it in 14 or 15 per cent, of all cases, and the latter believed it to be caused by flexure of the first portion of the cord near the umbilicus. For practical purposes it is quite valueless, and need only be mentioned as a phenomenon which an experienced auscultator may occasionally detect. The Viterme souffle is a peculiar single whizzing murmur which is almost always audible ou auscultation. It varies very remarkably in character and position. Sometimes it is a gentle blowing or even musical murmur ; at others it is loud, harsh, and scraping ; sometimes continuous, sometimes intermittent. It may also be heard at any point of the 'uterus, but most frequently low down and to one or other side, more rarely above the umbilicus or toward the fundus ; and it often changes its position so as to be heard at a subsequent auscultation at a point where it was previously inaudible. {It may be heard over a space of an inch or two only, gr in some cases over the whole uterine tumor;' or, again, it may sometimes be detected simultaneously over two entirely distinct portions of the uterus. ( It is generally to be heard earlier than the foetal heart-sounds, often as^soon as the uterus rises above the brim of the pelvis, and it can almost always be detected after the commence- ment of the fourth month. \ The sound becomes curiously modified by the uterine contractions during labor, becoming louder and more intense before the pain comes ou, disappearing during its acme, and again being heard as it goes off. Hicks attributes to a similar cause — viz. the uterine co ntractions duringj preguancy — the frequent variations in the souuti which are characteristic" of it.^ The uterine souffle is also audible after the death of the foetus, and it is believed by some to be modified and to become more continuously harsh when that event has taken place. A^ery various explanations have been given of the causes of this sound. For long it was supposed to be formed in the vessels of the placenta, and hence the name " pl acenta l souffle" by which it is often talked of, or, if not in the placenta, inthe uterine vessels in its immediate neigliborhood. The non-placental origin of the sound is sufficiently demonstrated by the fact that it may be heard for a considerable time after the expulsion of the placenta. Some have supposed that it is not formed in the uterus at ' Op. 0(7., p. 223. \ 1()0 PREGNANCY. all, Imt ill llic inatcnial vessels, t'sjx'cially tlic aorta and llie iliac art t-rics, enee of mammary changes and of ballottement will materially aid us in forming a diagnosis. The en gorged and enlarged ute rus fre(|uentlv met with in woivien suf- fering from uterine disease might readily be taken for an early i>reg- nancy if it happened to be associated with amenorrhoea. A little time would, of course, soon clear up the point l)v shoMing that j)rogressive increase in size, as in pregnancy, does not take place. This mistake could only be made at an early stage of pregnancy, when a positive diagnosis is never possible. The accompanying symjitoms — pain, inability to walk, and tenderness of the uterus on j)ressure — would prevent such an error. Ascit es. ;/f/: s e, could hardly be mistaken for pregnancy, for the uni- fornTTTisteiision and evident fluctuation, the absence of any definite tumor, the site of resonance on percussion changing in accordance with alteration of the position of the woman, and the unchanged cervix and uterus, should be sufficient to clear up any doubt. Pregnancy may, however, exist with ascites, and this combination may be difficult to detect, and might readily i)e mistaken for ovarian disease associated with ascites. The existence of mammary changes, the ])resence of the soft- ened cervix, ballottement, and auscultation — provided the sounds were not masked by the surrounding fluid — would afford the best means of diagnosing such a case. One of the most frequent sources of difficulty is the differential diag- nosis of large ab dominal tumo rs, either fibroid or ovarian, or of some enlargements due to malignant disease of the i)eritoneum or ai)dominal viscera. The most experienced have been occasionally deceived under such circumstances. As a rule, the presence of menstruation will pre- vent error, as this generally continues in ovarian disease, while in fibroids it is often exce&sive. The character of the tumor — the fluc- tuation in ovarian disease, the hard nodidar masses in fibroid — and the histon' of the case, especially the length of time the tumor has existed, ■will aid in diagnosis, wliile the al)sence of cervical softening (vide p. 141) and of auscultatory phenomena will fiui:her be of material value in forming a conclusion. Some of the most difficult cases to diagnose are those in which pregnancy complicates ovarian or fibroid disease. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 163 Then tlie tiinior iiiuy more or less completely obscure tlic ])liysical signs of pregnancy. The usual shape of" the abdomen will generally be altered considerably, and we may be able to distinguish the gravid uterus, separated from the ovarian tumor by a distinct sulcus or with the fibroid masses cropping out from its surface. Our chief reliance must then be ])laced in the alteration of the cervix and in the auscul- tatory signs of pregnancy. Spurious Pregnancy. — The condition most likely to give rise to errors is that very interesting and j)eculiar state known as x ynrious pix^n anci/. In this most of the usual phenomena of })regnaney are so strangely simulated that accurate diagnosis is often far from easy. There are hardly any of the more apparent symptoms of pregnancy which may not be present in marked cases of this kind. The abdomen may become prominent, the areolae altered, menstruation arrested, and aj)parent foetal motions felt, and, unless suspicion is aroused and a care- ful physical examination made, both the patient and the practitioner may easily be deceived. There is no period of the childbearing life in which spurious preg- nancy may not be met with ; but it is most likely to occur in elderly women about the climacteric period, when it is generally associated with ovarian irritation connected with the change of life ; or in younger women who are either very desirous of finding themselves pregnant, or who, being unmarried, have subjected themselves to the chance of being so. fin. all cases the mental f aculties have nnich to do with its production, and there is generany°eitlier very marked hysteria or even a condition closely allied to insanity. / Spurious i)regnancy is by no means confined to the human race. It is well known to occur in many of the lower animals. Harvey related instances in bitches, either after unsuccessful intercourse or in connection with their being in heat, even when no intercourse had occurred. In such cases the abdomen swelled and i3lilk_.a|5i5eared in the mammse. Similar phenomena are also occasionally met with in the cow. In these instances, as in the human female, there is probably some morbid irritation of the ovarian system. The ])hysical phenomena are often very well marked. The ap])ar- ent enlargement is sometimes very great, and it seems to be produced by a projection forward of the abdominal contents, due to dei)ression of the diaphragm, together with rigidity of the abdominal muscles, and may even closely simulate the uterine tumor on palpation. After the climac- teric it is frequently associated, as Gooch pointed out, with an undue deposit of fat in the abdominal walls and omentum, so that there may be even some dulness on percussion instead of resonance of the intestines. The foetal movements are curiously and exactly sinndated, either bv in- voluntary contractions of the abdominal walls or by the movement of flatus in the intestines. The patient also generally fancies that she suf- fers from the usual sympathetic disorders of ]>reonancy, and thus her account of her symptoms will still further tend to mislead. Not only may the supposed pregnancy continue, but at Avhat would be the natural term of deli very all the ])henomena of labor may super- vene. Many authentic cases are on record in which regular pains came 1G4 PREGNANCY. on, and oontinncd to increase in force and Imnuncy until the actual con- dition was (lia;^n;()S((l. Such nn'stakcs, however, arc only likclv to ha)i|)cn M'licn the >tatcincnts ol" the patient have luen received without further inquirv. ^\ hen once an accurate examination lia.s heen luade err(»r is no longer possible. We shall trenerally find that some of the phenomena ol" prcfrnanev are absent. Possibly, menstruation, more or less irregular, may have con- tinued, f Kxaminalion jtcr vayinum will at once clear up the case by showing that the uterus is not enlarged and that the cervix is inialtcred.N It n)ay then be very difficult to convince the ])atient or her friends that her symptoms have misled her, and for this purpose the inhalation of chloroform is of great value. As consciousness is abolished the semi- voluntary projection of the abdominal muscles is prevented, the large apparent tumor vanishes, and the l)ystanders can be readily con- vinced that none exists. As the patient recovers the tumor again ap])ears. Duration of Pregnancy. — The duration of pregnauc-y in the human female has always formed a fruitful theme for discussion amongst oi)ste- trieians. The reasons uhich render the point difficult of decision are obvious. As the large majority of cases occur in married women, in whom intercourse occurs frequently, there is no means of knowing the precise period at which conception took place. The only datum which exists for the calculation of the probable date of delivery is the cessation of menstruation, (it is quite possible, however, and indeed })robable, that conception occurred in a considerable nundjer of instances not im- mediately after the last perirxL Imt immediately before the proj)er epoch for the occurrence of the next.) Hence, as the interval Ijctweeu the end of one menstruation and the commencement of the next avei'ages twenty- five days, an error to that extent is always possible. Another source of fallacy is the fact, which has generally been overlooked, that even a sin- gle coitus does not fix the date of conception, but only that of insemi- nation. It is Mell known that in many of the lower animals the fertilization of the ovule does not take j)lace until several days after copulation, the spermatozoa remaining in the interval in a state of active vitality within the genital tract. It has been shown by Marion Sims that living spermatozoa exist in the cervical canal in the human female some days after intercourse. It is very probable, therefore, that in the human female, as in the lower animals, a c and collated from « numerous sources. It would serve no j^ractical purpose to re]>i'int the volunn'nous tables on this subject that are contained in obstetrical woiks. They are based on tw o princi])al methods of calculation : Fii'st, wc have the length of time between the cessation of menstruation and delivery. This is found to vary very considerably, but the largest ])ercentage of de- liveries occurs between the ■274th and 2S0th day after the cessation of men- struation, the averaL^e dav beinu the 278tli ; but in indiviilual instances DIFFKRENTIAL DIAdNOSIS OF PREGNANCY. IGo ven' considerable variations botli above and below these limits arc found to exist. Next, we have a series of cases, from various sources, in which only one coitus Mas believed to have taken place. Those are naturally open to some doubt, but, on the wliole, they may be taken as affording tolerably fair grounds for cahndation. Here, as in the other mode of calculation, there are marked variations, the average length of time, as estimated from a considerable collection of cases, being 275 days after the single intercourse. It may therefore be taken as certain that there is no definite time which we can calculate on as being the pro])er duration of ])regiian('y, and consequently no method of esti- mating the probable date of delivery on which we can absolutely rely. Methods of Predicting the Probable Date of Delivery. — The jirediction of the time at which the confinement may be expected is, however, a point of considerable practical importance, and one on which the medical attendant is always consulted. Various methods of making the calculation have been recommended. It has been customary in this country, according to the recommendation of Montgomery, to fix upon ten lunar months, or 280 days, as the probable period of gestation, and, as conception is supposed to occur shortly after the cessation of menstru- ation, to add this number of days to any day within the first week after the last menstrual period as the most probable period of delivery. As, however, 278 days is found to be the average duration of gestation after the cessation of menstruation, and as the method makes the calculation vary from 281 to 287 days, it is evidently liable to fix too late a date. Naegele's method was to count seven days from the first appearance of the last menstrual period, and then reckon backward three months as the probable date. Thus, if a patient last commenced to menstruate on August 10, counting in this way from August 17 would give May 17 as the probable date of the delivery. Matthews Duncan has ])aid more attention than any one else to the prediction of the date of delivery. His method of calculating is based on the fact of 278 days being the average time between the cessation of menstruation and parturition ; and he claims to have had a greater average of success in his predictions than on any other plan. His rule is as follows ( ^' Find the day on which the female ceased to menstruate, / or the first day of being what she calls ' well.' Take that day nine months \ forward as 275 — unless February is included, in which case it is taken ' as 273 — days. To this add tbrge days in the former case, or five if , February is in the count, to make up the 278. This 278th day should then be fixed on as the middle of the week, or, to make the prediction i the more accurate, of the fortnight, in which the confinement is likely \ to occur, by which means allowance is made for the average variation of either excess or deficiency."/ Various periodoscopes and titoles for fiicilitating the calculation have been made. The periodoscope of Dr. Tyler Smith is very useful for reference in the consulting-room, giving at a glance a variety of infor- mation, such as the probable period of quickening, the dates for the induction of premature labor, etc. The following table, prepared by Dr. Protheroe Smith, is also easily read and is very serviceable : 166 rREG NANCY. Table for Calculating tiik I'euiod of Utero-Gestation.' Nine Calendar Months. Ten Lunar Months. From To Days. To Days. Jamiarv J September 30 273 October 7 280 Kebniarv October 31 273 Novembei 1 280 Mairli November 30 275 December 5 280 April i December 31 275 January o 280 Mav January 31 276 February 4 280 June February 28 273 March 7 280 July .Alarc'li 31 274 April « 280 August April 30 273 Mav 7 280 September Mav 31 273 June 7 280 Oc-tolier June 30 273 July 7 280 November July 31 273 August 7 280 December August 31 274 i September I G 280 The (late at which the cjuickcniug has been perceived is relied on by many practitioners, and still more by patients, in calculating tlie ])roba- ble date of delivery, as it is generally sii])poscd to occur at the middle of pregnancy. The great variations, however, (if the time at Avhich this phenomcDon is first perceived, and the difficulty uhich is .'^o often experienced of a.scerlaining its presence with any certainty, render it a very fallacious guide. The only times at which the perception of quickening is likely to prove of any real value are Avhen impregnation has occurred during lactation (when men.'^truation is normally absent), or when menstruation is so uncertain and irregular that the date of its last appearance cannot be ascertained. As quickening is mo.-^t com- moidy felt during the fourth month — more frequently in its first than in its last fortnight — it may thus afford the only guide we can obtain, and that an uncertain one, for predicting the date of delivery. Is Protraction of Gestation Possible ? — From a medico-legal point of view the question of the jiossilile ])rolracti()n oi" pregnaiuy beyond the average time, and of the limits within which such pr(»trac- tion can be admitted, is of very great iui})ortance. The law sed from the death of the husband or the latent po.^sible opportu- nitv for sexual intereoiu'se. This limit is also adopted by Austria, while in Prussia it is fixed at .')()2 days. In Fngland and America no fixed date is admitted, but while 280 days is admitted as the " legiti- mum tempus pariendi," each case in which legitimacy is questioned is to be decided on its own merits. At the early ])art of the century the question was much discus.sed by the leading ol)stetricians in eoimcction ' The above ol)stetric " Ready Reckoner" consists of two columns, one of calenibir, the other of lunar months, and maybe read as follows: A patient has cea.se(l to men- struate on July 1 : her confinement may be expected at soonest about March 31 (the end of nine calcmhtr months), or at latest on April li {the end of ten lunar nionlli><). Another has ceased to menstruate on January 20 ; her confinement maybe expected on September .'W, plus 20 days {Ike end of nine calendar nionlk'<), at soonest, or on October 7, plus 20 days {the end of ten lunar monlhs), at latest. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 167 with the celebrated (jiarchier peerage case, and u eonsideruhlc dillcrence of opinion existed among them. Since that time many ai)parently per- fectly reliable cases have been recorded in which tlie dnration of gesta- tion was obvionsly nuich beyond the average, and in which all sources of fallacy were carefully excluded. Not to burden these pages with a number of cases, it may suffice to refer, as examples of protraction, to four well-known instances recorded by Simpson,^ in which the pregnancy extended respectively to 336, 332, 319, and 324 days after the cessation of the last menstrual })eriod. In these, as in all cases of protracted gestation, there is the possible source of error that impregnation may have occurred just before the expected advent of the next period. Making an allowance of 23 days in each instance for this, we even then have a number of days nuich above the average — viz. 313, 309, 296, and 301. Numerous instances as curious may be found scattered through obstetric literature. Indeed, the expe- rience of most accoucheurs will parallel such cases, which may be more common than is generally supposed, inasmuch as they are only likely to attract attention when the husband has been separated from the wife beyond the average and expected duration of the pregnancy. The evidence in favor of the possible prolongation of gestation is greatly strengthened by what is known to occur in the lower animals. In some of these, as in the cow and the mare, the precise period of insemination is known to a certainty, as only a single coitus is permit- ted. Many tables of this kind have been constructed, and it has been shown that there is in them a very considerable variation. In some cases in the cow it has been found that delivery took place 45 days, and in the mare 43 days, after the calculated date. Analogy would go strongly to show that what is known to a certainty to occur in the lower animals may also take place in the human female. The fact, indeed, is now very generally admitted ; but we are still unable to fix with any degree of precision on the extreme limit to which protraction is pos- sible. Some practitioners have given cases in which, on data which they believe to be satisfactory, pregnancy has been extremely protracted ; thus, Meigs and Adler record instances which they believed to have been prolonged to over a year in one case and over fourteen months in the other. These are, however, so problematical that little weight can be attached to them. On the wdiole, it would hardly be safe to conclude that pregnancy can go more than three or four weeks beyond the average time. This conclusion is justified by the cases we possess in which pregnancy followed a single coitus, the longest of which Avas 295 days. Dr. Duncan ^ is inclined to refuse credence to every case of supposed protraction unless the size and weight of the child are above the aver- age, believing that lengthened gestation must of necessity cause increased growth of the child. This point requires further investigation, and it cannot be taken as proved that the foetus necessarily nuist be large because it has been retained longer than usual in utero ; or, even if this be admitted, it may have been originally small, and so at the end of the protracted gestation be little above the average weight. There are, ^ Obstet. Memoirs, p. 84. * Fecundity and Fertility, p. 348. KJS PR I'JG NANCY. however, many eases whieli eertaiiily j)iuve that a prolonged prej^naiiey is at least often associated witii an unusually (leveloj)ed tJjetus. J)r. Dnnean himself eites several, and a very interestinhysiological rule, and therefore injurious to all concerned." The frequency of multiple births varies considerably under differ- ent circumstanccs.^Taking the average of a large number of ca.ses collected by authors in various countries, we find that ( t\vin pregnancies occu r abou t once in 87 labors ; triplets, once in 7679^ A certain number of quadruple ])regnancies, and some cases of early abortion in which there were five foetuses, are recorded, so that there can l)e no doubt of thejios- sibility of such occiuTcnces ; but they are so extremely uncommon that they may be looked upon as rare exceptions, the relative frequency of which can hardly be determined. The frequency of nnilti|)le ]iregnancv varies remarkably in different races and countrie s. The following table" ^vill show this at a glance: Relative Frequency of Multiple Pregnancies in Europe. Countries. England Austria Grand Diicliy of Baden Scotland . " France Ireland Mecklenburg-Sclivveiin Norway Prussia Russia Saxony Switzerland Wiirteniberg Proportion of Twin to Single Births. 1 : 116 94 89 95 99 64 68.9 1 : 81.62 89 50.05 79 1 : 102 1: 862 Proportion of Iriplets. 1 : 6720 1 : 6575 1 : 8256 1 : 4995 1 : 6436 1 : 5442 1 : 7820 1 : 4054 1 : 1000 1 : 6464 Proportion of Ciuadruplcts. 1 : 2,074.306 1 : 167,226 1 : 183.236 1 : .394,690 1 : 400,000 1 : 110.99L ' Med. Times and Gnz., Nov., 1862. ' Piiech, Des Naissances multiples. ABNORMAL rUEG NANCY. 171 It will be seen that the lar<>;est proportion of nuilti[)le l)irth.s occurs in Kiissia, and that the number of triple births is "greatest where twin preoiianc;ies arc most frequent. Puech concludes that tiie number of inuhi|)le pregnancies is in direct pro[)ortion to the general fecundity of the inhabitants. Dr. Duncan has deduced some interesting laws with regard to the production of twins from a large number of statistical observa- tions;' especially that (the tendency to the production of twins in- creases as the age of the woman advances^ and is greater in eacii succeeding pregnancy, exception being made 'for the first pngiumcy, in which it is greater than in any other. Newly-married women appear more likely to have twins the older they are. There can be no doul)t that there is often a strong hereditary tendency in individual families to multiple births. A remarkable instance of this kind is recorded by Mr. Ciu-genven,^ in which a woman had four twin preg- nancies, her mother and aunt each one, and her grandmother two. Simpson mentions a case of quadruplets, consisting of three males and one female, who all survivetl, the female subsequently giving birth to triplets,^ Sex of Children. — In the largest number of cases of twins the chil- dren are of opposite sexes , next most frequently there are two females, and twin males are the most uncommon. Thus, out of 59,178 labors, Simpson calculates that twin male and female occurred once in 199 labors, twin females once in 226, and twin males once in 258. The proportion of male to female births is also notably less in twin than in single pregnancies. Size of Foetuses. — Twins, and a fortiori triplets, are almost alwaysi smaller and less perfectly developed than single children. Hence the' chances of their survival are nuich less, and Clarke calculates the mortality amongst twin children as 1 out of 13. Of triplets, indeed, it is comparatively rare that all survive, while in quadruplets premature labor and the death of the foetuses are almost certain. ' It is a common observation that twins are often unequally developed at birth. By some this diiference is attributed to one of them beino; of a different asre to the other. ( It is probable, however, that in most of these cases the full development of one fretus has been interfered with by pressure of tlie. other. This is far from unconamonly carried to the extent of destroy- ing one of the twins, which is expelled at term mummified and flattened between the living child and the uterine wall. In other cases, when the foetus dies it may be expelled without terminating the pregnancy, the other being retained in utero and born at term ; and those who disbelieve in the possibility of superfoetatioii explain in this way the cases in which it is believed to have occurred. Multiple pregnancies depend on various causes. (The most common j is probably the simultaneous or nearly simultaneous maturation a nd ] rupture (»f two ( Jraalian fullicles, the ovules becoming impregnatiMl atj or about the same time. \ it by no means necessarily follows, even if < more than one follicle should rupture at once, that both ovules should 1 On Fecundity, Fertillti/, (Did SUrilili/, p. 99. 2 Obst. Trans.', 1870, vol. xi. p. lUG.' " Obst. Worh, p. 830. 172 j'lih'ayAycY. hv iinprojjnatcil. This is provt'd l>y tlic ocfiirronco of cases in \vlii
  • facts to prove that ovules thi'owii otV within a short time of" eacli other juay become separately imju'cgnated, as in cases in wliich negro women liave given birth to twins, one of which was pure negro, the other half- caste. I It may h appen, however, that a single Graafian follicle contains more than one oviileJas lias actually been observed before its ru])ture; or, as is not uncoinmon in the egg of the iowl, an ovule may contain a double germ, each of which may give rise to a scpai'ate fcetus. An'ang-eraent of the Foetal Membranes and Placentae. — The various modes in which twins may originate explain satisfactorily the variations which are met with in the arrangement of the fo'tal mem- branes and in the form aufl connections of the placentie. ^n a large proportion of cases there nve two distinct bags oi' membranes, the sep- tum betweeu them being composed of lour layers — viz. the chorion and amnion of each ovum J The placenta are jilsg entirely separate. Here I it is obvious that each twin is developed from a distinct ovum, having! its own chorion and amnion. On arriving in the uterus it is prob- able that each ovum becomes fixed independently in the mucous membrane and is surrounded by its own decidua reflexa. As growth advances the decidua reflexa generally atroj)hies from pressure, as it is not usual to find more than four layers of meinln-ane in the septum separating the ova. l^In other cases there is only one diorion, within Avhich are two distinct amnions, the se])tum tlicn consisting of two lavei's only.A Then the 2)lacentffi are generally in close ajipo- sitioi) and become 'fii>cd into a single mass, the cords, sejiarateT}' attached to each la'tus, not infrequently uniting shortly before reaching the placental mass, their vessels anastomosing freely. ' In other more rare instances both foetuses are contained in a common amnioti c sac ; but as the amnion is a purely fcetal membrane, it is ]irobable that When this arrangement is met with the originally existing septum between the amniotic sacs has been destroyed. Un both these latter cases the| twins must have been developed from a single ovule containing a| double germ) and Schroeder states that they are then always of the' same sex. Dr. Bruntou ^ has started a precisely op])osite theory, and has tried to prove that twins of the same sex are contained in se])anite bags of membrane, while twins of opposite sexes have a common sac. He says that out of 25 cases coming under his observation, in 15 the children contained in ditferent sacs were of the same sex, but in the remaining 10, in which there was only one sac, they were of opjiosite sexes. It is difficult to l)elieve that there is not an error in these observations, since twins contained in a single amniotic sjic do not occur nearly as often as ten times out of twenty-five cases, and no distinction is made between a common chorion with two anuiions and a single chorion and amnion. The facts of double monstrosity also disprove this view, since conjoined twins must of necessity arise froin a single ovule with a double germ, and there is no instance on record in which they were of ojiposite sexes. ' Obsl. Tram., vol. xi. p. 67. ABNORMAL PREGNANCY. 173 In triplets the membranes and })lacentte may be all separate, or, as isJ commonly the ease, there is one eomplete ba<^ of" membranes, and a] seeond having a common chorion with a double amnion. It is prob- able, therefore, that triplets are generally developed from two ovules,! one of which contains a double germ. Diagnosis of Multiple Preg-nancy. — It is comparatively seldom that twin pregnancy can be diagnosed before the birth of the first child, and even when suspicion has arisen its indications ai'e very defective. There is generally an unusual size and an irregularit y of^ shajie of the uterus, sometimes even a distinct depression or sulcus between the two foetuses. When such a sulcus exists, it may be possible to make out parts of each foetus by palpation on either side of the uterus. The only sign, however, on which the least reliance can be placed is the detection of two foetal hearts. If two distinct pulsations are heard at different parts of the uterus [ if on carrying the stethoscope from one point to another there is an interspace where pulsations are no longer audible, or when they become feeble and again increase in clearness as the second point is reached; and, above all, if we are able to make out a difference in frequency between them, — the diagnosis is tolerably safe. It must be remembered, however, that the sounds of a single heart may be heard over a larger space than usual, and hence a possible source of error. Twin pregnancy, moreover, may readily exist without the most careful auscultation enabling us to detect a double pulsation, especially if one child lie in the dorso-posterior position, -when the body of the other may prevent the transmission of its heart's beat. The so-called placental souffle is generally too diffuse and irregular to be of any use in diagnosis, even when it is distinctly heard at separate parts of the uterus. Superfoetation and Superfecundation. — Closely connected with the subject of multiple pregnancies are the conditions known as super- fecimdation and superfoetation, regarding which there have been much controversy and difference of opinion. By the former is meant the fecundation, at or near the same periodV of time, of two separate ovules before the decidua lining the uterus has! been formed, which by many is supposed to form an insuperable obsta- cle to subsequent impregnation. The possibility of this occurrence has been incontestably proved by the class of cases already referred to, in which the same woman has given birth to twins bearing evident traces of being the ofFs])ring of fathers of different races. By siiperfcetation is meant the impregnation of a second ovule when 1 ^^ the uterus already contains an ovum which has arrived at a considerable \ ' degree of development. The cases which are supposed to prove the possibility of this occurrence are very numerous. They are those in | which a woman is delivered simultaneously of foetuses of very different|| ages, one bearing all the marks of having arrived at term, the other of I prematurity; or those in which a w'omaii is delivered of an apparently ij mature child, and, after the lapse of a few months, of another equally! i mature. The possibility of superfoetation is strongly denied by many' practitioners of eminence*, and explanations are given which doubtless seem to account satisfactorily for a large proportion of the supposed 174 rjiKuxAycY. exaiiij)les. In tlio foniu'i* class of cases it is supposed, with imu-U j)n»l)al)ility, that there is an ordiiiarv twin j)reirth to many children without any suspicion of her abnormal ibrmation having arisen, and, had it not been detected by Dr. Ross, the case might iairly enough have been claimed as an indubitable exan)])le of suj)erf(jetatiou. Making every allowance for these ex])lnnations, there remains a con- siderable number of cases which it is very ditKcult to account lor excej)t on the supposition that the second child has been conceived a consider- able time after the first. Those interested in tlie subject will find a large number of examples collected in a valuable paper by Dr. Bonnar of Cu})ar.' He has adopted the ingenious plan of consulting the records of the British peerage, where the exact date of the birth of successive children of peers is given, without, of course, any reasonable possibility of error, and he has collected numerous examples of births rajiidly suc- ceeding each other wdiich are apparently inexplicable on any other theory. In one case he cites a child was born September 12, 1849, and the mother gave birth to another on January 24, 1850, after an inter- val of only 127 days. Subtracting from that 14 days, which Dr. Bonnar assumes to be the earliest possible jieriod at which a fresh impregnation can occur after delivery, we reduce the gestation to 113 days ; that is, to less than four calendar months. As both these chil- dren survived, the second child could not possibly have been the result of a fresh impregnation after the birth of the first ; nor could the first child have been a twin prematurely delivered, for if so it must have only reached rather more than the fifth mouth, at which time its survival would have been impossible. Besides the numerous examples of cases of this kind recorded in most obstetric works, there are one or two of miscarriage in the early months, in which, in addition to a foetus of four or five months' growth, a ]>er- fectly fresh ovum of not more than a month's develo|)ment was thrown off. One such case was shown at the 01)Stetrical Society in 1862, which was reported on by Drs. Harley and Tamier, who stated that in their opinion it was an examjile of superfbetation. A still more conclusive case is recorded by Tyler Smith :^ " A young married woman, pregnant for the first time, miscarried at the end of the fifth month, and some hours afterward a small clot was discharged enclosing a ]H'rfectly healthy ovum of about one month. There were no signs of a double uterus in this case. The patient had menstruated reguhirly during the time she had been pregnant." This case is of special interest from the fact of the patient having menstruated during pregnancy — a circiim- 1 Edin. Med. Jouni., lS()4-65. ' Manual of Obstetric.^, p. 112. ABNORMAL PREGNANCY. 175 stance only explicable on the same anatomical ^ronnds which render supcrfatation jxwsihle. So far as I know, it is the only instance in which the coincidence of superfaitatioii and menstruation during early pre<^nancy has been observed. The obiections to tlie possibility of superfictatio n are based on the| assumptions tliat theVk^'ichia so completely tills up the uterine cavity | that the ])assage of the spermatozoa is impossible; that their passage is| prevented l)v the^l nucous p lug which blocks up the cervix; and that! when impregnation has taken place t>vulation is suspend ed. Jtis, how-' ever, certain that none of these is an insuperable obstacle to a second impregnation. The first was originally based on the older and errone- ous view which considered the decidua to be an exudation lining the entire uterine cavity and sealing up the mouths of the Fallopian tubes and the aperture of the internal os uteri. ^The decidua reHexa, however, \ does not come into apposition with the decidua vera until about the eighth week of pregnancy, and therefore until that time there is a free space between the two membranes through which the spermatozoa might i pass to the open mouths of the Fallopian tube, and in which a newly- impregnated ovule might graft itself. / A reference to the accompanying figure of a pregnancy in the third mouth, copied from Coste's work, will readily show that, as far as the decidua is concerned, there is no mechan- FiG. 81. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa during the early months of pregnancy. (After Coste.) ical obstacle to the descent and lodgment of another impregnated ovule (Fig. 81). Then, as regards the plug of mucus, it is pretty certain that this is in no way different from the mucus filling the cervix in the non- pregnant state, which offers no obstacle at all to the passage of the sper- 176 PREGNANCY. nmtozoa. ' Lastly, rcspoftinj^tlu' ccssntion of ovulation (liiriiij; prcjjfnaiu'y, this, no doubt, is tlu' rule, and prohaltly satisllu-torily ('Xj)lains the rarity of supertcetation. \ riiore are, lu)\vevt'r, a sutticicnt number of aullicnti- cated cases of menstruation during pregnancy to prove that ovulatid into the following da-sses : 1st, and most common of all, tv hal gesta tion, and as varieties of this, although by .some made into distinct cla.sses, [a) interstitial, {b) tu bo-ovn - I'ian gestation, and (c) sub^igjtonegs^iclvic or intra-Ugamentous. /I n the first of these subdivisions the ovum is arrested in the part of the Fallo- pian tube that is situated in the substance of the uterine parietesi i n the second, l .lat or near the fimbriated extremity of the tube, so that jtart of its cyst is formed l)v the tube and part by the ovary 'j| i n the third , an originally tubal pregnancy develops into the broad ligament, ancT con- tinues this development beneath the peritoneum of the pelvic floor\\' The occurrence of this variety has been conclusively demonstrated by Hart and Carter.' 2d. Ahdominal gestatio n, in which an ovum, instead of finding its way into tlie tube,{[ialls into the peritoneal cavity, and there becomes attached and developed |;\ or the so-called \Becond a ry abdominal gestation, in which an extra-uterine pregnancy, originally tubal, becomes ventral through rupture of its cysts and escape of its contents into the abdominal cavityji; (^r in which an intra-ligamentous pregnancy continues to develop until it lifts up the abdominal peritoneum and forms a purely extra-peritoneal variety of abdominal gestation. This has been called by Hart and Carter subperitoneo-abdominal. .3d. (/ra- riwi gestation, the existence of whicii is denied by many writers of emi- nence, such as Velpeau and Arthur Farre, while it is maintained by others of equal celebrity, such as Kiwisch, Coste, and Hecker. It nuist be admitted that it is extremely difficult to understand how an ovarian pregnancy, in the strict sense of the word, can occur, for it implies that * Sectional Anatomy oj Advanceil Extm-uterine Gestation, Edin., 1887. ABNORMAL PREGNANCY. 177 the ovule has become imjiregiuited before the laceration of the Graafian follicle, through the coat.s of which the spermatozoa must have passed. Coste, indeed, believes that this frequently happens ; but, while sper- matozoa have been detected on the surface of the ovary, their penetra- tion into the Graafian follicle has never been demonstrated. Farre has also clearly shown that in many cases of su})posed ovarian ])rcgnancy the surrounding structures were so altered that it was impossible to trace their exact origin and to say to a certainty that the foetus was really within the substance of the ovary. ( Kiwisch gives a reasonable expla- nation of tiiese cases by supposing that sometimes the Graafian follicle may rupture, but that the ovule may remain within it without being discliarged.^ Through the rent in the walls of the follicle the spermato- zoa may reach and impregnate the ovule, which may develop in the situ- ation in which it has been detained. The subject has recently been ably considered by Puech,'^ who admits two varieties of ovarian pregnancy, according as the foetus has developed in a vesicle which has remained open or in one which has closed immediately after fecundation. He considers that most cases of so-called ovarian pregnancy are either der- moid cysts, ovario-tubal pregnancies, or abdominal pregnancies in which the placenta is attached to the ovary, and that even in the rare cases of true ovarian pregnancies the progress and results do not differ from that of abdominal pregnancy. (While, therefore, it is impossible to deny the existence of ovarian pregnancy, it must be considered to be a very rare \ ] and exceptional variety, the existence of which has never been actually J ' proved; which, as far as treatment and results are concerned, does not/ ' differ from tubular or abdominal gestation. ] 4th. There are two rare varieties in which an ovum is_ developed eitner in the supplementary horn of a bilobed uteru s or in a hernia l sac. For the sake of clearness we may place these varieties of extra-ute- rine gestation in the following tabular form : 1st. Tubal— fj (a) Insterstitial, (6) Tubo-ovarian, (c) Subjjeritoneo-pelvic. 2d. Abdominal — {a) Primary, (b) Secondary. 3d. Ovarian. 4th. In bilobed uterus, hernial, etc. Causes. — The etiology of extra-uterine foetation in any individual case must necessarily be almost always obscure. ( Broadly speaking, it may be said that extra-uterine foetation may be produced by any condi- tion which prevents or renders difficult the passage of the ovule to the uterus, while it does not prevent the access of the spermatozoa to the ovule, j Thus, inflammatory thickening of the coats of the Fallopian tubes Dy lessening their calibre, but not sufficiently so as to prevent the passage of the spermatozoa, may interfere Avith the movements of the tube which propel the ovum forward, and so cause its arrest. A similar effect may be produced by various morbid conditions, such as inflammatory adhesions, from old-standing peritonitis, pressing on the tube ; obstruction of its calibre by inspissated mucus di' small poly- poid growths ; the pressure of uterine or other tumors, and the like. 1 Anal, de Gyncc, 1878, toin. x. p. 102. 12 17S PRKG NANCY. The I'act that oxtra-iiteriiie prcgiiaiuics (uiiir most frequently in imil - tipaiU '. and coniiiaiativcly nuvly in women u nder thir ty yeai-s of age, tends to show that these oontlitions, which are clearly nirojtortion of eases occur in wonu'U who have either been ])reviouslv altogethe r sterile or in whom a lonir interval of time has elapsed since t heir last pregnancy . The disturbing effects of fright, either during coition or a few chiys afterward, have been insisted on by many authoi"S as a ])ossible cause. Numerous cases of this kind are recorded, and, j although the influence of emotion in the production of this condi- tion is not susceptible of proof, it is not difficult to imagine that spasms of the Fallopian tubes might be produced in *.his way which Avould either interfere with the passage of the ovum or direct it into \ the abdominal cavity. The occurrence of abdominal pregnancy is probably less difficult to account for if we admit, Mith Coste, that the ovule becomes impregnated on the surface of the ovary itself, lor there must be very many conditions which prevent the j)ro])er adaj)- tation of the fimbriated extremity of the tube to the suriace ol" the ovary, and, failing this, the ovum must of necessity drop into the abdominal cavity. Kiwisch has pointed out that this is ])articularly apt to occur when the Graafian follicle develops on the posterior sur- face of the ovary ; and, indeed, it is probable that it may be of com- mon occurrence, and that the comparative rarity of abdcmiinal preg- nancy is due to the difficulty with which the impregnated ovule engrafts itself on the surrounding viscera. Imj)regnation may act- ually occur in the abdominal cavity itself, of M'hich Keller * relates a remarkable instance. In this case Koebcrle had removed the body of the uterus and part of the cervix, leaving the ovaries. In the portion of the cervix that remained there was a fistulous ajierture opening into the abdominal cavity, through which semen passed and pn)duced an abdominal gestation. Several curious cases are also recorded, which have given rise to a good deal of discussion, in which a tubal pregnancy existed while the corpus luteum was on the oj^jio- site side (Fig. 82). The most probable explanation, however, is that the fimbriated extremity of the tube in Avhich the ovum was found had twisted across the abdominal cavity and gra.sped the ojijiosite ovary, in this way perhaps producing a flexion Avhich impeded the jirogre&s of the ovum it luid received into its canal. Tyler Smith suggested that such cases might be explained by supp(»siiig that the ovum, after reaching the uterus, failed to graft itself in the mucous jn( inbrane, but found its way into the (t]>])osite Fallopian tube. Kuss- maid- thinks that such a passage of the ovum across the tUerine cav- ity may be caused by muscular contraction of the uterus occurring shortly after conception, squeezing the yet free ovum up^vard toward the opening of the o]>]iosite tube, and possibly into the tube itself. The history and progress of cases of extra-uterine ])regnan(y arc materially different according to their site, and for practical ])urj)(>ses ' De.H Grosd'e.tses exira-uterine.% Paris, 1872. ^Mon.f. Ocburt., 1S62, Bd. xx. S. L'95. ABXORMA L PREGNANCY. 179 we may consider them as fonniii^ two great classes, the tubal (with its varieties) aiul the abdominal. Tubal Pregnancies. — When the ovum is arrested in any part of the Fallopian tul)e the ch orion soon commences to develop villi, just as in ordinary j)re<;'nancy, which engraft themselves into the mucous lining of the tube and fix the ovum in its new position. The Fig. 82. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the Opposite Side. The decidua is represented iu the process of detacliment from the uterine cavity. muc ous membrane becomes hyp ertrophied. much in the same way as that of the uterus under similar circumstances, so that it becomes developed iuto a sort of pseudo-decidua, the uterine extremity of which has been observed to be open and in communication with the lining membrane of the uterus.^ Inasmuch, however, as the mucous coat of the tubes is not furnished with tubular glands, a true decidua can scarcely be said to exist :■ nor is there any growth of membrane around the ovum analogous to the decidua reflexay The ovum is, therefore, comparatively speaking, loosely attached to its abnormal situation, and hence hemorrhage from laceration of the chorion villi can very readily take place. It is seldom that any development of the chorion villi into distinct placental structure is observed | this is probably owing to the fact that laceration and death generally occur before the period at which the placenta is normally formed. The muscular coat of the tube soon\ becomes hypertrophied, and as the size of the ovum increases the \ fibres are sej^arated from each other, so that the ovum protrudes at I certain points through them, and at these it is only covered by the stretched and attenuated mucous and peritoneal coats of the tube. At this time the tubal pregnancy forms a smooth oval tumor, which, as a rule, has not formed any adhesions to the surrounding structures (Fig. 83). The part of the tube unoccupied by the ovum may be found un- altered, and permeable in both directions, or, more frequently, it becomes so stretched and altered that its canal cannot be detected. Most fre- quently it is that part of the tube nearest the uterus which cannot be ' L. Bandi, BiUrolIt's HamJbuch dcr Frauenkronkheilcn. 180 PB EG NANCY. inadi' out. The coiKlitioi i of the uterus iu this a.s in other forms of ■ extra-uterine j)rei;naneyTias I)eeu the sulyeet of eonsiderahle diseussion. |(lt is now universally adniitted that the uterus undergoes a certain amount of svmpathetie eii'^or^ement, the c ervix becomes softene d as in natural pregnancy, and the nuicous meiubrane develops into a true Fig Tubal Pregnancy. (From a specimen in the Museum of King's College.) decidu al In many cases the decidua is found on post-mortem examina- tion, in others it is not, and hence the donl)ts that some have expressed as to its existence. The most reasonable ex]>lanation of its absence is that given by Duguet,^ who has sho\vn that \t, is f^n' from ^incn mmon for the uterino dcfidun to l)o thrown off ni vinssr durin ir the hemorrhagic dischargi'- wlii'li-o rrcipK'iitly piXTcilc tlic fatal i-s ue of extra-uteriu e gesta tion. Interstitial and False Ovarian Pregnancy. — When the ovum is arrested in that portion of the tube passing through the uterus in so- called interstitial ]n-egnancy, the muscular fibres of the uterus become stretched and distended and form the outer covering of the ovum. When, on the other hand, the site of arrest is in the fimbriated ex- tremity of the tube, the containing cyst is formed partly of the fimbriji? of the tube, partly of ovarian tissue; hence it is much more distcnsiljle, and the pregnancy may continue Avithout laceration to a more advanced period, or even to term, so that when the ovum is placed in this situa- tion the case mucli more nearly resembles one of abdominal pregnancy. Progress and Termination. — The termination of tubal pregnancy ill tlie immense majority of cases is death, ])roduced by laceration giving rise cither to interjiaLijemorrhage or to subsequent intense peritonitis. Rupture usually occurs at au early period of pregnancy, most generally * Annales de Gynecolofjie, 1874, torn. i. p. 269. ABNORMAL PREGNANCY. 181 from the f ourtli to tlio twelf'lli we ek, rarely later. However, a few in- stances are recorded in which it did not take place until the fourth or fifth month, and 8axtorj)h and Spicgclberg have recorded api)arently authentic cases in which the pregnancy advanced to term without laceration : these were, however, ])robably examples of the subpcri- toneo-pelvic or abdominal varieties. It is generally effected by dis- tension of the tube, Avhich at last yields at the point which is most stretched ; and sometimes it seems to be hastened or determined by accidental circumstances, such as a blow or fall or the excitement of sexual intercourse. Symptoms of Rupture. — The symptoms accompanying rupture are those of intense collapse, often associated with sever e abdominal paiu ^ produced by the laceration of the cyst. The patient will be found deadly p ale, with a small, thready, and almost imperceptible pulse, perhaps vo miti ng, but with mental facultie s clear. If the hemor- rhage be considerable she may die without any attempt at reaction. Sometimes, however — and this generally occurs in cases iu which the tube tears, the ovum remaining intact — the hemorrhage may cease on,, account of the ovum protruding through the aperture and acting as a'i( plug. The patient may then imperfectly rally, to be again prostrated by a second escape of blood, which proves fatal. If the loss of blood is not of itself sufficient to cause death from shock and ausemia, the fatal issue is generally only postponed, for the effused blood soon sets up a violent general peritonitis, which rapidly carries off the patient. If she should survive the second danger, the case is transformed into one of abdominal pregnancy, the foetus becoming surrounded by a capsule produced by inflammatory exudation (Fig. 84). The case is then subjected to the rules of treatment presently to be discussed when considering that variety of extra-uterine gestation. Diagnosis. — The possibility of diagnosing tubal gestation before rupture occurs is a question of great and increasing interest, from the fact that could its existence be ascertained we might very fairly hope to avert the almost certainly fatal issue which is awaiting the patient. Unfortunately, the symptoms of tul^al pregnancy are always obscure, and too often death occurs without the slightest suspicion as to. the nature of the case having arisen. ((In the first place, it is to be observed that all the usual sympathetic disturbances of pregnancy exist : the breasts enlarge, the areolae darken, and morning sickness is ])rescnt. /There is also an arrest of menstruation, but after the absence of one) V)r more periods there is o ften an irreirular hemorrhacric discharge. This is an important symptom, the value of which in indicating the existence of tubal pregnancy has of late years been much dwelt upon by various authors, both in this country and abroad. Barnes attributes it to partial detachment of the chorion villi, produced by the ovum growing out of proportion to the tube in which it is contained. AVhethcr this is the correct explanation or not, it is a fact that irregular hemorrhage very generally precedes the laceration for several days or more. (Associated with the hemorrhage there may occasionally be found shre(^s of the decidual lining of the uterus, the presence of which would materially aid the diagnosis. Aceunipanying this hemorrhage there is almost 182 mix; NANCY. always more or lc.r7irTvl)i(irTri('"'u\HriiTT:^'j71a(-<'(l, and this is sometimes de- seribed as beiii^ of very intense and crampy eljaraeter. \i\ then, we meet with a ease in which the symptoms of early pregnancy exi>t, in wliich then; are irregidar h)sses of Mood, possibly discharge of mem- Kk;. 84. Extra-uterine Pregnancy at Term of the Tubo-ovarian X'arioty. (After a case of Dr. A. Sibley Campbell's, of Augusta, Georgia!) branous shreds, and abdominal ])ain, a careful examination should be insisted on, and then the true nature of the ease may jiossibly he ascertained. Should extra-uterine fa:'tation exist, we should cx])ect to find the uterus somewhat enlarged and the cervix soitened, as in early jiregnancy, but both these chaugcs are doubtless generally less marked than in normal pregnancy. This fact of itself, however, is of little diagnostic value, for slight difrerenccs of this kind must always be too indefinite to justify a positive o})inioii. ( The existence of a periuterine tumor, rounded or oval in outline, and producing more or less displacement of the uterus, in the direction ojipo- site to that in Avhich the tumor is situated, may jioint to the existence of tubular lVetatif)n.'\ By bimanual examination, one hand depressing tiie abdominal wall,^vhile the examining finger of the other acts in concert with it either through the vagina or rectum, the size and relations of the growth may be made out. There are various conditions which give ABNORMAL PREGNANCY. \H3 rise to very similar piiysicul signs, sucli as small ovarian or fibroid growths, or the effusion of blood around the uterus ; and the differen- tial diagn(^sis must always he very diffieult, and often impossible. A curious example of the diiheulty of diagnosis is reeordcd by Joulin, in which Huguier and six or seven of the; most skilled obstetricians of Paris agreed on the existence of extra-uterine pregnane}', and liad, in consultation, sanctioned an operation, when the case terminated by abor- tion, and proved to be a natural pregnancy. The use of the uterineli sound, which might aid in clearing up the case, is necessarily contra-; indicated unless uterine gestation is certainly disproved. Hence it must' be admitted that positive diagnosis must always be very difficult. So that the most we can say is, that when the general signs of early preg- nancy are present, associated with the other symptoms and signs alluded to, the suspicion of tubal pregnancy may be sufficiently strong to justify us in taking such action as may possibly spare the patient the necessary fatal consequence of rupture. Treatment. — If the diagnosis were quite certain, the removal of the \ entire Fallopian tube and its contents by abdominal section would be j quite justifiable, and probably would neither be more difficult nor more, dangerous than ovariotomy^ for at this stage of extra-uterine foetation there are no adhesions to complicate the operation. As yet, however, the uncertainty of the diagnosis has prevented the adoption of the practice. Dr. T. Gaillard Thomas of New York ^ has recorded a most instruc- tive case in which he saved the life of the patient by a bold and judici- ous operation. The nature of the case was rendered pretty evident by the signs above described, ancf Thomas opened the cyst from the vagina by a platinum knife rendered incandescent by a galvano-caustic batterv, by which means he hoped to prevent hemorrhage. Through the open- ing thus made he removed the foetus. ; In subsequently attempting to remove the placenta very violent hemorrhage took place, which was only arrested by injecting the cyst M'ith a solution of persulphate of iron. The remains of the placenta subsequently came away piecemeal after an attack of septicperaia, which was kept in bounds by freely washing out the cyst with antiseptic lotion, the patient eventually recovering. If I might venture to make a criticism on a case followed by so brilliant a success, it would be that in another instance of this kind it would be safer to follow the rule so strictly laid down with regard to gastrotomv in abdominal jiregnancies, and leave the placenta untouched, trusting to the injection of antiseptics and the thorough drainage of the cvst to prevent mischief. [In a second operation, performed by Prof. Thomas on May 10, 1876, in a ease Avhere the foetus had been some time dead, he incised the abdomen through the linea alba, and extracted a foetus weighing nearlv seven pounds. The cord was cut off at its origin, and the wound closed except at its lower angle, where a drainage-tube was inserted. The ]ila- centa was removed in the middle of the fourth week, and the patient made a good recovery. Dr. Thomas has had several similar cases and results. This plan of non-interference with the placenta in the same ^ New York Med. Journ., 1875, vol. xxi. p. 561. 184 rJiEayAycY. cliaractcr of caffos was first tried in New York City about ninety years ap;o by Dr. ]Mc'Kni<^iit, and the woman reeovored. lie liad intended to })eel oil" the placenta, but, fortunately, the cord was broken otf in the oj)eration, and lie could not (ind it ; hence the resuh. Thus was estal)- lisiied the vahie of the method, although it was not generally known until quite recently. — Kd.] Means of Destroying the Vitality of the FcBtus. — Another mode of manaiiino- these cases is to destroy the fa'tus, so as to check its fur- ther growth, in the hope that it may remain inert and passive within its stie. Various o})erations have been suggested and practised tor thisj)ur- pose. Thus, needles have been introduced into the tumor, through which currents of electricity have been ])assed, cither the continuous current or, as has been suggested by Duchenne, a si)ark of franklinic electricity. Hicks, Allen, and others have endeavored to destroy the fa'tus by passing an electro-magnetic current through it by means of a needle. [Dr. Allen did not resort to galvano-]iuncture in any one of his three cases. — Ed.] Many successful cases have followed the use of the faradic current, one pole being passed through the rectum or vagina to the site of the ovum, the other being placed on a point in the abdom- inal wall two or three inches above Poupart's ligament ; or Apostoli's vaginal electrode, in which both poles are combined, might be used. The current shoidd be passed daily for at least ten minutes, and con- tinued for a M'eek or two until the shrinking of the tumor gives satis- factory evidence of the death of the foetus. This practice is per- fectly safe, and there can be no rational objection to its being tried. Aveling makes the reasonable suggestion that the ciu'rcnt acts by producing " tetanic contractions of the ftetal heart due to the re])eat- edly broken current of an induction machine." ^ Sim])le ])uncture of the cyst has been successfully practised on several occasions, either with a small trocar and canula or with a simple needle. A very interesting case, in which the development of a two months' tubal gestation was arrested in this way, is recorded by Greenhalgh,^ and another by Martin of ]>crlin.^ Joulin suggested that not only shoidd the c yst be p unctured, but that a solution of morphia should be injected into it, which by its toxic influence would ensure the destruction of the foetus ; and tins is probably one of the best means at our disposal of destroying the foetus. Other means jn-oposed for effecting the same object, such as pressure or the administration of toxic remedies by the mouth, are far too uncertain to be relied on. vThe simj^lest and most eirectual })lan would be to iiitrodiK-e the iicedjc()f an aspirator, by Avhich the liquor amnii would be drawn off and the further growth of the foetus eflcctually prevented, i Parry,^ indeed, is opposed to this practice, and has collected several cases in which the puncture of the cyst was followed by fatal results, either from hemorrhage or sejitica^- niia. In these, however, an ordinary trocar and canula were ])robably employed, which would necessarily admit air into the sac [Toxic '■'The Diagnosis and Electrical Treatment of Earlv Extra-uterine Gestation," Brit. Gyn. Joiirn., 1888-89, vol. iv. p. 24. 2 Lnncel, 1867. ^ Monal. f. G\6«W., 1868, Bd. xxxii. S. 140. * Parry on Extra-Uterine Pregnancy, p. 204. ABNORMAL PREGNANCY. 185 injections, even with asi)inition, arc very dan<^erous as foeticidal expe- dients, and the results of experiments reported do not reeonunend their adoption. — Ed.] It is difficult to imagine that a fine hair-like asj)ira- ting needle, rendered perfectly aseptic by carbolic acid, could have any injurious results ; and it could do no harm, even if an error of diagno- sis had been made and the suspected extra-uterine foetation turned out to be some other sort of growth. If the aspirator jiroves that an extra- uterine foetation exists, then, if the cyst be of any considcral)le size and the pregnancy advanced beyond the second month, we might, if deemed advisable, resort to a more radical operation, such as that so successfully practised by Thomas. Treatment when Rupture has Occurred. — AVhen the chance of arresting the growth of a tubular foetation has never arisen, and we first recognize its existence after laceration has occurred and the patient is collapsed from hemorrhage, what course are we to pursue ? Hitherto, all that has generally been done is to attempt to rally the patient by stimulants, and, in the unlikely event of her surviving the immediate effects of laceration, endeavoring to control the subsequent peritonitis, in the hope that the effused blood may become absorbed, as in pelvic hsem- atocele. This is, indeed, a frail reed to rest upon, and when laceration of a tubal gestation, advanced beyond a mouth, has occurred, death has been the most certain result. It is supposed by Bernutz — and his opinion is shared by Barnes — that rupture which does not prove fatal is probably not very rare in the first few days of extra-uterine gestation, and that it is not an uncommon cause of certain forms of pelvic h^em- atocele. [Unquestionably, the proper course to pursue when laceration has occurred is to perform gastrotomy, to sponge away the effused blood, and to place a ligature around the lacerated tube and remove it with its contents.\ This is no doubt a bold and heroic procedure, but no one who is acquainted with the triumphs of modern abdominal surgery can say that it would be either impossible or hopeless. The sponging out of effused blood from the abdominal cavity is an everv-day procedure in ovariotomy, nor is there any apparent difficulty in ligaturing and removing the sac of the extra-uterine pregnancy, for, as a rule, there are no adhesions formed to the surrounding parts. The history of these cases shows that death does not generally follow rupture for some hours, so that there would be usually time for the operation, and the extreme prostration might be, perhaps, temporarily counter- acted by transfusion. Pressure on the abdominal aorta, resorted to when the patient is first seen, might possibly be employed with advan- tage to check further hemorrhage until the question of operation is decided. We must remember that the alternative is death, and hence any operation which would afford the slightest ho])e of success would be perfectly justifiable. INIr. Lawson Tait and others have on many occasions successfully operated under such conditions, and there can be no question that when the diagnosis is sufficiently distinct such a procedure is not only justifiable, but affords the best hope for the patient. Abdominal Preg-nancy. — In the second of the two classes into which, for practical convenience, Me have divided extra-uterine gestation the 186 i'nj:<;yAycv. ovum is anu's hclicvi'S that it |trol)al)ly never is so, on aeeount of tlie ditliculty of" admitting that so minnte a body as the ovum shouhl bo ahle to fix itself on the smootli peritoneal surface. He therefore thinks that all abdominal })rc<:nancics ai'c primarily cither tul)al (.a.-c .iiMi>-c(l Labor. decomposition. A putrid and offensive discharge has then commenced, and eventually ])ortions of the disintegrating foetus iiave been expelled per rdf/inam. This discharge may go on until the entire f(etus is grad- ually thrown off, or more frcfjuently the i)atient dies from septic;emia or other secondary result of the presence of the decomposing mass in utero. Thus, ]McClintoek relates one ca.se' in m Inch .symptoms of labor came on in a woman 45 years of age at the exjx'cted period of delivery, but pas.sed off without the ex])ulsion of the fVetus. For a period of sixty-seven weeks a highly oilensive discharge came away, with i^ome few bones, and she eventually died with symptoms of pyemia. He also ' Dublin Quart. Jovrn., Feb. and May, 1S64. ABNORMAL PREGNANCY. 195 cites another case in wliicli tlie ]>atient died in the same way after the fa'tns had been retained for eleven years. Sometimes, when the foetus has been retained for a length of time, a further source of danger has been added by ulceration or destruction of the uterine walls, probably in consequence of an ineffectual attempt at its elimination. This occurred in Dr. Oldham's case (Fig. 87), in which the contained mass is said to have nearly worn through the ante- rior wall of the uterus; and also i^i one reported by Sir James Simp- son,' in which a patient died three mouths after term, the fretus having undergone fatty metamorphosis, an opening the size of half a crown having formed between the transverse colon and the uterine cavity. It is also stated that " the uterine walls were as thin as parchment." {in some few cases, however, probably when the entrance of air has been prevented, the fcetus has been retained for a length of time W'ith- out decomposing and without giving rise to any troublesome symptoms.l Such a case is reported by Dr. Cheston,^ in which the foetus remained irv uiero for fifty-two years. Th e causes of this strange occurrence are altogether unknown. Gen- erally the foetus seems to have died some time before the proper terra for labor, and this may have influenced the character of the pains. It is probably also most apt to occur in women of feeble and inert habit of body, possibly where there was some obstacle to the dilatation of the cervix wdiich the pains were unable to overcome. Barnes suggests ^ that some presumed examples of missed labor " Nvere really cases of intersti- tial gestation or gestation in one horn of a two-horned uterus ;" and Macdonald * recently recorded a very interesting case in which he per- formed laparotomy for what he believed to be a uterine fibroid, but which turned out to be one horn of a bifurcated uterus containing a foetus which had been retained for more than a year. He believes that most, if not all, cases of " missed labor " are of this kind, delivery at term proving impossible because of the narrow connection between the irajn-eg- nated horn and the cervix. Miiller of J^ancy has attempted to prove, by a critical examination of published cases^ that most examples of so-called " missed labor " Avere in reality cases of extra-uterine fcetation in which an ineffectual attempt at parturition took place, the foetus being subsequently retained. From what has been said, it will be seen that the dangers arising from this state are very considerable, and when once the full term has j passed beyond doubt, especially if the presence of an offensive dis- ' charge shows that decomposition of the foetus has commenced iit would j be pi'oper practice to empty the uterus as soon as possible! The neces-|i sary precaution^ however, is not to decide too quickly thatf the term has really passed ;; and therefore we must either allow sufficient time to 1 elapse to make it quite certain that the case really falls under this cate- i gory or have unequivocal signs of the death of the foetus and injury to the mother's health. If we had to deal with the case before any exten- sive decomposition of the foetus had occurred, we probably should find ^ Edin. Med. Jouni., 1865. = 3rrd.-CJnr. Trans., 1814. ■^ Diseases of Women, p. 445. * Edin. Med. Journ., vol. 18S4-S5, p. 873. 196 PREGNANCY. little (lin'u'iihy in its iiiaiiagenu'iit, i'ov the proper course then wouhl be to dilate the cervix with fiuid dilators, and remove the iitetus by turn- ing ; or before doing so we might endeavor to excite uterine action by j)ressure and ergot. If the case did not come under observation until disintegration of the foetus had begun, it would be more ilillieult to deal with, it' the lu'tus had become so nmch broken up that it was being discharged in j)ieces. Dr. McClintock says that " in regard to treatment our measures should consist mainly of j)alliatives — viz. rest and hip- baths — to subdue uterine irritation ; vaginal injections, to secure clean- liness and prevent excoriation ; occasional digital examination, so its to detect any fragments of bone that might be presenting at the os, and to assist in removing them, 'i'hese are plain rational measures, and beyond tliem we shall scarcely, perhaps, be justilied in venturing. Nevertheless, under certain circumstances 1 would not hesitate to dilate the cervical canal so as to permit of examining the interior of the Avomb and of extracting any fragments of bone that may be easily accessible; but unless they could thus be easily reached and removed, the safer course woidd be to defer, for the present, interfering with them." ' n It may be doubted, I think, whether, considering the serious results ' which are known to have followed so many cases, it would not, on the whole, be safer to make at least one decided effort, under chloroform, to remove as much as possible of the putrefying uterine contents after the OS has been fully dilated. Such a procedure would be less irritating than frequently-repeated endeavors to pick away detached portions of the fa?tus as they present at the os uteri. When once the os is dilated, antiseptic iutra-uterine injections, as of diluted Condy's fluid, might safely and advantageously be used. Unquestionably, it would l)e better ])ractiee to interfere and empty the uterus as soon as we are (juite satis- fied of the nature of the case, rather than to delay until the fwtus has been disintegrated. Macdonald thinks that abdominal section would be the best course to pursue, either removing the sac entire or resoi'ting to Porro's operation. This advice is based on the assumption that " missed labor " is essentially the retention of a foetus in one horn of a biloljed uterus — a theory which certainly cannot yet be taken as proved. [Causes of " Missed Labor." — From several cases that have been rej)orted in the United States we find that the failure of the uterus to expel its contents may be due to a variety of causes. If we are certain that the foetus is actually in ntero, that there is no pelvic or vaginal obstruction, and that the uterus is itself of normal form, then we must look for the cause of difficulty in the organ itself. By an examination of our reports of Ciesarean operations we find that thei-e iiave been sev- eral cases in which the power of the uterine contractions was insuffi- cient jtp. overcome the resistance to expansion in the cervix. This niayj. be due either to a want of contractile force in the muscular coat, toll a change in the tissues of the cervix as the result of inflammation, or'' to both conditions combined. AVhere the muscular power of the uterus is in its integrity, the resistance in the cervix may Ije such that the os may remain unchanged after it is slightly opened, and the patient con- ^ Dublin Quart. Jouru., vol. xxxvii. p. 314. I ABNORMAL PREGNANCY. VM tiime in labor until the contractile power of the uterus is exhausted wlieu all nuiscular contraction will cease. Efllbrts at exjiulsiyn may recur at intervals covering a period of many months, when they will cease finally. In two Csesareau cases in the tJnited States, the subjects i being blackf there was found a calcareous incrustation over and around I the internal os uteri. I The first operation ^vas performed in Virginia in 1828 upon a multipara of 25.^ She was taken in la])or at term, and had })ains for two or three days together, at intervals, for about four weeks, after which pains returned occasionally during fifteen months. The cervix admitted the index finger, and in time the foetus became putrid. When operated upon she had carried the fcetus two years. There was very little hemorrhage in the operation, although the uterus failed to contract, and for this reason was sutured. The woman died in the second week, of peritonitis, following an attack of indigestion produced by a meal of animal food and cider. The second case, also a multipara, was operated upon in Georgia in 1877, after a labor of four days, by Dr. Theodore Starbuck, who describes the deposit as " ossific." The child was dead, and the woman died of internal hemorrhage very suddenly on the third day.^ In a third case, also black, the cause of retention appears to have been a prevention of the descent of the foetus, from its arm and leg being secured within the uterus. The woman was 33 years old and the mother of one child, and w^as operated upon by Dr. J. C Egau of Shreveport, Louisiana, August 25, 1860.^ On May 4, 1857, while at work in the field, she felt a sudden and violent pain in the left side ; fainted, remained insensible so long as to be thought dead, but finally revived, and was pronounced four months pregnant. Labor began in November ; the os dilated, head presented, but did not descend ; pains continued at intervals for a month. In the fall of 1858 an abscess opened, leaving a fistula 1:^ inches below the umbilicus. When ope- rated upon nearly two years later, she was greatly emaciated and affected with hectic fever. The uterus being adherent, the peritoneal cavity was not opened. When the foetus was extracted, its left foot and hand were wanting, and, search being made, were found in a pouch on the left side of the uterus, enclosed by bands which were cut for their liberation. The uterus was examined bimanually to make sure that the cervix was sufficiently open for drainage. The decomposed foetus had been carried thirty-three months after maturity. Dr. Egan believes that a partial rupture of the uterus took place at the time of her attack in the field, and that the arm and leg were caught in its partial cicatrization. The woman made a good recovery. jNIuch light is thrown upon a possible way of accounting for some of the mysterious cases of missed labor, which have been claimed to be extra-uterine in order to account for them, by a case recently operated upon in Portland, Maine, by Dr. Stanley P. Warren, and kindly reported to me by letter. The woman was a native, of Scotch-Irish [^ Am. Journ. Med. ScL, vol. xviii. p. 257.] [^ Communicated by the operator, 1S80.] l/^N. 0. Med. and iiurg. Journ., July, 1877, p. 35; also communicated bv operator, 1878.] 198 riii:ayAycY. (lesot'Ut, :iresented by right arm and side ; placenta thin and far advanced in fatty degeneration ; no hem- orrhage on its removal; uterus did not contract; sutured by continuous stitch with catgut. Child 8J pounds. Woman rallied slightly, Init died of shock in 28 hours. Drs. T. A. Foster and S. C. Gordon were associated with Dr. Warren in the management of the case. It would a]^])ear in this instance of mjssed labor that the changes produced b\-( metro-peritonitis prevented the natural dilatation of the cervixi and the contractile action of the muscular coat of the uterus. Possibly, fatty degeneration of the muscular fibres had taken place, but this could not be ascertained, as there Avas no autopsy. The Cesarean case of Dr. Brodie S. Herndon of Fredericksburg, Virginia, operated upon with success in 1845, bears a close resemblance in many of its features to that of Dr. Warren. The subject was a white multipara of 30, whose ])ains of labor gave place to the contin- uous pain and other characteristic symptoms of peritonitis. This disease lasted a mouth, during which time the fluid contents of the uterus escaped and the vaginal discharge became very ofllensive. Five weeks after the jieritonitis commenced the os uteri admitted two fingers, and attempts at dilatation were made, l)ut failed. Under ergot an otlensive placenta was expelled, but the fcetus could not be removed. The Avoman being greatly wasted and her room filled with stench, the Cfesa- rcan operation was performed on November 16, forty-six days after the first signs of labor appeared. The uterus being adherent, the perito- neal cavity was Jiot exposed ; the uterus was sponged out, but did not contract ; it was closed in the suturing of the abdomen. The patient DISEASES OF PREGXAXCY. 199 made a good recovery. As m tlie Warren ease, the uterus became unsuited for performing the functions of hibor by reason of changes in its tissues eti'ected by inflammatory action. — Ed.] CHAPTER yil. DISEASES OF PREGNANCY. The diseases of pregnancy form a subject so extensive that they niight well of themselves furnish ample material for a separate treatise. The pregnant woman is of course liable to the same diseases as the non- pregnant ; but it is only necessary to allude to those whose course and eifects are essentially modified by the existence of pregnancy or which have some peculiar effect on the patient in consequence of her condi- tion. There are, moreover, many disorders which can be distinctly traced to the existence of pregnancy. Some of them are the direct results of the sympathetic irritations which are then so commonly observed, and of these several are only exaggerations of irritations w'hich may be said to be normal accompaniments of gestation. These functional derangements may be classed under the head of neuroses, and they are sometimes so slight as merely to cause temporary inconve- nience, at others so grave as seriously to imperil the life of the patient. Another class of disorders is to be traced to local causes in connection with the gravid uterus, and are either the mechanical results of pres- sure or of some displacement or morbid state of the uterus ; while the origin of others may be said to be complex, being partly due to sympa- thetic irritation, partly to pressure, and partly to obscure nutritive changes produced by the pregnant state. Derang-ements of the Digestive System. — Among the sympathetic derangements there are none which are more common, and none which more frequently produce distress, and even danger, than those Avhich affect the digestive system. Under the heading of " The Signs of Pregnancy " the frequent occurrence of nausea and vomiting has already been discussed and its most probable causes cousi'cTered (p. 147). A certain amount of nausea is indeed so common an accompaniment of pregnancy that its consideration as one of the normal symptoms of that state is fully justified. We need here only discuss those cases in which the nausea is excessive and long continued, and leads to serious results from inanition and from the constant distress it occasions. Fortunately, a pregnant woman may bear a surprising amount of nausea and sick- ness without constitutional injury, so that apparently almost all aliments may be rejected without the nutrition of the body very materially suf- fering. At times the vomiting is limited to the earlv^jjaTt_jj£,t'i^l'\^'' when all food is rejected, and when there is a Ircquent retching of 200 PRIiayA.WCY. glairy, transparent fluid, in scvoi-al cases mixed with bile, while at the latter ))art of the day the stomach jnay be able to retain a suflicient (juantity ol" food and the nausi-a disaj)|)ears. ^ Jn other cases the nausea :uid vomitin<5 are aliuust incessant} i'he j)atieut leels constantly .sick, ^^'j and the mere taste or sight of f'ootl may bring on excessive and painful > vomiting. The duration of this distressing accojujianiment of j)reg- iiancy is also variable, ( (ienerally it connnences between the second anj. 1 third months, and disa])])ears after the woman luus quickene d^ Some- times, however, it begins with conception, and continues inial)ated initil the ])regnancy is over. Symptoms of the Graver Cases. — In the worst class of ca.«cs, when all nourishment is rejected and when the retching is continu- ous and painful, sym])toms of very great gravity, which may even prove fatal, develop themselves. The countenance Ijccomes haggard from suffering, the tongue dry and coated, the epigastriiun tender on pressure, and a state of extreme nervous irritability, attended with rest- lessness and lo.ss of sleep, becomes establTsIied. In a still more aggra- vated degree there is general feverishness, with a rapid, small, and thready pulse. Extreme emaciation supervenes, the result of wast- ing from lack of nourishment. The breath is inten.sely feticl_and the tongue dry and black. The vomited matters are sometimes mixed with blood. The patient becomes profoundly exhausted, a low form of delirium ensues, and death may follow if relief is not obtained. , Prognosis.— \Symptoms of such gravity are fortunately of extreme . rarity, but they do from time to time arise and cause much anxiety> j Gueuiot collected 118 cases of this form of the disease, out of which ' 46 died; and, out of the 72 that recovered, in 42 the symptoms only ceased when abortion, either spontaneous or artificially pro- duced, had occurred. When pregnancy is over the symptoms occa- sionally cease with marvellous rapidity. The power of retaining and as.similating food is rapidly regained and all the threatening symptoms disap]iear. Treatment. — In the milder forms of obstinate vomiting one of the first indications will be to remedy any morbid state of the })rimse via?. The bowels will not unfrequently be found to be obstinately consti- ])ated, the tongue loaded, and the breath offensive; and when attention has been ]>aid to the general .state of the digestive organs by general a])erient medicines and antacid remedies, such as bismuth and .^xla and lif^uor pepticus after meals, the tendency to vomiting may abate witliout furtlier treatment. The careful regulation of the diet is very important. Great benefit | is often derived from recommending the patient not to rise from the! recinnbent ))osition in the morning until she has taken something. Half a cup of milk and lime-water, or a cuji of strong coffee, or a little rum and milk or cocoa and milk, a glass of sparkling kou- mis.s, or even a morsel of biscuit, taken on waking, often has a remarkable cti'ect in diminishing the nausea. AVhen any attempt at swallowing .solid food brings on vomiting, it is better to give u]> all ])retenee at keeping to regular meals, and to order .such light and easily DfSEASES OF PREGNAXCV. 201 assiinilatod food at short intervals as can he retained. Iced milk, ^^•ith lime or soda-water, given frequently, and not more than a mouthful at a time, will frequently be retained when nothing else will. Cold beef- jelly, a spoonful at a time, will also be often kept down. iSparkling koumiss has been strongly recommended as very useful in such cases, and is worthy of trial. It is well, however, to bear in mind, in regu- lating tiie diet, that the stomach is fanciful and capricious, and that the patient may be able to retain strange and apparently unlikely articles of food, and that if she expresses a desire for such the experiment of letting her have them should certainly be tried. The medicines that have been recommended are innumerable, and the practitioner will often have to try one after the other unsuccessfully, or may tind, in an individual case, that a remedy will prove valuable which in anotiier may be altogether powerless. Amongst those most generally useful are effervescing draug^lits, containing from three to five minims of dilute hydrocyanic acid ; the creas ote mixture of the Pharmacopoeia ; tmcture of nux vomica, in doses of five or ten minims; single minim doses of viuum. ipecacuanhre , every hour in severe cases, three or four times dailyTfTffexse wiiicllare less urgent ; salicine, in doses of three to five grains three times a day, recommended by Tyler Smith ; oxalate of cerium in the form of a pill, of which three to five grains may be given tliree times a day — a remedy strongly advocated by Sir James Simpson, and Avhich occasionally is of undoubted service, but more often fails ; the compound pyroxylic spirit of the London Pharmacopoeia, in doses of five minims every four hours, with a little compound tincture of cardamoms — a drug which is comparatively little known, but which occasionally has a very marked and beneficial effect in checking vomit- ing ; opiates in various forms — which sometimes prove useful, more often not — may be administered either by the mouth, in pills contain- ing from lialf a grain to a grain of opium, or in small doses of the solution of the bimeconate of morphia or of Battley's sedative solu- tion, or subcutaneously — a mode of administration which is much more often successful. The hydrochlorate of ^CQcalue is said to be very efficacious : two grains are dissolved in five ounces of water by means of spirit, of which mixture a teaspoonful may be taken every hour. A ntipyrin e in ten-grain doses has sometimes proved useful. If there is much tenderness about the epigastrium, one or two leeches may be advantageously applied, or one-third of a grain of morphia may Jje sprinkled on the s urface o f a small blister, or cloths saturated in laudanum may be kept over the pit of the stomach. The admrnisfration j>fr rectum of tw enty grains of chloral , combined with the same amount of bromide of potassium, in a small enema, is said to very useful. In many cases I have found that the application of a spinal ice-bag to the cervical vertebrre, in the manner recommended by Dr. Chapman, has checked the vomiting when all drugs have failed. The ice may be placed in one of Chapman's spinal ice-bags, and applied for half an hour or an hour twice or three times a day. It invariablv produces a comforting sensation of warmth, which is always agreeable to the patient. Ice may be given to suck ad libitum, and is very useful; while if there be much exhaustion small quantities of iced cham- 202 rrj'JGXAycY. j):ii;ii(.' may also he t^iyeii Intin time to time. The aj)j)Hr.itioii of the ether spray over the ej)igastrium has been highly recommended. lua^jinueh as the vomiting; unqnestionably has its origin in the uterus, it is only natural that practitioners should endeavor to check it by reme- dies calculated to relieve the irritability of" that organ. Tiius, morphia in the form of pessaries jjcr rtnjiiiain or belladonna aj)plied to the cervix has been reconunendcd, and the former especially is often of undoubted service. A pessary containing one-third to half a grain of morj)liia* may be introduced night and morning uitliout interfering with other methods of treatment. Dr. Henry Beunet directs especial attention to the cervix, Mhich, he says, is almost ahvays congested and inflamed and covered with granular erosions. This condition he reconunends to be treated by the application of nitrate of silver through the speculum. Dr. Clay of ^Manchester corroborates this view, and strongly advocates, especially when vomiting continues in the latter mouths, that one or two leeches should be applied to the cervix. Excejition may fairly be taken to both these methods of treatment as being somewhat hazardous, unless other means have been tried and failed. I have little doubt, however, that in many cases a state of uterine congestion is an important factor in keeping up the unduly irritable condition of the uterine fibres, and an endeavor sliould always be made to lessen it by insisting on absolute rest in the recumbent posture. Of the importance of this precaution in obstinate cases there can be no question. Dr. Copeman of Xorwich strongly recommended dilatatiijn_of the cervix by the finge r, and stated that lie found it very scrvicealile in checking nausea. It is obvious that this treatment must be adopted with great caution, as, roughly ])erformcd, it might lead to the production of abortion. Dr. Hewitt's views as to the dependence of sickness on flexions of the uterus have already been adverted to, and reasons have been given for doubting the general cor- rectness of his theory. It is quite likely, however, that well-marked dis])lacements of the uterus, either forward or backward, may serve to intensify the irritability of the organ. Cazeaux mentions an obsti- nate case immediately cured by replacing a retroverted uterus. A care- ful vaginal examination should therefore be instituted in all intractable cases, and if distinct displacement be detected an endeavor should be made to support the uterus in its normal axis. If retroverted, a Hodge's jK'Ssary may be safely employed; if anteverted, a small air-ball pessary, as recommended by Hewitt, should be inserted. I believe, however, that such displacements are the exception, rather than the rule, in cases of severe sickness. The importance of promoting^ nutrition l)y every means in our ])ower should always be borne in mind. The e ffervescing kou miss, which can now be readily ol)tained, I have found of great value, as it can often be retained when all other aliment is rejected. The exhaustion produced by want of food soon increases the irritable state of the nervous sys- tem, and if the stomach will not retain anything Me can only combat it by occasional mitrient encmata of strong beef-tea, yolk of cixi:, and the "like. The Production of Artificial Abortion. — Finally, in the worst class of cases, when all treatment has faileil, and when the patient has DISEASES OF FEEGNANCY. 203 fallen into the eonditioh of extreme ])i'ostration already deserihetl, M-e may be driven to consider the necessity of ])rodaciiiorridg e, etc. Some medicinal treatment will also be necessary, and in selecting the drugs to be used eare should be taken to choose such as are mild and unirritatiug in their action and tend to improve the tone 6i' the nuiscular coat of the intestine. A^small quantity of aperient mineral ■\vater in the early morning, such as tlie Ilnnyadi, Friedrich^halle, or l^ullna water, often answei*s very well ; or an occ-asional dose of the con- fection of sulphur; or a pill containing three or four grains of the ext ract of col ocynth, whh a quarter of a grain of the extract of nux vomicn and iT grain of extract of h voscvam us at bedtime; or a tea- spoonful of the compound liquorice powder in juilk at bedtime. Con- stipation is also sometimes effectually cond)ated Ijy administering, twice daily, a pill containing a couple of grains of insjiissated ox-gall, with a quarter of a grain of extract of belladonna. Knem ata of soa)) an d wate r are often ver}- useful, and have the advantage of uot disturb- ing the digestion. In the latter mouths of pregnancy, especially in the few weeks preceding delivery, the irritation produced by the collection of hardened feces in the bowel is a not infrequent cause of the annoy- ing false pains which then so commonly trouble the patient. In order to relieve them it will be necessary to empty the bowels thoroughly by an aperient/ such as a good dose of castor oil, to which fifteen or twenty minims of laudanum may be advantageously added.) Should the rec- tum become loaded with scybalous masses, it may be necessary to break down and remove them by mechanical means, provided we are unable to effect this by co]")ious enemata. Hemorrhoids. — The loaded state of the rectum so common in preg- nancy, combined with the mechanical effect of the pressure of the gravid uterus on the hemorrhoidal veins, often ])roduces very troublesome symptoms from piles. ' In such cases a regular and gentle evacuation of the bowels siiould be secured daily, so as to lessen as much as ]>os- sible the congestion of the veins. y Any of the aperients already men- tioned, especially the sulphur electuary, may be used. Dr. Fordyce Barker ' insists that, contrary' to the usual imi)re.ssion, one of the best remedies for this purpose is a pill containing a grain or a grain and a lialf of powdered aloes, Avith a quarter of a grain of extract of nux vomica, and that castor oil is distinctly iirejudicial and apt to increase the symptoms. I have certainlv found it answer well in several cases. IAVf.en the piles are tender and swollen they should be freely covered with an ointment consisting of four grains of muriate of morphia to an ounce of simple ointment, or with the ung. galla? c. opio of the Phar- ' macopoeia ; and, if ])rotruded, an attempt should be made to push them gently above the sphincter, l)y which they are often unduly constricted. Relief may also be obtained by frequent hot fomentations, and some- ' Ttte Puerperal Diseases, p. 33. DISEASES OF PREGNANCY. 205 times, when the piles are niueh swollen, it will be found useful to puncture tlieni, so as to lessen the congestion, before any attempt at reduction is made. Ptyalism. — ^V profuse discharge from the s alivary- glands is an occ a- sional distressing accompaniment of pregiiaiicy! It is generally cou- fined to the eai:ly niontlis, but it occasionally continues during the whole period of gestation, and resists all treatment, only ceasing when delivery is over. Under such circumstances the discharge of saliva is sometimes enormous, amounting to s everal quarts a da}', and the distress and annoyance to the patient are very great. In one case under my care the saliva poured from the mouth all day long, and for several months the patient sat with a basin constantly by her side, incessantly emptying her mouth, until she was reduced to a condition giving rise to really serious anxiety. This profuse salivation is no doubt a purely nervous disorder, and not readily controlled by remedies. Astringent gargles containing tannin and chlorate of potash, frequent s ucking of ice or of tannin lozenges, inhalation of turpentine and creasote, co unter-irritat ion over the salivary glands by lilisters or iodine, the continuous galvanic current applied over the parotids, the bromides, opiuni internally, small dos^_of^^elladonna or atropine, may all be tried in turn, but none of them can be depended on with any degree of confidence. Toothache and Caries of the Teeth. — Severe dental neuralgia is also a frequent accompaniment of pregnancy, especially in the early months. When purely neuralgic, quin ine in tolerably large doses is the best remedy at our disposal ; but not unfrequently it depends on actual caries of the teeth, and attention should always be paid to the condition of the teeth when facial neuralgia exists. There is no doubt that pregnancy predisposes to caries, and the observation of this fact has given rise to the old proverb, '' For every child a tooth." jNIr. Oakley Coles, in an interesting paper ^ on the condition of the mouth and teeth during pregnancy, refers the prevalence of caries to the coex- istence of acid dyspepsia, causing acidity of the oral secretions. There is much unreasonable dread amongst practitioners as to interfering with the teeth dui'ing pregnancy, and some recommend that all operations, even stopping, should be postponed until after delivery. It seems to me certain that the suffering of severe toothache is likely to give rise to far more severe irritation than the operation required for its relief, and I have frequently seen badly-decayed teeth extracted during pregnancy"N and with only a beneficial result. / Affections of the Respiratory Organs. — Amongst the derange- ments of the respiratory organs, one of the most common is gpas - modic cough , which is often excessively troublesome. Like many other of the sympathetic derangements accompanying gestatilesome in the latter months, and con- tinues unrelieved until delivery or until the sinking of the uterine tumor Avliich immediately precedes it. Beyond taking care that the l^ressure is not increased by tight lacing or injudicious arrangeme of the clothes, there is little that can be done to relieve this fo of breath lessuess. [Unless the patient has some cardiac lesion she Avill find nmch relief from insomnia at night b}' sleeping on her back in a reclined position. An inclined ])]ane may be improvised by using a four-foot board about eighteen inches wide, avcH packed with pillows, and ex- tending from above the middle of the bed to the head-board at an angle of forty-five degrees or less. The abdomen of the patient should be anointed twice a day with Avarm olive oil or inodorous lanolin, and she should bend her knees in bed over a large pillow, to relax her abdomen and to prevent her sli])ping down in the bed: she, in fact, sits on the })illow. Her head should also be supported forward on a cruss-p i 1 ] ow. — Ed. ] (Palpitation, like dyspnoea, may be due either to sympathetic dis- turbance or to mechanical interference with the jtroper action of the heart.' When occurring in weakly women it may be relerred to the functional derangements which accompany the chlorotic conditi(»n of the blood often associated with pregnancy, and is then best remedied by a general tonic reg imen and the administration of ferruginous pre i>:ii:a- tjons. At other times antispasmodic remedies may be indicated, and it is .seldom sufficiently serious to call for much special treatment. Attacks of fainting- are not rare, especially in delicate women of liighly-developed nervous temperament, and are, ])erhai>s, most common at or about the period of quickening. In most ciises these attacks can- not be classed as cardiac, but are more probably nervous in character, and they are rarely associated with complete abolition of consciousness. They rather, therefore, resendjle the condition described by the older authors as /ifpot/ieinia. The ])atient lies in a s(>mi-unconscions condition with a ieeble pulse and widely dilated l)upil, and this state lasts for DISEASES OF FREG NANCY. 207 varying periods from a few minutes to half an liour or more. In one very troublesome case under my care the condition often i-ecurred as frequently as three or four times a day, I have observed tliat it rarely occurs when the more common sympathetic ])henomena of preg- nancy, especially vomiting, are present. Sometimes it terminates with the ordinary symptoms of hysteria, snch as sobbing. (The treatment should consist during the attack in the administration of diffusible stinudants, such as ether, sal-volatile, and valerian, the patient being placed in the recumbent })osition, with the head low.i If frequently re- })eatod it is unadvisable to attempt to rally the patient by the too free administration of stimulants, [in the intervals a generally tonic regi- men and the administration of ferruginous remedies are indicated. If they recur with great frequency the daily application of the spinal ice- bag has proved of much service, l Extreme Anaemia and. Chlorosis. — In connection with disorders of the circulatory system may be noticed those which depend on the state of the blood. The altered condition of the blood, which has already been described as a physiological accompaniment of pregnancy (p. 143), is sometimes carried to an extent which may fairly be called morbid ; and either on account of the deficiency of blood-corpuscles or from the increase in its watery constituents a state of extreme anaemia and chlorosis may be developed. This may sometimes be carried to a very serious extent, the condition amounting to that known as " perni- cious anaemia." Thus, Gusserow^ records five cases in which nothing but excessive anaemia could be detected, all of which ended fatally. Generally, when such symptoms have been carried to an extreme ex- tent, the patient has been in a state of chlorosis before pregnancy. In cases of this aggravated type the patient will probably miscarry, and the induction of premature labor or abortion may even become im2:)era- tive. [The writer once made an interesting autopsy in a case of pernicious anaemia that went to full term and was delivered by an accoucheur whose patients had escaped death from the effects of labor in private practice during the thirty years prior to this event. He had remarked some weeks before, when her appearance was commented upon by the writer, "that such women were not fit to have children." Death took place in three hours after the birth of a female child now grown up, and was evidently due to an amount of blood-loss which would not be felt by a healthy woman. There was no external escape of blood after the uterus contracted, and the coagulae in the uterus and vagina only amounted to a few ounces. She was the most anaemic woman prior to her lying-in that the Avriter has ever seen in a pregnant state.— Ed.] Treatment. — The treatment must of course be calculated to improve the general nutrition and enrich the impoverished blood : a light and easily assimilated diet, milk, eggs, beef-tea, and animal food — if it can be taken — attention to the proper action of the bowels^ a due amount of stimulants, and abundance of fresh air, will be the chief indications in the general management of the case. Medicinally, ferruginous prep- ^Arch.f. G>/n, 1871, Bd. ii. S. 218. 208 riiKoxANcr. aratioMs will bo roquii'cd. Sonic j)i'af'titioiici"s (thjcct, apparciitlv without sulliciL'iit n-ason, to tlu' admiiii-ti-alioi) of inni diii-iii^ jn-cjiiiaiicv, as liabk' to j)roinote abortion. This uiil()un(k'(l jn-cjiidicc njay pnjbaljly be traced to the .sii])posed enunenat>;ohorus, such as the phosj)hide ol" /inc or fre e ])hnsp horus, also promise favorably and are well worthy of trial. / Some of tlie more a>;gravated cases are associated withja considirablei amount of serous efl"usiou into the cellular tissue, generally limited to the lower extremities, but occasionally extending to the arms, face, and neck, and even producing ascites and })leuritic ef!"usion. 1 Under the latter circumstances this complication is, of course, of great gravity, and it is said that after delivery the disa])pearance ol" the serous effu- sion may be accompanied by metastasis of a fatal character to the lung.s or the nervous centres. This form of oedema must be distinguished from the slight cedematous swelling of the feet and legs so commonly observed as a mechanical result of the pressiu'e of the gravid uterus, and also from those cases of redema associated with albuminuria. The\ treatment must be directed to the cause, while the disappearance of the effusion niay be promoted by the administration of diiu-etic drinks, the occasional use of saline aperients, and rest jnjjie horijzontjdj20si.tion. Albuminuria.— (-The existence of albumen in the urine of })rcgnant "women has for many years attracted the attention of obstetricians, and it is now well known to be associated, in ways still imperfectly understood, W'ith many important puerperal diseases.! Its ])resence in most cases of puerperal eclampsia was long ago pointed out by Lever in this country and Rayer in France, and its association with this disease gave rise to the theory of the dependence of the convulsion on uramiia, which is generally still entertained. It has been shown of late years, especially by Braxton Hicks, that this association is by no means so universal as was supposed ; or, rather, that in some cases the albuminuria l"ollows and does not precede the convulsions, of which it might therelbre be supposed to be the consequence rather than the cause; so that further investigations as to these particular points are still required. Modern researches have shown that there is an intimate connection between many other affections and albuminuria ; as, for example, certain i"orms of })aralysis, either of special nerves, as puerperal amaurosis, or of the S])inal system ; cephalalgia and dizziness; puerperal mania; and pos- sibly hemorrhage. It cannot, therefore, be doubted that albuminuria in the pregnant woman is liable, at any rate, to be associated with grave disease, although the present state of our knowledge does not enable us to define very distinctly its ])recise mode of action. The presence of albumen in the urine of ])regnant women is far from a rare phenomenon. Blot and I^itzman met with albuminuria in 20 per cent, of pregnant women ; which is, however, far above the esti- mate of other authors; Fordyce Barker' thinks it occurs in about 1 out of 25 cases, or 4 per cent.; while Hofmeier- found it in 137 out of ' Amrrican Jounxil of ObKtetric.t, 1878, vol. xi. p. 449. * Berlin, klin. Wocli.', h?e[)t., 1878. I DISEASES OF PREGNANCY. 209 5000 deliveries in the Berlin Gyniceologicul Institution, or 2.74 per cent. As in the large majority of these cases it ra[)i(lly (lisap})ears alter delivery, it is obvious that its presence must, in a large proportion of cases, depend on temporary causes, and has not always the same serious imj)ortance as in the non-pregnant state. This is further proved by the undoubted fact that albumen, rapidly disa])])earing after delivery, is often found in urine of pregnant women who go to term and jiass through labor without any unfavorable sym])toms. Pressure by the Gravid Uterus. -|^The ol)vious facts that in preg- nancy the vessels supplying the kidneys are subjected to mechanical pressure from the gravid uterus, and that congestion of the venous cir- ^ culatiou of those viscera must necessarily exist to a greater or less degree, suggest that here wq may find an explanation of the frequent occurrence of albuminuria.) This view is further strengthened by the fact that the albumen rarely appears until after the fifth month, and therefore not ! ^k> until the uterus has attained a considerable size ; and also that it is com- ■ paratively more frequently Jnet with in primiparse, in whom the resist- ance of the abdominal parietes, and consequent pressure, must be greater than in women who have already borne children. It is indeed probable that pressure and consequent venous congestion of the kidneys have an important influence in its production ; but there must be, as a rule, some other factors in operation, since an equal or even greater amount of pressure is often exerted by ovarian and fibroid tumors without any such consequences. They are probably complex. (One important con- dition is doubtless the increased amount of work the kidneys have to do in excreting the waste procfucts^oT'tlienfoeTus^as well as those of the mother. /The increased arterial tension throughout the body associated with hypertrophy of the heart, known to exist in pregnancy, also operates in the same direction. Bat in the large majority of cases, although these conditions are present, no albuminuria exists, and they must therefore be looked upon as predisposing causes, to which some other is added before the albumen escapes from the vessels. AVhat this is generally escapes our observation, but probably any condition pro- ducing sudden hypertemia of the kidneys and giving rise to a state analogous to the first stage of Bright's disease — such, for example, as sudden exposure to cold and impeded cutaneous action — may be suf- ficient to set a light to the match already prepared by the existence of pregnancy. It has more recently been pointed out that a transient albu- minuria, disappearing in a few days, is very common after delivery, and probably depends on a catarrhal condition of the urinary tract. Inger- sten observed this in 50 out of 153 deliveries, and in 15 only had any albumen existed before the confinement.' In addition to these tem- jjorary causes it must not be forgotten that pregnancy may supervene in a ]>atient already suiFering from Bright's disease, when of course the albumen will exist in the urine from the commencement of gestation. * The various diseases associated with the presence of albumen in the urine will require separate consideration. Some of these, especially puerperal eclampsia, are amongst the most dangerous complications of 1 Zeilschrift f. OebttrL, 1879, Band v. Heft 2. 14 210 rni:axAycr. prognancv. Others, such as paraly-is, ccplialalgia, dizzinoss, may also be of (•()nsi(leral)le gravity. 'Jlie jux-cisc mode of their produetioii, and whether they can be traced, as is generally believed, to the retention of urinary elements in the i)lood, either nrea(jr free carbonate of ammonia prodni-ed by its decomposition, or whether the two are only common results of some undetermined cause, will be considered when we ((tme to discuss j)uerperal convulsions. Whatever view may ultimatelv l>e taken on these jjoints, it is sufficiently obvious that albuminuria in a pregnant woman must constantly be a source of nuuh anxiety, and must induce us to look forward Mith considerable apprehension to the termi- nation of the case. Prognosis. — We are scarcely in possession of a sufficiently large number of oljservations to justify any very accurate conclusions as to the risk attending albuminuria during pregnancy, but it is cert ainly by n o mea ns sligh t. Hofraeier believes that albuminuria is a most severe complication both for woman and child, even when uncomplicated with eclampsia. The prognosis, he thinks, depends on whether it is acute in its onset — that is, coming on within a few days of labor — or is extended over several weeks. The former is more likely to pass entirely away after delivery, M'hile in the latter there is more risk of the morbid state of the kidneys becoming permanent and leading to the establishment of Bright's disease after the pregnancy is over. Goubeyre estimated that 49 per cent, of primiparse who have albuminuria, and who escape eclampsia, die from morbid conditions traceal)]e to the albuminuria. This conclusion is prol)al)ly much exaggerated, l)Ut if it even ai)})rox- imate to the truth tlie danger must be verv great. Besides the ultimate risk to the mother, albuminuria stron gly ])re dis- poses to abor tion, no doubt on account of the imperfect nutrition of the foetus by blood impoverished by the drain of albuminous materials through the kidneys. This fact has been observed by luany writers. A good illustration of it is given by Tanner,' who states that 4 out of 7 women he attended suffering from Bright's disease during |)regnaucy aborted, one of them three times in succession. Symptoms. — The symptoms accompanying albuminuria in preg- nancy are by no means uniform or constantly ])resent. That which most frequently causes suspicion is the anasarca — not only the redcma- tous swelling of the lower limbs which is so conuuon a consequence of the pressure of the gravid uterus, but also of the face and up})er extrem- ities. Any puffiness or infiltration about the face or any redema about the hands or arms should always give rise to suspicion and lead to a careful examination of the urine. Sometimes this is carried to an exag- gerated degree, so that there is anasarca of the whole body. Anomalous nervous sym])toms — such as headach e, transi ent dizz iness, diraiiess, of vision, spots before the eyes, inability to see objects dis- tinctly, sickness in Avomen not at other times suffering from nausea, sleeplessness, irritabilrty of temper — are also often met with, sometimes to a slight degree, at others very strongly developed, and should always arouse suspicion. Indeed, knowing as we do that many morbid states may be associated with albuminuria, we should make a point of carefully exam- * Signs and Diaaises of Pregnancy, p. 428. DISEASES OF PREGNANCY. 211 ining the urine of all patients in whom any unusually morbid phenom- ena show themselves during pregnancy. The co ndition of the urine vari es considerably, but it is generally scanty and highly colored, and, in addition to the albunie n. es[)ecially in cases in which the albuminuria has existed for some time, we may iind epithelium cells, tube-casts, and occasionally blood-corpuscles. Treatment. — The treatment must be based on what has been said as to the causes of the albuminuria. Of course it is out of our power to remove the pressure of the gravid uterus, except by inducing labor ; but its effects may at least be lessened by remedies tending to ] )romote an UK:]:ei.ig.t;d secretion of urine , and thus diminishing the congestion of the renal vessels. The administration of saline diuretics, such as the acetate ofl4)otash or bitartrate of potash , the latter being given in the form of the well-known imperial drink, will best answer this indication. The action of the bowels may be solicited by purgatives producing watery motions, such as occasional doses of the c ompound jalap p owder. Dry Clipping over the loins, frequently repeated, has a beneficialeffect in less- ening the renal hypersemia. The action of the skin should also Be promoted by the use of the vapor-bath, and with this view the Turkish bath may be employed with great benefit and perfect safety. Jaborandi and pilocarpin have been given for this purpose, but have been found by Fordyce Barker to produce a dangerous degree of depres- sion. The next indication is to improve the condition of the blood by appropriate diet and medication. A very light and easily assimilated diet should be ordered, of whic h milk should form the staple. Tarnier^ has recorded several cases in which a purely milk diet was very success- ful in removing albuminuria. With the milk, which should be skim- med, we may allow white of egg or a little white fish. jThe tincture of the perchloride of iron is thel)est medicine we can give, and it may be advantageously combined with small doses of tincture of digitalis, which acts as an excellent diuretic. ^ Finally, in obstinate cases we shall have to consider the advisabilityX "•of inducing premature labor. The propriety of this procedure in thef albuminuria of pregnancy has of late years been much discussed. Spiegelberg^ is opposed to it, while Barker^ thinks it should only be resorted to " when treatment has been thoroughly and perseveringly tried without success for the removal of symptoms of so grave a cha- racter that their continuance would result in the death of the patient." Hofmeier,* on the other hand, is in favor of the operation, which he does not think increases the risk of eclampsia, and may avert it alto- gether. I believe that, having in view the undoubted risks which attend this comj)lication, the operation is unquestionably indicated and is perfectly justifiable in all cases attended with symptoms of serious gravity. It is not easy to lay down any definite rules to guide our decision / but I should not hesitate to ado]>t this resource in all cases in which tire quantity of all)umen is considerable and progressively increasing, and in which treatment has failed to lessen the amount I and, above all, in every case attended with threatening symptoms, such as ^ Annal. de Oynec, 1876, torn. v. p. 41. ' Lehrbuch der Geburt. ' Amer. Jaiirn. of Obstet., 1878, vol. xi. p. 4-49. * Op. cit. 212 PREGNANCY. severe hcadaclie, dizziness, or loss of si^^l't- Tlie risks of the operation are infinitosiinal compared to those whicli tiie patient would run in tl«e event of puer|)eral convulsions supervening or chronic Bright s disease becoming cstahlished. As the operation is seldom likely to be indi- cated until the diild has reached a viable age, and as the albumimn-ia places the child's life in danger, Ave are (piite justified in considering the mother's safety alone in deteriiiining on its perlbrniance. Diabetes. — The occurrence of pregnancy in a woman suffering from diabetes may lead to serious consequences, and has recently been s])e- cially investigated by Dr. IMatthews Duncan.' This must be carefully distinguished from the physiological glycosuria commonly present at the end of })regnancy and (hiring lactation. It is probable that diabetic patients are ina])t to conceive, but A\'hen ])regnancv does occur under such conditions the case cannot be considered devoid of anxiety. From the cases collected by Dr. Duncan it would appear that pregnancy is very liable to be interrupted in its course, generally by the death of the foetus, which has very often occurred. In some instances no bad results h'ave been observed, while in others the patient has collajised after delivery. Diabetic coma does not seem to have been observed. Out of 22 pregnancies in diabetic women, 4 ended fatally, so that the mor- tality is obviously very large. Too little is known on this subject to justify positive rules of treatment; but if the symptoms are serious an( increasing it would probably be justifiable to niduce labor ]irematurely so as to lessen the strain to which the patient's constitution is sub jected. CHAPTER VIII. DISEASES OF PREGNANCY (CONTINUED). Disorders of the Nervous System. — There are many'disordei's of the nervous system met with during the course of pregnancy. Among the most common are morbid irritab ility of tem|) cr, or a state of men- tal despondency and dread of the resu Tts of t hembor, sometimes almost amounting to insanity or even progressing to actual mania. These are but exaggerations of the highly susceptible state of the nervous system generally associated with gestation. AVant_of jdeej) is not uncommon, and if carried to any great extent may cause serious trouble from the irritability and exhaustion it produces. In such cases we should* endeavor to lessen the excitable state of the nerves by insisting on the avoidance of late hours, overmuch society, exciting anuisemcnts, and the like; while it may be essential to promote sleep by the administration of sedatives, none answering so well as the c hloral hydrate, in combi- » 06s/. Trans., 1882, vol. xxiv. p. 256. DISEASES OF PREGNANCY. 2i3 nation with large doses of tlie bromide of potassium or sodium, wliicli greatly intensify its hypnotic effects. Severe he adache s and various intense neuralgias are common. Amongst the latter the most frequently met Avith are pain in the breasts, due to the intimate sympathetic connection of the mamnue with the gravid uterus, and intense intercostal neuralgia, which a careless observer might mistake for pleuritic or inflammatory pain. The thermometer, by showing that there is no elevation of tempera- ture, would prevent such a mistake. Neuralgia of the uterus itself or severe pains in the groins or thighs — the latter being probably the mechanical results of dragging on the attachments of the abdominal muscles — are also far from uncommon. (In the treatment of such neur- algic affections attention to the state of the general health and large doses of quinine and ferruginous preparations whenever there is much debility will be indicated, i Locally sedative applications, such as bella- donna and chloroform linunents, fi'ictiou with aconite ointment when the pain is limited to a small space, and in the worst cases the subcuta- neous injection of mor]ihia, will be called for. ' Those pains which apparently depend on mechanical causes may often be best relieved by lessening the traction on the muscles by wearing a Avell-made elastic belt to support the uterus. Paralysis. — Among the most interesting of the nervous diseases are various paralytic aff^ections. Almost all varieties of paralysis have been observed, such as paraplegia, h emipleg ia (complete or incomplete), facial paralysis, and paralysis of the nerves of special sense, giving rise to amaurosis, deafness, and loss of taste, Churchill records 22 cases of paralysis during pregnancy, collected by him from various sources. A large number have also been brought together by Imbert-Goubeyre in an interesting memoir on the subject, and others are recorded by For- dyce Barker, Joulin, and other authors ; so that there can be no doubt of the fact that paralytic affections are common during gestation. In a large proportion of the cases recorded the jjaralyses have been asso- ciated with albuminuria, and are doubtless ursemic in origin. Thus in 19 cases related by Goubeyre albuminuria was present in all; Darcy,^ however, found no albuminuria in 5 out of 14 cases. The dependency of the paralysis on a transient cause explains the fact that in the large majority of these cases the paralysis was not permanent, but disap- peared shortly after labor. In every case of paralysis, whatever be its nature, special attention should be directed to the state of the urine, and should it be found to be albuminous labor should be at once induced. This is clearly the ])roper coui'so to pursue, and we should certainly not be justified in running the risk that must attend the progress of a case in which so formidable a symptom has already developed itself. ^Mieu the cause has been removed the effect Avill also genei'ally rapidly disaji- pear, and the prognosis is therefore, on the whole, favorable. Should the ))aralysis continue after delivery, the treatment must be such as we would adopt in the non-pregnant state, and small doses of strychnia, along with faradization of the affected limbs, would be the best reme- dies at our disposal. 1 These de Pari.% 1877. 214 Pli EG NANCY. There are, liowevcr, unquestionably some cases of j)uerj)eral paraly- ■;is Avhicli are not unoniic in their oriaralysis, .-^ueh as cerebral c(m<:estion or embolism, may, now and a_i!;ain, be met uilli dtiiiiiii- j)regnancy, but cases of this kind uuist be of comparative rarity. Other cases are functional in their origin. Tarnier relates a case of hemiplegia which he could only refer to extreme ana?- nu'a. Some, again, may be hyslei'ical. Parai)legia is a))parenlly more\ frequently uneoinieeted with albuminuria than the other foi-ms of ])aralv-' sis; and it may eithei- dej)end on pi-essure of the gi'avid uterus on tlie uervcs as they })ass through the pelvis, or on rcHex action, as is some- times observed in connection with uterine disease. A\'hen, in such cases, the absence of albuminuria is ascertained by frequent examination of the urine, there is obviously not the same risk to the ])atient as in cases depending on urjcmia, and therefore it may be justifiable to allow pregnancy to go on to term, trusting to subsequent general treatment to remove the paralytic sym])toms. As the loss of power here depends on a transient cause, a favorable prognosis is quite justifiable. Partial })ar- alysis of one lower extremity, generally the left, sometimes occurs from pressure of the ftetal occiput, and may continue fur days or weeks, with a gradual improvement after ])arturition. Chorea. — Chorea is not infrequently observed, and forms a serious com])lication. It is generally met with in y oung wom en of delicate health and in the first pregnancy. In a large projiortion of the ca.ses the patient has already suffered from the disease befoi-e marriage. On the occurrence of pregnancy the disposition to the disease again becomes evoked, and choreic movements are re-established. This fact may be explained partly by the susceptible state of the nervous system, jiartly by the impoverished condition of the blood. Prognosis. — That chorea is a dangerous comjilication of ])regnancy is ajijiarent by the fact that out of 56 cases collected by Dr. Barnes' no less than 17, or 1 in 3, })roved fatal. Nor is it danger to life alone that is to be feared, for it appears certain that chorea is more apt to leave permanent mental disturbance when it occurs during ])regnau(y than at other times. Jt has also an unquestionable tendency to bi'ing on abor- tion or premature labor, and in most cases the life of the v\u\d is sacrificed. Treatment. — Tlie treatment ot" chorea during ])regnancy does not differ from that of the disease under more ordinary circumstances, and our chief reliance Avill be ])laced on such drugs as the licpior arseuicalis, b rnmide of p otassium, and iron . In the severe form of the disease the incessant movements and the weariness and loss of sleep may very seriously imjieril the life of the patient, and more prompt and radical measures will l)e indicated. (If, in spite of our remedies, the parox- vsms go on increasing in severity, and the patient's strength apjx'ai's to be exhausted, f)ur oidy resource is to remove the most evident cause by inducing labor, s Generally the symptoms lessen and disa]>j)ear soon after this is dune. There can be no question tliat the operation is per- ' Obd. Trans., ISGH, vol. x. \k 147. DISEASES OF PREGNANCY. 215 feotly jiistifiiil)]e, anarently sometimes of a neuralgic character, at othei"s associated with aphthous ' Arch. gen. de Med., 1856. DISEASES OF rREG NANCY. 217 patches on the iniK'ou.s luembmne, ascaridcs in the rectum, or pediculi in the Juiii-s oC the mens Veneris and labia. Cases are even recorded in which the pruritic irritation extended over the whole Ixxly. (Tlic trcatniejit is ditHcult and unsatisla(;toryi Various sedative a])plications may be tried, such as weak solutions of Goulard's lotion, oi{ a lotion composed of an ounce of the solution of the nnu-iate of niorphia, with a drachm and a half of hydrocyanic acid, in six ounces of watei\| or lone formed by mixing one part of chloroform with six of almond oil.) [A very useful form of medicatioii consists in the insertion into the vagina of a pledget of cotton-wool soaked in equal parts of the glycerin of borax and sulphurous acid; this may be inserted at bedtime, and withdrawn in the morning by means of a string attached to it. < Smearing the parts with an ointment consisting of boracic acid and | vaseline often answers admirably. In the more obstinate cases the solid nitrate of silve r may be lightly brushed over the vulva, or, as recommended by Tarnier, a solution of bichloride of mercury, of about the strength of two grains to the ounce, may be applied night and morning. The state of the digestive organs should always be attended to, and aperient mineral water may be usefully administered. When the pruritus extends beyond the vulva, or even in severe local cases, large doses of bromide of potassium may perhaps be useful in lessening the general hyperpesthetic state of the nerves. GEdema of the Lower Limbs. — Some of the disorders of pregnancy are the direct results of the mechanical pressure of the gravid uterus. The most common of these are ced_eraa and a varicose state of the j^ns .of..th,a-lawer._extremities, or even of the vulva. The former is of little consequence, provided Ave have assured ourselves that it is really the result of j^ressure, and not of albuminuria, and it can gener- ally be relieved by rest in the horizontal position. A varicose state of the veins of the lower limbs is very common, especially in multiparae, in whom it is apt to continue after delivery. The varicosity is gener- ally limited to the superficial veins, chiefly the saphena, ancl the veins on the inner surface of the leg and thigh ; sometimes the deeper veins are also aifected, and this is said to be accompanied by severe pain in the sole of the foot when the patient is standing or walking. Occasion-| ally the veins of the vulva, and even of the vagina, are also enlarged^ and varicose, producing considerable swelling of the external genitals. | Rest in the recumbent position and the use of an abdominal belt, so as to take the pressure off the veins as much as possible, are all that can be done to relieve this troublesome complication. If the veins ofj the legs are much swollen some benefit may be derived from an elas-} tic stocking or a carefully applied bandage. Laceration of the Veins. — Serious and even fatal consequences have followed the accidental laceration of the swollen veins. When lacera- tion occurs during or immediately after delivery — a not uncommon result of the pressure of the head — it gives rise to the formation of a vaginal thrombus. It has occasionally happened from an accidental injury during pregnancy, as in the cases recorded by Simpson, in which death followed a kick on the pudenda, producing laceration of a vari- cose vein, or in one mentioned by Tarnier, where the patient fell on the 218 rRKayAycv. t'do;o()f a chair, Sevoiv liciuoirliatic has lollowcd the acrcidcntal ni)>tiire of a vein in the h-g. Tiic only .sitisltu-tory ti-catiiiciit i.s prcssurt', a|t- |)liccl directly to the hleediiitr |)arts hy means of tlie Hntoms of consequence. \ In all ])rol)ability it is common enough when jiregnancv occurs in a uterus which is more than usually antevertcd or is anteflexed. Under such circumstances there is not the same risk of incarceration in the pelvic cavity as in cases in Avhich pregnancy exists in a retroflexcd uterus, for as the uterus increases in size it rises without difliculty DISEASES OF PREGNANCY. 219 into the alxloniiiiul cavity. Fn the oai'ly months the pressure of thej fundus on the hhulder may account for the irrital)ility of tliat viscus then so commonly observed. It will be remembered that Graily Hewitt! attributes great importance to this condition as explaining the sickness of ])regnuncy — a theory, however, which has not met with general acceptation. Extreme anteversion of the uterus at an advanced })cri()(! of i)reg- nancy is sometimes observed in multipanc with very lax abdominal walls, occasionally to such an extent that the uterus falls completely forward and downward, so that the fundus is almost on a level with the patient's knees. This form of pendulous belly niay be associated with a separation of the recti muscles, between which the womb forms a ventral hernia covered only by the cutaneous textures. When labor comes on this variety of displacement may give rise to trouble by de- stroying the proper relation of the uterine and pelvic axes. The_ii'eat- ment is purely mechanical^ keeping the patient lying on her back as much as possible and supporting the pendulous abdomen by a proi)erly adjusted bandage. A similar forward displacement is observed in cases of pelvic deformity, and in the worst forms in rachitic and dwarfed Avomen it exists to a very exaggerated degree. The most important of the displacements, in consequence of its occasional very serious results, is retroversion of the gravid uterus. It was formerly generally believed that this was most commonly pro- duced by some accident, such as a fall, which dislocated a uterus pre- viously in a normal position. Undue distension of the bladder was also considered to have an important influence in its production by pressing the uterus backward and downward. Causes. — It is now almost universally admitted that, although the above-named causes may possibly sometimes produce it, in the very large proportion of cases /it depends on pregnancy having occurred in a uterus previously reh'overted or retroflexed.j Tlie merit of pointing out this fact unquestionably belongs to tire late Dr. Tyler Smith, and further observations have fully corroborated the correctness of his views. In the large majority of cases in which pregnancy occurs in a uterus so displaced, as the womb enlarges i t str aighj£ns,.itaelf and rises into the abdominal cavity, M-ithout giving any particular trouble; or, as not unfrequently happens, the abnormal ]>osition of the organ interferes so much with its enlargement as t o p rqduce-jabortion. Sometimes, ho^v- ever, the uterus increases without leaving the pelvis until the third or fourth month, when it can no longer be retained in the pelvic cavity without inconvenience. It then presses on the urethra and rectum, and eventually becomes completely incarcerated within the rigid walls of the bony jK'lvis, giving rise to characteristic sym])toms. Symptoms. — The first sign which attracts attention is generally some trouble connected with micturit ion, in consequence of pressure on the urethra! On examination the bladder will often be found to be enormously distended, forming a large, fluctuating abdominal tumor M'hich the patient has lost all power of emptying. Frequently small quantities of urine dribble away, leading the woman to believe that she 220 rnhayAycY. has |)ass('(l water, aii empty the bowels "licconie estab- lished al)(»nt the san)e time. These symptoms increase, accom|)anie(l by some pelvic i)ain and a sense of weiosterior vaginal wall, which occasionally ])rotrudes beyond the vulva. On ])assing the finger forward and upward we shall generally be able to reach the cervix, high up behind the pubes and pressing on the ure- thral canal. In very complete retroversion it may be difficult or impos- sible to reach the cervix at all. . On abdominal examination the fundus uteri cannot be felt above the pelvic brim i this, as the retroversion docs not give rise to serious symptoms until between the third and fbiyth months, should, under natural circumstances, always be possible. (By l)imanual examination we can make out, with due care, the alternate relaxation and contraction of the uterine parietes characteristic of the gravid uterus, and so differentiate the swelling from any other in the same situation^ The accomjxuiving ])henomcna of ]>regnancy will also prevent any mistake of this kind. In some few cases retroversion has been supposed to go on to term. Strictly speaking, this is impossible; but in the su]i])osed examples, such as the well-known case recorded by Oldham, part of a retroflexed uterus remained in the pelvic cavity, while the greater ]>art developed in the abdominal cavitv. The uterus is therefore divided, as it were, DISEASES OF PREGNANCY. 221 into two portions — one, Avliicli is the flexed finulns, remaining in the pelvis, the otiier, containint;' tlie greater part of tlie fVetns, rising above it. Under these eircnnistanees a tumor in the vagina would exist in combination with an abdominal tumor, and pregnancy might go on to term. Considerable difficulty may even arise in labor, but the malpo- sition generally rectifies itself before it gives rise to any serious residts. Treatment. — Tlie treatment of retroversion of the gravid uterus should be taken in hand as soon as possible, for every day's delay involves an increase in the size of the uterus, and leads, therefore, to greater difficulty in reposition. Our object is to restore the natural direction of the uteru s by lifting the fundus above the promontory of the sacrum. The first thing to be done is to relieve the patient by e mptying- the blad der, the retention of urine having probably originally called attention to the case. For this purpose it is essential to use a long elastic male catheter of small size, as the urethra is too elongated and compressed to admit of the passage of the ordinary silver instrument. Even then it may be extremely difficult to introduce the catheter, and sometimes it has been found to be quite impossible. Under such cir- cumstances, provided reposition cannot be effected without it, the bladder may be punctured an inch or two above the pubes by means of the fine needle of an aspirator, and the urine drawn off. Dieulafoy's work on aspiration proves conclusively that this may be done without risk, and the operation has been successfully performed by Schatz and others. It very rarely happens, hoAvever, and in long-neglected cases ouly, that the withdrawal of the urine is found to be impossible. The bladder being emptied, and the bowels being also opened, if pos- sible, by copious enemata, we proceed to. attempt reduction. For this purpose various procedures are adopted. ( If the case is not of very long standing, I am inclined to think that the gentlest and safest plan is the continuous pressure of a caoutchouc bag, filled with water, placed in the vagina. \ The good effect of steady and long-continued pressure of this kind was proved by Tyler Smith, who effected in this way the reduction of an inverted uterus of long standing, and it is not difficult to under- stand that it may succeed when a more sudden and violent effort fails. I have tried this plan successfully in two cases, a pyriform india-rubber bag being inserted into the vagina and distended as far as the patient could bear by means of a syringe. The Avater must be let out occasion- ally to allow the patient to empty the bladder, and the bag immediately refilled. In both my cases reposition occurred within twenty-four hours. Barnes has failed with this method ; but it succeeded so Avell in my cases, and is so obviously less likely to prove hurtful than forcible reposition with the hand, that I am inclined to consider it the prefer-_ able procedure and one that should be tried first. (Failing with the fluid pressure, we should endeavor to replace the uterus' in the following way: The patient should be placed at the edge of the bed in the ordi-1 nary obstetric position, and thoroughly ana?sthetizcd. This is of import- ance, as it relaxes all the parts and admits of much freer manipulation than is otherwise possible. One or more fingers of the left hand are then inserted into the rectum — if the patient be deeply chloroformed it is quite possible, with due care, even to pass the whole hand — and an 222 PREGNAycv. attempt is tlien iiiadi' to lift or j)ush tlic ("uikIus above the promontory of the sacniin. At the same time iej)ositioii is aided bv chawinji; down tlie cervix witli tiie tin«iers of the ri<2;ht hand j/cr luu/iiKnn. It has been insisted tiiat the jiressnre shoidd be made in the direction of one or other saero-iliac synchondrosis I'ather than directly npward, so that the uterus may not be jammed against the j)rojectiou of the promontory of tlie sacrum. Failing reposition througli the rectum, an attempt may be madeyyr/' r(i(/iii(i/it, and for this some liave advised the uj)\\ard |)r(ssnre of the closed fist passed into the canal. (Others reeonnnend the hand-and- knee position as facilitating rej)osition, but this prevents the administra- tion of chloroform, Avhich is of more assistance than any change of position can possibly be. Various complex instruments have been invented to facilitate the operation, but they are all more or less danger- ous, and are unlikely to succeed when manual ])ressure lias failed. As soon as the reduction is accomplished, subsequent descent of the uterus should be prevented by a large-sized Hodge's ])essarv, and the patient should be ke])t at rest for some days, tlie state of the bladder and bowels being ])articularly attended to. \\' hen repositiou has been fairly effected a relapse is unlikely to occur. >-ln cases in which reduction is found to be impossible our only /resource is the artificial induction of abortion. Under such circum- stances this is imperatively called for. It is best effected by ])unctur- ing the membranes, the discharge of the liquor amuii of itself lessen- ing the size of the uterus, and thus diminishing the pressure to -which the neighboring parts are subjected. After this, rej)osition may be pos- sible, or Ave may wait until the foetus is spontaneously expelled. It is not ahvays easy to reach the os uteri, although we can generally do so Avith a curved uterine sound. If we cannot j)uncture the membranes, the liquor amnii may be drawn off through the uterine walls by means of the aspirator inserted through either the rectum or vagina. The injurv to the uterine walls thus inflicted is not likely to be hurtful, and the risk is certainly far less than leaving the case alone. Naturally, so extreme a measure would not be adopted until all the simpler means indicated have l)eon tried and failed. Diseases coexisting with Prep-nancy . — The ])regnant woman is, of cou^e^iaEle^con tract thii yuiliy diseases as in the non-pregnant state, and pregnancy may occur in M'omen already the subject of some constitutional disease. There is no doubt yet much to be learned as to the influence of coexisting disease on pregnancy. It is certain that some diseases are but little modified by pregnancy, and that others are so to a considerable extent, and that the influence of the disease on the foetus varies much. The subject is too extensive to be entered into at any length, but a few words may be said as to some of the more important affections that are likely to be met with. The eruptive fevers have often very serious consequences, propor- tionate to the intensity of the attack. Of these variol a has the most disastrous results, Avhieh are related in the writings of the older authors, but which are, fortunately, rarely seen in these days of vaccination. (The severe and confluent forms of the disease are almo.s^ certainly fata l to both the mother and child .) In the discrete form and in modified DISEASES OF PREGNANCY. 223 smallpox after vaccination the patient generally has the disease favor- ) ably, and, although abortion frequently results, it does not necessarily^ do so. " If scarlet fever of an intense character attacks a pregnant woman, a bortio n is li kely to occur and the risks to the mother are very great. The mlTd^LT cases run their course without the production of any unto- ward symptoms. Should abortion occur, the well-known dangerous effect of this zymotic disease after delivery will gravely influence the prognosis. Cazeaux was of opinion that pregnant women are not apt to contract the disease ; while Montgomery thought that the ]}oison when absorbed during pregnancy might remain latent until delivery, when its characteristic effects were produced. yVEeasles, unless very severe, often ru ns its course without seriously affecting the mother or child. \ I have myself seen several examples of this. De Tourcoing, however, states that out of 15 cases the mother aborted in 7, these being all very severe attacks. Some cases are recorded in which the child was born with the rubeolous eruption upon it. The pregnant woman may be attacked with any of the continued fevers, and if they are at all severe they are apt to produce a bortion . Out of 22 cases of typhoid, 16 aborted, and the remaining 6, who had slight attacks, went on to term ; out of 63 cases of relapsing fever, abortion or premature labor occurred in 23. According to Schweden, the main cause of danger to the foetus in continued fevers is the hyper- l^yrexia, especially when the maternal temperature reaches 104° or upward. The fevers do not appear to be aggravated as regards the mother, and the same observation has been made by Cazeaux with regard to this class of disease occurring after delivery. Pneu monia seems to be specially d angerous, for of 1 5 cases collected by Grisolle,' 11 died — a mortality immensely greater than that of the disease in general. The larger proportion also aborted, the children being generally dead, and the fatal result is probably due, as in the severe continued fevers, to hyperpyrexia. The cause of the maternal mortality does not seem quite apparent, since the same danger does not appear to exist in severe bronchitis or other inflammatory affections. Contrary to the usually received opinion, it appears certain that pregnancy has no retarding influence on coexisting phthisis, nor does the disease necessarily advance with greater rapidity after delivery. Out of 27 cases of ])hthisis collected by Grisolle, 24 showed the first symptoms of the disease after pregnancy had commenced. Phthisical Avomen are not apt to conceive — a fact which may probably be explained by the frequent coexistence in such cases of uterine disease, especially severe leucorrhoea. The entire duration of the phthisis seems to be shortened, as it averaged only nine and a half months in the 27 cases collected — a fact which proves at least that pregnancy has no material influence in arresting its progress. If we consider the tax on the vital powers which pregnancy naturally involves, we must admit that this view is more physiologically ])robable than the one generally received, and apparently adopted without any due grounds. ' Arch. gen. de Med., vol. xiii. p. 291. 224 piiKayAycY. Tlu' I'vil ofTccts of preornaiicy aixl paidirition on clironic h eart dis- e ase ha ve ol" late rercivcd iiiufli attention from Sj>ieo;eIl)('rj;, I'^ritnli, Peter, and other ^\■riters. The subject has been ably discussed ' in a series of elaborate papers bv Dr Angus Maedonald, which are well worthy of study. Out of 28 eases collected by him, 17, <>v 00 per cent., proved iiital. This, no doubt, is not altogether a relialjlc estimate of the pr(»l)able risk of the coMiplication ; but, at any rate, \t shou.>|< the serious anxiety which the occui'rence of pregnancy in a patient Mif4 j Ifering from chronic heart-disease nuist cause, i Dr. Maedonald refers thqj //evils resulting from pregnancy in connection with cardiac lesions to 'two causes: first, destruction of that ecpiilibriuni of the circulation which has been established l)y compensatory arrangements ; secondly, the occurrence of fresh inflammatory lesions upon the valves of the heart already diseased. The dangerous symptoms do not usually appear until after the first half of the pregnancy has passed, and the j>regnaucy seldom advances to term. The pathological phenomena generally met with in fatal cases are pulmonary congestion, especially of the l^ronchial mucous mem- brane, and pulmonary oedema, with occasional pneumonia and })leurisy. ]Mitral stenosis seems to be the form of cardiac lesion most likely to prove serious, and next to this aortic incompetency. The r»l)vious deduction from these facts is that heart disease, especially when asso- ciated with serious symptoms, such as dyspncca, palpitation, and the like, should be considered a strong contraindication of marriage. When pregnancy has actually occurred, all that can be done is to enjoin the careful regulation of the life of the patient, so as to avoid exposure to cold and all forms of severe exertion. The important influence of syphili s on the ovum is fully considered elsewhere. As regards the mother, its effects are not different from those at other times. It need only therefore be said that whenever indications of syphilis in a pregnant woman exist, the a})proj)rinte treatment should be at once instituted and carried on during her ges- tation, not only with the view of checking the progress of the disease, but in the hope of preventing or lessening the risk of abortion or of the birth of an infected infant. So far from pregnancy contraindica- ting mercurial treatment, there rather is a reason for insisting on it more stronglv. As to the precise medication, it is advisable to choose a form that can be exhil)ited continuously foi' a length of time without produ- cing serious constitutional results. VSmall doses of the bichloride of i mercury, such_aa.QJaCrSixte£nth_of .ILgrain thrice daily^orbf the iodide jof mercury, or of the hydrargyrum cum_creta in wmbination with 'reduced iron, answer the ])nrposc well; or in the early stages of preg- nancv the me rcurial vapor-b ath or cutaneous i nunction may be employed. Dr. Weber of St. Petersburg ^ has made some observations showing the superiority of the latter methods, which he found did not interfere with the course of pregnancy ; the contrary was the case when the mer- cury was administered by the mouth, probably, as he supposes, from disturbance of the digestive system. It must be borne in mind that in 1 Obst. Journ., vol. v., 1877, p. 217. » Allyem. Med. Cent. Zeit., Feb., 1875. DISEASES OF PREGNANCY. 225 married women it may sometimes be expedient to preserihe an anti- sypliilitic course M'itliout their knowledt^e of its nature, so tliat inunc- tion is not always feasible. The influence of j)regnancy on ^ pilep sv chjcs not api)ear to be as uni-* form as might perhaps be expected. In some cases the number and{ intensity of the fits have been lessened, in others the disease becomes aggravated. Some cases are even recorded in wliich epilepsy api)eared for the first time during gestation. On account of the resemblance' between epilepsy and eclampsia there is a natural apprehension that a pregnant epileptic may suffer from convulsions during delivery. Fortunately, this is by no means necessarily the case, and labor often goes on satisfactorily without any attack. Certain diseases of the eye are observed during pregnancy. They have been well studied by l^lr. Power.^ One of the most common disturbances of vision is due to temporary impairment of accommoda- tion, most generally in patients who are naturally hypermetroj^ ic, and is dependent on exhaustion of the neuro-muscular apparatus. The symptoms are chiefly difficulty in reading, sewing, or other work requiring minute vision — pain, black spots before the eyes, lachryma- tiou, etc. Suitable convex glasses may be req uired, and with attention to the general health the symptoms may disappear. Other diseases more serious and lasting in their results are also met with. Mr. Power describes certain important changes in the eye met with in cases of albu- minuria. The optic disk is swollen and congested, and irregular hem- orrhages and white disks are seen in the retina. The hemorrhages he ascribes to actual rupture of the vessels ; the white patches to a lesser degree of distension, admitting of the escape of white corpuscles through the vascular walls. In many of these cases the vision was ultimately regained. Another form of disease he describes is " white atrophy of the optic disk," probably following neuritis, occurring in cases in which there had been irreat loss of blood. Jaundice, the result of acute yellow atrophy of the liver, is occa- \ sionally observed, and is said to have been sometimes epidemic, Inde- ' pendently of the grave risks to the mother, it is most likely to produeej abortion or the death of the foetus. According to Davidson,- it origi- nates in catarrhal icterus, the excretion of the bile-products being impeded in consequence of ]">reguancy, and their retention giving rise to the fatal blood-poisoning which accompanies the severer forms of the disease. Slight and transient attacks of jaundice may occur without being accompanied by any bad consequences. Their production is probably favored by the mechanical pressure of the gravid uterus on the intestines and the bile-ducts. The occurrence of pregnancy in a woman suffering from malignant disease of the uterus is by no means so rare as might be supjiosed, and must naturally give rise to much anxiety as to the result. The obstet- rical treatment of these cases will be discussed elsewhere. Should we be aware of the existence of the disease during gestation, the question will arise whether we should not attempt to lessen the risks of delivery by bringing on abortion or premature labor. The question is one which 1 Barnes, Obst. Med., vol. i. p. 390. « Monat.J. GeburL, 1S67, Bd. xxx. S. 452, 15 226 PREGNANCY. is by no means oasy to settle. AVc have to deal with a disease wliieh is certain to prove fatal to the mother l)ef"ore l(»n^, and the pn^gre.ss of which is })r<>i)ably accelerated after labor, while the manipnlations neces- sary to induce delivery may very unfavorably influence the diseased structures. Again, by such a measure we necessarily sacrifice the child, while we are by no means certain that we materially lessen the danger to the mother. The question cannot be settled excejit on a considera- tion of each ])articu]ar case. If we see the patient early in pregnancy, by inducing abortion we may save her the dangers of labor at term — possibly of the Ctesareau section — if the obstruction be great. Under such circinn stances the operation would be justifiable. If the pregnancy has advanced beyond the sixth or seventh month, unless the amount of malignant deposit be very small indeed, it is probable that the risks of labor would be as great to the mother as at term, and it Avould then be advisable to give her the advantage of the few months' delay. Cases are occasionally met with in Avhich pregnancy occurs in women who are suifering from ovarian tumor, and their proj)er management has g-iven rise to considerable discussion. There can be no doubt that such cases are attended with very dangerous and often fatal conse- quences, for the abdomen cannot well accommodate the gravid uterus and the ovarian tumor, both increasing simultaneously. The result is that the tumor is subject to much contusion and pressure, which has some- times led to the rupture of the cyst and the escape of its contents into the peritoneal cavity; at others, to a low form of inflammation attended with much exhaustion, the death of the patient supervening either before or shortly after delivery. The danger during delivery from the same cause in the cases which go on to term is also very great. Of 13 cases of delivery by the natural powers which I collected in a paper on *' Labor complicated with Ovarian Tumor," ^ far more than one-half proved fatal. Another source of danger is twisting of the pedicle, and consequent strangulation of the cyst, of which several instances are recorded. It is obvious, then, that the risks are so manifold that in » every case it is advisable to consider whether they can be lessened by i surgical treatment. ' /' The means at our disposal are either to induce labor prematurely, to ( treat the tumor by tap])ing, or to j)erform ovariotomy. /^The (juestion j has been particularly discussed by Spencer Wells in (his works on' Ovariotomy, and l)y Barnes in his Obsfdric Operation.^. The Ibrmer holds that the proper course to pui-sue is to tap the tumor when there is any chance of its being materially lessened in size by that ]>rocedure, but that when it is multilocular or when its contents are solid ovariotouiyl should be performed at as early a period of pregnancy as possible/ Barnes, on the other hand, maintains that the safer course is to imitate the means by which nature often meets this complication, and bring ou premature labor without interfenng with the tumor. He thinks ovari- otomy out of the question, and that tajiping may be insufficient and leave enough of the tumor to interfere seriously with labor. So far as recorded cases go, they unquestionably seem to show that tajiping is not more dangerous than at other times, and that ovariotomy may be 1 Obst. Trans., 1867, vol. ix. p. 69. DISEASES OF PREGNANCY. 227 practised flaring ]>regiiancy with a fair amount of success. AVells records 10 cases which were surgically interfered with. In 1 tapping was j)erfornied, and in 9 ovariotomy ; and of these 8 recovered, the j)regnancy going on to term in 5. On tlie other hand, 5 cases were left alone, and either went to term or spontaneous premature labor super- vened ; and of these, 3 died. The cases are not sufficiently numerous to settle the question, but they certainly favor the view taken by Wells rather than that by Barnes. It is to be observed that unless we give up all hope of saving the child and induce abortion, the risk of induced premature labor when the pregnancy is sufficiently advanced to hope for a viable child woidd almost be as great as that of labor at term ; for the question of interference will only have to be considered with regard to large tumors, which would be nearly as much affected by the pressure of a o-ravid uterus at seven or eio-ht months as bv one at term. Small tumors generally escape attention, and are more apt to be impacted before the presenting part in delivery. The success of ovariotomy during pregnancy has certainly been great; and we have to bear in mind that the woman must necessarily be subjected to the risk of the operation sooner or later, so that we cannot judge of the case as one in which abortion terminates the risk. Even if the operation should put an end to the pregnancy — and there is at least a fair chance that it will not do so — there is no certainty that that would increase the risk of the operation to the mother, while as regards the child we should only have the same result as if we intentionally produced abortion. On tlTeTN whole, then, it seems that the best chance to the mother, and certainly j the best to the child, is to resort to the apparently heroic treatment | recommended by Wells. The determination must, however, be to some extent influenced by the skill and experience of the operator. If the medical attendant has not gained that experience which is so essential for a successful ovariotomist, the interests of the mother would be best consulted by the induction of abortion at as early a period as possible. One or other procedure is essential ; for, in spite of a few cases in which several successive pregnancies have occurred in women who have had ovarian tumors, the risks are such as not to justify an expectant practice. Should rupture of the cyst occur, there can be no doubt that ovariotomy should at once be resorted to, with the view of removing the lacerated cyst and its extravasated contents. Pregnancy may occur in a uterus in which there are one or more fibroid tum ors. During pregnancy they may lead to premature labor or abort ion, to peritonitis , or they may cause so much pain and discom-™ fort from their size as to rciidci' interference imperative. ir'the5^*are situated low down and in a jjosition likely to obstruct the passage of the foetus, they may very seriously comjilicate delivery. AVhen thev are situated in the fundus or body of the uterus they mav give rise to risk from hemorrhage or from inflammation of their o-svu- structure. Inas-| much as they are structurally similar to the uterine walls, they partakel of the growth of the uterus during pregnancy, and frequently increasej remarkably in size. Cazeaux says : " I have known them in several instances to acquire a size in three or four months which they would not have done in several years in the non-pregnant condition." Con- 228 PRi'y;\A.\CY. vcrsely, tlicy sliaro in the iiivdliitioii (»(" tlic uterus after dclivorv, and often lessen <;ivatly in size or even entirely disapjx'ai". Of" this I'act I have elsewhere recorded several curious exani])les;' and many other instances of" the complete disappearance of oven large tumors have Iteen described by authors whose accuracy of observation cannot be (jues- tioued. The tr eatment will vary w ith the size and position ol" the tumoi-, ami every case must be treated on its own merits, since it is not possible to lay down rules that will aj)})ly to all cases alike. A f"nll report of" all recent cases will be found in Dr. John l*hillii)s'^ recent j)aper, which shows how serious the results often are. If the position of the tumor be such as to render it certain to obstruct delivery, the production of early abortion is perhajjs the best course to })ursue. It is not without serious risks, but j)rubal)ly less than allowing- pregnancy to proceed to term. In several instances either the removal of the tumor itself by abdominal section (myomotomy) or the remov al of the tum or a nd th e gravid uterus (^liillcr's ablation) has been resorted to on accounl of the grave concomitant symptoms, aud with a fair measure of success. If the tumor is well out of the way, interference is not so urgently called for. The principal danger then is that the tumor will impede the post- partum contraction of the uterus and favor hemorrhage. Even if this should happen, the flooding could be controlled by the usual means, especially by the injection of the perchloride of iron. I have seen several cases in which delivery lias taken place under such circum- stances without any untoward accident. The danger from inflamma- tion and subsequent extrusion of the fibroid masses would proi)ably be as great after abortion or premature labor as after delivery at term, ^'i seems, therefore, to be the proper rule to interfere when the tumors are i likely to impede delivery, and in other cases to allow the pregnancy to { go on, and be prepared to cope with any complications as they arise, t The risks of pregnancy should be avoided in every case in which uterine ; fibroids of any size exist, the patients being advised to lead a celibate j life. 1 Obst. Trans., 1869, vol. x. p. 102; 1872, vol. xiii. p. 288 ; 1877, vol. xix. p. 101. ^ " The Management of Fibro-myomata complicating Pregnancy and Labor," Brit. Med. Journ., 1888, vol. i. p. 1331. PATHOLOGY OF THE DECIDUA ASD OVUM. 229 CHAPTER IX.- PATHOLOGY OF THE DECIDUA AND OVUM. Patholog-y of the Decidua. — Comparatively little is, unfortunately, known of the pathological changes Avhich occur in the mucous mem- brane of the uterus during pregnancy. It is probable that they are of much more consequence than is generally believed to be the case, and it is certain that they are a fi'('(jii('iit cause of abortion. ' One of the most generally obscrxcd probably depends on endome- tritis antecedent to conception. When the impregnated ovulelreaclied the uterus it engrafted itself on the inflamed mucous membrane, which Fig. 88. Hypertrophied Decidua laid open, with the ovum attached to its fundal portion. (After Duncan.) was in an unfit condition for its reception and growth. ( A not uncom- mon result under such circumstances is the laceration of some of the decidual vessels, extravasation of the blood between the decidua and the 230 mEnxAXCY uterine walls, and consequent ahurti(jn at an early stajje of prerol)ably depends on some obscure morbid state of the uteriue mucous membrane. By it is meant a dis- chaj'ge of clear watery fluid at in- tervals during pregnancy. It may happen at any period of gestation, but is most commonly met with in the latier nioiiths. It may com- mence with a mere dribbling, or there may be a sudden and copi- ous discharge of fluid. Afterward the watery fluid, which is genei'ally of a pale-yellowish color and trans- ])arent like the liquor amnii, may continue to escape at intervals for many weeks, and sometimes in very ' Vircliow'n Archir. fur Path., ISOl, 1st ed. * Researches in Obstetrics, p. '293. Fig. 89. Imperfectly developed Decidua Vera, with the ovum. (After Duncan.) 1 PATHOLOGY OF THE DECIDUA AND OVUM. 231 •great abiuidaiu'c, so as to saturate the patient's clothes. Very frequently it is expelled in gushes and at night, when the patient is lying quietly in bed; its esea])e is then ])rol)ably due to uterine (contraction. Many theoricij have been held as to its cause. Wy some it is attrib- uted to the nipiiirc of a cyst placed between the ovum and the uterine walls: Baudelocque referred it to a transudation of the liquor amnii through the membranes, while Burgess and T)ul)ois l)elieved If to de[)end on a l aceration of the memb ranes at a distance from the os iiteri ; (.Mattel more recently has attributed" irio tlie existence of a sac between the chorion and the amnion. \ It may be that in some instances a single discharge of fluid may come from one of the two last- mentioned causes. But if it be continuous or repeated, another source must be sought for. Heger^ maintains that it is the result of abundant secretion from the glands of the mucous iiicnil)rane, which are iifa state of chronic inflammation, the fluid accumulating between the decidua and chorion and escaping through the os uteri. If this occur, the decidua is probably in an hypertro^ihied and otherM'ise morbid state. (Hydrorrha?a is chiefly of interest from the error of dia^osis it is likely to give rise to,'^ for on being summoned to a case in which watery discharge has occurred for the first time, we are naturally apt to sup])Ose that the membranes have ruptured and that labor is imminent. Nor is there any very certain means of decid- ing if this be so. In hydrorrha?a we find that pains are absent, the os uteri unopened, and ballottement may be made out. Even if the mem- branes be ruptured there will be no indication for interference unless labor has actually commenced ; and the repetition of the discharge and the continuance of the pregnancy will soon clear up the diagnosis. Hydrorrhoea, although apt to alarm the patient, need not give rise to any anxiety. The pregnancy generally ]>r(igrcsses favorably to the full period, although in exceptional "cases jnomature labor may supervene. No treatment is necessary, nor is there any that could have the least effect in controlling the discharge. Patholog"y of the Chorion. — The only important disease of the chorion with which we are acquainted is the well-known condition which is variously described as uterine hydatids, cystic disease pj. the ovum, hydatid if orm degeneration of the chorion, or vesicular mole. The name of uterine hydatids was long given to it on the supposition that the grape-like vesicles which characterize the disease were true hydatids^ similar to those which develop in the liver and other structures. This idea has long been exploded, and it is now known as a certainty that the disease originates in the villi of the chorion. The precise mode and the causes of its production are, however, not yet satisfactorily settled. The disease is characterized by the existence in the cavity of the uterus of a large number of translucent vesicles, containing a clear limpid fluid which has been found on analysis to bear close resemblance to tlie li(pK)r amnii. These small bladder-like bodies, which vary in size from that of a millet-seed to an acorn, are often described as resembling a bunch of grapes or currants. On more minute examination they are found not to be each attached to independent pedicles, as is the case in ' Monat. f. GeburL, 1863, Bd. xxii. S. 429. O'lO PREOXANCY. a buucli of ;j;rai)(-'s, l)nt some oi" tlu'iii «5ro\v Iroiu other vt'sicles, while other.s liavo distinct pedicles attached to the chorion, the jx'dicles themselves sometimes bein The first physical sign remarked is rapid increase _of the uterine tu mor, which soon does not correspond in size to the supposed period of pregnancv. . Thus at the tliiiil mouth the uterus may be found to reach up to or beyond the umbilicus. About ' Virchow's Archiv, vol. xliv. p. 86. ^ 06s/. Trans., 1871, vol. xii. p. 237. ^ McClintock's Diseases of Women, p. 398. 234 PREGNANCY. this time there generally are more or less profuse watery and san^-Miiiic - o us dis eh artres . which have heen deserihed as reseiiii)liii<'' ciirraiit-iiiicc. jThey no doiri)t depend on the l)r('akin<>: down and cxjjulsion of the \cysts, caiisetl by })ainles8 uterine contractions. They are soniotiiucs excessive in amount, recur wMth threat lVe(iueney, and often reduce the patient extremely. Portions of cysts may now generally be found minoled with the discharge, and sometimes large masses of them are expelled from time to time, ijndeed, the d iscovery of portions of cvst s is the only certain diagnostic sign."^ Vaginal examination, bcfoi-c the os has dilated, will give no information except the absence of ballottement. An unusual hardness or density of the uterus — described by Lcishman, who attributes much importance to it, as "a peculiar doughy, boggy feeling" — has been pointed out by several writers. The contour of tlie uterine tumor, moreover, is often irregular. In addition, we of course fail to discover the usual auscultatory sig-ns of prep^nanc v. All this may aid in diagnosis, but nothing except the presence of cysts in the watery bloody discharge will enable us to pronounce with certainty as to the nature of the disease. Treatment. — As soon as the diagnosis is established the indications for treatment are obvious. T he sooner the u terus is cloarod of its con - t ents th e better. Ergot may be given with acKantagc to favor uterine contraction and the expulsion of the diseased ovum. Should this fail, more especially if the hemorrhage be great, the fingers or the whole handjnuist be^introduced into the uterus and as much as jiossible of the mass removed. As the os is likely to be closed, its preliminary dilata- tion by sponge or laminaria tents, or by a Barnes' bag if it be already opened to some extent, will in most cases be required. If chloroform be theu administered, the remaining steps of the operation will be easy. On account of the occasional firm adhesions of the cystic mass to the uterus, too energetic attempts at complete separation should be avoided. Any severe hemorrhage after the operation can be controlled by swabbing out the uterine cavity with the jierchloride-(»f-irou solu- tion. Under the name of myxoma flbrosum (Fig. 91) a more rare degen- eration of the chorion has been described by Yirchow and Hilde- brandt,^ characterized not by vesicular but fibroid degener ation of the connective tissue of the chorion, ^t results in the enlargement of the chorionic villi by fibrous hypertrophy, forming distinct tumors in the placental structure, and is more frequently met with in the later than the earlier ]ieriods of pregiuuuy. It does not, therefore, necessarily lead to the death of the child.^ Pathology of the Placenta. — The pathology of the placenta has of late years attracted nuich attention, and it has an important practical bearing in consequence of its effect on the child. Placentic vary considerably in shape. They may be crescentic or spread over a considerabl(~surface in oofisequence of the chorion villi entering into communication with a larger portion of the decidua than usual {placenta mcmbranacea). Such forms, however, are merely of ^Monal. /. Geburf., May, 1865. ^ I'riestlfv, Tlic Patholvyy uf Intra-uterinc Death, p. 156. PATHOLOGY OF THE DECWUA AND OVUM. 235 scientific interest. The only anomaly of shape of any practical import- ance is the formation of what have been called place nta s uccen t urice . /These consist of one or more separate masses of placental tissue, pro- Iduced by the development of isolated patches of chorion villi. Hohl believes that they always form exactly at the junction of the anterior j Fjg, 9!. Myxoma Fibrosum of the Placenta. (After Storch and posterior walls of the uterus, which in early pregnancy is a mere line. As the uterus expands the portions of placenta on each side of this become separated from each other. (They are only of consequence from the possibility of their remaining ' unnoticed in the uterus after delivery and giving rise to secondary post-partum hemorrhage.\ The rare form of double placenta M'ith a single cord figured in the accom- panying woodcut (Fig. 92) was probably formed in this way, and the supplementary portion in such a case might readily escape notice. The placenta may also vary in dimensions. (Sometimes it is of ex- cessive size, generally when tlie child is unusually big, but not unfrequently in connection with hydramnios, the child being dead and shrivelled. In other cases it is remarkably small, or at least appears to be so. If the child be healthy, this is probably of no pathological importance, as its smallness may be more apparent than real, depending on its vessels not being distended with blood. A^^hen true_atrophy of the placenta exists, the vitality of the foetus may be seriously interfered with. This condition may depend either on a diseased state of the chorion villi or of the decidua in which they are implanted.^ The latter is the more common of the two; and it generally consists in hyperplasia of the connective tissue of the decidua, • Whittaker, Amer. Jnunt. of Obstd., 1870-71, vol. iii. p. 229. •J36 pnECX.iycY. which ]>r(^'oint: "The disj>osition to reject placentitis altogether increases in modern times. Indeed, it is im- possible to conceive of inflammation on the modern theory (Cohnheim) of that process, since there are no capillaries, in the maternal portion at least, through whose walls a 'migration' might occur, and there are no nerves to regulate the contractility of the vessel-walls in the entire structure." Robin thus explains the various ])athological changes above alluded to: "What has been taken for inflammation of the ' Virchow's Archir, 1871. PATHOLOGY OF THE DECIDUA AND OVUM. 237 placeuta is nothing else than a condition of transformation of Ijlood- clots at various periods. AVhat hits been regarded as pus is only fibrin in the course of disorganization, and in those cases where true pus has been found the pus did not come from the placenta, but from an inflam- mation of the tissue of the uterine vessels and an accidental deposition in the tissue of the placenta." The extravasations of blood here alluded to are of very common occurrence, and they are found in all parts of the organ — in its substance, on its decidual surface, or imme- diately below the amnion, where they serve as points of origin for the cysts that are there often observed. The fibrin thus deposited under- goes retrograde metamorphosis as in other parts of the body; it becomes decolorized, undergoes fatty degeneration, or becomes changed into cal- careous masses; and in this w^ay, it is supposed, may be explained the various pathological changes which are so commonly observed. The amount of retrograde metamorphosis and the precise appearance presented will, of course, depend on the time that has elapsed since the blood extravasations took place. Patty deg-eneration of the placenta, and its influence on the nutrition of the foetus, have been specially studied in England by Fig. 93. Fatty Degeneration of the Placenta. Ba mon rues and Druitt. (Yellowish masses of varying sizes are very com-i >nly met wdth in placentae, and these are found to consist, in great! part, of molecular fat, mixed with a fine network of fibrous tissu^ (Thetruefatty degeneration, however, specially affects the chorion villi ] (Fig. 93). On microscopic examination they are found to be altered 238 rnj'jGWAscy and inissliapt'ii in tlieir contour and to In- loaded with fine granular fiit- ^rluljulcs. Siniiiur ro.ving fatal. The subject is of great importance, and is well worthy of study. There is still much to be done in this direction, which may lead to important practical results. I can, however, do little more than enumerate some of the principal affections which have been observed. Diseases Transmitted through the Mother. — It is a well-estab- lished fact that the various eruptive fevers fr om which the mother may suffer may be communicated to the foetus in utero. When the mother is attacked with confluent small-pox she almost always aborts, but not necessarily so when it is discrete or modified. In such cases it has often happened that the foetus has been born with evident marks of small- poK. Cases are on record which prove that the foetus was attacked subsequently to the mother. Thus, a mother attacked with small-i)0X has miscarried, and has given birth to a living child showing no trace of the disease, which, however, showed itself in two or three days; proving that it had been contracted and had run through its usual period of in- cubation when the foetus was still in utero. It does not follow, however, that the foetus is affected, as Serres has collected 22 cases in which women suffering from small-pox gave birth to children who had not contracted the disease. It has been supposed that in such cases the child is pro- tected from small-pox, though it has shown no symptom of having had the disease. Tarnier, however, cites two instances in which such chil- dren had small-pox two years after birth. INIadge and Simpson record cases in which vaccination performed on the mother during pregnancy protected the foetus, on whom all subsequent attempts at vaccination failed. There is evidence also to prove that the disease may be trans- mitted to the foetus through a mother who is herself unsusceptible of contagion, the child having been covered with small-pox eruption, the mother being quite free from it. It is probable that the same facts \vhich have been observed Avitli regard to small-pox hold true with reference to other zymotic diseases, s uch as ^arlet feve r and measles , although there is not sufficient evidence to justify a positive asser- tion to that effect. Amongst other maternal diseases, malari a and l ead-poisoning are known to aflTcct the foetus in idcro. Dr. Stokes relates cases in which the mother suffered from tertian ague, the child having also attacks, as 16 LM2 PflEf.XAXCy. cvidt'iict'd l)y its convulsive iiKiNciiiciits, jipprociahlc l)V the motlu'r, Avliich took i)laoo at tlic regular interval^, hut at a (lifl'd-cnt tinu; iVoni the mother's paroxysms. In otlier cases the febrile paroxysm comes on at the same time in the foetus as in tlie mother; and the fact has been verified by the oi)Servation tiiat the paroxysms continued to rei-ni- simnhancously aliter delivery. Tlie iu-tus has also been b(»rn with dis- tinct malarious enlarii'cment . 117. PATIIOLOdY OF THE DECIDUA AND OVUM. 243 and at others it secius to have resuhed from sf)iii(' morbid condition of the fcetal viscera, Plenrisy with effusion is anotiicr inflammatorv aili'c- tion which has been noticed. The dropsical alfections most generally met M'ith are ascites and l ivdrocpj ^ ^hidiis which may both have the effect of impeding clefivery. Of these, hydrocej>halns is the more common, and may give rise to much difficulty in labor. Its canses are nncertain, but it prolxibly de- pends on some altered state of the mother's health, as it is apt to recur in several successive pregnancies, and is not infrequently associated with an imperfectly-developed vertebral column and spina bifida. The fluid collects in the ventricles, which it greatly distends, and these then pro- duce expansion and thinning of the cranium, the bones of which are ^\•idely sei)arated from each other at the sutures, which are prominent and fluctuating. In a few cases internal hydroce[)halus may be com- ]>licated, and the diagnosis in labor consequently obscured by the coex- istence of what has been called "external hydrocephalus." This cou- sists of a collection of fluid between the skull and the scalp, which may be either formed there originally or ma}^ collect from a rupture of one of the sutures or fontanelles during labor, through wdiich the intracranial fluid escapes. Ascites is generally associated with hydramuios, and sometimes with hydrothorax or other dropsical effusions. It is a rare affection, and according to Depaul ' extreme distension of the bladder is not infre- quently mistaken for it. Tumors of different kinds may be met with in various parts of the chikTFbody, which sometimes grow to a great size and impede delivery. Tarnier records cases of meningocele larger than a child's head, and large cystic growths have been observed attached to the nates, pectoral region, or other parts of the body. Cancerous tumors of considerable size, either external or of the viscera, have also been met with. Other foetal tumors may be produced by congenital deformities, such as projec- tion of the liver or other abdominal viscera through a deficiency of the abdominal wall ; or spina bifida from imperfectly-developed vertebrae. The amount of dystocia produced by such causes will, of course, vary much in proportion to the size, consistency, and accessibility of the tumor. I Wounds and Injuries of the Pootus.— iAecidents of serious gravity to the fretus may happen from violence to which the mother has been subjected, such as falls or blows, without necessarily interfering with gestation./ Many curious examples of this kind are on record. Thus, a child has been born presenting a severe lacerated wound extending the whole length of the spine, Avhere both the skin and the muscles have been torn, and which seems to have resulted from the mother having fallen in the last month of pregnancy. Similar lacerations and contu- sions have been observed in other parts of the body, the wounds being in various stages of cicatrization corresponding to the lapse of time since the accident had occurred. Intra-u ferine fractures are not rare, ap])ar- ently arising from similar causes. In some of these cases the broken ends of the bones had united, but, from want of accurate apposition, at ' Tarnier's Cazcanx, p. 855. 244 pni:(;yA\cy. Fig. 95. ."Ill acute antrlc, so as to <>:iv(' rise to imicli siibscquont (loforiiiity. C'liaiissior records two ca.scs in Aviiicli tliere were many Iractiires in the sjuue child — in one 113, .and in another 42 — which were in different .stages of i-epair. He attributes this curion.s occurrence to some con- genital delect in the nutrition of the hones, possibly allied to mollities ossiuni.' Intra-nterine a mputation s of fa?tal lind)s have not nnfrcijuently been observed. Children are occasionally born Avith one extremity more or less completely absent, and cases are known in which the whole four extremities were wanting (Fig. 95). The mode in which these malformations are produced has given rise to much discussion. At one time it was suj)- ])osed that the deficiency of the limb was due to gangrene of the extremity and subscfpient separation of the sphacelated ])arts. Iteu.ss, who has studied the whole .subject very minutely,- considers gangrene in the nnru])- tured ovum to be an impossibility, for that change cannot occur unless there is access oi" oxygen ; and when portions of the .separated extremity are found in utero, as is often the case, they show evidences of maceration, but not of decomposition. ((The geneiid belief isj that these intra-uterine amjiutntions depend' on constriction of the limb by folds or bands' of the amnion — most often met with when the liquor aranii is deficient in quantity — which obstruct the circulation and thus give rise to atroj)hy of the part below the constriction|| It has been su})posed that the umbilical cord might, by encircling tne limb, produce a like result. It a]>pears doubt- ful, however, whether this cause is sufficient to j)roduce com])lete sejia- ration of the limb, as any great amount of constriction would interfere with the circulation through the cord. ) Sometimes, when intra-uterine amputation occurs, the separated portion of the limb is found lying loose in the amniotic cavity, and is expelled after the child. Cases of this kind have been recorded by Martin, Chaussier, and AVatkinson. ^Nloi-e often no trace of the separated extremity can be found. The explanation probably depends upon the period of utero-gestation at which amputa- tion took ])lace. If it occurred at a very early period of ])regnancy, before the third month, the detached portion would be minute and soft and would easily disa])pear by .solution. If at a later period, this could hardly hajjpcn and the detached portion would remain /;/ vfrro. In cases of the latter kind cicatrization of the stump has often been observed to be incomplete. ( Simjison pointed out the occasional exist- ence of rudimentary fingers or toes on the stumj^of an amjiutated limb, such as are seen on the thighs in Fig. 95. jt These lie attributed to an abortive reproduction of the separated exti'emity, analogous to what is observed in some of the lower animals. This explanation has been con- ' Gazette hebdom., 1860. ' Scanzoni's Bcitriigc, 1869. Intra-utcriiic Ampiuation Ijotli Arms and Legs. of rATllOLOdV OF THE DKCIDrA AM) OVUM. 'lA') tested with luiich show of reason. Martin believes that tlie rej)ro(hi(> tion is only apparent, and that the rudimentary extremities are, in reahty, instanees t>f arrested devek»])ment. The eonstrietln<^ agents interfered with the eirculation sufficiently to arrest the growth of" the limb below the site of" constriction, but not sufficiently to effect complete separation. If constriction occurred at a very early stage of develop- ineut, an appearance similar to that observed by Simpson would be pro- duced. It does not follow, however, that all cases of absence of limbs depend on intra-utcriue amputations. ( In some cases they would, appear to be the result of a spontaneous arrest of development or of con-' genital moustrosityJ Mr. Scott ' relates a case in which a distinct hereditary tendency was evident ; and here the deformity certainly could not have resulted from the constriction of amniotic bands. In this family the grandfather had both forearms wanting, with rudi- nientary fingers attached ; the next generation escaped, but the grand- child had a deformity precisely similar to the grandfather. [Arrested Pullulation.-t-The absence of a hand w^here there are ru- dimentary evidences of an attempt to form the thumb and fingers can be accounted for much more satisfactorily on the theory of an arrested development taking place in the latter half of the second month of embryonic life than upon the hypothetical idea that there has been first an amputation in utero, and then an attempt of nature to reproduce the lost digits by a new budding process, as taught by Simpson and Annan- dale. \ More than thirty years ago I became fully satisfied that there was an inclination in nature to repeat itself so exactly during the pullu- lative period of embryonic growth that cases of congenital deficiency of the thumb and fingers of a precisely similar character must from time to time present themselves to the eye of the medical observer. It so happened that three such typical cases, all exactly alike, in two boys and one girl, each being strangely without the left hand, came under my notice during a short period of years. The forearm in each ended in a well-rounded and slightly-flattened stump, from which protruded a row of pisiform nailless bodies representing the embryonic commencement of the formation of a thumb and four fingers. I saw these subjects at different ages of infancy and childhood, and the little pea-like bodies remained the same, with the exception that they became slightly larger. In a fourth case, a boy, the finger-rudiments were entirely absent, and there was an attempt to form a thumb, which was useless and about three-quarters of an inch long : the boy developed into a powerful man of six feet. Cases of the precise type of the three first named have come under the observ^ation of medical friends. — Ed.] Death of Fcetus.— (-When from any cause the foetus has died during pregnancy, it may be either soon expelled, or it may be retained in utcro for a longer or shorter time or even to the full period.' The changes observed in such foetuses vary considerably according to the age of the fetus at the time of death or the time that it has been retained //; utero. If it die at an early period, when the tissues are very soft, it may entirely dissolve in the liquor amnii, and no trace of it may be found when the mendjranes are expelled. Or it may shrivel or mummify; and if this ' Obst. Trans., 1872, vol. xiii, p. 94. 246 j'j:Jx;.\Aycy. happoM in a twin pirgnancy, as sometimes oceiirs, tli«! f;ru\ving fittus may compress aiul tiatteii the dead one against the uterine waU. At a hiter period of pregnanev a \ This is contrari' to the statement in many obstetrical works. ThuSj^HCyler Smith says '' there seems to be a V 248 i'A'AY.Xl.VCr. j^roator (laiijj^cr of tliis accident in llic first ])rc j)rinii])ai-ic ; and Dr. Whitehead of Manchester, wlio has particidarly studied the sul)je(t, beheves that aboi'tioii is inore apt to occur ;dter the third and I'ourlli pregnancies, especially Avhon these take place toward the time for the cessation of menstruation. \There can be no doubt that women who ha\-e aborted more than once are ju'culiarly liable to a recurrence of the aci-ident.^ 'J'his can :nancics ; as, for exainj)le, a syj)hilitic t:reg- iiancy, and it occurs much more often in the early months , because of the com})aratively s light connection then existing between the chorio n and the decidua . At a very early period of })i-egnancy the ovum is cast off with such facility, and is of such minute size, that the fact of abor- tion having occurred passes unrecognized. Very many cases in which the patient goes one or two weeks over her time, and then lias what is supposed to be merely a more than usually profuse period, are probably instances of such early miscarriages. A'elpcau detected an ovum of about fourteen days which was not larger than an ordinary pea, and it is easy to understand how so small a body should pass unnoticed in the blood which escapes along with it. Up to the end of the third month , when miscarriage occurs, the ovum is generally (jast off enjncm^, the decidua subsecpiently coming away in shreds or as an entire membrane. The abortion is then comparatively easy. From the third to the sixth month, after the j)laccnta is formed, the amnion is, as a rule, first ruptured by the ntei-inc contractions and the foetus is expelled by itself. The placenta and membranes may then be shed as in ordinary labor. It often hapj)cns, however, that on account of the firmness of the placental adhesion at this jieriod the secundines are retained for a greater or less length of time. This sub- jects the patient to many risks, especially to those of profuse hemoi- rhagc and of se})tica?mia. For this reason jn'emature termination of the jM'egnancy is attended by much greater danger to the mother between the third and sixth months than at an earlier or later date. After the sixth month the course of events is not different from that attending ordinary labor. The ])rognosis to the child is more unfavorable in ]>ro- ])ortion to the distance from the full jK'riod of gestation at which premature labor takes place. Causes. — The causes of abortion mav conveniently be subdivided into the prcjUspo.sinr/ and c.vcifiii(/, the latter being often slight, and such as would have no effect inlnducing uterine contractions in women unless associated with one or more of the fonner class of causes. The ' Schroeder, 3Ianuj in other words, the mechanism of delivery. Causes of Labor. — Before proceeding to the consideration of these important topics a few words may be said as to the determining causes of labor. This subject has been from the earliest times a qucestio ve.v- ata among physiologists, and many and various are the theories which have been broached to explain the curious fact that labor spontaneously commences, if not at a fixed epoch, at any rate approximately so. It must be admitted that even yet there is no explanation which can be implicitly accepted. The explanations which have been given may be divided into two classes : those which attribute the advent of labor to the foetus, and j those which refer it to some change connected with the maternal 1 generative organs. The former is the opinion which was held by the older accoucheurs, who assigned to the foetus some active influence in efl'ecting its own expulsion. It need hardly be said that such fanciful views have no kind of physiological basis. Others have supposed that there might be some change in the placental circulation or in the vascular sys- tem of the foetus which might solve the mystery. /The majority of obstetricians, however, refer the advent of labor to [( purely maternal causes.) Among the more favorite theories is one which was originally started in this country [/. e. England] by Dr. Power, and adopted and illustrated by Depaul, Dubois, and other Avriters. It is based on the assumption that there is a sphincter action of the fibres of the cervix, analogous to that of the sphincters of the bladder and rectum, and that when the cervix is taken up into the general uterine cavity as pregnancy advances, the ovum presses upon it, irritates its nerves, and so sets up reflex action, which ends in the establishment of 259 260 LABOR. uterine rontraetion. This theory \v:is founded on erroneous ooneept ions of the chanties that oceurn'd in tlie neck of the uterus; and, as it is certain that ol)lit('ralion ol' tlic cervix docs not really take phice in the manner that l*o\ver believed ^vhen liis theory was broached, it is obvious that its supposed result cannot follow. A modification of this theory is that held by Stoltz and Bandl. / According to this view, when the cer- vix softens duriuii; the last two weeks of pregnancy the ])ainless uterine contractions of gestation act upon the os internum, and open it suffi- ciently to admit of the ovum pressing on the lower segment of the uterus, aiid so inducing labor. ( Exti'eme distension of the uterus has been held to be the determining cause of labor — a view lately revived by Dr. King of Washington,' who believes that contractions are induced because the uterus ceases to augment in capacity, while its contents still continue to increase. This hypothesis is sufficiently disproved by a number of clinical fiicts whi<-h show that the uterus may be subject to excessive and even rapid disten- sion — as in cases of hydramnios, multiple pregnancy, and hydatidifbrm degeneration of the ovum — without the supervention of uterine contrac- tions. \ I Another inciter of uterine action has been supposed to be the separa- tion of the ovum from its connections to the uterine parietes, in conse- quence of fatty degeneration of the decidua occurring at the end of pregnancy. The supposed result of this change, which undoubtedly occurs, is that the ovum becomes so detached from its organic adhesions as to be somewhat in the position of a foreign body, and thus incites the nerves so largely distributed over the interior of the uterus. This (theory, which has been widely accepted, was originally started by Sir James Y. Sim])son, who pointed out that some of the most efficient means of inducing labor (such, for example, as the insertion of a gum- * elastic catheter between the ovum and the uterine walls) jwobably act in the same way — viz. by effecting separation of the membranes and detachment of the ovum. Barnes instances, in o])position to this idea, the fact that ineffectual attempts at labor come on at the natural term of gestation in cases of extra-uterine pregnancy, when the foetus is altogether independent of the uterus, and therefore, he argues, the cause cannot be situated in the uterus itself. A fair answer to this argument would be that although, in such cases, the Momb does not contain the ovum, it does contain a decidua, the degeneration and sejiaration of which might suffice to in- duce the abortive and partial attempts at lal)or then witnessed. LeopokP suggests that the advent of labor may be connected with other changes in the decidua M'hich occur in advanced ]iregnaucv. He ]ioints out that then giant-cells, containing many nuclei, appear in the serotina which penetrate the uterine sinuses, and cause the formation in them of thrombi. The obstruction in the calil)re of a number of these vessels leads to a stasis of the maternal blood returning from the ]>la- eonta, and to an increase of carbonic acid in it, which may excite the motor centre for uterine contraction. ^ Amerirmi JnurnnI of Obslclrirs, 1S70-71, vol. iii. p. 561. ^".Studien iiber die Schleimbaut," etc., Arch. f. Gyn., 1877, Bd. xi. S. 443. Til?: PHENOMENA OF LABOR. 201 Objections to these Theories. — A serious objection to all tlitse theories — wliieli are l)ase(l on the assnni])tion tiiat some local irrita- tion brings on contraction — is the fact which has not been generally appreciated, that uterine c ontr actions ixvci^ al^i:il;y■s present during preg- nancy as a normal occurrence, and that they may be, and often are, readily intensified at any time so as to result in j)reraature deKvery. It is indeed most likely that at or about the full term the nervous supply of the uterus is so highly developed, and in so advanced a state of irritability, that it more readily responds to stimuli than at other times. If by separation of the decidua or in some other ^vay stimula- tion of the excitor nerves is then effected, more frequent and forcible contractions than usual may result, and, as they become stronger and more regular, terminate in labor. But, allowing this, it still remains quite unexplained why this should occur with such regularity at a def- inite time. Tyler Smith tried, indeed, to prove that labor came on naturally at what would have been a menstrual epoch, the congestion attending the menstrual nisus acting as the exciter of uterine contraction. He therefore refers the onset of labor to ovarian, rather than to uterine, causes. Although this view is upheld with all its author's great talent, there are several objections to it difficult to overcome. Thus, it assumes that the pieriodic changes in the ovary continue during pregnancy, of which there is no proof. Indeed, there is good reason to believe that ovulation is suspended during gestation, and with it, of course, the menstrual nisus. Besides, as has been well objected by Cazeaux, even if this theory were admitted, it would still leave the mystery unsolved, for it would not explain why the menstrual nisus should act iu this way at the tenth menstrual epoch rather than at the ninth or eleventh. In spite, then, of many theories at our disposal, it is to be feared that we must admit ourselves to be still in entire ignorance of the reason] Avhy labor should come on at a fixed epoch. Mode in which the Expulsion of the Child is Effected. — The expulsion of the child is effected by thefcou tractions of the muscular fibres of the uterus) aided by those of some of the abdominal miiscles. These efforts are in the main entirely independent of volition. So far as regards the uterine contractions, this is absolutely true, for the mother has no power of originating, lessening, or increasing the action of the uterus. As regards the abdominal muscles, however, the mother is certainly able to bring them into action, and to increase their power by voluntary efforts ; but, as labor advances and the head passes into the vagina and irritates the nerves supplying it, the abdominal muscles are often stimulated to contract, through the influence of reflex action, inde- pendently of volition on the part of the mother. (There can be little doubt that the chief agent in the expulsion of the child is the contraction of the uterus itself.) This opinion is almost unanimously held by accoucheurs, and the influence of the abdominal muscles is believed to be purely accessory. Dr. Haughtou/ however, ' "On the Muscular Forces employed in Parturition," etc., Dublin Quart. Journ. Med. Sc, 1870, vol. xlix. p. 459. 2()2 LABOR. iniiiiilains a view wliicli is directly contrarv to this. From an cxaiiii- iiation of" the lorce of" the uteiiiic contractions, arrived at hy nieasnring the anionnt of nuiseiUar fibre contained in the \valls of tlie uterus, lie arrives at the conclusion that the uterine contractions are chiefly in- Huential in rupturing the membranes and dilating the os uteri, bringing into action, if needful, a force e(juivalent to 54 ])Ounds; but when this is cllcctcd, and the second stage of" labor has coinnienced, he thinks the remainder of the labor is mainly completed by the conti'actions of the alxloininal nuiscles, to which he attributes enoriuous ])o\vers, equivalent, il" netdfui, to a pressure of 523.65 jxiunds on the area of the jx-lvic canal. These views bear on a topic of ])rinuiry consequence in the ])hysi- ology of labor. They have been fully criticised l)v Duncan, who has devoted much ex])eriinental research to the study of the powers brought into action in the expulsion of the child. His conclusions are that, so far from the enormous force being employed that Ilaughton estimated, in the large majority of cases the effective force brought to bear on the child by tlie combined action of both the uterine and abdriminal mus- cles is less than uL!4)onmls — that is, less than the force which Ilaughton attributed to the uterus alone. In extremely severe labors, when the resistance is excessive, he thinks that extra power may be em])loyed; but he estimates the maximum as not above 80 ])ounds, including in this total the action of both the uterine and abdominal muscles. Joulin arrived at the conclusion that the uterine contractions were capable of resisting a maximum force of about one hundredweight. Both these estimates, it will be observed, are much under that of Ilaughton, which Duncan describes as representing "a strain to which the maternal machinery could not be subjected without instantaneous and utter destruction." f There are many facts in the history of parturition which make it 'certain that the chief factor in the expulsion of the child is the uteru-y Among these mav be mentioned occasional cases in which thPfirtTon of the abdominal muscles is materially lessened, if not annulled — as in ])rofound antesthesia and in some cases of para])legia — in which, nevertheless, uterine contractions suffice to effect delivery. The most familiar example of its influence, however, and one that is a matter of everv-day observation in ])ractice, is when inertia of the uterus exists. In such cases no eilbrt on the ])art of the mother, no amount of vi»lun- tary action that slu; can bring to bear on the child, has any apjn'cciable influence on the progress of the labor, which remains in abeyance until the defective uterine action is re-established or until artificial aid is given. The contraction of the uterus, then, l)eing the main agent in deliveiy, it is important for us to appreciate its mode of action and its eflect on the ovum. Uterine Contractions at the Commencement of Labor. — We have seen that intermittent and generally paiidess uterine contractions exist during pregnancy. As the period for delivery approaches these, become more fre(jncnt and intense, until labor actually commences, when they begin to be sufficiently developed to effect the opening up THE PHENOMENA OF LABOR. 203 of the OS uteri witli a view to the passage of the child. They are now accompauied by pain, wliieh increases as labor advances, and is so cha- racteristic that "pains" are universally used as a descriptive term for the contractions tlieinselves. It does not necessarily follow that uterine contractions are painless unless they connnence to effect dilatation of the OS uteri. On the contrary, during the last days or even -weeks of pregnancy women constantly have irregular contractions, accompanied by severe suffering, which, however, pass off" without producing any marked effect on the cervix. When labor has actually begun, if the hand is placed on the uterus when a ]>ain commences, the contraction of its muscular tissue is very apparent, and the Avhole organ is observed to become tense and hard, the rigidity increasing until the pain has reached its acme, the uterine walls then relaxing, and remaining soft until the next pain comes on. (At the commencement of labor these} pains are few, separated from each other by a considerable interval, and of short duration. In a perfectly tyj^ical labor the interval between the pains becomes shorter and shorter, while at the same time the dura- tion of each pain is increased. At first they may occur only once in an hour or more, while eventually there may not be more than a few minutes' interval between them^ If, when the pains are fairly established, a vaginal examination be made, the os uteri will be found to be thinned and dilated in propor- tion to the progress of the labor. During the contraction the bag of membranes will be felt to bulge, to become tense from the downward pressure of the liquor amnii within it, and to protrude through the os if it be sufficiently open. /The membranes, with the contained liquor amnii, thus form a fluid wedge, which ha^ a most important influence in dilating the os uteri (see Frontispiece).; (This does not, however, form \ ( the sole mechanism by which the os uteri is dilated, for it is also acted | ) upon by the contractions of the muscular fibres of the uterus, which }/ tend to pull it open.^ It is probable that the muscular dilatation of the •' OS is effected chiefly Ify the longitudinal fibres, which as tliey shorten act upon the os uteri, the part where there is least resistance. Partly, then, by muscular contraction, partly by mechanical pressure, the cervical canal is dilated, and as it opens up it becomes thinner and thinner until it is entirely taken up into the uterine cavity. There is no longer any obstacle to the passage of the presenting part , of the child into the cavity of the pelvis, and the force of the pains I now generally effects the rupture of the membranes and the escape of / the liquor amnii. There is often observed at this time a temporarv relaxation in the frequency of the pains, Avhich had been steadily increasing; but they soon recommence v/ith increased vigor. If the abdomen be now examined, it will be observed to be nuich diminished in size, partly in consequence of the escape of the liquor amnii, partly from the descent of the fcetus into the pelvic cavity. (The character of the pains soon changes. They become stronger, longer in duration, separated l)y a shorter interval, and accompanied l)y a distinct forcing efibrt, being generally described as "the bearing-down " pains, j Now is the time at which the accessory muscles of jxirturition come into operation) The patient brings them into play in the manner ■2(ii LABOR. which will he siil)>('(|iK'ntly (lc'sciil>0(l, and tho comhincd aotion of the uterine and aluloniinal nuiseles continues until the expulsion of the child is cllccte chiefly seated in the back, from whence it shoots round the loins and dow n the thigh sT It is then probably produced partly by pressure on the nerve-filaments caused by contraction of the muscular fibres to which they are distributed, and partly by stretching and dilatation of the muscular tissue of the cervix. ^I. Beau believes that in this stage the pain is not produced, strictly speaking, in the uterus itself, but is rather a neuralgia of the lumbo-abdominal nerves. The pains at this time are generally described as " acute " and " grinding" — terms which sufficiently well express their nature. In highly nervous women these pains are often much less well borne than those of a later stage, and the suffering they undergo is indicated by their extreme restlessness and loud cries as each contraction supervenes. As the OS dilates and the labor advances into the expulsive stage other sources of suffering are added. The presenting part now passes into the vagina and p resses on th^ vaginal nerv es, as well as on the large ner- vous plexuses lying in the pelvis. As it descends lower it stretches the perineum and yul>"a, and presses on the bladder and rectum. Hence cramps are produced in the muscles supplied by the nerve-plexuses, as well as an intolerable sense of tearing and stretching in the vulva and ])erineum, and often a distressing feeling of tenesmus in the bowels. By this time the accessory muscles of parturition are brought into action, and they, as well as the uterine nuiscles, are thrown into frequent and 266 LABOR. violent contractions, which, independently of the other causes mentioned, are sufficient of themselves to ))r(Mluce f^reat pain, likened to that of colic, produced by involuntary and rcpeatetl contraction of the muscles of the intestines. Takinu- all these causes into consideration, there is no lack of sufficient cxplanatiiin of the intoli'ral)le suflering which is so constant an accom- paniment ot" childbirth. Effect of the Pains on the Mother and Foetus. — The effect of the pains on the mother's circulation is well marked. ^Fhe rapidity of the j)ulse increases distinctly with each contraction, and as the jiain [)asses ofrTFagaiTrdc'Tliic- u> \i< forinci' -i.iti'. A >iinilar observation has been made Avith repaid tn the sounils i.t' ihe tirial heart, esjiecially alter the expulsion of the liquor amnii. ) Hicks has pointed out that during a pain the muscular vibrations give rise to a sound which often resembles that of the foetal heart, and which completely disappears when the muscular tissue relaxes. The effect of the pain in intensifying the uterine souffle has been already mentioned. The strong muscular efforts would natu- rally lead us to expect a marked elevation of temjierature during laboi-. Further observations on this point are required ; but Squire asserts that there is generally only a very slight increase in temperature during delivery, rapidly passing off as soon as labor is over. Division of Labor into Stages. — Such being the jihysiological |r facts in connection with laljor-pains, we may now describe the ordinary n progress of a natural labor — that is, one terminated by the natural pow- ers and with a head presenting. For facility of description obstetricians have long been in the habit of dividing the course of labor into sfar/es, which correspond pretty accu- rately Avith the natural sequence of events. For this purpose we gen- erally talk of thi'ee stages: viz. (1) from the commencement of regular pf pains until the c omplete dilatation of the cervix (star/e of effacement (Did \ dilatation) ; (2) from the complete dilatation of the cervix until the I expulsion of the child {stage of expulsion) ; (3) the concluding stage, I comprising the permanent contraction of the uterus and the se])aration \ and e xpulsion of the placenta {xt<(fje of the aftcr-birtJt). To these we e may conveniently add a preparatory stage, antecedent to the regular commencement of the labor. Preparatory Stage. — For a short time before delivery, varying from a few days to a week or two, certain premonitory symptoms gen- erally exist which indicate the ap])roacliing advent of labor. Sometimes they are well marked and cannot be mistaken ; at others they are so slight as to escape observation. (Amongst the most connnon is a sink- iinr of the ntcriis into the pelvic cavitv ] resulting from the relaxation of the soft parts preceding delivery.\ Tlie result is that the upj)er edge of the uterine tumor is less high than l)efore, and in consequence the j)res- sure on the respiratory organs is diminished, and the woman often feels lighter and altogether less unwieldy than in the ])revious weeks. If a vaginal examination be made at this time, the lower segment of the utei'us will be found to have sunk lower into the pelvic cavity ; and the consequence of this is that, while the respiration is less embarrassed and the patient feels less bulky, other accompaniments of pregnancy, such THE PHENOMENA OF LABOR. 267 as heiuOTrhoids, irriUibilily of the bladder and bowels, and redeiiia of the limbs, become aggravated. The increased jjressure on the bowels often induces a sort of temporary diarrhoea, which is so far advantageous that it empties the bowels of feces which may have collected within them. As has already been pointed out, the contractions which have been going on at intervals during the latter months of pregnancy now get more and more marked, and they have the effect of i)roducing a real shortening of the cervix, which is of great value i)reparatory to its dila- tation. ^ More marked mucous disch arjj'e from the cavity of the cervix also generally occurs a sliort tmie betore labor, ana it is not unfrequeutly tinged with blood from the laceration of minute capillary vessels. This discharge, popularly known as the " shows, " is a pretty sure sign that labor is not far off. It may, however, be entirely absent, even until the birth of the child. When copious, it serves to lubricate the passages, ^nd is generally coincident with rapid dilatation of the parts and a speedy labor. During this time (^premonitory stage) painful uterine contractions are often present, which, however, have no effect in dilating the cervix. In some cases they are frequent and severe, and are very apt to be mistaken for the commencement of real labor. Such "/sisfi-Ji^y -s/' as they are termed, are often excited and kept up by local irritations, such as a loaded or disordered state of the intestinal canal ; and they frequently give rise to considerable distress and much inconvenience both to the ])atient and practitioner. They are, it should be remembered, only the normal contractions of the uterus, intensified and accompanied with pain. First Stage, or Dilatation. — As labor actually commences the uterine contractions become stronger, and the fact that they are " true " pains can be ascertained by their effect on the cervix, (if a vaginal examination be made during one of these, the membranes will be felt to become tense and bulging during the paiu. and the os uteri will be found partially dilated and thinned at its edges. I As labor advances this effect on the OS becomes more and more marked. At first the dilatation is very slight, perhaps uot more than enough to admit the tip of the examining finger, and both the upper and lower orifices of the cervix can be made out. As the pains get stronger and more frequent, dilatation proceeds in the way already described and the cervix gets more thin and tense, until we can feel a thin circular ring (which is lax between the pains, but becomes rigid and tense during the contraction when the bag of waters bulges through it) without any distinction between the upper and lower orifices. During this time the patient, although she may be suf- fering acutely, is generally able to sit up and walk about. The amount of pain experienced varies much according to the character of i:he patient. In emotional women of highly- developed nervous susceptibili- ties it is generally very great. They are restless, irritable, and despond- ing, and when the pain conies oi ucrv out loudly. fThe character of the cry is peculiar and well marked during the first stage, and has constantly been described by obstetric writers as characteristic. It is acute and high, and is certainly very different from the deep iri-oans of the second stage, when the breath is involuntarily retainetTto assisf the parturient 2G8 LABOR. eilbrt.] Wlii'ii dilatation is nearly coinjjli'tt'd various reflex nervous plie- uoniena olten show themselves. One of" these is uausea and voniitinir; another is uneontrollablc shiyerinj^, which is not acconipanietl by a sense of euldness, the i)atient beinu' ol'teii hot and j)ersj)irine will shoi-tly com- menee ; and tiiey may be i-cnardcd ;is l'avt)ra!>le rather than otherwise, although they aiv a])t to alarm the })atient and her friends. Jiy this time the os is fully dilated, the membranes jjenerally rui)tnre sponta- neously, and a considerable portion of the liquor amnii flows away. The head, if presenting, often acts as a sort of ball-valve, and, falling - ject has been well studied by Berry Hart,' who Iuls shown that during the contractions of the third stage of labor the })lacenta is "thrown into heights and hollows," and, if the case be left entirely to nature, it descends with its edge or a })oint near its edge first, its uterine and" detached surface gliding along the inner surface of the uterus, the foldings of its structure being parallel to the long diameter of the uterine cavity (Fig. 98). \Iu this way it is expelled into the vagina, and during the process little or no hemorrhage occurs. When the ])lacenta is dra\\n out iu the wa}' too generally ])ractised, it obstructs the aperture of the os, and, acting like the piston of a pump, tends to promote hemorrhage. The corollaries as to treatment drawn from these facts will be subsequently considered. I am anxious, however, here to direct attention to nature's meeh- anism, because I believe there is no ])art of labcir about the management of which erroneous views are more prevalent than that of this stage, and none in which they are more apt to lead to serious Mode in which the pia- cousequeuces; and unless the mode in which Nature pX^d.^'A^tcrDuncaii') ^'^^^'^^ ^^^^ cxpulsiou of the ])lacenta and ])revents hemorrhage is thoroughly understood, we shall cer- tainly fail in assisting her in a proper manner. In the large i)ropor- tion of cases, when left entirely to themselves, the placenta would be retained, if not in the uterus, at any rate in the vagina, for a consider- able time — possibly for several liours; and such delay would very unnecessarily tire the ])atience of the ])ractitionei- and be ])rejndicial to the patient. It is, therefore, our duty in the majority of cases to promote the expulsion of the after-birth ; and when this is ])ropcrly and scientifically done we increase rather than diminish the patient's safety and comfort. But in order to do this we must assist Nature, and not act in op|)osition to her method, as is so often the case. After-Pains. — When once the ])lacenta is expelled the uterus con- tracts still moi-e firmly, and in a tyjiical case is felt just within the pelvic brim, hard and firm, and about the size of a cricket-ball, (tcii- erally for several liours, or even for one or two days, it occasionally relaxes and contracts, and these contractions give rise to the " after- pains" from which women often suffer nuich. ^ The object of these pains is no doubt to ex})el any coagula that may remain in the uterus, ' " Sectional Anatomy of Labor," J^diii. Med. Jouni., Novenil)er, 1S87. I THE PHENOMENA OF LABOR. 271 and there fore, liowever unpleasant tliey ]nay be to the })atient, they must be considered, unless very excessive, to be salutary rather than otherwise. | Duration of Labor. — The length of labor varies extremely in differ- ent cases, and it is quite impossible to lay down any definite rules with regard to it. Bubject to exceptions, labor is longer in priniipane than in multiparse, on account of the greater resistance ' oT t Ii e soft parts in the former, especially of the structures about the vagina and vulvaj It is also generally stated that the difficulty of labor increases with the age of the ]>atient, and that in elderly primiparse it is likely to l)e lunisually tedious, from rigidity of the soft parts. It is very doubtful if this opinion has any real basis, and in such cases the practitioner often finds himself agreeably disappointed in the result. Mr. Roper,^ indeed, argues that the wasting of the tissues which occurs after forty years of age diminishes their resistance, and that first labors after that age are easier, as a rule, than in early life. The habits and mode of life of patients have no doubt a considerable influence on the duration of labor, but we are not in possession of any very reliable facts with regard to this subject. It is reasonable to suppose that the tissues of large, muscular, strongly-developed women will offer more resistance than those of slighter build. On the other hand, women of the latter class, especially in the upjjer ranks of life, more often develop nervous susceptibilities, which may be expected to influence the length of their labors. The average duration of labor, calculated from a large number of cases, is from eight to_ ten hours • even in primiparse, however, it is constantly terminated in one or two hours from its commencement, and may be extended to twenty-four hours without any symptoms of urgency arising. In multiparre it is frequently over in even a shorter time. Indications calling for interference may arise at any time during the progress of labor, independently of its length. The proportion between the length of the first and second stages also varies considerably. The first stage is generally the longest, and it is stated by Cazeaux to be normally about twice the length of the second. This is probably under the mark, and I believe Jouliu to be nearer the truth in stating that the first stage should be to the second as four or five to one, rather than as two to one. Often when the first stage has been very prolonged the second is terminated rapidly. The practitioner is constantly asked as to the probable length of labor, and the uncertainty of this should always lead him to give a most guarded opinion. Even when labor is progressing apparently in the most satisfactory manner the pains frequently die away, and delivery may be delayed for many hours. In the first stage a cervix that is apjiarently rigid and unyielding may rapidly and unexpectedly dilate, and delivery soon follow. In either case, if the practitioner has com- mitted himself to a positive opinion he is apt to incur blame, and it is far better always to be extremely cautious in our predictions on this point. Period of the Day at "which Labor Occurs A somewhat larger proportion of deliveries occur in the early hours of the morning than at ' Ohst. Trans., 1886, vol. vii. p. 51. 272 LABOR. other times. Tims. West ' found that out of 2019 deliveries, 780 took phioe from 11 i'. M. to 7 A. M., GG2 ironi 7 A. M. to 3 r. M., and 577 from 3 i>. M. to 11 I'. M. CHAPTER II. MECHANISM OF DELIVERY IN HEAD PRESENTATION. Importance of the Subject. — It is quite impossible to over-estimate the importanee of thorouohly understanding the mechanism of the pas- sage of the foetus through the pelvis. This dominates the Avhole .scien- tific practice of midwifery, and the practitioner cannot acquire more than a merely empirical knowledge, such as may be po.sse.ssed by any unedu- cated midwife, or conduct the more difficult cases requiring operative interference with safety to the patient or satisfaction to himself, unless he thoroughly ma-sters the subject. In treating of the physiological phenomena of labor it was assumed that we had to do with an ordinary case of head presentation, the descrip- tion being applicable, with slight variation!?, to j^resentations of other parts of the foetus. So in discussing the mechanical ])henomena of delivery I shall describe more in detail the mechanism of head presenta- tions, reserving any account of the mechanism of other presenta- tions until they are separately studied. Head presentation is so much more frequent than that of any other part — amounting to 95 per cent , of all ca.ses — that this mode of studying the subject is fully justified ; and, when once the student has mastered the ])henomena of delivery in head presentations he will have little difficulty in understanding the mechanism of labor when other jxirts of the fcetus present, based, as it always is, on the same general plan. Mode of Recognizing- the Position of the Head by its Sutures and Fontanelles. — In entering on this study we come to appreciate the importance of the sutures and fontanelles in enabling us to detect the ]iosition of the foetal head, and to watch its ])rogress through the jiclvis ; and unless the tacfns cntditvs by which these can be distinguished from each other has been acquired, the practitioner will be unable to .«atisfy himself of tlie exact j^rogress of the labor. Nor is this always easy. Indeed, it requires considerable experience and practice before it is pos- sible to make out the position of the head with absolute certainty ; but tliis knowledge should always be aimed at, and the student will never regret the time and troul)le he spends in acquiring it. At the commencement of labor the long diameter of the head lies in almost any diameter of the pelvic brim, except in the antero-posterior, where there is not space for it. In the large majority of ca.ses, how- ^ Amer. Med. Jourii., 1854. MECHANISM OF DELIVERY IN HEAD PRESENTATION. 273 ever, it enters the pelvis in one or other of tlie oblique diameters, or in one between the oblique and transverse ; but until it has fairly passed through the brim it more freciuently lies directly in the transverse diam- eter than has been generally su})i)()sed. Hence obstetricians are in the habit of describing the head as lying in four [)Ositious according to the parts of the pelvis to which the occiput points; the first and third posi- tions being those in which the long diameter of the head occupies the right oblique diameter of the pelvis, the second and fourth those in which it lies in the left oblique. Many subdivisions of these positions have been made, which only complicate the subject and render it more difficult to understand. Pour Positions Described. — The positions, then, of the fcetal head after it has entered tlie brim, which it is of importance to be able to distinguish iu practice, are — First {left occipito-antcrior, occipito-lceva anterior^ O.L.A.). — The occi- JDut points to the left foramen ovale, the sinciput to the right sacro-iliac synchondrosis, and the long diameter of the head lies in the right ob- lique diameter of the pelvis. Second (right occipito-anterior, occipito-dexfra anterior^, o.d.a.). — The occiput points to the right foramen ovale, the forehead to the left sacro-iliac synchondrosis, and the long diameter of the head lies iu the left oblique diameter of the pelvis. Third {right occipito-p)Osterior , occipito-dextra posterior, O.D.P.). — The occiput points to the right sacro-iliac synchondrosis, the forehead to the left forameu ovale, and the long diameter of the head lies in the right oblique diameter of the pelvis. This position is the reverse of the first. Fourth (left ocoipito-posterior, occipito-lceva posterior, o.l.p.). — The occiput points to the left sacro-iliac synchondrosis, the forehead to the right foramen ovale, and the long diameter of the head lies in the left oblique diameter of the pelvis. This position is the reverse of the second. The relative frequency of these positions has long been, and still is, a matter of discussion among obstetricians. Accordino' to Naeo-ele, to whose classical essay we owe the greater part of our knowledge of the subject, the head lies in the right oblique diameter in 99 per cent, of all Naegele Naegele, Jr. ... Simpson and Barry Dubois Murphy Swayne First Position (O.L.A.) 70.00 64.64 7G.45 70.83 63.23 86.36 Second Position (O.D.A.) .29 2.87 16.18 9.79 Third Position (O.D.P.) 29.00 32.88 22.68 25.66 16.18 1.04 Fourth Position (O.L.P.) Not ; Classified .58 .62 4.42 2.8 1.00 2.47 cases. More recent researches have thrown some doubt on the accuracy of these figures, and many modern obstetricians believe that the second (o.d.a.) position, which Naegele believed only to be observed as a 18 274 LA noii. transitional stao:P iii tlic natural jji-o^i-css of the third (o.d.p.) posi- tion, i.s nuu'h more t'onmiun than he siij)j)ose(l. Tliis quostion \vill be more fully discuased when mo treat of the mechanism of occipito- ])osterior delivery, and in the mean time it may serve to show the discrej)anc'y which exists in the opinions of modern writers if ^\e fnrnisii the ])r('ccdinji- table of the relative i'requency of the various positions,^ copied from Ijeislinuin's work. Here it will be seen that all ol)stetricians are agreed as to the immensely greater frequen(y of tlie Hrst (o.L.A.) position — the only point at issue being the relative frequency of the second (o.d.a.) and third (o.d.p.). A'^arious explanations have been given of the greater frequency with which the head lies in the right oblique diameter. By some it is referred to the natural tendency of the back of the foetus, as shown by the experimental researches of Honing and other writers, to be directed, in consequence of gravitat ion, forward and to the left side of the mother in the erect attitude, and backward and to her right side in the recumbent. The explanation given by Simpson was that the head lay in the right oblique diameter in consequence of the measurement of the left oblique being more or less lessened by the presence of the r ectum . When the rectum is collapsed, indeed, the narrowing of the diameter is slight; but it is so often distended by fecal matter — sometimes, when constijjation exists, to a very great extent — that it may really have a very important influence in determining the position of the icetal head. In describing the mechanism of delivery it will be well for us to con- centrate our attention on the first (o.l.a.) or most common position, dwelling subsequently more briefly on the diiferences between it and the less common ones. Description of the First Position. — In this position, when the head commences to descend the occiput lies in the brim pointing to the left ileo-pectineal eminence, the forehead is directed to the right sacro-iliac synchondrosis, and the sagittal suture runs obliquely across the ])elvis in the right-oblique diameter. The back of the child is turned toward the left side of the mother's abdomen, the right shoulder to her right side, the left to her left side (Fig. 99). If a vaginal examination be now made (the patient lying in the ordinary obstetric position), and the os be sufficiently open, the finger Mill imj)inge upon the ])rotuberanee of the right parietal bone, M'hich is described as the "presenting part" — a term which has received various definitions, the best of M'hich is probably that adopied by Tyler Smith — viz. "that portion of the feetal head felt most prominently "within the circle of the os uteri, the vagina, and the os tincre in the successive stages of labor." If the tip of the examin- ing finger be passed slightly upAvard, it M'ill feel the sagittal suture running obli({uely across the })elvis, and if this be traced dowmvard and to the left it Mill come upon the triangular posterior fontanelle, M'ith the lambdoidal sutures diverging from it. If the finger could be passed sufficiently high in the o])])Osite direction, upward and to the right, it Mould come upon the large anterior fontanelle; but at this time that is too high up to be M'ithin reach. The chin is slightly flexed upon the ' Leisliuian's System of Midv:ijery, p. 341. MECHANISM OF DELIVERY IN HEAD PRESENTATION. 27 rj sternum, this flexion, as we shall presently see, being greatly increased as the head begins to descend. The head at the commencement of labor generally lies within the Fig. 99. Attitude of Child in First Position (o.l.a.). (After Hodge.) pelvic brim, especially in primiparse. In multiparas, owing to the relaxation of the abdominal parietes, the uterus is apt to fall some- FiG. 100. First Position (o.l.a.) : movement of flexion. what forward, and the head consequently is more entirely above the brim, but is pushed within it as soon as labor actually commences. 276 LABOR. Xaotxolo — and his doscriptioii has hccii n(ln])ted by most sul)Sosi- tion (o.l.a.), substituting the Avord " left " for " right." Thus the finger im})inges on the left parietal bone ; the occiput turns from right to left during rotation. After the birth of the head the occiput turns to the right thigh of the mother, the face to the left thigh. Third, or Right Occipito-sacro-iliac Position. — In the third j)osi- tion (o.D.P.) the head enters the pelvic brim with the <>ci'i))ut direete(l backward to the rigiit sacro-iliac synchondrosis, and the sinciput ibr- ward to the left foramen ovale (Fig. 105). The posterior fontanelle is directed backward, the anterior fontanelle forward, while the examining finger impinges on the left parietal bone. The mechanism of delivery in these cases is of much interest. In the large majority of cases dur- MECHANISM OF DELIVERY IN HEAD PRESENTATION. 281 iiig the jirogress of delivery the occiput rotates forwaixl along the right side of the pelvis, until it comes to lie almost in the antero-posterior diameter of the outlet and passes under the pubic arch, the forehead passing over the perineum. It will be seen that during part of this extensive rotation the head must lie in the second position (o.d.a.), and Third Position (o.d.p.) of Occiput, at Brim of Pelvis. the case terminates just as if it had been in the second position (o.d.a.) from the commencement of labor. Manner in ■which the Occiput is Rotated For"ward. — How is it that this rotation is eifected, and that the sinciput, occupying the position of the occiput in the first position (o.l.a.), should not be rotated for- ward to the pubes, as that is? This, no doubt, may be explained by the fact that the uterine force transmitted through the vertebral column causes the occiput to descend lower than the sinciput, so that in most cases in making a vaginal examination the posterior fontanelle can be readily felt, while the anterior is high up and out of reach. The head is therefore extremely flexed, and so descends into the pelvic cavity, until the occipui, being how below the right ischial spine, experiences the resistance of the pelvic floor opposite the right sacro-ischiatic liga- ment, by which it is directed forward. The forehead is, at this time, supposing flexion to be marked, too high to be influenced by the ante- rior pelvic plane. Pressure continuing, the occiput rotates forward, the forehead passes round the left side of the pelvis, and labor is terminated as in the second position (o.d.a). The period of labor at which rotation takes place varies. In the majority of cases it does not occur until the head is on the floor of the pelvis, for it is then that resistance is most felt ; but the greater the resistance the sooner will rotation be produced. Hence it is more likely to occur early when the head is large and the pelvis comparatively small. The facility with which this movement is effected obviously depends 282 LABOR. u[»un tlu' coinplett' flexion of the chin on the sternum, hy which the anterior fontanelle is so elevated that its rotation backward is not resLsted l)v the inward jjrojcction of tlic left ischial spine, and theoc-cipnt is cor- respondingly depressed. If, |m»ovpr^ fl.;< ^\^.^^\au is pot complete, rnid the anterior fnntanelle is so low as to be readily within reach of the finger, considerable difficulty is likely to be experienced. In many such cases rotation is still eventually effected, but in others it is not ; and tiie labor is then terminated Avith the face to the pubes, but at the expense of considerable delay and ditliculty. According- to Dr. Uvedale West of Alford, who devoted much careful study to the subject, this termi- nation occurs in about 4 per cent, of occipito-posterior positions. When it is about to happen the anterior fontanelle may be felt very low down, and soiuetimes even the forehead and superciliary ridges. The utei'ine force pushes down the occiput, the sinciput l)eing fixed behind the pubes, which it obviously cannot pass under, as does the occiput in the fii'st position. The sinciput, therefore, becomes more flexed and pushed upward, while the resistance of the pelvic floor directs the occii)ut for- ward. The perineum now becomes enormously distended by the back part of the head, and is in great danger of laceration. The occiput is eventually, but not without much difficulty, expelled. A process of extension now occurs, the nape of the neck being fixed, as it were, against the centre of the perineum, the expelling force now acting on the forehead, and producing rotation of the head on its transverse axis. The forehead and face are thus protruded, and the body follows without difficulty. It is said that in a few exceptional cases, where the anterior fonta- nelle is much depressed, the labor may terminate l)v the conversion of the presentation into one of the face, the head rotating on its transverse axis, the forehead passing to the posterior part of the pelvis, and the chin emerging under the perineum. It is obvious, however, that this change can only occur when the head is unusually small, and it must of necessity be extremely rare. Reference has already been made to Xaegele's views as to the rarity of the second position (o.d.a.), and to his o])inion that cases in which the occiput was found to point to the right foramen ovale were only transitional stages in the rotation of occipito-posterior positions. Sucli an assumjition, however, is unwarrantable, unless the case has been watched from the very commencement of labor. Many perfectly qual- ified observers have arrived at the conclusion that second ])ositions (o.d.a.) are far more common than Xaegele sujiposed ; and in the table already quoted it will be seen that while ]\fur])liy estimates the second (o.d.a.) and third (o.D.P.) as being equally I'requent, Swayne believes the second (o.d.a.) to be much more common than the third (o.D.P.). It is probable that the weight of Naegele's authority has induced many observers to classifv second (o.d.a.) jiositions as third (o.D.P.) jiositions in which partial rotation has already been acconn)lished. ^ly own experience would certainly lead me to think that second (o.d.a.) posi- tions are very far from uncommon. The question, however, must be considered to be in abeyance-until t'urther observations by competent authorities enable us to decide it conclusively. I MECHANISM OF DFJJVERY IN HEAD PRESENTATION. 283 Fourth or Left Occipito-sacro-iliac Position. — Tho fourth position (o.T..i>.) is just as luucli (he ivverse of the sec-ond as the third is of the first. The' occiput points to the left (Fig. 106) sacro-iliac synchondrosis, Fig. 106. Fourth Position (o.l.p.) of Occiput at Pelvic Brim. and the finger impinges on the right parietal bone. The mechanism is precisely the same as in the third position (o.d.p.), the rotation taking place from left to right. Formation of the Caput Succedaneum. — The formation of the caput succedaneum has been already alluded to. /This term is applied to the oedematous swelling which forms on the head, and is produced by effusion from the obstruction of the venous circulation caused by the pressure to which the head is subjectedA It follows that t he size of the swelling is in direct proportion to the length of the laborj In rapid deliveries, in ^vhich the head is forced through the pelvis quickly, it is scarcely, if at all, developed ; while after protracted labor it is large and distinct, and may obscure the diagnosis of the position by preventing the sutures and fontanelles being felt. Its situation varies according to the position of the head; thus, in the first (o.l.a.) and fourth (o.l.p.) positions it forms on the right parietal bone, in the second (o.d.a.) and third (o.D.P.) on the left ; and we may therefore verify by inspection of its site the accuracy of our diagnosis. An ordinary mistake which has been made by obstetricians is to regard the caput succedaneum as formed at the point where the head has been most subjected to pressure, while in fact it forms on that part Avhich is most unsupported by the maternal structures, and where the swelling may consequently most readily occur. Therefore, in the early stages of the labor it always forms on the part of the head which lies in the circle of the os uteri^ while in subsequent stages it forms on that which lies in the axis of the vaginal canal, and eventually is most prominent on the part that is first expelled from the vulva. Alteration in the Shape of the Head from Moulding-. — A few words may be said as to the alteration in the form of the fetal head which occurs in tedious labors, and results from the moulding which it has undergone in its passage through the pelvis. The smaller the pelvis and the greater the pressure applied to the head during the delivery, 284 LABOR. the more nmrkcd is tliis. Tho result is that in vortex presentations the ot'eii)ito-niental anil occipito-f'rontal (iianictoi-s arc elongated to the extent of an inch or even more, ■\vliilc the transverse diamcteis are lessened from compression of the parietal bones. This moulding is of iniqucstionable value in facilitating the birth of the child. The amount of apparent deformity is very considerable, and may even give rise to some anxiety. It is ■well to remendjcr, tiierclbre, that it is always transient, and that in a few hours, or days at most, the elasticity of the soft cranial bones causes them to resume their natural form. The caput succedanenm also disappears rapidly; therefore no amount of deformity from either of these causes need give rise to anxiety or call for any treatment. CHAPTER HI. MANAGEMENT OF NATURAL LABOR. Although labor is a strictly physiological function, and in a large majority of cases might, no doubt, be safely accom})lislied without assist- ance from the accoucheur, still, medical aid, properly given, is always of value in facilitating the process, and is often absolutely essential for the safety of the mother and child. Preparatory Treatment. — The management of the pregnant woman before delivery is a point which should always receive the attention of the medical attendant, since it is of consequence that the labor should come on when she is in as good a state of health as ])Ossible. For this purpose ordinary hygienic ])recauti ons should never be neglected in the latter months of gestation. The jiatient should take regular and gentle exorcis e short of fatigue, and, if the weather permit, should spend as nuieh of her time as possible in the o pen air. Hot I'ooms, late hours, and oxeitoniont of all kinds should be strictly avoided: The diet should be simple, nutritious, and unstimulating. The state of the bowels should be strictly attended to. During the few days preceding labor the descent of the uterus often causes ])rcssurc on the rectum and prevents its evacuation. Hence it is customary to prescribe occasional gentle a_perieuts, such as small doses of castoi* oil, for a few days before the expeetecTperiod of delivery. Some caution, however, is necessary, as it is certainly not very uncommon for labor to be determined rather sooner than was anticipated, in conse(|uence of the irritation of too large a purgative dose. The state of the b owels should always be inquired into at the commencement of labor, and, if there be any reason to susjiect that they are loaded, a co])ious enema should be administered.^ This is always a proper ])recaution to take, for a loaded rectum is a common cause of irregular and ineffective uterine action ; MANAGEMENT OF NATURAL LA BOB. 285 and even when it does not produce this result, the escape of the feces in consequence of pressure on the bowel during the propulsive stage is always disao-rccahlo both to tlie patient and practitioner. The dress of the patient during pregnancy may be here adverted to, for much discomfort may arise and tiie satisfactory progress of labor may even be interfered with from errors in this respect. After the uterus has risen out of the pelvis the ordinary corset which most women wear is apt to produce very injurious pressure ; still more so when attempts are made to conceal the increased size by tight lacing. After the fourth or fifth month, therefore, the comfort of the patient is much increased by wearing a specially-constructed pair of stays with elastic let into the sides and front, so that they accommodate them- selves to the gradual increase of the figure. Such are made by all stay- makers, and should be worn whenever the circumstances of the patient .permit. Failing this, it is better to avoid the use of the corset altogether, and to have as little pressure on the uterus as possible, although many women cannot do without the support to which they are accustomed. To multiparse, especially if there be much laxity of the abdominal parietes, a well-fitting elastic abdominal belt is often a great comfort. This is constructed so that it can be tightened when the patient is walking and in the erect position, w^hen such support is most required, and readily loosened when desired. Necessity of Attending to the First Summons. — It is hardly// necessary to insist on the necessity of the practitioner attending irame-l/ diately to the first summons to the patient. It is true that he may very' often be sent for long before he is actually required. But, on the other hand, it is quite impossible to foresee what may be the state of any in- dividual case. By prompt attention he may be able to rectify a mal- position or prevent some impending catastrophe, and thus save his patient from consequences of the utmost gravity. The practitioner should always be provided with the articles which he may require. The ordinary obstetric cases, containing one or two bottles and a catheter, such as are sold by most instrument-makers, are cumbrous and useless, while "obstetric bags" are expensive luxuries not within the reach of all. Every one can manufacture an excellent obstetric bag for himself at a small expense by having compartments for holding bottles stitched on to the sides of an ordinary leather bag, j^^ ^^ such as is sold for a few shillings at any portmanteau-maker's. It is a VT ^ o great comfort to have at hand all that may be required, and the bag y* should contain chloroform or other anaesthetic, antiseptics in a concen- (V/* trated form, chloral, laudanum, the liquor ferri perchloridi of the Phar- ^kJ macopoeia, the liquid extract of ergot, and a 'li ypocle rmic S3''ringe, with V bottles containing caibolized oil, ether, and a solution of ergotiue for subcutaneous injection. If it also contain a Higginson's ^^[uge, a small elastic cath eter, a good pair of forceps, and one or two suture- needles, with some silver wire or carbolized catgut, the practitioner is provided against any ordinary contingency. Other articles that may be required, such as thread, scissors, and the like, are generally provided by the nurse or patient. Duties on First Visiting the Patient. — On arriving at the house 286 LABOR. the ]>i-a('titioiior slioiild liavc liis visit annoiinced to tlic paticDt, and lie will very oltcn liiid that the lirst eilect of his jiresenee is to arrest the pains that have been hitherto i)roj;res.sin^ rai)idly, thereby allbrdinj; a very conclusive jn-oof of" the influence of mental inij)ressions on the progress of labor. If the ])ains be not already ])ropulsive, it is ^vell that lie should occujiy himself at first in general in<|uiri('s from the attendants as to the progress of the labor, and in seeing that all the necessary arrangements are satisfactorily carried out, so as to allow the patient time to get accustomed to his presence. If he have any choice in the matter, lie should endeavor to secure a large, airy, and well- ventilated apartment for the lying-in room, as far removed as possible from Mithout. He may also see to the bed, Mliich should be without curtains and jn-epared for the labor by having a waterproof sheeting laid under a folded blanket or sheet, ou Avhich the })atient lies. These receive the discharges during labor, and can be pulled from under the patient after delivery, so as to leave the diy clothes beneath. ["We would, in this connection, particularly recommend to accoucheurs the caoutchouc dam and a])ron devised as a protector and conduit by Prof. Howard A. Kelly of Philadelphia, as it not only prevents the soiling of the bed and the undergarments of the patient, but will admit of a reliable measurement of the amniotic fluid when in excess, and of that removed from the head by tapping in hydrocephalus. It has been found specially useful in cases of emergency and in practice among the poor and unprepared. — Ed.] Among the lower classes the lying-in chamber is considered a legitimate meeting-place for numerous female friends to gossip, whose conversation is often distressing, and is certainly injurious, to a woman in the excitable condition associated with labor. The medical attendant should therefore insist on as much quiet as pos- sible, and should allow no one in the room except the nuree and some one friend whose presence the jiatient may desire. The husband's presence must be left to the wishes of the patient. Some women like their husbands to be with tliem, while others prefer to be without them ; and the medical attendant is bound to act in accordance with the patient's desire. If pains be actually present a vaginal examination is essential, and should not be delayed. It enables us to ascertain whether the labor has commenced or not, and whether the presentation is natural or otherwise. The pains, although apparently severe, may be altogether spurious, and labor may not have actually commenced. It is of much imjK)rtance, both for our own credit and comfort, that we should' be able to diagnose the true character of the ])ains; for if they be so-called "false" jiains, we might wait hours in fruitless expectation of ]>rogress, while delivery is still far off. The necessity of ascertaining, therefore, the actual state of affairs need not further be insisted on. [In this connection we desire to remind the obstetrician that the vagina of the ])atient and his own hands should be rendered aseptic before he employs his index linger in making "the touch." A ]>hysician with ozaena should never practise obstetrics, for fear of poisoning his ]>atient by the touch after using his handkerchief. Many deaths have been in this way produced. — Ed.] False pains are chiefly characterized by their i rregula rity, sometimes MANAGEMENT OF NATURAL LABOR. 287 coming on at short intci'vals, sometimes Avith many liours between them: they also vary much in intensity, some being very sharp and ])ainfnl, while others ai"e slight and transient. In these respects they diHer from the true pains of" the first stage, which are at first slight and short, and gradually recur with increased force and regularity. /The s ituation of t he t wo kinds of ])ains also varies, the false pains being chiefly situated in front, while the true pains are felt most in the back and gradually shoot round toward the abdomen.) Nothing short of a vaginal examination will enable us to clear up the diagnosis satisfac- torily, [i If the labor have actually commenced, the os will be more or( less dilated and its edges thinned, while with each jmin the cervix will J become rigid and the membranes tense and prominent.) The false | pains, on the contrary, have no effect on the cervix, which remains flaccid and undilated, or, if the os be sufficiently open to admit the tip of the finger, the membranes will not become prominent during the contraction. Under such circumstances we may confidently assure the patient that the pains are false, and measures should be taken to remove the irritation which produces them. ' In the large majority of cases the cause of the spurious pains will be found to be some disordered state of the intestinal tract;) and they will be best remedied by a gentle aperient, such as castor oil or the compound colocynth pill with hyoscyamus, fol- lowed by or combined with a sedative, such as twenty minims of lauda- num or chlorodyne. Shortly after this has been administered the false pains will die away, and not recur until true labor commences. Mode of Conducting a Vaginal Examination. — For a vaginal examination the patient is placed by the nurse on her left side, close to the edge of the bed, with the legs flexed on the abdomen. The practi- tioner, being seated by the edge of the bed, passes the index finger of the right hand, the proper antiseiDtic precautions having previously been taken, up to the vulva, and gently insinuates it into the orifice of the vagina, then pushes it backward in the axis of the vaginal outlet, and finally turns it upward and forward, so as to more readily reach the cer- vix (Fig. 107). This it may not always be easy to do, for at the com- mencement of labor the cervix may be so high as to be reached with difficulty, or it may be directed backward so as to point toward the cavity of the sacrum. vThe exploration is often much facilitated by depressing the uterus from Avithout by the left hand placed on the abdo- men. Our object is not only to ascertain the state of the cervix as to softness and dilatation, but also the presentation, the condition of the vagina, and the capacity of the pelvis. /The examination is generally commenced during a j^ain, at which time it is less depressing to the patients but in order to be satisfactory the finger must remain in the vagina until the pain is over, the examination being concluded in the interval between this pain and the next. In head presentation the round mass of the cranium is generally at once felt through the lower part of the uterus, and then Ave have the satisfaction of being able to assure the patient that all is right. If the OS be sufficiently dilated, we can also feel through it the occiput covered by the membranes. ( It is im]2pssible at this time to make out the exact position of the head by means of the sutures and fontauelles, which 288 LABOR. are too liigli up to bo Avitliin reach. ) Nor should any attempt l)e made to do so, for fear of prematurely rupturing the membranes. The fact that the head is presenting is all that we require to know at this stage of the labor. The condition of the os itself as to rigidity and dilatation -M-ill materially assist us in ibrming an opinion as to the progress and proba- FiG. 107. Examination during the First Stage. ble duration of the labor; but, although the friends will certainly press for an opinion on this point, the cautious practitioner will be careful not to commit himself to a positive statement which may so easily be falsified. It will suffice to assure the friends that everything is satis- factory, but that it is impossible to say with any certainty how rajiidly or the reverse the case may progress. If the pains be not very frequent or strong, and the os not dilated to more than the size of a shilling, a considerable delay may be anticipated and the presence of the medical attendant is useless. He may therefore safely leave the patient for an hour or more, provided he be within easy reach. It is needless to say that this should never be done unless the exact presentation be made out. If some part other than the head be presenting, it M'ill probably be impossible to make it out until dilata- tion has progressed further ; and the practitioner must be incessantly on the watch until the nature of the case be made out, so as to be able to seize the most favorable moment for interference, should that be necessary. Position of Patient during- First Stage. — The position of the patient is a matter of some moment in the first stage. It is a decided advantage that she should n ot be then in a rec u mbent position on her side, as is usual in the second stagey, for it is o? importance that the MANAGEMENT OF NATURAL LABOR. 289 expulsive force should act iu siieli a M^ay as to favor the descent of the head into the pelvis — /. c. perpendicularly to the plane of its brim — and also that the weight of the child should operate in the same way. ([riierefore, the ordinary custom of allowing the patient to walk about I or to recline in a chair is decidedly advantageous^ and it will often be' observed that the ])ains are more lingering and ineftective if she lie in bed. ( If the patient be a multipara or if the abdomen be somewhat ])endulous, an a bdominal bandag e, by supporting the uterus, will greatly favor the progress of this stage. ) Keeping the patient out of bed has the further advantage of preventing her being unduly anxious for the termination of the labor, and a little cheerful conversation will keep up her spirits and obviate the mental depression which is so common. Good beef-tea may be freely administered, with a little brandy and water occasionally if the patient be weak, and will be useful in sup- porting her strength. ^' Over-frequent vaginal examinations at this period should be avoided, for they serve no useful purpose and are apt to irritate the cervix. It will be necessary, however, to ascertain the progress of the dilatation at intervals. When once the os is fully dilated the membranes may be artificially ruptured if they have not broken spontaneously, for they no longer sei-ve^any useful purpose and only retard the advent of the propulsive stage. \ This can be easily done by pressing on them, when they are rendered tense during a pain, by some pointed instrument, such as the end of a hairpin, which is always at hand. In some cases, indeed, it is even expedient to rupture the membranes before the os is fully dilated. Thus it not unfrequently happens, when the amount of liquor amnii is at all excessive, that the os dilates to the size of a silver dollar or more ; but, although it is perfectly soft and flaccid, it opens up no farther until the liquor amnii is evacuated, when the propulsive pains rapidly complete its dilatation. Some experience and judgment are required in the detection of such cases, for if we evacuate the liquor amnii prematurely the pressure of the head on the cervix might pro- duce irritation and seriously prolong the labor. This manoeuvre is most likely to be useful when the pains are strong and the os perfectly flaccid, but when the membranes do not protrude through the os so as to effect further dilatation. It is sometimes not easy to ascertain whether the membranes are rup- tured or not. This is most likely to be the case when the head is low down and the amount of liquor amnii is so small that the pouch does not become prominent during the pains. A little care, however, Mill enable us, if the membranes are ruptured, to feel the rugosities of the scalp covered witli hair, and to distinguish it from the smooth polished surface of the membranes. After the evacuation of the liquor amnii there is generally a lull in the progress of the labor, the pains, however, soon recurring with in- creased force and frequency, and propelling the head through the pelvic cavity. The change iu the character of the pains is soon appreciated by the bearing-down efforts by which they are accompanied, as well as by their increased length and intensity. 2i)() LAJiOR. Position of the Patient during the Second Stage. — It is now ndvi.siMc- that t lu' ]>atiL'n t l>c |)jarc;d_ inhcHl ; and in Knirl:iiiresenting part and the bony pelvis. This mode of assistance is very different from the digital dila- tation of a rigid cervix, which was formerly much jmtctised, especially in Edinl)urgh, in consef|uence of the recommendation of Hamilton, and which was projK'rly oljjected to l)y the great majority of oltstctricians. li' the pains be ]iroducing satisfactory ])rogress, no further interfer- ence is required, /' The medical attendant should, however, see that the bladder is evacuated, and if it have not been so for sonic hours it may be necessary to draw off the urine by the catheter, ^^'llenever the labor is lengthy he should occasiona lly practise auscultation , so MANAGEMENT OE NATURAL LABOR. 291 as to satisfy liiinsc]!' tliat the i\vAii\ circiilatioii is hciii}^ salisfactorilv carried on. The regulation of the bearing-down eiibrts at this time is of import-' ance. It is common for the nurse to urge the patient to lielj) lierself by straining, and it is certain tliat by vohintary action of this kind she can materially increa-se the action of the accessory muscles of parturi- tion. If the pains be strong and the labor promise to 1)C rapid, such voluntary exertions are not likely to be prejudicial. On the other hand, if the case be progressing slowly, they ouh^ unnecessarily fatigue the })atient, and should be discouraged. When the perineum is distended Me may even find it advisable to urge the patient to cease all voluntary eifort and to cry out, for the express purpose of lessening the tension to which the perineum is subjected. This is the stage in which anaesthesia is most serviceable, but its employment nmst be separately discussed. Distension of the Perineum. — As the head descends more and more the perineum becomes distended, and there is considerable difference of opinion amongst accoucheurs as to the management of the case at this time. In most obstetric works the practitioner is advised to endeavor to prevent laceration by the manreuvre that is described as " supp^ortlng t he perineu m." vBy this is meant laying the palm of the hand on the distended structures and pressing firmly upon them during the acme of the pain, with the view of mechanically ])reveuting their tearing.) There can be little doubt that this or some modification of it is the practice now followed by the large majority of practitioners. Of late years the evil effects likely to follow it have been specially dwelt upon by Graily Hewitt, Leishman, Goodell, and other writers, who maintain that by pressure exerted in this fashion we not only fail to prevent, but actually favor, laceration, in consequence of the pressure joroducing increased uterine action just at the time when forcible distension of the perineum is likely to be hurtful. Therefore some hold that the peri- neum ought to be left entirely alone, and that the head should be allowed gradually to distend it, without any assistance on the part of the prac- titioner. Much error may be traced to a misconception of ^hat is required. The term " supporting the perineum " conveys an unquestionably erro- neous idea, and it is certain that no one can prevent laceration by Jiiechanical support. If the term " relaxation of the perineum " was employed, we should have had a fiir more accurate idea of what should be aimed at, and if this be borne in mind I think it cannot be ques- tioned that nature may be most usefully assisted at this stage. Dr. Goodell of Philadelphia has specially studied this subject, and has recommended a method the object of which is to relax the per- ineum, ( His advice is that one or two fingers of the left hand should be inserted intojh^rectuni, by which the perineum should be hooked up and pulled forward over the head, toward the pubcs, the thumb of the same hand being placed on the advancing head, so as to restrain its progress if needful.\ I have adopted this plan frequently, and believe that it admiraoly answers its purpose, especially when the perineum is greatly distended and la(«ratiou is threatened. It nuist be admitted that the insertion of the fino-ers into the anal orifice in 2ii2 LABOR. titinner must aim at. | greatly, the tlmiul) aiui (the iiiamier recnnimeiuled is rcpiij^iiant hotli to llie i»i"actitii»iier ami the patient, ami the same result can be obtained in a less unj)lcas- ant wav. I mention it, however, to show what it is that the ))rae- If", when the head is distending the perineum greariv, tne iimmi) luui forefinger of" the right hand an; j)laeed along its sides, it can be pushed gently forward over the head at the height of the pain, while the tips of" the fingers may, at the same time, press upon the advancing vertex, so as to retard its progress if advisable \ (Fig. 108). By this means the sudden and forcible stretching of ^^ Fig. 108. Mode of effecting Relaxation of the Perineum. the perineal structures is prevented and the chance of laceration reduced to a minimum, while nature's mode of relaxing the tissues by dilatation of the anal orifice is favored. This is very different fr6m the mechanical support that is usually recommended, and the less pressure that is applied directly to the perineum the l)etter. Nor is it either needful or advisable to sit by the patient with the hand applied to the perineum for lioin's, as is so often practised. Time should be given for the gradual distension of the tissues by the alter- nate advance and recession of the head, and we need only intervene to assist relaxation when the stretching has reached its height and the head is about to be expelled. pV na])kin may be interposed between , the hand and the skin for the purpose of cleanliness. Should the \ perineum be excessively tough and resistant, assiduous fomentation with a hot sponge may be resorted to, and Avill be of some service in promoting relaxation. Incision of the Perineum. — [When the tension is so great that laceration seems inevitable it is generally recommended that a slight incision should be made on each side of the central raphe, with the view of preventing spontaneous laceration. ^ This may no doubt be MANAGEMENT OE NATURAL LABOR. 293 ;e miuht occnr. The cord is tied abont an inch and a half" from the child, and it is usual — though, of course, not essential — to place a second lig'ature about two inches nearer the placental extremity t)f the cord. The latter is ])erhaps of some use by retaininrac- tice as to the management of this stage is opposed to the natural mei-han- ism of placental ex])ulsion, and is far from being well adapted to secure the im})ortant objects which we ought to have in view. Let us see what is the practice usually recommended and followed, and then we shall be in a ]K)sition to understand in what respects it is erroneous. For this j)ur[)ose I cannot do l)etter than copy the directions contained in one of our most deservedly popular obstetric textbooks, which inidoubtedly expresses the usual ])ractice in the management of this stage : " ^^ hen the binder is applied the patient may be allowed to rest a while if there ' BiiHin, Profffh medicfil. 1876. toiii. iv. pp. 2, 3G. ^Archil: de Tocologie, 1879, p. 577. MANAGEMENT OF NATURAL LABOR. 295 is no flooding; after wlilcli, ir/icn the idrrus contraHs^ gv.uth'. traction may l)e made by the funis to ascertain if the placenta he detached. If so, and especially if it be in tlie vagina, it may be removed by continu- ing the traction steadily in the axis of the upper outlet at first, at the same time making pressure on the uterus." ' [In this country, for many years, the uniform teaching has been that the binder should not be applied until the uterus has expelled the pla- centa and become lirmly contracted.^ Although the plan of expression was not carried out as completely as is noAv taught under the Crede method, that of stimulating the contractions of the uterus by manipula- tion and pressure was certainly in use forty years ago. When the size and solidity of the uterus, as ascertained by the compressing hand, indi- cate that the placenta has been expelled into the vagina, it is a question whether we shall cause it to be forced through the vulva by pressing down the uterus upon it, or make traction upon it by the finger hooking down its edge. Occasionally, we find a patient who is very sensitive to pressure made upon her uterus after it has become firmly contracted ; and in such a case it may be well to depend partly upon traction for completing the delivery of the secundines. That it is possible for the uterus to expel the placenta suddenly from the vagina where no pressure has been made is evident from the fact that a physician of this city, who was making traction upon the cord under the old method some vears ago, was surprised to find the placenta shoot out from the vulva and dangle by the funis as he held it in his hand. In such a case the uterus, must have been aided during a contraction by voluntary abdominal pressure, causing the os to descend nearly to the vulva. It is very evi- dent that the uterus is subject to muscular fatigue and to the exhaustion of its contractile power Mhen long in action ; hence there is a greater risk of uterine atony and hemorrhage after a long labor than a short one, and we may expect a more complete expulsion of the placenta in the latter. It is also clear, from cases in my own experience, that the muscular power of the uterus is by no means in proportion to the gen- eral strength of the woman. The power to assist by bearing down no doubt is, but the independent power of the organ itself does not appear to be. Certainly some of the most perfect in parturient power that have come under my care were small women with little general nuis- cular force. One little woman of 86 pounds weight appeared almost to have escaped the curse pronounced upon Eve ; and another, still smaller, expelled a placenta from her vagina almost M'ithout any loss of blood. — Ed.] This may fairly be taken as a sufficiently accurate description of the practice usually followed. The objections I have to make are: (1) That it inculcates the common error of relying on the binder as a means i of promoting uterine contraction, advising its apj)lication before the expulsion of the placenta, while I hold that the binder should never be I applied until after the placenta is expelled, and not even then unless the uterus is perfectly and permanently contracted. (2) That it teaches that traction on the cord should be used as a means of withdrawing the pla-. centa; whereas /the uterus itself should be made to expel the after-birth,/ ' ChurohiU's Tlwonj and Practice of Mkhcij'enj, p. 162. 29() LAliOlt. aiie , such as a drachm or more of the liquid extract. \ The ])ro])erty jiossessed by this drug of producing tonic and persistent contraction of tlie uterine fibres, which renders it of doubtful utility as an oxytocic during labor, is of s'^iecial value after delivery, when such contraction is jirecisely what we desire. I have long been in the habit oi' administering the drug at this period, and believe it to be of great value, not only as a j)rophy- lactic against hemorrhage, but as a means of lessening al'ter-pains. Application of the Binder.— ^When we are satisfied that the uterus is ])ermanently contracted we may apjdy the binder, but this should rarely be done until at least half an hour after the birth of tlie^child. The soiled clothes should be gently withdraMii from under the jiatient, moving her as little as jiossible, and the binder should be at the same time sli])ped under the body, taking care that it is ]iassed wvW below the hij)s, so as to secure a firm hold. Xo kind of l)andagc is better than a piece of stout jean of sufficient breadth to extend from the trochanters to the ensiform cartilage ; a jack-towel or bolster slip answei*s the ])ur- ])Ose very well. These are preferable, at any rate at first, to the sha]>ed binders that are often used. One or two folded na})kins are generally })laced over the uterus, so as to form a ])ad to keep up ])ressure. Once in position, the binder is pulled tight and fiistcni'd by pins. The utility ANJESTHESIA IN LABOR. 299 of careful bandaginj^ al'tcr delivery can scarcely be doubted, altiiough some years ago it became the liisliiou to dispense with it. It gives a comfortable support to the lax abdominal walls, keeps up a certain amount of pressure on the uterus, and tends to restore the figure of the j)atient. /After the bandage is applied a warm napkin should be placed on the vulva, as a means of estimating the quantity of" tlie dis- charge, andT tli(r|)atient may be allowed to rest. After-treatment. — Unless the labor has been very long and fatigu- ing an opiate, often exhibited as a matter of routine, is unadvisable, although it may be well to leave one with the nurse, to be given if the ])aticnt cannot sleep or if the after-pains be very troublesome. 'The practitioner may now leave the room, but not the house, and at least an hour should elapse after delivery before he takes his departure.'^ Before doing so he should visit the patient, inspect the napkin to see that there is not too much discharge, and satisfy himself that the uterus is contracted and not distended with coagula. He should also count the pulse, which, if the patient be progressing satisfactorily, will be found at its normal average. If, however, it be beating over one hundred per minute, he should on no account leave, for such a rapidity of the cir- culation renders it extremely probable that hemorrhage is impending. This is a good practical rule, laid down by McClintock in his excellent paper On the Pulse in Childbed, attention to which may often save the patient from disastrous consequences. Before leaving the practitioner should see that the room is darkened, all bystanders excluded, and the patient left as quiet as possible to recover from the shock of labor. CHAPTER IV. ANESTHESIA IN LABOK. A FEW words may be said as to the use of anaesthetics during labor — a practice which has become so universal that no argument is required to establish its being a perfectly legitimate means of assuaging the suf- ferings of childbirth. Indeed, the tendency in the present day is in the Oj)posite direction, and a common error is the administration of chloro- form to an extent which materially interferes with the uterine contrac- tions and predisposes to subsecpient post-])artum hemorrhage. Agents Employed — Practically speaking, the only agent hitherto employed in England is ch loro form, although the bichloride _of methylene and ether have been occasionally tried. Of late years chloral has been extensively used by some, and, as I believe it to be an agent of very great value, I shall tirst indicate the circumstances under which it may be employed. 300 LABOR. The pcouliar vmIuo of c lilor al in labor is that it maybe safely atlniin- istered at a time when chlorotoi-ni cannot be te;i(l w itii !Lire:it :i(lvaiitational cases, all danger may be avoided. Otiiers have a very great fear of it, and universally trust to the safer ana'stlietie. It is an error to su]>pose that the ]iarturient state robs chloroform of much of its danger, the a])])arent innnunity being due to its intermittent and incomplete administration ; complete anaes- thesia being but a fraction less dangerous than in siu'gical ojieratious upon women who are not pregnant. Dr. Lusk, already quoted, after a large experience with the use of chloroform, says: ^' Pafioifs in /ahor (Jo iiotenjoii (Oil/ (thmlnfc imtnuiiifj/ from fJic ])cr)ii('ious ejf'cct'i of cJi/oro- form."^ It is nmch to be regretted that tliis more ])leasant anasthetic is so much more dangerous than ether as an inhalant ; but in considera- tion of the difference of risk, that of tlieir relative effects upon the nose [' Opus C(7.] PELVIC PRESENTATIONS. 303 and trac'liea is scarcely to be considered. Chloroform acts u|)on the respiratory centres just as ether does ; and this is an element of daii<:;<'r in each, hut is capable of being counteracted by artificial res])ii'atioM. Hut, beyond this, chloroform is i\\v more dan^-erous, in acting- upon the motor ti'anolia of the heart and i)i'o(,lucino; sudden death. Accordintr to the experiments of Yulpian u[)on animals, uot more than one case of cardiac failure in forty can be restored by artificial res})iration. He atKrms that there is danger at the comraencemeDt, during the course, and at the close of chloroformization, and even some hours or days subsequent to it. Nelatou made the important discovery that the cc^rebral anaemia produced by chloroform, with its accompanying death- like condition, might be remedied by long perseverance in artificial i-es- piration with the patient turned head downward. Antiesthesia in labor is much less popular, both with obstetricians and patients in this country, than it was soon after its introduction. Im- provements in the purity of sulphuric ether have made the narcosis more reliable, but the general effect upon j)atients varies very decidedly, being all that can be desired in some, and just the reverse in others. Some of the undesirable effects I have witnessed are intoxication, with cessation of labor, hysterical excitement, nightmare, and post-partum inertia and hemorrhage. I have also witnessed the most delightful results from ether that could be desired. In a small, delicate multip- ara, whose mother died of phthisis, and to whom I had been obliged to administer stimulants in the first and much of the second stage of labor, the use of ether had the effect to revolutionize her condition. Her pulse became strong ; her expulsive power increased ; she had no suflFering ; her placenta was expelled without accompanying blood ; and there was no subsequent uterine relaxation. But such cases are, unfor- tunately, exceptional. — Ed,] CHAPTER V. PELVIC PRESENTATIONS. Under the head of pelvic presentations it is customary to include all cases in which any part of the lower extremities of the child presents. \ By some these are further subdivided into breech, footlinr/, and l-nce ' presentations; but, although it is of consequence to be able to recognize the feet and the knee when they present, so far as the mechanism and management of delivery are concerned the cases are identical, and there- fore may be most conveniently considered together. Frequency. — Presentations comino- under this head are far from t ^-* .']()4 LABOR. iiiR-oinmoii : those in wliicli llic hrcccli alone occupies the pelvi.s are ^x.- met with, according- to (hurcliiJl, once in 52 lal)ors, wliile Ranishothani ^ estimates that it ])rescnts more f'reciuently — viz. onc(! in liS.H hilxtrs. < Footliiiii' presentations occur only once in 1*2 cases. They are j)r(tl)al)ly often the mere conversion oforij^inal hreech presentations, the i'eet hav- ing come down during the labor, either in consequence of the sudden escape of the liquor amnii, v.hen the breech was still freely movable above the brim, or from some other cause. Knee presentations are extremely rare, as may be readily understood if it be borne in mind that to admit them the thighs nuist be extended, hence the vertical measure- ment of the child must be givatly increased, and therefore it could not be readily accommodated within the uterine cavity unless of unusually small size. As a matter of fact, Mme. LaChapelle found only one knee presentation in upward of 3000 cases. The causes of pelvic presentations are not known. They are ])rob- ably the same as those which produce other varieties of malpresenta- tions, cspecially(an excess of liquor amn iiand s light pelvic contractio n : and it is not unlikely that m certain women thci'e may be(sonie pecu- liaritv in the shape of the uterine cavity which favors their production} * It would be difficult otherwise to explain such a case as that mentioned by Yelpeau in which the Ijreoch presented in six labors. Prognosis. — The results as regards the mother are in no way more unfavorable than in vertex presentations. The first stage of 'tlie lalTor is generallv tediouss, since the large rounded mass of the breech does not adapt ifseTf so"well as the head to the lower segment of the uterus, and dilatation of the cervix is consequently apt to be retarded. ^The second stage is, however, if anything, more rapid than in vertex cases; and even when it is protracted the soft breech does not produce such inju- rious pressure on the maternal structures as the hard and unyielding head. The result is very different as regards the child. Dubois calculated that 1 out of 11 children was stillborn. Churchill estimates the mor- tality as much higher — viz. 1 in 31-. The latter certainly indicates a larger number of stilll)irths than is consistent with the experience of most practitioners, and more than should occur if the cases be })roperly managed ;(but there can be no doubt that the risk to the child is, even under the most favorable circumstances, very great) (Even when the child is not lost it may be seriously injured.) Dr. Ruge has tabulated a series of 29 cases in which there were found to be fractures of bt>nes or other injuries.' The chief source of danger is pressui'e on the umbilical cord in the interval elapsing between the birth of the body and the liead. At this time the cord is very generally compressed between the head of the child and the pelvic walls, so that circulation in its vessels is arrested. Hence the aeration of the foetal blood cannot take ]>lace, and jnilmonary respiration not having been yet established, the child dies asphyxiated. There are other conditions present which tend, although in a jninor degree, to produce the same result. One of these is that the pbc-enta is probab ly often separivted by the uterine contractions when the bulk ' Bull. (/en. de Therap., August, 1875. PELVIC PRESENTATIONS. 305 of the body is being expelled, as, indeed, takes place under analogous circumstances when the vertex presents, the necessary result being the arrest of placental respiration. Joulin thinks that the same effect may be produced by the compression of the placenta between the con- tracted uterus and the hard mass of the foetal skull. Probably all these causes combine to arrest the functions of the placenta ; and if the deliv- ery of the head, and consequently the establishment of pulmonary res- piration, be delayed, the death of the child is almost inevitable. The corollary is that the danger to the child is in direct proportion to the length of time that elapses between the birth of the body and that of the head. The risk to the child is greater in footling than in breech cases,' because in the former the maternal structures are less perfectly dilated in consequence of the small size of the feet and thighs, and therefore the birth of the head is more apt to be delayed. Diagnosis. — Inasmuch as the long axis of the child corresponds with the long axis of the uterus in pelvic as in vertex presentations, there is notlihig iu the shape of tlie uterus to arouse suspicion as to the character of the case. Still, it is often sufficiently easy to recognize a pelvic presentation by abdominal examination if we have occasion to make one. The facility with which it may be done depends a good deal on the individual patient. If she be not very stout, and if the abdominal parietes be lax and non-resistant, we shall generally be able to feel the round head at the uj)per part of the uterus, much firmer and more defined in outline than the breech. (The conclusion will be for- tified if we hear the fcjetal heayt beating on a level wi th or above the umbilicus.\ The greater resistance on one side of the abdomen will also enable us to decide with tolerable accuracy to which side the back of the child is placed. Information thus acquired is, at the best, uncer- tain, and we can never be quite sure of the existence of a pelvic pres- entation until we can corroborate the diagnosis by vaginal examina- tion. " [In view of the greater risk to the life of the foetus in a delivery by the breech over that by the vertex, it is advisable, when the posi- tion is determined while the membranes are still intact, to change the presentation from pelvic to cephalic by external bimanual manipula-j tion. — Ed.] The first circumstance to excite suspicion on examination per vaginam, even when the os is undilated, is the absence of the hard globular mass felt through the lower segment of the uterus, so characteristic of vertex presentations. ^ When the os is sufficiently open to allow the membranes to protrude, although the presenting part is too high up to be within reach, we may be struck witli the peculiar shape of the bag of mem - branes, which, instead of being rounded, projects a considerable distance through the os, like the finger of a glove. This is a peculiarity met with in all mal presentations alike, and is, indeed, much less distinct in breech than in footling presentations, because in the former^ the mem- branes are more stretched, just as they are in vertex cases. '^Vhen the membranes rupture, instead of the waters dribbling away by degrees^ they often es cape with a rush, in consequence of the pelvic extremity 20 306 LABOR. not filling up the lower part nC the iitorus so accurately as the head, ■which acts lus a sort o-l' i)all-\:iiv(-' and |)i-('vcnts the sudden and i-uinplete dischai'go of the waters. Often on first examining, even when the membranes arc ruptured, the presentation is too high up to be made out accurately. All that we can be certain of is, that it is not the head ; and the case nuist be csire- i'ully watched and exaniinations fri'(|uently repeated until the precise iKitiiiv of the j)resentation ean be established, it' the breech pi'esent, the finger first impinges on a round, soft })rominence, on depressing >viiieli a bony protul)erance, the trochanter major, Ciui be felt. (Jn })assing the finger upward it reaches a groove, beycmd whi(;h a similar fleshy mass, the other buttock, can be felt. In this groov e various characteristic j)oints diagnostic of the presentation can be made out. Toward one end we can feel the movable tij) of" the coccyx, and above ^ it the hard . sgcrum with its rough project jng ju'omiiienccs. These points, ^ ^ if accurately Tnarte out, are quite cTiaracteristic, and resemble nothing in any other presentation. In front there is the anus, in which it is some- times, but by no means ahvays, possible to insert the tip of the finger. If this can be done, it is easy to distinguish it from the mouth, with Avhicli it might be confounded, by observing that the hard alveolar ridges are not contained within it. Still more in front we mav find the genital organs, the scrotum in male children being often much swollen if the labor has been protracted. Thus it is often possible to recognize the sex of the child before birth. The l2i'eech might be mistaken for the face, especially if the latter be much swollen ; but this mistake can readily be avoidal by feeling the spinous processes of the sacrum. The jvue e is recognized by its having two tuberosities with a depres- sion between them. It might be confounded with the heel, the elbow, or the shoulder. From the heel it is distinguished by having two tuberosities instead of one ; from the elbow, by the latter having one sharp tuberosity, with a depression on one side, instead of a central depression and two lateral ])rominences ; and from the shoulder, by the latter being more rounded, having only one prominence, running from which the acromion and clavicle can be traced. t T he, fo ot may be mistaken for the hand. This errc»r will be avoided ^ VxMmy remembering that all the toes are in the same line, and that the great ^ I toe cannot be brought into apjiosition with the others, as the thumb can J^ftA|,»with the fingers. The internal border of the foot is nuich tiiicker than ' vM* 1 ^^^ external, whereas the two bordei^s of the hand are of the same thick- j ness. Moreover, the foot is articulated at right angles to the leg, and I cannot be brought into a line with it, as the hand can with the arm. Finally, the projection of the calcaneum is characteristic and resembles nothing in the hand. Mechanism. — As is the case in other presentations, obstetricians have very variously subdividcxl breech presentations with the effect of needlessly com})licating the subject. The simplest division, and that which will most readily imj^rcss itself on the memory of the student, is to describe the breech as ])resenting in four positions, analogous to those of the vertex, the sacrum being taken as representing the occiput, and PELVIC PRESENTATIONS. 307 the positions being numbered according to the part of the pelvis to which it points. Thus we liave — First, or left sdcro-anterior (sacro-lseva anterior, s. L. A., correspond- ing to the first position of the vertex). The sacrum of the child points to the left foramen ovale of tlie mother. Second, or right sacro-anterior (sacro-dextra anterior, s.D. A., corre- sponding to the second vertex position). The sacrum of the child points to the right foramen ovale of the mother. Third, or right sncro-posterior (sacro-dextra posterior, S.D. P., cor- responding to the third vertex position). The sacrum of the child points to the right sacro-iliac synchondrosis of the mother. Fourth, or left sacro-posterior (sacro-lseva posterior, S. l. p., corre- sponding to the fourth vertex position). The sacrum of the child points to the left sacro-iliac synchondrosis of the mother. vOf these, as with the corresponding vertex positions, the first (s. L. A.) and third (s.D. r.) are the most common,^ their comparative frequency no doubt depending on the same causes. The mechanical conditions to which the presenting part is subjected are also identical, but the alterations of position of the breech in its progress are by no means so uniform as those of the head, on account of its less perfect adaptation to the pelvic cavity. The mechanism of the delivery of the shoulders and head in breech presentations, moreover, is of much greater practical importance than that of the body in vertex presen- tations, inasmuch as the safety of the child depends on its speedy and satisfactory accomplishment. Bearing these facts in mind, it will suffice to describe briefly the phenomena of delivery in the first (s. L.A.) and third (s.D. p.) breech positions. Position of the Child at Brim. — In the first position (s. L.A.) (Fig. Ill) the sacrum of the child points to the left foramen ovale; its back is consequently placed to the left side of the uterus and anteriorly, and its abdomen looks to the right side of the uterus and ])osteriorly. The sulcus between the buttocks lies in the right oblique diameter of the pelvis, while the transverse diameter of the buttocks lies in the left oblique diameter, the left buttock being most easily within reach. As in vertex presentations, the hips of the child lie on the same level at the pelvic brim, although Naegele describes the left hip as placed lower than the right. As the pains act on the body of the child the breech is gradually forced through the pelvic cavity, retaining the same relations as at the brim, its progress being generally moi'e slovv than that of the head, .-^ until it reaches the lower pelvic strait, when the same mechanism which \ produces rotation of the occiput comes to operate upon it. The result \^^ is a rotation of the child's pelvis, so thatiits transverse di amet er comes to lie approximately in the antero-posterior diameter of the outlet) 'its antero-posterior diameter corresponds to the transverse diameter oi the mother's pelvis, the_left liip lies behind the pubes and the right toward the sacrum. The rotation, which is admitted by the majority of obstet- ricians, is altogether denied by Naegele. There can be no doubt, how- ever, that it does generally take place, but by no means so constantly as the corresponding rotation of the vertex; and/ it is not uneonnnon for it to 308 LABOR. be entirely absent and for the hips to be bom in the obliq ue diam eter of the outletj) (^The body ol" the chiltTTs said frequently not to follow Fi(i. 111. First, or Left Sacro-anterior Position (s. l. a.) of the Breech. the movement imparted to the hips, so that there is more or less of a twist iu the vertebral column.^ The left hip now becomes firmly fixed behind the pubes, and a move- FiG. 112. Passage of the Slioul.i. r> and Partial Rotation of the Tliorax. ment of extension analogous to that of the head in vertex presentations takes place. Tlic right or posterior hip revolves round the fixed one , gra du all y distends (the perippnm^ nnd is e xpelled first , the left hip rapidly following. (As soon as both hi]is a're born tiie feet slip out, unless the legs are completely extended upon the child's abdomen.'N The shoulders soon follow, lying in the left oblique diameter of the pelvis (Fig. 112). The left shoulder rotates forward behind the pubes, PELVIC PRESENTATIONS. 309 where it becomes fixed, the right shoulder swccpiug over the perineum and being born first. The arms of tlie child are generally found placed upon its thorax, and are born before the shoulders. Sometimes they are extended over the child's head, thus causing considerable delay and greatly increasing the risk to the child. (It is now generally admitted that sucli extension is most apt to occur when traction lias been made on the child's body with the view of hastening delivery, and that it is rarely met with when the expulsion of the body is left entirely to the normal powers. J Delivery of the Head. — When the shoulders are expelled the head enters the pelvis in the opposite, or right oblique, diameter, the face look- ing to the right sacro-iTiac^^nchondrosis. As the greater part of the child is now expelled, and as the head has entered the vagina, the uterus, having a comparatively small mass to contract upon, must obviously act at a mechanical disadvantage. Still, the pressure of the head on the vagina is a powerful inciter, the accessory muscles of parturition are brought into strong action, and there may be sufficient force to ensure expulsion of the head without artificial aid. On account of the great resistance to the descent of the occiput from its articulation with the spinal column, the pains have the effect of forcing down the anterior portion of the head, and this ensures the complete f lexio n of the chin upon the sternum (Fig. 113). This is a great advantage from a mechan- FiG. 113. Descent of the Head. ical point of view, as it causes the short occipito-mental diameter of the head to enter the pelvis in the axis of the uterus and the brim. If the head should be in a state of partial extension — as sometimes happens when the pelvis is usually roomy — the occipito-frontal diameter is placed in a similar relation to the brim — a position certainly less favor- able to the easy birth of the head. As the head descends it experiences a movement of rotation, the occiput passing forward and to the right behind the pubic arch, the flice turning backward into the hollow of the sacrum. The body of the child will be observed to follow this move- ment, so that its back is turned toward the mother's abdomen, its anterior surface to the perineum. The nape of the neck now becomes ■■«MMMnda«Ma«MMaM 310 LABOR. firmly fixed uikIci' tlic arcli <»t' the ])iil)c>; the pains act chiefly on the anTeVior portion of the head and cause it to sweej) over tlie perineum, the cliin hcin*]; first horn, then the mouth and forehead, and lastly the occiput. It is nei'dless to descril)e the differences i)et\veen the mechanism of the second (s. d. a.) and first (s, l. a.) positions, which the student, who lias mastered the sui)jeet of vertex presentations, will readily uuder- staud. It is necessary, however, to say a few words as to sacro-poste- rior positions, choosing for that purpose\jhe third (s. D. P.), which is the more common of the twoj This is exactly the opposite of the first (s. L. A.) position. The sacrum of the child ]»oints to the riractitiouer. It is no doubt tempting to use traction on the partially-born trunk in the hope of expediting delivery ; but when it is remembered that this is almost certain to produce extension of the arms above the he;ul, and subse- PELVIC PRESENTATIONS. 311 quently extension of the occiput on the sj)ine, both of which seriously increase the difhculty of delivery, the necessity of leaving the case as nuicli as possible to nature will be apparent. Having once, therefore, determined the existence of a pelvic presen- tation, nothing more should be done until the birth of the breech. The ine mbran es sliould be even more carefully prevented from prematurely r^pturmg tluin in vertex ] ) resentations . since thev serve to dilate the genitid j)a.ssages better than the presenting part. I Ilence they should be preserved intact, if possible, until they reach the floor of the pel-' vis, instead of being punctured as soon as the os is fully dilated. The breech when born should be received and supported in the palm of, the hand.) When tlie body is expelled as far as the umbilicus, the dangers to the child commence ; for now the cord is apt to be pressed betweea the body of the child and the pelvic walls. To obviate this risk as much as possible^ a loop of the cord should bp pnllpd down) and carried to that part ot' the pelvis where there is most room, which, will generally be opposite one or tlie other sacro-iliac synchondrosis As long as the cord is freely pulsating we may be satisfied that the life of the child is not gravely imperilled, although delay is fraught with danger from other sources which have been already indicated In most cases the arras now slip out ; but it may happen, even with out any fault on the part of the accoucheur, that they are extended above the head, and it is of great importance that we should be thoroughly acquainted with the best means of liberating them from their abnormal position. '' They must, of course, never be drawn directly downward) or the almost certain result would be fracture of the fragile bones. \We should endeavor to make the arm sw eep over the fiice and chest of the child, so that the natural movements of its joints should not be opposed. If the shoulders be within easy reach, the finger of the accoucheur should be slipped over that which is posterio r — because there is likely to be more space for this manoeuvre toward the sacrum — and gently carried downward toward the elbow, wliich is drawn over the face, and then onward, so as to liberate the forearm. The same manoeuvre should then be applied to the opposite arm. It may be that the shoulders are not easily reached, and then they may be depressed by altering the position of the child's body. If this be carried well up to the mother's abdomen, the posterior shoulder Avill be brought lower down ; and by reversing this procedure and carry- ing the body back over the perineum the anterior shoulder may be similarly depressed. It is only very exceptionally, however, that these expedients are required. Birth of the Head. — The arms being extracted, some degree of artificial assistance is at this time almost always required. If there be~niuch delay, the child will almost certainly perish. Attempts have been made, in cases in which delivery of the head could not be rap- idly eifected, to estal)lisli pulmonary respiration by passing one or two fingers into the vagina, so as to press it back and admit air to the child's mouth, or by passing a catheter or tube into the mouth. t y, 312 LABOR. ^'^oitliei* of tliose expedients is reliai)le, and we shctiiid inilier seek to aid imtiire in completing the l)iith of" tlie liead jls ra])idiy a.s possi- ble. /^The fii*st thing to do, supposing the face to have rotated into the Aiivity of the sacrum, is to carry the body of the child well up toward the pubcs and abdomen of the mother without ap})lving anv traction, for fear of intcrteriiig with the all-important flexion of the I'hin on the sternum.) Jf now the patient bear down strongly, the natural powei-s may be sufficient to complete delivery. If tiiere Ije any delay, traction must be resorted to, and we mu.st endeavor to apply it in such way as to ensure flexion. ^For this ])ur])ose, while the body of the child is grasj)ed by the left hand and drawn upwai-d toward the mother's abdomen, the index and middle fingers of the right hand are placed on the back of the child's neck, so that their tips press on either side of the base of the occiput and pu.-jb-the head i nto a state of flexion. In most works we are advised to pass the inlJex" and middle fingers of the left hand at the same time over the child's face, so as to depress the superior maxilla . Dr. Barnes insists that this is quite unnecessary, and that extraction in the manner indicated, by pressure on the occiput, is quite sufficient. Should it not prove so, flexion of the chin may be very effectually assisted by downward pressure on the forehead through the rectum. One or two fingers of the left hand can readily be inserted into the bowel, and the expulsion of the head is thus materially facilitated. By far the most powerful aid, however, in hastening delivery of the head, shcjuld delay occur, is p j^;ssure from above . This has been, strangely enough, almost altogether omitted by wflfers on the subject. It has been strongly recommended by Professor Penrose, and there can be no question of its utility. Indeed, as the uterus contracts tight- ly round the head uterine expression can be applied aluKJst directly to the head itself, and without any fear of deranging its projier relation to the maternal passages. It is very seldom indeed that a judicious combination of traction on the part of the accoucheur, with firm pres- sure through the abdomen a})plied by an assistant, will fail in affecting delivery of the head before the delay has had time to prove injiwious to the child. Application of the Forceps to the After-coming Head. — Many accoucheurs — anmng others, !Meigs and Kigby — advocate the ajiplica- tion of the forceps when there is delay in the birth of the after-coming head. If the delay be due to want of expulsive force in a pelvis of normal size, manual extraction in the manner just described will be found to })e sufficient in almost every case, and preferable, as being more rapid, easier of execution, and safer to the child. The forceps may be quite properly tried if other means have failed, esj)ccially if there be some disprojxjrtion between the size of the head and the pelvis. Difficulties in delivery may also occur in sacro-posterior positions. Up to the time of the birth of the head the labor usually ))rogresses as readily as in sacro-anterior positions. If the forward rotation of the hips do not take place, much subsequent difficulty may be j)re- vented by gently favoring it by traction apjilied to the breech during PELVIC PRESENTATIONS. 313 the pains, the finger Ijeing passed for this pui-poso into the fold of the groin. It is after the birth of the shonlders that the absence of rotation is most likely to prove troublesome. It has been recommended that the body should then be grasped in the interval between the pains and twisted round so as to bring the occiijut forward. It is by no means certain, however, that the head Wduld follow the movement imparted to the body, and there must be a serious danger of giving a fatal twist of the neck by such a manoeuvre. The better plan is to direct the face backward toward the cavity of the sacrum, by pressing on the anterior temple during the continuance of a pain. In this Avay the proper rota- tion will generally be eifected without much difficulty, and the case will terminate in the usual way. If rotation of the occiput forward do not occur, it is necessary for the practitioner to bear in mind the natural mechanism of delivery under such circumstances. In the majority of cases the projDcr plan is to favor flexion of i\\Q chin by upward pressure on the occiput, and to exert traction directly backward, remembering that the nape of the neck should be fixed against the anterior margin of the perineum. If this be not remembered, and traction be made in the axis of the pelvic out- let, the delivery of the head will be seriously impeded. In the rare cases in which the head becomes extended and the chin hitches on the upper margin of the pubes, traction directly forward and upward may be required to deliver the head ; but before resorting to it care should be taken to ascertain that backward extension of the head has really taken place. It remains for us to consider the measures which may be adopted in those troublesome cases in which the breech refuses to descend, and becomes impacted in the pelvic cavity either from uterine inertia or from disproportion between the breech and the pelvis. The peculiar shape of the presenting part unfortunately renders such cases very difficult to manage. Three measures have been chiefly employed : 1st, the forceps; 2d, bringing down one or both feet, so as to break up the presenting part and convert it into a footling case ; 3d, traction on the breech, either by the fingers, a blunt hook, or fillet passed over the groin. Forceps. — The forceps has generally been considered unsuited for breech cases in consequence of its construction to fit the fcetal head, which renders it liable to slip when^applied to the breech. This objec- tion, probably to a great extent true with reference to most forceps, seems not to hold good when the axis-traction forceps of Tarnier or Simpson is used. Lusk strongly recommends it, and Harvey of Cal- cutta has published six consecutive cases in which he employed this method of delivery — in three with complete success. Truzzi,^ who has written strongly in favor of the forceps in difficult breech cases, prefers it greatly to traction either by the fingers or the fillet when the breech is high in the pelvis, and recommends that in order to secure a strong hold the blades should be passed so that their extremities extend above the crests of the foetal ilia, I have only used it myself in one 1 Gaz. Med. Ital. Lomb., August, 1SS3. 314 LABOR. or two cases, but in these tlie results were extremely good, anil t down the accoucheur has a com])lete contro l over the progress of the labor wlucli lie can gam ui no other way^ If the breech be arrested at or near the brim, there Mill generally be no great difficulty in effect- ing the desired object, (it will be necessary to give chloroform to the extent of complete anaesthesia,) and to pass the hand over the child's abdomen in the same manner and with the same i)recautions iis in per- forming podalic version until a foot is reached, which is seized and pulled down. If the ^eet be placed in the usual May close to the but- tocks, no great difficulty is likely to be expericnced.j ( If, however, the legs be extended on the abdomen, it Avill be necessary to introduce the hand and arm very deeply, even up to the fundus of the uterus — a procedure which is always difBcult and which may be very hazardous. Nor do I think that the attempt to bring down the feet can be safe when the breech is low^ down and fixed in the pelvic cavity. A cer- tain amount of repression of the breech is possible, but it is evident that this cannot be safely attempted when the breech is at all low doMU. Traction on the Groin. — Under such circumstances traction is our only resource, and this is always difficult and often unsatisfactory. Of all contrivances for this purpose, none is better than the hand of the accoucheur. The index finger can generally be slipped over the groin M'ithout difficulty, and traction can be api)lied during the pains. Fail- ing this or when it proves insufficient, an attempt should be made to pass a fillet over the groins. A soft silk handkerchief or a skein of worsted answers best, l)ut is by no means easy to aj)ply. The simplest plan, and one which is far better than the expensive instruments con- trived for the purpose, is to take a stout piece of co])per wire and bend it double into the form of a hook. The extremity of this can gener- ally l)e guided over the hips, and through its loo})ed end the fillet is passed. The wire is now withdrawn, and carries the fillet over the groins. I have found this simple contrivance, Mhich can be manu- factured in a few moments, very useful, and by means of such a fillet very considerable tractive force can be employed. The use of a soft fillet is in every way preferable to the blunt hook which is contained in most obstetric bags. A hard instrument of this kind is <|uite as difficult to apply, and any strong traction employed by it is almost certain to seriously injure the delicate fcotal structures over whi<'h it is placed. As an auxiliary the emj)loyment of uterine expression should not be forgotten, since it may give material aid Avhen tlie difficulty is only due to uterine inertia. After a difficult breech labor is completed the child should be carefully examined to see that the bones of the thighs and arms have not been injured. Fractures of the thigh are far from PRESENTATIONS OF THE FACE. 315 uncommou in such cases, and tlie soft bones of the newly-ljorn child will readily and ra])idly unite if placed at once in proper splints. Embryotomy. — Failing all endeavors to deliver by these expedients, there is no resource left but to break up the presenting part by scissors or by craniotomy instruments ; but, fortunately, so extreme a measure is but rarely necessary. CHAPTER VI. PEESENTATIONS OF THE FACE. Presentations of the face are by no means rare, and, although in the great majority of cases they terminate satisfactorily by the unassisted powers of nature, yet every now and again they give rise to much dif- ficulty, and then they may be justly said to be amongst the most formi- dable of obstetric complications. It is therefore essential that the prac- titioner should thoroughly understand the natural history of this variety of presentation, with tlie view of enabling him to intervene with the best prospect of success. The older accoucheurs had very erroneous views as to the mechanism and treatment of these cases, most of them believing that delivery was impossible by the natural efforts, and that it was necessary to intervene by version in order to effect delivery. Smellie recognized the fact that spontaneous delivery is possible, and that the chin turns forward and under the pubes ; but it was not until long after his time, and chiefly after the appearance of Mme. La Chapelle's essay on the subject, that the fact that most cases could be naturally delivered was fully admitted and acted upon. Frequency. — The frequency of face presentation varies curiously in different countries. Thus, Collins found that in the Rotunda Hospital there was only 1 case in 497 labors, although Churchill gives 1 in 249 as the average frequency in British j)ractice. while in Germany this pres- entation is met with once in 169 labors. ' The only reasonable expla- nation of this remarkable difference is that the dorsal decubitus, gener- ally followed abroad, favors the transformation of vertex presentations into those of the face./ The mode in which this change is effected — for it can hardly be / doubted that in the large majority of cases face presentation is due to a ■ backward displacement of the occiput after labor has actually com- menced, but before the head has engaged in the brim — has been made the subject of various explanations. It has generally been supposed that the change is induced by a hitch- 31 G LABOR. ing of the occii)ut on the l)riiii of tli<- ixlvis, so its to produce exteusiou of the head ami descent of tiie face, the occurreuee being favored by the oblique position of the uterus so fre(juently met \vitli in pregnancy, Hecker' attaches considerable importance to a peculiarity inlthe shape of the fu'tal head] generally observed in face presentations, thV cranium having the dolicKoccphalons form, })romincnt posteriorly with the occi- put projecting, which has the effect of incrcasijig the length of the pos- terior cranial lever arm and facilitating extension when cii'cumstanees favoring it are in action. Dr. Duncan^ thinks(that uterine obliquity has much influence in the })roduction of face ])resentation, but in a dif- ferent way to that al)ovc referred to) He points (jut that when oblircssure on the shoulder and breast through the abdominal wall by one hand, while the breech is raised and steadied by the other. By this means the occi]nit is elevated, and then the breech is jiresscd downward, when head flexion is produced by the resistance of the ])elvic walls. Of this method I have had no ])ractical exjierience, l)ut it obviously requires an unusual amount of skill and practice in abdominal pal- ])ation. When once the face has descended into the pelvis, difficulties may arise from two chief causes — u terine inert ia and non-rotation fo i'ward of the chin. The treatment of the former class must be based on ]>reeiscly the same general i)rinci]iles as in dealing Avith proti-acted labor in vertex })resentatious. The forceps may be applied with advantage, bearing in mind the necessity of getting the chin under the jnibes, and, when this has been effected, of directing the traction forward, so as to make the occiput slowly and gradually distend and sweep over the perineum. > Sydem of Obsktrics, p. 335. ^ Arch. f. Gyn., 1873, Bd. v. S. 313. PRESENTATIONS OF THE FACE. 323 The second class of" difficult face cases is much luore inijjortant, and may try the resouvces of the accoucheur to the utmost, pur first endeavor must be, if possible, to secure the anterior rotation of the chin. \ For this purpose various manoeuvres are reconnnended. vBy some we are advised to introduce the finger cautiously into the mouth of the child and draw the chin forward during a pain; by others, to pass the finger up behind the occiput and press it backward during the pain. tSchroeder jmints out that the difficulty often depends on the fact of the head not being sufficiently extended, so that the chin is not on a lower level than the forehead, and that rotation is best promoted by )ressing the forehead upward with the finger during a pain, so as to | I piuse the chin to descend. \ Penrose^ believes that non-rotation is gener- ally caused by the want oi a j)o'mt cVaiypui below, on account of the face being unable to descend to the floor of the pelvis, and that if this is supplied rotation will take place. In such cases he applies the hand or the blade of the forceps so as to press on the posterior cheek. By this means the necessary point cVappui is given ; and he relates several inter- esting cases in which this simple manoeuvre was effectual in rapidly terminating a previously lengthy labor. Any or all of these plans may be tried. We must bear in mind in using them that rotation is often delayed until the face is quite at the lower pelvic strait, so that we need not too soon despair of its occurring. If, however, in spite of these manoeuvres it does not take place, what is to be done ? If the head has not passed through the mouth of the uterus, turning would be the sim- plest and most eifectual plan. I have succeeded in delivering in this way when all attempts at producing rotation had failed ; but generally the face will be too decidedly engaged to render it possible. An attempt might be made to bring down the occiput by the vectis or by a fillet; but if the face be in the pelvic cavity, it is hardly possible for this plan to succeed. An endeavor may be made to produce rotation by the forceps, but it should be remembered that rotation" of the face mechani- cally in this way is very difficult, and much more likely to be attended with fatal consequences to the child than when it is effected by the nat- ural efforts. In using forceps for this purpose the second or pelvic curve is likely to prove injurious, and a short straight instrument is to. be preferred. If rotation be found to be impossible, an endeavor may be made to draw the face downward, so as to get the chin over the perineum and deliver in the men to-posterior position ; but unless the child be small or the pelvis very capacious the attempt is unlikely to succeed. Finally, if all these means fail there is no resource left but lessening the size of the head by craniotomy — a dernier ressort Avhich, fortunately, is very rarely required, but which is certainly preferable to long-continued and violent endeavors to deliver with the chin pointing backward. Brow Presentations. — It sometimes happens that the head is par- tially extended, so as to bring the os frontis into the brim of the pelvis and form what is described as a "brow presentation." Should the head descend in this manner the difficulties, although not insuperable, are apt to be very great, from the fact that the long cervico-frontal diameter of ^ Ainer. Supplement to Ohst. Journ., 1876-77, vol. iv. p. 1. 324 LABOR. the 1k:u1 is engaged in the pchic cavity. 'I'lie diagnosis is not difficult, iur the os fVnntis will Ik- detected hy its rounded snrlace, while the anterior I'ontani-lle is within reach in one direction, the orbit and root ot" the nose in another, \ Fortunately, in the hu'ge majority of cases the brow presentations are spontaneously converted into either vertex or face presentations accord- ing as flexion or extension of" the head occurs^ and these must be regarded as the desirable terminations and the oiujk to be favored. For this pur[)ose upward j)ressure must be made on one or other extremity of the presenting part during a pain, so as to favor flexion or extension; or, if the j)arts be sufficiently dilated, an attempt may be made to pass the hand over the occiput and draw it down, thus performing cephalic version. The latter is the plan recommended by Hcxlge, who describes the operation as easy. Long, in an excellent ])aper on this subject, has given figures to show that correction of the malpresentation by mani})- idation has given better results than any other method of treatment.^ It is questionable, however, if a well-marked brow presentation be dis- tinctly made out while the head is still at the brim, whether j)odalic version would not be the easiest and best operation. If the forehead have descended too low for this, and if the endeavor to convert it into either a face or vertex presentation fail, the forceps will probably be required. In such cases the face generally turns toward the pubes, the superior maxilla becomes fixed behind the pubic arch, and the occiput sweeps over the perineum. Very great difficulty is likely to be experi- enced, and if conversion into either a vertex or face presentation cannot be effected, craniotomy is not iwlikely to be required. CHAPTER VII. DIFFICULT OCCIPITO-POSTERIOR POSITIONS. A FEW -words may be said in this place as to the management of occipito-posterior positions of the head, especially of those in which forward rotation of the occiput does not take place. It has already been pointed out that in the large majority of these cases the occiput rotates forward without any ]iarticidar dilHculty, and the labor termi- nates in the usual way, Avitli the occi])ut emerging under the arch of the pubcs. In a certain number of cases such rotation docs not occur, and diffi- culty and delay are apt to follow. The proportion of cases in which face-to-pubes terminations of occipito-posterior positions occur has been variously estimated, and they are certainly more common than most of ' American Journal of Obstelrics, 1885, vol. xviii. p. 897. DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 325 0111" textbooks lead us to expect. Dr. Uvedalc West/ who studied tlie subject with great care, ibuud the hibor ended in this way in 79 out of" 2585 births, all these deliveries being exceptionally difficult. Causes of Face-to-Pubes Delivery. — He believed that forwaixl rotation of the head is [)revented by the absence of flexion of the chin on the sternum, so that the long occipito-frontal ((TjTTjTTnstead^oFIhe short subocci])ito-breguiatic (s.o.ii.), diameter of the head is ])rought into contact with the pelvic diameter ; hence the occi^jut is no longer the lowest point, and is not subjected to the action of those causes which produce forward rotation. Dr. Macdonald, who has written a thought- ful paper on the subject,^ believes that the non-rotation forward of the occiput is chiefly due to the lai'ge size of the head, in consequence of which " the forehead gets so wedged into the pelvis anteriorly that its tendency to slacken and rotate forward does not come into play." Dr. West's explanation, which has an important bearing on the management of these cases, seems to explain most correctly the non-occurrence of the natural rotation. The important question for us to decide is, How can we best assist in the management of cases of this kind when difficulties arise and labor is seriously retarded? Mode of Treatment of Such Cases. — Dr. West, insisting strongly on the necessity of c omplete flexi on of the chin on the sternum, advises that this should be favored by upward pressure on the frontal bone, with the view of causing the chin to approach the sternum and the occiput to descend, and thus to come within the action of the agencies which favor rotation. Supposing the pains to be strong and the fonta- nelle to be readily within reach, we may in this way very possibly favor the descent of the occiput, and without injuring the mother or increasing the difficulties of the case in the event of the manoeuvre failing. The beneficial effects of this simple expedient are sometimes very remarkable. In two cases in which I recently adopted it, labor, previously delayed for a length of time without any apparent progress, although the pains were strong and effective, was in each instance rapidly finished almost immediately after the upward pressure was applied. The rotation of the face backward may at the same time be favored by pressure on the pubic side of the forehead during the pains. Others have advised that the descent of the occiput should be pro- moted by downward traction, applied by the vectis or fillet, The latter is the plan specially advocated by Hodge ;^ and the fillet certainly finds one of its most useful applications in cases of this kind, as being simpler of ap]>lieation and probably more effective than the vectis. Although any of these methods may be adopted, a word of caution is necessary against prolonged and over-active endeavors at producing flexion and rotation when these seem delayed. All who have watched such cases must have observed that rotation often occurs spontaneous- ly at a very advanced period of labor, long after the head has been pressed down for a considerable time to the very outlet of the pelvis, and when it seems to have been making fruitless endeavors to emerge, '■ Cranial Presentations, p. 33. ^ Edin. Med. Journ., -vol. 1874-75, p. 3()2. ^ Sydcm of Obstetrics, p. 308. 326 LABOR yo lliat a liltli' ])ationcc \vill oi'tcn Ije sufficient to overcome llie ditliciilty. In the event of" assistance being- absolnlely re(juired there is noreas(»ii \\\\\ the I brccps should not he used. Tlie instrument is not nioreditticult to ajtply tiian under ordinary circnnistances, nor, as a I'ule, is nnich more traction necessary. Dr. Mac(U)nald, indeed, in the paper ah'eady alhided to maintains that in persistent occij)ito-})osterioi' ]K)sitions tliere isahnost always a M'ant of proportion between the head and the pelvis, and that therefore the forceps will be generally required ; and he i)refers it to any artificial attempts at rectification. Some p(>culiarities in the mode of tlelivery are necessiny to bear in mind. In most Avcjrks it is taught that the operator should pay special attention to the rotation of the head, and should endeavor to im})art this movement by turning the occiput forward during extraction. Thus, Tyler Smith says: "In delivery with the forcejis in occipito-posterior presentations the head should be slowly rotated during the process of extra(;tion so as to bring the vertex toward the pubic arch, and thus convert them into occipito-anterior presentations." The danger accompanying any forcible attemi)t at artificial rotation /vill, however, be evident on slight consideration. It is true that in many cases ^vhen simple traction is applied the occiput will of itself rotate forward, carrying the instrument with it. But that is a very diiferent thing from forcibly twisting round the head with the blades of the forceps, without any assurance that the body of the child will follow the movement. It is im])ossible to con- ceive that such violent interference should not be attended with serious risk of injury to the neck of the child. If rotation do not occur, the fair inference is that the head is so placed as to render delivery with the face to the pubes the best termination, and no endeavor should be made to prevent it. This rule of leaving the rotation entirely to nature, and using traction only, has received the a}i])r()val of Barnes and most modern authorities, and is the one which recommends itself as the most scientific and reasonable. There are cases in which the pelvic curve of the forceps is of doubt- ful utility. When applied in the usual way the convexity of the blades ])oints backward. If rotation accompany exti-action, the blades neces- sarily follow the movement of the head and their convex edges will turn forward. It certainly seems probable that such a movement M'ould subject the maternal soft parts to considerable risk. I have, however, more than once seen such rotation of the instrument happen Avithout any apparent bad result ; but the dangers are obvious. Hence it would be a wise precaution either to use a pair of straight forceps for this particular operation, or to remove the blades and leave the case to be terminated by the natural powers when the head is at the lower strait and rotation seems about to occur. Prof. Ilichardson ^ advises that when the forceps is applied in persistent occipito-posterior positions it should be introduced with the pelvic curve reversed. He claims for this method that the traetic^n is chiefly exerted on the occi])ut, where it is most needed, which thereby descends and produces the necessary flexion of the chin on the sterninn. The forceps is then removed, and, ^ Medical Communications of (he Massachusetts Medical Society, 1885, vol. xiii. No. 4. DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 327 if tlic pains are sufficient, rotation ibrward is sure to take ])]ace. Of this plan I have no personal experience. When there is no rotation more than usual care should be taken Avith the perineum, which is necessarily much stretched by tlu.' rounded occiput. Indeed, the risk to the perineum is very considerable, and even with the greatest care it may be impossible to avoid laceration. Bearing these precautions in mind, delivery with the forceps in occipito-]>osterior positions offers no special difficulties or dangers. [Version by the Vertex. — The following are the teachings of sev- eral eminent American obstetricians upon the management of occipito- posterior positions : 1. "In primitive oblique occipito-posterior positions of the head nature will almost without exception cause spontaneous rotation of the occiput to the symphysis pubis ; but to favor this movement the bag of waters should be preserved." 2. " Spontaneous rotation, as a rule, does not begin until the head meets with resistance from the floor of the pelvis : hence no effort to force rotation should be made until nature has proved herself inade- quate." 3. " Where rotation forward is prevented, it is probably due to the l)Osition of the occiput having been originally directly backward, and only becoming oblique after the descent of the head into the pelvis, the position of the child's body preventing the anterior movement of its occiput ; that is, the sixth position of Hodge has changed into a fourth or fifth, but will not without assistance become a first or second." 4. " If, then, rotation is not spontaneous after the head reaches the floor of the pelvis, version by the vertex will not take place, except it be forced by the vectis or forceps." Use of the Hand in Occipito-posterior Positions. — The introduc- tion of the hand for the purpose of effecting version by the vertex was strongly advocated by the late Dr. John S. Parry of Philadelphia, whose hand was very small and thin, and could be used to great advan- tage. Prof. Ottavio Morisani of Naples is said to use his Avith even greater success, because of its smaller size. Large hands should not be used in primiparse. By this mancBuvre I once brought an occiput under the pubic arch of a primipara in three pains, after she had labored for hours to deliver herself. — Ed.] 328 LABOR. al CHAPTER VITI. PRESENTATIONS OF THE SHOULDER, ARM, OR TRUNK.— COMPLEX PRESENTATIONS.— PROLAPSE OV THE FUNIS. In the prcscntatiftus already considered the lung diameter ol' the la'- tu.s corresponded Avith that of tlie uterine cavity, and in all of them the birth of the child by the maternal efforts was the general and normal termination of labor. We have now to discuss those im])ortant cases in which the long diameter of the ftctus and uterus do not corresjxjud, but in which the long fo'tal diameter lies obliquely across the uterine cavity. In the large majority of these it is either the shoulder or some j)art of the upper extremity that presents; for it is an admitted fact that although other parts of the body, such as the back or alxlomen, may in exceptional cases lie over the os at an early period of laljor, yet as labor progresses such presentations are almost always converted into those oi" the upper extremity. For all practical purposes we may confine ourselves to a consideration of shoulder presentations, the further subdivision of these into dboir or hand presentations being no more necessary than the division of })elvic presentations into breech, knee, aud footling ca.ses, since the mechanism and management are identical whatever part of the uj^per extremity presents. There is this great distinction betM'een the presentations we are now considering and those already treated of, that on account of the rela- tions of the foetus to the pelviSjTleli very by the natural powers is impos- sible except under sj^ecial ana very unusual circumstances that i-an never be relied upon.\ Intervention on the part of the accoucheur is therefore absolutely essential, and the safety of both the mother and child depends upon the early detection of the abnormal position of the foetus ; for the necessary treatment, which is comparatively easy and safe before labor has been long in progress, becomes most*difficult and hazardous if there have been nuich delay. Position of the Foetus. — Presentations of the ujiper extremity or trunk are often spoken of as ''transverse presentations" or " cross- births ;" but l)oth of these terms are misleading, as they imply thaftlie ffctus is placed transversely in the uterine cavity or that it lies directly across the ])elvic brim. ( As a matter of fact, this is never the case, for the child lies (il)li(|ncly in the uterus — not indeed in its long axis, but in oiic iiitcniicdiiiic between its long and transverse diameters.^ ^Two great divisions of shoulder presentati(»ns are recognized — the one in whicli the back of the child looks to the abdomen of the mother, (Fig. 118),(and the other in which the back of tiie child is turned toward the sjiine of the mother (Fig. 119))) | Each of these is subdivided into two sui)sidiarv classes, according as the head of the child is jilaced in the right or left iliac fossa. Thus in dorso-anterior position.s, if the FRESENTATIOXS OF THE SHOULDEM, ETC. head lie in the left iliac fossa (left scapula-anterior — scapula-lseva rior, S.L.A.), the right shoulder of the child presents ; if in the Fig. 118. 329 ante-j righfl Dorso-anterior Presentation of the Arm (s.l.a.). iliac fossa (right scapula-anterior — scapula-dextra anterior, s.d.a.), the | left. So iu dorso-posterior positions, if the head lie in the left iliac 1 Fig. 119. Dorso-posterior Presentation of the Arm (s.d.a.). fossa (left scapula-posterior — scapula-lfieva posterior, s.l.p.), the left ,. .shoulder presents; if iu the right^the right (right scapula-posterior — y scapula-dextra posterior, s.D.p.y | Of the two classes the dorso-ante- ' ' Left and right refer in tliis nomenclature, as in all positions, to the left and right side of tlie mother, without regard to that of the child. 330 LABOR. rioi' positions iirc nioiv (•(nniiion, in tlio jiroportion, it is said, of" two to ouc.l The Causes of sIiouKUt jji-csentatiun are not well known . Amongst those most commonly mentioned are pr ematurity of the ia-tus and*c xeess of hquor anni ii ; either of these, b y inereiising the mobility of the ftetus in idcro, Mould probably have consi(leral)le iiifluenee. ('Jlie fact that it occurs much, more frequently amoniList ])remature births has lono- been recoonized./-^ Undue obliquity of the ute rus has prolxibly some influence, since tlie early ])ains might cause the presenting part to hitch against the pelvic brim and the shoulder to descend. An^)unusuall y low attach- me nt of the ])Iacen ta to the inferior segment of the uterine cavity has been mentioned as a j)redisposing cause. In consequence of this the head does not lie so readily in the lower uterine segment, and is apt to slip up into one of the iliac fosste. This is sui)posed to explain the fre- quency of arm presentations in cases of partial or complete placenta prsevia. Danyau and Wigand believe that shoulder presentations are favored by irregularity in the shape of the uterine cavity, especially a relative increase in its trar^verse~cnanieFe]\ Tins' tlieoryllas been gen- erally discredited by "writers, and it is certainly not susceptil)le of proof; but it seems far from unlikely that some peculiarity of shape may exist, not capable of recognition, but sufficient to influence the position of the foetus. How otherwise are Ave to explain those remarkable cases, many of which are recorded, in which similar malpositions occurred in many successive labors ? Thus, Joulin refers to a ])atient who had an arm presentation in three successive pregnancies, and to another who had a shoulder })resentation in three out of four labors. Certainly, such con- stant recurrences of the same abnormality could only be explained on the hypothesis of some very persistent cause such as that referred to. Pinard^ states that shoulder presentations are seven times more common in multipara than in primiparse, in consequence, as he believes, of the 'laxity of the abdominal walls in the former, which allows the uterus to fall forward,) and thus prevents the head entering the pelvic brim in the latter weeks of pregnancy. It is probable that merely accidental causes have most influence in the production of shoulder presentations, such as falls or undue pressure exerted on the abdomen by badly-htting '^•sJ or tight stays. Partiall}^ transverse positions during pregnancy are cer- J tainly much more common than is generally believed, and may often be ^•. detected by abdominal palpation. The tendency is for such malpo- sitions to be righted either before labor sets in or in the early period of labor ; but it is quite easy to understand how any persistent jiressure, aj)plied in the manner indicated, may perpetuate a position which other- wise would have been only temporary. Prognosis and Frequency. — According to Churchill's statistics, shoulder prescntati(jns occur about once i n 2G0 c ases; that is, only slightly less frequently than those of the faceTTThe ]}rognosis to both the mother a nd ch il d is m uch moi-e unfiivorablel for he estimates that out of 235 cases, T in 9 oF tlie inotliers'aiid naif the children Avere lost. The ])rognosis in each individual case will, of course, vary much with the period of delivery at which the mali)osition is recognized. If * Annul. d'Hij(j. Pub. ei de Med., Jan., 1879. PBESENTATTONS OF THE SHOULDER, ETC. 331 detected early, interference is easy and tlie prognosis onglit to be good; whereas there are few obstetric dithcnlties more trying than a case of shoulder presentation, in which the necessary treatment has been delayed until the presenting part has been tightly jammed into the cavity of the pelvis. Diagnosis. — Bearing this fact in mind, the paramount necessity of an accurate diagnosis will be apparent; and it is specially important tliat we should be able not only to detect that a shoulder or arm is })resenting, but that we sliould, if possible, determine which it is and how the body and head of the child are placed. The existence of a shoulder presen- tation is not generally suspected until the first vaginal examination is made during labor. The practitioner will then be struck with the a bsence of the rounded mass of the foetal head, and, if the os be opened and the membranes protruclTng, Tn^'tlTeii'elongated form, which is com- mon to this and to other malpresentations. f If the presenting part be| too high to reach, as is often the case at an early period of labor, an| endeavor should at once be made to ascertain the foetal position by* abdominal exami uation.'^t This is the more important as it is much more easy to recognize presentations of the shoulder in this way than those of tlie breech or foot( and at so early a period it is often not only possible, but comparatively easy, to alter the position of the foetus by abdominal manipulation alone,\ and thus avoid the necessity of the more serious form of version. The method of detecting a shoulder presentation by ex- amination of the abdomen has already been described (p. 127), and need not be repeated. The chief points to look for are — the alt ered shape ' of the uterus ami twosolid JMIses, the head and the breech, one in either iliac fossa.) The facility with which these parts may be recog- nized varies much in different patients. In thin women with lax ab- dominal parietes they can be easily felt, while in very stout women it may be impossible. Failing this method, we must rely on vaginal examina- tions, although before the membranes are ruptured and when the pre- senting part is high in the pelvis it is not always easy to gain accurate information in this way. The difficulty is increased by the paramount importance of retaining the membranes intact as long as possible. It should be remembered, therefore, that when a presentation of the suj^erior extremity is suspected, the necessary examinations should only be made in the intervals between the pains when the membranes are lax, and never when they are rendered tense by the uterine contractions. As either the shoulder, the elbow, or the hand may present, it will be best to describe the peculiarities of each sejjarately, and the means of distinguishing to which side of the body the presenting part belongs. 1. The shoulder is recognized as a round, s mooth prominen ce, at one point of which may often be felt the sharp edge of the acromion. If the finger can be passed sufficiently high, it may be possible to feel the clavicle and the spine of the scapula. A still more complete exami- nation may enable us to detect the ril^ and the intercostal spaces, M-hicli would be quite conclusive as to the nature of the presentation, since there is nothing resembling them in any other part of the bodv. At the side of the shoulder the hollow of the axilla mav aenerallv be made out. 332 LABOR. In order to ascertain the position of the cliiid we liave to find <»ut in Avliich iliac fossa the head lies. This may be done in two ways: 1st, the head may be I'elt throngh the ab(]oniinal parietcs J^j^4}ajj)^ and, 2d, since the axilla aj\va\-s points toward the feet, if it point to the left side the head nuist lie m tlie riij^Titlliae fossa; if to the riffht, the head mnst be placed in the left iliac fossa. (Again, the S])ine of the sea])nla nnist correspond to the back of the child, the clavicle to its abdomen ,j and, by feeling one or other Me know whether we liave to do with a uoi-so- antcrior or dorso-posterior position. If we cannot satisfactorily de- termine the position by these means, it is quite legitimate practice to (bring down the arm carefully, jirovided the membranes are i-uptiu'cd, so as to e xamine the han d, Mhich will be easily recognized as right or left. \ This expedient will decide the point; but it is quc Avhich it is better t o avoid if possible, for it not only slightly increases the difficulty of turning, altliougli perhaps not very materially, but the arm might possibly be injured in the endeavor to bring it down. The only part of the body likely to be taken for the shoulder is the breech ; but in that its larger size, the groove in mIhcIi the genital organs lie, the second prominence formed by the other but- tock, and the sacral spinous processes are sufficient to prevent a mis- take. 2. The elbo-w is r arely felt at the os, and may be readily recognized by/the sharj) prominence of the olecranon, situated between two lesser prominences, the condyles.\ As the elbow always jjo iuts toward the feet:, the ])ositiou of the fcetus Gnu be easily ascertained. 3. The hand is easy to recognize, and can only be confounded with the foot. It can be distinguished by its borders being of the same th ickness , by the fin gers being wider ajia rt and more re a dily se|)arated from each other than the toes, and aljove all by the mob ility of the thumb, which can be carried across the palm and placed in apposition with each of the fingers. It is not difficult to tell which hand is presenting. If the hand be in the vagina or beyond the vulva, and within easy reach, we recognize Mhich it is by laying hold of it as if we were about to shake hands. \ If the palm lie in the palm of the practitioner's hand, with the two thumbs in apposition, it is the right hand ; if the l)ack of the hand, it is the left. ^ Another siniple way is for the practitioner to imagine his own I hand placed in precisely the same position as that of tlie foetus, and this ■ will readily enable him to verifv the previous diagnosis. A simple rule tells us how the body of the child is placed, for, jirovided we are sure the hand is in a state of supination, the back of the hand ])oints to the back of the child, the palm to its abdomen, the thund) to the head, and the little finger to the feet. Mechanism. — It is perhaps hardly })ro])er to talk of a mechanism of shoulder presentations, since if left una.ssisted they almost invariably lead to the gravest consequences. Still, Nature is not entirely at fault even here, and it is well to study the means she adojits to terminate these nial]iositions. Terminations of Shoulder Presentation. — There are two possible terminations of shoulder presentation, j In one, known as '^s pontaneou s atatii flu PRESENTATIONS OF THE SHOULDER, ETC. 333 version /^ some other part of the foetus is substituted for that originally presenting in the other, ^^ s pontaiieous evolution ," the fcjetus is expelled by being^jueezed through the pelvis, without the originally presenting part being withdrawn. It cannot be too strongly impressed on the mind that neither of these can be relied on in practice. Spontaneous Version.-(-Spontaneous version may occasionally occur before or immediately after the rupture of the membranes, when the foetus is still readily movable within the cavity of the uterus.) A few authenticated cases are recorded in which the same fortunate isiue took place after the shoulder had been engaged in the pelvic brim for a con- siderable time, or even after prolapse of the arm ; but its probability is necessarily much lessened under such circumstances. Either the head or the breech may be brought down to the os in place of the original presentation. The precise mechanism of spontaneous version or the favoring cir- cumstances are not sufficiently understood to justify any positive state- mput with regard to it. f Cazeaux believed tion of the uterus. remains inert or only this may effect spontaneous version let us suppose tEat the child is lying with the head in the left iliac fossa. Then, if the left side of the uterus should contract more forcibly than the right, it would clearly tend to push the head and shoulder to the right side until the head came to present instead of the shoulder. A very interesting case is related by Geneuil,' in which he was present during spontaneous version, in the course of which the breech was substituted for the left shoulder more than four hours after the rupture of the membranes. In this case the uterus was so tightly contracted that version was impossible. He observed the side of the uterus opposite the head contracting ener- getically, the other remaining flaccid, and eventually the case ended without assistance, the breech presenting. The natural moulding action of the uterus, and the greater tendency of the long axis of the child to lie in that of the uterus, no doubt assist the transformation ; and much must depend on the mobility of the fcetus in any individual case. That such changes often take place in the latter weeks of pregnancy, and before labor has actually commenced, is quite certain, and they are probably much more frecjuent than is generally supposed. When spon- taneous version does occur it is of course a most favorable event, and the termination and prognosis of the labor are then the same as if the head or breech had originally presented. Spontaneous Evolution. — The mechanism of spontaneous evolution, since it was first clearly worked out by Douglas, has been so often and carefully described that we know precisely how it occurs. Although every now and then a case is recorded in which a living child has been born by this means, such an event is of extrem e rarity ; and there is no doubt of the accuracy oFthe general opinion,"tTTaFspontancous evolution c an only happen when the pelvi s is unusually roomy and the child ^ Ann. de Gynicologk', 1876, vol. v. p. 468. 334 LABOR. sma ll, ami that it almost necesstirily inv olves the death of the frjetus ou aofount of the iimuonse pressure to"~\vTH7Ti"Tf'Ts .^uhjcrtcd. Two varieties arc (lescril)ed, in one of which the head is fii^t horu, in the other the breech ; in both the originally presenting arm remained prola})sed. The forjiier is of extreme rarity, and is believed only to have hapj)ened with very premature children whose bodies were small and flexible, and when traction had been made on the presenting arm. Under such circumstances it can hardly be called a natural process, and we may confine our attention to the latter and more common variety. AVhat takes })lace is as follows : the j)resenting arm aud shoulder are tightly jammed down, as far as possible, by the uterine contractions, and the head becomes stronglv flexed ou tho shoulder.^ As umch of Fig. 1-JU. Spontaneous Evolution, (.\fter Cbira.) Thia drawing was made from a. iwtient who died undelivered, the body being frozen and bisected. the body of the foetus as the pelvis will contain becomes engaged, and then a movement of rotation occurs which brings the body of the child nearly into the autero-posterior diameter of the pelvis (Fig. 120). The shoid'der projects under the arch of the pubes, the head lying above the symphysis and the breech near the sacro-iliac synchondrosis. It is essentiid that tlie head should lie forward above the pubcs, so that the PRESENTATIONS OF THE SHOULDER, ETC. 335 length of the neck may permit tlic .sliouldor to project nnder the puhic arcli without any part of the head entering tlie pelvic cavity. The shoulder and neck of the child now become fixed points round which the body of the child rotates, and tJic whole force of the uterine con- tractions is expended on the breech. The latter, with the body, there- fore becomes more and more depressed, until at last the side of the thorax reaches the vulva, and, followed by the breech and inferior extremities, is slowly pushed out. As soon as the limbs are born the head is easily exj)elied. The enormous pressure to which the body is subjected in this process can readily be understood. As regards the practical bearings of this termination of shoulder presentations, all that need be said is that if we should happen to meet with a case in which the shoulder and thorax were so strongly depressed that turning w^as impossible, and in which it seemed that nature was endeavoring to effect evolution, we should be justified in aiding the descent of the breech by traction on the groin before resorting to the difficult and hazardous operation of embryotomy or decapitation. Treatment. — It is unnecessary to describe specially the treatment of shoulder presentation, since it consists essentially in performing the operation of turning;, which is fullv described elsewhere. It is only needful here to insist on the advisability oi pertorming the operation in tiie way which involves the least interference with the uterus. Hence if the nature of the case be detected before the membranes are ruptured, an endeavor should be made — and fcught generally to succeed — to turn by external manipulation only.) If we can succeed in bringing the breech or head over the os in this way, the case will be little more troublesome than an ordinary presentation of these parts. Failing in this, turning by; combined external and internal manipulation] should be attempted, and the introduction of the entire hand should be reserved for those more troublesome cases in which tlie~waters have long drained away and in which both these methods are inapplicable. Should all these means fail, we must resort to the manipulation of the child by em bryulc ia or d ecapitati on, probably the most difficult and dangerous of all obstetric operations. [The C sesarean operatio n has been performed in the United States in 14 cases where the foetus was impacted' in a transverse position, with a saving of 10 women, or 71.3-7 per cent. In seven cases the arm protruded ; in three the pelvis was small ; and in two it was deformed. In three women there were natural labors at subsequent periods. The four deaths were produced as follows : Case 3 was in labor ninety-six hours, three days under a midwife, and died of exhaustion in seventeen hours. Case 7 was twenty-six hours ' in labor, and had been under the care of a midwife, who had given ergot freely ; she was much prostrated and died in twelve liours. Case 9 would in all probability have recovered had she not risen from her bed on the third day to defend her mother against her husband, who came home drunk. The fright, excitement, and exertion caused her death in a few hours. Case 13 was three days in labor, and ergot Avas largely used ; forceps, version, and craniotomy were all tried. Death came on the tenth day from the bursting of an abscess of the abdomi- 336 LABOR. nal Nvall into the peritoneal cavity, resulting in septic peritonitis. Case 11 Mas ojH'ratcd ii])(»ii in June, ISSO; was up and at Avork in a month ; iR'oainc pregnant in two and a liali' more, and hore a child natnrallv in twelve and a half months after the operation. The uterine wound was closed with two silver-wire sutures. This oj)eration certainly j)romises w^cll in ca.ses of impaction with an arm j)rotrudino- Avhere there has been no deforming pelvic disease. With the new conservative method such cases should be saved in large pro])ortion in the United States. AVill embryulcia or decapitation be likely to succeed as -weW in this country? — Ed.] Complex Presentations. — There are various so-called complex pres- entafioits in which more than one part ()f jthe foet al body prese nts. Thus we may have a hand^or a foot presenting wTtli the head or a foot and hand presenting simultaneously. The former do not necessarily give rise to any serious difficulty, for there is generally sufficient r(X)m for the head to pass. [Indeed, it is unlikely that either the hand or foot should enter the pelvic brim with the head, unless the head was unusu- ally small or the pelvis more than ordinarily capacious. \ As regards treatraentjfit is no doubt advisable to make an attempt to replace the hand or root by pushing it gently above the head in the intervals between the pains, and to maintain it there until the head be fully engaged in the pelvic cavit}-^ The engagement of the head can be hastened by abdominal pressure, which will be of great value. (^Fail- ing this, all we can do is to place the presenting member at the part of the pelvis w^here it will least impede the labor and be the least subjected to pressure ; and that will generally be opp osite the tem ple of the child) As it nuist obstruct the passage of the head to a certain extent, the application of the forceps may be necessary. "When the feet and hands pre sent at the same time, in addition to the confusnig nature of the presentation from so many ]>arts being felt together, there is the risk of the hands coming down and converting the case into one of arm presentation, fit is the obvious duty of the accoucheur to prevent this by ensuring the descent of the feet, and traction should be made on them either with the fingers or with a fillet, until their descent and the ascent of the hands are assured. Dorsal Displacement of the Arm. — In connection with this subject may be mentioned the curious dorsal displacement of the arm first described by Sir James Simpson,' in which the forearm of the child becomes thrown across and behind the neck. The result is the forma- tion of a ridge or bar which ])revents the descent of the head into the pelvis by hitching against the brim (Fig. 121). /The difficulty of diag- nos'is is very great, for the cause of obstruction ts too high up to be felt.) But if we meet with a case in which the ])elvis is roomy and the jiains strong, and yet the head does not descend after an adc(|uatc time, a full ex])1oration of the cause is essential. For this purpose we would nat- urally p ut the pat ient ujid^'_c[iloroforni aji^ hand sufficiently high. We might then feel the arm in its abnormal position. That was what took ])lacc in a case under my own care in which I failed to get the head through the brim with the forceps, and eventually deliv- ' Selected Obslet. Worh, vol. i. PRESENTATIONS OF THE SHOULDER, ETC. 337 ered by turning. The same course was adopted by my friend Mr. Jar- dine Murray in a similar case.^ (Simpson advises that the arm should be brought down so as to convert the case into an ordinary hand-and- hcad presentation^ This, if the arm be above the brim, must always be difficult, and I believe the simpler and more effective plan is podalic v ersion . ^A similar displacement may cause some difficulty in breech presentations and after turning (Fig. 122). Delay here is easier of Fig. 121, Fig. 122. Dorsal Displacement of the Arm. Dorsal Displacement of the Arm in Footling Presen- tations. (After Barnes.) diagnosis, since the obstacle to the expulsion will at once lead to careful examination. By carrying the body of the child well backward so as to enable the finger to pass behind the symphysis pubis and over the shoulder, it will generally be easy to liberate the arm.^»' Prolapse of the Umbilical Cord. — It occasionally happens that the umbilical cord falls down past the presenting part (Fig. 123), and is apt to be pressed between it and the walls of the pelvis. The consequence is that the f oetal circulation i s seriously interfered Avith, and the death of the child from asphyxia is a common result. Hence prolapse of the funis is a very serious complication of labor in so far as the child is concerned. Frequency. — Fortunately, it is not a very frequent occurrence. Churchill calculates that out of over 105,000 deliveries it was met with. 1 Med. Times and Gazette, 1861. 22 338 LABOR. once in 240 eases, ami Seanzuni once in 254. Its frequency varies much under ditterent circumstances and^m different places. We Hnd from Churchill's figures a remarkable difference in the proportional number of cases observed in France, England, and Germany — viz. 1 in 44Gi, 1 in 207f, and 1 in 156, respectively. Great as is the proportion refer- FiG. 123. Prolapse of the Umbilical Cord. red to Germany in these figures, it has been found to be exceeded in special districts. Thus, Engelman records 1 case out of 94 labors in the lying-in hospital at Berlin, and Michaelis 1 in 90 in that of Kiel. These remarkable differences are at first sight not easy to account for. Dr. Simpson suggests, with considerable show of probability, that the difference in frequency in England, France, and Germany may depend on the varying positions in which lying-in women are placed during labor in each country. In France, Avhere, although the patient is laid on her back, the pelvis is kept elevated, the complication occui"s least frec^uently ; in England, where she lies on her side, more often ; and in Germany, where she is placed on her back with her shoulders raised, most often. The special frequency of prolapsed funis in certain dis- tricts, as in Kiel, is supposed by Engelman ^ to depend on the preva- lence of rickets, and consequently of deformed pelvis, which we shall presently see is probably one of the most frequent and important causes of the accident- Prognosis. — With regard to the danger attending prolapsed funis, ^as far as the mother is concerned it may be said to be altogether unim- portant,]) butithe universal experience of obstetricians points to the great risk to which the child is subjected^ Scanzoni calculates that 45 per cent, only of the children were saved ; Churchill estimated the number at 47 per cent. ; thus, under the most favorable circumstances thiscom- ^Avier. Journ. of Obst., 1873-74, vol. vi. pp. 409, 540. PRESENTATIONS OF THE SHOULDER, ETC. 339 plication leads to the death of more than half the children. Engelman found that out of 202 vertex ])i'eseiitall<>iis lishcd some twenty or thirty years ago. It may he fairly assumed that the })raetice of the distinguished heads of that well-known school rep- resents the most advanced and scientific opinion of the day. When we find that less than thirty years ago tlie forceps was not used more than once in 310 labors, while, according to the report for 1873, the late master ap])lied it once in 8 labors, it is apparent how great is the change which lias taken place. Causes. — Labor may be prolonged from an immense number of causes, the principal of which will require separate study. Some depend simply on de fecti ve or i rregular act ion of tlie uterus -others act by opposing the expulsion of the child, as, foFexampTe, undue r igidity of the-pai'turient passages, tumors, bony deformity, and_tliejike. What- ever the source of delay, a train of formidable symptoms is developed which are fraught with peril both to the mother and the child. As regards the mother, they vary much in degree and in the rapidity with which they become established. In many cases, in which the action of the uterus is slight, it may be long before serious results follow ; while in others, in which a strongly-acting organ is exhausting itself in futile endeavors to overcome an obstacle the worst signs of protraction may come on with comparative rapidity. The stage of labor in which delay occurs has a marked effect in the production of untoward symptoms. ■ It is a well-established fact that prolongation is of coniparatively small conse(][uence to either the mother or child in the first stage, when the membranes are still intact and when the soft parts of the mother, as well as the body of the child, are protected by the liquor amnii from injurious pressure^ whereas if the membranes have ruptured prolongation becomes of the utmost importance to both as soon as the head has entered the pelvis, when the uterus is strongly excited by reflex stimulation, when the maternal soft parts are exposed to continuous pressure, and when the tightly con- tracted uterus presses firmly on the foetus and obstructs the placental circulation. It is in reference to the latter class of cases that the change of practice, already alluded to, has taken place, with the utmost bene- ficial results both to mother and child. It must not be assumed, however, that prolongation of labor is never of any consequence until the second stage has commenced. ) The fallacy of such an opinion was long ago shown by Simpson, who proved in the most conclusive way that both the maternal and foetal mortality were greatly increased in proportion to the entire length of the labor ; and all practical accoucheurs are familiar with cases in M'hich symptoms of gravity have arisen before the first stage is concluded. Still, relatively speaking, the opinion indicated is undoubtedly correct. In the present chapter we liave to do only M'ith those causes of delay connected with the expulsive powers. Inasmuch, however, as the inju- rious effects of protraction are similar in kind, whatever be the cause, it will save needless repetition if we consider, once for all, the train of symptoms that arise whenever labor is unduly prolonged. Delay in the First Stage is Rarely Serious. — As long as the delay is in the first stage only, with rare exceptions no symptoms of real grav- 344 LABOR. ity arise for a lon<2;tli of time, i t iiiav be even for day s. There is ofteu, however, a partial cessation of the pains, which in consequence of tem- porary exhaustion of nervous force may even entirely disa])]K'ar for many consecutive hours. ^Under such circumstances, after a perifMJ of rest either natural or j>roduced by suitable sedatives, they recur with renewed vi^or. ^ Symptoms of Protraction in the Second Stage. — A similai- tem- ])orary cessation of the pains may often be observed after the hciul has ]):Ls.sed through the os uteri, to be also followed by renewed vigorous action after rest. But now any such irregularity nuist be nuich more anxiously watched. In the majority of cases any marked alteration in the force and frequency of the jwins at this period indicates a much more serious form of delay, which in no long time is acc(tmpanied by grave general symptoms. The pulse begins to ris e, the skin to becom e hot an d dry , the ] )aticnt to be restles s and i rritaljl e. The longer the delay and the more violent the efforts of the uterus to overcome the obstacle, the more serious docs the state of the patient l)ecome. The tongue 2* loaded with fur, and in the worse cases dry and black ; n ausea ana vomiting often become marked7~tTie vagi na feels ho t and dry, the ord inar y abundant miicous secretion being al)sent ; in severe cases it may be much s}yollen, and if the presenting part be firmly impacted a slough may even form. CShould the patient still remain undelivered, all these symptoms become greatly intensified: the vomiting is incessant, the pulse is rapid and almost imperceptible, low nmttering de lirium super- venes^ and the patient eventually dies with all the worst indications of profound irritation and exhaustion.^ So formidable a train of symptoms, or even the slighter degrees of them, should never occur in the practice of the skilled obstetrician ; and it is precisely because a more scientific knowledge of the process of par- turition has taught the lesson that under such circumstances ])revention is better than cure, that earher interference has become so much more the rule. Those who taught that nothing should be done until nature had had every possible chance of effecting delivery, and mIio, therefore, allowed their patients to drag on in many weary hours of labor at the ex])ense of great exhaustion to themselves and imminent risk to their ofi'sjtring, made much capital out of the time-honored maxim that " mctldlesome mid\yifery is bad." AVhen this proverb is applied to restrain the rash interference of the ignorant, it is of undeniable value ; but when it is quoted to jn-event tlie scientific action of the experienced, who know ])reciscly when and why to interfere, and who have acquired the indispensable mechanical skill, it is sadly misn])j>lied. State of the Uterus in Protracted Labor. — The nature of the ])ains and the state of the uterus in ca-scs of j)rotractcd labor are pecu- liarly worthy of study, and have been verj' clearly pointed out by Dr. Braxton Hicks.* ( He sho\ys that, when the jiains have apparen tly fallen o ff and beco me fe^v and feeb le, or have ent irely ceased, the uterus is in a state of continuous or tome contraction, a nd that the irritation resuhing from this is the chief cause of tlie more marked symptoms of ' Obst. Trans., 1867, vol. ix. p. 207. PROLONGED AND PRECIPITATE LABORS. 345 powerless labor. If in a case of the kind the uterus be examined by \ palpation, it will be foinid fi rmly contracted between th e j)ains. Tiie i correctness of this observation is beyond question, and it will no doubt ' often be an important guide in treatment. Under such circumstances instrumental interference is imperatively demanded. Causes. — In considering the causes of protracted labor it will be well first to discuss those which aifect the expulsive powers alon e, leav- ing those depending on morbid states of the passages for future consid- eration ; bearing in mind, however, that the results as regards both the mother and the cliild are identical whatever may be the cause of delay. The g eneral const itutional state of the patient may materially influ- ' ence the force and efficiency of the pains. Thus it not unfrequeutly happens that they are feeble and ineffective in women of very weak con- stitution or who are much exhausted by debilitating disease. Cazeaux pointed out that the effects of such general conditions are often more tlian counterbalanced by flaccid ity and want of resistance of the tissues, so that there is less obstacle to the passage of the child. Thus in phthisi- cal patients reduced to the last stage of exhaustion labor is not unfre- queutly surj)risingly easy. Lfl-Ug residence in t ropical clim ates causes uterine inertia, in conse- i^ quence of the enfeebled nervous power it produces. It is a common observation that European residents in India (ai'e peculiarly apt to suffer from post-partum hemorrhage from this cause.^ The general mad e of hf e of patients has an unquestionable effect ; and it is certain that deficient and irregular uterine action is more common in women of the higher ranks of society, who lead luxurious, enervating lives, than in women Avhose habits are of a more healthy character. Tyler Smith lays much stress on frecpient cliildbeariug as a cau-e of ' ' inei-tia, pointing out that a uterus which has been very frequently sub- jected to the changes connected with pregnancy is unlikely to be in a typically normal condition. [ It is doubtful, however, whether the uterus of a perfectly healthy woman is affected in this way ) certainly, if childbearing had undermined her general health, the labors are likely to be modified also. , Age has a decided e ffect. ( In the very young the pains are apt to be irregular, oii'account of imperfect development of the uterine muscle.) /Labor taking place for the first time in women advanced in life is also apt to be tedious) but not by any means so invariably as is generally believed. The apprehensions of such patients are often agreeably falsified, and where delay does occur it is probably more often refer- able to rigidity and toughne&s of the parturient passages than to feeble- ness of the pains. . Morbid st;vtes_of_tlie prinife vioe frequently cause irregular, painful, v^ and feel)le contractions. A l oaded state of thel'ectu m has a remark- ame~TnHuen"ce, as evidenced l)y the sudden and distinct change in the character of the labor Avhich often follows the use of suitable remedies. Undue distensi on of the bladd er may act in the same way, more espe- cially in the second stage. When the urine has been allowed to accu- mulate unduly, the contraction of the accessory muscles of jiarturition often causes such intense suffering, by compressing the distended viscus, ;}4G LABOR. tliMt till' jmtient is al)S(»liit('ly iiiuiblc lo bear down. IIciicc tlic lalxtr is (•allied on by uterine eonliactions alone, slowly and at the expense of iniieh suil'erinjr. A similar inteiierence with the action of tlie accessory muscles is often jnoduced by other causes. [We sometimes meet Avitli what may be desitriiated as reenrrent uterine fati{:;ue, in which the first stage of lal)or ])ro<;resses slowly, with intervals ol' entire suspension of uterine action, when the organ W(»uld appeal" to l)e taking a rest. This peculiar irregularity may be ibund where the patient is in a fair degree of health and lias not been enfeebled by any recognizable c-ause. In one very marked instance under my care in the higher walks of life labor came on at night, ceased in the morning, and was susj)eiided for the day, the patient being up and about ; on the second night labor was renewed, to be followed by a second day of cessation. The third night I went to bed in the house, antici])ating the possibility (»f a rapid second stage, in wdiich I was not disaj)pointed. As might also be looked for in such a case, there was a recurrence of uterine inertia an hour after the placenta came away, and a disposition to hemorrhage lasting for six hours. The child born was the third, and in the fourth labor there Mas no trouble of any kind. — Ed.] Thus if labor comes on when the patient is suffering from bronchitis or other clu'st disease she may be r^uite unable to fix tlie chest by a deep in.spiration, and the dia- phragm and other accessory muscles cannot act. In the same way they may be prevented from acting when the abdomen is occupied by an ovarian tumor or by ascitic fluid. ^Mental conditions have a very marked effect. This is so commonly ' observetl that it is familiar to the incrost beginner in midwifery prac- tice. The fact that the pains often diminish temporarily on the entrance of the accoucheur is known to every nurse; and so also undue excite- ment, the presence of too many peo])le in the room, overmuch talking, have often the same prejudicial effect. Depression of mind, as in unmarried women, and fear and despondency in women who have looked forward with ap])rehcnsion to the labor, are also common causes of irregular and defective action. t/ Undue distension of the uterus from an e xcessive amount of liquo r aQUiji not unfrequeutly retards the first stage, I)y preventing the uterus from contracting efficiently. When this exists, the jiains are feeble and have little effect in dilating the cervix bevond a certain degree. This cause may be suspected Avhen undue jji'otraetion of the first stage is associated with an unusually large size and marked fluctuation of the uterine tumor, through which the foetal limbs cannot be made out on palpation. On vaginal examination the lower segment of the uterus will be found to be very rounded and prominent, while the bag of membranes will not bulge through the os during the acme of the pain. A somewhat similar cause is undue obliquity of the uterus, which prevents the pains acting to the best mechanical advantage, and often retards the entry of the presenting part into the brim. The most com- mon variety is aji tcversion ^resultini: from undue laxity of the abdomi- nal parietes, which is especially found in women who liave borne many children. Sometimes that is so exces.sive that the fundus lies over the PROLONGED AND PRECIPITATE LABORS. 347 pubes, and even projects downward toward the patient's knees. Tlie consequence is, tliat when labor sets in, unless corrective means be taken, the pains force the liead against the sacrum, instead of directing it into the axis of the pelvic inlet. Another common deviation is lateral o I)liquity, a certain degree of which exists in almost all cases'," but sometimes it occurs to an excessive degree. Either of these states can readily be detected by palpation and vaginal examination com- bined. In the former the os may be so high up and tilted so far back- ward that it may be at first difficult to reach it at all. Irregular and Spasmodic Pains.— ^Besides being feel)]e, the uterine contractions, especially in the first stage, are often irregular and spas- modic, intensely painful, but producing little or no effect on the prog- ress of the labor.) This kind of case has been already alluded to in treating of the use of ausesthetics (p. 299), and is very common in highly nervous and emotional women of the upper classes. In such cases c ocaine has been of late used as a local application with decided benefit. It appears to act by deadening the pain resulting from the stretch ino; of the nerves of the cervix or from slight cervical lacera- tions. It has no effect in relieving the suffering caused by uterine contraction.^ It has been applied by means of a cotton-wool tampon steeped in a 2 per cent, solution and placed against the os. A much better way of using it is by " Moore's cones," ^ made with cacoa butter, one of which is placed on the examining finger like a thimble and inserted within the os, where it rapidly melts. Such irregular contractions do not necessarily depend on mental causes alone, and they often follow conditions producing irritation, such as loaded bowels, too early rupture of the membranes, and the like. Dr. Trenholme of ]MoutreaP believes that such irregular pains most fre- quently depend on abnormal adhesions bet^s'een the decidua aud the uterine walls, which interfere with the proper dilatation of the os, and he has related some interesting cases in support of this theory. Treatment. — The mere enumeration of these various causes of pro- tracted labor will indicate the treatment required. (Some of them, such as the c onstitutional state of the patient, age, or me ntal emotion , it is of course beyond the power of the practitioner to influence or modify ;) but in every case of feeble or irregular uterine action a careful investi- gation should be made M-ith the view of seeing if any removable cause exist. For example/the effect of a large enema when we suspect the existence of a loaded rectum is often very remarkable,) the pains fre- quently almost immediately changing in character, and a previously lingering labor being rapidly terminated. (Excessive distension of the uterus can only be treated by artificial e vacuation of the liquor am nii ;\and after this is done the characTer of the pains often rapidly changes. This expedient is indeed often of con- siderable value in cases in which the cervix has dilated to a certain extent, but in which no further progress is made, esjiecially if the bag of membranes does not protrude through the os during the pains, and ^ " The Value of Cocaine in Obstetrics," by John Phillips, B. A., M. D., Lancet, November 26, 1887. ^Brit. Med Journ., 1885, vol. ii. p. 1140. = Obst. Trans., 1873, vol. xiv. p. 231. 348 LABOR. thf cervix it.^oir is soft and appaiviitly readily (lilatable. Under .-iieh circinustances rupture of the meuibraues, even l)efore the os fully dilaterogress of the case anxiously after the second stage has fairly conmienced, and to be guided by an estimate of the advance that is being made and the character of the ])ains, beoring in mind that the risk of the mother, and still more to the child, increases seriously with each hour that elapses. | If we find the })rogress slow and unsatisfactory, the j)ains flagging and nisiiflicicnt. and incapable of being intensified by the means indicated, then, provitlcd the head be low in the pelvis, it is better to assist at once by the forceps, rather than to wait uiiTTl we are driven to do so by the state of the patient.- * ' Obxt. Tranx., 1872, vol. xiii. p. 55. ^ It may, perhaps, be of interest in connection witli this important topic in practical midwifery if I rcjjrint a letter I published some years ago in the Medical Timea and fkizette. An historical case, snch as that of which it treats, will l)etter illustrate the evil effects that may follow nnnecessary delay than any amonnt of argument. It seems to me impo.ssible to read the details of the delivery it describes withont being f()rcii)ly struck with the disastrous results which followed the practice adopted, which, however, was strictly in accordance with that considered correct, up to a quite recent date, l>y the highest obstetric authorities: ON THE DEATH OF THE PRINCESS CHARLOTTE OF WALES. (Ti> the Editor of the Medical Times and Gazette.) Sir: The letter of your correspondent, " An Old .\ccoucheur." regarding the death of the Princess Charlotte, raises a question of great interest — vi/. whether the fatal result might have been averted under other treatment? The liistory of the ca.sc is most in.structive, and I think a careful cousidcratiou of it leaves little room to doubt that, though the management of the labor w;us ipiite in accordance with the teaching of tlie day, it was entirely opposed to that of modern obstetric science. The following PROLONUK]) AND PRECIPITATE LABORS. 355 [The late Dr. William Harris of Philadelphia said to the writer more than twenty-five years ago : "I am in the hahit of using the forceps account of the labor uuiy interest your readers, ami will jjrohably he new to most of them. It is contained iii a letter from Dr. John 8ims to the late Dr. Joseph Clarke of Dublin : " London, November 15, 1817. " My de.vr Sir : I do not wonder at your wishing to have a direct statement of the labor of Her Royal Highness the Princess Charlotte, the fatal issue of which has involved the whole nation in distress. You must excuse my being very ccmcise, as I have been, and am, very much hurried. 1 take the opportunity of writing this in a Iving-in chamber. Her Royal Highness' labor commenced by the discharge of the li(|U()r anniii about seven o'clock on Monday evening, and the pains ibllowed soon after. They continued through the night and a greater part of the next day — sharp, soft, but very inettectual. Toward the evening Sir Richard Croft began to suspect that labor wouldnot terminate without artilicial assistance, and a message was despatched for me. I arrived at two on Wednesday morning. The labor was now advancing more favorably, and both Dr. Baillie and myself concurred in the opinion that it would not be advisable to inform Her Royal Highness of my arrival. From this time to the end of her labor the progress was uniform, though very slow, the patient in good spirits, the pulse calm, and there never was room to entertain a question about the use of instruments. About six in the afternoon the discharge became of a green color, which led to a suspicion that tiie child might be dead; still, the giving assistance was quite out of the question, as the pains now became more efl'ectual, and the labor pro- i'eeded regularly, though slowly. The child was born without artificial assistance at nine o'clock in the evening. Attempts were made for a good while to reanimate it by inflating the lungs, friction, hot baths, etc., but without effect ; the heart could not be made to beat even once. Soon after delivery Sir Richard Croft discovered that the uterus was contracted in the middle in the hour-glass form, and as some hemorrhage commenced, it was agreed that the placenta should be brought away by introducing the liand. This was done about half an hour after tlie delivery of the child with more «ase and less blood than usual. Her Royal Highness continued well for about two hours ; she then complained of being sick at stomach and of noise in the ears, began to be talkative, and her pulse became frequent ; but I understand she was very quiet after this and her pulse calm. About half-past twelve o'clock she complained of severe pain in the chest, became extremely restless, with rapid, weak, and irregular pulse. At this time I saw her for the finst time. It has been said that we had all gone to bed, but that is not a fact ; Croft did not leave her room, Baillie retired about eleven, and I went to my bedchamber and laid down in my clothes at twelve. By dissection some bloody fluid (two ounces) was found in the pericardium, supposed to be thrown out in ariiculo mortis. The brain and other organs all sound, except the right ovarium, which was distended into a cyst the size of a hen's egg. The hour- glass contraction of the uterus still visible, and a considerable quantity of blood in the cavity of the uterus — but those present dispute about the quantity, so much as from twelve ounces to a pound and a half — her uterus extending as high as her navel. The cause of Her Royal Highness' death is certainly somewhat obscure ; the symptoms were sucli as attend death from hemorrhage, but the loss of blood did not seem to be suf- ficient to account for a fatal issue. It is possible that the effusion into the pericardium took place earlier than was supposed, and it does not seem to be quite certain that this juight not be the cause. That I did not see Her Royal Highness more early was awk- ward, and it would have been better that I had been introduced before the labor was expected ; and it should have been understood that when labor came on I should be .sent to without waiting to know whether a consultation was necessary or not. I thought so at the time, but I could not propose such an arrangement to Croft. But this is entirely entre nous. I am glad to hear that your son is well, and, with all my family, wisli to be remembered to him. We were liappy to hear that he was agreeably nuirried. " I remain, my dear doctor, " Ever yours most truly, " John Sijis, M. D. " This letter is confidential, as perhaps I might be blamed for writing any particu- lars without the permission of Prince Leopold." What are the facts here shown '.' Here was a delicate young wonuui, prepared for 3r)() i.M-.oi:. \vv\ .] Pi'ecipitate Labor less Common than Ling-ering.-^Undue i'a|)idity of lai)or is certainly more unconuuon than its converse, but still it is by no means of iuifre(|uent occurrence. \ ]\Iost obstetric works contain a Ibrmidable catalogue of evils that may attend it, such as ru^jture of the cervix, or even of the uterus itself, from the violence of the uterine action ; laceration of the perineum from the presenting part being driven through before dilatation has occun-ed ; fainting from the sud- den eni])tying of the uterus ; hemorrhage from the same cause. A\'ith regard to the child, it is held that the ])ressure to which it is subjected, and sudden expulsion while the mother is in the erect position, may prove injurious. Without denying that these results may possibly occur now and again, in the majority of cases over-rapid labor is not attended with any evil effects. Precipitate labor may generally be traced to one of two conditions, dr the trial before her, as Baron Stockmar tells us, by " lowering the organic strength of the mother by bleeding, aperients, and low diet," who was allowed tf) go on in linger- ing feeble labor for no less than fifty-lwo hours after the escape of the ]i(|uor aninii I Siieh was tlie groundless dread of instrumental interference then j)revalent that, although the case dragged on its weary length with feeble, ineHeotual pains, every now and tlien increasing a little in intensity and then falling ofi'again, it is stated " there never was room to entertain a question about the use of instruments," and even " when tlie discharge became of a green color, .... still, the giving assistance was cjuite out of the question " ! Can any reasonable man doubt that if the forcejjs had been enqiloyed hours and hours before — say on Tuesday, when the pains fell otl' — tlie result would probaljly have been very different, and that the life of tiie cliild, destroyed l)y tlie enormously prolonged second stage, would have been saved? It nnist be remend)ered that early on Tuesday morning delivery was expected, so that the head nuist then liave been low in the pelvis [ride Stockniar's Memoirs, vol. i. ]>. 63). It would be difficult to tind a case which more forcibly illustrates the danger of delay in the second stage of labor. Tiien what follows ? The uterus, exhausted by the lengthy eHbrts it should have been spared, fails to contract eflectually, nor do we hear of any attemjits to pro- duce contraction by pressui'e. Tiie relaxed organ becomes full of clots extending up to the imibilicus, and all the most characteristic symptoms of concealed posl-jiartum hemorrhage develop themselves. She complained "of being sick at stomach, and of noise in her ears, began lrtion only of the cervix, which they render hard, rigid, and uudilatable, while the remainder has its natiu-al soft- ness. They can readily be made out by the examining finger. A somewhat similar, but much more formidable, obstruction is occasion- ally met with in cases of old-standing hyjiertrophic elongation of the cervix, which is generally associated with prolapse. ^In most cases of this kind the cervix becomes softened during pregnancy, so that dila- tation occurs without any unusual difK<'ulty."S J>ut this does not always happen. A good example is related by ]\iix Roper in the seventh vol- ume of the Obstetrical Transactions (p. 233), in which such a cervix formed an almost insuperable obstacle to the paasage of the child. Carcinoma of the cervix uteri, which produces extensive thickening and induration of its tissues, and even advanced malignant disease of the uterus, is n o bar to conce ption. The relations of malignant disease to pregnancy and parturition nave recently been well studied by Dr. Her- <;man.^ He concludes that cancer renders the patient inapt to conceive, (but that when pregnancy does occur there is a tendency to the intra- / uterine death and premature expulsion of the fretus, and the growth of ' the cancer is accelerated. When delivery is accomplished, naturally there ','is generally expansion of the cervix by fissuring of its tissue, but the ''harder forms of cancer may form an insu])erable obstacle to delivery. Agglutination of the margins of the os uteri is occasionally met with, and must of course have occurred after conception. It is gen- erally the result of some inflammatory attection of the cervix during the early months of gestation, and 1 have known it to recur in the same woman in two successive ])regnaucics. ^Usually it is not asso- ciated with any hardness or rigidity, but the entire cervix is stretchej)ear to be dilatable, this procedure may advantageously be adopted 362 LABOR. ht'i'orc incision, and as a nialti-r ol' iiict it is coninionly juactiscd in the Kotuiula H<)S])ital. An operation involving, beyond doubt, of itself some risk, and rc(|nirinji- considerable o])erative dexterity, would natur- ally not lie liuhily and inconsiderately undertaken. J>ut when it is remembered that the alternative is the destruction of the child, tin; risk of exhaustion, and at least as great mechanical injury to the mother, its ditliculty nee ascertained must be anxiously watched. [The nsk of bemo_rrliage is ^ perhaps the greatest, '^for if the tumors be at all Targe' efficient contrac- tion of the uterus after the birth of the child must be more or less interfered with. Fortunately, it is not so common as might almost be expected. Out of 5 cases recorded in the Ohsfetrical Transaction.'^, 2 of which were in my own ]n-actice, no hemorrhage occurred ; nor does it seem to have happened in any of the 26 cases collected bv INIagde- laine in his thesis on the subject. I recently saw an interesting example of this in a patient whose case was looked forward to with much anxietv in consequence of the existence of several enormous fibroid masses pro- jecting from the fundus and anterior surface of the bodv of the uterus, and Avhose labor was nevertheless typically normal in everv Avav. / Should hemorrhage occur after delivery, the injection of styptic solutions 36-1 LAlHiR. would probably bo j)e(Miliarly vahiabic, since llic ordinary means of promoting:; contraction are likely to fail.) It is when the iibroid ji^rowths inij)lieiite the lower uterine zone and the cervical region that the greatest difficulties are likely to be met witii. The j)ractice then to be adopted must be regulatereg- nant state, the expedient seems certainly well worthy of a trial if their site and attachments render it at all feasil)le. Interesting examples of the successful i)crformance of this operation are recorded by Danyau, Braxton Hicks, Lomer, and Munde. Should it be found impracticable, the case must be managed in reference to the amount of obstruction, and the forcejis, cjiailiotomy, or even one of the varieties of abdominal section, may be necessary [vifle p. 228). [Cesarean records in cases of pelvic obstructions due to fibroid tumoi-s show a very discouraging mortality. There have been 14 such ojiera- tions in the United States, with only 4 women and o children saved. Add these to 31 cjises collected in 1882 by Dr. Max Siinger of Leipzig from other countries, and we have 45 cases with 36 deaths. An early operation under the Sanger method should be followed by better results. — Ei).] Tumors of the Ovaries. — The next most common class of obstruct- ing tumors are those of the ovary (Fig. 12(5), and it is ajiparently y|^ th e large st of these which arc most apt to descend into the pelvic cavity^ AVhen the tumor is of any considerable size, its bulk is such that it cannot be contained in the true pelvis, and it rises into the abdominal ' OhM. Trans., 1867. vol. ix. p. 73. "^ Ibid. Jot 1877, vol. xix. p. 101. * This procednre is objected to in Di-. John Phillips' paper, already quoted, but it seems to me on insufficient grounds. OBSTRUCTION FROM CONDITION OF SOFT PARTS. 365 cavity with the uterus. Hence, the existence of tlie tumor that offers/ the most formidable obstacle to delivery is rarely suspected before labor I sets in. In order to estimate the results of the various methods of treatment I have tabulated 57 cases.' In 13, lal)or was terminated by the natural powers alone, but of these, 6 mothers, or nearly one-half, died, la Fig. J2G. Labor complicated by Ovarian Tumor. favorable contrast with these we gave the cases in which the size of the tumor was diminished by puncture. These are 9 in number, in all of which the mother recovered, 5 out of the 6 children being saved. The reason of the great mortality in the former cases is apparently the bruising to which the tumor, even when small enough to allow the child to be squeezed past it, is necessarily subjected. This is extremely apt to set up a fatal form of dii^use inflammation, the risk of which was long ago pointed out by Ashwell,^ who draws a comparison between cases in which such tumors have been subjected to contusion and cases of strangulated hernia; and the cause of death in both is doubtless very similar. This danger is avoided when the tumor is punctured so as to become flattened between the head and the pelvic walls. ( On this I account I think it should be laid down as a rule that puncture .should / be performed in all cases of ovarian tumor engaged in front of the \ presenting part, even when it is of so small a size as not to preclude y the possibility of delivery by the natural powers.N In 5 of the 57 caseslit was found possible to return_tlie tumor above t he pelvi c brim, and in these also the termination was very fa\oral)le/ all tlie mothers recovering. Should })uncture not succeed — and it may fail on account of the gelatinous and semi-solid nature of the contents of the cyst — it may be possible to dispose of the tumor in this way, 1 ObM. Trans., 1867, vol ix. p. 69. '•* Gwjs Hospital Reports, vol. ii. 3()n LMion. evc'ii wIk'H it soeiiis tu he Jiriiii\' \v(»l;i,((l dnwn in IVont nl' the picscnt- iii^' part and to hi' liopok'ssly fixed in its uni;iv(»raljle potsitioji. ( Failing' eitlier oi" those resourees, it may he necessary to resort to er anioton iy. ])rovided the size of the tumor prcchides the pctssihiiity of delivery hy force jit. [A prohipsed diTnioid (yst of large size may prove such an obstacle as to recpiire delivery by ahdoniinal section. I'his has hapjjened hnt once in the United States, the cyst containing seventy hours after the <»])eration half a gallon of pus. The patient Mas oj)ei-ated upon hy Dr. Ktheridgc of Chicago on Feb. 21, 1888, and dietl in eighty-two lionrs. —El).] The question of the effect on labor of ovarian tumor -which does not obstruct the pelvic canal is one of some interest, but there are not a sufficient number of cases recorded to throw much light on it. I am disposed to think that labor generally goes ou favorabi} . AVhat delay there is depeuds on the mefficient action of the accessory muscles engaged in parturition, on account of the extreme distension of the abdomen. There are a few other conditions connected with the maternal struc- tures which may impede delivery, but Avhicli are of comparatively rare occurrence. Amongst them is vaginal cystoc ele, consisting of a prolapse of the distended bladder in front of the presentation, where it forms a tense fluctuating pouch which has been mista ken ibr a hvdroceph alic luad or for the bag of membranes.' This complication is only likely to arise when the bladder has been allowed to become unduly distended from want of attention to the voiding of urine during labor. ' The diag- nosis should not offer any difficulty, for the finger will be able to pass behind, but not .infmnt of, the swelling, and reach the presenting part, Avhile the pain and tenesmus will further put the practitioner un his guard. T he treatment consists in cm])tving the l)la(lder, but there may be some difficulty in passing tTie catheter, in conse(]uence of the urethra being dragged out of its natural direction, A long elastic male catheter will almost always pass if used with care and gentleness. Should it be found impossible to draw off the water — and this is said to have some- times happened — t lie tense ]wuch might be punct ured without danger bv the fine needle of an aspirator trocar and its contents withdrawn. AVhen once the viscus is emptied, it can easily be pushed above the presenting part in the intervals between the i)ains. In some few cases difficulties have arisen from the existence of a v esical calculu s. Should this be pushed down in front of the head, it can readily be understood that^the maternal structun'S would run the risk of being seriously bruised and injured. \ Should we make out the existence of a calculns — and if the j)resence of one be suspected the diag- nosis could easily be made by means of a sound — an endeavor should be made to pil&h .iLi^Jil>ve,idie J2rmi of the pelvis. '*If that be found to be impossible, n o resource is left but its remcn-al , either by cr u§ }iinp; or bv rapid dilatation of the urethra, followed by I'xtraction. Should wei be aware of'tTTe^exferPirrcTTf'Ti calculus during pi-egiiniuy, its removal] should certainlv l)e nndertaken before labor sets in. OBSTRUCTION FROM CONDITION OF SOFT PARTS. :M\1 Hernial protrusion in Douglas' sjKur may sometimes give i-isc to anxiety, from the pressure aiul ('oiitu.sioii to wliicli it is neeessarily siih- jected. xVn endeavoi' must be made to replace it and to modoa-ate the straining efforts of the patient; and it may even be advisable to apply the forceps so as to relieve the mass from pressure as soon as possible. It is, however, of jireat rarit y. Fordyce Barker, in an interesting paper on the subject,' records several examples, and states that he has met with no instance in which it has led to a fatal result, either to mother or child, although it cannot but be considered a serious com])lication. Scyb alous masses in the intestines may be so hard and impacted { as to form an obstructionT' The necessity of attending to the state of the j rectum has already been pointed out. Should it be found impossible to ompty the bowel by large enemata, the mass must be mechanically broken down and removed by the scoop. [Our Southern readers are aware of the fact that their lowest class of women living in the country sometimes eat clay as a remedy for heart- burn, and occasionally in excessive quantities, during the pregnant state. Impacted clay in the lower bowels has on two occasions proved such an obstacle to delivery that the Csesarean operation Avas performed, one case occurring in Louisiana and the other in Georgia, in the years .1866 and 1882 respectively, after labors of sixty hours and three days. The first case recovered, the clay being removed by an attack of diar- rhoea on the sixth day. The second died of convulsions in twenty days after the uterine and abdominal wounds had healed. Under chloro- form about two and a half pounds of sand and marl were removed three days after the operation. — Ed.] Excessive oedejnatQ13^_ infiltration may sometimes cause obstruction, and require diminution in size, which can easily be effected by numerous small punctures. / Hsematic effusions into the cellular tissue of the vulva or vagina form a grave complication of labor.N Such blood-swellings are most usually met with in one or both labia or under the vaginal wall ; in the gravest forms the blood may extend into the tissues for a considerable distance, as in the case recorded by Cazeaux, where it reached upward as far as the umbilicus in front and as far as the attachment of the diaphragm behind. The conditions associated with pregnancy, the distension and engorge- ment to which the vessels are subjected, the interference with the return of the blood by the pressure of the head during labor, and the violent efforts of the patient, aflPorcl a ready ex])lanation of the reason why a ves- sel may be predisposed to rupture and admit of the extravasation of blood. The accident is fortunately for from a common one, although a suf- ficient number of cases are recorded to make us familiar with its symp- toms and risks. The dangers attending such effusions would seem to be great if the statistics given by those who have written on the subject are to be trusted. Thus, out of 124 cases collected by various French authors, 44 proved fatal. Fordyce Barker points out that since the nature and a])pro]iriate treatment of the accident have been more thor- ' Anur. Journ. of Obat., 1876, yu\. ix. p. 177. 3()H LABOR. j)cns during labor when the liead is low down in the pelvis, not nnfrc(picntly just as it is al)OUt to escai)e from the vulva, liciice the extravasation is more often met with low down in the vagina, and more frequently in one of the hibia than in any other situation. I have met with a case in which I liad every reason to believe that an extravasation of i)lood had occurred within the tissues immediately surrounding the cervix. It is natural t(» su])pose that a varicose condition of the veins about the vulva wouhl predispose to the accident, but in most of the recorded examples this is not stated to liave been the case. Still, if varicose veins exist to any marked degree, some anxiety on this point cannot but be felt. The thrombus occasionally, though rarely, forms before delivery. Most commonly it first forms toward the end of labor or after the birth of the child. In the latter case it is probable that the laceration in the vessels occurred before the birth of the child, and that the j)ressure of the presenting part prevented the escape of any quantity of blood at the time of laceration. The syraptoras are not by any mea nscha racter istic. Pain of a tearing character, occasionally very intense, and exteiKlin g toTR e back aiKLdoxviLtJie, thighs, is very generaTly associated with the formaFion of the thrombus. If a careful physical examination be made the nature of the case can readily be detected. (When the blood escapes into the labium, a firm, hard swelling is felt, which has even been mistaken for the foetal head. . If the effusion implicate the internal parts only, the diagnosis may not at first be so evident. But even then a little care sliovdd prevent any mistake, for the swelling may be felt in the vagina, and may even form an obstacle to the passage of the diild. C'azeaux mentions cases in which it was so extensive as to compress the rectum and urethra, and even to prevent the exit of the lochia. ^In some cases the distension of the tissues is so great that thcA- lacerate, and then hem- ori-hage, sometimes so profuse as directly to imperil the life of the ])atient, may occur. \The bursting of the skin may take place some time subsequent to the formation of the thrombus. Constitutional symptoms will be in proportion to the amount of blood lost, either by extravasa- tion or externally, after the rupture of the superficial tissues. Occasion- ally they are considerable, and are the same as those of hemorrhage from any cause. Tiie termination of thromlius is either sjiontaneous absorption, M"hich may occur if the amount of blood extravasated be small ; or the tumor may burst, and then there is external hemorrhage ; or it may supjmrate, the contained coagula being discharged from the cavity of the cyst; or, finally, sloughing of the supei-ficial tissues has occurred. The t reatm ent must nattu-ally vary with the size of the throml)Us and the time at which it forms. If it be met with during labor, unless ' Thr Puerperal Dkenses, j). 60. OBSTRUCTION FROM CONDITION OF SOFT PARTS. 369 it be extremely small, it will be very apt to form an obstruction to the j)assaj2;e of" the child. Under such circumstances it is clearly advisable •to terminate the labor as soon as possible, so as to remove the obstacle to the circulation in the vessels. (For this purpose the f orce }) s should be applied as soon as the head can be easily reached .1 If the tumor itself obstruct the })assage of the head or if it be of any consideral)le size, it will be necessary to i ncise itii 'eelv at its most prominent point and turn out the coagula, controlling the hemori'hage at once by filling the cavity with cotton wadding saturated in a solution of perchloride of iron, while at the same time digital compression with the tips of the fin- gers is kept up. By this means pressure is applied directly to the bleeding point, and the hemorrhage can be controlled without difficulty. This is all the more necessary if spontaneous rupture have taken place, for then the loss of blood is often profuse, and it is of the utmost importance to reach the site of the hemorrhage as early as possible. IJf the thrombus be not so large as to obstruct delivery, or if it be not detected until after the birth of the child, the question arises whether the case should not be left alone, in the hope that absorption may occur, as in most cases of jjelvic haematocele. ) This expectant treatment is advised by Cazeaux, and it seems to be the most rational plan we can adopt. True, it may take a longer time for the patient to conva- lesce completely than if the coagula were removed at once and the hem- orrhage restrained by pressure on the bleeding point ; but this disad- vantage is more than counterbalanced by the absence of risk from hemorrhage, and of septicsemia from the suppuration that must neces- sarily follow, i Softening and suppuration may in many cases occur in a few days, necessitating operation, but the vessels will then be probably occluded and the risk of hemorrhage much lessened) Dr. Fordyce Barker, however, holds the opposite opinion, and thinks that the proper plan is to open the thrombus only, controlling the hemorrhage in the manner already indicated, unless the thrombus is situated high in the vaginal canal. Whenever the cavity of a thrombus has been opened, either by incision ' , or by spontaneous softening at some time subsequent to its formation, it ^ must not be forgotten that there is considerable risk of septic absorp- / tion. To avoid this, care must be taken to use a ntisepti c dressings freely, such as iodoform powder or avooI, applied directly to the part, and frequent vaginal injections of diluted Condy's fluid. Barker lays i special stress on the importance of not removing prematurely the coagula I formed by the styptic applications, for fear of secondary hemorrhage, but of allowing them to come away spontaneously. [Polypus. — Large uterine polypi may act as serious obstacles to deliviSiT. When sufficiently long in pedicle, a polypus may be ex- truded before the head of the ftetus. The tumor may also be detached in its expulsion, or may be removed by an ecraseur if recognized in time: it may also be pushed up out of the way and secured by bringing down the child. I once rejjlaced a large polypus that was extruded before the head, and the woman carried it two years longer ; by which time, being much wasted by the discharge, she made up her mind to have it removed. — Ed.] 24 ^-> 370 LABOR. A d CHAPTER XI. DIFFKTLT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE FCETUS. Plural Births. — The subject of multiple pregnancy in general having already been fully considered, we have now only to discu.ss its practit-al bearing as regards labor. Fortunately, the existence of twins rarely gives rise to any serious difficulty. Tin the large proportion of cases the presence of a second foetus is not suspected until the birth of the fii-st, when the nature of the case is at once apparent from the fact of the uterus remaining as large, or nearly as large, as it was before.) There may possil)ly be some delay in the birth of the fir-^t child, inas- luuch as the extreme distension of the uterus mav interfere with 'it$ thoroughly efficient action; (while, in addition, t he uterine ^ di rectly conveyed to the ov Fig. 127. g ])ressure is no tjj M um as in single \ n births, but indirectly throngh the anniintic [' sac of the second child (Fig. 127).) Such^ delay is especially apt to arise \\i\en the first child presents by the breech, for even if the body be expelled spontaneously, difficulty is likely to occnr M'ith the head, since the uterus does not contract upon it, as is ordinarily the case. Hence, tiie in- tervention of the accoucheur to save the life of the child by the extraction of the head will be almost a matter of necessity. In the majority of eases, after the birth of the first child there is a temporary lull in the pains, which soon recommence, generally in from ten to twenty minutes, and the second child is rapidly expelled, for on account of the fujl dilatation of the soft parts there is no obstacle to its delivery^ Sometimes there is a considerable interval Twin Prcgnamy, BrlcIi and Head before the pains rccur, and instances are Presenting. i i • i • i 11 recorded in which even several clays elapsed between the births of the two children. Treatment. — In most cases the management of twins does not ditt'er from that of ordinary labor. As soon as we are certain of the existence of a second IVi'tn.s we should inform the bystanders, but not necessarily the mother, to whom the news might ])rove an luiplcasant and even dangerous shock. Then, having taken care to tie the cord of the first child for fear of vascular comnumication between tlie plac-enta?, our duty is to wait for a recurrence of the pains. If these come on i*apidly and DYSTOCIA FROM FCETUS. 371 the presentation of tlie second foetus be normal, its birth is managed in the usual way. If there be any unusual delay we have to consider the ])roper. course to pursue, and on this the opinions of authorities differ greatly, ' Some advise a delay of several hours, and even more, if pains do not recur s})ontaueously ; while others — Murphy, for example — recommend that the second child should be delivered at once. ^Either extreme of prac- tice is probably wrong, and the safest and best course is doubtless the m ediu m one. The second point to bear in mind is, that in multiple pregnancy, on account of the extreme distension of the uterus, there is a tendency to inertia, and consequently to post-partum hemorrhage, and that, therefore, it is better that the birth of the second child should be delayed, even for a considerable time, rather than that the patient should run the risk attending an empty and uncontracted uterus. If, however, uterine action be present, there is an obvious advantage in the delivery of the second child before the dilatation of the passages passes off. The best plan would seem to be if, after waiting a quarter of an hour, Jabor-pains do not occur, to try and induce them by uterine friction and pressure and by the administration of a dose of ergot, to which, as there can be no obstacle to the rapid birth or~tlie second child, there can be now no objection. [(The membranes of the second child should alwaysl be ruptured at onc^ if easily within reach, as one of the speediest means\ of inducing contraction.^ If no progress be made and speedy delivery be indicated — a necessity which may arise either from the exhausted state of the patient, the presence of hemorrhage, extremely feeble pul- sations of the foetal heart (showing that the life of the second child is endangered), or malpresentations of the second foetus — turni ng is prob- ably the readiest and safest expedient. Under such circumstances the operation is performed with great ease, since the passages are amply dilated. After bringing down the feet the birth of the body should be sloMdy effected, with the view of ensuring as complete subsequent con- traction as possible. ', If the head has descended in the pelvis, of course turning is impossible and the forceps must be applied) DiflB,culties arising from Locked Twins. — Occasionally very seri- ' ous difficulties arise from parts of both foetuses presenting simultane- ously, and thus impeding the entrance of either child into the pelvis, or getting locked together, so as to render delivery impossible without artificial aid. Such difficulties are not apt to arise in the more ordinary cases, in which each child has its own bag of membranes, since then the foetuses are kept entirely separate,(but in those in which the twins are contained in a common amniotic cavity or in which both sacs have burst simultaneously.' They are very puzzling to the obstetrician, and it may be far from easy to discover the cause of the obstruction. Nor is it pos- sible to lay down any positive rules for their management, which must be governed to a considerable extent by the circumstances of each indi- vidual case. Sometimes both heads present simultaneously at the brim, and then neither can enfer unless they be unusually small or the pelvis very capacious, when both may descend ; or rather the first head may descend 372 LABOR. low into the pelvic cavity, and then the second head enters the brim and get.« Janiined against the thorax of the first child (Fig. 128). Reiniann' relates a curious; example of this iu which he delivered the head first Fio. 128. Shows Head-locking, both children presenting head first. (After Barnes.) •with the forceps, but found the body M-^ould not follow, and on exami- nation a second head was found in the pelvis. He then applied the for- ceps to the second head; the body of the first child Mas then born, and afterward that of the second. Such a mechanism must clearly have been impossible unless the pelvis had been extremely large. . Whenever both heads are felt at the brim it will generally be found ] possible to get one out of the way by appropriate manipulation, one ' hand being passed into the vagina, the other aiding its action from Avithout. Then the forceps may be applied to the other head, so as to engage it at once in the pelvic cavity. If both have actually jxissed into the pelvi.s, as in the case ju.st alluded to, the difficulty will be much greater. (It will generally be easier to jnish up the second head, while the lower is drawn out by the forceps, than to deliver the second, leav- ing the first in situ. ' In other cases a foot o r ha nd may descend along withjihe head, and even the four feet iiiay present simultaneously. Tiie rule iuTlie former case is to push the part descending with the head out of the way, and in the latter to disengage one child as soon as possible. Great care is necessaiy, or we might possibly bring down the limbs of separate children. V. The most common kind of difficulty is when the fii-st child presents by the breech, and is delivered as far as the head, which is then found » Arch. f. Gyndk., 1871, Bd. ii. p. 99. DYSTOCIA FROM FCETUS. 373 to be locked with the head of the second cliild, which has descended into the pelvic cavity (Fig. 129). i Here it is clear that the obstruction must be very great, and, unless the children are extremely small, insuperable. The first endeavor should be to disentangle the heads: this is sometimes feasible if the second be not deeply engaged' in the pelvis and the hand be passed up Fig. 129. Shows Head-locking, first child coming feet fir.st ; impaction of heads from wedging in brim. (After Barnes.) D. Apex of wedge, e, c. Base of wedge, which cannot enter brim, a, b. Line of decapitation to decompose wedge and enable head of second child to pass. SO as to push it out of the way. This will but rarely succeed -jl^ then it may be possible to apply the forceps to the second head and drag it past the body of the first child i and this is the method recommended by Reimann, who has written an excellent paper on the subject.^ ^Gen- erally, the sacrifice of one of the children is essential, and as the body of the first cTiild must have been born for some time, it is probable that the pressure to which it has been subjected will have already ' American Journal of Obstetrics, 1877, vol. x. p. 47. 374 LABOR. iiiijH'rilK'd, if it h;is not dt'stroyt'd, its life, and tlicrclnrc tlic |)laM usually reconuuouded is to docapitato. This can easily be done witli scissors or a wire ccraseur, after which the second child is expelled ■without difiiculty, leaving the head of the first in utcro to be subse- quently dealt Avith.") AnotluT mode of nuuiai2;int>; these cases is to perforate the u|)pcr head anil draw it past the lower with the cephalotribe or craniotomy forc('])s. This })lan has the disadvantage of probably sacrificing both children, since the other child can hardly survive the pressure and delay ; where- as the former plan gives the second child a fair chance of being born alive. Double Monsters. — In connection with the snl)ject of twin labor we may consider those rare cases in which the bodies of the fietuses are partially fused together. The mechanism and management of delivery in cases of double monstrosity have attracted comparatively little attention, no doubt because authors have considered them matters of curiosity merely, rather than of practical importance. The frequent occurrence of such monstrosities in our museums, and the numerous cases scattered through our })eriodical literature, are suf- ficient to show that they are not so very rare as we might be inclined to imagine; and, as they are likely to give rise to formidable difficul- ties in delivery, it cannot be unimjiortant to have a clear idea of the usual course taken by nature in effecting such births, with a view of enabling us to assist in the most satisfactory manner should a similar case come under our observation. Unfortunately, the authors Avho have placed on record the birth of double monsters liave generally occupied themselves more with a descrip- tion of the structural peculiarities of the foetuses thau with the mechan- ism of tlieir delivery ; so that, although the eases to be met with in medical literature are very numerous, comparatively few of them are of real value from an obstetric point of view. Still, I have been able to collect the details of a considerable number* in which the history of the labor is more or less accurately described ; and doubtless a more extensive research would increase the list. Double Monstrosity may be Divided into Four Classes. — For obstetric purposes we may confine our attention to ibur jirineipal varie- ties of double monstrosity which are met with far more frequently than any others. These are : A. Two nearly .separate bodies united in front, to a varying extent, by thorax or abdomen. B. Two nearly separate bodies united back to back by the sacrum and lower part of the spinal column. C. Dice]>halous monsters, the bodies being single below, but the heads separate. D. The bodies separate below, but the heads partially united. This classification by no means includes all the varieties of monstei'S that we meet with. It does, however, include all that are likely to give rise to much difficulty in delivery; and all the cases I have collected may be placed under one of these divisions. ' OOxt. Tran^., 1867, vol. viii. p. 300. DYSTOCIA FROM FCETUS. 375 The first point that strikes us in looking over the history of these deliveries is the frequency with which they have lx*n terniinate<^I liv tiie natural powei-s alone, without any assistance on the part of the acc-ouchcur. Thus, out of the 31 cases, no Ic^s than 20 were deliven-d naturallv, and apparently without much trouble. Nothing can better show the wonderful resoiu*ces of nature in overc-oming difficulties of a verv fnrmidable kind. it is })rettv generally assumed by authors that the children are neces- sarilv premature, and therefore of small size, and that delivery before the full term is rather the rule than the exception. Duges states that the children are often dead, and that putrefaction has taken place, which facilitates their expulsion. Both these assumptions seem to me to have Ijeen made without sufficient authority, and not to be borne out bv the recorded facts. In only 1 of the 31 cases it is mentioned that the children were premature: nor is there any sufficient rea.son that I can see why labor should commence before the full term of gestation. Class A. — By far the greatest number are included in the first class — that in which the bodies are nearly separate, but united by some part of the thorax or alxlomen. This is the diWsion which includes the celebrate*:! Siamese Twins, an account of whose birth, I may observe, I have not l)een able to discover.^ /Out of the 31 c-ases, 19 come under this heading. The details of the labors are briefly as follows: 1 died undelivered ; 8 were terminated by the natural powers, in 3 of which the feet, and in 3 the head, presented ; in 2 the presentation is doubt- ful ; 6 were delivered by turning or by traction on tiie lower extremi- ties ; 4 were delivered instrumentally. The details of the cases in which the feet presented or in ^shieh turn- ing was performed clearly show that footling pr^ntation was by far the most favorable; and it is fortunate that the feet often present naturally. The inference of course is that version should be resorted to whenever any other presentation is met with in cases of double mon- strosity of this type : but, unfortunately, this rule could rarely be carried into execution, since we possess no means of diagnosing the junction of the fcetases at a sufficiently early stage of lalx»r to admit of tiu^ning being performed. It is only under exceptionally favorable circumstances that this can be done ; as, for example, in a case recorded by Molas, in wliich both heads presented, but neither would enter the brim of the pelvis. The great difficidty mtist, of course, be in the delivery of the heads, f jr in all the recorded cases, with one exception, the Ixxlies have passed through the pelvis parallel to each other with comparative ease imtil the necks have appeared, and then, as a rule, they could be brought no [' The mother of these twins was once seen by Dr. Ruschenbei^r of Philadelphia at Bangkok : she was a Chinese half-breed, short, and with a broad pelvis, and had borne several children previously. She stated on several occasions, in conversation with parties in Siam. that the twins were bom reversed, the feet of one being followed by the head of the other, and that they were very small and feeble at binh and for several months afterward. The twins confirmed this statement by affirming that they could, when little boys at play on the ground, turn themselves end for end upon the ensiform attachment up to the age of ten or twelve, the attachment being then soft and pliable. Although called Siamese, they were three-quarters Chinese. — Ed.] 37() LABOR. farther. It is clear that the rcinaiiidcr of tho foetuses could no longer pass sinniltanoonsly, and were direct traction continued the heads would be inextricably fixed above the brini.'^ In accordance with the direction of the pelvic axes the posterior head must first engage iu tlie inlet ; and in order to effect this it will be necessary to carry the bodies of the children well over the abdomen of the mother.) This seems to be a point of primary importance. ; It Avould also be advisable to see tiiat the borovided the amount of contained fluid be small, it may be sufliciently diminished in size by the moulding to which it is subjected to admit of its being squeezed through the pelvis.) In the majority of cases, however, the size of the head is too great lor this to occur. (^ The uterus therefore exhausts itself, and may even rupture, in the vain endeaTDr to overcome thc~oT)stacle, while the large aiicl distended head presses firmly on the cervix, or on the pelvic ti.ssues if the os be dilated, and all the evil effects of prolonged com])ression are a]>t to follow. The diagnosis of intra-uterine hydrocephalus is by no means so easy as the descri])tion in obstetric works would lead us to believe. It is true that the head is much larger and more rounded in its contour than the healthy fcetal cranium, aiTa also that tlie sutures and fontanclles are more wide and admit occasionally of fluctuation being jierceivcd through them. Still, it is to be remembered that the head is always arrested above the brim, where it is consequently high up and difticult to reach, and where these peculiarities are made out with much difficulty. As a matter of fact, the true nature of the case is comparatively rarely dis- DYSTOCIA FROM FCETUS. 379 covered before delivery; thus Chaussier' found that in more than one-half of the cases he collected an erroneous diagnosis had been made. V AVhenever we meet with a ease in which either the history of ])revious labor or a careful examination convinces us that there is no obstacle due to pelvic deformity, in which the pains are strong and forcing, but in which the head persistently refuses to engage in the brim, we may fairly surmise the existence of hydrocephalus. Nothing, how- ever, short of a careful examination under anaesthesia, the whole hand being passed into the vagina so as to explore the presenting part thor- oughly, will enable us to be quite sure of the existence of this compli- cation. Under these circumstances such a complete examination is not only justified, but im})erative; and when it has been made the difficulties of diagnosis are lessened, for then we may readily make out the large round mass, softer and more compressible than the healthy head, the widely separated sutures, and the fluctuating fontanel les. Jn a considerable proportion of cases — as many, it is said, as 1 out of 5 — the foetus presents by the breechJ The diagnosis is then still more difficult; for the labor ])rogresses easily until the shoulders are born, when the head is completely arrested, and refuses to pass with any amount of traction that is brought to bear on it. Even the most care- ful examination may not enable us to make out the cause of the delay, for the finger will impinge on the comparatively firm base of the skull, and may be unable to reach the distended portion of the cranium. At this time abdominal palpation might throw some light on the case, for, the uterus being tightly contracted round the head, we might be able to make out its unusual dimensions. The wasted and shrivelled appear- ance_of the child's body which so often "accompanies hydrocephalus would also arouse suspicion as to the cause of delay. (On the whole, such cases may be fairly assumed to be less dangerous to the mother than when the head presents! for in the latter the soft parts are apt to be subjected to prolonged pressure and contusion, while in the former delay does not commence till after the shoulders are born, and then the charac- ter of the obstacle would be sooner discovered and appropriate means earlier taken to overcome it. The treatment is simple, and consists in tapping the head, so as to allow the cranial bones to collapse. There is the less objection to this course, since the disease almost necessarily precludes the hope of the child's surviving. The aspirator would draw off the fluid effectually, and would at least give the child a chance of life ; and under certain circumstances the birth of a child who lives for a short time only may be of extreme legal importance. More generally the perforator will be used, and as soon as it has penetrated a gush of fluid will at once verify the diagnosis. ^^Schroeder recommends that after perforation turning should be performed, on account of the difficulty with which the flaccid head is propelled through the pelvis\ This seems a very unnecessary complication of an already sufficiently troublesome ease. As a rule, when once the fluid has been evacuated, the pains being strong, as they generally are, no delay need be apprehended. Should the head not ' Qazette medicale, 1864. 380 LABOR. cuiUL' iloNvii, the ('0])1ki1( (tribe may be a})plied, Nvhicli lakes a firmer grasp than the forceps, and enables the liead to be crushed to a very small size and readily extracted. WIkii the brceeh presents the head nuist be perforated through the occipital bone, and generally this may be acc(tnij)lished behind the ear Avithont nuich ditlicnity. In a case of Tarnier's the vertebral column was divided by a bistoury and an ela.stic male catheter intnxluced into the vertebral canal, through which the intracranial fluid' escaped, the labor being terminated s])ontaneously.^ In any case in which it is found difficult to reach the skull with the perforator this procedure should certainly be tried. Other forms of dropsical efFusion may give rise to some difficulty, but by no means so serious. In a few rare ca*^es tiie thorax has been so distended with fluid as to obstruct the passage of the child. Asci^s is somewhat more common, and occasionally the child's bladder is so dis- tended with urine as to prevent the birth of the loody. The existence of any of these conditions is easily ascertained ; for the head or breech, whichever haj)pens to present, is delivered without difficulty, and then the rest of the body is arrested. This will naturally cause the prac- titioner to make a careful exploration, when the cause of the delay will be detected. The treatment consists in the evacuation of the fluid_by^j2JJLliCtui"e- In the case of ascites this should always be done, if possible, by a fine trocar or aspirator, so as not to injure the child. This is all the more important since it is impossible to distinguish a distended bladder from ascites, and an opening of any size into that viscus might prove fatal, whereas aspiration would do little or no harm and would prove quite as efficacious. FcBtal Tumors Obstructing Delivery. — Certain foetal tumors may occasion dystocia, such as malignant growths or tumors of the kjdney, liver, or spleen. Cases of this kind are recorded in most obstetric works. Hydro-encephalocele or hydro-rachitis, depending on defective formation of the cranial or spinal bones, with the formation of a large protruding bag of fluid, is not very rare. The diagnosis of all such cases is somewhat obscure, nor is it jwssible to lay down any definite rules for their management, which must vary according to the particidar exigencies. /The tumors are rarely of sufficient size to ])rove formidable obstacles to Melivery, and many of them are very compressible) This is specially the case with the spina bifida and similar cystic growths. Puncture — and in the more solid growths of the abdomen t»r thorax evisceration — may be required. Otlier deformities, such as the ane ncephalou s foetus, or defective development of the thorax or abdominal parietes, with protrusion of the viscera, are not likely to cause difficulty, but they may much em- barrass the diagnosis by the strange and unusual presentation that is felt. If in any case of dou])t a full and careful examination be under- taken, introducing the whole hand if necessary, no serious mistake is? likelv to be made. Dystocia from Excessive Development of the Foetus. — In addi- * Hergott, Maladies /(Stales qui peuvent /aire obstacle d P accouchement, Paris, 1878. DYSTOCIA FROM FCETUS. 381 tiou to dystocia from morbid conditions of the frctus, difficulties may arise from its uinliif development, and especially from excessive size and advanced ossificaliun of the skull. This last is especially likely to cause delay. Even the slight difference in size between the male and female head was found by Simpson to have an appreciable effect in increasing the difficulty of labor when the statistics of a large number of cases were taken into account ; for he proved beyond doubt that tlie difficul- ties and casualties of labor occurred in decidedly larger proportion in male than in female births. Other circumstances besides sex have an important effect on the size of the child. Thus, Duncan and Hecker have shown that it increases in proportion to the age of the mother and the frequency of the labors ; while the size of the parents has no doubt also an important bearing on the subject. Although these influences modify the results of labor en masse, they have little or no practical bearing on any particular case, since it is impossible to estimate either the size of the head or the degree of its ossification until labor is advanced. Treatment. — When labor is retarded by undue ossification or large size of the head, the case must be treated on the same general princi- ples which guide us when the want of proportion is caused by pelvic contraction. Hence, if delay arise which the natural powers are insuf- ficient to overcome, it will seldom happen that the disproportion is too great for the forceps to overcome. If we fail to deliver by it, no resource is left but perforation. Large size of the body of the child is still more rarely a cause of difficulty, for if the head be born the compressible trunk will almost always follow. Still, a few authentic cases are on record in which it was found impossible to extract the foetus on account of the unusual bulk of its shoulders and thorax. Should the body remain firmly impacted after the birth of the head, it is easy to assist its delivery by traction on the axillae, by gently aiding the rotation of the shoulders into the antero-posterior diameter of the pelvic cavity, and, if neces- sary, by extracting the arras, so as to lessen the bulk of the part of the body contained in the pelvis. Hicks relates a case in which eviscera- tion was required for no other apparent reason than the enormous size of the body. The necessity for any such extreme measure must of course be of the greatest possible rarity ; and it is quite exceptional for difficulty from this source to be beyond the powers of nature to over- come. 382 LABOR. CHAPTER XII. DEFORMITIES OF THE PELVIS. Deformities of the pelvis form one of the most important subjects of obstetric study, for from them arise some of the gravest difficuhies and dangers connected uith parturition, A kno\vlees are also flattened, while the ischia are more widely separated than in a normal pelvis, thus pro- ducing a greater wid^tli of the pubic arch, while the acetabnla are turned forward. The depression of the sacral promontory would tend to produce strong traction through the sacro-iliac ligaments on the posterior end of Fig. 132. Scolio-rachltic Pelvis. (From a spcciiiu'ii in tlic Mnseuiii of St. Bjirtliolomew's Ilcispital.) the sacro-cotyloid beams, and thus induce expansion of the iliac bones and consequent increa.se of the transverse diameter of the brim. So an unusual length of the transverse diameter is verv often described as DEFORMITIES OF THE PELVIS. 387 accom])anyino- this dcluriiiity)^ but j^robably it is not so often apparent as might otherwise be expected, on account of the imperfect develop- ment of the bones generally accompanying rickets^ and Barnes' says that in the parts of London where deformities are most rife any enlarge- ment of the transverse diameter is exceedingly rare. Fre<][uently the sacrum is not onlydepressed, but displaced more or less to one side, mosi pncially to tHeleft, thus interfermg with the reg- ular shape of the dci'urined brim. This is often the result of a lateral liexion of the spinal column, depending on the rachitic diathesis, and wlien well marked is known as the scolio-r achit ic pelvis (Fig. 132), in which one side of the pelvis, that corresponding to tlie direction of the pelvic curve, is asymmetri cal and contracted, the ilio-pectineal line being sjiai^jjcur ved iu,:5i:ard about the site of the sacro-iliac synchondrosis, the sympliysis pubis being displaced toward the opposite side. A somewhat similar but much less marked, unilateral asymmetry may exist in cases of scoliosis [^] unconnected with rickets, but rarely to a sufficient degree to interfere materially with labor. In most cases of this kind the cavity of the pelvis is not diminished in size, and is often even more than usually wide. The constant pressure on the ischia which the sitting posture of the child entails tends to force them apart and also to widen the pubic arch. Consider- FiG. 133. Eickety Pelvis, with backward depression of symphysis pubis. able advantage results from this in cases in which we have to perform obstetric operations, as it gives plenty of room for manipulation. ' Lectures on Obst. Operations, p. 280. [^Although liunchbacks frequently have well-formed pelves, it is not uncommon to find a deformed spine associated with an asymmetrical pelvis or even a much con- tracted one. Spinal distortion from caries, "especially in the lumbar region, is thus associated, and the pelvic deforinity will be increased if there has been coxalgia, either double or single, or if from any cause one leg sliould be shorter than "the other. In the records of the Porro operation we find under "the cause of diffi- culty," " pseudo-osteomalacia," " liimbo-dorsal ki/pho.ih," " kyphoscoliosis," etc. Pseiido- osteomalacia is the result of rickets in a walking child, "the form of pelvis being changed meclianically, as in osteomalacia. Jjumbo-dorsal kyphosis may or mav not give rise to the kyphotic pelvis, as nnich will depend upon the extent of vertebral caries._ Scoliosis is apt to result from rickets, and may be associated with lordosis. Scoliosis, from cr/voPiwf, crooked— a distortion of the spine to one side. Lordosis, from ?.op6oc, curved— applied particidarlv to the forward bending of the spine. Kyphosis, from Kvipuaic, gibbous, arched, or vaulted— a hump or backward curvature of the spine. — Ed.] 38 S LABOR. Figure-of-eight Deformity. — In a few exceptional cases tlie narr ow- i'liL -'l-ilit'_^''-!-'''iiU5'itVLilJ^'"t>ter is increased by a backward depression of tlie syin]>hysis j)ubis, yliTdi gives tlie pelvic brim a sort of fiunre-of- eiglit shape (Fig. lo-'i). (The most reasonable exj)lanation of this jx-cn- liarity seems to be that(it is tiie resnlt of the mnscnlar contraction of the recti mnscles at their point of attachment, when the centre of gravity of tlie body is thrown backward on acc-ount of the projection of the sacral promontory.) Sometimes also the F^<'- l-^^- antero-})osterior diameter of the cavity is nnnsually lessened by the disappearance of the vertical curva- ture of the sacrum, which instead of forming a distinct cavity is nearly flat (Fig. 134). Spondyl-olisthesis. — In a few rare cases, to wliich attention was first called in 1853 by Kilian of Bonn, a very formidable narrow- ing of the conjugate diameter of the pelvic brim ig, produced by a downward displacement of the _ foiirth and fifth lumbar vertebra'^; Flatness of Sacrum, with narrowing of pi'lvic -which bcCOmC (lislocatcd forward,, or, if not actually dislocated, at least separated from their several articulations to a sufficient extent to encroach very seriously on the dimensions of the pelvic inlet. This condition is known as spondyl-olis- thesis (Fig. 135). The effect of this is sufficiently obvi- ous, for the projection of the lumbar vertebrae prevents the passage of the child. To such an extent is obstruction thus produced that in the majority of the recorded cases the Cfesarean section Mas necessary. The true conjugate diam- eter, that between the promontory of the sacrum and the symphysis pubis, is in- creased rather than diminished ; but for all practical pur])oses the condition is sim- ilar to extreme narrowing of the conjugate from rickets, for the bodies of the disj>lacc(l vertebrae project into and obstruct the ])el- vic brim. The cause of this deformity seems to be different in different cases. In some it .«eems to have been co ngen ital, and in othei's to have depended 'on/ some antecedent disease of the bones,) such as tuberculosis or scrofula, producing inflannnation and softening of the comicction between the last lumbar vertebra and the sacrum, thus permitting downward displacement of the bones.. Fig. 135. Pelvis Deformed by Spondyl-olis- thcsis. (After Kiliuu.) DEFORMITIES OF THE PELVIS. 389 Laiiibl believed that it generally luUowed spina bifida, whieh had become partially cured, but which had produced deformity of the vertebra? and favored their dislocation. Brodhurst,* on the other hand, thinks that it most probably depends on raciiitic inflammation and softening- of the osseous and ligamentous structures, and that it is not a dislocation in the strict sense of the word. This condition has recently been made the subject of special study by Dr. Franz L. Neugebauer,^ who believes that the forward displacement is never the result of antecedent disease of the bones, but depends either on congen- ital want of development of the vertebral arches or on traumatism, such as fracture of the articular processes, which allows the wefgfit of the trunk to displace the body of the last lumbar vertebra forward, either jxartially or entirely. [We are indebted to Kilian of Germany for the first careful investi- gation of the true character of spondyl-olisthetic deformity, although the credit of initial mention is due to Rokitansky of Austria, who wrote Fig 1 ..h in 1839, antedating the monograph of the former (1853) by fourteen years. No special mention is made of this peculiar lordosis by Roki- tansky in his Manual of Patholog- ical Anatomy in 1844, but in his Lehrhuch (1855) it is given, with due credit, to Kilian. During the thirty-three years that have passed since Kilian prepared his paper from observations made upon three pelves ^vhich had been obtained from sub- jects in whom the Cresareau section had proved fatal, one of them after a second operation, there have ap- peared numerous monograplis and descriptions of cases, much the most valuable and extensive of which are those by Dr. Franz Ludwig Neuge- bauer pf Warsaw and Dr. A. Swedelin of St. Petersburg, the latter of whom furnishes the bibliography of the subject. These valuable papers cover 223 and 40 pages respectively of the Archiv fur Gyndkologie, Berlin, vols, xix., xx., xxi., xxii., and xxv., for 1882-85. V.The most frequent origin of spondyl-olisthetic deformity appears to lie in an incomplete ossification of the' last lumbar vertebra, whereby its anterior and posterior portions are rendered liable to separate under the superincumbent weight of the body.^ Hence the subjects of the slipplnc/ are frequently stout, heavy women. This was markedly the case in the woman who came under the care of Prof. James Blake of San Francisco.'^ This patient was married at fifteen ' Obsf. Trans., 1865, vol. vi. p. 97. ^ Contribiidon cl la Pathoqenie du Bamn vide par le Glissement vertebral, Paris, 1884. pPac. Med. and Surg. Journ., Feb., 1867.] [Spondyl-olisthesis. (After Neugebauer.)] 390 LABOR. yciirs c»l" a<:(', :il wliicli time .slio \\fij::lic'rctrnancy, to briufj; on labor prematurely. She became pretjnant for tlie eighth time at the age of twenty-six, when she weigiied 220 ])ounds. Labor was induced in the seventh month, but the fcetus was lost, as it weighed nearly six pounds and the lumbo-])ubic s]>ace Mas reduced to 3 inches. This woman is said to have undergone the change in her vertebne witliout j»ain or sign of ill-health, and to have retained a remarkable activity for her weight. After her eighth delivery she was up in six days and down stairs in ten. The history of this case would indicate that the deforming process must have been slowly progressing during more than ten years. In contrast with this painless case in a midtijiara we have the oppo- site in a nullipara, reported by Dr. Olshausen, formerly of Halle. The disease commenced in his patient when a girl of eighteen with severe pains in the sacrum and hips, as in malacosteou. She had not had rickets in childhood, had enjoyed good health up to this time, and was quite straight. As her disease progressed she found on awaking one morning that she could not straighten her spine, and was forced to walk with her body bent forward. She was jnit under medical treatment at the surgical clinic; had no fever, and in time ceased to sutler, and was discharged. Becoming pregnant at the age of twent}'-four. Dr. Olshausen delivered her in 1863 by the Cfesarean section: the child lived, but she was lost on the fourth day by peritonitis. The lumbo- pubic diameter Mas found to mcasvire 3 inches, and the line of the con- jugate struck the loMcr margin of the third lumbar vertebra. — Ed.] Spondyl-olizema. — A somewhat analogous deformity has been de- scribed by PTergott ' under the name of suo)u Ji/l-o lizem a. In this the bodies of t he loMcr lumb:ir vertebra* hnvini> of tlic ^ .,;4.„ -p „ r\^^ ^-i -^^i^^ Robert's, or double obliquely-contracted Deformity from Old-standmg j-eivis. (After DunJau.; - Kyphotic Pelvis. (Fi'om a specimen in the Museum of St. Bartholomew's Hospital.) 394 LABOR. Fig. 142. Hip-joint Disease. — Anotlicr cause ol" transvenso defbrn^ijj}' <»c'ea.-5ion- ally met with is luxation of the head of the femur depending on old- standing joint disease. The head of the femur in this case presses on the innomintite bone at the site of dislocation, and the result is that the iliac fossa on the affected side, or both if the accident ha])pens on both sides, is pushed inward, the transverse diameter of the brim being less- ened. The tuberosity of the ischium is, however, projected outward, so that the outlet of the jielvis is increased rather than diminished. Deformity from Tumors, Fractures, etc. — Obstruction of the ])elvic cavity from exostoses or other forms of tumors growing from the bones is of grea t rarity (Fig. 142). It may, hoAvever, produce "~ very serious dystocia. Several curious examples are collected in Mr. A^^ood's article on the pelvis, in some of %vhich the obstruction was so great as to ne- cessitate the Csesarean section. Some of these growths were true e xostos es, and, according to stadfeldt,^ these are commonly found in pelves that are otherwise contracted ; others, osteo- sarcomatous tumors attached to the pelvic bones, most generally the ui)per part of the sacrum ; and others Avere malignant. In some cases spicuhe of bone have developed about the iinea nio-jiectinea or other parts of the pel- vis, which may not be sufficient to produce obstruction, but which may injure the uterus, or even the fo'tal head, Avhen they are pressed upon them. Irregular })rojections may also arise from /the callus of old fractures of the pelvic bones.N All such cases deiy classification, and differ so greatly in their extent and in their effect on labor that no rules can be laid down for them, and each must be treated on its own merits. The effects of pelvic contractions on labor vary, of coui'se, greatly with the amount and nature of the deformity, but they must always give rise to anxiety, and in the graver degrees they produce the most serious difficulties we have to contend with in the whole range of obstetrics. ( In the lesser degrees, in which the proportion between the presenting part and the pelvis is only slightly altered, we may observe little al)nor- mal beyond a greater intensity of the jxiins and some protraction of the labor: It is generally observed that the uterine contractions are strong and forcible in cases of this kind, probably because of the increased resistance they have to contend against ; and this is obviously a desir- able and conservative occurrence, which may of itself suffice to overcome the difficulty. The first stage, however, is not unfVequently prolonged, and the pains are ineffective, for the head does not readily engage in the 1 Obstetrical Journal, 1879-80, vol. vii. p. 201. Bony Growth from Sacrum obstructing the I'elvic Cavity. DEFORMITIES OF THE PELVIS. 395 brim, the uterus is more mobile than in ordinary labors, and it probably acts at a disadvantage. Risks to the Mother.-(-Tu the more serious eases the mother is suIj- jected to many risks directly proportionate to the amount of obstruction and the length of the labor.) The long-contiinicd and excessive uterine action, produced by the vain endeavors to push the child through the contracted pelvic canal, the more or less prolonged contusion and injury to which the maternal soft parts are necessarily subjected (not unfre- quently ending in inflammation and sloughing with all its attendant dangers), and the direct injury which may be inflicted by the measures we are compelled to adopt for aiding delivery (such as the forceps, turning, craniotomy, or Csesarean section), all tend to make the progno- sis a matter of grave anxiety. [The Csesarean operation has been per- formed 9 times in the United States in cases of pelvic exostosis, with 4 recoveries. One woman was operated upon three times and died from the third operation : 4 of the 9 children were saved. Of the fatal cases, 3 were in labor three days, 1 two days and 1 had been in convulsions for twenty-four hours. Of the 4 that recovered, 1 was in labor " a few hours;" 1, twelve hours; 1, twenty-four hours; and 1, thirty-eight hours. — Ed.] Risks to the Child.— ^or are the dangers less to the child, and a very large proportion of stillbirths will ahvays lie met with.^ The infan- tile mortality may be traced to a variety ol' causes, the most important being the pi;otraction of the labor an(l"tlVe continuous pressure to which the presenting part is subjected. For this reason,, even in cases in which the contraction is so slight that the labor is terminated by the natural poAvers, it has been estimated that thai (Irlnrniitics oi" tin- [R-lvis, except of tlie gravest kind, are .siispeited hetore labor hits actually cominenciHl, ami therefor^ we are not often CiiUed upon to give an opinion as t(j the c(»ndition of the j)elvi.s before delivery. Should we be, there are various <'iren instances ^hich may aid us in arriving at a correct conelasion. Prominent among them is the liistop- of the patient in childho(Ml. If she is known to have sutt'ered from rickets in early life, more especially if the disease has left evident traces in deformities of the lind)s or in a dwarfed and stunted growth or in curvature of the spine, there will l)e strong presumptive evidence of pelvic deformity ;(a markedly jiendu- lous state of the abdomen juay also tend to connrm the suspicion^ Xothing short of a careful examination of the pelvis itself will, how- ever, clear up the point with certainty; and even l)v this means to estimate the precise degree of deformity with accuracy requires con- siderable skill and practice. The ingenuity of practitioner's has been much exercised — it might perhaps be justly said wasted — in the inven- tion of various more or less complicated pelvimeters for aiding us in obtaining the desired object. It is, however, pretty generally admitted bv all accoucheurs that the hand forms the best and most relialjle instru- ment for this purpose — at any rate, as regards the interior of the pelvis ; although a pair of callipers, such as Baudelocque's well-known instru- ment, is essential for accurately determining the external measurements. The objections to all internal pelvimeters, even those most simj)le in their construction, are their cost and complexity and the impossibility of using them without pain or injury to the patient. It was formerly thought that by measuring the distance l)etween the spinous processes of the sacrum and the symphysis pubis, and subtract- ing from it what we judge to be the thickness of the bones and soft parts, we might arrive at an approximate estimate of the measurement of the conjugate diameter of the pelvic brim, ^t is now admitteplies, of course, only to the lesser degree of deformity, in which the birth of a living child is not hopeless. When the antero-posterior diameter of the brim measures from 2J to 3 inches, it is universally admitted that the destruction of the child is inevitable, unless the ])elvis be so small as to necessitate the performance of the Ca?sarean section. DEFORMITIES OF THE PELVIS. 401 But when it is between 3 inelies and tlie normal measurement tlie com- parative merits of the tbrcej)S, turning, and the induction of premature labor foriu a fruitful theme for discussion. With one class of accouch- eurs the force])s is chietiy advocated, and turning admitted as an occa- sional resource when it has failed; and this indeed, speaking broadly, may be said to have been the general view held in England. j\Iore recently we find German authorities of eminence, such as Schroeder and Spiegelbei'g, giving turning the chief place, and condemning the forceps altogether in (jontractcd })elves, or at least restricting its use within very narrow limits. More strangely still, we find, of late, that the induction of premature labor, on the origination and extension of which British accoucheurs have always prided themselves^ is placed without the pale and spoken of as injurious and useless in reference to pelvic deformities. To see our way clearly amongst so many conflicting opinions is by no means an easy task, and perhaps we may best aid in its accomplishment by considering separately the three operations in so far as they bear on this subject, and pointing out briefly what can be said for and against each of them. The Forceps. — In England and in France it is pretty generally admitted that in the slighter degrees of contraction the most reliable means of aiding the patient is by the forceps. It should be remembered that the operation under such circumstances is always much more serious than in ordinary labors simply delayed from uterine inertia, when there is ample room and the head is in the cavity of the pelvis ; for the blades have to be passed up very high, often when the head is more or less movable above the brim, and much more traction is likely to be required. VFor these reasons artificial assistance when pelvic deformity is suspected is ]iot to be lightly or hurriedly resorted to. ) Nor, fortunately, is it always necessary, for if the pains be sufficiently sti^ong and the con- traction not too great to prevent the head engaging at all, after a lapse of time it will become so moulded in the brim as to pass even a con- siderable obstruction. In all cases, therefore, sufficient time must be given for this ; and if no suspicious symptoms exist on the part of the mother — no elevation of temperature, dryness of the vagina, rapid pulse, and the like, and the fostal heart-sounds continue to be normal — labor may be allowed to go on for some hours after the rupture of the mem- branes, so as to give nature a chance of completing the delivery. When this seems hopeless the intervention of art is called for. The forceps is generally considered to be applicable in all degrees of contraction from the standard measurement down to about 3^ inches in the conjugate of the brim. There can be no doubt that in such cases traction with the forceps often enables us to effect delivery when the natural efforts have proved insufficient, and holds out a very fair hope of saving the child. Out of 17 cases in which the high-forceps opera- tion M'as resorted to for pelvic deformity, reported by Stanesco, in 13, living children were born. If the length of tlie labor and the long- continued compression to which the child has been subjected be borne in mind, this result must be considered very favorable. What are the objections which have been brought against the opera- tion ■? These have been principally made by Schroeder and other Ger- , j^ 402 LABOR. man writers. Tlicv arc, cliitlly, the difficulty of passiii<]j tlic iiistrunient, the risk o{ injuring the inalcnial sti'iictnrcs, and the siqipositioii that, as till' hladt's iiuist seize the head l)y the loi'clicad and ciccipnt, their eoin- jtressive action will diminish its lonj^itudinal and incivase its transverse diameter (whieii is opj)osed to the contracted part of the brim), and so enlarge the head just where it ought to be smallest. Tliere is little doubt that these writers much exaggerate the compressive ])ower of the force])s. CVrlainly, with the forms generally used in England any disadvantage likely to accrue from this is more than countei'balaneed by the traction of the head ; and the fact that minor degrees of obstruction can be thus overcome with safety both to the mother and child is abundantly proved by tlie uumberless cases in which the for- ceps has been used. It is very likely that the forceps does not act e(pially well in all ca.ses. C^Vlien the head is loose above the brim; when the contraction is chiefly limited to the antero-posterior diameter, and there is abundance of room at the sides of the pelvis for the occiput to occupy after version ; and when, as is usual in these cases, the anterior fontiuielle is depressed and ithe head lies transversely across the brim, — it is probable that turning may be the safer operation for the mother, and the easier pcrformetD AVhen, on the other hand, the head has engaged in the brim and lias become more or less impacted, it is obvious that version could not be performed without pushing it back, which may be neither easy nor safe. In the generally-contracted j^elvis, in which the head enters in an exaggerated state of flexion and lies obliquely, the posterior fontauelle being much depressed, the forceps is more suitable. Mechanical Advantage of Turning in Certain Cases. — The special reasons why version sometimes succeeds when the forceps fails, or why it may be elected from the first as a matter of choice, have been by no one better pointed out than by Sir James Simpson. Although the operation was performed by many of the older obstetri- FiC4. 146. Fto. 147, Section of Fcetal Cranium, showing its conical I'orm Showing llu' iJri'aicr Rrcadlh of the IJiparictal liiaincter of the Fcetal Cranium. (After Simpson.) ciaus, its revival in modern times and the clear enunciation of its princi- ples can undoubtedly be traced to his writings. He points out that the head of a child is .shaped like a cone its narrowest portion the ba.se of the DEFORMITIES OF THE FELVIS. 403 cranium (Fig. 146, h b), ineasiiriiig, on an average, from -| to f of an inch less than the broadest portion (Fig. 146, a a) — viz. the biparietal diameter. In ordinary head presentations the latter part of the head has to pass first; but if the feet are brought down, the narrow apex of the cranial cone is brought first into ai)])osition with tlie contracted brim, and can be more easily drawn tiirough than the broader base can be pushed tiirough by the uterine contractions. Nor is this the only advan- tage, for after turning the narrower bitemporal diameter (Fig. 147, b b) — which measures, on an average, half an inch less than the biparietal (Fig. 147, a a) — is brought into contact with the contracted conjugate, wliile the broader biparietal lies in the comparatively wide space at the side of the pelvis (Fig. 148). These mechanical considerations are Fig. 148. Showing the Greater Space for the Biparietal Diameter at the side of the pelvis in certain cases of deformity. (After Simpson.) sufficiently obvious, and fully explain the success which has often attended the performance of the operation. It is generally admitted that it may be possible, for the reasons ju.st mentioned, to deliver a living child by turning through a pelvis con- tracted beyond tlie point which would permit of a living child being extracted by the forceps. Many obstetricians believe that it is possible to deliver a living child by turning in a pelvis contracted even to the extent of 2f inches in the conjugate diameter. Barnes maintains that, although an unusually compressible head may be drawn through a pel- vis contracted to 3 inches, the chance of the child being born alive under such circumstances must necessarily be small, and that from 3j inches to the normal size must be taken as the proper limits of the operation. That delivery is often possible b y turnin g after the forceps and the natural powers have failed, and wliennoother resource is left but the d estruction of_i hej;Jjild, mu.st, I think, be admitted by all, for the records ot obstetrics are full of such cases. To take one example only : Dr. Braxton Hicks ^ records 4 cases in which the forceps was tried unsuccessfully, in all of which version was used, 3 of the children being born alive. Here are the lives of three children rescued from destruc- tion within a short period in the practice of one man ; and a fact like this would of itself be ample justification of the attempt to deliver by turning when the child was known to be alive and other means had failed. The possibility that craniotomy may still be required is no ^ Gin/s Hospital Beports, 1870. 4U4 LABOli. artriinK'nt against the ojicration ; for altlif)ui!:h jiorforatioji of tho aftcr- coiuiiii;' head is certainly not so casv as pci'loratioii of" a j)rt'sc'iitinarati(>n of tlip ]>lacenta at its more usual position, termetl by him, in c-outradistinctictii, '* acfidcntul liC'morriiaeral hemorrhage the tendency of uterine contraction is to check the hemor- rhage, and that, provided the j)ains arc sufficiently cnci'getic, Nature may be capable of stopping the flooding Avithout artificial aid. It is but rarely, however, that she can be trusted for the purjiose ; and we \shall presently see that these theoretical views have an important ]>rac- tical bearing on the subject of treatment. Prognosis. — The prognosis to both the mother and cliild is certainly grav e in all cases of ])laccnta ])r{evia. l\ead, in his treatise on jilacenta ])r;evia, estimates the maternal mortality, from the statistics of a large Munibcr of cases, as 1 in 4 J cases, and Churchill as 1 in 3. This is unquestionably too higli an estimate, and based on statistics tlie accm-acy of which cannot be relied on. The mortality will, of coui"se, greatly eliiii, and Lonier, promises iiiueli hettei' results than any otliei* method ol" treatment in eases of phieenta pnevia. Aeeording; to Dr. Lonier's report in the Am. Journ. of Ob.stdric^ i'or December, 1(S84, Dr. Hol'meier operated upon 37 cases, and saved 3G women and 14 children; Dr. Behni, upon 40 cases, all saved, but lost 31 children ; and he himself, with eirjht other assistants, upon 101 cases, savino- 94, with 50 children. This *>ives (S deaths of women and 105 of cliildren in 178 cases, or a mortality of 41 ])er cent, of the former and GO ])er cent, of the latter. Dr. Lomer's directions lU'c as follows: " Turu by the bimanual method as soon as possil)le; pull down the leg, and tampon with it and with the breech of the child the ruptured vessels of the placenta. Do not extract the chikJ then : let it come by itself, or at least only assist its natural expulsion by jjentle and rare tractions. Do away with the plug as much as possible; it is a dangerous thing, for it favors infection and valuable time is lost with its api)lication. Do not wait iu order to perform turning until the cervix and the os are suffi- ciently dilated to allow the hand to pass. Turn as soon as you can pa.ss one or two fingers through the cervix. It is unnecessary to force your finffers throno;h the cervix for this. Introduce the Avhole hand into the vagina, pass one or two fingers through the cervix, rupture the mem- branes, and turn by Braxton Hicks' bimanual method." .... "If the placenta is in your way, try to rupture the membranes at its margin ; but if this is not feasible, do not lose time: perforate the placenta with your finger ; get hold of a leg as soon as possible, and bring it down." —Ed.] ^ «> CHAPTER XIY. HEMORRHAGE FROM SEPARATION OF A NORMALLY-SITUATED PLACENTA. Definition. — This is the form of hemorrhage which is generally de- scribed in obstetric works as " acciftcntal,'' m contradistinction to the "unavoidable" hemorrhage of placenta previa. In discussing the lat- ter we have seen that the term " accidental " is one that is apt to mis- lead, and that the cause of the hemorrhage in placenta pripvia is, in some cases at least, closely allied to that of the variety of hemorrhage we are now considering. When, from any cause, separation of a normally-situated ])lacenta occurs before delivery, more or less blood is necessarily effused Irom the ruptured utcro-])lacental vessels, and tlie subsequent course of the case may be twofold :( 1. The blood, or at least some part of it, may find its [' Lancet, July, 1800 ; Obdclrical Transactions, vol. v. p. 222.] PLATE IV. -I'laccniul site Bi.MMi-ciiit__yo Placi'iitiil sill •(- ^' J'listrrioi' wall of iiturns Ketro-plafeiital bluod-clot %4 — Pliicciita attaclu'tl to wall prodnciiif; ■''^ its inversion Anterior wall of uterus Membranes Placenta VERTICAL MESIAL SECTlOX OK ITEIUS WITH PLArEXTA I'AKTIALLY ATTACIIED- froiu a case of abdominal section lor heniorrlia.ne during labor. After Barbour. {To face page 110.) HEMORRHAGE BEFORE DELIVERY. 419 way between the membranes and the decidua, and ( -\soape from the 9s utej'i.j This constitutes the typical "accidental" hemorrhage of authors. 2.(Tne blood may jjul to find a passage externally, and may collef-f. in- ternally (see Plate IV.), giving rise to very serious symptoms, and even proving fatal, before the true nature of the case is recognized.^ Cases of this kind are by no means so rare as the small amount of attention paid to them l)y authors might lead us to suppose, and from the obscur- ity of the symptoms and difficulty of diagnosis they merit special study. Dr. GoodelP has collected together no less than 106 instances in which this complication occurred. Causes and Pathology. — The causes of placental separation may be very various. In a large number of cases it has followed an acci- dent or exertion (such as slipping down stairs, stretching, lifting heavy freights, and the like) which has probably had the effect of lacerating some of the placental attachments./ At other times it has occurred yjth- out such appreciable cau sA and then it has been referred to some chang^ e in the uterus, such as a more than usually strong contraction producing separation, or some accidental determination of blood causing a slight extravasation between the placenta and the uterine wall, the irritation of which leads to contraction and further detachment. Causes such as these, which are of frequent occurrence, will not produce detachment except in women otherwise predisposed to it. It generally is met with in women who have borne many children, more especially in those of weakly constitution and impaired health, and rarely in primiparse. Cer- tain constitutional states probably predispose to it, such as albuminuria or exaggeraiEe3!''aiiteTHTa, and, still more so, degenerations and diseases of the placenta itself! This form of hemorrhage rarely occurs to an alarming extent until the latter months of pregnancy, often not until labor has commenced. The great size of the placental vessels in advanced pregnancy affords a reasonable explanation of this fact. Symptoms and Diagnosis.-^-If, after separation of a portion of the placenta, the blood finds its way between the membranes and the de- cidua, its escape ^3j)ily terminated, and its alarming effect on the patient, who is often placed in the utmost danger in a few mo- ments, tax the presence of mind and the resources of the practitioner 422 LABOR. to tlie utmost, and render it an iinixTative duty on every one who practises niidwilery to make liimsell' thoroughly acquainted with its causes and preventive and curative treatment. There is no emergency in obstetrics wliich leaves less time for reflection and consultation, and tiie life of the patient will often de])end on the prompt and immediate action of the medical attendant. Frequency of Post-partum Hemorrhage. — Post-partura hemor- rhage is one of the most frequent complications of delivery. I do not know of any statistics which enable us to judge with accuracy of its fre- quency, but I believe it to be an unquestionable fact that, especially in the upjKM- ranks of society, it is very c omm on indeed. This is jn-obably due to the ellects of civilization and to the mode of life of ])atients of that class, mIiosc whole surroundings tend to produce a lax habit of body "svhich favors uterine inertia, tlie princij^al cause of post-partum hemorrhage. In the report of the Registrar-General for the five years from 1872 to 1876, 3524 deaths are attributed to flooding. 'Tlie majority of these must have been caused by post-partum hemorrhage, although some may have been from other forms. F(jrtunately, it is, to a great extent, a i)reventable accident. I believe this fact cannot be too strongly impressed on the practitioner. l(^ If the third stage of labor be properly conducted, if every case be treated, as every case ought to be, as if hemorrhage were impending, it would be much more infrequent than it is. )/ It is a curious fact that post-partum hemorrhage is much more common in the practice of f-ome medical men than in that of others, the reason being that those who meet with it often are careless in the management of their patients immediately after the birth of the child. That is just the time when the assistance of a properly qualified practitioner is of value, much more so than before the second stage of labor is concluded ; hence \\hen I hear that a medical man is constantly meeting with severe post-jiartum hem- orrhage I hold myself justified, ipso fado, in inferring that he does not know^ or does not practise the proper mode of managing the third stage of labor. Causes. — The placenta, as we have seen, is separated by the last pains, and the blood, which in greater or less quantity accompanies the foetus, probably comes from the utero-placental vessels which are then lacerated. Almost immediately afterward the uterus contracts firndy, and in a typical labor assumes the hai'd cricket-ball form which is so comforting to the accouclieur to feel. (See Plate V.) Tlie result is the compression of all tlie vascular trunks which ramify in its walls, both arteries and veins, and thus the flow of blood through them is pre- vented. By referring to Avhat has been said as to the anatomy of the mascular fibres of the gravid uterus, especially at the placental site (p. 62), it W'ill be seen how admirably they are adapted for this pur- pose. The arrangement of the vessels themselves favors the luemo- static action of uterine contraction. The large venous sinuses are placed in layers one aliove the other in the thickness of the uterine walls, and they anastomose freely. AVhen the superimposed layers comnuniicate with those immediately below them, the junction is by a falciform or semilunar opening in the floor of the vessel nearest the extei'ual surface JIEMURIUIAGE AFTER DELIVERY. 423 of the uterus. Within the iuaro;ins of this aperture there are muscular fil)res, the contraction of wliich prol)ably tends to i)reveut retrogression of blood from one layer of vessels into the other. The venous sinuses themselves are of a flattened form, and they are intimately attached to the muscular tissues. It is obvious, theu, that these anatomical arrange- ments are eminently adapted to facilitate the closure of the vessels. They are, however, large, and are destitute of valves j( £^d if contrac- tionlx' abse nt or if it be partial and h-regula r, it is equally easy to unckislaiul why blood should pour forth ui the appalling amount which is sometimes observed.) If uterine action be firm, regular, and continuous, the vessels must be sealed up and hemorrhage effectually prevented. This fact has been doubted by many authorities. Gooch was the first to describe what he called "a peculiar form of hemorrhage" accompanying a contracted womb. Similar observations have been made by other writers, such as Yelpeau, Rigby, and Gendrin. Simpson says on this point that strong uterine contractions "are not probably so essential a part in the mechanism of the prevention of hemorrhage from the open orifices of the uterine veins as we might a priori suppose." ^ With regard to Gooch's cases, it has been pointed out that his own descrip- tion proves that, however firmly the uterus may have contracted imme- diately after the expulsion of the child, it must have subsequently relaxed, for he passed his hand into it to remove retained clots — a raanceuvre which he could not have practised had tonic contraction been present. In some of these cases the hemorrhage has been found to come from a laceration of the cervix . Of course blood may readily escape from mechanical injury of this~kind, although the uterus itself be in a satisfactory state of contraction ; and the possibility of this occurrence should always be borne in mind. Instances of the success- ful treatment of this variety of post-partum hemorrhage by sutures applied to the lacerated cervix have been related by Fallen and others. /Although, then, we may admit that post-partum hemorrhage is*' incompatible with persistent contraction of the uterus, it by no means follows that the converse is true./ On the contrary, it is not uncommon; to meet with cases in which the uterus is large, and apparently quite flaccid, and in which there is no loss of blood// Alternate relaxation and contraction of the uterus after delivery are also of constant occur- rence, and yet hemorrhage during the relaxation does not take place. The explanation no doubt is that immediately after the birth of the child there was sufficient contraction to prevent hemorrhage, and that during its continuance coagula formed in the mouths of the uterine sinuses by which they were sufficiently occluded to prevent any loss when subsequent relaxation occurred, i In all probability, both uterine contraction and thrombosis are in operation in ordinary cases; and we sliall presently see that all the means employed in the treatment of post-partum hemorrhage act by pj^-oducing one or other of them. ' Uter m£_iiie rtia after labor, then, may be regarded as the one great 1 Selected Obstd. Works, p. 234. 424 LABOn. })riinarv oauso of post-partnm lu-niorrlinfrc X but there are various sL'coiulary causes wliidi tend to produce it, oiie of tlie most freijueiit of whic-li is exliaustion followiiii!; a protracted labor. \ The uterus j^cts uorn out by its cllbrts, ami when the fcetus is expelk'd it remains in a relaxed state and hemorrhage results.' Over-distension of the uterus acts in the same way. Henee hemorrhage is very frequently met with when there has been an excessive amount of liquor amnii or in nudti- plc pregnancies. One of the worst cases I ever met with was after the l)irth of tri])lets, the uterus having been of an enormous size. Kapid e motvinor of the uteru s, during wliicli there has Jiot been sufficient tune for complete separation of the placenta, often tends to the same result. This is the reason why hemorrhage so frequently follows forceps delivery, especially if the operation have been unduly hurried ; and it is ojie of the chief dangers in what are termed "precipitate labors." The t^'-eu - eral con dition of the patien t may also strongly predispose to it. Thus, i^^nore^bften met with m women who have borne families, especially if they be weakly in constitution, comparatively seldom in primi})ane, and for the same reason that after-paius are most conuuon in the former — namely, that the uterus, Aveakened by frequent childbearing, contracts inefficiently. The experience of practitioners in the tropics shows that European women, debilitated by the relaxing effects of warm climates, are peculiarly prone to it, and it forms one of the chief dangers of child- birth amongst the English ladies in India. f Another important cause of post-partuni hemorrhage is partial and ijj'Pprnlar nnnfrap ^.jon of the utcr us. \ Part of the muscular tissue is firmly contracted, while another pari is relaxed, and the latter very often the placental site. This has been especially dwelt on by Simp- son. He says : " The morbid condition which is most frequently and earliest seen in connection with post-partum hemorrhage is a state of irregularity, and w-ant of equability in the contractile action of differ- ent parts of the uterus — and, it may be, in different planes of the nnis- cular fibres — as marked by one or more points in the organ feeling hard and contracted at the same time that other })ortions of the parietes are soft and relaxed." \Oue peculiar variety, which has been much dwelt on by writers, and is a prominent bugbear to obstetricians, is the so-called "hour-glass con- tracfion."/\ This, in reality, seems to depend on spasmodic contraction of the i ntert ill '^>s ulori by means of w hich the placenta becomes enc\'?itT?d in the lip])er pol-tion of the ii Ferns, which is relaxed. On introducing tlie hand it first passes through the lax cervical canal, luitil it comes to the closed internal os, with the umbilical cord passing through it, Avhich has generally been supposed to be a circular contraction of a portion of the body of the uterus. Encystment of the jdaccnta, however, although more rarely, unques- tionably takes ])lace in a ])ortion only of the body of the uterus (Fig. 149). Then, a])parently, the jrlacental site remains more or less ]x\va- lyzed, with the placenta still attached, while the remainder of the body of the uterus contracts firmly, and thus encystment is produced. These irregular contractions of the uterus are by no means so common as our older authors supi)osed. AVheu they do occur, I believe them HEMORRHAGE AFTER DELIVERY. 425 almost invariably to tlcpend on defective nuiuagenient of the third stage of labor. " Tlie in(jst frequent cause," says Kigby/ " is from over-anxiety to remove the placenta ; the cord is frequently pulled at, and at length the os uteri is excited to contract." AVhile this is being done no attempts are probably being made to excite the fundus to Fig. 149. Regular Contraction of the Uterus, witli Encystment of the Placenta. proper action, and therefore the hour-glass contraction is established. Oohnstoue^ has pointed out that in a large proportion of cases ergot nas been given before the expulsion of the placenta. Duncan say S of this condition :/ " Hour-glass contraction cannot exist unless the parts above the contraction are in a state of inertia ; were the higher parts of the uterus even in moderate action, the hour-glass contraction Avould soon be overcome." ^ If placental expression were always employed, if it were the rule to eifect the expulsion of the placenta by a vis it tergo instead of extracting by a vis a fronte, I feel confident that these irregular and spasmodic contractions — of the influence of which in pro- ducing hemorrhage there can be no question — would rarely if ever be met with. It is to be observed that even in these cases it is not because the uterus is in a state of partial contraction, but because it is in a state of ])artial relaxation, that hemorrhage ensues. Placental Adhesions.— ^Adhesions of the placenta to the uter ine parietes may cause hemorrhage, (■s])ccially li tliey be partial ana the remainder of the placenta be detached) The frequency of these has been over-estimated. Many cases believed to be examples of adherent placentre are, in reality, only cases of placentre retained from uterine inertia. The experience of all who see much midwifery will probably corroborate the observation of Braun, that " abnormal adhesions and hour- glass contraction are more frequently encountered in tiie experience of the young practitioner, and they diminish in frequency in direct ratio to increasing years."* /The cause of adhesions is often obscure, but it most probably results from a morbid state of the deeidua, which is produced ' Rigby's Midwiferii, p. 225. ^ Researches in Obstetrics, p. 3S9. ^ Glasgow Med. Journ., 18S7, vol. xxvii. p. 188. * Braun's Lectures, 18G9. 42(j LAliOPx. bv aiitececk'nt disease of the uterine mucous meuibranc; then tiie adiu'sit)!! is apt to recur in subsequent prejiuanciesA The deciclua is altered and tliickened, and patches ot" calcareous and fibrous degenera- tion may be often found on the attached surface of the placenta. Most frequently the placenta is oidy partially adherent, patches of it remain firndy attached to the uterus, while the rest is separated; lience the uterine walls remain relaxed and hemorrhage fre(piently follows. The tliagnosis and manaticment of these very troublesome cases will be found described under the head of treatment (p. 429j. Finally, I think it must be admitted that there are some women who really merit the appellation of ^^f iooder s" which has been aj)j)lied to them, and who, do Nvhat we may, have the most extraordinary tendenc y to hemorrhage after delivery. 1 do not think that these cases, liowever, are by any means so common as some have sui)posed. 1 have attended several j)atients who have nearly lost their lives from post-partum hem- orrhage in ibrmer labors, some who have suffered from it in every pre- ceding confinement, and I have only met with two cases in which the assiduous use of preventive treatment failed to avert it. In these (one of which I have elsewhere published in detaiP), in s])ite of all my efforts, I could not succeed in keeping up uterine contraction, and the patients would certainly have lost their lives were it not for the means Avhich modern improvements have fortunately placed at our disposal for producing thrombosis in the mouths of the bleeding vessels. The nature of these rare cases recjuires further investigation : possibly they may, to some extent, be the subjects of the so-called hemorrhagic diathesis. / The loss of blood may commence immediately after the birth of trie child before the expulsion of the placenta, or not until some time afterward, when the contracted uterus has again relaxedJ It may ct»m- mence gradually or suddenly : in the latter case it may begin with a gush, and ni tlie worst form the bedclothes, the bed, and even the floor, are deluged with the blood which, it is no exaggeration to say, is jiour- ing from the patient. If now the hand be placed on the abdomen, we shall miss the hard round ball of the contracted uterus, which will be found soft and flabby, or we may even be unable to make out its contour at all. If the hemorrhage be slight or if we succeed in controlling it at once, no serious consequences follow; but if it be excessive or if we fail to check it, the gravest results ensue. There are few sights more appalling to witness than one of the worst cases of post-partum hemorrhage. The pulse becomes rapidly affected, and may be reduced to a mere thread or it may become entirely imper- ceptible. Syncope often comes on — not in itself always an unfavorable occurrence, as it tends to promote thrombosis in the venous sinuses; or, short of actual syncoj)e, there may be a feeling of intense debility and faintncss. Extreme restlessness soon supervenes, the j)atient throws her- self about the bed, tossing her arms wildly above her head; respiration becomes gasping and sighing, the "besoin de respirer" is acutely felt, and the patient cries out for more air; the skin becomes deadly cold and covered with profuse persj^iratiou : if the hemorrhage continue unchecked, ' Obst. Journ., 1873-74, vol. i. p. 89. HEMORRHAGE AFTER DELIVERY. 427 we next may have complete loss of vision, jaftitation, convulsions, and death. Formidable as such symptoms are, it is satisfactory to know that recovery often takes place, even when the powers of life seem reduced to the lowest ebb. If we can check the hemorrhage while there is still some power of reaction left, however slight, we may not unreasonably hope for eventual recovery. The constitution, however, may have received a severe shock, and it may be months, or even years, before the patient recovers from the effects of only a few minutes' hemor- rhage. A death-like pallor frequently follows these excessive losses, and the patient often remains blanched and exsanguine for a long time. Treatment. — The pr e yj ^ntive treatmen t of post-partuni hemor- rhage should be carefully practised in every case of labor, however normal. If the practitioner make a habit of never removing h is hand from the uterus after tlie birth of the child until the placenta is cxpellecA and of keeping up continuous uterine contraction for at least half aj hour a fter delivery is completed, not necessarily by I'ncfiou on ttie tu'ndus, but by simply grasping the contracted womb with the palm of the hand and preventing its undue relaxation, cases of post-partum flooding will seldom be met with. As a rule, we should, I think, not apply the binder until at least that time has elapsed. The binder is an effective means of keeping up, but not of producing, contraction, and it should never be trusted to for the latter purpose. If it be ])ut on too soon, the uterus may relax under it, and become filled with clots with- out the practitioner knowing anything about it ; whereas this cannot possibly take place as long as the uterine globe is held in the hollow of the hand. I have seen more than one serious case of concealed hemor- rhage result from the too common habit of putting on the binder imme- diately after the removal of the placenta. ( I believe also, as I have formerly said, that it is thoroughly good practice to administer a full dose of the Ijaijid extract of ergot in all cases after the placenta has been expelled, to ensure persistent contraction and to lessen the chance of blood-clots being retained in utero.\ These are the precautions which fdiould be used in all cases alike ; but wlien_we have reason to fear the occurrence of hemorrhage from the history of previous lal^ors "or other cause, special care should be taken. ^The ergot should be given, and preferably in the form of the subcutaneous injection of crgotine, before the birth of the child, when the presentation is so far advaiiced that we estimate that labor will be concluded in from ten to twenty minutes, as we can hardlv expect the drug to produce any effect in less time. .^ Particular attention, moreover, should then be paid to the state of the uterus. Every means should be taken to ensure regular and strong contraction, and it is advisable to rupture the meml)ranes early, as soon as the os is dilated or dilata- ble, to ensure stronger uterine action. If any tendency to relaxation occur after delivery, a piece of ice should be passed into the vagina or into the uterus. Should coagula collect in the uterus, they mav be readily expelled by firm pressure on the fundus, and the finger should be passed occasionally up to the cervix, and any Avhich are felt there should be gently picked away. 428 LABOR. \\'c slidiild be sjK'cially on our <;ii;inl in all cases in which the pulse docs not iall alter deliveiT. It' it heat at 100 or more .some ten minutes or a quarter oi" an hour after the birth ol" the child, hemorrliaping the lower part of the abdomen with a wet towel is less objec- tionable.) ' Ice can generally be obtained, and a piece should be intro- duced into the uterus. This is a very powerful haemostatic, and often excites strong action Mhen other means fail. I constantly employ it, and have never seen any bad results follow. A large piece of ice i.nay ' Obstetric Operations, p. 440. *See an interesting paper bv Dr. Thrush on " Retention of the Placenta in Labor at Term," Amcr. Journ. of Obstct'., 1877, vol. x. pp. 389, 506. HEMORRHAGE AFTER DELIVERY. 431 also be held over the IiiikIiis, and removed and reajiplied from time to time, llced water may be injected into the rectum. A very powerful remedy is washing out the uterine cavity with a stream of cold Avater by means of the vaginal pijjc of a Higginsf)n's syringe carried uj) to the fundus. Another means of applying cold, said to be very effectual, is the application of the ether spray, such as is used for producing local ana3sthesia, over the lower part of the abdomen.^ All these remedies, however, depend for their good results on the fact of the patient being in a condition to respond to stinuilus, and their prolonged use, if they ftiil to excite contraction rai)idly, Avill certainly prove injurious, Rigby used to look upon the aj)plication of the child to the breast as one of the most certain inciters of uterine action. It may be of service after the hemorrhage has been checked in keeping up tonic contraction, and should therefore not be omitted ; but we certainly cannot waste time in inducing the child to suck in the face of the actual emergency. Of late, intra-uterine injections of hot water at a temperature of from 100° to 120° have been highly recommended as a powerful means of arresting post-partum hemorrhage, often proving effectual when all other treatment has failed. The number of published cases in which it has proved of great value is now considerable. The present master of the Rotunda, Dr. Lombe Atthill, has recorded 16 cases ^ in which it checked hemorrhage at once, in many of which ergot, ice, and other means had failed. He speaks of it as especially useful in those trouble- some cases in which the uterus alternately relaxes and hardens, and resists all our efforts to produce permanent contraction. Its superiority to cold water has been well shown by Milne Murray^ by means of experiments on pregnant and non-pregnant rabbits, which proved that while cold applications produce a temporary contraction, when applied for any length of time they rapidly exhaust the excitability of the ute- rine muscle, while the reverse effect is produced when hot water is used. ^My own experience of this treatment is very favorable. I I have now used it in several cases, in some of which the tendency to hemorrhage was very great, and in every instance it has at once produced strong uterine action and instantly checked the flow. It is, moreover, much more agreeable to the patient than cold applications. I think it cannot be doubted that we have in these warm irrigations a valuable addition to our methods of treating uterine hemorrhage. [Hot-water injections, to be effective, should have a temperature of about 115°. Water simply warm — that is, only a little above blood-heat — favors the hemorrhagic loss. — Ed.] The late Dr. Earlc pointed out* that a distended bladder often pre- vents contraction, and to avoid the possibility of this the catheter should be passed. Plugging of the vagina has often been used. It is only ncecssarv to mention it for the purpose of insisting on its ab solute inapp ljcjij )i I i ix in all cases of post-partum hemorrhage ; the only effect it could have would be to prevent the escape of blood externally, which might then collect to any extent in the cavity of the uterus. ' Griffiths, Practitioner, 1877, vol. xviii. p. 176. ' Lancet, Febrnarv 9, 1878. 3 Edin. Med. Journ., 1886-87, pp. 131, 215. * Earle's Flooding after Delivery, p. 163. 432 LABOR. Copipressign of tlie abdominal aorta is liiglily tliought of by many continental authorities, but it is little known or practised in Eng'land. It lias been objected to by some on the theoretical ground that the iiem- orrhage is chiefly venous, and not arterial, and that it Avould only favor the reflux of venous blood into the vena cava. Cazeaux points out that on account of the close anatomical relations between the aorta and the vena cava it is hardly possible to compress one vessel without the other. The backward flo\v of blood, therefore, through the vena cava may also be thus arrested. (There is strong evidence in favor of the occasional utility of compression. Its chief recommendation is that it can Ije prac- tised immediately, and by an assistant who can be shown how to iipply the pressure. ' It is most likely to prove useful in sudden and severe hemorrhage, and if it only control the loss for a few moments it gives us time to apply other methods of treatment. As a temjiorary expedi- ent, therefore, it should be borne in mind and adopted when necessary. It has the great advantage of supplementing, without superseding, other and more radical plans of treatment. The pressure is very easily applied, on account of the lax state of the abdominal walls. The artery can readily be felt pulsating above the fundus uteri, and can be com- pressed against the vertebras by three or four fingers applied lengthways. Baudelocque, who was a strong advocate of this procedure, stated that he had on several occasions controlled an otherwise intractable hemor- rhage in this way, and that he on one occasion kept up compression for f our consecutive hours., Cazeaux believes that compression of the aorta may have a further advantageous effect in retaining the mass of the blood in the upper part of the body, and thus lessening the tendency to syncope and collapse. If an aortic tourniquet, such as is used for com- pressing the vessel in cases of aneurism, could be obtained, it might be used with advantage in such cases. If a battery is at hand the fara dic current may be used, and is, it is said, a very powerful agent in inducing uterine contraction, one pole being introduced into the uterus, the other applied over it through the abdominal ]:)arietes. When the hemorrhage has been excessive and there is jirofound exhaustion, firm bandaging of the extremities, by preference with Esmarch's elastic bandages if they can be obtained, may be advanta- geousl\- adopted, with the view of retaining the blood as much as pos- sible in the trunk, and thus lessening the tendency to syncope. xVs a temporary expedient in the worst class of cases it may occasionally prove of service. [Lives of patients in extremis have been saved by the expedient of raising the body of the woman and lowering her head, so as to turn the current of blood toward the brain. This may have to be repeated sev- eral times in the treatment of a case where attacks of syncope indicate it. A bladder containing ice may be held under the hand of the ope- rator over the abdomen and above the fundus uteri, and compression made upon the uterus and aorta at the same time. In one case I was forced, by the long-continued inertia of the uterus and the tendency to a return of hemorrhage, to keep up this form of compression for six and a half hours. The hand of the operator should be protected by a com- HEMORRHAGE AFTER DELIVERY. 433 press of flannel, or he may have an attack of local neuralgia, or possibly rheumatism, in his arm. — Ed.] Supposing these means fail, and. the uterus obstinately refuses to con- tract in spite of all our efforts — and, do what we may, cases of this kind will occur — the only other agent at our command is the application of a pcMfirfuLsty^tic to the bleeding surface to produce thrombosis in the vessels. " The latter," says Dr. Ferguson,* alluding to this means of arresting hemorrhage, " appears to be the sole means of safety in those cases of intense flooding in which the uterus flaps about the hand like a wet towel. Incapable of contraction for hours, yet ceasing to ooze out a drop of blood, there is nothing apparently between life and death but a few soft coagula plugging up the sinuses." These form but a frail barrier indeed, but the experience of all who have used the in jection of f perch loride of iron in such cases proves that they are thoroughly effec- tual, and their introduction into practice is one of the greatest improve- ments in modern midwifery. Although this method of treating these obstinate cases is not new, since it was practised long ago in Germany, its adoption in England is unquestionably due to the energetic recom- mendation of Dr. Barnes. Although the dangers of the practice have been strongly insisted on, and with a degree of acrimony that is to be regretted, I know of only one published case in which its use has been followed by any evil effects. Its extraordinary power, however, of instantly checking the most formidable hemorrhage has been demon- strated by the unanimous testimony of all who have tried it. As it is not proposed by any one that this means of treatment should be employed until all ordinary methods of evoking contraction have failed, and as in cases of this kind the lives of the patients are of necessity imperilled, we should be fully justified in adopting it, even if its possibly injurious effects had been much more certainly proved. It is surely at any time justifiable to avoid a great and pressing peril by running a possible chance of a less one. Whenever, therefore, we have tried the plans above indicated in vain, no time should be lost in resorting to this expe- dient. No practitioner should attend a case of midwifery without hav- ing the necessary styptic with him. / The best and most easily obtain- able form of using the remedy is the " liquor ferri perchloridi fortior " of the London Pharmacopoeia, which should be diluted for use with six times its bulk of water. \ This is certainly better thana weaker solution. The vaginal pipe of a Higginson's syringe, through which the solution has once or twice been pumped to exclude the air, is guided by the hand to the fundus uteri and the fluid injected gently over the uterine surface. The loose and flabby mucous membrane is instantaneously felt to pucker up, all the blood with which the fluid comes in contact is coagulated, and the hemorrhage is immediately arrested. \ I think it is of import- ance to make sure that the uterus and vagina are emptied of clots before injection. In the only cases in which I have seen any bad symptoms follow this precaution had been neglected.) The iron hardened all the coagula, which had remained in utero, and septicaemia supervened ; Avhich, however, disappeared after the clots had been broken up and washed away by intra-uterine antiseptic injections. After we have ' Preface to Gooch On Diseases of Women, p. xlii., New Sydenham Society, 1859. 28 434 LABOR. , if.sortocl to this treatineut all lurtlicr prcs-siirc (»n tlie uterus slioukl l)e \ stopped. We must renieuiber that we have now abandoned eontiaetion as a haemostatic, and are trusting to throndmsis, and that ])ressure inijrht detach and loosen the coagula Avhich are preventing the escape <»f blood. Other local astringents may l)o eventually found to he of use. Tinc- ture of matico jjossibly might l)e serviceable, although I am not aware that it has been tried. Dupierris has advocated tincture of icxlin e, and has recorded 24 cases in which he employed it, in all without acci- dcnt and with a successful issue. Penrose strongly recommends coni- mon vinegar, which has the advantage of being alwavs readilv obtain- able.p] But nothing seems likely to act so innnediately or so effectu- ally as the perchloride of iron. Hemorrhage from Laceration of Maternal Structures. — A word may here be said as to the occasional dependence of hemori'hage after delivery on laceration of the cervix or other injury to the maternal soft parts. Duncan has narrated a case in which the bleeding came from a ruptured perineum. If hemorrhage continue after the uterus is per- manently contracted, a careful examination should be made to ascertain if any such injury exist.Y Most generally the source of bleeding is the cervix, and the flow can be readily arrested by swabbing the injured textures with a sponge saturated in a solution of the perchloride.' The secondary treatment of post-partum hemorrhage is of import- ance. When reaction commences a train of distressing symptoms often show themselves, such as intense and throbbing headache, great intoler- ance of light and sound, and general nervous prostration ; and when these have passed away we have to deal with the more chronic effects of profuse loss of blood. Nothing is so valuable in relieving these symptoms as opium . It is the best restorative that can be employed, but it must m 'administered in larger doses than usual. Thirty to forty drops of Battley's solution should be given by the mouth or in an enema. At the same time the patient should be kept perfectly still and (|uiet in a darkened room, and the visits of anxious friends strictly forbidden. Strong beef-essence or gravy soup, milk, or eggs beaten uj) with milk, and similar easily absorbed articles of diet, should be given frequently and in small quantities at a time. Stimulants will be required according to the state of the patient, such as warm brandy-and-water, port wine, etc. Rggtlo l^ed should be insisted on, and continued nuich beyond the usual time. Eventually, the remedies which act by promot- ing the formation of blood, such as the various preparations of irgu, will be found useful, and may be required for a length of time. Under the head of Transfusion I have separately ti'eated the applica- tion of that last resource in those desperate cases in which the loss of blood has been so excessive as to leave no other hope. Secondary Post-partum Hemorrhag-e. — In the majority of cases, if a few hours have ela])sed after delivery without hemorrhage we may consider the patient safe from the accident. It is by no means very ['This remedy was used as a uterine injection witli signal effect in a case of violent ixjst-parium heniorrhatre by a Frencli surgeon in country practice in ilie days of Astnic, who wrote of it in 170-3 {Slakuliv^ d>:.-< Fcmmo^, vol. iv. p. 227 i. — Ed.] HEMORRHAGE AFTER DELIVERY. 435 rare, however, to meet witli even profuse losses of blood coming on in the course of convalescence at a time varying from a few hours or days up to several weeks after delivery. These cases are described as exam- ples of ^^ secondary hoiiorrliafjej" and they have not received at all an adequate amount of attention from obstetric writers, inasmuch as they often give rise to very serious, and even fatal, results, and are always somewhat obscure in their etiology and difficult to treat. We owe almost all our knowledge of this condition to an excellent paper by Dr. McClintock of Dublin, who has collected characteristic examples from the writings of various authors, and accurately described the causes Avhich are most apt to produce it. (jVe must, in the first place, distinguish between true secondary hemor- rhage and profuse lochial discharge continued for a longer time than usual. ) The latter is not a very uncommon occurrence, and is generally met with in cases in which involution of the uterus has been checked, as by too early exertion, general debility, and the like. The amount of the lochial discharge varies in different women. In some patients it habitually continues during the whole puerperal month, and even longer, but not to an extent which justifies us in including it under the head of hemorrhage. ( In such cases prolonged rest, avoidance of the erect posture, occasional small doses of ergot, and, it may be, after the lapse of some weeks astringent injections of oak-bark or aTum, will be all that is necessary in the way of treatment./ True secondary hemorrhage is often sudden in its appearance and serious in its effects. McClintock mentions 6 fatal cases, and Mr. Bassett of Birmingham^ has recorded 13 examples which came under his own observation, 2 of which ended fatally. The causes may be either constitutional or some local condition of the uterus itself. Constitutional Causes. — Among the former are such as produce a •disturbance of the vascular system of the body generally or of the uterine vessels in particular. The state of the uterine sinuses, and the slight barrier Avhich the thrombi formed in them offer to the escape of blood, readily explain the fact of any sudden vascular con- gestion producing hemorrhage. Thus, mental emotions, the sudden assmiiption of the erect_,^osture, any undue exertion, the incautious use of stimulants, a loaded condition of the bowels, or sexual inter- course shortly after delivery, may act in this way.^ McClintock records the case of a lady in whom very profuse hemorrhage occurred on the twelfth day after labor, when sitting up for the first time. Feeling faint after suckling, the nurse gave her some brandy, whereupon a gush of blood ensued, " deluging all the bed-clothes and penetrating through the mattress so as to form a pool on the floor." Here the erect position, the exquisite pain caused by nursing, and the stimulating drink, all concurred to excite the hemorrhage. In another instance the flooding Avas traced to excitement produced by the sudden return of an old lover on the eighth day after labor. Moreau especially dwells on the influ- ence of local congestion produced by a loaded condition of the rectum. Constitutional affections, producing general debility and an impover- 1 Brit. Med. Journ., 1872, vol. ii. pp. 216, 491. 436 LABOR. islit'd state of the hlood, probably also may have the same effect. Blot S})ecial!y mentions albiiiiiinmia as one of these, and Saboia states that in JJra/il secondary hemorrhage is a common symptom of miasmatic j)oisonin<^, and can only be cured by change of air and the free use of quinine.' Local Causes. — I^ocal conditions seem, however, to be the more fre- quent factors in the ])r(»duction of sec(jndary hemorrliage. These mav be generally classed under the following heads: 1. Irregular and inefficient contraction of the uterus. 2. Clots in the uterine cavity. 3. Portions of retained placenta or membranes. 4. Retroflexiou of the uterus. 5. Laceration or inflammatory state of the cervix. 6. Thrombosis or luematocele of the cervix or vulva. 7. Inversion of the uterus. 8. Fibroid tumors or polypus of the uteras. The first four of these need only now be considered, the others being described elsewhere. Relaxation of the, uterus and distension of its cavity by coagula may give rise to hemorrhage, although not so readily as immediately after delivery, for coagula of consideral^le size are often retained in utero for many days after labor. The uterus will be found larger than it ought to be, and tender on pressure. Usually the coagula are expelled with severe after-pains; but this may not take place, and hemorrhage may ensue several days after delivery. Or there may be only a relaxed state of the uterus without retained coagula. Bassett relates 4 cases traced to these causes, and several illustrations will be found in McC'lintock's paper. Portions of retained placenta or membranes are more fre(|uent causes. The retention may be due to carelessness on the part of the practitioner, especially if he have removed the placenta by traction and failed to satisfy himself of its integrity. It may, however, often be due to circumstances entirely beyond his control, such as adherent pla- centa, which it is impossible to n.move \\ithout leaving portions in iitcro, or more rarely placenta succenturia. ( In the latter case there is a small supplementary portion of placental tissue developed entirely separate from the general mass, and it may remain in utero without the j)rac- titioner having the least suspicion of its existence,; Portions of the membranes are veiy apt to be left in utero. It is to prevent this that they should be twisted into a rope and extracted very gently after expression of the ]>lacenta. Hemorrhage from these causes generally does not occur until at least a Aveek after deliver}', and it may not do so until a nuich longer time has elapsed. In 4 cases recorded by Mr. Bassett it commenced on the tenth, twelfth, fourteenth, and thirty-second day. It may come on suddenly, and continue, or it may stop, and recur frequently at short intervals. In my experience retention of portions of the placenta is very common after abortion, when adhesions are more generally met with than at term. In addition to the hemorrhage there is often a fetid discharge, due to decomposition of the retained portion, and possibly more or less marked septicfcmic symptoms, which may aid ' Saboia, Traite des Accouchemeiits, p. 819. HEMORRHAGE AFTER DELIVERY. 437 iu the diagnosis. The placenta or membranes may simply be lying loose as foreign bodies in the uterine cavity, or they may be organi- cally attached to the uterine walls, when their removal will not be so easily effected. Barnes has especially pointed out the influence of retroflexion of the uterus in producing secondary hemorrhage/ which seems to act by im- peding the circulation at the point of flexion and thus arresting the pro- cess of invt)lution. Treatment. — In every case in which secondary hemorrhage occurs to any extent, careful investigation into the possible causes of the attack and an accurate vaginal examinatiijn are imperatively required. If it be due to general and constitutional causes only, we must insist on the most absolute rest on a hard bed in a cool room, and on the absence of all causes of excitement. The liquid extract of ergot will be very gen- erally useful in sj doses repeated every six hours. McCliutock strongly recommends the tinctiire of Indiau hemp, which may be advantageously combined with the ergot iu doses of 10 or 15 minims, suspended in mucilage. Astringent vaginal pessaries of matico or perchloride of iron may be used. Special attention should be paid to the state of the bowels, and if the rectum be loaded it should be emptied by ene- niata. In more chronic cases a mixture of ergot, sulphate of iron, and small doses of sulphate of magnesia will prove very serviceable. This is more likely to be effectual when the bleeding is of an atonic and passive character. McCliutock speaks strongly in favor of the application of a blister over the sacrum. When the hemorrhage is ex- cessive more effectual local treatment will be required. Cazeaux advises plugging of the vagina. Although this cannot be considered so dangerous as immediately after delivery, inasmuch as the uterus is not so likely to dilate above the plug, still it is certainly not entirely without risk of favoring concealed internal hemorrhage. If it be used at all, a firm abdominal pad should be applied, so as to compress the uterus, and the abdomen should be examined from time to time to ensure against the possibility of uterine dilatation. AVith these pre-, cautions the plug may prove of real value. [In any case of really alarming hemorrhage I should be disposed rather to trust to the ap- plication of styptics to the uterine cavity) The injection of fluid in bulk, as after delivery, could not be safely practised, on account of the closure of the os and the contraction of the uterus. But there can be no objection to swabbing out the uterine cavity with a small piece of sponge attached to a handle and saturated in a solution of the perchlo- ride of iron. There are few cases which Avill resist this treatment. If we have reason to suspect retained placenta or membranes, or if the hemorrhage continue or recur after treatment, a careful exploration of the interior of the womb will be essential. On vaginal examination we may possibly feel a portion of the ])lacenta ])rotruding through the os, which cau then be removed without difficulty. If the os be closed, it must be dilated with sjionge or lamiuaria tents or by a small-sized Barnes bag, and the uterus can then be thoroughly explored. This ought to be done under chloroform, as it cannot be efiectually accom- ^ Obdelric Operations, p. 492. 438 LABOR. j)lislietl without intrtKliiciiio- the wliolc liaiul into the vagina, wiiicli necessarily causes much ])ain. If the placenta or membranes be locjse ill tile uterine cavity, they may be removed at once, or if tiuy be organ- ically attached, they may be carefully picked olf. The uterus should at tiic same time, as loiiii; as the os remains ])atulous, be thorouglily wasiied out with Condy's Huid and water to diminish the risk of septicaemia. Retroflexion can readily be detected by vaginal examination, and the treatment consists in careful reposition with the hand and the application of a large-sized Hodge's pe&sary. CHAPTER XVI. RUPTUKE OF THE UTERUS, ETC. Rupture of the uterus is one of the most dangerous accidents of lal)or, and until of late years it has been considered almost necessarily fatal and beyond the reach of treatment. Fortunately, it is not of very frequent occurrence, although the j)ublished statistics vary so much that it is by no means easy to arrive at any conclusion on this point. The exjjlanation is, no doubt, that many of the tables confound partial and com})aratively unimportant lacerations of the cervix and vagina with rupture of the body and fundus. It is only in large lying-in institu- tions, where the results of cases are accurately recorded, that anything like reliable statistics can be gathered, for in private practice the occur- rence of so lamentable an accident is likely to remain uin)ublished. To show the difference between the figures given by authorities, it may be stated that, while Burns calculates the projiortion to be 1 in 940 labors, Ingleby fixes it as 1 in 1300 or 1400, Churchill as 1 in 1331, and Leh- mann as 1 in 2433. Dr. Jolly of Paris has jaiblished an excellent thesis containing much valuable information.^ He finds that out of 782,741 labors, 230 ruptures, excluding those of the vagina or cervix, occurred — that is, 1 in 3403. Ijacerations may~occur in any part of the uterus — the fundus, the body, or the cervix. ^ Those of the cervixlu'e comjiaratively of small consequence, and occur, to a slight extent, in almost all first laboi-s.^ Only those which involve the sujiravaginal jiortion are of really serious im})ort. Ruptures of the upper part of the uterus are much less frequent than of the portion near the cervix ; partly, no doubt, liecause the fundus is beyond the reach of the mechanical causes to which the accident can, not unfrequently, be traced, and jiartly because the lower third of the organ is apt to be compressed between the jircscnting ])art and the bony pelvis. (The site of placenU\l..i.ngg.rtlun is said by i\Iadame La Chapelle ' Rupture uterine pendant le Travail, Pai'is, 1873. RUPTURE OF THE UTERUS, ETC. 439 to be rarely involved in the rupture, but it does not always eseape, as inimerous recorded cases prove. jfThe most frequent seat of rupture is near the junction of the body and neck, either anteriorly or posteriorly^ opposite the sacrum, or behind the syni])hysis pubis, but it may occur at the sides of the lower segment of the uterus. In some cases the entire cervix has been torn away, and separated in the form of a ring.\ The laceration may be partial or complete, the latter being the more common. The muscular tissue alone may be torn, the peritoneal coat remaining intact ; or the converse may occur, and then the peritoneum is often fissured in various directions, the muscular coat being unimpli- cated. The extent of the injury is very variable, in some cases being only a slight tear, in others forming a large aperture, sufficiently exten- sive to allow the foetus to pass into the abdominal cavity. The direction of the laceration is as variable as the size, but it is more frequently vei'- tical than transverse or oblique. The edges of the tear are irregular and jagged ; probably on account of the contraction of the muscular fibres, which are frequently softened, infiltrated with blood, and even gangren- ous. Large quantities of extravasated blood will be found in the perito- ueal cavity; such hemorrhage, indeed, being one of the most important sources of danger. The causes are divided into predisposing and exciting ; and the prog- ress of modern research tends more and more to the conclusion that the cause which leads to the laceration could only have operated because the tissue of the uterus was in a state predisposed to rupture, and that it would have had no such effect on a perfectly healthy organ. What these predisposing changes are, and how they operate, is yet far from being known, and the subject offers a fruitful field for pathological investigation. ' It is generally believed that lacerations are more common in mul- tiparse than in primiparse. Tyler Smith contended that ruptures are relatively as common in first as in subsequent labors, while Bandl ^ found that only 64 cases out of 546 ruptures were in primiparte. Statistics are not sufficiently accurate or extensive to justify a positive conclusion, but it is reasonable to suppose that the pathological changes presently to be mentioned as predisposing to laceration are more likely to be metAvith in women whose uteri have frequently undergone the alteration attend- ant on repeated pregnancies, i^e seems to have considerable influence, as a large proportion of cases have occurred in women between thirty and forty years of age. Alterations in the tissues of the uterus are probably of very great importance in predisposing to the accident, although our information on this point is far from accurate. Among these are morbid states of the muscular fibres, the r esult of blow s and coirtusions during pregnancy ; premature fatty degeneration of the muscular tissues, an anticipation, as it were, of the normal involution after delivery; fibroid tumors or malig- nant infiltration of the uterine walls, which either produce a morbid state of the tissues or act as an impediment to the expulsion of the ftx-tus. The importance of such changes has been specially dwelt on by ]\Iur- pliy in this country and by Lehmann in Germany, and it is impossible ' ZTebcr Ruptur der Gcbdrmuiier, Wien, 1815. 440 LABOR. not to oonceJo their j)robable iiilliRMuc in favorin*:: laceration. How- ever, as yet these views are Ibuucled more on reasonable hypothesis than «n accurately oljserved pathological facts. Another and very iMi])ortant class of predisposing causes are those which lead to a want of proper jirojjortion between the pelvis and the fictus. Deformity of the pelvis has been very frequently met with in cases in which the uterus has ruptured. Thus, out of 19 ca-^es carefully recorded by Radford," the pelvis was contracted in 11, or more than one- half. ( Radford makes the curious observation that ruptures seem more likely to occur when the deformity is only slight, and he explains this by supposing that in slight deformities the lower segment of the uterus engages in the brim, and is therefore much subjected to compression, while in extreme deformity the os and cervix uteri remain above the brim, the body and fundus of the uteiais hanging down between the thighs of the mother. This explanation is reasonable, but the rarity with which ruptured uterus is associated with extreme pelvic deformity may rather depend on the iufrequency of advanced degrees of contraction. Bandl, who has made the most important of modern contributions to our knowledge of the subject, points out thatl rupture nearly always begins in the lower segment of the uterus, which becomes abnormally stretched and distended when from any cause the expulsion of the foetus is delayed.) The upper portion of the uterus becomes at the same time retracted and much thickened. (See Fig. 150.) As the pains continue, the stretching of the lower segment, called by Spiegelberg ;, the " obstetrical cervix," becomes more and more marked until at last ' its fibres separate and a laceration is established. The line of demar- cation })etween the thickened body and the distended lower segment, known as the ring of Bandl, can in such cases be occasionally made out by palpation above the pubes. Amongst causes of disproportion depending on the foetus are either malpresentation, in which the pains cannot eifect expulsion, or undue size of the presenting part. In the latter way may be ex])laincd the ol)servation that rupture is more frequently met with in the delivery of male than of female children, on account, no doubt, of the larger size of the head in the former. The influence of intra-uterine hydroceph- alus was first prominently pointed out by Sir James Simpson," who states that out of 74 cases of intra-uterine hydrocephalus the uterus ruptured in 16. In all such cases of disjirojjortion, whether referable to the pel- vis or foetus, rupture is produced in a twofold manner — either by the excessive and fruitless uterine contractions which are induced by the efforts of the organ to overcome the obstacle, or by the compression of the uterine tissue between the presenting part and the bony pelvis, lead- ing to inflammation, softening, and even gangrene. The j^roximate cause of rupture may be classed under two heads — (mechanical injury) and /excessive uterine contraction.) Under the former are j)laced those nncommon cases in which the uterus lace- rates as the result of some injury in the latter months of pregnancy, such as blows, falls, and the like. Xot so mre, unfortunately, are lace- ' Obst. Trans., 1867, vol. viii. p. 150. ^ Selected Obstetric Works, p. 385. RUPTURE OF THE UTERUS, ETC. 441 rations prodnood l)v unskilled attempts at dellvciy on the part of the iiiodical attendant, such as by the hand dtn-ing turning or by the l)lades of the forceps. Many such cases are on record in which tiie accoucheur has used force and violence, rather than skill, in his attempts to over- come an obstacle. That such unhappy results of ignorance are not so uncommon as they ought to be is proved by the figures of Jolly, who Fig. 150. lUustrating the Dangerous Thinning of the Lower Segment of Uterus, owing to non-descent of head in a case of intra-uterine hydrocephalus. (After Bandl.) has collected 148 cases of rupture of the uterus ; of which 71 occurred during version by the feet ; 37 under the use of the forceps ; 10 under that of the cephalotribe, and 30 during other operations, the preci.se nature of which is not stated.' The modus operandi of protracted and ineffectual uterine contractions as a proximate cause of rup- ture is sufficiently evident, and need not be dwelt on. It is neces- sary to allude, however, to the effect of ergot, incautiously adminis- tered, as a producing cause. There is al)undant evidence that the injudicious exhibition of this drug has often been followed by lace- ration of the unduly stimulated uterine fibres. Thus, Trask, talking of tlie subject, says that Meigs had seen 3 cases, and Bedford 4, distinctly traceable to this cause. Jolly found that ergot had been administered largely in 33 cases in which rupture occurred. Premonitory Symptoms. — Some have believed that the impending occurrence of rupture could frequently be ascertained by peculiar pre- 1 Op. cii. 442 LABOR. moil itorv symptoms, sucli as excessive and acute erainpy j)aiiis about the k)\ver ])art ol" tlic al)(loMii'U, due t(» the compression (»f j)ai-t of the utei'ine wails. Tliese are l"ar too indefinite to l)e relied on, and it is certain that the ru])ture irenerally takes place without any symptoms that would have aflorded reasonal)le iirouuds for suspicion. The general symptoms are often so distinct and alarmiujs; as to leave no doubt as to the natmv of the case. Not infre(juently, however, especi- ally if the lacei'ation be ])artial, they are by no means so well marked, and the j)ractitioner may be imcertain as to what has taken place. In the former class of cases a sudden excruciatint;- pain is experienced in the abdomen, generally during the uterine contractions, accompanied by a feeling on the part of the patient of something having given way. In some cases this has been accompanied by an audible sound which has been noticed by the bystanders. At the same time, there is gener- ally a considerable escaj)e of blood from the vagina, and a prominent symptom is the sudden cessation of the previously strong ])ains. Alarming general symptoms soon develop, ])artly due to shock, partly to loss of blood, both external and internal. The face ex- hibits the greatest suffering, the skin becomes deadly cold and covere;- (juoted. " I do not hesitate," lie says, "to niaUe the statement that J have never met with a case of vesico-va<:inal fistula which, without doubt, could be shown to have resulted from instrumental delivery. On the contrary, the entire weight of evidence is conclusive in showino; that the injury is a consequence of delav in delivery.'" Treatment. — As to the treatment of va.laconta be ])artially or entirely detached. Tho loss of blood depends to a groat extent on the condition of the uterine parietes. If there be much contraction on the part that is not inverted, the introsusce]>tcd part may be .suifieiently compressed t(t jirovent any groat loss. If the entire organ bo in a state of rolax;ition, the loss may be excessive. The occurrence of such symptoms shortly alter delivery would of necessity lead to an accurate examination, when the nature of the case may be at once a.scertained. On pa.ssing the finger into the vagina we either find the entire uterus forming a globular ma.ss — to which the placenta is often attached — or, if the invasion be incomplete, tho vagina is occupied by a firm, round, and tender swelling, Avhich can be traced Partial Inversion of the Fundus. (From a pn-parsition in tlie Museum of Guy's Hospital.) INVERSION OF THE UTERUS. 451 upward tlir(nirac- titioners, it was not actually performed until the year 1804. In France the opposition w^as long-continued and bitter. Many of the leading teachers strongly denounced it, and the Academy of ^Nlcdicine formally discountenanced it so late as the year 1827. Tlie objections were chiefly based on religious grounds, but partly, no doubt, on mis- taken notions as to the object jiroposed to be gained. Although fre- (piently discussed, the o])eration was never actually carried into practice until the year 1831, when Stoltz performed it with success. Since that time opposition has greatly ceased, and it is now employed and highly recommended by the most distinguished obstetricians of the French .schools. Objects of the Operation. — In inducing premature labor we ]>ro- ]i0se to avoid or lessen the I'isk to which in certain cases the mother is exposed l)y delivery at term, or to save the life of the child, Avliich might otherwise l)e endangered. /Hence the operation may be indicated eitlier on account of the mother alone or of the child alone, or. as not unfro(|nently ha]>pens, of l)oth together) INDUCTION OF PREMATURE LABOR. 457 In by far the largest nuiiilxn' of cases tlic operation is performed on account of defective propoi-tion Ixitween the child and the niatei'iial passages, due to sonic abnormal condition on the part of the mother. This want of proportion may depend on the presence of tumors either of the uterus or growing from the pelvis. But most fre({uently it arises from deformity of the pelvis (]). 404), and it is needless to repeat what has been said on that point. I shall therefore only briefly refer to a few more uncommon causes which occasionally necessitate its i)er- formancc. One of these is an habitually large or over-firraly ossified foetal head. Should we meet with a case in which the labors are always extremely difdcult and the head ap})arently of nnusual size, although there is no apparent want of space in the i)elvis, the induction of labor would be perfectly justifiable, and in all probability would accomplish the desired object. In such cases the full period of delivery would require to be anticipated by a very short time. A week or a fortnight might make all the difference between a labor of extreme severity and one of com- parative ease. There is a large class of cases in which the condition of the mother indicates the operation. Many of these have already been considered when treating of the Diseases of Pregnancy. Amongst them may be mentioned vomiting which has resisted all treatment, and which has produced a state of exhaustion threatening to prove fatal ; chorea, albu- minuria, convulsions, or mania ; excessive anasarca, ascites, or dyspnoea connected with disease of the heart, lungs, or liver, which may be, in a great measure, caused by the pressure of the enlarged uterus ; in fact, any condition or disease affecting the mother, provided only we are con- vinced that the termination of pregnancy would give the patient relief, and that its continuance would involve serious danger. /It need hardly be pointed out that the induction of labor for any suchNcauses involves grave responsibility, and is decidedly open to abuse : no jiractitioner would, therefore, be justified in resorting to it — especially if the child have not reached a viable age — without the most anxious consideration.! No general rules can be laid down. Each case must be treated on its own merits. It is obvious that the nearer the patient is to the full period, the greater will be the chance of the child surviving, and the less hesita- tion need then be felt in consulting the interest of the mother. In another class of cases the operation is indicated by circumstances affecting the lifejp f the c hild alone. Of these the most common are those in which the child dies, in several successive pregnancies, before the termination of utero-gestation. This is generally the result of fatty, calcareous, or syphilitic degeneration of the placenta, Mhich is thus ren- dered incapable of performing its functions. These changes in the pla- centa seldom commence until a comparatively advanced period of preg- nancy ; so that if labor be somewhat hastened we may hope to enable tlie patient to give birth to a living and healthy child. The experience of the mother will indicate the period at which the death of the fretus has formerly taken place, as she would then have a])preciated a difier- ence in her sensations, a diminution in the vigor of the fetal move- ments, a sense of weight and coldness, and similar signs. For some 458 OBSTETRIC OPERATIOyS. weeks before the time at wliidi this eluiii'.'-c lias heeii e.\|t( riciiccd we slumkl careful Iv aiisi-iiltate llie I'u'tal heart {"r»»iii day to day, and in must cases the a])])i'oach oi' danuncture of the membranes being eventually neces.>^ary in order to hasten the process. (Indeed, my omii expe- rience Mould lead me to the conclusion that as means of evoking uterine contraction cervical dilatation is very unsatisfactory.] (Dr. ]]arnes himself has evidently .seen rea.son to modify his original vicMs, for while he at first talked of the bags as enabling us to induce labor M'ith certainty at a given time, he has since recommended that uterine action sliould be first provoked by other means, the dilators being subsequently used to accele- rate the labor thus brought on. The bags thus employed find, as I believe, their mo.-;t useful and a very valuable application ; l)ut when used in this M'ay they cannot be considered as a means of originating uterine action.) A subsidiary objection to the bags is the risk of displacing the presenting part. I have, for example, introduced them M'hen the head Mas presenting, and on their removal found the .'ihoulder lying over the os. It is not difficult to understand hoM- the continuous pressure of a di.stended bag in the internal os might easilv push away the head, M'hich is so readily movable .•^o long as the membranes are unruptured. Still, if labor be in progress and the os insufficiently dilated, the possibility of this occurrence is not a sufficient Barnes Bag for Dilating the Cervix. INDUCTION OF PREMATURE LABOR. 461 reason for not availing ourselves of the undouljtedly valuable assistance wliieli the dilators are eapalile of giving. Separation of the Membranes. — Some processes for inducing labor act directly on the ovum by separating the membranes to' a greater or less extent from the uterine walls. The first procedure of the kind was reconnnended by Dr. Jlamilton of Ivlinburgh, and consisted in the gradual separation of the membranes fur one or two inches all round the lower segment of the uterus. To reach them the finger had to be gently insinuated into the interior of the os, which was gradually dilated to a sufficient extent by a series of successive operations repeated at intervals of three or four lipurs. When this had been accomplished the forefinger was inserted and swept round between the membranes and the uterus, but it was frequently found necessary to introduce the greater ]iart of the hand to effect the object; and sometimes even this was not sufficient, and a female catheter or other instrument had to be used for the purpose. The method was generally successful in bringing on labor, but it now and then failed, even in Dr. Hamilton's hands. It is certainly based on correct principles, but it is tedious and painful both to the practitioner and the patient, and very uncertain in its time of action. For these reasons it has never been much practised. Vaginal and Uterine Douches. — In the year 1 836, Kiwiseh sug- gested a plan which from its simplicity has met with much approval. It consists in projecting at intervals a stream of warm or cold water against the os uteri. Its action is doubtless complex, (jviwisch himself believed that relaxation of the soft parts through the imbibition of water was the determining cause of labor) (Simpson found that the method failed unless the w^ater mechanically separated the membranes from the uterine walls. Besides this effect, it probably directly induces reflex.iietion by distending the vagina and dilating the os. In using it, it"Tias been customary to administer a doucKelAvice daily, and more frequently if rapid effects be desired. The number required varies in different cases. The largest number Kiwiseh found it necessary to use was seventeen, the smallest five. The average time that elapses before labor sets in is four days. Hence the method is obviously useless when raj)id delivery is required. Dr. Cohen of Hamburg introduced an important modification of the process Avliich has been considerably jiractised. It consists in passing a silver or gum-elastic catheter some inches within the os, between the membranes and the uterine walls, and injecting the fluid through it directly into the cavity of the uterus. He used creasote or tar-water, and injected without stopping until the patient complained of a feeling of distension. Others have found the plan equally efficacious when thev only employed a small quantity of plain water, such as seven or eight ounces. Professor Lazarewitch of St. Petersburg is a strong advocate of this method. He believes that uterine action is evoked nuich more rapidly and certainly if the water be injected near the fundus, and he has contrived an instrument for the purpose with a long metallic nozzle. Dangers of these Plans. — So many fatal cases have followed these methods that it cannot be doubted that, in spite of their eertainty and simplicity, there is an element of risk in them that should not be over- 462 OBSTETiur oj'j-n.iTioys. looked. Many of these are recorded in IJarnes' work, and lie conM-s to the eonelnsion, which the facts uncjnestionaidy jnstiiy, that "the douche, whether vauinai nr inti'a-ntei'ine, onti;ht to he ai)sohit('ly condemned as a nu'ans of" inthicinti' hihoi-." 'i'lic precise reason of the dan- of the uterine walls, |H"o(hicin<:- shock, has been supposed to have caused it ; but in many of the fatal cases the symptoms have been rather those attending the pa&sage of ajr into the veins, and it is easy to understand how air may have been intrcMluccd in this way into the large uterine sinuses. Sim})son and Scanzoni have l)oth tried with success the injection of carbonic-acid y-as into the vagina. Fatal results have, however, fol- lowed its employment, and k5im})son has expressed an oj)inion that the ex|)eriment should not be re})eated. Sim})son originally induced labor by pas-sing the ut erine soun d within the OS and up toward the fundus, and, when it had been inserted to a sufficient extent, moving it slightly from side to side, lie was led to adopt this procedure in the belief that we might thus closely imitate the separation of the deeidua which occurs previous to labor at term. Uterine contractions were induced with certainty and ease, but it was found impossible to foretell what time might ela})sc between the com- mencement of labor and the operation, which had fre(juently to l)e ])erfornied more tlian once. (He subsequently modified this ])rocer from snl)si'(jnent complications. As rcoards the child the mcjitalityj is little, if at all, greater than in original hreecii and footling prescn-' tations. Xor is there any good reason why it should he so, seeing that' cases of turning after the feet are brought througii the os are virtually reduced to those of feet presentation, and that the mere version, if effected sufliciently soon, is not likely to add materially to the risk to Avhich the child is exposed. The possibility of etlecting version by external manipulation has been recognized by various authors, and Avas made the subject of an excellent thesis by Wigand, -who clearly described the manner of per- forming the operation. In spite of the manifest advantages of the procedure, and the extreme facility with which it can be accomplished in suitable cases, it has by no means become the established custom to trust to it, and probably most practitioners have never attempted it, even under the most favorable conditions. (The possibility of the operation is based ou the extreme mobility of the fa?tus before the membranes are ruptured.^ After the watei-s have escaped the uterine walls embrace the foetus more or less closely, and version can no longer be readily performed in this manner. ( It may therefore be laid down as a rule that it should only be attempted when the abnormal position of the fcetus is detected before labor has commenced, or in the early stage of labor, when the mem- branes are unruptured.^ It is also unsuitable for any but transvei*se presentations, for it is not meant to effect complete evolution of the foetus, but only to substitute the head for the ujiper extremity. It is juseless whenever rapid delivery is indicated, for after the head is ^.broujrht over the brim the conclusion of the case must be left to the Natural powers. The manner of detecting the presentation by palpation has been already described (p. 127), and the success of the operation depends on our being able to ascertain the positions of the head and breech through the uterine walls. Should labor have commenced and the os be dilated, the transverse presentation may be also made out by vaginal examination. Should the abnormal presentation be detected before labor has actually begun, it is in most cases easy enough to alter it and to bring the foetus into the longitudinal axis of the uterine cavity. Pinard ' recommends that after this has been done the fVetus should be maintained in position by a well-fitting elastic abdomina l bel t. It is seldom, however, discovered until labor has commenced/and even if it be altered the child is extremely apt to resume in a short time the faulty position in which it Mas formerly lying. Still, there can be no harm in making the attemjit, since the operation itself is in no way painful, and is absolutely without risk eiti)er to the mother or child. AVhen the transverse presentation is detected early in labor, I believe it is good practice to endeavor to remedy it by external manipulation, and if it fail we may at oncie proceed to other and more certain methods of operating. The procedure itself is abundantly simple. The patient is placed on her back, and the position of the foetus ascertained by ])al- ^ De la Version par Maneuvres externes, Paris, 1878. TURNING. 4G7 pation as accurately as possible, in the manner already described.) The palms of" the hands being- then j)luced over the opposite poles of the foetus, by a series of gentle gliding movements the head is pushed toward the pelvic brim, while the breech is moved in the opposite direction. The facility with which the foetus may sometimes be moved in this way can hardly be apjn-eciated by those who have never attempted the operation. As soon as the change is effected the long diameters of the foetus and the uterus will correspond, and vaginal examination will show that the shoulder is no longer presenting and that the head is over the pelvic brim. If the os be sufficiently dilated and labor in progress, the membranes should now be punctured and the position of the foetus maintained for a short time by external pressure, until we are certain that the cephalic presentation is permanently estab- lished. If labor be not in progress, an attempt may at least be made to effect the same object by pads and a binder, one pad being placed on the side of the uterus in the situation of the breech, and another on the opposite side in the situation of the head. On account of the difficulty of performing cephalic version in the manner usually recommended, it has practically scarcely been attempted, and with the exception of some more recent authors it is generally con- demned by writers on systematic midwifery. Still, the operation offers unquestionable advantages in those transverse presentations in which rapid delivery is not necessary, and in which the only object of inter- ference is the rectification of malj)Osition ; for if successful the child is spared the risk of being drawn footling through the pelvis. (The objections to cephalic version are based entirely on the difficulty of performance^ and, undoubtedly, to introduce the hand within the uterus, searcn for, seize, and afterward place the slippery head in the brim of the pelvis, could not be an easy process, even under the most favorable circumstances, and must always be attended with considerable risk to the mother. Velpeau, who strongly advocated the operation, was of opinion that it might be more easily accomplished by pushing up the presenting part than by seizing and bringing down the head. Wigand more distinctly pointed out that the head could be brought to a proper position by external manipulation, aided by the fingers of one hand within the vagina. Braxton Hicks has laid down clear rules for its performance, which render cephalic version easy to accomplish under favorable conditions, and will doubtless cause it to become a recognized mode of treating malpositions. The number of cases, however, in which it can be performed must always be limited, since, as in turn- ing by external manipulation alone, it is necessary that the liquor anniii should be still retained or at least have only recently escaped; that the presentation be freely movable about the pelvic brim; and that there be no necessity for rapid delivery. (J)y. Hicks does not believe protrusion of the arm to be a contraindication, and advises that it should be carefully replaced within the uterus. \ When, how- ever, protrusion of the arm has occurred, the thorax is so constantly pushed down into the pelvis that replacement can neither be safe nor pra(tieable, except under unusually favorable conditions, and podalic version will be necessary. 4(J.S OBSTETRW OPKRA TIONS. Method of Performance. — It is impossihUi to {Icscribc the nu'thod of ])L'rl()niiinj;- i-cjtlialic vorsion more t'onoiscly and clearly than in J)r. Hieks' own words, "introduce," lie says, "the left hand into the vagina, as in podalic version ; ])Iace the right hand on tiie outside of the abdomen, in order to make out the position of the lu'tus and the direction of its head and feet. IShould the should er, for instance, ju'e- sent, then push it with one or two fingers in the direction of the feet. At the same time pressure with the other hand should be exerted on the ce])halic end of the child. This will bring the iiead down to the OS ; then let the head be received on the ti})S of the two inside fingers. The head Mill play like a ball between the two hands; it will be under their command, and can be placed in almost any part at will. Let the head then be placed over the os| taking care to rectify any tendency to face presentation.) It is as well, if the breech will not rise to the fundus readily, after the head is fairly in the os to withdraw the hand from the vagina, and with it press up the breech from the exterior. The hand which is retaining gently the head from the outside should continue there for some little time, till the pains have ensured the retention of the child in its new position and the adaptation of the uterine walls to its new form. (Should the membranes be perfect, it is advisable to rujiture them as soon as the head is at the os uteri ^ during their flow and after the head will move easily into its proper position." The procedure thus described is so simple, and would occupy so short a time, that there can be no objection to trying it. Should we fail in our endeavors, we shall not be in a worse position for eifecting I delivery by podalic version, which can be proceeded with without removing the hand from the vagina or in any way altering the position ^_^of the patient. "y^ The method of performing podalic version varies with the nature of fi each particular case. In describing the operation it has been usual to b divide the cases into those in which the circumstances are favorable and the necessary manoeuvres easily accomplished, and those in Avhich there are likely to be considerable difficulties and increased risk to the mother. This division is eminently practical)le, since nothing can be more varia- ble than the circumstances under which version may be required. Belbre describing the steps of the operation, it may be w^ell to consider some general conditions applicable to all cases alike. In England the ordinary position on the left side is usually em- ployed. On the Continent and in America the patient is placed o n her bac k, with the legs supporfed by assistants, as in lithotomy. The former position is jM-eferable, not only as a matter of custom and as involving much less fuss and exposure of the person, but because it admits of both the operator's hands being more easily used in concert. In cei-tain difficult cases, when the liquor amnii has escaped and the l)ack of the child is turned toward the spine of the mother, the dorsal decubitus presents some advantages in enabling the hand to pass more readily over the body of the child; but such cases are comjiaratively rare. (The patient should be brought to the side of the bed, across, which she should be laid, with the hips projecting over and parallel to the edge, the knees being flexed toward the abdomen, and separated TURNING. 4G0 from each other by a pillow or by an assistant. Assistants should also be placed so as to restrain the patient if necessary, and prevent lier involuntarily startinj^ from the operator, as this mi<^ht not only embar- rass his movements, but be the cause of serious injury. The exhibition of aiugsthetics is peculiarly advantageous. There is nothing which tends to facilitate the steps of the process so much as stillness on the part of the patient and the absence of strong uterine contraction. When the vagina is very irritable and the uterus firmly contracted round the body of the child, complete anaesthesia may enable us to effect version when without it we should certainly ftiil. The most favorable time for operating is when the os is fully dilated, before or immediately after the rupture of the membranes and the dis- charge of the liquor amnii. The advantage gained by operating before the waters have escaped cannot be overstated, since we can then make the child rotate with great facility in the fluid medium in which it floats. In the ordinary operation, in which the hand is passed into the uterus, it is essential to wait until the os is of sufificient size to admit of its being introduced with safety. This may generally be done when the OS is the size of a dollar, especially if it be soft and yielding. The practice followed with regard to the hand to be used in turning varies considerably. Some accoucheurs always employ the right hand, others the left, and some one or other according to the position of the child. In favor of the right hand it is said that most practitioners have more power with it, and are able to use it with greater gentleness and delicacy. In transverse presentations, if the abdomen of the child be placed anteriorly, the rigjit hand is said to be the proper one to use, on account of the greater facility with which it can be passed over the front of the child ; and in difficult cases of this kind, when w^e are ope- rating with the patient on her back, it certainly can be employed with more precision than the left. In all ordinary cases, however, the left hand can be introduced much more easily in the axis of the passages, the back of the hand adapts itself readily to the curve of the sacrum, and even when the child's abdomen lies anteriorly it can be passed for- ward without difficulty so as to seize the feet. These advantages are sufficient to recommend its use, and very little practice is required to enable the practitioner to manipulate with it as freely as with the right. If, in addition, we remember that the right hand is required to operate on the foetus through the abdominal walls — and this is a point which should never be forgotten — we shall have abundant reasons for laying it down as a rule that the left hand should generally be employed. Before passing the hand and arm they should be freely lubricated, with the exception of the palm, which is left untouched to admit of a firm grasp being taken of the foetal limbs. It is also advisable to remove the coat and bare the arm as high as the elbow. As it should be a cardinal rule to resort to the simplest procedure when practicable, it will be well to consider first the method by com- bined external and internal manipulation without })assing the hand into the uterus, and subsequently that which involves the introduction of the hand. Turning- by Combined External and Internal Manipulation. — To 470 OBSTETRIC OPERATIONS. Fig. 154. / eifect pmlalio version hy the (■<)iiil)iii('(l iiictliod it is an oi5.sential prclim- iiiarv to ascertain the sitnation of" tlio lu'tiis as accurately a.< possible. It will jicnerally be eii-^^y in transvei-se j)resentation to make out the breech and head by ])alpation, while in head j)re.sentations the fonta- nelleswill show to which side of the pelvis the lace is turned. The left liand is then to be pas.sed carefully into the va<;ina, in the axis of the canal, to a suflicient extent to admit of the fingers pa.-^sing freely into the cervix. To eflect this it is not always necessary to insert the whole hand, three or four fingers being generally sufficient. If the head lie in the first (o.l.a.) or fourth (o.l.p.) position, push it upward and to the left, while the other hand, placed externally on the abdomen, depresses the breech toward the right (Fig. 154). By this means mc act simultaneously on both extremities of the child's body, and easily alter its position. The breech is pushed down gently but firmly by gliding the hand over the abdominal wall. The head will now pass out of reach, and the shoulders will arrive at the OS and will lie on the tips of the fingers. This is similarly pushed upward in the same di- rection as the head (Fig. 155), the breech at the same time being still further depressed, until the kn^c_comes within reach of the fingers, when (the membranes be- ing now ruptured, if still unbro- ken) it is seized and pulled d(twii through the os (Fig. 156). Oc- casionally the foot comes imme- diately over the os, when it can be .seized instead of the knee. Vei-sion may be facilitated by changing the position of the ex- ternal hand and pushing the head First stage of Bipolar Version : Elevation of the upward from the iliaC fossa, iu- llcad and Depression of the Breech. (After / , « ,. . ,, ,, Barnes.) stcad 01 Continuing the attempt to depress the breech (Figs. 156 and 157). tThcse manipulations .should always be carried on in the intervals, and desisted from when the ]>ains come on ; and when the pains recur with great force and frequeiuy the advantage of chloroform will be particularly a]ij)arent. In the second (o.d.a.) and third7t).i),r.) positions the steps of the operation should be reversed : the head is pushed upward and to the right, the breech downward and to the left. »u hen the position cannot be made out with certainty, it is well to assume that it is the first (o.l.a.), since that is the one most frequently met with ; and even if it be not, no great inconvenience is likely to occur. ( If the os be not sufficiently open to admit of delivery being TURNING. All concluded, the lower extremity can be retained in its new position with one finger until dilatation is sufficiently advanced or until the uterus Fig. 155. Second Stage of Bipolar Version : Elevation of the Shoulders and Depression of the Breech. (After Barnes.) has permanently adapted itself to the altered position of the child ; either of which results will generally be effected in a short space of time. In transverse presentations the same means are to be adopted, the shoulder being pushed upward in the direction of the head, while the Fig. 156. Third Stage of Bipolar Version : Seiznre of the Knee and Partial Elevation of the Head. (After Barnes.) breech is depressed from without. This is frequently sufficient to bring the knees within reach, e.'^pecially if the membranes are entire, but ver- sion is much facilitated by pressing the head upward from without, 472 OBSTETRIC OPERA TIOSS. alternately wit li depression of the l)reecli. i. If the liqiior amnii has escaped, and the uterns is Hrinly contracted round tlie l)odyof the child, it will be found impossible to ettect an alteration in its position without the introduction of the hand, and the ordinary method of turning must be cmplovcd.^ The peculiar advantage of the combined process is, that it in nowav interferes with the latter, lor should it not succeed the IkukI can be passed on into the uterus without withdrawal from the vagina P'iG. 157. Fourth Stage of Bipolar Version : Drawing Down of the Legs and Completion of Version. (After Barnes.) (provided the os be sufficiently dilated), and the feet or knees seized and brought down. Turning with the hand introduced into the uterus, provided the waters have not or have only rec-cntly escaped and the os be sufficiently dilated, is an operation generally performed with ease. The first step, and one of the most important, is the introduction ot" the hand and arm. The fingers having been pre&sed together in the form of a cone, the thumb lying between the rest of the fingers, the hand, thus reduced to the smallest possible dimensions, is slowly and carefully pa.s.sed into the vagina, in the axis of the outlet, in an interv al between the pain.s, and j)a.«sed onward in the .res- eutation, and it comes to be a question whether delivery should now be 1 Ob.-^t. Trans., for 1877, vol. xix. p. 239. Drawing Down of the Feet and Completion of Version. the I VSii TURNING. Alb left to nature or terminated by art. Tliis niust depend to a certain extent on the case itself and on the cause which necessitated version, but generally it will be advisable to finish delivery without unnecessary delay. To accomplish this, downward traction is made during the pains and desisted from in the intervals (Fig. 160). As the umbilical cord appears, a loop should be drawn down ; and if the hands Fif4. 160. be above the head they nnist be disengaged and brought over the face, in the same manner as in an ordinary footling presentation. The management of the head after it descends into the cavity of the pelvis must also be con- ducted as in labors of that descrip- tion. Turning in Placenta Praevia. — In cases of placenta prsevia the OS will, as a rule, be more, easily dilatable than in trans-' verse presentations. Hicks' method offers the great advan- tage of enabling us to perform version much sooner than was formerly possible, since it only requires the introduction of one or two fingers into the os uteri. Sliould we not succeed by it, and the state of the patient indicates that delivery is necessary, we have at our command in the fluid dilators a means of artificially dilating the os uteri which can , be employed with ease and safety. V If we have to do with a case of entire placental presentation, the hand should be passed at that point where the placenta seems to be least attached.) This will always be better than attempting to perforate its substance — a measure sometimes recommended, but more easily performed in theory than in practice. If the placenta only partially present, the hand should of course be inserted at its free border. It will frequently be advisable not to hasten delivery after the feet have been brought through the os, for they form of tliemselves a very efficient plug, and effectually prevent further loss of blood; while if the patient be much exhausted she may have her strength recruited by stimulants, etc. before the completion of delivery. Turning in Abdomino-anterior Positions. — In abdomino-anterior positions, in which the waters have escaped, and in which, therefore, some difficultv may be reasonably anticipated, the operation is gener- ally more easily performed with the patient on her bac k : the rjo;ht hand is then introduced into the uterus, and the left employed exter- nally (Fig. 161). In this way the internal hand has to be passed a Showing the Completion of Version. (After Barnes.) 476 OBSTETRIC OPh-RATIOXS. shorter (listiiiK'c :iii;o of the hod in Fi«. 161. Showing the Use of the Right Hand in Abdomino-anterior Position. the lithotomy position with the thighs ^separated, and the right hand is passed np behind the pubes and over the abdomen of the child. DiflBcult Cases of Arm Presentation. — The difficulties of turning culminate in those unfavorable cases of arm ])resentation in which the membranes have been long ruptured, the shoulder and arm pressed down into the pelvis, and the uterus contracted round the body of the child. The uterus being firmly and spasmodically contracted, the attempt to introduce the hand often only makes matters worse by indu- cing more frequent and stronger pains. Even if the hand and arm be successfully passed, much difticulty is often experienced in causing the body of the child to rotate; for we have no longer the fluid medium present in which it floated and moved with ease, and the arm of the operator may be so cramped and pained by the pressure of the uterine walls as to be rendered almost powerless. The risk of laceration is also greatly increased, and the care necessary to avoid so serious an acci- dent adds much to the difficulty of the ojieratiou. Value of Anaesthesia in Relaxing- the Uterus. — In these perplex- ing cases various ex]>cdients have been tried to cause relaxation of the spasmodically contracted uterine fibres, such as copious venesection in the erect attitude until fainting is induced, M'arm baths, tartar emetic, and similar depressing agents. None of these, however, are so useful as the free administration of ch lorof orm, which has practically super- seded them all, and often answers most effect ually when given to its full surgical extent. The hand nuist be introduced with the precautions already described. TURNING. 477 If the arm be completely protruded into the vagina, we should pass the hand along it as a guide, and its palmar surface will at once indicate the position of the child's abdomen. No advantage is gained by amputation, as is sometimes recommended. When the os is reached the real difficulties of the operation commence, and if the shoulder be firmly pressed down into the brim of the pelvis it may not be easy to insinuate the hand past it. It is allowable to repress the presenting part a little, but with extreme caution, for fear of injuring the con- tracted uterine parietes. Herman Mias pointed out that in some cases the difficulty is increased by the shoulder of the prolapsed arm being caught beneath the contraction-ring (Bandl's), and he advises that it should be released by pressing it toward the centre of the cervical canal. It is better to insinuate the hand past the obstruction, which can generally be done by patient and cautious endeavors. Having succeeded in passing the shoulder, the hand is to be pressed forward in the intervals, being kept perfectly flat and still on the body of the foetus when the pains come on. It is much safer to press on it than on the uterine walls, which might readily be lacerated by the project- ing knuckles. When the hand has advanced sufficiently far, it will be better, for the reasons already mentioned, to seize and bring down one knee only. "When the Foot is brought Down, but the Foetus -will not Revolve. — Even when the foot has been seized and In'ought through the OS, it is by no means always easy to make the child revolve on its axis, as the shoulder is often so firmly fixed in the pelvic brim as not to rise toward the fundus. (Some assistance may be derived from push- ing the head upward from without, which of course would raise the shoulder along with it./ If this should fail, we may effect our object by passing a noose of tape, or wire ribhoP.. round the limb, by which traction is made downward and backward ; at the same time the other hand is passed into the vagina to displace the shoulder and push it out of the brim. It is evident that this cannot be done as long as the limb is held by the left hand, as there is no room for both hands to pass into the vagina at the same time. By this manoeuvre version may be often completed when the foetus cannot be turned in the ordinary way. Various instruments have been invented both for passing a fillet round the child's limb and for repressing the shoulder, but none of them can compete, either in facility of use or safety, with the hand of the accoucheur. When Mutilation is Necessary. — Should all attempts at version fail, no resource is left but the mutilation of the child, either by evis- ceration or decapitation. This extreme measure is, fortunately, sel- dom necessary, as with due care version may generally be eifected, even under the most unfavorable circumstances. ^ " Note on One of the Causes of Difficulty in Turning," Obst. Trcuis., for 18S(i, vol. xxviii. p. 150. 478 OBSTE'IRIC OPERATIONS. CHAPTER III. THE FORCEPS. Use of the Forceps in Modern Practice. — Of all ol)stetric o]-)era- tions, the most important, because the most truly conservative, both to the mother and child, is the application of the forceps. In mper performance, and must never be undertaken without anxious considera- tion. It is because these two classes of operations have been confused that the use of the instrument is regarded by many Avith such unreason- able dread. Tin-: F( J IK 'EPS. 485 Preliminary Considerations. — Before attemptinjir to introduce the forceps there are several points to which attention .should be directed: 1st. friie nienibranes must of course be ruptured.) 2dly. (For the safe and easy application of the instrument it is also advisable that the os sliouhl be iuHy dilated and the cervix retracted over the heatt) Still, tliesc two points cannot be regarded, as many have laid down, as being sine qud non. Indeed, we are often compelled to use the instrument when, although the os is fully dilated, the rim of the cervix can be felt at some point of the contour of the head, espe- cially in cases iu which the anterior lip is jammed between the head and the pubes. Provided due care be taken to guard the cervical rim with the fingers of one hand as the instrument is slipped past it, there need be no fear of injury from this cause. If the os be not fully dilated, but is sufficiently open to admit of the passage of the forceps, the operation, under urgent circumstances, may be quite justifiable, but it must necessarily be a somewhat anxious one. 3dly.(The position of the head should be accurately ascertained by means of the sutures and fontanelles.^ Unless this be done the opera- tion will always be haphazard and unsatisfactory, as the practitioner can never be in possession of accurate knowledge of the progress of the case. It may be that the occiput is directed backward; and, although that does not contraindicate the application of the forceps, it involves special precautions being taken. 4thly. i.The bladder and bowels should be emptied.) Question of Administering- Anaesthetics. — Before proceeding to operate the question of anaesthesia will arise. In any case likely to be difficult it is of the greatest assistance to have the patient com- pletely under the influence of an anaesthetic to the surgical degree, so as to have her as still as possible ; but whenever this is deemed neces- sary another practitioner should undertake the responsibility of the administration. In simple cases I believe it is better to dispense with anaesthetics altogether, partly because they are apt to stop what pains there are — which is in itself a disadvantage — but chiefly because under partial anaesthesia the jiatient loses her self-control, is restless, and twists herself into awkward positions which give rise to the utmost difficulty and inconvenience in the use of the instrument. Moreover, if no anaes- thetic be given the patient can assist the operator by placing herself iu the most convenient attitude. Description of the Operation. — In describing the method of applv- ing the f )rceps I shall assume that we have to do with the simpler variety of the operation, when the head is low in the pelvis. Subse- quently I shall point out the peculiarities of the high operation. As to the position of the patient, I believe there can be no doubt of the superiority of that which is usually adopted in Great Britain. /On the Continent and in America the forceps is always employed with The patient lying o n her back — a position involving much needless exposure of the person and requiring more assistance from others. ) In certain cases of unusual difficulty the position on the back is of unquestionable utility, but we may at least commence the operation in the usual way, and subsequently turn the patient on her back if desirable. 486 OBSTETRIC OPERA TIOXS. Much of the i'acility Avith mIucIi the hhiclos are intrfxhicod depends on the patient's being properly j)hieed. (Plence, ahhough it gives rise to a h'ttle more trouble at lirst, I believe that it is always best to pay particular attention to this point, whether the hitrh or low forceps ope- ration l)e about to be performed. vThe patient should be brought quite to tlie side llf_,thej.)ed, with her nates jja rail el_ to and projecting some- Avhat over its edge. The body should lie almost directly across the lu'd, and nearly at right angles to the hips, with the knees raised toward the iabdomen (Fig. 167). In this way there is no risk of the handle of the Fig. 167. Position of Patient for Forceps Delivery, and Mode of Introducing Lower Blade upper blade, Avhen depressed in introduction, coming in contact with the bed. The blades should be warmed in tepid water, lubricated with cold cream or carbolized vaseline, and placed ready to hand. These ])reliminaries having been attended to, we ])roceed to the intro- duction of the blades, sitting by the side of the bed opposite the nates of the patient. The imjiortant question now arises, In what direction are the blades to be ])nssed ? The almost universal rule in our standard works is that they must be passed as nearly as ])ossible over the child's cars , without any reference to the pelvic diameters. Hence, if tlie licad have not made its turn, but is lying in one oblique diameter, the blades would require to be passed in the opposite oblique diameter; in .short, the posi- tion of the forcejis as regards the jielvis must vary according to the position of the head. Some have even laid down the rule that the for- ceps is contraindicatcd unless an ear can be felt — a rule that would very seriously limit its aj^plication, as in many ca.ses in which it is urgently required it is a matter of great difficulty, and even impossibility, to feel the ear at all. Tit is admitted that in the high-forceps operation the THE FORCEPS. 487 blades must be introduced in the transverse di_an7.eter of the pelvis, without relation to the position of the lieiul) On the Continent it is generally reconnnended that this rule shouhl be a[)plied to all cases of forceps delivery alike, whether the head be high or low; and(,I have now for many yeai's ado[)ted this plan and passed the blades in all cases, whatever be the position of the head, iii t he tr ansverse diameter o f the pfilvis , Avithout any attempt to pass them over tlic" t)TpiirietaI ditniieteroi the child's head. ) Dr. Barnes points out with great force that, do what we will and attem])t as we may to pass the blades in rela- tion to the child's head, they find their way to the sides of the j^elvis, and that the marks of the fenestrfe on the head always show that it has been gras])cd by the brow and side of the occiput. Of the perfect cor- rectness of this obser\'ation I have no doubt ; hence it is a needless ele- ment of complexity to endeavor to vary the position of the blades in each case, and one which only confuses the inexperienced practitioner and renders more difficult an operation which should be simplified as much as possible. While, therefore, it is of importance that the precise position of the head should be ascertained in order that we may have ian intelligent notion of its progress, I do not think that it is essential as a guide to the introduction of the forceps. Method of Introducing- the Lower Blade. — As a rule, the lower blade, lightly grasped between the tips of the index and middle fingers and thumb, should be introduced first. Poised in this way, we have perfect command over it and can appreciate in a moment any obstacle to its passage. Two or more fingers of the left hand are introduced into the vagina and by the side of the head as a guide. The greatest care must be taken, if the cervix be within reach, that they are passed within it, so as to avoid the possibility of injury. The handle of the instrument has to be elevated, and its point slid gently along the palmar surface of the guiding fingers until it touches the head (Fig. 167). At first the blade should be inserted in the axis of the outlet, but as it progresses the handle must be depressed and carried backward. As it is pushed onward it is made to progress by a slight sideHto-side motion, and it is of the utmost importance to bear in. mind that the greatest gentleness must always be used. If any obstruc- tion be felt we are bound to withdraw the instrument partially or entirely, and attempt to manoeuvre, not force, the point past it. As the blade is. guided on in this way, it is made to pass over the convexity of the head, the point being always kept slightly in contact Avith it, until it finally gains its proper position. When fully inserted the handle is drawn back toward the perineum, and given in charge to an assistant. The insertion must be carried on only in the intervals between the pains, and desisted from during their occnnviicc, otherwise there would be a serious risk of injuring the soft ])arts t)f the mother. IntrodiTction of the Upper Blade. — The second blade is passed directly opposite to the first, and is generally somewhat more difficult to introduce, in consequence of the sjiace occupied by the latter. It is passed along two fingers directly opjiosite the first blade, and M'ith ex- actly the same precautions' as to direction and introduction, except that at first its handle has to be depressed instead of elevated (Fig, 168j. 488 OBSTETRIC OPERATIONS. The handle M'hich was in charge of the assistant is now laid hold of by the operator, and the two handles are drawn together. If the blades Fig. 168. Introduction of the Upper Blade. have been properly introduced, there should be no difficulty in locking; but should we be unable to join them easily, we must withdraw one or Fig. 169. Forceps in Position : Traction in the Axis of the Brim Downward and Backward. other, either partially or entirely, and reintroduce it with the .esidcs direct traction we may impart to the instru- ment a uentle waviny; motion from handle to handle, which briny;s into ojieration its power as a lever ;/ but this must be done only to a very slii^ht extent and must always be subservient to direct traction. j Proceedinti; thus in a slow and cautious manner, carefully reres.sed with the value of the system as taught by Simpson, upon the principle of whose forceps, modelled somewhat after that of the late Prof, Gunning S. Bedford of Xew York, he in 1858 presented to the medical profes- sion the instrument that bears his name. The forceps of Prof, liedford has a traction-ring on each side where the Elliot has a cornu, has a but- ton joint, instead of a Smellie, has no screw top, and has diverging instead of superimposed shanks. These j)oints have generally been con- sidered as improvements, and hence the Elliot has taken precedence in large measure over the Bedford instrument in Xew York, the two being the leading forceps in demand. The instrument of AVhite of Buffalo is perhaps next, and then Hodge's. But few of Prof. "Wallace's force])S, long the leading instrument in Fig. 174. Philadelphia sales, are ordered. The Wliite is a long forceps, a compound of the Elliot blade, long superimposed shanks of Hodge, Siebold lock, and short corrugated steel handles bowed out like dental forceps and end- ing in thin blunt hooks. The Sawyer and Simpson short forceps are said to be about equally in demand in Xew York. The former is almost unknown in Philadel- phia, and but comparatively few of the Simpson are asked for, al- though the system of their appli- cation has several advocates in this city. The Sawyer Forceps. — This is the lightest of all the varieties of the short forceps, weighing but 5 ounces, and measuring Of inches in length; the handle being 3 inches, shank li, and sawyer Forceps, chord of blade-curve b\. The blades are 1 J inches wide, with oval fenestra | inch wide, and separated 2§ inches at their widest j>art and I inch at the tips. This in.strument was invented eight yeai-s ago by Prof. Edw. A\'arren Sawyer of Rush IMed- ical College, Chicago, and has been highly commended by Prof, By ford and others. The forceps has the blades of Davis, superimpo.sed shanks Elliot Forceps. THE FORCEPS. 497 of Hodge, and lo(;k of Sniellio, wiiii liardrubbcr plates moulded hot upon the handles. The several parts have been somewliat modified, the objeet being to seen re a traetor for cases of deficient expulsive force where the foetal head is low in the pelvis. Professor Sawyer says: "In the labors to which my forceps is appli- cable it is not necessary for the operator's body to be in line with the pelvic axis. My mode of procedure is the following: The woman is placed u])on her back and drawn to the edge of the bed ; the outside leg is now flexed ; beneath this flexed extremity and the bed-covering I apply the forceps — often using but one hand in the operation. When the instrument is locked, I grasp the handle in such a manner that the palm of the hand looks upward ; one hook then rests naturally upon the extensor surface of the first phalanx of the index finger, while the other hook rests upon a corresponding part of the thumb. When thus adjusted, I lift the head from the pelvic outlet, at the same time invok- ing the pendulum movement if desired. At this moment the advan- tage of the hooked handle is very apparent to the operator." .... "AH practitioners must have often felt, during the last moments of labor, when the uterus and the mother seemed fatigued, the need of a little help to the expulsive powers. The ordinary instruments are too formidable to be used at the last moment, and it is then that this little forceps is useful." I have given the names and characters of the various forceps most in use in New York and Philadelphia, and by the large number of gradu- ates of their respective schools, as shown by their preferences in select- ing instruments of the leading makers of the two cities. [ The mechan- ism of instrumental delivery is much simplified by applying the forceps to whatever parts of the foetal head may be opposite the sides of the pelvis, but it is very questiouable whether it is the scientific method or the safer for the child.\ With one blade over the side of the occiput, and the other over that of the forehead — which is the manner of seizure in oblique positions of the vertex — we certainly have not a very secure hold and run some risk of injury to the foetus. The advocates of this system claim that they use no compression, only a simple traction ; which may be true in one sense, but amounts to the same in effect, else how could Dr. Elliot, by traction with great force, straighten out one of the blades of his Simpson forceps, as related in the JSVw YorJ: Journ. of Medicine for September, 1858, p. 161, in the paper which he pre- sented describing his new forceps and a number of cases in which he had tested them ? It makes but little difference whether we compress the head before we begin to pull, or pull so as to wedge the head between the blades, and thus compress it, except as to the difference of fit in the two instances ; the adjusted and even pressure being the less likely to injure the foetus. I have always believed that the forceps should fit the head, and that the student should be taught how to accomplish it correctly in the various positions of the foetus. If the student has a mechanical turn of mind, a delicate sense of touch, and a clear head, he will soon learn ; if he is not a mechanic, he will be forced to adopt a more simple method of delivery. In a large city there are but few first-class obstetrical manipulators as a general rule, and they 32 498 OBSTETRIC OPEliA TlnXS. liw usually well kiK)\vn as such, for tlu- rea.M»u that l)ut lew have all the reijuisiti'S t(» enable tlieiu to achieve notners, but we cannot see why his plan of delivery should be exclusivelv used on anv mode of scientific reasoning. THE FORCEPS. 409 I present a series of plates in illustration of the American method of delivery with the force])s, the position, as will be seen, being that of France and Germany — on the back. AVhen it is decided to use the for- ceps, in almost all cases in the United States the patient is brought to the edge of the bed on her back, with her nates close to the edge, her feet on two chairs, and her knees widely se2)arated, as in the plate above. The patient is covered with a sheet, or heavier covering if in winter, and there is no necessity of exposure, as the whole manipulation may be done by the sense of touch. The position is by far the most con- venient for the obstetrician, and enables him much more easily to keep in Fig. 177. Application ol the Forceps with the Head at the Superior Strait, the left blade held in place by an assistant. his mind all the anatomical relations of the foetus and pelvis than when in the English decubitus. We study the anatomy with the subject on the back, and the mechanism of labor in front of the pelvis or manikin ; 500 OBSTETRIC OPERATIONS. thou why eonij)lieatc' iiiatters bv a chaiisitioii, and i'roiu the (•(»iii|)aiativc I'acility of its introduction it would })robably be the preferable instrument of the two. CHAPTER y. OPEEATIONS INVOLVING DESTRUCTION OF THE FCETUS. Operations involving the destruction and mutilation of the child were amono; the first practised in midwifery. Craniotomy was evidently known in the time of Hippocrates, as he mentions a mcxle oi" extracting the head by means of hooks. Cclsus describes a similar oi)e- ration, and was acquainted with the manner of extracting the fa'tus in trai>sverse presentations by decapitation. Similar procedures were also practised and described by Aetius and others among the ancient writei's. The physicians of the Arabian school not only employed perforators for opening the liead, but were acquainted with instruments for compressing and extracting it. Religious Objections to Craniotomy. — Until the end of the seven- teenth century this class of operation was not considered justifiable in the case of living children : it then came to be discussed whether the life of the child might not be sacrificed to save that of the mother. It was authoi-itatively ruled by the Theological Faculty of Paris that the destruction of the child in any case was mortal sin : " Si I'on ne ])eut tirer I'enfant sans le tucr, on ne pent sans peche niortel le tirer." This dictum of the Roman Church had great influence on continental mid- Avifery, more especially in France, where uj) to a recent date the leading obstetricians considered craniotomy to be only justifiable when the death of the foetus had been positively ascertained. Even at the ])reseut day there are not wanting practitioners who, in their praiseworthy objections to the destruction of a living child, counsel delay until the child has died — a practice thoroughly illogical, and only sparing the operator's feelings at the cost of greatly increased risk to the mother. In England the safety of the child has always been considered subservient to that of the mother; and it has been admitted that in eveiy case in wliich the extraction of a living fa'tus l)y any of the ordinary means is impos- sible its mutilation is perfectly justifial)le. Formerly Performed with Unjustifiable Frequency. — It must be admitted that the frequency with which craniotomy has been per- formed in England constitutes a great blot on British midwifery. Dur- ing the mastership of Dr. I^abbat at the Rotunda Hospital the foiveps was never once ajiplied in 21,867 labors. Even in the time of Clarke and Collins, when its fVequeiicy was mucli diniinishcd, craniotomy was OPERATIONS INVOLVING DESTRUCTION OF THE FOETUS. 505 performed tliree or four times as often as fore(,'ps deliv^cry. Tliese fig- ures indieate a destruetion of foetal life which wc cannot look back to without a shudder, and which, it is to be feared, justify the reproaches which our continental brethren have cast upon our practice. Fortu- nately, professional opinion has now completely recognized the sacred duty of saving the infant's life whenever it is practicable to do so; and British obstetricians now teach as carefully as those of any other nation the imperative necessity of using every endeavor to avoid the destruc- tion of the foetus. Divisions of the Subject. — The operation now under consideration may be necessary — 1st, when the head requires either to be simply per- forated or afterward more completely broken up and extracted — an ope- ration which has received various names, but is generally known in England as craniotomy, and which may or may not require to be fol- lowed by further diminution of the trunk ; 2dly, when the arm presents and turning is impossible : this necessitates one of two procedures — decapitation, with the separate extraction of the body and head, or evis- ceration. [Or, what is equally promising in such cases, where the w^oman has had no deforming disease and is far less difficfdt of execu- tion, the conservative Cesarean section. — Ed.] In both classes of cases similar instruments are employed, and those generally in use at the pres- ent time may be first briefly described. Instruments Employed. — 1. The object of the perforator is to pierce the skull of the child, so as to admit of the brain being broken up and the consequent collapse and diminution in size of the cranium. The perforator invented by Denman or some modification of it has been Fig. 181. Fig. 182. Fig. 183. Various Forms of Perforators. principally employed. It requires the handles to be separated in order to open the blades, and this cannot be done by the operator himself. This difficulty is overcome in the modification of Naegele's perforator 506 OBSTETRIC OPERA TIONS. used in Edinhurgli, in wliidi the handles jire so constructed that thd with a joint at its centre to prevent their opening too soon. By tiiis arrangement the instrument can be manipulated by one hand only. The sharp-pointed portion has an external cutting edge, with projecting shoulders at its base to prevent its penetrating too I'ar into the cranium. Many modifications of these arrangements have since been contrived (Figs. 181, 182, 183). In some parts of the Continent a perforator is used constructed on the principle of the trephine, but this is vastly more difficult to work, and has the great disadvantage of simply boring a hole in the skull, instead of splitting it up as is done by the shai'p- pointed instrument. Crotchets and Craniotomy Forceps. — The instruments for extrac- tion are the crotchet and craniotomy forceps. The crotchet is a sharp-pointed hook of highly-tempered steel which can be fixed on some portion of the skull, either internal or external, traction being made by the handle. The shank of the instrument is either straight or curved (Figs. 184 and 185), the latter l)eing prefer- able, and it is either attached to a wooden handle or Figs. 184, 185. forged in a single piece of metal. A modification ot" ^Ijv this instrument is known as Oldham's vertebral hook. VlX It consists of a slender hook, measuring with its han- \\ die 13 inches in length, which is passed through the foramen magnum and fixed in the vertebral canal, so as to secure a firm hold lor traction. { X\\ forms of crotchets are open to the serious objection of being liable to slip or break through the bone to which they are fixed, so wounding either the soft parts of the mother or the fingers of the operator placed as a guard.) Hence they are discountenanced by most re- cent wi'iters, and may with propriety be regarded as obsolete instruments. Their place as tractors is well supplied by the more modern craniotomy forceps (Fig. 186). These are intended to lay hold of the skull, one blade being introduced within the cranium, the other externally, and when a firm grasp has been obtained downward traction is made. \A. second object it fulfils is to %J) break away and remove portions of the skull when j>pi-f oration and traction alone are insufficient to efiect delivery. ) jNIany forms of craniotomy forcejis are in use — some armed with formidable teeth ; others, of simpler construction, depending on their roughened Crotchets. and Serrated internal surfaces for firnnie.ss of grasp. For general use there is no better in.strument than the cranioclast of Sir James Simpson (Fig. 187), which admiral)ly ful- fils both these indications. It consists of two .separate blades fastened by a button joint. The extremities of the blades are of a duck-l)illed shape, and are sufficiently curved to allow of a firm gra.-^p of the skull being taken : the upper blade is deeply grooved to allow the lower to OPERATIONS IXVOLVIXG DESTRUCTION OF THE FCETUS. 507 sink into it, and this gives the instrument great power in fracturing tlie cranial bones when that is found to be necessary. It need n(jt, how- ever, be employed for the latter purpose, and, the blades being serrated on their under surface, form as perfect a pair of craniotomy forceps as Fig. 186. Fig. 187. Craniotomy Forceps. Simpson's f'ranioclast. any in ordinary use. Provided with it, we are spared the necessity of procuring a number of instruments for extraction. Cephalotribe. — Amongst modern improvements in midwifery there are few which have led to more discussion than the use of the cephalo- tribe. This instrument, originally invented by Baudelocque, was long eraploved on the Continent before it was used in Great Britain, the prej- udice against it being no doubt due to its formidable size and appear- ance. Of late years many of our leading obstetricians have used it in preference either to the crotchet or craniotomy forceps, and have materi- ally modified and improved its construction, so that the most objection- able features of the older instrument are now entirely removed. The Instrument. — ^The cephalotribe consists of two powerful solid blades which are applied to the head after perforation and approximated by means of a screw so as to crush the cranial bones, and after this it may be also used for extraction.) The peculiar value of the instrument is that w4ien properly applied it crushes the firm base of tlie skull, wdiich is left untouched by craniotomy, or if it does not it at least causes the base to turn edgeways within the blades, so as to be in a more favor- able position for extraction. Another and specially valuable property is that it crushes the bones within the scalp, which forms a most efficient protective covering to their sharp edges. In this way one of the prin- cipal dangers of craniotomy — the wounding of the maternal passages bv spiculse of l)one — is entirely avoided. The cephalotribe, therefore, acts in two ways — as a crusher and as a 608 OBSTETRIC OPERA TIONS. tractor. Some ol).eing used. Dr. Barnes has suggested that the same results may be obtained by dividing the head with a strong wire ecraseur. So far as I know, this suggestion has never yet been carried out in practice, not even by him- self, and therefore it is not possible to say much about it. I should imagine, however, that there would be considerable difficulty in satis- factorily passing the loop of wire over the skull in a pelvis in which there is any well-marked deformity. Cases requiring- Craniotomy. -iThe most common cause for which craniotomy or cephalotripsy is performed is a want of proper proportion between the head and the maternal passages.) This may arise from a variety of causes. The most important, and tliat most often necessitat- ing the operation, is os seous dQi grmity. This may exist either in the brim, cavity, or outlet, and it is most often met wdth in the antero- posterior diameter of the brim. Obstetric authorities differ consider- ably as to the precise amount of contraction which will prevent the passage of a living child at term. Thus, Clarke and Burns believe that a living child cannot pass through a pelvis in which the antero- posterior diameter at the brim is less than 3j inches. Ramsbotham iixes the limit at 3 inches, and Osborne and' Hamilton at 2|_inches. (The latter is the extreme limit at which the birth of a living child is possible ^ but there can be no doubt that under favorable circumstances it may be possible to draw the foetus, after turning, through a pelvis of that size. The opposite limit of the ojjeratiou is still more open to dis- cussion. Various authorities have considered it quite possible to draw a mutilated foetus through a pelvis in which the antero-posterior diam- eter does not exceed 1^ inches, and indeed have succeeded in doing so, /But then there must be a fair amount of space in the transverse diam- \eter of the pelvis to admit of the necessary manipulations. If there be a clear space here of 3 inches and upward, it is no doubt possible to deliver per vias naturales ; but in such extreme deformities the difficul- ties are so great, and the bruising of the maternal structures so exten- sive, that it becomes an operation of the greatest possible severity, with results nearly as unfavorable to the mother as the Csesarean section. Hence some continental authorities liave not scrupled to prefer the latter operation in the worst forms of pelvic deformity. The rule in English practice always has been that craniotomy must be performed whenever it is practicable and there can be no doubt that it is the right one. < Between from 2f to 3 inches antero-posterior diameter in the one (direction. If inches in the other, may be said to be the limits of crani- iotomy, provided, in the latter case, there be a fair amount of space in ^the transverse diameter. The same limits may be laid down with regard to tumors or other sources of obstruction. There are a few other conditions in which craniotomy is justifiable, independently of pelvic contraction, such as certain changes in the soft parts which are supposed to render the passage of the head peculiarly dangerous to the mother. Among them may be mentioned s welli ng and inflam mation of the vagina from the length of the previous labor, 510 OBSTETRIC OPERATIONS. bands and ciciUxk:*^ i>t tlic vaiiiiia, and occlusiuii anil rigidity ol' the o.s. Jt is hardly too niiich to say that with a proper use of the resources^oT niidwit'ery the destruction of a livinjj; fetus for any of these conditions may be obviated. 'J'hc most common of them is undoubtedly s\vcllin of the soft parts, causint;- impaction of the head — an occurrence winc-h i ought to be invariably prevented by a tiiuely use of the forceps. .Should interference unfortunately be delayed until impaction has actually taken place, doubtless ny Braxton Hicks, Kidd, and others cannot fail to be struck with the rapidity with wliich the broken- down head may often be extracted. This is far from being the case with the craniotomy forceps, even when the obstruction is moderate only ; for it may be necessary to use considerable traction, or the blades may take a proper grasp with difficulty, or it may be essential to break down and remove a considerable jwrtion of the vault of the cranium before the head is lessened sufficiently to pass. During the latter process, how- ever carefully performed, there is a certain risk of injuring the mater- nal structures, and in the hands of a nervous or inexperienced operator this danger, which is entirely avoided in cephalotripsy, is far from slight. The passage of the blades of the cephalotribe is by no means difficult, and I think it must be admitted that the possible risks attending it are_ comparatively small. ( On account, therefore, of its simplicity and safet} to the maternal structures, I believe cephalotripsy to be decidedly the preferable operation in all cases of moderate obstruction. ) When we approach the lower limit and have to do with a ver marked amount of pelvic deformity, the two operations stand on a more equal footing. Then the deformity may be so great as to render it dif- ficult to pass the blades of even the smallest cephalotribe sufficiently deep to grasp the head firmly, and even when they are passed the space is often so limited as to impede the easy working of the instrument. Besides this, repeated crushings may be required to diminish the skull sufficiently. I attach but little importance to the argument that the diminution of the skull in one diameter increases its bulk in another. LThe necessity of removing and replacing the blades on another part of the skull, and of repeating this perhaps several times, in the manner recommended by Pajot, is a far more serious objection^ To do this in a contracted pelvis involves, of necessity, the risk of much contusion. Fortunately, cases of this kind are of extreme rarity, much more so than is generally believed, but when they do occur they tax the resources of the practitioner to the utmost. On the whole, the conclusion I would be inclined to arrive at with\ regard to the two operations is that in all ordinary cases cephalotripsy V is safer and easier,! whereas in cases with considerable pelvic deformity I the advantages of cephalotripsy are not so Avell marked, and craniotomy \ mav even prove to be preferable. \ (The first step in using'tKe cephalotribe is the passage of the blades. These are to be inserted in precisely the same manner and with the same precautions as in the high-forceps operation.) In many cases the os is not fully dilated, and it is absokitely essential to pass the instrument within it. Special care should therefore be taken to avoid any injury to its edges, and for this ]uirpose two or three fingers of the left hand, or even the whole hand, should be passed high up, so as thoroughly to protect the maternal structures, (in order that the base of the skull may. be reached and eflFectually crushed the blades must be deeply inserted/ 33 514 OBSTETRIC OPERATIONS. and in cluing this groat care and geiitlcnf.ss must be used. As the pro- jecting promontory of the sacrum generally tilts the head forward, the handles of the instrument, after locking, must be ■well pressed back- ■ward toward the })erineum. \If the blades do not lock easily or if any obstruction to their passage be experienced, one of them nuist be with- drawn and reintroduced, just as in forceps operations. ) Care must be taken, as tiie instrument is being inserted, to fix and steady tlie head by_abdoininal pressure, since it is generally far above the brrm, and would readily recede if this precaution were neglected. AA'heu tiie blades are in situ we proceed to crush by turning the screw sktwly, and as the blades are approximated the bones yield and the ce])halotribe sinks into the cranium. The crushed portion then measures, of course, no more than the thickness of the blades, that is, about 1-^ inches. This is necessarily accompanied by some bulging of the part of the cranium that is not within the grasp of the instrument (Fig. 190), but in slight deformity this is of no consequence, and Me may proceed to extraction, waiting, if possible, for a pain, and drawing at first down- ward in the axis of the pelvic inlet, as in forceps delivery, then in the axis of the outlet. The site of perforation should be examined to see that no spicuke of bone are projecting from it, and if so they should be carefully removed. In such cases the head often descends at once and with the greatest ease. Should it not do so or should the obstruction be considerable, a quarter turn should be given to the handles of the instrument, so as to bring the crushed por- tion into the narrower diameter and the uncrushed portion into the wider transvei'se diameter. It may now be advisable to re- move the blades carefully, and to reintro- duce them with tlie same precautions, so as to crush the unbroken portion of the skull. This adds materially to the difficulties of the case, since the blades have a tendency to fall into the deep channel already made in the cranium, and so it is b}- no means always easy to seize the skull in a new direction. Before reapplying them, if the condition of the patient be good and ]iains be present, it may be well to wait an liour or more, in the hope of the head being moukled and pushed down into the pelvic cavity. I This was the plan adopted by Dubois, and, according to Tarnier, was the secret of iiis great success in the operation. Pajot's method of repeated crushing in the greater degrees of contrac- tion is based on the same idea, and he recom- mends that the instrument should be intro- duced at intervals of two, three, or four hours, according to the state of Foetal Heart Crushed by the Cephalotribe. OPEB.ATIONS INVOLVING DESTRUCTION OF THE FCETUS. 515 Fig. 191. the patient, until the head is thoroughly crushed, no attempts at traction being used and expulsion being left to the natural powers. This, he says, should always be done when the contraction is below 2} inches, and he maintains that it is quite possible to effect delivery by this means when there are only 1| inches in the antero-posterior diameter. The repeated introduction of the blades in this fashion must necessarily be hazardous, except in the hands of a very skilful operatoi- ; and I believe that if a second application foil to overcome the difficulty, which will only be very exceptionally the case, it would be better to resort to the measures presently to be described. Professor Simpson of Edinburgh ^ has recently suggested the use of an instrument which he calls a " basilyst." Its object is to break up the base of the foetal skull from witRTn^ after the method originally proposed by Guyon. The screw-like portion of the instrument (Fig. 191), which is inserted through the perforation made in the cranial vault, is driven through the hard base, which is then disintegrated by the separate movable blade. If experience proves that this instrument can be readily worked, it promises to be a valuable addition to our armamentarium, since it will effectually destroy the most resistant ^^ortion of the skull without risk of injury to the maternal structures, and thus very materially facilitate extraction. Extraction by the Craniotomy Forceps. — Should we elect to trust to the craniotomy forceps for extraction, one blade is to be introduced through the perforation, and the other, in apposition to it, on the outside of the scalp. In moderate deformities traction applied during the pains may of itself suffice to bring down the head. Should the obstruction be too great to admit of this, it is necessary to break down and remove the vault of the cranium. For this purpose Simpson's cranioclast answers better than any other instrument. One of the blades is passed within the cranium, the other, if possible, between the scalp and the skull, and the portion of bone grasped between them is broken off; this can generally be accomplished by a twisting motion of the wrist without using much force. The separated portion of bone is then extracted, the greatest care being taken to guard the maternal structures during its removal by the fingers of the left hand. The instrument is then applied to a fresh part of the skull and the same pro- cess repeated, until as much of the vault of the cranium as may be neces- sary is broken up and removed. Dr. Braxton Hicks ^ has conclusively shown that in difficult cases, after the removal of the cranial vault, the proper procedure is to bring down the face, since the smallest measurement of the skull after the removal of the upper part of tlie cranium is from the orbital ridge to the alveolar edge of the superior maxillary bone. This alteration in the presentation he proposes to effect by a small blunt hook made for the purpose, which is forced into the orbit, by means of which the face Professor Simpson's Basilyst. ' Ed'm. Med. Joiirn., vol. 1879-80, p. 865. Obst. Trans., 1867, vol. vii. p. 57. 516 OBSTETRIC OPERATIONS. Fjg. 192. Fig. 193. is made to descend, liariies reeonnnond.s tliut this should he done by fixing the craniotomy forceps over the forehead and face, and making traction in a backward direction, so Jis to get the face j)a.st tlie projecting promontory ol" the sacrum. U'he importance of bringing down tlie face was long ago j)ointcd out by Burn.s, but it had b(,-en lost sight of until Hicks again drew attention to it in the paper referred to. In the class of cases in whicii tliis procedure is vahiable the risk to the maternal passages from the removal of the fractured portions of bone must always be considerable, and it is of great im})ortance not only to j)re.serve the scalp as entire as po-ssible, so as to protect them, but to use the utmost po.ssible care in removing the broken pieces of bone. Extraction of the Body. — When the extraction of the head lias been effected, either by the cephalotribe or the craniotomy forceps, there is seldom much difficulty with the body. By traction on the head one of the axilke can easily be brought within reach, and if the body do not readily pass, the blunt hook should be introduced and traction made until the shoulder is delivered. The same can then be done with the other arm. If there be still difficulty the cephalotribe may be used to crush the thorax. The body is, however, so compressible that this is rarely required. [The craniotomy forceps chiefly in use with us were devised by the late Prof. Charles D. jSIeigs for his second operation upon i\li-s. Reybold of Philadelphia in 1833, and have been used re- jjeatedly since, either as tractors or for reducing the size of the foetal head, in cases of deformity of the pelvis.' Some obstetricians prefer the less curved and broader-bladed instrument of Great Britain as a tractor ; but for the general ]iurposes of picking away the cranial bones aud drawing down the base of the skull in cases of extreme pelvic deformity there is no more simple aj)j)li- ance than that of Dr. ]Meigs. To act upon an oval body like the fcetal head Dr. ]\I. was obliged to prepare two forms of fbr- cep.s — straight and curved — to ))e used as might be required according to the part of the skull to be brokeu down or drawn upon. These are lightlv made, serrated, and 12.', inches in length. — Ei)".] Embryotomy. — There only remains for us to consider the second cla.ss of destructive operations. These may be necessary in long-neglected cases of arm presentation in which turning is found to l)e impracticable. Here, fortunately, the question of killing the fVetus does not arise, since it will, almost necessarily, have already perished from the continuous pressure. We have two operations to select from — decapitation and evisceration. [' Tlie illustrations given are taken from the instruments devised by Dr. Meigs a.s an improvement upon his original pattern, nnd will be seen to differ from those usually presented in American obstetrical publications. — Ed.] Straight Curved Craniotomy Craniotomy Forceps. " Forceps. OPERATIONS INVOLVING DESTRUCTION OF THE FQiTUS. .017 The former of these is an operation of great antiquity, having l)een fully described by Cclsus. It consists in severing the neck, so as to separate the head from the body ; the ]>ody is tiien withdrawn by means of the protruded arm, leaving the head in vtero, to be snbsc^quently dealt with. If the neck can be reached without great difficulty — and in the majority of cases the shoulder is sufficiently pressed down into the pelvis to render this quite i)0ssible — there can be no doubt that it is much the simpler and safer operation. The whole question rests on the possibility of dividing the neck. For this purpose many instruments have been invented. (The one generally recommended in England is known as Ramsbotham's hook, and consists of a sharply curved hook with an internal cutting edge) This is guided over the neck, which is divided by a sawing motion. There is often considerable difficulty in placing the instrument over the neck, although if this were done it would doubtless answer well. Others have invented instruments based on the principle of the apparatus for plugging the nostrils, by means of which a spring is passed round the neck, and to the extremity of the spring a short cord or the chain of an ecraseur is attached ; the spring is then withdrawn and brings the chain or cord into position. The objection to any of these apparatuses is that they are unlikely to be at hand when required, for few practi- tioners provide themselves with costly instruments which they may never require. It is of importance, therefore, that Ave should have at our command some means of dividing the neck which is available in the absence of any of these contrivances. ^Dubois recommends for this purpose a strong pair of b lunt scisso rs. The neck is brought as low as possible by traction on the prolapsed arm, and the blades of the scissoi-s guided carefully up to it. By a series of cautious snipping movements it is then completely divided from below upward. This, if the neck be readily within reach, can generally be effected without any particular difficulty, j Dr. Kidd of Dublin,^ who strongly advocates this operation, recommends that an ordinary male elastic catheter, strongly curved and mounted on a frrm stilet, or, still better, on a uterine sound, should be passed round the neck. Previous to introduction a cord should be passed through the eye of the catheter, which is left round the neck when it is withdi-awn. By means of this cord a strong piece of whip- cord or the wire of an 6craseur can easily be drawn round the neck and used for dividing it. The former, to protect the maternal structures, mav be worked through a speculum, and by a series of lateral move- ments the neck is easily severed. The ecraseur, however, offers special advantage, since it entirely does away with any risk of injuring the mother. "Withdrawal of the Body and Delivery of the Head. — After the neck is divided the remainder of the operation is easy. The body is withdrawn without difficulty by the arm, and Ave then proceed to deliA^er the head, f By abdominal pressure this in most cases can be jnished down into the pelvis, so as to come easily within reach of the cephalo- tribe, which is by far the best instrument for extraction. ' Preliminary perforation is not necessary, since the brain can esca])e through tlie ^ Dublin Quart. Jouni. of Med. Science, 1871, vol. li. p. 383. 518 OBSTETRIC OPERATIONS. severed vertebral eanal. The secret of doing this easily is to fix and press down the head sufficiently Irom aljove, otherwise it would slip away from the o;i"as]> of the instrument. The perforator and craniotomy ibrceps may he used if the cephalotrihe be not at hand. Perforation is, however, by no means always easy, on account of the nioi)ility of the head. After it is accomplished one blade of the craniotomy forceps is pas.sed within the skull, the other externally, and the head slowly drawn down. Evisceration. — The alternative operation of evisceration is a much more troublesome and tedious procedure, and should only be used when the neck is inaccessible. The first step is to j)erforate the thorax at its most depending part, and to make as wide an opening into it as possi- ble in order to gain access to its contents. Through this the thoracic viscera are removed piecemeal, being first broken up as much as possi- ble by the perforator, and then, the diaphragm being penetrated, those in the abdomen. The object is to allow the body to collapse and the pelvic extremities to descend as in spontaneous evolution. This can be much facilitated by dividing the spinal column with a sti'ong pair of scissors introduced into the ojaening made in the thorax, so that the body may be doubled up as on a hinge. Here the crotchet may find a useful application, for it can be passed through the abdominal cavity and fixed on some point in the interior of the child's pelvis, and thus strong traction can be made without any risk of injury to the mother. It can be readily understood that this process is so lengthy and difficult as to render it probably the most trying of obstetric operations; it is cer- tainly inferior in every respect to decapitation, and is only to be resorted to when that is impracticable. I CHAPTER VI. THE CiESAEEAN SECTION— PORRO'S OPERATION. SYMPHYSIOTOMY. History of the Csesarean Section. — The Cfcsarean section has per- haps given rise to more discussion than any other subject connected with midwifery, and there is yet much difierence of opinion as to the limits of, and indications for, the operation. The period at which Caesarean section was first resorted to is not known with accuracy. It seems to have been practised by the Greeks after the death of the mother, and Pliny mentions that Scipio Africanus and INIanlius were born in this way. The name of ('a>sar is said to have been given to children so extracted, and afterward to have been assumed as a family patronymic. These children were dedicated to Apollo, whence arose THE CJESABEAN SECTION. .519 the practice of tliin<>;s sacred to that god being taken under tlie special protection of the family of the CVesars. Many celebrities have been supposed to owe their lives to the operation, among the rest aEsculapius, Julius Qesar, and Edward VI. of England. Regarding the two latter, there is conclusive proof that the tradition is without founda- tion. There is no doubt that the operation was constantly practised on women who had died at an advanced period of pregnancy, and indeed it has at various times been enfor(!ed by law. Thus, among the Romans it was decreed by Numa that no pregnant woman should be buried until the foetus had been removed by abdominal section. The Italian laws also made it necessary, and the operation has always receiv- ed the strong support of the Roman Church. So lately as the middle of the eighteenth century the king of Sicily sentenced to death a phy- sician who had neglected to practise it. The first authentic case in "which the operation was jDcrformed on a living woman occurred in 1491. It was afterward practised by Nufer in 159i) [^] ; and in 1581, Rousset published a work on the subject in which a number of success- ful cases were related. In English works of that time it is not alluded to, although it was undoubtedly performed on the Continent, and to such an extent that its abuse became almost proverbial. We have evidence in Shakespeare, however, that the operation was familiarly known in Great Britain, since he tells us that — P] " . . . . Macduff was from his mother's womb Untimely ripped." Pare and Guillemeau, amongst the writers of the period, were noted for their hostility to the operation, while others equally strongly upheld it. In England it has scarcely ever been performed in a manner which offers even the faintest hope of success. It has been looked upon as almost necessarily fatal to the mother, and it has therefore been delayed until the patient has arrived at the utmost stage of exhaustion. For example, in looking over the record of British cases it is uo uncommon thing to find that the Csesarean section was resorted to two, three, or even six days after labor had begun, and when the patient was almost moribund. With rare exceptions within the last few years the opera- tion has been performed in what may be called a haphazard way. In many cases long and fruitless attempts at delivery by craniotomy had already been made, so that the passages had been subjected to much contusion and violence. Little or no attempt has been made to obvi- ate the well-known risks of abdominal operations ; no care has been taken to prevent blood and other fluids finding their way into the peritoneal cavity ; and no means have been adopted subsequently to remove them. It is, therefore, not so much a matter of surprise that the mortality has been so great, but rather that any cases have [' Probnbly in 149S ; the boy delivered lived to be seventy-seven years old ; calcu- lating backward gives tliis date. Rousset says, " about the year 1500." — Ed.] ['■^ Holinshed, the historian, (1577), makes Macdufl' say, " I was ripped out." INIrs. Macdufl" was probably operated on by a cow. Horned cattle have performed tlie operation 11 times since 1646, with a loss of 3 women and 6 cliildren ; one case in Edin- burgh resulted favorably to both uiotlier and cliild. Three male Macdutls are proba- bly now living in North America: one, of twenty-one, is at West Point. — -Ed.] 520 OBSTETRIC OPERATIOXS. recovered. [This does not ap])ly to the nianagcnient of several recent operations. — Ed.] From what Ave know of tli(! history of ovariotomy, its early fatality, and the extreme and even aj)])arently exaggerated preeantions which are essential to its success, it is iair to conclude that if the (Cesarean section were performed, as it is to be hoped it always ^\■ill be in future, with the same careful attention to minute details as ovariotomy, the results would not be so disastrous. ]\Iaking every alloM-auce for these facts, it must be admitted that tlie Ciesarean section, as hitherto performed, has been necessarilv almost a forlorn hope, altliough, happily, recent statistics show that this need no longer be considered the case. In making these observations I have no intention of contesting the McU-established rule of British practice that it is not admissible as an operation of election, and must onlv be resorted to when delivery per vias naturcdes is impossible. Statistical Returns not Reliable. — The mortality, as given in sta- tistical returns from various sources, differs so greatly as to make them but little reliable. Radford has tabulated the operations performed in Great Britain up to 1879, [^] and the list has been completed by Harris up to 1889. The cases amount to 154 in all, of Avhich 32 were success- ful. Michaelis and Kayser found that out of 258 cases and 338 opera- 1?ions, 54 and 64 per cent., respectively, were fatal. These iuclude operations performed under all sorts of conditions, even when the patient was almost moribund ; and until we are in possession of a sufBcient number of cases performed under conditions showing that the result is certainly due to the operation — in Avhich it was under- taken at an early period of labor and performed with a reasonable amount of care — it is obviously impossible to arrive at any reliable conclusions as to the mortality of the operation. [The Csesarean sta- tistics of the past, with the exception of those of the years 1885, 1886, 1887, and 1888, are of very little real value in calculating the present dangers of the Porro-Csesarean and Siinger-Csesarean methods, which have only within the years named ceased to be in some degree experi- mental. Old records are of historical interest and show the progressive steps by which the present low rate of death was reached. Even the miscalled " classic " operation can now be performed "with nnich less risk ; but no wise man will trust the uterine wound to nature's closing when multi])le suturing is so much more to be relied on. AVhat is still to be learned, particularly in the United States and Great Britain, is the great value of elective, early, and time-chosen operations. — Ed.] That it is necessarily hopeless is certainly not the case, and mc know that on the Continent, where it is resorted to much oftener and earlier in labor than in Great Britain, there are authentic cases in which it has been performed twice, thrice, and even, in one instance, four times, on the same patient. Keyser thinks that a second operation on the same patient affords a l)etter prognosis than a first, ]M'()l)ably because ])eri- toneal adhesions resulting from the first operation have shut off the general abdominal cavity from the uterine wound ; and he believes that in second operations the mortality is not more than 29 j)er cent. [' Obscrvniiom on the CcBsarean Section and Craniotomy, by Thomas Radford, M. D., London, 1880.— Ed.] THE CESAREAN SECTION. 521 The Caesarean Section in America. — The Caesarean section has been much more successful in America than in Great Britain. Dr. Harris of Phihidclpliia, who has paid much attention to the subject, lias collected 184 cases occurring in the United States, of which 70, or about 38 per cent., we're successful as regards the mother. These [relatively] favorable results he refers partly to the fact that none of the American cases were the subjects of mollities ossium, rachitic patients forming one-half of the entire number, partly to the preva- lence of habits of beer and gin-drinking in Great Britain. He also gives some interesting facts showing how remarkably the mortality of the operation is lessened when it is performed soon and the patient is not exhausted by long and fruitless labor. ( Out of 28 selected cases of this kind, 21, or 2.5 per cent., were successful. I [23 children were delivered alive, and 19 were saved. — Ed.] The latest European sta- tistics show that the modifications of the operation now universally adopted upon the continent of Europe are followed by the most grati- fying results. Thus, out of 22 recent operations 18 mothers recovered. Results to the Child. — The mortality of the children likewise can- not be ascertained from statistical returns, since in the large majority of cases in which dead children were extracted the result had nothing to do with the operation. Indeed, there is nothing in the operation itself which can reasonably be supposed to aifeet the child. /If, therefore, the child be alive when the operation is commenced, there is every proba- bility of its being extracted alive ;| and Radford's conclusion, that " the risk to infants in Caesarean births is not much greater than that which is contingent on natural labor, provided correct principles of practice are adopted," probably very nearly represents the truth. [The records of elective operations show a mere fraction of foetal deaths. — Ed.] Causes Requiring" the Operation. — TheCsesarean section is required ^vhen there is such defective proportion between the child and the mater- nal passages that even a mutilated foetus cannot be extracted. This in by far the greatest number of cases is due to deformity of the pelvis arising from rickets or mollities ossium. The latter may occur in a patient who has been previously healthy and who has given birth to living children. It is a more common cause of the extreme varieties of deformity than rickets ; and out of 132 British cases tabulated by Radford, P] in 56 tlie deformity was produced by osteo mal acia and in 31 by rickets. In certain cases the pelvis itself may be of normal size, but has its cavity obstructed by a solid tumor of the ovary, of the uterus itself, or one growing from the pelvic wall. The obstruction may also depend on morbid conditions of the maternal soft parts, of which the most common is advanced malignant disease of the cervix. Other con- ditions may, however, render the operation essential. Thus, Dr. New- man ^ records a case in which he performed it for insurmountable resist- ance and obstruction of the cervix which M'as believed at that time to be caused by malignant disease. The patient recovered, and was subse- quently delivered naturally and without anything abnormal being made out. This renders it probable that the disease was not malignant, and it may possibly have been an extensive inflammatory exudation into the [1 Edition of 1880.— Ed.] ^ Obst. Trans., 1866, vol. vii. p. 343. 522 OBSTETRIC OPERATIOyS. tissues of the cervix sul)Sf([nenl]y :il)S(»rl)e(l. I myself was ])resent at a ( 'lesarean section pcrfornud in ("alcutta in the year 1857, when the pelvis was so imifornily blocked u}) with exudation, j))-oijal)ly due to extensive pelvic celhditis or lueinatocele, that the operation w.is essential. Limits of Obstruction Justifying the Operation. — Different accoucheurs have iixed on various limits for the operation. Most British authorities are of opinion that it need not be resorted to if the smallest diameter of the ])elvis exceed 1 -J inches.' This (juestion has already been considered in discussing cranTotoni}', and it has been shown that a mutilated foetus may be drawn through a pelvis of li inches antero-posterior diameter, provided there be a space of 3 inches in the transverse diameter. If sufficient space for using the necessary instru- ments do not exist, the Csesareau section may be required, even when there is a larger antero-posterior diameter than 1^- inches. This is especially likely to occur when we have to do with deformity arising from mollities ossium, in "which the obstruction is in the sides and out- let of the pelvis, the true conjugate being sometimes even elongated. On the Continent the Caesarean section is constantly practised as an ope- ration of election when the smallest diameter measures from 2 to 2^ inches ; and when the child is known to be alive some foreign authors recommend it when there is as much as 3 inches in the antero-posterior diameter. In Great Britain, where the life of the child is most prop- erly considered of secondary importance to the safety of the mother, we cannot fix one limit for the operation when the child is living and another when it is dead. Nor, I think, can we admit the desire of the mother to run the risk, rather than sacrifice the child, as a justification of the operation, although this is laid down as an indication by Schroe- der.^ Great as are the dangers attending craniotomy in extreme deform- ity, there can be no doubt that we must perform it whenever it is prac- ticable, and only resort to the Csesarean section when no other means of delivery are possible. [One of the vital questions of the day is, " Shall the Ctesarean ope- ration be performed in cases under relative indications f" That is, Is it proper to elect to perform the operation where the indications for it are not absolute and positive? If by foetal destruction the mother can in all probability be saved, is it a justifiable act to run a greater risk in order to save the child? Are the wishes of the parents for a living child to be considered in deciding as to the method of delivery? In view of the fact that a premature delivery cannot save the child in a given case, and the mother has already lost one or more fwtuses by cra- niotomy, is it proper to save the child by an operation in which one out of five or six women have died? We think it is, and for the reason that such cases generally have a less mortality than the average here given. — Ei).] For this reason I think it unnecessary to discuss the question whether w^e are justified in destroying the foetus in several successive pregnan- cies when the mother knows that it is impossible for her to give birth ' In Dr. Parry's table of 70 craniotomies there are 34 cases of 2 to 2^ inches con- jugate. ^ Manual of Midwifery, p. 202. THE CESAREAN SECTION. 523 to a living child. Denman was the first to question the advisal)ility of repeating craniotomy on the same patient. Amongst modern authors Radlbrd takes the most decided view on this point, and distinctly teaches that even when delivery by craniotomy is possible it "can be justified on no principle, and is only sanctioned by the dogma of" the schools or by usage," and that therefore the Csesarean section should be performed with the view of saving the child. Doubtless much can be said from this point of view ; but nevertheless he would be a bold man who would deliberately elect to perform the Csesarean section on such grounds.^ It is to be hoped, however, that in these days the induction of premature labor or abortion would always spare us the necessity of deciding so delicate a point. Post-mortem Csesarean Operation. — The Csesarean section may also be required in cases in which death has occurred during pregnancy or labor. This was the indication for which it was fii'st employed, and it has constantly been performed when a pregnant woman has died at an advanced period of utero-gestation. There is no doubt that a prompt extraction of the child under these circumstances has frequently been the means of saving its life, but by no means so often as is genei:ally sup- posed. Thus, Schwarz ^ showed that out of 107 cases not one living child was extracted. Duer^ has written an interesting paper on this subject, in which he has tabulated 55 cases of post-mortem Csesarean sections. In 40 a living child was extracted, the time elapsing after the death of the mother being as follows : " Between one and five minutes, including ' immediately ' and ' in a few minutes,' there were 21 cases ; between five and ten minutes, none ; between ten and fifteen minutes, 13 cases; between fifteen and twenty-three minutes, 2 cases; after one hour, 2 cases ; and after two hours, 2 cases." In thosej extracted, however, after the lapse of an hour the children did not ulti-j mately survive, and the cases themselves seem open to some doubt. Want of Success in Post-mortem Operation. — The reason that the want of success has been so great is doubtless the delay that must necessarily occur before the operation is resorted to, for, independently of the fact that the practitioner is seldom at hand at the moment of death, the very time necessary to assure ourselves that life is actually extinct will generally be sufficient to cause the death of the foetus. Considering the intimate relations between the mother and child,, we can scarcely expect vitality to remain in the latter more than a quarter, or, at the outside, half, an hour after it has ceased in the former. The recorded instances in which a living child was extracted ten, twelve, and: even forty hours after death were most probably eases in which thei mother fell into a prolonged trance or swoon, during the continuance of/ which the child must have been removed. A few authentic cases, how-^ ^ This was done twice siiccessfnllv by Prof. William Gibson in the case of Mrs. Eey- bold of Philadelphia in 1835 and 1837, after she had twice been delivered by craniot- omy under Prof. Charles D. Meigs, who declined destroying any more children for her. Mrs. R. still lives at the age of seventy, and the daughter and son likewise, with their six children. — Harris' note to 3d American edition. [She died Aug. 15, 1885, aged 76. — Ed.] 2 Monat. f. Geburt. suppl. 1862, Bd. xviii. S. 112. ^ 3 " Post-mortem Delivery," Amer. Journ. of Obst., 1879, vol. xii. pp. 1 and 374. 524 OBSTETRIC OPERATIONS. ever, are known in which there can be no reasonable doubt that the operation was performed successfully several hours after the mother was actually dead. I Since, then, there is a chance, however slight, of saving the child's life, we are bound to perform the operation, even when so much time has elapsed as to render the chances of success extremely small.) It might be considered almost superfluous to insist on the uece&sity of assuring; ourselves of the mother's death before commencing the neces- sary incisions; but, unfortunately, numerous instances are known in which mistakes in diagnosis have been made, and in which the tirst steps of the operation have shown that tiie mother was still alive. The operation should therefore always be performed with the same care and caution as if the mother were living. If death have occurred during labor, some have advised version as a preferable alternative. This can only be resorted to with any hope of success if the passages be in a con- dition to admit of delivery with rapidity ; otherwise the delay occa- sioned by dilatation, even when forcibly accom})lished, and the drawing of the child through the pelvis, will be almost necessarily fatal. The only argument in favor of version is that it is less painful to the friends; and if they manifest a decided objection to the Cesarean section, there can be no reason why an attempt to save the child in this way should not be made. Causes of Death after Caesarean Section. — The causes of death after the Ceesarean section may, speaking generally, be classed under four principal heads: hemorrhage, perit(mitis and metritis, shock, septi- ceemia and exhaustion from long delay. These are pretty much the same as those following ovariotomy, and the resemblance between the two operations is so great that modern experience as to the best mode of performing ovariotomy, as well as regards the after-treatment, may be taken as a guide in the management of cases of Caesarean section. Hemorrhage to an alarming extent is a frequent complication, though seldom the cause of death. Thus, out of 88 operations, the particulars of which have been carefully noted, severe hemorrhage occurred in 14, 6 of which terminated successfully, and in 4 only could the fatal result be ascribed to the loss of blood. In 1 of these the source of the hem- orrhage is not mentioned, in another it came from the wound in the abdominal wall, and in the other 2 from the uterine incision being made directly over the placenta. In neither of the two latter was the loss of blood immediatelv fatal, for it was checked bv uterine contraction, and only recurred after many hours had elapsed. The divided uterine sinuses, and the open mouths of the vessels at the placental site are the most common sources of hemorrhage. Much may be done to diminish the risk of bleeding, but even with every precaution it must be a source of danger. Hemorrhage from the abdominal wall may be best prevented by making (the incision as nearly as possible in the line of the linea alba; so as not lo Mound the epigas- tric arteries, and by controlling bleeding by pressure-forccjis as we pro- ceed, as is done in ovariotomy. The principal Toss oF blood will be met with in dividing the uterus, and this will be the greatest when the incis- ion is near or over the placental site, where the largest vessels are met THE CMSAREAN SECTION. 525 with. We are recominended to ascertain the position of the placenta by auscultation, and thus, if possible, to avoid openino; the uterus near its insertion. But even if we admit the placental souffle to be a guide to its situation if the placenta be attached to the anterior walls of the uterus, a knowledge of its position would not always enable us to avoid opening the uterus in its immediate vicinity. (We must, in the event of its lying under the incision, rather hope to control the hemorrhage by removing it at once fi'om its attachments and rapidly emjptying the uterus. I AVhen the child has been removed there may be a large escape of blood, but this will generally be stopped by the contraction of the uterus in the same manner as after natural labor. Should contraction not take place, the uterus may be firmly grasped for the purpose of exciting it. This plan is advocated by Ludwig Winckel, who had a large experience in the operation, and by using free compression in this way, and making a point of not closing the wound until the uterus is firmly contracted, he has never met with any inconvenience from hem- orrhage. If bleeding continue, styptic applications may be used, as in a case reported by Hicks, who was obliged to swab out the uterine cav-. ity with a solution of perchloride of iron. The method first used by [^] ) Miiller, and now adopted by most operators, of placing a soft-rubber f cord round the uterus after its contents have been removed, will tend effectually to control hemorrhage, and should always be employed. [It is often applied before the uterine incision is made. — Ed.] Among the most frequent causes of death are peritonitis and metritis. Kayser attributes the fatal results to them in 77 out 123 unsuccessful cases. [Of 79 deaths specially noted in this country, 31 were from peritonitis, 17 frona exhaustion, 14 from septicaemia, 12 from shock, and 5 from internal hemorrhage. — Ed.] The mere division of the peritoneum will not account for the fre- quency of this complication, since its occurrence is considerably more frequent than after ovariotomy, in which the injury to the peritoneum is quite as great, and indeed greater if we take into account the adhe- sions which have to be divided or torn in that operation. The division of the uterus must be regarded as one source of this danger. Dr. West lays great stress on its unfavorable condition after delivery for reparative action. He believes that the process of involu- tion or fatty degeneration which commences in the muscular fibres pre- vious to delivery renders them peculiarly unfitted to cicatrize ; and he points out that on post-mortem examination the edges of the incision have been found dry, of unhealthy color, gaping, and showing no tend- ency to heal. On this account Hicks and others have operated ten days or more before the full period of labor, in the hope that the risk from this source might be avoided. [Recent careful investigations have proved this to be a fallacy. There is nothing in the post-partum uterine changes to interfere with the process of healing if the tissues of the organ are in a normal state. An operation before labor or just after it has begun will be followed usually by a rapid cicatrization if thcAvoman is in fair health. — Ed.] It is by no means certain, however, that the change in the uterine fibres is tlie cause of the wound not healing, and \} It was by Prof. Litzmann of Kiel, in 1878. — Ed.] 526 OBSTETRIC OPERATIONS. involution will commence at once when the uterus is emptied, even if the full period of pregnancy have not arrived. As a point of ethics, moreover, it is questionable if we are justified in anticipating the date of so dangerous an operation, even by a few weeks, unless the l^enefit to be derived is very decided indeed. [The teaching of Profs. Goodell, (Lusk, and Kelly, all successful operators, having saved seven cases collec- jtively, is not in correspondence Avitli this opinion. Having far less fear /of the operation than Prof. Playfair has, our best operators prefer in (many cases to make the section before Jabor has commenced, so as to select an opportune time and secure the best possible results. — Ed.] One important cause of peritonitis is the escape of the lochia through the uterine incision into the cavity of the peritoneum, Mhieh there decompose and act as an unfailing source of irritation.) This maybe prevented, to a great extent, by seeing that the os uten is patulous, so as to afford a channel for the escape of discharges and by effective closing of the uterine wound by sutures. In addition, there is the danger arising from blood and liquor amnii escaping into the peritoneum, and subsequently decomposing. There is little evidence that ^' la toilette du peritoiue," on which ovariotomists now lay so much stress, has ever been particularly attended to in Csesarean operations. [^] The chief predisj)osing cause of these inflammations, however, must be looked for in the condition of the patient, just as asthenic inflamma- tion in ovariotomy is most frequently met with in those whose general health is broken down by the long continuance of the disease. We are fully justified, therefore, in assuming that peritonitis and metritis will be more likely to occur after the Csesarean section when that operation has been unnecessarily delayed and when the patient is exhausted by a protracted labor. In proof of this we find that in a large proportion of the cases above mentioned peritonitis occurred when the operation was performed under unfavorable conditions. The sources of septicsemia are abundantly evident, not the least, probably, being absorption by the open vessels in the uterine incision. The last great danger is general shock to the nervous system. In Kayser's 123 cases, 30 of the deaths are referred to this cause. In the large majority of these the patient was profoundly exhausted before the operation was begun. It is in predisposing to these nervous com- plications that "we should, a priori, expect that vacillation and delay w^ould be most hurtful ; and in operating Avheu the patient's strength is still unimpaired w^e afford her the best chance of bearing the inevitable shock of an operation of such magnitude. In addition, a few cases have been lost from accidental complications, w'hich are liable to occur after any serious operation, and which do not necessarily depend on the nature of the procedure. There is only one source of daiiger special to the child which is worthy of attention. fAs the infant is W'uv^ rciiiovcd from the cavity of the uterus the muscular parietes sometimes contract with great rapidity and force, so as to seize and retain some part of its body. ) This occurred in two of Dr. Radford's cases, and in one of them it is stated that " the \} This certainly does not apply to many recent operations in our country and upon the continent of Europe. — Ed.] THE CESAREAN SECTION. 627 child was vigorously alive when first taken hold of, but from the length of time occupied in extracting the head it became so enfeebled as to show only slight signs of life/' and subsequently all attempts at resuscitation failed. I have myself seen the head caught in this way, and so forcibly retained that a second incision was required to release it. In Dr. Rad- ford's cases the placenta happened to be immediately under the incision, and he attributes the inordinate and rapid contraction of the uterus to its premature separation. It is difficult to believe that this was more than a coincidence, because the contraction does not take place until the greater part of the child's body has been withdrawn, and because numer- ous cases are recorded in which the uterus was opened directly over the placenta or in which it was lying loose and detached, in none of which this accident occurred. The true explanation may, I think, be found in the varying irritability of the uterus in different cases. Irrespective of the risk of portions of the child being caught and detained, rapid contraction is a distinct advantage, since the danger of hemorrhage is thereby thus diminished.;' Serious consequences may be best avoided by removing, when practicable, the head and shoulders of the child first, or by employing both hands in extraction, one being placed near the head, the other seizing the feet.) Either of these methods is preferable to the common practice of laying hold of the part that may chance to lie most conveniently near the line of incision. If this point were properly attended to, although the detention of the lower extremities might occasionally occur, the life of the child would not be imperilled. [We teach just the reverse in this country, and timt is to deliver by the feet ; which is also in accordance with the directions given in continental Europe. A rapid pedal delivery runs no risk of the foetus being caught by the neck. — Ed.] The Patient should be Prepared for the Operation. — The prep- aration of the patient for the operation should seriously occupy the attention of the practitioner, and this is the more essential since almost all patients requiring the Csesarean section are in a wretchedly debili- tated condition. If the patient be not seen until she is actually in labor, of course this is out of the question. But this will rarely be the case, since the deformed condition of the patient must generally have attracted attention. Every possible means should be taken, therefore, when practicable, to improve the general health by abundance of simple and nourishing djet, plenty of" fresh air, and suitable tonics (amongst which preparations of iron should occupy a prominent place), while the state of the secretions, the bowels, skin, and kidneys should be specially attended to. Whenever it is possible a large, airy apartment should be selected for the operation, which should never be done in a hospital if other arrangements be practicable. [^] These details may seem trivial and unnecessary, but to ensure success in so hazardous an undertaking no care can be considered superfluous, and probably the want of attention to such points has had much to do with increasing the mortality. The question arises whether we should operate before labor has com- menced. By selecting our own time, as some have advised, we certainly \} In this country we believe now that cases do better in hospital, as a general rule, than at tlieir own homes. — Ed.] 628 OBSTETRIC OPERATIONS. have llic advaiitairc <»i' ojx'ratinjx iiiuk'i- the most favoral)lo oonditioiis i instead of possil)lv liui-ricdly. (Tlicre arc, liowcvcr, miiiHTous advan- tages in waiting until s])ontaneous uterine aetion has ooniinenced which seem to me to more than counterbalance the advantages of choosing our own time.) Prominent among these is the })artial opening of the os uteri, so as to aflbrd a channel ibr the escape of the lochia, and the cer- taintv of active contraction of the uterus to arrest hemorrhage. Barnes recommends that premature labor should be first induced, and then the operation performed. This seems to me to introduce a needless element of com})lexity ; and besides, in cases of great deformity it is by no means always easy to reach the cervix with the view of bringing on labor. All needful arrangements should be made, so as to avoid hurry and excitement when the operation is commenced, and we may then wait patiently until labor has fiiirly set in./ [I have seen ojicrations yjperformed before labor began, soon after laoor was induced, and after '/it came on naturally, and confess that I prefer the advantages aff()rded /jbv the first. Unless there is stenosis of the cervix it Avill generally be }} wide enough open for drainage ; if it is not, labor can be safely induced 1 1 at a selected time. — Ed.] The Administration of Anaesthetics. — The operation itself is sim- ple. The patient should be placed on a table in a good light and with the temperature of the room raised to about 65°. Chloroform has so frequently been followed by severe vomiting that it is probably better not to administer it. For the same reason, Mr. Spencer Wells has long given up using it in ovariotomy, and finds that chloro-methyl answers admirably; ether also is devoid of the disadvantages of chloroform. In one or two cases local anaesthesia has been used by means of two sjiray- producers acting suiiiirtaneously ; and this plan, if the patient have suf- ficient fortitude to dispense with general anaesthesia, has the further advantage of stimulating the uterus to poMcrful contraction. To ensure as great a measure of success as possible the operation should be performed with all the minute precautious used in ovari- otomy. Description of the Operation. — The incision should be made as much as possible in the line of the Ijiiea^alba, so as to avoid wounding the epigastric arteries. On account of the deformity the configuration of the abdomen is often much altered, and some liave advised that the incision should be made oblique or transverse and on the most promi- nent part of the abdomen. The risk of hemorrhage being thus much increased, the practice is not to be recommended. [The color-lhie .so common in ])rcgnancy will indicate in many women the direction the incision is to take in order to strike the linea alba correctly. The more truly this is done, the less likely is hemorrhage to occur from the edges of the wound. — Ed.] (The incision, commencing a little above the umbilicus, is carried down for about three inches below it. ) The skin and muscular fibres are carefully divided, layer by layer, until the shin- ing surface of the peritoneum is reached, and any bleeding vessels should be secured as we proceed. A small oj)eniug is now made in the pei'itoneum, which should be laid open along the whole length of the incision upon two fingers of the left hand introduced as a guide. A THE CJESAREAN SECTION. 529 few silk sutures, three or four, should now he passed throufrh the upper end of the ineision. The objeet of these is to temporarily elose the abdominal parietes after the uterus is opened, so as to prevent the escape of the intestines, or the entrance of blood, etc. into the peritoneal cavity. Before incising; the uterus an assistant should carefully suj)port it in ai proper position, and push it forward by the hands placed on either side! of the incision, so as to bring its surface into apposition with the exter-j nal wound and ]3revent the escape of the intestines. If we have' reason to believe that the placenta is situated anteriorly, we may incise the uterus on one or other side ; otherwise the line of incision should be as nearly as possible central. The substance of the uterus is next divided until the membranes are reached, which are punctured and divided in the same way as the peritoneum. The uterine incision should be of the same length as that in the abdomen, and it should not be made too near the fundus, for not only is that part more vascular than the body of the uterus, but wounds in that situation are more apt to gape, and do not cicatrize so favorably. After the uterus is opened Dr. Lud- wia: Winckel recommends that the fineers of an assistant should be placed in the two terminal angles of the wound, so that the ends of the incision may be hooked up and brought into close apposition with the abdominal opening. By this means he prevents not only the escape of blood and liquor amnii into the cavity of the peritoneum, but also the protrusion of the abdominal viscera. Removal of the Child. — The child should now be carefully removed, the head and shoulders being taken out (if possible) first; [^] the placenta and membranes are afterward extracted. Should the placenta be unfor- tunately found immediately under the incision, a considerable loss of blood is likely to take place, which can only be checked by removing it from its attachments and concluding the operation as rapidly as pos- sible. Eventration of the Uterus. — As soon as the child is removed the uterus should be turned out of the abdominal cavity, which is tempo- rarily closed by the sutures already introduced, and further protected by placing a large flat sponge behind the uterus. At the same time, hem- orrhage is controlled by a rubber cord tied round the cervix. [Inl many cases the uterus is turned out whole, the cervix is constricted by I manual pressure or the tube of Esmarch, and then the uterus is opened \ and the foetus removed. In such operations the foetus is usually some- \ what asphyxiated. — Ed.] This gives time thoroughly to attend to the suturing of the uterine incision, a point of great importance. The uterus should now be surrounded by soft napkins wrung out of warm l-iu-2000 perchloride-of-mercury solution. After the placenta has been removed and the hemorrhage arrested we should see that the os uteri is open, so that any fluid in the uterine cavity may drain into the vagina. The cavity should also be dusted with iodoform. Importance of Securing Uterine Contraction. — As soon as the child and the secundines have been extracted, the sooner the uterus con- tracts the better. It will usually do so of itself, but should it remain [^ We say here, feet first, according to the most experienced continental authori- ties. — Ed.] 3i 530 OBSTETRIC OPIJRATJOXS. lax ami flabhv it sliould l)e pivssL-d and sliimilated hy the iiaiid. We arc spL'cially warned against iiandlin*!; the uterus l>y Kanishotliuni and others; hut there seems no valid reason why we should not restrain hemorrhage in this way as after a natural labor. The intervention of the abdominal i)arietes in their lax condition after delivery can make very little diilerence between the two cases. E rgot in c administered liyj)odermieally will also be useful in promoting enieient contraction. Closure of the Uterine "Wound. — Much of the recent success in this operation is due to the carefid closing of the uterine incision by .sutures. Sanger, who has paid great attention to this point, strips off the peritoneum for about five centimeters on each side of the incision, and then resects the muscular wall for about two centimeters.['] [This is very rarely done now by any oj^erator, unless the peritoneum is so tightly adherent that it will not slide over the nniscular coat, which is seldom the case. — Ed.] This done, he inserts eight to ten deep sutures of soft silver wire through the peritoneum aud muscle, but not through the mucosa, taking care to turn in the soft peritoneal flaps so as to bring them into accurate contact, Avith the view of securing rapid adhesion. The reason for not passing the suture into the uterine cavity is to pre- vent the possibility of sejitic material finding its way along the track of the sutures into the peritoneum. Finally, he passes twenty to twenty- five fine silk sutures through the inverted edges of the peritoneum. Leopold, who saved sixteen out of nineteen cases at Dresden, adopts much tlie same plan, but he does not strip off the peritoneal flaps nor excise any portion of the uterine walls; and his method is certainly simpler and apparently quite as effectual. The provisional elastic tub- ing may now be removed aud the uterus replaced in the abdominal cavity. [Pure Chinese silk is the material generally preferred for both the deep, and superficial uterine sutures. The Lembert stitches are usu- ally a few more than the deep-seated: 10 or 12 deep, and 14 to 16 Lembert, are about the average. Silver wire is still preferred by a few operators, and chromic catgut by others, for the deep sutures. Catgut is not a very safe material for holding its knots. — Ed.] ( A point of great importance, and not sufficiently insisted on, is the 1 advisability of not closing the abdominal wound until we are thoroughly ■ satisfied that hemorrhage is completely stopped, since any escape of ; blood into the peritoneum would very materially lessen the chances of recovery. In a successful case reported by Dr. Newman- the Mound was not closed for nearly an hour. [Where the uterus is proj)erly sutured there can be no occasion for this delay. The Esmarch tube prevents blood-loss while the uterine wound is being closed, and the suture-pres- sure prevents it after the tube is taken off. Under the old operation delay was valuable, but it is not required now. AVe have seen three successful operations entirely completed in thirty-five, thirty-two, and twenty- five minutes respectively. The great danger from hemorrhage is dur- ing the incising and evacuating of the uterus where the placenta is [^ These measures are in error by an oversight. Five centimeters are nearly two inches, and two are i| of an incli ; millimeters are intended. — Ed.] ^ Obst. Trans., 1867,, vol. viii. p. o43. THE CjESAREAN SECTION. 531 under the line of incision. — Ed.] Before doing so all blood and dis- charges should be carefully removed from the peritoneal cavity by clean soft sponges dipped in warm water. The abdominal wound should be closed from above downward by wire or silk sutures, which should be inserted at a distance of an inch from each other and passed entirely through the abdominal walls and the peritoneum, at some little distance from the edges of the incision, so as to bring the two surfaces of the peritoneum into contact. [^] By this means we ensure the closure of the peritoneal cavity, the opposed surfaces adhering with great rapidity. If, as should be the case, the operation is performed with full antiseptic pre- cautions, the wound should now be dressed precisely as after ovariotomy. Subsequent Management. — Into the subsequent treatment it is unnecessary to enter at any length, since it must be regulated by gen- eral principles, each symptom being met as it arises. It has been cuB-t tonTary to administer opiates freely after the operation, but they seem to! have a tendency to produce sickness and vomiting, and ought not to be' exhibited unless pain or peritonitis indicates that they are required. In fact, the treatment should in no way differ from that usual after ovari- otomy, and the principles that should guide us will be best shoMai by the following quotation from Mr. Spencer Wells' description of that opera- tion : "■ The principles of after-treatment are — to obtain extreme quiet, comfortable warmtli, and perfectly clean linen to the patient ; to relieve pain by warm applications to the abdomen and by opiate enemas ; to give stimulants when they are called for by failing pulse or other signs of exliaustion; to relieve sickness by ice or iced drinks; and to allow plain, simple, but nourishing fobd. The catheter must be used every six or eight hours, until the patient can move without pain. The sutures are removed on the third day, [^] unless tympanitic distension of the stomach or intestines endangers reopening of the wound. In such circumstances they may be left for some days longer. The superficial sutures may remain until union seems quite firm." Porro's Operation. — Within the last few years an important modi- fication of the Csesarean section has been adopted, which is generally known as Porro's operation, from Professor Porro of Pa via, who was the first European surgeon who practised it. In this operation, after the uterus is emptied the entire organ is drawn out of the abdominal wound and excised, its neck being first constricted so as to suppress hemorrhage, the stump being fixed externally in the manner of the pedicle in ovariotomy. The idea is by no means new. It appears to have been first suggested by an Italian — Dr. Cavallini — in 1768. In 1823 the late Dr. Blundell made the same proposal, and fortified it by numerous experiments on pregnant rabbits, in the course of which he found that he lost all by the Csesarean section, but saved three out of four in which he ligatured and amputated the uterus. The suggestion was not, however, carried into actual practice until Dr. Storer of Boston in 1869 removed the uterus in a case of fibroid tumor obstructing the pelvis and impeding delivery. \} American operators prefer to put their sutures much nearer tlian this, to diminish the individual tension. — Ed.] |[* Rarely before the sixth to eighth in the United States. — Ed.] 532 OBSTETRIC OPERATIONS. Since Porro's first case the operation has been frequently performed on the Continent, with resuhs which are, on the whole, encouraging. The cases have been carefully tabulated by Dr. Harris of Philadelphia, and more recently and very comj^letely by Dr. Clement Godson,' who has collected 215' cases, out of which 109, or 50.6 i)er cent., were suc- cessful as regards the mother, [Dr. Godson is much behind in his record, as my table has 260 cases \\\) to the same date, with 142 women saved. There were 89 operations, with 19 deaths and 1 suicide, in the years 1885, 1886, 1887, and 1888.— Ed.] The obvious advantage of _ this plan is, that instead of leaving the incised uterus, with its proba-' bly gaping wound and all the attendant risk of septic mischief, in the abdominal cavity, it is fixed externally and in a position Avhere it can be readily dressed. The objection is that it entirely uusexes the patient, but in the class of women requiring the Csesarean section from pelvic deformity it is questionable whether this can be fairly considered as a drawback. It is perhaps not justifiable to attempt as yet any positive decision as to the indications for this plan. It certainly seemed at first to be less dangerous than the Csesarean section, but the improved results recently obtained in the latter operation have shown how it affords the patient as good if not a better chance, without permanent mutilation. " It seems probable, therefore, that in future the Porro operation will be chiefly adopted when for some reason, such as the existence of fibro- myoraata, the ablation of the uterus is specially indicated." [We believe that the Porro operation will, in all probability, meet Avith better success than the " conservative " method in Great Britain, from the fact that the last five cases in order have all recovered. Holding the views there generally advocated, the section M'ill only be made in badly-deformed rachitic dwarfs and in the subjects of malacosteon, which are much more frequently thus delivered than the former. These will probably do better under the exsective method, which besides has the advantage that it sometimes cures malacosteon, as shown by the results in continental Europe. — Ed.] The operation in the suc- cessful cases has been performed M'ith full antiseptic precautious, and the neck of the uterus, after the organ is emptied, carefully secured by ligatures before its body is amputated. Some operators have encircled the neck of the uterus Avith a chain or wire ecraseur before removing it, and by this means completely controlled hemorrhage. Richardson ^ transfixed the neck of the uterus with two large pins crossing each other before removing the wire of the ecraseur, and encircled it with stout carbolized cord. Miiller of Berne has rcconnncndcd that the entire uterus shoidd l)e turned out of the abdominal cavity through a long incision before it is emptied, so as to avoid the risk of its fluid contents entering the abdomen ; but this manoeuvre has not always proved feasi- .ble. The pedicle has generally been fixed in the lower angle of the abdominal wound and dressed antiseptically. In most cases one or ' " Form's Operation," Brit. Med. Journ., 1884, vol. i. p. 142. * Dr. Godson has kindly made up these figures for rue up to the present date (Janu- ary, 1889). ^American Journ. of Med. Science, 1881. THE CESAREAN SECTION. 533 more drainage-tubes have been used, either through Douglas' space or ill the abdominal wound. Symphysiotomy. — Bearing in mind the great mortality attending the Ciesarean section, it is not surprising that obstetricians should have anxiously considered the possibility of devising a substitute which should afford the mother a better chance of recovery. The first pro- posal of the kind was one from which great results were at first antici- pated. In 1768, Sigault, then a student of medicine at Angers, sug- gested symphyHiotom.}!, which consists in the division of the symphysis pubis with a view of allowing the pubic bones to separate sufficiently to admit of the passage of the child. [The idea was not original, but came from reading the work of Severin Pineau, who suggested it. — Ed.] Although at first strongly opposed, it was subsequently ardently advocated by many obstetricians, and was often performed on the Continent and in a few cases in England. [^] It is generally admitted that it is quite impossible to make this a substi- tute for the Cajsarean section, since the utmost gain which a wide sep- aration of the symphysis pubis would give would be altogether insuffi- cient to admit of the passage of even a mutilated foetus. Dr. Churchill concludes that if it were possible to separate it to the extent of four inches, we should only have an increase of from four lines to half an inch in the antero-posterior diameter, in which the obstruction is gen- erally most marked. In the lesser degrees of deformity this might possibly be sufficient to allow the foetus to pass, but the risk of the operation itself, and the subsequent ill effects, P] altogether contra- indicate it in cases of this description. [As the Neapolitan advocates of symphysiotomy do not advise its performance in cases with a conjugate of less measure than 67 milli- meters, or 2f inches, it is not adapted to extreme pelvic deformities, and cannot take the place of the Csesarean section. The design of the operation is to avoid craniotomy in cases where the forceps cannot be made effective, and where a moderate increase of pelvic space will enable a mother to deliver herself of a living foetus. The first 50 operations after the revival in Naples in 1866 saved 40 women and 41 children. — Ed.] ['Once only by Mr. Jolm Welcliman of Kingston, Eng., in 1782. — Ed.] ['■'Prof. Ottavio Morisani of Naples, tlie best living authority, denies the existence of the " subsequent " ill effects claimed by Robert Barnes and others in England. Women have been twice operated upon with success. — Ed.] 534 OBSTETRIC OPERATIONS. CHAPTER VII. LAPAKO-ELYTKOTOMY. In the early etlitions of this Avork laparo-elytrotomy was Ijriofly CO II. side red as one of the suggested substitutes for the ("lesarean section Mhieh merited careful study and a])peared to he of a promising chara<-- ter, but of which too little Mas known to justify any positive conchi- sions with regard to it. The subject naturally attracted considerable attention, and several interesting papers have appeared in Avhich its indications, difficulties, and advantages have been carefully considered. Since Thomas' first case was })ublislK'd several operations have been performed, with results so encouraging that I cannot but believe that the ojieration has a i'uture before it, and that it may sometimes be resorted to instead of the more hazardous Csesareau section unless some special contraindication exists. Under these circumstances it seems proper no longer to consider it as an addendum to the description of the Cfesarean section, but to study it more in detail in a separate chapter. History. — The history of the operation is curious and interesting. The earliest suggestion of a procedure of this character seems to have been made by joerg in the year 1806, who proposed a modified Cesa- rean section, without incision of the uterus, by the division of the linea alba and of the upper part of the vagina, the foetus being extracted through the cervix. Tliis suggestion was never carried into practice, and it is obvious that it misses the one chief advantage of lai>aro- elytrotomy, the leaving of the peritoneum intact. In 1820, Kitgeu proposed and actually attempted an o])eration much resembling Thomas', in which section of the peritoneum was avoidal. He failed, however, to complete it, and was eventually compelled to deliver his patient by the CVesarean section. In 1S2.'>, Baudcl()c(|ue the younger independently conceived the same idea, and actually car- ried it into practice, although without success. Lastly, in 1837, Sir Charles Bell suggested a similar operation, clearly ])erceiving its advan- tages. Hence it appears that previous to Thomas' recent work in the matter the operation was independently invented no less than three times. It fell, however, entirely into oblivion, and was only occasionally men- tioned in systematic works as a matter of curious obstetric history, no one ajipareutly aj)preciating the promising character of the procedure. In the year 1870, Dr. T. Gaillard Thomas of New York read a paper before the ^ledical Association of the town of Yonkers on the Hudson River entitled " Gastro-elytrotomy a Substitute f()r the i'vosa- rean Section,'' in which he descril)ed the operation as he had jierformed it three times on the dead subject, and once on a married woman in 1870, with a successful issue as regards the child. It seems bcvond doubt that LArARO-EL YTROTOMY. 535 Thomas invented the operation for himself", being ignorant of Ritgen's and Baudelo('(|uc''s previous attempts, and it is eertain, to quote Gar- rigues/ that to him " belongs the glory of having Ijeen the first who performed gastro-elytrotomysoas to extract a living child from a living mother in his first operation, and of having brought both mother and child to complete recovery in his second operation." Since Thomas' first case the operation has been performed four times by Dr. Skene of Brooklyn, and has found its way across the Atlantic, having been performed by llime in Sheffield, Ed is in London, and Poullet in Lyons. [Laparo-elytrotomy has been performed 14 times with 7 recoveries: 5 children were dead ; 1 died in an hour ; 1 died in eighteen days, and 7 are recorded as " saved." In successful issue it is now much behind the average of the Sanger and Porro operations of the last four years. — Ed.] Nature of the Operation. — The object of laparo-elytrotomy is to reach the cervix by incision through the lower part of the abdominal, wall and upper part of the vagina, aud through it to extract the foetus ( as may most easily be done. Advantages over the Caesarean Section. — If this procecUire is found practicable, the enormous advantages it offers over the Csesareaa section are at once apparent, since in dividing the abdomen the ab- dominal wall only is incised and the peritoneum is left intact. The vagina is divided, but incision of the uterine parietes, which forms one of the chief risks of the Cesarean section, is entirely avoided. Now there is nothing in either of these procedures alarming in itself, and if further experience proves that the practical difficulties of the operation do not stand in the way of its adoption. Dr. Thomas will have intro- duced by his able advocacy of the operation probably the greatest improvement in modern obstetrics. / Cases Suitable for the Operation.— ^It may be broadly stated that laparo-elytrotomy is applicable in all cases calling for the Cesarean sec- tion when the mother is alive. ;In post-mortem extractions of the fetus the Cnesarean section, being the most rapid procedure, would certainly be preferable.: Exceptions must be made for certain cases of morbid conditions of the soft parts which render delivery per vias naturales impossible, and in which laparo-elytrotomy could not be performed, as in cases of tumor obstructing the pelvic cavit)', also in carcinoma or fibroid of the uterus.] When the head is firiuly impacted in the pelvic brim and cannot be dislodged, the operation would be impossible, as the vagina could not be incised. [In more than 25 per cent, of American Csesareau cases laparo-elytrotomy was certainly inapplicable. It was probably so in a number more, perhaps in all nearly one-third. — Ed.] Unlike the Cesarean section, the oj)eration cannot be performed twice n the same patient, at least on the same side, since adhesions left by the former incisions would prevent the separation of the peritoneum and division of the vagina.] It remains to be seen whether in certain cases of extreme deformity, with pendulous abdomen and distorted thighs, the site of incision might not be so difficult to reach as to ren- der the necessary manoeuvres im]>ossible. ' New York Mai. Jonrn., 1878, vol. xxviii. pp. 337, 449. ^ 536 OBSTETRIC OPERATIONS. Anatomy of the Parts concerned in the Operation. — It will facilitate the proper comprehension of the operation, and i-ender an avoidance of its possi])]e dangers more easy, if the anatomical relations of the parts concerned are bi'iefly described. The abdominal incision extends from a j)oint an inch above the ante- rior superior iliac spine, and is carried, with a sliglit arallel to Pon])art's ligaments until it reaches a point one inch and three-quarters above, and to the outside of, the spine of the j)ul)es. Beyond the latter point it must not extend, so as to avoid the risk of wounding the round ligament and the epigastric artery. In this incis- ion the skin, the aj)oneurosis of the external oblique, and the fibres of the internal oblique and transversalis muscles are divided. The rectus is not implicated. After the muscles are divided the transversalis fascia i$ reached. It is fortunately rather dense in this situation, and is sep- arated from the peritoneum by a layer of connective tissue containing fat. The superficial epigastric artery is necessarily divided, but is too small to give any trouble. The internal epigasti-ic is fortunately not divided, but is so near the inner end of the incision that it may acci- dentally be so. In one of Dr. Skene's operations it was laid bare. Starting from the external iliac about a quarter of an inch above Pou- jiart's ligament, it runs dow'u ward, forward, and inward to the ligament, thence it turns upward and inward, in front of the round ligament and to the inner side of the internal abdominal ring, behind tlie jiostcrior layer of the sheath of the rectus nuiscle, which it finally enters. The circumflex iliac arten; also rises from the external iliac a little below the epigastric. It runs between the peritoneum and Poupart's ligament until it reaches the crest of the ilium, to the inner side of which it runs. It thus lies altogether below the line of the incision, and is not likely to be injured. After the transversalis fascia is divided the peritoneum is reached, and is readily lifted up intact, so as to expose the ujiper part of the vagina, through which the fcctus is extracted. It is fortunate, as facil- itating this manoeuvre, that the peritoneum is much morgja-x than in the non-pregnant state, and it has been found very easy to lift it out of the way in all the operations hitherto performed. The division of the vagina is the part of the operation likely to give rise to most trouble and risk. It is to be noted that in cases of pelvic contraction calling for this operation the uterus with its contents will be almormally high and altogether above the pelvic brim ; the vagina is therefore necessarily elongated and brought more readily within reach. It is enlarged in its upper part during jiregnancy, and thrown into folds rcadv f"or dilatation during the passage of the child. It is k>osely .surrounded by the other tissues, and is composed of muscular fibres easily separable and an internal mucous layer. Its vascular arrange- ments are very complex, and the risk of he morrha ge is one of the prom- inent difficulties of the oju'ration. In Baudelocque's attem])t, in which the vagina was cut instead of torn, the loss of blood was so great as to lead to a discontinuance of the operation. The arteries are numerous, consisting of l)ranches from LAPARO-ELYTROTOMY. 537 the hypogastric, inferior vesical, uiternal piidic, and hemorrhoidal. The veins form a network surrounding the whole canal, but are largest at its extremities, so that it is desirable to open the vagina as low down as possible. Behind the vagina lies the pouch of peritoneum known as Douglas' space, and below that the rectum. In front of it lies the bladder, and the risk of injuring that viscus or the ureter entering it constitutes another of the dangers of the operation. The relations of these jiarts have been specially studied by Garrigues ^ with the view of facilitating the safe performance of the operation, and I quote his description : " The anterior superior surface of the vagina is in its upper part bound by loose connective tissue to the bladder on a surface that has the shape of a heart. In the lower or anterior part the boundary-line of this surface runs parallel to, and a little outside of, the tngonum vesi- cale. In the upper part it follows the outline of the vagina, from which it passes over to the cervix. The distance from the internal opening of the urethra to the neck of the womb is one inch and a quarter (3.2 centimeters). The bladder extends five-eighths of an inch (1.5 centi- meters) upon the cervix. It is very liable to be reached by the vaginal rent if the latter is made too high up or too horizontal. The lower part of the antero-superior wall carries in the middle line the urethra. In the uppermost part, a little outside of and behind the bladder, lies the ureter. In order to avoid the ureter and the bladder the incision of the vagina should be made nearly an inch and a half (3.8 centime- ters) below the uterus, and in a direction parallel to the ureter and the boundary-line between the bladder and the vagina." The Operation. — The operation has hitherto been performed on the right side only. In consequence of the position of the rejctum on the left, it seems doubtful if the difficulties of performing it on that side would not render the operation impossible. This point can only be cleared up by experience, and in the mean time the right side should certainly be selected. [This is an error, as the operations of Hime of Sheffield, Dandridge of Cincinnati, and Poullet of Lyons, in 1878, 1883, and 1885, respectively, were all performed upon the left side. In no case of the three was the bladder injured. — Ed.] For the proper performance of the operation four assistants are necessary, besides one who administers the ansesthetic. The patient is placed on her back on the o})erating-table, with the j)elvis raised and in the same position as for ovariotomy. In consequence of access of air jx'r rar/iitam strict antiseptic precautions cannot be ado[>ted. Before commencing the ope- ration the cervix is dilated as nuich as possible by Barnes' bags, assisted, if necessary, by digital dilatation. The ojierator stands on the right side of the patient, while an assistant, standing on her left, lays his hand on the uterus and draws it upward and to the left, so as to put the skin on the stretch. The incision is com- menced at a point one inch above the anterior superior spine of the ilium, and is carried inward in a slightly curved direction until it reaches a point one and three-quarter inches above and outside the spine of the pubes. The skin and nuiscular and aponeurotic tissues are care- ' Loc. ciL, p. 479. 538 OBSTETRIC OPERATIONS. I'ully divided layer bv layer, any arterial hranehes beiug seeured as they are .severed, until the transverssdis fascia is reached. This is raised by a fine tenaculum, and an aperture is made in it through which a dii-ec- tor is introduced, and on this the i'aseia is divided in the whole length of the superficial incision. The operator now separates the peritoneum from the transversalis and iliac fascia with his fingers, and an assistant, placed on his left, elevates it, as well as the contained intestines, by means of a fine warmed napkin, and keeps it well out of the way during the rest of the operation. A third assistant now introduces a silver catheter into the bladder, and holds it in the position of the boundary- line between it and the vagina, and below the uterus. A blunt wooden instrument like the obturator of a speculum is intro- duced into the vagina, which is pushed up by it above the ilio-])ectineal line. On this an incision is made by Pacj^uelin's thermo-cautery heated to a red heat only, as fir below the uterus as possible, and parallel to the ilio-pectineal line and the catheter felt in the bladder. When the vagina has been burnt through, the index fingers of both hands are pushed through the incision, and the vagina torn through as far forward as is deemed safe by the guide of the catheter in the bladder, and as far backward as possible. When this has been done the uterus is depressed to the left, and the cervix lifted into the incision by the fingers, and the membranes are ruptured. Through the cervix thus elevated the child is extracted, according to the presentation, either by simple traction by the forceps or by turning. Before concluding the oj)eration the bladder should be injected with milk to make sure that it has not been wounded. \ Should it be so, the laceration may be at once united by carbolized gut. The principal risk at this stage is hemorrhage from the vaginal vessels, which, however, fortunately, did not give rise to much trouble in any of the recent operations. If it occurs it must be dealt with as best Me can, either by ligature, by the actual cautery, or by thoroughly plugging the vaginal wound with cotton-wool both through the incision and per raghwm. If the latter be not nece&sary, the wound should be cleaned by injecting a warm solution of weak carbolized water (2 per cent.}, its edges united by iuterru])tcd sutures, and dressed as is deemed best. The subsequent treatment must be conducted on general surgical principles, and will much resemble that necessary after other severe abdominal operations, such as ovariotomy. The vagina should be gently syringed two or three times daily with a weak antiseptic lotion. The diet should be light and nutritious, chiefly consisting of milk, beef- tea, and the like. Pain, jn'rexia, etc. must be treated as they arise. [In the I'ace for supremacy lajiaro-elytrotomy has been left far in the rear by the Sanger-Ctesarean and Porro-Oesarcan operations. The last laparo-elytrotomy on record was performed on September 18, 1887, since which date we have reports of 82 Sanger ca.ses with 14 deaths, and 29 Porro cases with 3 deaths. It looks as if the operation of Prof. Thomas was not in favor, — Ed.] THE TEAJS'SFUSION OF BLOOD. . 539 CHAPTER VIII. THE TRANSFUSION OF BLOOD. The transfusion of blood in desperate and apparently hopeless cases of hemorrhage offers a possible means of rescuing the patient which merits careful consideration. It has again and again attracted the attention of the. profession, but has never become popularized in obstetric practice. The reason of this is not so much the inherent defects of the operation itself — for quite a sufficient number of success- ful cases are recorded to make it certain that it is occasionally a most valuable remedy — but the fact that the operation has been considered a delicate and difficult one, and that it has been deemed necessary to employ a complicated and expensive apparatus which is never at hand when a sudden emergency arises. Whatever may be the difference of opinion about the value of transfusion, I think it must be admitted that it is of the utmost consequence to simplify the process in every possible way, and it is above all things necessary to show that the steps of the operation are such as can be readily performed by any ordinarily quali- fied practitioner, and that the apparatus is so simple and portable as to make it easy for any obstetrician to have it at hand. There are com- paratively few who would consider it worth while to carry about with them, in ordinary every-day work, cumbrous and expensive instruments which may never be required in a lifelong practice ; and hence it is not unlikely that in many cases in which transfusion might have proved useful the opportunity of using it has been allowed to slip. Of late years the operation has attracted ranch attention, the method of per- forming it has been greatly simplified, and I think it will be easy to prove that all the essential apparatus may be purchased for a few shillings, and in so portable a form as to take up little or no room, so that it may be always carried in the obstetric bag ready for any possible emergency. History of the Operation. — The history of the operation is of con- siderable interest. In Villari's Life of Savonarola it is said to have been employed in the case of Pope Innocent VIII. in the year 1492, but I am not aware on what authority the statement is made. The first serious proposals for its performance do not seem to ha\'e been made until the latter half of the seventeenth century. It Mas first actually performed in France by Denis of Montpellier, although Lower of Oxford had previously made experiments on animals which satisfied him that it might be undertaken with success. In November, 1667, some months after Denis' case, Lower made a public experiment at Arundel House in which twelve ounces of sheep's blocxl were injected into the veins of a healthy man, who is stated to have been very well after the operation, which must, therefore, have proved successful. 540 OBSTETRIC OPERATIONS. These nearly siiiinltaneous cases gave rise to a controversy as to priority of invention, which was long carried on with much bitterness. The idea of resorting to transfusion after severe heniori'hage does not seem to have l)een then entertained. It was recommended as a means of treatment in various diseased states or witli the extravagant liope of imparting new life and vigor to the old and decrepit. The hlood (jf the lower animals only was used ; and under these circumstances it is not surprising that the operation, although practised on several occasions, was never established as it might have been had its indications been better understood. From that time it fell almost entirely into ol^livion, although experi- ments and suggestions as to its applicability were occasionally made, especially by Dr. Harwood, professor of anatomy at Cambridge, who published a thesis on the subject in the year 1785. He, however, never carried his suggestions into practice, and, like his predecessors, only proposed to emjiloy blood taken from the lower aniiuals. In the year 1824, Dr. Blimdell published his well-known work, entitled Be.'<, Physiological and Pathological, which detailed a large number of experi- ments ; and to that distinguished physician belongs the undoubted merit of having brought the subject prominently before the profession, and of pointing out the cases in which the operation might be performed with hopes of success. Since the publication of this work transfusion has been regarded as a legitimate operation under special circumstances; but, although it has frequently been performed with success and in spite of many interesting monographs on the subject, it has never become so established as a general resource in suitable cases as its advantages would seem to warrant. Within the last few years more attention has been paid to the subject, and the writings of Pauum, Martin, and De Beliua abroad, and of Higginsou, McDonnell, Hicks, Aveling, and Schiifisr at home, amongst others, have thrown much light on many points con- nected with the operation. Nature and Object of the Operation. — Trransfusion is practically only employed in cases of profuse hemorrhage connected with labor,J although it has been su ggeste d as possibly of value in certain other puerperal conditions, such as eclampsia or puerperal fever. Theo- retically, it may be expected to be useful in such diseases ; but inas- much as little or nothing is known of ics practical effects in these diseased states, it is only possible here to discuss its use in cases of excessive hemorrhage. Its action is probably twofold : 1st, the actual restitution,of JMood which has been lost ; 2d, the sujiply of a sufficient quantity of blood to stimulate the heart to contraction, and thus to enable the circulation to be carried on until fresh blood is formed. The influence of transfusion as a means of restoring lost blood must be trivial, since the quantity required to produce an effect is generally very small indeed, and never sufficient to counterbalance that which has been lost. Its stimulant action is no doubt of far more imjiort- ance; and if the operation be performed before the vital energies are entirely exhausted, the effect is often most marked. Use of Blood taken from the Lower Animals. — In the earliest operations the blood used was always that of the lower animals, gen- THE TRANSFUSION OF BLOOD. 541 erally of the sheep. It has been thought by Brown-Sequard and others that the blood of sonic of the lower animals, especially of those in which the corpuscles are of smaller size than in man, as of the sheep, might be used in safety, [)rovided it is not too rich in carbonic acid and too poor in oxygen, and injected in small quantity only. /Landois,' however, has conclusively proved that the blood of any of the lower . animals has a most injurious effect on the human red corpuscles, which rapidly become swollen and decolorized, and discharge thejLr..-Coloring matter into the serum. It is certain, therefore, that this plan cannot be adopted in practice. / The great practical difficulty in transfusion has always been the coagu- lation of the blood very shortly after it has been removed from thelBody. WlTen fresh-drawn blood is exposed to the atmosphere the fibrin com- mences to solidify rapidly, generally in from three to four minutes, sometimes much sooner. It is obvious that the moment fibrination has commenced the blood is, ipso facto, unfitted for transfusion, not only because it can be no longer passed readily through the injecting apparatus, but because of the great danger of propelling small masses of fibrin into the circulation, and thus causing embolism. Hence, if no attempt be made to prevent this difficulty it is essential, no matter wdiat apparatus is used, to hurry on the operation so as to inject before fibrination has begun. This is a fatal objection, for there is no opera- tion in the whole range of surgery in which calmness and deliberation are so essential, the more so as the surroundings of the patient in these unfortunate cases are such as to tax the presence of mind and coolness of the practitioner and his assistants to the utmost. All the recent improvements have had for their object the avoidance of coagulation, and practically this has been effected in one of three ways: 1^ by /immediate transfusion from arm to arni, without allow- ing the blood to'be exposed to the atmosphere, according to the methods proposed by Aveling, Roussel, and Schiifer ; 2d, by adding to the blood chemical reagents which have the property of preventing coagulation; 3d, removal of the fibrin entirely by promoting its coagulation and straining the blood, so that the liquor sanguinis and blood-corpuscles alone are injected. Inasmuch as the success of the operation altogether depends on the method adopted, it will be well, before going further, to consider briefly the advantages and disadvantages of each of these plans. Aveling-'s Method. — The method of immediate transfusion has been brought prominently before the profession by Dr. Aveling, who has invented an ingenious apparatus for performing it. The apparatus consists essentially of a minature Higginson's syringe without valves, and with a small silver canula at either end. One canula is inserted into the vein of the person supplying blood, the other into a vein of the patient, and by a curious manipulation of the syringe, subsequently to be described, the blood is carried from one vein into the other. It must be admitted that if there were no practical difficulties this instru- ment would be admirable, and it is therefore not surprising that it should have met Avith so much favor from the profession. I cannot ^ Die Transfusion des Bluies, Leipzig, 1875. 542 OBSTETRIC OPERATIONS. but think, however, that the operation is not so simple as at fii'st sight appears, and tliat therefore it wants one of the essential elements required in any procedure for performing transfusion. One of my objeotions is that it is by no means easy to work the apparatus without considerable practice. Of this I have satisfied myself by asking mem- bers of my class to work it after reading the printed directions, and finding that they are not always able to do so at once. Of course it may be said that it is easy to acquire the necessary manipulative skill ; but when the necessity for transfusion arises there is no time left foi' prac- tising with the instrument, and it is essential that an apparatus to be universally applicable should be capable of being used immediately and without previous experience. Other objections are — the necessity of several assistants, the uncertainty of there being a sufficient circula- tion of blood" m the veins of the donor to afford a constant supply, and the possibility of the whole apparatus being disturbed by restlessness or jactitation on the part of the patient. For these reasons it seems to me that this plan of immediate transfusion is not so simple nor so generally applicable as defibrination. Still, it is impossible not to recognize its merits, and it is certainly well worthy of further study and investi- gation. Roussel's Method. — Another method of immediate transfusion is that recommended by Roussel,^ whose apparatus has recently attracted considerable attention. It possesses many undoubted advantages, and is beyond doubt a valuable addition to our means of performing the operation. It has, however, the great disadvantage of being costly and complicated, and hence I do not believe that it is likely to come into general use. Schafer's Method. — The third method is that recommended by Dr. Schiifer in his recent excellent reports on transfusion submitted to the Obstetrical Society.^ Schafer suggests two methods of performing the operation — one from vein to vein, the other from artery to artery. The latter, he holds, has the advantage of supplying pure oxygenated blood under the best possible conditions for securing the amelioration of a patient suffering from the effects of profuse hemorrhage. The neces- sary operative proceedings are, however, somewhat complicated, and it seems to me very doubtful if this plan is likely to be at all commonly used. His method of immediate transfusion, however, is very simple and is well worthy of trial. In his experiments on the lower animals it answered admirably. I am not aware that it lias yet been tried on the human subject, but I do not see any practical difficulty in its applica- tion. For the description of the operation I have inserted Dr. Schafer's own directions for the performance of both arterial and venous imme- diate transfusion. The second plan for obviating the bad effects of clotting is the addi- tion of some substance to the blood which shall prevent coagulation. It is well known that several salts have this property, and the experi- ments made in the case of cholera patients prove that solutions of some of them may be injected into the venous system without injury. This ^ Obstetrical Transactions for 1876, vol. xviii. p. 280. ^Ibid., for 1879, vol. xxi. p. 316. THE TRANSFUSION OF BLOOD. 543 method has been specially advocated by Dr. Braxton Hicks, who uses a solution of three ounces of fresh phosphate j)f soda in a pint of water, about six ounces of which are added to the quantity of blood to be injected. He has narrated 4 cases ^ in which this plan was adopted successfully, so far as the prevention of coagulation was concerned. It certainly enables the operation to be performed with deliberation and care, but it is somewhat c omplic ated, and it may often happen that the necessary chemicals are not at hand. A further objection is the bulk of fluid which . m list, be injected, and there is reason to believe that this has in some cases seriously embarrassed the heart's action and interfered with the success of tlie operation. In many of the successful cases of transfusion the amount of blood injected has been very small, not more than two ounces. Dr. Richardson proposes to prevent coagulation by the addition of liquor ammonise to the blood in the proportion of two minims diluted with twenty minims of water to each ounce of blood. Defibrination of the Blood. — The last method, and the one ^vhich, on the whole, I believe to be the simplest and most eifectual, is defibrina- tion. It has been chiefly practised in Great Britain by Dr. McDonnell of Dublin, who has published several very interesting cases in which he employed it, and by Martin of Berlin and De Belina of Paris. The process of removing the fibrin is simple in the extreme, and occupies a few minutes only. Another advantage is that the blood to be transfused may be prepared quietly in an adjoining apartment, so that the operation may be performed with the greatest calmness and deliberation, and the donor is spared the excitement and distress which the sight of the apparently moribund patient is apt to cause, and which, as Dr. Hicks has truly pointed out, may interfere with the free flow of blood. The researches of Pauum, Brown-Sequard, and others have proved that the blood-corpuscles are the true' vivifying element, and that defibrinated blood acts as well in every respect as that containing fibrin. It has been proved that the fibrin is reproduced within a short time,^ and the whole tendency of modern research is to regard it, not as an essential element of the blood, but as an excrementitious product resulting from the degradation of tissue, which may therefore be advan- tageously removed. Another advantage derived from defibrination is • that the corpuscles are freely exposed to the atmosphere, oxygen is taken ( up, and carbonic acid given ofl", and the dangers which Brown-Sequard i has shown to arise from the use of blood containing too much carbonic \ acid are thereby avoided. There can be, therefore, no physiological 'i objection to the removal of the fibrin, which, moreover, takes away all practical difliculty from the operation. The straining to which the defibrinated blood is subjected entirely prevents the possibility of even the most minute particle of fibrin being contained in the injected fluid ; the risk from embolism is therefore less than in any of the other pro- cesses already referred to. My own experience of this plan is limited to 3 cases, but in 2 it answered so well that I can conceive no reason- able objection to it. I should be inclined to say that transfusion, thus performed, is amongst the simplest of surgical operations — an ' Guy's Hospital Reports, 1869, vol. xiv., 3d series, p. 1. ''Panum, Virehow's Arch., vol. xxvii. 544 OBSTETRIC OPERATIONS. opinion whicli the experience of McDonnell and others fully con- firms. Transfusion of Milk. — Recently the intravenous injection of freshly - cl4:aAvn warm milk has been recommended as a substitute for blood, chiefly in AmerTca, It was first used by Dr. Hodder of Toronto, but has been introduced and strongly advocated by Thomas of New York, who has used it twice after ovariotomy. Brown-Scquard in experi- menting on the lower animals found that it answered as well as either fresh or defibrinated blood, and about half an hour after the injection no trace of the milk-corpuscles could be found in the blood. Schiifer, however, found that the action of milk on the blood-corpuscles was highly deleterious, and that it introduces the germs of septic organisms likely to produce very serious results. He therefore pronounces strongly against its use. Statistical Results. — The number of cases of transfusion are per- haps not sufficient to admit of completely reliable conclusions. It is certain, however, that transfusion has often been the means of rescuing the patient when apparently at the point of death after all other means of treatment had failed. Professor Martin records 57 cases, in 43 of which transfusion was completely successful, and in 7 temporarily so, while in the remaining 7 no reaction took place. Dr. Higginson of Liverpool has had 15 cases, 10 of which were successful. Figures such (as these are encouraging, and they are sufficient to prove that the opera- Ition is one which at least offers a fair hojDC of success, and which no iobstetrician would be justified in neglecting when the patient is sinking 'from the exhaustion of profuse hemorrhage. It is to be hoped also that further experience may prove it to be of value in other cases in which its use has been suggested, but not, as yet, put to the test of exjDeriment. Possible Dangers of the Operation. — The possible risks of the operation would seem to be the danger of injecting minute particles of fibrin, which form emboli, of bubbles of air, or of overwhelming the action of the heart by injecting too rapidly or in too great cj^uantity. These may be, to a great extent, prevented by careful attenfion to the proper performance of the operation, and it does not clearly appear, from tlie recorded cases, that they have ever proved fatal. AVe must also bear in mind that transfusion is seldom or never likely to l)e attempted until the patient is in a state which would otherwise almost certainly preclude the hope of recovery, and in whicli, therefore, much more hazardous proceedings would hp fully justified. Cases Suitable for Transfusion.-vThe cases suitable for transfusion are those in which the patient is reduced to an extreme state of exhaus- tion from hemorrhage during or after labor or miscarriage, whether by the repeated losses of placenta prsevia or the more sudden and profuse flooding of post-partum hemorrhage.) The operation Avill not be con- templated until other and simpler means have been tried and failed, or until the symptoms indicate that life is on the verge of extinction. If the patient should be deadly pale and cold, with no pulse at the Avrist or one that is scarcely perceptible ; if she be unable to swallow or vomits incessantly ; if she lie in an unconscious state ; if jactitation or convul- THE TRANSFUSION OF BLOOD. 545 sions or repeated faiDtings should occur ; if the respiration be laborious or very rapid and sighing • if the pupil do not act under the influence of light, — it is evident that she is in a condition of extreme danger, and it is under such circumstances that transfusion, performed suflfici- ently soon, offers a fair prospect of success. It does not necessarily follow because one or other of these symptoms is present that there is no chance of recovery under ordinary treatment, and indeed, it is within the experience of all that patients have rallied under apparently the most hopeless conditions. But when several of them occur together the prospect of recovery is much diminished, and transfusion would then be fully justified, especially as there is no reason to think that a fatal result has ever been directly traced to its employment. Indeed, like most other obstetric operations, it is more likely to be postponed until too late to be of good service than to be employed too early ; and in some of the cases reported as unsuccessful it was not performed until respiration had ceased and death had actually taken place. It has some- times been said that transfusion should never be employed if the uterus be not firmly contracted, so as to prevent the injected blood again escap- ing through the uterine sinuses. The cases in which this is likely to occur are few ; and if one were met with the escape of blood could be prevented by the injection into the uterus of the perchloride of iron. Description of the Operation. — In describing the operation I shall limit myself to an account of Aveling's and Schafer's method of imme- diate transfusion, and to that of injecting defibrinated blood. I con- sider myself justified in omitting any account of the numerous instru- ments which have been invented for the purpose of injecting pure blood, since I believe the practical difficulties are too great ever to render this form of operation serviceable. The great objection to most of them is their cost and complexity ; and as long as any special apparatus is con- sidered essential, the full benefits to be derived from transfusion are not Fig. 194. Method of Transfusion by Aveling's Apparatus. likely to be realized. The necessity for employing it arises suddenly ; it may be in a locality in which it is impossible to procure a special iustru- 35 546 OBSTETRIC OPERATIONS. ment ; and it would be well if it were understood that transfusion may- be safely and effectually performed by the simplest means. In many of the successful cases an ordinary syringe was used ; in one, in the absence of other instruments, a child's toy syringe was emjjloyed. I have myself performed it with a simple syringe purchased at the nearest chemist's shop when a special transfusion apparatus failed to act satis- factorily. In immediate transfusion (Fig. 194) the donor is seated close to the patient, and, the veins in the arms of each having been opened, the silver cauula at either end of the instrument is introduced into them (a b). The tube between the bulb and the donor is now pinched (d), so as to form a vacuum, and the bulb becomes filled with blood from the donor. The finger is now removed so as to compress tlie distal tube (d'), and, the bulb being compressed (c), its contents are injected into the patient's vein. The bulb is calculated to hold about two drachms, so that the amount injected can be estimated by the number of times it is emj3tied. The risk of injecting air is prevented by filling the syringe with water, which is injected before the blood. Schafer's Directions for Immediate Transfusion. Direct Venous Transfusion. — "■ Procure two glass canulas of appro- priate size and shape (see Fig. 195), and a piece of black india-rubber tubing seven inches long, and not less than a quarter of an inch bore, fitted to the canulas. This apj)aratus could always be Fig. 195. improvised. "Place the transfusion-tube in a basin of hot water containing a little carbonate of soda. Put a tape round the arm of the patient just below the place where the vein is to be opened, and another just above. Expose the vein by an incision through the skin, which should be made transversely if the position of the vein cannot be made out tlirough the skin. Clear a small piece of the vein with forceps and slip a pointed piece of card underneath it. By a snip with scissors make an oblique opening into the vein, and partly insert a small blunt instrument (such as a wool-needle), so that the aperture is not lost. Remove the upper tape. Next prepare the vein of the giver. To do this put tapes around the arm just below and above the place where the vein is to be opened. Expose the vein by a longitudinal incision through the skin. Clear a small piece of the vessel with forceps and pass a thread ligature underneath. A slip of card may also be placed under this vein. Make a snip into the vein just above the ligature, and then, taking the transfusion-tube out of the soda solution, slip one of the canulas into the vein of the giver and tie it in with a simple knot, which can be readily untied. Let the giver go to the bedside and place his arm alongside that of the patient. Hold the end of the india-rubber tube with the second canula up a little, and release the lower tape on the arm of the blood-ffiver. As soon as the blood flows out of the second THE TRANSFUSION OF BLOOD. 547 canula pinch the india-rubber tube close to the canula, so as to stop the flow, and, removing the wool-needle, slip the end of the canula into the vein of the patient ; hold it there, and allow the blood to pass freely along the tube. Three minutes will generally be long enough for the flow, which can be stopped by compressing the vein of the giver below the canula. Both canulas may now be withdrawn and the ligature removed from the vein of the giver, the cut veins being dealt with in the usual way. Of course, the other tape on the arm of the donor must be removed as soon as the transfusion is over. " Instead of using the transfusion-tube empty, it may be filled with soda solution, to the exclusion of air. It is necessary to have one or two spring clips on the tube to prevent the escape of the solution. This is a much better plan than the other, for the blood need not be allowed to flow into the tube until the second canula is inserted, and then by opening the clips it may drive the soda solution before it into the vein. The small quantity of carbonate-of-soda solution necessary to fill the simj)le tube will do the patient no harm. " In the first place, we have to determine what artery or arteries would be most available for the purpose. The (left) radial artery could be most easily dealt with, and its use would involve less subsequent inconvenience to the donor of the blood than any other. But if it is considered necessary to choose some other artery, I think the dorsal artery of the foot should be selected, for its employment presents sev- eral advantages. It is a minor artery, but nevertheless large enough for the insertion of a canula ; it is comparatively superficial and pretty easily found ; and by causing the person yielding the blood to stand up a great amount of pressure may be obtained in it. In the bloodless patient, especially if there be much subcutaneous fat, this artery might not be readily found. Apparatus Required. — "A piece of india-rubber tubing six or seven inches long, two glass canulas of appropriate size and shape, and some spring clips, two of M^hich should be small for compressing the arteries, the others larger and adapted for clipping the tube. The smaller clips might be dispensed with, and ligatures fastened with a slip bow might be used instead, in the way Lower recommended. Be- fore commencing it is important to ensure that the india-rubber tube cannot slip off the canulas. It ought to be secured to them by tight ligatures or by binding wire. This precaution is necessary because the arterial blood is under considerable pressure. This would tend to force the tubes apart and might cause copious hemorrhage. " The transfusion-tube is to be placed as before in carbonate-of-soda solution. Procedure. — "The artery of the patient must first be exposed. To do this make an incision an inch in length through the skin over the line of the artery, and then divide to an equal extent the subcutaneous tissue and fascia which cover it. About three-quarters of an inch in length of the vessel is to be separated from the ensheathing connective tissue and from its accompanying veins by slipping a blunt instrument, such as an aneurism-needle or the blade of a forceps, underneath and moving it up and down. A small piece of card, cut into a long trian- 548 OBSTETRIC OPERATIONS. gular shape, may then be placed under instead of the needle. A liga- ture is then tied tightly around the lower end of the piece of artery, another is looped loosely around the middle, and a spring clip is put on close to the upper end. The vessel may now be opened just above the lower ligature by a snip with the scissors. "If the artery have any branch at the exposed part, this ought to be tied before commencing to isolate the vessel. In the person who is to yield the blood exactly the same process is carried out. "The transfusion-tube is next filled (by suction) with soda solution, and this is prevented from escaping by one or two spring clips on the tube. " One of the glass terminals is tied into the artery of the giver, and the other into the artery of the patient, the ends of both being directed toward the heart, "All is now ready for the transfusion. To effect this, remove the clips on the india-rubber tube and open the clip on the artery of the patient ; then open — not remove — that on the artery of the giver, and keep it open onejminute, or a little longer if it seems advisable. Allow the clips to close again, and if the patient's condition is ameliorated the operation may be ended by tying the arteries — first that of the giver, then that of the patient — -just above the clips. " Finally, cut out and remove the canulas, together with the pieces of artery into which they are tied." Injection of Defibrinated Blood. — For injecting defibrinated blood various contrivances have been used. ("McDonnell's instrument is a simple cylinder with a nozzle attached, from which the blood is pro- pelled by gravitation.' When the propulsive power is insufficient, increased pressure is applied by breathing forcibly into the open end of the receiver. De Belina's instrument is on the same principle, only atmospheric pressure is supplied by a contrivance similar to Richard- son's spray-producer attached to one end. The idea is simjjle, but there is some doubt of a gravitation instrument being sufficiently powerful, and it certainly failed in my hands. ' I have had valves applied to Aveling's instrument, so that it works by compression of the bulb, like an ordinary Higginson's syringe. ' This, with a single silver canula at one end for introduction into the vein, forms a perfect and inexpensive transfusion apparatus, taking up scarcely any space. If it be not at hand, any small syringe with a tolerably fine nozzle may be used. The first step of the operation is defibrination of the blood, M'hich should, if possible, be prepared in an apartment adjoining the patient's. The blood should be taken from the arm of a strong and healthy man. The quality cannot be unimportant, and in some recorded cases the fail- ure of the operation has been attributed to the fact of the donor having been a weakly female. The supply from a woman might also prove insufficient ; and although it has been shown that blood from two or more persons may be used with safety, yet such a change necessarily causes delay, and should, if possible, be avoided. A vein having been opened, eight or ten ounces of blood are withdrawn and received into some perfectly clean vessel, such as a dessert finger-glass. As it flows it should be briskly agitated with a clean silver fork or a glass rod, and THE TRANSFUSION OF BLOOD. 549 very shortly strings of fibrin begin to form. It is now strained through a piece of fine muslin, previously dipped in hot water, into a second vessel which is floating in water at a temperature of about 105°. By this straining the fibrin and all air-bubbles resulting from the agitation are removed, and if there be no excessive hurry it might be well to repeat the straining a second time. If the vessel be kept floating in warm water, the blood is prevented from getting cool, and we can now proceed to prepare the arm of the patient for injection. This is the most delicate and difficult part of the operation, since the veins are generally collapsed and empty, and by no means easy to find. The best way of exposing them is that practised by McDonnell, who pinches up a fold of the skin at the bend of the elbow and transfixes it with a fine tenotomy-knife or scalpel, so making a gaping wound in the integument, at the bottom of which they are seen lying. A probe should now be passed underneath the vein selected for opening, so as to avoid the chance of its being lost at any subsequent stage of the opera- tion. This is a point of some importance, and from the neglect of this precaution I have been obliged to open another vein than that origi- nally fixed on. A small portion of the vein being raised with the for- ceps, a nick is made into it for the passage of the canula. Injection of the Blood. — The prepared blood is now brought to the bedside, and, the apparatus having been previously filled with blood to avoid the risk of injecting any bubbles of air, the canula is inserted into the opening made in the vein and transfusion commenced. It should be constantly borne in mind that this part of the operation should be conducted with the greatest caution, the blood introduced very slowly, and the effect on the patient carefully watched. The injec- tion"hiay be proceeded with until some perceptible effect is produced, which will generally be a return of the pulsation, first at the heart and subsequently at the wrist, an increase in the temperature of the body, greater depth and frequency of the respirations, and a general appear- ance of returning animation about the countenance. Sometimes the arms have been thrown about or spasmodic twitchings of the face have taken place. The quantity of blood required to produce these effects varies greatly, but in the majority of cases has been very small. Occa- sionally 2 ounces have proved sufficient, and the average may be taken as rangino; between 4 and 6, althoua;h in a few cases between 10 and 20 have been used. The practical rule is to proceed very slowly with the injection until some perceptible result is observed. Should embarrassed, or frequent respiration supervene, we may suspect that we have been injecting either too great a quantity of blood or with too much force and rapidity, and the operation should at once be suspended, and not resumed until the suspicious symptoms have passed away. It may hap- pen that the effects of the transfusion have been highly satisfactory, but that in the course of time there is evidence of returning syncope. This may possibly be prevented by the administration of stimulants; but if these fail there is no reason why a fresh supply of blood should not again be injected, but this should be done before the effects of the first transfusion have entirely passed away. Secondary Effects of Transfusion. — The subsequent effects iu 550 OBSTETRIC OPERATIONS. successful cases of transfusion merit careful study. In some few cases death is said to have happened within a few weeks, with symptoms resembling pytemia. Too little is known on this point, however, to justify any positive conclusions witli regard to it. [Transfusion with defibrinated blood was, I believe, first tried in America by Dr. Joshua G. Allen of Philadelphia on December 30, 1868, on a woman who suffered from the effects of repeated attacks of uterine hemorrhage. Six fluidouuces were injected, and the patient recovered a reasonable degree of health. In 1869, Dr. Allen repeated the operation 4 times, in 2 of the cases being associated with Dr. Thomas G. Morton at the Pennsylvania Hospital, and using a double vessel for keeping the blood warm, consisting of a conical cup for hold- ing the blood and a lower vessel for containing warm water, the two being made in one and the temperature ascertained by an outside ther- mometer. Dr. Morton repeated the experiment on two other patients in 1870 and 1874, the second, a girl of eleven, being operated on twice, at intervals of six weeks, for bleeding from the nose and bladder, the effect of purpura : she entirely recovered. Dr. ]M. used a set of instru- ments specially designed for the work, and shown in illustration in the American Journal of the Medical Sciences, July, 1874, p. 112. Between 1874 and 1886 he repeated the operation on several hospital and private patients. \ Intravenous saline injections are far more readily used, are safer, 1 and are believed from the tests that have been made to be quite as effi- 1 cacious as blood. What has bfeen called artificial serum consists of 20 ! grammes of sulphate of soda and 10 grammes of chloride of sodium in 2 | litres of water. The solution should be injected into a large vein slowly I and in large quantity, as much as a pint or more at a time, and repeated | at intervals : the fluid should be blood-warm. Another formula consists I of pure common salt 1|^ fluiddrachms, liquor potassse 1 minim, and/ pui'e carbonate of potash 45 grains in two quarts of water. — Ed.] / PART V. THE PUERPERAL STATE. CHAPTER I. THE PUERPEEAL STATE AND ITS MANAGEMENT. Importance of Studying- the Puerperal State. — The key to the management of women after labor, and to the proper nnderstanding of the many important diseases which may then occur, is to be found in a study of the phenomena following delivery and of the changes going on in the mother's system during the puerperal period. No doubt nat- ural labor is a physiological and healthy function, and during recovery from its effects disease should not occur. It must not be forgotten, however, that none of our patients are under physiologically healthy conditions. The surroundings of the lying-in woman, the effects of civilization, of errors of diet, of defective cleanliness, of exposure to contagion, and of a hundred other conditions which it is impossible to appreciate, have most important influences on the results of childbirth. Hence it follows that labor, even under the most favorable conditions, is attended with considerable risk. The Mortality of Childbirth, — It is not easy to say with accuracy what is the })recise mortality accompanying childbirth in ordinary domestic practice, since the returns derived from the reports of the Registrar-General or from private sources are manifestly open to serious error. The nearest approach to a reliable estimate is that made by Dr. Matthews Duncan,^ who calculates, from figures derived from various sources,; that no fewer than 1 out of every 120 women, delivered at or near the full time, dies within four weeks of childbirth.] This indicates a mortality far above that which has been generally believed to accom- pany childbearing under favorable circumstances. It, however, closely approximates to a similar estimate made by McClintock,^ who calculates the mortality in England and Wales as 1 in 126, and in the upper and middle classes alone, where the conditions may naturally be supposed to be more favorable, at 1 in 146; more recently he has come to the conclusion, from his own increased experience and the published results of the practice of others, that 1 in 100 would more correctly represent the rate of puerperal mortality.^ In these calculations there are some ^ The "Mortality of Childbed," Edin. Med. Journ., vol. 1869-70, p. 399. ^ Dublin Quarterly Journ.. of Med. Science, 1869, vol. xlviii. p. 256. =* Brit. Med. Journ., 1878, vol. ii. p. 215. 551 552 THE PUERPERAL STATE. obvious sources of error, since they include deatlis from all causes Avitliiu four weeks of delivery, some of which must have been inde- pendent of the puerperal state. But it is not the deaths alone which should be considered. All prac- titioners know how large a number of their patients suffer from morbid states M'hich may be directly traced to the effects of childbearing. It is impossible to arrive at any statistical conclusion on this point, but it must have a very sensible and important influence on the health of childbearing women. Alterations in the Blood after Delivery. — The state of the blood during pregnancy, already referred to (p. 143), has an important bear- ing on the puerperal state. There is hy perinos is, which is largely increased by the changes going on immediately after the birth of the child, for then the large supply of blood which has been going to the uterus is suddenly stopped, and the system must also get rid of a quan- tity of effete matter thrown into the circulation in consequence of the degenerative changes occurring in the muscular fibres of the uterus. Hence all the depurative channels by which this can be eliminated are called on to act with great energy. If, in addition, the peculiar condi- tion of the generative tract be borne in mind — viz. the large open ves- sels on its inner surface, the partially bared inner surface of the uterus, and the channels for absorption existing in consequence of slight lacera- tions in the cervix or vagina — it is not a matter of surprise that septic diseases should be so common. It will be well to consider successively the various changes going on after delivery, and then we shall be in a better position for studying the rational management of the puerperal state. Some degree of n ervou s_ shock or exhaustion is observable after most labors. In many cases it is entirely absent ; in others it is well marked. Its amount is in proportion to the severity of the labor and the susceptibility of the patient ; and it is therefore most likely to be excessive in women who have suffered greatly from pain, who have undergone much muscular exertion, or who have been weakened from undue loss of blood. It is evidenced by a feeling of exhaustion and fatigue, and not uncommonly there is some shivering, which soon passes off, and is generally followed by refreshing sleep. The extreme nervous susceptibility continues for a considerable time after delivery, and indicates the necessity of keeping the lying-in patient as free from all sources of excitement as possible. Immediately after delivery the puke^falls, and the importance of this as indicating a favorable state of tlie ])atient has already been alluded to. The condition of the pulse has been carefidly studied by Blot,' who has shown that this diminution, which he believes to be connected with a diminished tension in the arteries due to tlie sudden arrest of the uterine circulation, continues in a large proportion of cases for a considerable number of days after delivery ; and as a matter of clinical import as long as it does the patient may be considered to be in a favor- able state. In many instances the slowness of the pulse is remarkable, often sinking to 50, or even 40^ beats per minute. / Any increase abov^e 1 Arch, gen de Med., 1864. THE PUERPERAL STATE AND ITS MANAGEMENT. 553 the normal rate, es2:>ecially if at all continuous, should always be care- fully noted and looked on with suspicion."^ In connection with this sub- ject, however, it must be remembered that in puerperal women the most trivial circumstances may cause a sudden rise of the pulse. This must be familiar to every practical obstetrician, who has constant opportuni- ties of observing this effect after any transient excitement or fatigue. In lying-in hospitals it has generally been observed that the occurrence of any particularly bad case will send up the pulse of all the other patients who may have heard of it. The temperature in the lying'-in state affords much valuable information. During and for a short time after labor there is a slight elevation. It soon falls to, or even somewhat below, the normal level. Squire found that the fall occurred within twenty-four hours, sometimes within twelve hours, after the termination of labor. ^ For a few days there is often a slight increase of temperature, especially toward the evening, which is probably caused by the rapid oxidation of tissue in connection with the involution of the uterus. In about forty-eight hours there is a rise connected with the establishment of lactation amounting to one or two degrees over the normal level, but this again subsides as soon "as the milk is freely secreted. Crede has also shown ^ that rapid but transient rises of temperature may occur at any period, connected with trivial causes, such as constipation, errors of diet, or mental disturbances. But if there be any rise of temperature whicli\ is at all continuous, especially to over 100° Fahr., and associated with . rapidity of the pulse, there is reason to fear the existence of some com- plication. The Secretions and Excretions. — The various secretions and excre- tions are carried on with increased activity after labor. The skin especially acts freely, the patient often sweating profusely. There is also an abundant secretion of urine, but not uncommonly a difficulty of voiding it, either on account of temporary paralysis of the neck of the bladder, resulting from the pressure to which it has been subjected, or from swelling and occlusion of the urethra. For the same reason the rectum is sluggish for a time, and constipation is not infrequent. The a^etite is generally indifferent, and the patient is often thirsty. ('Generally in about forty-eight hours the secretion of milk becomes established, and this is occasionally accompanied by a certain amount of constitutional irritation.] The breasts often become turgid, hot, and painful. There may or may not be some general disturbance, quicken- ing of pulse, elevation of temperature, possibly slight shivering, and a general sense of oppression, which are quickly relieved as the milk is formed and the breasts emptied by suckling. Squire says that the most constant phenomenon connected with the temperature is a slight elevation as the milk is secreted, rapidly falling when lactation is established. Barker noted elevation either of temperature or pulse in only 4 out of 52 cases which were carefully watched. There can be little doubt that the importance of the so-called " milk fever " has been immensely exaggerated, and its existence as a normal accompani- ^ " Puerperal Temperature," Obstetrical Transactions, 1868, vol. ix. p. 129. '^Monat.f. Gebiirt., 1868, Bd. xxxii. S. 453. 554 THE PUERPERAL STATE. ment of the puerperal state is more than doubtful. It is certaiu, how- ever, that in a small minority of cases there is an appreciable amount of distur])ance about the time that the milk is formed. Out ;/Hfecfeal secretion. As usually applied, in the form of belladonna plaster, it is likel;^' to pi'ove hurtful, since the breast often enlarges after the plasters arc appTrc'TT^'anatne i)ressure of the unyield- ing leather on Avhich they are spread produces intense suffering. A better way of using it is by rubbing down a drachm of the extract of belladonna with an ounce of glycerin, and applying this on lint. In some cases it answers extremely well, but it is very uncertain in its action, and frequently is quite useless. A deficiency of milk in nursing-mothers is a very common source of difficulty. In a wet-nurse this drawback is, of course, an indication for changing the nurse ; but to the mother the importance of nursing is so great that an endeavor must be made either to increase the flow of milk or to suj:)plement it by other food. (Unfortunately, little reliance can be placed on any of the so-called galactagoguesy' The only one Avhich in recent times has attracted attention is the leaves of the cni^t or- oiTplaiit, Avliich, made into poultices and applied to the breast, are said to iiave a beneficial effect in increasing the flow of milk. More reliance must be placed in a sufficiency of nutritious food, especially such as contains phosphatic elements : stewed eels, oysters, and other kinds of sliell-fish, and the Revalenta Arabica, are recommended by Dr. Routh, mIio has paid some attention to this point,^ as peculiarly appropriate. If the amount of milk be decidedly deficient, the child should be less often applied to the breast, so as to allow milk to collect, and projierly prepared cow's milk from a bottle should be given alternately with the breast. This mixed diet generally answers well, and is far preferable to pure hand-feeding. [There is no diet equivalent to milk for a nursing-mother, where it agrees with her. This I have tested repeatedly in women who had failed entirely in former attempts to nurse their infants. One lady who had lost her milk three times at the end of a month, and had nursed two babies into starvation, was enabled to nurse her fourth while on a milk diet for eighteen months, and gained while doing so nineteen pounds. Another gained sixty-five pounds -while nursing, and her son was very large for his age. A third lost a child by hand-feeding, and nursed the next infant on a milk diet, at the same time becoming fatter than she had ever been. A decided advantage in the use of milk is, that it prevents the exhausted feeling so common with delicate nursing mothers. I have had a patient of 86 pounds weight use two quarts of milk a day, and at the same time eat her usual measure of food, which had always been of small amount. — Ed.] Depressed Nipples. — A not uncommon source of difficulty is a 7u TiiK ri'icnrKnAL statk. tlic l)roast altofrotlicr. (An t'lukavor sliould Ik* made to clonp^ato the nipple hetnrc piittiiii;- it into tlic cliild's njontli, citluT l)v the 7rn<:;('rs or hy sonic lurni ol" hnast-pnnij), wliidi liciv iinds a n.-ctnl aitplit-ation. Jn the worst ehiss of eases, when the Jiip])k' is permanently (U'j)ressvith glycerin, or the belladonna liniment sprinkled over the surface of the poultices. The local application of ice in india-rubber bags has been highly extolled as a means of relieving the pain and tension, and is said to be much more effectual than heat and moisture.^ Generally, the pain and irritation produced l^y putting the child to the breast are so great as to contraindicatc nursing from the affected side altogetlicr, and we must trust to relieving the tension by poultices, suckling being in the mean time carried on by the other breast alone. In favorable cases this is quite possible for a time, and it may be that if the inflanimation do not end in suppuration, or if the abscess be small and localized, the affc-cted breast is again able to resume its functions. Often this is not possible, and it may be advisable in severe cases to give uj) nursing altogether.' The subsequent management of the case consists in the opening of the abscess as soon as the existence of pus is ascertained, either by fluctuation, or, if the site of the abscess be deep-seated, by the explor- ing-needle. Mt maybe laid do^vn as a }>rincij)le that the sooner the j)us is evacuated the better, and nothing is to be gained by waiting until it is superficial.^ On the contrary, such delay only leads to more exten- sive disorganization of tissue and the further spread of inflammation. The method of opening the abscess is of primary importance. It has ahyays been customary simply to open the abscess at its most dependent jiart, ^\•ithont using any precaution against the admission of air, and afterward to treat secondary abscesses in the same Avay. The results are Avell kiKnvn to all })ractical accoucheurs, and the records of surgery fully show how many Ayeeks or months generally elapse in bad cases before recovery is complete. The antiseptic trca-tment of mam- mary abscess in the way first jiointcd out by Lister aifords results "vvhich are of the most remarkable and satisfactory kind. Instead of being weeks and months in healing, (^I believe that the practitioner who fairly and minutely carries out Sir Jose[)h leister's directions may confi- dently look for complete closure of the abscess in a few days;\ind I know of nothing in the whole range of my professional experience that ^Coi-son, Avw. Joimi. Ohstet., 1881, vol. xiv. p. 48. MANAGEMENT OF THE JNFANT, LACTATION, ETC. 573 has given me more satisfaction than llic a})plication of this method ta abscesses of the breast. The j)lan I first used is that recommended by Lister in tlie Lancet for 1867, but which is now superseded by his improved methods, whicli of course will be used in pi-eference by all who have made themselves familiar with the details of antiseptic sur- gery. The former, however, is easily within the reach of every one, and is so simple that no special skill or practice is required in its appli- cation ; whereas the more perfected antiseptic appliances will probably not be so readily obtained and are much more difficult to use. I there- fore insert Sir Joseph Lister's original directions, which he assures me are perfectly antiseptic, for the guidance of those ^vho may not be able to obtain the more elaborate dressings : "A solution of one part of crys- tallized carbolic acid in four parts of boiled linseed oil having been prepared, a piece of rag from four to six inches square is dipped into the oily mixture and laid upon the skin where the incision is to be made. The lower edge of the rag being then raised, while the upper edge is kept from slipping by an assistant, a common scalpel or bistoury dipped in the oil is plunged into the cavity of the abscess, and an opening about three-quarters of an inch in length is made; and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneath which the pus flows out into a vessel placed to receive it. The cavity of the abscess is firmly pressed, so as to force out all existing pus as nearly as may be (the old fear of doing mischief by rough treatment of the pyogenic membrane being quite ill-fouuded); and if there be much oozing of blood or if there be considerable thick- ness of parts between the abscess and the surface, a piece of lint dipped in the antiseptic oil is introduced into the incision to check bleeding and prevent primary adhesion, which is otherwise very apt to occur. The introduction of the lint is effected as rapidly as may be, and under the protection of the antiseptic rag. Thus the evacuation of the original contents is accomplished with perfect security against the introduction of living germs. This, however, would be of no avail unless an anti- septic dressing could be applied that would^ effectually prevent the decomposition of the stream of pus constantly flowing out beneath it. After numerous disappointments I have succeeded with the following, which may be relied upon as absolutely trustworthy: About six tea- spoonfuls of the above-mentioned solution of carbolic acid in linseed oil are mixed up with common whiting (carbonate of lime) to the con- sistence of a firm paste, which is, in fact, glazier's putty with the addi- tion of a little carbolic acid. This is spread upon a piece of common tinfoil about six inches square, so as to form a layer about a quarter of an inch thick. The tinfoil, thus spread with putty, is placed upon the skin so that the middle of it corresponds to the position of the incision, the antiseptic rag used in opening the abscess being removed the instant before. The tin is then fixed securely by adhesive plaster, the lowest edge being left free for the escape of the discharge into a folded towel placed over it and secured by a bandage. The dressing is changed, as a general rule, once in twenty-four hours, but if the abscess be a very large one it is prudent to see the patient twelve hours after it has been opened, when, if the towel should be much stained with. 574 Till'. rri:i:i'i:iiM. state. disi'l large, tlic tlrL'^siug- ^;lH)ul^l be cliaiird steady supporl"aucl compress the opposing pyogenic surfaces, will give the best results. It may be necessary to lay open some of the sinu.ses or to inject tinct. iodi or other stimulating lotions, so as to moderate the discharge, the subsequent surgical treatment varying according to the requirements of each case. In such neglected cases Bilh'oth i-ecom- mends that after the ])atient has been aucosthetized the openings should Ije dilated so as to admit the finger, by which the septa between the various sinuses should be broken down and a large single abscess-cavity made. This sliould then be thoroughly irrigated with a 3 per cent, .solution of carbolic acid, a drainage-tube introduced, and the ordinary antiseptic dressings a]i])lied. As the drain on the system is great and the constitutional debility generally i)ronounced, much attention nuist be paid to general treatment, and abundance of nourishing food, ajij^ro- priate stimulants, and such medicines as iron and quinine Avill be indi- cated. Hand-feeding". — In a consideral)le numl)er of cases the inability of the mother to nurse the child, her invincible re])ugnance to a wet-nur.se, or inability to bear the expense renders hand-feeding essential. It is, therefore, of importance that the accoucheur should be thoroughly familiar with the best method of bringing up the child by hand, .«o as to be able to direct the jn'ocess in the way that is most likely to be successful. Much of the mortality following hand-feeding may be traced to unsuitable food. Among the ])Oorer classes cs[)ccially there is a ])reva- lent notion that milk alone is insufficient, and hence the almo.st universal custom of administering various fariuaceous foods, such as corn-flour or arrowroot, even from tiie earliest period. ^Nlany of these consist of starch alone, and are therefore absolutely unsuited for fornung tlie .sta])le of diet on account of the total al)sence of nitrogenized elements. Independently of thisXit has been shown that the saliva of infants has not the same digestive property on starch that it sul)sequently acquires) and this affords a further explanation of its so constantly producing MANAGEMENT OF TlIK INFANT, LA(JTATION, FTC. hJPt intestinal (lei'an<^eJiicnt. iica.s(jii as well as experience abundantly })rovcs that the object to be aimed at iu liand-feeding is to imitate as nearlv as possible the food whicii nature .sup])lie,s for the newborn f child/and therefore the obvious course i.s to use Jiiilk from some ani- mal, so treated as to make it resenibl<' liumaii milk as nearly as may bej Of the various milks used, that of the ass, on the whole, most closely resembles human milk, containing less casein and butter and more saline ingredients. It is not always easy to obtain, and in towns it is excess- ively expensive. jNIoreover, it does not always agree with the child, being apt to produce diarrhoea. ^Ve can, however, be more certain of its being unadulterated, which in large cities is iu itself no small advantage, and it may be given without the addition of water or sugar. Goat's milk in England is still more difficult to obtain, but it often succeeds admirably. In many places the infant sucks the teat directly, and certainly thrives well on this plan. Cow's Milk, and its Preparation. — In a large majority of cases we have to rely on cow's milk alone. It differs from human milk in con- taining less water, a larger amount of casein and solid matters, and less sugar. Therefore, before being given it requires to bejdiluted and sweetened. A common mistake is over-dilution, and it is far from rare for nurses to administer one-third cow's milk to two-thirds water. The result of this excessive dilution is that the child becomes pale and puny, and has none of the firm and plump appearance of a well-fed infant. The practitioner should therefore ascertain that this mistake is not being made ;( and the necessary dilution will be best obtained by adding to pure fresh cow's milk one-third hot water, so as to warm the mixture to about 96°, the whole beino; slightlv sweetened with sugar of milk or ordinary crystallized suga r.) ( After the first two or three months the amount of water may be lessened, and pure milk, warmed and sweetened, given instead. ) Whenever it is possible the milk should be obtained from the same cow, and in towns some care is requisite to see that the animal is properly fed and stabled, Of late years it has been customary to obviate the difficulties of obtaining good fresh milk by using some of the tinned milks now so easily to be had. These are already sweetened, and sometimes answer well if not given in too weak a dilution. One great drawback in bottle-feeding is the tendency of the milk to become acid, and hence to produce diarrhoea. This may be obviated to a great extent by adding a tablespoonful of lime-water to each bottle, instead of an equal quantity of water. Artificial Human Milk. — An admirable plan of treating cow's milk, so as to reduce it to almost absolute chemical identity M'ith human milk, has been devised by Professor Frankland, to whom I am indebted for ])ermission to insert the recipe. I have followed this method in many cases, and find it far superior to the usual one, as it produces an exact and uniform compound. "With a little practice nurses can employ it with no more trouble than the ordinary mixing of cow's milk with water and sugar. The following extract from I)r. Frankland 's w'ork^ ^ Frankland's Fxperunental Besearches in Chemistry, p. 843. o76 TllK PUERPERAL STATE. \\\\\ (.'Xiihiiii the iniiiiiplcs int of new milk and two teaspoonfuls of cream, well stirrin.o- the whole together. If dur- ing the first month the milk is too rich, use rather more than a third of a pint of whey." 37 57S 77//-; PrERPERAL STATE. answering satisfactorily, 1111(1 that sonic cliaiit^c' is required. Jltlie eliild be not too old, and will still take the breast, that is certainly the best remedy, but if that be not possible it is necessary to alter the diet, AVhen milk disa^irces, crj^uni, in the j)roportion of one tai)lcsp()()nful to three of water, soiiietimcs answers as well. Occasionally also Jjiebitr's or Mel bn's^ infants' food, when carefully jn'cpared, renders jj;(Kid service. Too often, however, when once diarrluea oi- other intestinal disturi)ance has set in, all our efforts may prove unavailincral convul- sions from the confounding of several essentially distinct diseases under the same name. Thus in most obstetric works it has been customary to describe three distinct claases of convulsion — the epileptic, the Injs-fer- icnl, and the apoplectic. The two latter, however, come under a totally different category. A ])regnant woman may suffer from hysterical [>ar- oxysms, or she may be attacked with apoplexy accom])anied with coma and followed by paralysis. But these conditions in the jtregnant or PUERPERAL ECLAMPSIA. 579 parturient woman arc identical with the same diseases in the non-preg- uant, and are in no way special in their nature. True eclampsia, how- ever, is different in its clinical history from epilepsy, althouj^h tlu; ])ar- oxysms while they last are essentially the same as those of an ordinary epileptic fit. Premonitory Symptoms. — An attack of eclampsia seldom occurs without havino- been preceded by certain more or less well-marked pre- cursory sym])toms. It is true that in a considerable number of cases these are so slight as not to attract attention, and suspicion is not aroused until the patient is seized with convulsions. Still, subsequent investi- oations will very generally show that some symptoms did exist, w'hich if observed and properly interpreted might have put the practitioner on his guard, and possibly have enabled him to ward oif the attack. Hence a knowledge of them is of real practical value. The most com- mon are associated with the cerebrum, such as severe h eadach e, which is the one most generally observed, and is sometimes limited to one side of the head. Transient attacks of giddiness, spots before theses, loss of jj^ht, or impairmeijt.of the iutellecfual faculties are also not uncom- mon. These signs in a pregnant woman are of the gravest import, and should at once call for investigation into the nature of the case. Less- marked indications sometimes exist in the form of irritability, slight headache or stupor, and a general feeling of indisposition. Another important premonitory sign is oedema of the subcutaneous cellular tis- sue, especially of the face or upper extremities, which should at once lead to an examination of the urine. Whether such indications have preceded an attack or not, as soon as the convulsion comes on there can no longer be any doubt as to the nature of the case. The attack is generally sudden in its, onset, and in its character is precisely that of a severe epileptic fit or of the convul- sions in children. Close observation shows that there is at first a short period of tonic spasm affecting the entire muscular system. This is almost immediately succeeded by violent clonic contractions, generally commencing in the muscles of the face, which twitch violently ; the expression is horribly altered, the globes of the eyes are turned up under the eyelids, so as to leave only the white sclerotics visible; and the angles of the mouth are retracted and fixed in a convulsive grin. The tongue is at the same time protruded forcibly, and if care be not taken is apt to be lacerated by the violent grinding of the teeth. The face, at first pale, soon becomes livid and cyanosed, while the veins of the neck are distended and the carotids beat vigorously. Frothj^ saliva collects about the mouth, and the whole appearance is so changed as to render the patient quite mirecognizable. The convulsive movements soon attack tho. muscles of the body. The hands and arms, at first rig- idly fixed with the thumbs clenched into the palms, begin to jerk, and the whole muscular system is thrown into rapidly-recurring convulsive spasms. It is evident that the in v olunta iT ,.mug£les are implicated in the convulsive action as well as the voluntary. This is shown by a temporary arrest of respiration at the commericement of the attack, fol- lowed by irregular and hurried respiratory movements producing a peculiar hissing sound. The occasional involuntai-y expulsion of uriue 580 THE PUERPERAL STATE. ami feces indicates . ilit' .suno I'act. During; the attack the patieut is absohitely unconscious, sensibility is totally suspended, and she has ai'terward no recollection ol' what has taken ])]ace. Fortunately, the convulsion is not of long duration, and at the outside does not last nioi-e than thi'ce or ibur minutes, generally not so long; and it has been pointed out that a longer paroxysm Mould almost uecessiirily prove fatal on account of the implication of the respiratory muscles. In most cases, after an interval there is a recurrence of the convulsion characterized by the same phenomena, and the jniroxysms are repeated Avith more or less force and frequency according to the severity of the attack. Sometimes several hours may elapse before a second convulsion comes on ; at others the attacks may recur very often, -with only a few minutes between them. In the slighter forms of eclampsia there may not be more than two or three paroxysms in all ; in the moi'e serious as many as Mty or sixty have been recorded. Condition between the Attacks. — After the first attack the patient generally soon recovers her consciousness, being somewhat dazed and somnolent, with no clear conception of what has occurred. If the paroxysms be frequently repeated, more or less jDrofound coma con- tinues in the intervals between them, which no doubt depends upon intense cerebral congestion, resulting from the interference with the circulation in the great veins of the neck, produced by spasmodic con- traction of the muscles. The coma is rarely complete, the patieut showing signs of sensibility when irritated, and groaning during the uterine contractions. In the worst class of cases the torpor may become intense and continuous, and in this state the patient may die. When the convulsions have entirely stopped, and the patieut has com])letely regained her consciousness and is apparently convalescent, recollection of what has taken place during and some time before the attack may be entirely lost ; and this condition may last for a considerable time. A curious instance of this once came under my notice in a lady who had lost her brother, to whom she w^as greatly attached, in the week immediately preceding her confinement, and in whom the mental dis- tress seemed to have had a great deal to do in determining the attack. It was many weeks before she recovered her memory, and during that time she recollected nothing about the circumstances connected with her brother's death, the whole of that w^eek being, as it were, blotted out of her recollection. Relation of the Attacks to Labor. — If the convulsions come on during pregnancy, we may look upon the advent of labor _as almost a ce^giiit}^; and, if we consider the severe nervous shock and general disturbance, this is the result Ave might reasonably anticipate. If they occur, as is not uncommon, for the first time during labor, the pains generally continue with increased_force and frequency, since the uterus partakes of tlie convulsive action. It has not rarely hajipened that the pains have gone on with such intensity that the child has been born quite unexpectedly, the attention of the practitioner being taken up with the patient. In many cases the advent of fresh paroxysms is associated with the commencement of a pain, the irritation of which seems sufficient to brinsr on the convulsion. PUERPERAL ECLAMPSIA. 581 Results to the Mother and Child. — The results of eclampsia vary accortling- to tlie severity of the paroxysms. It is generally said that about \oiie iu three or four cases dies. [. The mortality has certainly lesseued of late years, probably in conseqfuence of improved knowledge of the nature of the disease and more rational modes of treatment. This is well shown by Barker,^ who found in 1885 a mortality of 32 per cent, in cases occurring before and during labor, and 22 per cent, in those after labor, while since that date the mortality has fallen to 14 per cent. The same conclusion is arrived at by Dr. Phillips,^ who has shown that the mortality has greatly lessened since the practice of repeated and indiscriminate bleeding, long considered the sheet-anchor in the disease, has been discontinued and the administration of chloro- form substituted. """" "" .-——--v. Caiise of Death. — Death may occur during the paroxysm, and then it may be due to the long continuance of the tonic spasm producing asphyxia. ' It is certain that as long as the tonic spasm lasts the respi- rafion is suspended, just as iu the convulsive disease of children known as laryngismus stridulus ; and it is possible also that the heart may share. in the convulsive contraction which is known to aifect other involuntary muscles. QVIore frequently, death happens at a later period from the combined effects of exhaustion and asphyxia. ; The records of post- mortem" exainTMlioiis are not numerous ; iu those we possess the prin- cipal changes have been an anaemic condition of the brain with some cedematous infiltration. In a few rare cases the convulsious have resulted in effusion of blood into the ventricles or at the base of the brain. The prognosis as regards the child is also serious. (Out of 36 children. Hall Davis found 26 born alive, 10 being stillborn.) ,' There is good reason to believe that the convulsion may attack the child hi\ utero — of this several examples are mentioned by Cazeaux — or it may^ be subsequently attacked with convulsions, even when apparently healthy at birth. Patholog-y, — The precise pathology of eclampsia cannot be con- sidered by any means satisfactorily settled. When, in the year 1843, Lever first showed that the_uniie iu patients suffering from puerperal convulsions was generally ;.highly charged with albumen — a fact which subsequent experience has amply confirmed — it was thought that a key to the etiology of the disease had been found. It was known that chronic forms of Bright's disease were frequently associated with retention of urinary elements in the blood, and not rarely accom- panied by convulsious. The natural inference was drawn that the convulsions of eclampsia were also due to toxaemia resulting from the retention of urea in the blood, just as in the urtemia of chronic Bright's disease;. and this view was adopted and supported by the authority of Brauu, Frerichs, and many other Avriters of eminence, and was pretty generally received as a satisfactory explanation of the facts. Frerichs modified it so far that he held that the true toxic element was not urea as such, but carbonate of ammonia resulting from its decomposition; and experiments were made to prove that the injection of this substance into the veins of the lower animals produced convulsions of precisely the ' The Puerperal Diseases, p. 125. ^ Guy's Hospital Reports, 1870. 582 THE PUERPERAL STATE. same character as eclampsia. ^Dr. llaiiiiaoiul' of Maryland siibsequent- \ ly made a series of coiintcr-exj)eriraent.s, whicli were held as proving I that there \va.s no reason to believe that urea ever did become decom- j posed in the blood in the way that Frerichs supposed, or that the symp- I tonis of uriemia were ever produced in this Avay. Others have believed \ that the poisonous elements retained in the blood are not urea or the products of its tlecomposition, but other extractive matters which have escaped detection. xVs time elapsed evidence accuumlated to show that the relation between albuminuria and eclampsia was not so universal as was supposed, or at least that some other factors were neces'^arv to explain many of the cases. Numerous cases were observed in Mhich albumen was detected in large quantities without any convulsion fol- lowing, and that not only in women who had been the subject of Bright's disease before conception, but also when the albuminuria was known to have developed during pregnancy. Thus, Imbert-Goubeyre found that out of 164 cases of the latter kind, 95 had no eclampsia; and Blot, out of 41 cases, found that 34 were delivered without untoward symptoms. It may be taken as proved, therefore, that aliju- minuria is by no means necessarily accompanied by eclampsia. Cases were also observed in which the albumen only appeared after the con- vulsion ; and in these it was evident that the retention of urinary elements could not have been the cause of the attack, and it is highly probable that in them the albuminuria was produced l)y the same cause which induced the convulsion. Special attention has been called to this class of cases by Braxton Hicks,^ who has recorded a considerable num- ber of them. He says that the nearly simultaneous appearance of albu- minuria and convulsion — and it is admitted that the two are almost inva- riably combined — must then be explained in one of three ways : 1st. That the convulsions are the cause of the nephritis. 2dly. That the convulsions and the nephritis are produced by the same cause — e. g. some detrimental ingredient circulating in the blood, irritating both the cerebro-spinal system and other organs at the same time. 3dlv. That the hisrhlv cono;ested state of the venous system induced by the spasm of the glottis in eclampsia is able to produce the kidney com])lication. ]\Iore recently, Tratibe and Rosenstein have advanced a theory of eclampsia pur})orting to explain the anomalies. They refer the occur- rence of eclampsia to acute cerebral anaemia resulting from changes in the blood incident to ])regnancy. The |>rimary factor is the hydrjemic condition of the blood, which is an ordinary concomitant of pregnancy, and of course when there is also albuminuria the watery condition of the blood is greatly intensified ; hence the frequent association of the two states. Accompanying this condition of the blood there is increased tension of the arterial system, which is favored by the hypertrophy of the heart which is known to be a normal occurrence in pregnancy. The result of these combined states is a temporary hyperemia of the brain, which is rapidly succeeded by serous effusion into the cerebral tissues, resulting in pressure on its minute vessels and consequent anaemia. 1 Amer. Joum. of Med. Sci, 1861. ' Obstet. Trans., 1867, vol. viii. p. 382. fe PUERPERAL ECLAMPSIA. 583 There is much in this thcury that accords witli the most recent views as to the etiology of convulsive disease; as, for example, the researches of Kussmaul and Tenner, who had experimentally proved the dependence of convulsion on cerel)ral anaemia, and '(•^ amount regulated by the effect produced, is all that is ever likely U) 1)C ^ of service. 'j As a temporary expedient, having the same object iu view, compres- -^^ siou of the carotids during the paroxysms is worthy of trial. This was jn-oposed by Trousseau in the eclampsia of infants, and in the single case of eclampsia in which I have tried it it seemed to be decidedly beneticial. It is a simple measure, and it offers the advantage of not leading to any permanent deterioration of the blood, as iu venesection. ^ As a subsidiary means of diminishing vascular tension the adminis- tration of a str ong purgati ve is desirable, and has the further effect of removing anylrfitant maTter that may be lodged in the intestinal tract. If the patient be conscious, a full dose of the compound jalap powder may be given or a few grains of calomel combinecTAvTtli jalap; and if she be comatose and unable to swa1lT7vr,'a drop of croton oil or a quar- | t *T ter of a grain of elaterium may be placed on the back of the tongue. Lj ^ The great indication in the management of eclampsia is the control- / ( ling of convulsive action by means of sedatives. Foremost amongst O ^_i them must be placed the inhalation of chloroform, a remedy which is frequently remarkably useful, and which has the advantage of being- applicable at all stages of the disease and whether the patient be coma- tose or not. Theoretical objections have been raised against its employ- ment, as being likely to increase cerebral congestion. Of this there is no satisfactory proof; on the contrary, there is reason to think that chloroform inhalation has rather the effect of lessening arterial tension, while it certainly controls the violent muscular action by which the hypersemia is so much increased. Practically, no one who has used it can doubt its great value in diminishing the force and frequency of the convulsive paroxysms. Statistically, its usefulness is shown by Char- pentier in his thesis on the effects of various methods of treatment in eclampsia, since out of 63 cases iu which it was used, in 48 it had the effect of diminishing or arresting the attacks, 1 only proving fatal. The mode of administration has varied. Some have ffiven it almost con- tiuuously, keeping the patient in a more or less profound state of anaes- thesia. Others have contented themselves with carefully Avatching the patient, and exhibiting the chloroform as soon as there were any indica- tions of a recurring paroxysm, with the view of controlling its inten- sity. The latter is the plan I have myself adopted, and of the value of which in most cases I have no doubt. Everv now and again cases will occur in which chloroform inhalation is insufficient to control the paroxysm, or in which, from the very cyanosed state of the patient, its administration seems contraiudicated. INIoreover, it is advisable to have, if possible, some remedy more continuous in its action and requiring less constant personal supervision. Latterly, the internal administration of c hloral has been recommended for this purpose. My own experience is decidedly in its favor, and I have used, as I believe, with marked advantage a combination of chloral with bromide of potas- sium, in the proportion of twenty grains of the former to half a drachm of the latter, repeated at intervals of from four to six hours. If the patient be unable to swallow, the chloral may be given in an enema or hypodermically, six grains being diluted iu oj of water and injected 586 THE PUERPERAL STATE. uikIlt the skill. Tlic rtiiiarknhU' induciict' of hroiiiidr ot" pota.-sium in fontrollini^ the eclampsia oi" infants would seem to be an indication for its use in ])Uorperal cases. Fortlyce Baker is opposed to the use of chloral, which he thinks excites insteatl of lesseninir reflex irritability.' Another remedy, not entirely free from theoretical objections, but strongly recommendetl, is the subcutaneous inject 1^211. of niorphja, which lias the advantage of being- aj)plicable when the ])atient^s (juite unable to swallow. It may be given in doses of one-third of a grain, rej)eated in a few hours, so as to keep the patient well under its influence. It is to be remembered that the object is to control muscular action, so as to prevent as much as possible the violent convulsive parttxysm, and therefore it is necessary that the narcosis, however ])ro(luced, should be continuous. It is rational, therefore, to combine the intermittent action of chloroform -with the more continuous action of other remedies, so that the former should supplement the latter when insufficient. Inha- lation of the nitrite of amyl has been recommended on j)hysiological grounds as likely to be useful, and is well worthy of trial ; but of its action I have as yet no personal experience. Several very successful eases of treatment by the inhalation of oxygen have been recorded by Schmidt of St. Petersburg.^ Pilocarpine has recently been tried, in the hope that the diaphoresis and salivation it produces might diminish arterial tension and free the blood of toxic matters. Brauu^ admin- istered 3 centigrammes of the muriate of pilocarpine hypodermically, and reports favorably of the result ; Fordyce Barker,^ however, is of opinion that it produces so much depression as to be dangerous. Other remedies, supposed to act in the way of antidotes to ursemic poisoning, have been advised, such as acetic or benzoic acid, but they are far too uncertain to have any reliance placed on them, and they distract attention from more useful measures. Precautions during the Paroxysm. — Precautions are necessary during the fits to prevent the patient injuring herself, especially to obviate lacei-ation of the tongue ; the latter can be best done by placing something between the teeth as the paroxysm comes on, such as the handle of a teaspoon enveloped in several folds of flannel. Obstetric Management. — The obstetric management of eclampsia will naturally give rise to much anxiety, and on this point there has been considerable difference of opinion. On the one hand, we have practitioners who advise the immediate emptying of the uterus, even when labor has commenced ; on the other, those who would leave the lalior entirely alone. Thus Gooch said : " Attend to the convulsions, and leave the labor to take care of itself; and Schroeder says: '' Especi- allv no kind of obstetric manipulation is recpiired for the safety of the mother," but he admits, how^e\'er, that it is sometimes advisable to hasten the labor to ensure the safety of the child. In cases in which the convulsions come on during labor the pains are often strong and regular, the labor progresses satisfactorily, and no inter- ' The Puerperal Diseases, p. 1 20. "^London Med. Rec, 188G, vol. xiv. p. 75 (extract from Rnx.'i/caia Meditz., No. 32, 1885, p. 595). "^ Berlin, /din. Woch., June IG, 1879. * New York Med. Rcc, Mardi 1, 1879. PUERPERAL INSANITY. 587 ference is needful. In others we cuuiiot but feel that emptying the uterus would be decidedly beneficial. We have to reflect, however, that any active interference might, of itself, prove very irritating and excite fresh attacks. [Eclampsia is sometimes ]iurely reflex, and not at all dangerous, although it may be alarming. The convulsive move- ments may arise from nerve-disturbance due to the; flctal head distend- ing the cervix in the last stage of dilatation in primipane. When the head begins to distend the perineum the convulsive seizure often ceases. Such patients are safer without the forceps. — Ed.] The influenceof uterine irritation is apparent by the frequency with which the paroxysms recur Avitli the pains. If, therefore, the os be undilated and labor have not begun, no active means to induce it should be adoj)ted, although the membranes may be ruptured with advantage, since that procedure pro- duces no irritation. Forcible dilatation of the os, and especially turn- ing, are strongly contraiudicated. The rule laid down by Tyler Smith seems that which is most advisa- ble to follow — that we should adopt the course which seems least likely to ])rove a source of irritation to the mother. Thus, if the fits seem evidently induced and kept up by the pressure of the foetus, and the head be within reach, the forceps may be resorted to. But if, on the other hand, there be reason to think that the operation necessary to complete delivery is likely j^er se to prove a greater source of irritation than leaving the case to nature, then we should not interfere. [If called to a case of convulsions followed by coma in a primipar;B near term, but not in labor, draw ofl" a little urine and examine it, as the patient may be far advanced in Bright's disease and the coma purely urremic. In such a case little can be gained by bringing on labor and delivering the foetus. — Ed.] CHAPTER IV. PUERPERAL INSANITY. Classification. — Under the head of "Puerperal Mania" writers on obstetrics have indiscriminately classed all cases of mental disease con- nected with pregnancy and parturition. The result has been unfortu- nate, for the distinction between the various types of mental disorder has, in consequence, been very generally lost sight of. But little study of the subject suffices to show that the term "puerperal mania" is wrong in more ways than one, for we find that a large number of cases are not cases of " mania " at all, but of melani'holia, while a considerable num- ber are not, strictly speaking, "puerperal," as they either come on during 588 THE PUERPERAL STATE. piegnancv or long after the iininediate risks of the jnierperal period are over, beiny; in tiie latter case associated with aiuernia produced i)y over- lactatiou. For the sake of brevity, the generic term " puerperal insanity " may be employed to cover all cases of mental disorders connected with gestation, which may be further conveniently subdivided into three classes, each havinii; its special characteristics, viz.: I. The Insanltii of Pregnancy. II. Fucrpend Jiisdjiifi/, properly so called; that is, insanity coming on within a limited period after delivery. III. The Insanity of Lactation. This division is a strictly natural one, and includes all the cases likely to come under observation. The relative proj)ortion these classes bear to each other can only be determined by accurate statistical observations on a large scale, but these materials we do not possess. The returns from large asylums are obviously open to objection, tor only the M'orst and most couHrmed cases find their way into these institutions, while by far the greater proportion, both before and after labor, are treated in their own homes. Proportion of these Porras of Insanity. — Taking such returns as only a])proximate, we find from Dr. Battv Tuke ' that in the Edinburgh Asylum, out of 155 cases of puerperal insanity, 28 occurred before delivery, 73 during the puerperal period, and 54 during lactation. The relative proportions of each per hundred are as follows : Insanity of pregnancy, 18.06 per cent. Puerperal insanity, 47.09 " Insanity of lactation, 34.83 " Marc4 ^ collects together several series of cases from various authorities, amounting to 310 in all, and the results are not very different from those of the Edinburgh Asylum, except in the relatively smaller num- ber of cases occurring before delivery. The percentage is calculated from his figures : Insanity of pregnancy, 8.06 per cent. Puerperal insanity, 58.06 " Insanity of lactation, 30.30 " As each of these classes differs in various important respects from the others, it Avill be better to consider each separately. The insanity of pregnancy is, Mithout doubt, the least common of the three forms. The intense mental depression which in many women accompanies pregnancy, and causes the })atient to take a despondent view of her condition and to look forward to the result of her labor with the most gloomy apprehension, seems to be often only a lesser degree of the actual mental derangement which is occasionally met with. The relation between the two states is further borne out by the fact that a large majority of cases of insanity during pregnancy are well-marked types of melancholia : out of 28 cases recorded by Tuke, 15 were examples of jmre melancholia, 5 of dementia with melancholia. In many of the.se the attack could be traced as developing itself out of ' Edin. Med. Journ., vol. x. ' Traite de la Folic des Femmes enceintes. PUERPERAL INSANfTY. 589 the ordimiiy hypoehoiidriasis of pregnancy. In others the symptoms come on at a later jwriod of pregnancy, the earlier months of which had not been marked by any nnusual lowness of spirits. The age of the patient seems to have some influence, the proportion of cases between thirty and forty years of age being much larger than in younger women. A larger proportion of cases occurs in p rimip ara) than in multiparie — a fact that no doubt depends on the greater dread and ai)[)reliension experienced by women who are pregnant for the first time, es[)ecially if not very young. Hereditaiy disposition plays an import- ant part, as in all forms of puerperal insanity. It is not always easy to ascertain the fact of an hereditary taint, since it is often studiously concealed by the friends. Tuke, however, found distinct evidence of it in no less than 12 out of 28 cases. Furstner ^ believes that other neur- oses have an important influence in the causation of the disease. Out of 32 cases he found direct hereditary taint in 9, but in 11 more there was a family history of epilepsy, drunkenness, or hysteria. Period of Pregnancy at which it Occurs. — The period of preg- nancy at which mental derangement most commonly shows itself varies. Most generally, perhaps, it is at the end of the third or the beginning of the fourth month. It may, however, begin with conception, and even refiirh with every impregnation. Montgomery relates an instance in which it recurred in three successive pregnancies. Marce distin- guishes between true insanity coming on during pregnancy and aggra- vated hypochondriasis, by the fact that the latter usually lessens after the third month, while the former most commonly begins after that date. It is unquestionable that in many cases no such di'stiuction can be made, and that the two are often very intimately associated. The form of insanity does not differ from o rdinary nielancholia. The suicidal tendency is generally very strongly developed. Should the mental disorder continue after delivery, the patient may very prob- ably experience a strong impulse to kill her child. Moral perversions have not been uncommonly observed. Tuke especially mentions a tendency to dipsomania in the early months, even in women who have not shovv^n any disposition to excess at other times. He suggests that this may be an exaggeration of the depraved appetite or morbid crav- ing so commonly observed in pregnant wbliien, just as melancholia may be a farther development of lowness of spirits. Laycock mentions a disposition to " kleptmiiania " as very characteristic of the disease. 'Casper^ relates a curious case where this occurred in a pregnant lady of rank, and the influence of pregnancy in developing an irresistible tend- ency was pleaded in a criminal trial in which one of her petty thefts had involved her. .^ Prognosis. — The prognosis may be said to be, on the whole, favor- able. Out of Dr. Tuke's 28 cases, 19 recovered within six months. There is little hope of a cure until after the termination of the jn-eg- nancy, as out of 19 cases recorded by Marce only in 2 did the insanity disappear before delivery. Transient Mania during Delivery. — There is a peculiar form of ' Archiv fur Psychiatrie, Band v. Heft 2. ' Casper's Forensic Medicine, New Syd. Soc, vol. iv. p. 308. r)9() THE rVERPKRAL STATE. mental derangenicnt sometiiiies observt-d (liiriii!;- laboiMvliich is l)y sdiiu' talked of as a teni|H)raiy iiii^anity. It may ]»(_'rliai)s bo more accurately described as a kind of acute (liHrium, produced in the latter stage of labor by the intensity of TlTe'siiiferTng caused by the pains. According to Montgomery, it is most aj)t to occur as the head is passing througli the OS uteri, or at a later period during the ex])ulsion of the child. It may consist of merely a loss of control over the mind, during which the patient, unless carefully watched, might in her agony seriously injure herself or her child. Sometimes it produces actual hallucina- tion, as in the case described by Tarnier in which the patient fancieure specu- lation, and in the supposed analogous case of eclampsia the all)uminuria certainly lasts as long as its effects. It is not easy to understand also why ursemic poisoning should in one case give rise to insanity, and in another to convulsions. For all we know to the contrary, transient albuminuria may be much more common after delivery than has been generally supposed, and further investigation on this point is required. Albumen is by no means unfrequently observed in the urine for a short time in various conditions of the body, without any serious consequences, as, for example, after bathing ; and we may too readily draw an imjusti- fiable conclusion from its detection in a few cases of mania. There are, however, many other kinds of blood-poisoning besides ura?mia which may have an influence in the production of the disease, and it is to be hoped that future observations may enable us to speak with more cer- tainty on this ])oint. The progTiosis of puerperal insanity is a jwint which will always dee])ly interest those who have to deal with so distressing a malady. It may resolve itself into a consideration of the immediate risk to life and of the chances of ultimate restoration of the mental faculties. It is an old a])horism of Gooch's — and one the correctness of which is justi- fied by modern experience — that/" mania is more dangerous to life, melancholia to reason.V It has veiy generally been supposed that the inniiccliate risk to life m puerperal mania is not great, and on the whole this may be taken as correct. Tuke found that death took ])lace from all causes in 10.9 per cent, of the cases under observation ; these, how- PUERPERAL INSANITY. 593 ever, were all women who had been admitted into asylums, and in wlium tiie attack may be assumed to have been exceptionally severe. Great stress was laid by Hunter and Gooch on extreme ra])idity of the pulse as indicating a fatal tendency. There can be no doubt that it is a symp- tom of great gravity, but by no means one wliich need lead us to despair of our ])atient's recovery. The most dangerous class of cases are those attended with some inflannuatory complication ; and if there be marked elevation of temperature, indicating the presence of some such concom- itant state, our prognosis must be more grave than when there is mere excitement of the circulation. Post-mortem Signs. — There are no marked post-mortem signs found in fatal cases to guide us in formiirg~air*opTriiori as To the nature of the disease. " No constant morbid changes," says Tyler Smith, " are found within the head, and most frequently the only condition found in the brain is that of unusual paleness and exsanguinity. Many pathologists have also remarked upon the extremely empty condition of the blood-vessels, particularly the veins." The duration of the disease varies considerably. Generally speak- S ing, cases of mania do not last so long as melancholia, and recovery ( takes place within a period of three months, often earlier. Very few of the cases admitted into the Edinburgh Asylum remained there more than six^jQianths, and after that time the chances of ultimate recoveiy greatly lessened. When the patient gets well it often happens that her recollection of the events occurring during her illness is lost ; at other times the delusions from which she suffered remain, as, for example, in a case which was under my care in which the personal antipathies which the patient formed when insane became permanently established. Insanity of Lactation. — 54 out of the 155 cases collected by Dr. Tuke were examples of the insanity of lactation, which would appear, therefore, to be nearly twice as common as that of pregnancy, but con- siderably less so than the true puerperal form. fl!ts dependence ou causes producing ansemia and exhaustion is obvious and well markedA In the large maiority of cases it occurs in multiparse who have been debilitated by frequent jDregnancies and by length of nursing. When occurring in primiparse, it is generally in Avomen who have suffered from post-partum hemorrhage or other causes of exhaustion, or whose constitution was such as should have contraindicated any attempt at lactation. The bruit de diable is almost invariably present in the veins of the neck, indicating the impoverished condition of the blood. The type is far more frequently melancholic than maniacal, and when the latter form occurs the attack is much mQre_„tiailsient than in true puerperal insanity, y The danger to life is not great, especially if the \\ cause producing debility be recognized and at once removed. ' ' There seems, however, to be more risk of the insanity becoming per- manent than in the other forms. In 12 out of Dr. Tuke's cases the melancholia degenerated into dementia and the patients became hope--- lessly insane. Symptoms. — The symptoms of these various forms of insanity are practically the same as in the non-pregnant state. Generally in cases of mania there is more or less premonitory iudica- 594 Tin-: PUERPERAL STATE. tion of mental (listurbance, wliicli may pass iin|K'rceivoein^ a very common and Mcll-marked symptom, or if tlie patient do sleep her rest is broken and disturbed by dreams. Cau seles s dislikes to those around her are often observed ; the nurse, the husbaniT,' tlie dcx'tor, or the ehild becomes the object of suspicion, and unless })roj)er care be taken the child may be seriously injiu'ed. As the disease advances the ])atient Ix'coraes incoherent and rambling in her talk, and in a fully-developed case she is incessantly pouring forth an unconnectetl jumble of sentences out yf Mhich DO meaning; can be made. Often some prevalent idea which is dwelling in the patient's mind can be traced running through her rav- ings, and it has been noticed that this is frequently of a sexual charac- ter, causing women of unblemished reputation to use obscene and dis- gusting language which it is difficult to understand even when heard. The tendency of such patients to make accasations impugning their own chastity was specially insisted on by many eminent authorities in a recent celebrated trial, when Sir James Simpson stated that in Ins experience " the organ diseased gave a type to the insanity, so that with women suffering from affections of the genital organs the delu- sions would be more likely to be connected with sexual matters." Religious delusions — as a fear of eternal damnation or of having committed some unpardonable sin — are of frequent occurrence, but ])crhaps more often in cases which are tending to the melancholic type. There is generally intolerable restlessness, and the patient's whole man- ner and appearance are those of excessive excitement. She may refuse to remain in bed, may tear off her clothes, or attempt to injure herself The suicidal tendency is often very marked. In one c-ase under my care the patient made incessant efforts to destroy hei-self, which were only frustrated by the most careful watching ; she endeavored to strangle herself with the bed-clothes, to swallow any article she could lay hold of, and even to gouge out her own eyes. Food is generally persistently refused, and the utmost coaxing may fail in inducing the patient to take nourishment. The pujse is rapid and small, and the more violent the excitement and furious the delirium the more excited is the circulation. The toug;ue is coated and fiu'red, the bowels consti- pated and disordered, and the feces as well as the urine are frequently passed involuntarily. The urine is scanty and high-colored, and after the disease has lasted for some time becomes loaded with phosphates. The lochia and the secretion of milk generally become arrested at the commencement of the disease. The waste of tissue, from the incessant restlessness and movement of the patient, is very great, and if tiie dis- ease continue for some time she falls into a condition of marasmus, Avhich may be so excessive that she becomes wasted to a shadow of her former size. A\^j^ii, the insanity assumes the fo rpi of jiielaacholia its advent is more gradual. It may commence with depression of spirits without any adequate cause, associated with insomnia, disturbed digestion, head- ache, and other indications of bodily derangement. Such symptoms, showing themselves in women who have been nursing for i\ length of time or in whom any other evident cause of exhaustion exists, should PUERPERAL INSANITY. 595 never pass unnoticed. Soon the signs of mental depression increase and positive delusions show themselves. TTiese may vary much in their amount, hut they are all more or less of the same tyjie, and very often of a religious character. The amount of constitutional disturb- ance varies nuich. In some cases which a})proach in character those of mania there is considerable excitement, rapid pulse, furred tongue, and restlessness. Probably cases of acute melancholia, coming on during the puerperal state, most often assume this form. In others, again, there is less of these general symptoms, the patients are profoundly dejected, and sit for hours without speaking or moving, but there is not nnich excitement ; and this is the form most generally characterizing the insanity of lactation. In all cases there is a marked disinclination to food. There is also, almost invariably, a disposition to suicide ; and it should never be forgotten in melancholic cases that this may develop itself in an instant, and that a moment's carelessness on the part of the attendants may lead to disastrous results. Treatment. — Bearing in mind what has been said of the essential character of puerperal insanity, it is obvious that the course of treat- ment must be mainly directed to maintain the strength of the patient, so as to enable her to pass through the disease without fatal exhaustion of the vital powers, while we endeavor at the same time to calm the excitement and give rest to the disturbed brain. Any over-active measures — for example, bleeding, blistering the shaven scalp, and the like — are distinctly contraindicated. There is a general agreement on the part of alienist physicians that in cases of acute mania the two things most needed are a sufficient quantity of suitable food and sleep. Every endeavor should be made to induce the patient to take plenty of nourishment to remedy the defects of the excessive waste of tissue and support her strength until the disease abates. Dr. Blandford, who has especially insisted on the importance of this, says:^ "Now, with\, regard to the food, skilful attendants will coax a patient into taking a large quantity, and we can hardly give too much. Messes of minced meat with potato and greens, diluted with beef-tea, bread and milk, rum and milk, arrowroot, and so on, may be got down. ('Never give mere liquids as long as you can get down solids. \ As the malady progresses the tongue and mouth may become so dry and foul that nothing but liquids can be swallowed ; but, reserving our beef-tea and brandy, let us give plenty of solid food while we can." The patient may in mania, as well as in melancholia, perhaps even more in the latter, obstinately refuse to take nourishment at all, and we may be compelled to use force. Various contrivances have been employed for this purpose. One of the simplest is introducing a des- sert-spoon forcibly between the teeth, the patient being controlled by an adequate number of attendants, and slowly injecting into the mouth suitable nourishment by an india-rubber bottle Avith an ivory nozzle, such as is sold by all chemists. Care must be taken not to inject more than an ounce at a time, and to allow the patient to breathe between each deglutition. So extreme a measure will seldom be required if the ^ Blandford, Insanity and its Treatment. 596 THE rVErxPERAL STATE. patient have experienced attendants, who can overcome her resistance to food by gentler means ; but it may be essential, and it is far better to employ it than to allow the ])atient to become exhausted from want of nourishment. In one case I had to feed a j)atient in this way three times a day tor several weeks, and used for the purpose a contrivance known in asylums as Paley's feeding-bottle, which reduced the difficulty of the process to a minimum. Beef;tea or strong soup mixed with some farinaceous material, such as Kevalenta Arabica or wheaten flour, or milk, forms the best mess for this purpose. In the early stages the patient is probably better withou t stimul ants, which seem only to increase the excitement. As the disease progi'esses and exhaustion becomes marked, it may be necessary to have recourse to them. In melancholia they seem to be more useful, and may be administered with greater freedom. The state of the bowels requires special attention. They are almost always disordered, the evacuations being dark and offensive in odor. In the early stages of the disease the prompt clearing of the bowels by a suitable purgative sometimes has the effect of cutting short an impend- ing attack. A curious example of this is recorded by Gooch, in which the patient's recovery seemed to date from the free evacuation of the bow'els. A few grains of calomel or a dose of compound jalap powder or of castor oil may generally be readily given. During the continu- ance of the illness the state of the primae vise should be attended to, and occasional aperients will be useful, but strong and repeated purga- tion is hurtful from the debility it produces. One of the most important points of treatment is to procure^ ^lec} ). For this purpose there is no drug so valuable as the hydrate of c hloral , either alone or in combination with bromide of sodiuiii, which has a dis- tinct effect in increasing its hypnotic action. Given in a full dose at bedtime, say 15 gi'S. to 3ss, it rarely fails in procuring at least some sleep, and in the early stage of acute mania this may be followed by the best effects. It may be necessary to repeat this draught night after night during the acute stage of the malady. If we cannot induce the patient to swallow' the medicine, it may be given in the form of enema. It is generally admitted that in mania i)reparations of opium, formerly much relied on in the treatment of the disease, are apt to do more harm than good. Dr. Blandford gives a strong opinion on this point. He says: "In prolonged delirious mania I believe opium never does good, and may do great harm. AVe shall see the effects of narcotic poisoning if it be pushed, but none that are beneficial. This applies equally to opium given by the mouth and l)y subcutaneous injection. The latter, as it is more certain and effectual in producing good results, is also more deadly when it acts as a narcotic poison. After the administration of a dose of morj^hia by the subcutaneous method the patient will probably at once fall asleep, and we congratu- late ourselves that our long-wished-for object is attained. But after half an hour or so the sleep suddenly terminates, and the mania and excite- ment are worse than before. Here you may possibly think that had the dose been larger instead of half an hour's sleep you would have obtained one of longer duration, and you may administer more, but PUERPERAL INSANITY. 597 with a like result. Large doses of nior[)]ii:i not merely fail to produce refreshinj^ sleep ; they poison the patient, and produce, if not the symp- toms of actual narcotic poisoning, at any rate that typhoid condition which indicates prostration and approaching collapse. I believe there is no drug the use of which more often becomes abused than that of opium." It is otherwise in cases of melancholia, especially in the more chronic forms. In these oi)iates in moderate doses, not pushed to excess, may be given with great advantage. The subcutaneous injection of morphia is by far the best means of exhibiting the drug, from its rapid- ity of action and facility of administration. There are other methods of calming tiie excitement of the patient besides the use of luedicines. The prolonged use of the ^varm bath, the patient being immersed in water at a temperature of tJTT°or9^ for at least half an hour, is highly recommended by some as a sedative. The wet ])a ck serves the same purpose, and is more readily applied in refractory subjects. Judicious nursing is of primary importance. The patient should be kept in a cool, well-ventilated, and somewhat darkened room. If possible she shoiild remain in bed^ or at least endeavors should be made to restrain the excessive restless motion, which has so much effect in promoting exhaustion. ;The presence of relatives and friends, especially the husband, has geuer^ly a prejudicial and exciting effect-^ and it is advisable to place the patient under the care of nurses experienced in the management of the insane, who as strangers are likely to have more control 0%'er her. It is not too much to say that much of the success in treatment must depend on the manner in which this indication is met. Rough, unskilled nurses, who do not know how to use gentleness combined with firmness, will certainly aggravate and prolong the dis- order. Inasmuch as no patient should be left unwatched by day or night, more than one nurse is essential. The question of the removal of the patient to an asylum is one which will give rise to anxious consideration. As the fact of having been under such restraint of necessity fixes a certain lasting stigma upon a patient, this is a step which every one would wish to avoid if possible. In cases of acute mania, ^vhich will probably last a comparatively short time, home treatment can generally be efficiently carried out. Much must depend on the circumstances of the patient. If these be of a nature which preclude the possibility of her obtaining thoroughly effi- cient nursing and treatment in her own home, it is advisable to remove her to a place where these essentials can be obtained, even at the cost of some subsequent annoyance. In cases of chronic melancholia, the man- agement of which is on the whole more difficult, the necessity for such a measure is more likely to arise, and should not be postponed too late. Many examples of incurable dementia arising out of puerperal melan- cholia can be traced to unnecessary delay in placing the patients under the most favorable conditions for recovery. Treatment during- Convalescence. — When convalescence is com- mencing change of air and scene will often be found of great value. Removal to^ome quiet country place, where the patient can enjoy abun- dance of air and exercise in the company of her nurses, without the 598 Tin-: rVKiiPKRAL state. excitement of .•seeing many people, is espeeially to ho reeoni mended. I Great caution must be used in admitting the visits of" relatives and friends. In two ciises under my own care the patients relaj)sed when apparently progressing favorably because the husl)anils iusisteil, contrary to advice, on seeing them./ On the other hand, Gooch has pointed out that when the patient is not recovering, when month after month has been passed in seclusion without any improvement, the visit of a friend or relative may produce a favorable moral impression and inaugurate a change for the i)etter. \ It is i)robably in cases of melancholia, rather than in mania, that this is likely to hap])en. The exi)eriment may under such circumstances be worth trying, but it is one the result of which we must contemplate with some anxiety. CHAPTER A\ PUERPERAL SEPTICEMIA. Difference of Opinion as to Puerperal Fever. — There is no subject in the whole range of obstetrics which has cau.sed so much discassion and difference of opinion as that to which this chapter is devoted. Under the name of " puerperal fever " the di-sejise we have to consider has given rise to endless controversy. One writer after another has stated his view of the nature of the affection with dogmatic precision, often on no other grounds than his own preconceived notions and an erroneous inter})retation of some of the })ost-mortem appearances. Thus, one states that puerperal fever is only a local inflammation, such as peritonitis; others declare it to be phlebitis, metri- tis, metro-peritonitis, or an essential zymotic disease, sui generis, which affects lying-in women only. The result has been a hopeless confusion, and the student rises from the study of the sul)ject with little more n.sc- ful knowledge than when he began. Fortunately, modern research is beginning to throw a little ligiit upon this chaos. Modern View of the Disease. — The whole tendency of recent investigation is daily rendering it more and more certain that obstetri- cians have been led into error by the special virulence and inteusitA' of the di.sease, and that they have erroneously considered it to lie some- thing special to the puerperal state, in.stead of recognizing in it a form of septic disea.se practically identical with that which is familiar to .sur- geons under the name of pytemia or septicaemia. If this view be correct, the term " jnierperal fever," conveying the idea of a fever such as typhus or tyjihoid, nuist be acknowledged to be mi.sleading, and one that should be discarded as only tending to confu- sion. Before di.scu.ssing at length the reasons which render it probable PUERPERAL SEPTICEMIA. 599 that the disease is in no way spceifie or j)efuliar to the puerperal state, it will be well to relate briefly some of" the leadiiii^ facts connected with it. History. — More or less distinct references to the existence of the so-called ])uerperal fever are met with in the classical authors, proving beyond doubt that the disease was well known to them ; and Hippoc- rates, besides relating several cases the nature of which is unquestion- able, clearly recognizes the possibility of its originating in the retention and decomposition of jwrtions of the placenta. Although Harvey and other writers showed that they were more or less familiar wath it, and even made most creditable observations on its etiology, it was not until the latter half of the last century that it came prominently into notice. At that time the frightful mortality occurring in some of the principal lying-in hospitals, especially in the Hotel Dieu at Paris, attracted atten- tion, and ever since the disease has been familiar to obstetricians. Mortality in Lying-in Hospitals. — Its prevalence in hospitals in which lying-in women are congregated has been constantly observed both in England and elsewhere, occasionally producing an appalling death- rate, the disease, when once it has appeared, frequently spreading from one patient to another in spite of all that could be done to arrest it. It would be easy to give many startling instances of this. Thus it pre- vailed in London in the years 1760, 1768, and 1770 to such an extent that in some lying-in institutions nearly all the patients died. Of the Edinburgh Infirmary in 1773 it is stated that "almost every woman as soon as she was delivered, or perhaps about twenty-four hours after, was seized with it, and all of them died, though every method was used to cure the disorder." On the Continent, where the lying-in institutions are on a much larger scale, the mortality was equally great. Thus in the Maisou d'Accouchements of Paris in a number of different years sometimes as many as 1 in 3 of the women delivered died, on one occasion 10 women dying out of 15 delivered. Similar results were observed in other great continental hospitals, as in Vienna, where, in 1823, 19 per cent, of the cases died, and in 1842, 16 per cent.; and in Berlin in 1862 hardly a single patient escaped, the hospital being eventually closed. Such facts, the correctness of which is beyond any question, prove to demonstration the great risk which may accompany the aggregation of lying-in women. Whether they justify the conclusion that all lying- in hospitals should be abolished is another and a very wide question which can scarcely be satisfactorily discussed in a practical work. It is to be observed, however, that most of the cases in which the disease produced such disastrous results occurred before our more recent know- ledge of its mode of propagation was acquired, M'lien no sufficient hygienic precautions were adopted, when ventilation was little thought of, and when, in a Avord, every condition prevailed that would tend to favor the spread of a contagious disease from one patient to another. ]\Iore recent experience proves that when the contrary is the case the occurrence of epidemics of this kind may be entirely prevented and the mortality approximated to that of home practice. The results almost universally obtained of late years by the introduction of strict antisepsis into lying- in institutions aflbrd a most instructive commentary on the causes of GOO THE PUERPERAL STATE. puerperal fever. Thus, in the Maternite in Paris tlie mortality from 1858 to 1870 was 1 in 11 ; at the present time it is only 1 in 100. At the Foundlinti- Hospital in St. Petersburg- the mortality before the intro- duction of antiseptics was 1 in 27 ; since their use, 1 in 147, Similar satisfactory results have been reported in lying-in institutions in London, America, and indeed universally whatever antiseptic precautions have been adopted.^ The more closely the history of these outbreaks in hospitals is studied, the more apjnuvnt does it become that they are not dependent on miasm necessarily j)roduced by the aggregation of puer]>eral patients, but on the direct conveyance of septic matter from one patient to another. In numerous instances the disease has been said to be generally epidemic in domiciliary jDractice, much in the same way as scarlet fever or any zymotic complaint might be. Such e])idemics are described as having occurred in Loudon in 1827-28, in Leeds in 1809-12, in Edinburgh in 1825, and many others might be cited. (There is, liow- ever, no sufficient ground for believing that the disease has ever been epidemic in the strict sense of the w^ord.\ That numerous cases have often occurred in the same place and at the same time is beyond ques- tion, but this can easily be explained without admitting an epidemic influence, knowing, as we do, how readily septic matter may be con- veyed from one patient to another. In many of the so-called epidemics the disease has been limited to the patients of certain midwives or prac- titioners, while those of others have entirely escaped — a fact easily under- stood on the assumption of the disease being produced by septic matter conveyed to the patient, but irreconcilable with the view of general epidemic influence. We are not in possession of any reliable statistics of the mortality arising from puerperal septicaemia in ordinary general practice. It has, however, been m'cII pointed out in the re})ort on puer- peral fever presented by the Obstetrical Society of Berlin to the Prussian minister of health ^ that not only do the published returns of death from metria afford no reliable estimate of the actual mortality from this source, but that they arc very far more numerous than deaths from any other cause in connection with pregnancy and childbirth. Theories Advanced Regarding its Nature. — It would be a useless task to detail at length the theories that have been advanced to explain the (.lisease. Indeed, it may safely be held that the supposed necessity of providing a theory which would explain all the facts of the disease lias done more to surround it with obscurity than even the difticulties of the sul)ject itself. If any real advance is to be made, it can only be Ijy adopting a humble attitude, by admitting that we are only on the threshold of the inquiry, and by a careful observation of clinical facts without drawing from them too positive deductions. Theory of its Local Origin. — ]\Iany have taught that the disease is essentially a local inflannnation, pnuhicing secondary constitutional effects. This view doubtless originated from too exclusive attention 'See "The Prevention of Lving-in Fever," bv Wassily Sutugin, Edin. Med. Joimi., vol. 1884-85, p. 781. ^ " Dentschrift der Puerperalfieber-Commission," Zcitschrift f. Geh. u. Gyn., 1878, Band iii. S. 1, translated in Ediu. Med. Journ., vol. 1878-79, p. 435. PUERPERAL SEPTICAEMIA. 601 to the inorbitl cliangcs luuiul on post-mortem examination. Extensi\'(! peritonitis, phlebitis, inflammation of the lymphatics or of the tissues of the uterus arc very commonly found after death ; and eacii of these lias in its turn been believed to be the real source of the disease. This view finds but little favor with modern pathologists, and is in so many ways inconsistent with clinical facts that it may be considered to be obsolete. No one of the conditions above mentioned is universally found, and in the worst cases definite signs of local inflammation may be entirely absent. Nor will this theory explain the conveyance of the disease from one patient to another or the peculiar severity of the con- stitutional symptoms. Theory of an Essential Zymotic Fever. — A more admissible theory, and one which has been extensively entertained, is that there is an essential zymotic fever peculiar to, and only attacking, puerperal women, which is as specific in its nature as typhus or typhoid, and to which the local phenomena observed after death bear the same relation t>hat the pustules on the skin do to smallpox or the ulcers in the intes- tinal glands to typhoid. This fever is supposed to spread by contagion and infection, and to prevail epidemically both in private and in hos- pital practice. The most recent exponent of this view is Fordyce Barker, who in his excellent work on the Puerperal Diseases has entered at length into all the theories of the disease. He, like others who hold his opinions, has, I cannot but think, entirely failed to bring forward any conclusive evidence of the existence of such a specific fever. It is no doubt true that in typhus and typhoid and other undoubted examples of this class of disease there are well-marked local secondary phenomena, but then they are distinct and constant. He makes no attempt to prove that anything of the kind occurs in puerperal fever. On the contrary, probably there are no two cases in M'hich similar local phenomena occur, nor is there any case in which the most practised obstetrician could foretell either the course and the duration of the ill- ness or the local phenomena. Again, this theory altogether fails to explain the very important class of cases which can be distinctly traced to sources originating in the patient herself — viz. the absorption of septic matter from decomposing coagula and the like. Barker meets this dif- ficulty by placing such cases of auto-infection under a separate category, admitting that they are examples of septicaemia. But he fails to show that there is any difference in symptomatology or post-mortem signs between them and the cases he believes to depend on an essential fever; nor would it be possible to distinguish the one from the other by either their clinical or pathological history. Theory of its Identity "with Surgical Septiceemia. — The modern view, which holds that the disease is, in fact, identical with the condi- tion known a.s pyaemia or septicaemia, is by no means free from objec- tions, and nuich patient clinical investigation is required to give a satis- factory explanation of certain peculiarities Avhich the disease presents; but in sjjite of these difficulties, which time may serve to remove, it offers a far better explanation of the phenomena observed than any other that has yet been advanced. According to this theory, the so-called puerperal fever is produced by 602 THE PUERPERAL STATE. the absorption of septic matter into the system through solutions of continuity in the generative tract, such as always exist after labor. It is not essential that the poison should be })eculiar or speeitic; for, just as in surgical pyremia, any decomposing organic matter, either originat- ing within the generative organs of the patient herself or coming from without, may set uj) the morbid action. In deseril)ing the disease under discussion 1 shall assume that, so far as our present knowledge goes, this view is the one most consonant with facts ; but, bearing in mind that very little is yet known of surgical septicaemia, it must not be expected that obstetricians can satisfactorily explain all the phenomena they observe. The best basis of description I know of is that given by Burdon Sanderson, when he says : " In every pysemic process you may trace a focus, a centre of origin, lines of diffusion or distribution, and secondary results from the distribution — in every case an initial process from which infection commences, from which the infection spreads, and secondary processes which come out of this primary one." ^ Adopting this divis- ion, I shall first treat of the mode in which the infection may com- mence in obstetric cases, and point out the special difficulties which this part of the subject presents. Channels through -which Septic Matter may be Absorbed. — The fact that all recently-delivered women present lesions of continuity in the generative tract, through which septic matter, brought into con- tact with them, may be readily absorbed, has long been recognized. The analogy between the interior of the uterus after delivery and the surface of a stump after amputation w^as particularly insisted on by Cruveilhier, Simpson, and others — an analogy which was, to a great extent, based on erroneous conceptions of what took place, since they conceived that the whole interior of the uterus w-as bared. It is now well known- that this is not the case; but the fact remains that^at the placental site, at any rate, there are open vessels through which absor])- tion may readily take place.j That absorption of septic material occurs through this channel is prdftable in certain cases in W'hich decomposing materials exist in the interior of the uterus, especially when from defective uterine contraction the venous sinuses are abnormally patu- lous and are not occluded by thrombi. It is difficult to understand how septic matter, introduced from without, can reach the placental site. Other sites of absorption are, however, ahvays available. These exist in every case in the form of slight abrasions or lacerations about the cervix or in the vagina, or, especially in primiparje, about the four- chette and perineum. There is even some reason to think that absorp- tion of septic matter may take place through the mucous membrane of the. vagina or cervix without any breach of surface. This might serve to account for the occasional, although rare, cases in which symptoms of the disease develop themselves before delivery, or so soon after it as to show that the infection must have jireceded labor ;( nor is there any inherent improbability in the su[)position that septic material may be A occasionally absorbed through the unbroken mucous membrane, as is \ certainly the case with some poisons — for example, that of syphilis. [/| ' Clinical Transactions, vol. vii. p. cviii. PUERPEBAL SEPTICEMIA. 603 Hence there is no difficulty in recognizing the similarity of a lying-in woman to a patient sutilering from a recent .surgical lesion, or in under- standing how se})tic matter conveyed to her during or shortly after labor may be absorbed. It is necessary, however, to suppose that absorption takes place immediately or very shortly after these lesions of continuity are formed, for it is well known that the ])Ower of absorption is arrested after they have commenced to heal. This fact may explain the cases in which sloughing about the perineum or vagina exists without any septicaemia resulting, or the far from uncommon cases iu which an intensely fetid lochial discharge may be present a few days after delivery without any infection taking place. The character and sources of the septic matter constitute one of the most obscure questions iu connection with septicaemia, and that which is most open to discussion. Division into ATitogenetic and Heterog-enetic Cases. — The most practical division of the subject is into cases in which the septic matter originates within the patient, so that she infects herself, the disease then being properly autogenetic ; and into those in which the septic matter is conveyed from* without and brought into contact with absorptive surfaces iu the generative tract, the disease then being Jieterogenetic. Sources of Self-infection. — The sources of auto-infection may be various, but they are not difficult to understand, ^ny co ndition giving ri^!i£_i2.,tl^£Qmpositiou, either of the tissues of the mother herself, of matters retained in the uterus or vagina that ought to have been expelled, or decomposing matter derived from a putrid foetus, may start the sep- ticsemic process. J Thus it may happen that from continuous pressure on the maternal soft parts dui'ing labor sloughing has set in, or there may be already decomposing material present from some previous morbid state of the genital tracts, as in carcinoma. A more common origin is the retention of coagula or of small portions of membrane or of pla- centa in tKeTntertoFof the uterus, w^hich have putrefied from access of air; or in the decomposition of the lochia. That the retention of por- tions of the placental tissue has at all times been the cause of septicae- mia may be illustrated by the case of the Duchesse d'Orleans (iu the time of Louis XIII.), who had an easy labor, but died of childbed fever. An examination was made by the leading physicians of Paris, in their report of which it was stated: "On the right side of the womb was found a small jjortion of after-birth, so firmly adherent that it could hardly be torn off by the finger-nails."^ The reason why self- infection does not more often occur from such sources, since more or less decomposition is of necessity so often present, has already been referred to in the fact that absorption of such matters is not apt to occur when the lesions of continuity, always existing after parturition, have commenced to heal. This observation may also serve to explain how previous l^ad states of health, by interfering with the healthy reparative process occurring after delivery, may predispose to self-infection. It is interesting to note that puerperal septicaemia arising from such sources is not limited to the human race. In the debate on pya?mia at the Clinical Society, Mr. Hutchinson recorded several well-marked exam- ^ Louise Pourgeok, by Goodell. 604 THf: PUERPERAL STATE. pies oecuring in o\ve> in ^^■ll<)^(■ nteii portions of retained placenta were Ibuntl. Source of Heterog-enetic Infection. — Tlie sources of septic matter conveyed Irojn witlmnt aiv luucli more difficult to trace, and there are many facts connected with hetero<^enetic inl'ection which are very diffi- cult to reconcile with theory, and of which, it nuist be admitted, we are not yet able to give a satisfactory explanation. It is probable that any decomposing organic matter may infect, l)Ut that some forms operate with more certainty and greater virulence than others. One of these, which has attracted special attention, is what may be termed cadaveric poison, derived from dissection of the dead subject in the anatoluicaT aiicl post-mortem theatres, and conveyed to the genital tract by the hands of the accoucheur. Attention was pai-ticularly dh-ected to this source of infection by the observations of Semmelweiss, who showed that in the division of the Vienna Lying-in Hospital attended by medical men and students wlio frequented the dissecting- rooms the mortality was seldom less than 1 to 10, while in the division solely attended Iw women the mortality never exceeded 1 to 34 ; the number of deaths in the former division at once falling to that of the latter so soon as proper precautions and means of disinfection were used. Manv other facts of a like nature have since been recorded which ren- der this origin of puerperal septicaemia a matter of certainty. An interesting example is related by Simjison with characteristic candor : "In 1836 or 1837, !Mr. Sidey of this city had a rapid succession of five or six cases of puerperal fever in his practice at a time when the dis- ease was not known to exist in the practice of any other practitioners in the localitv. Dr. Simpson, who had then no firm or proper belief in the contagious propagation of puerperal fever, attended the dissection of Mr. Sidev's patients and freely handled the diseased i)arts. The next four cases of midwifery which Dr. Simpson attended were all atiected with puerperal fever, and it was the first time he had seen it in jirac- tice. Dr. Patterson of Leith examined the ovaries, etc. The three next cases which Dr. Patterson attended in that town were attacked W'ith the disease."' Negative examples are of course brought forward of those who have attended post-mortem examinations without injuiy to their obstetric patients, which merely prove that the cadaveric poison does not, of necessity, attach itself to the hands of the di§or; and no amount of such testimony can invalidate such positive evidence as that Just narrated. Barnes Ix'lieves that there is not so much danger attending the dissection of ])atients who have died of any ordinary dis- ease, but that the risk attending the dissection of those who have died of infectious or contagious complaints is very great indeed." I })re- surae there is no doubt that the risk is greater when the subject has died from zymotic disease ; but the distinction is too delicate to rely on, and the attendant on midwifery will certainly err on the safe side by avoid- ing as much as possible having anything to do Avith the conduct of dis- sections or post-mortem examinations. ^Selected Obstet. Worh, p. 508. *■' Lectures on Puerperal Fever," Lancet, 18G5, vol. ii. p. 112. PUERPERAL SEPTICEMIA. 605 Infection from Erysipelas. — Another })o.s.sible source of infectioii is erysipe latous dis ease in all its forms. The intimate connection between erysipelas and surgical pytemia has long been recognized by sui-geons, and the inHuence of erysipelas in producing puei-peral septicaemia has been specially observed in surgical hospitals into wliicli lying-in |)atients were also admitted. Trousseau relates instances of this kind occurring in Paris. The only instance that I know of in London was in the lying-in Avard of King's College Hospital, where, in spite of every hygienic precaution, the mortality was so great as to necessitate the closure of the ward. Here the association of erysij)elas with puci-peral septicaemia was again and again observed, the latter proving fatal in direct proportion to the prevalence of the former in the surgical wards. The dependence of the two on the same poison was in one instance curiously shown by the fact of the child of a patient who died of puer- peral septicaemia dying from erysipelas which started from a slight abra- sion produced by the forceps. A more recent and very remarkable example is related by Dr. Lombe Atthill.' A patient suffering from erysipelas was admitted into the Rotunda Hospital on February 15, 1877. The sanitary condition of the hospital was at the time excel- lent. The patient was removed next day, but of the next 10 patients confined in adjoining wards, 9 were attacked with puerperal peritonitis, the only one who escaped being a case of abortion. But the connection between erysipelas and puerperal septicaemia is not limited to hospitals, having been often observed in domiciliary practice. Some interesting facts have been collected by Dr. Minor,^ who has shown that the two diseases have frequently prevailed together in various parts of the United States, and that during a recent outbreak of puerperal fever in Cincinnati it occurred chiefly in the practice of those physicians who attended cases of erysipelas. Many children also died from erysipelas whose mothers had died from puerperal fever. Infection from Other Zymotic Diseases. — There is good reason to believe that thecontagium of other zymotic diseases may produce a form of disease indistinguishable from ordinary puerperal septicaemia, and presenting none of the characteristic features of the specific complaint from which the contagium was derived. This is admitted to be a fact by the majority of the most eminent British obstetricians, although it does not seem to be allowed by continental authorities, and it is strongly controverted by some writers in Great Britain. It is certainly difficult to reconcile this with the theory of septicaemia, and we are not in a posi- tion to give a satisfactory explanation of it. I believe, however, that the evidence in favor of the possibility of puerperal septicaemia origi- nating in this way is too strong to be assailable. The scarlatinal poison is that regarding which the greatest nund)er of observations have Been made. Numerous cases of this kind are to be found scattered through our obstetric literature, but the largest num- ber are to be met with in a paper by Dr. Braxton Hicks in the twelfth volume of the Obstetrical Transactions, and they are especially valuable from that gentleman's well-known accuracy as a clinical observer. Out ^Medical Press aiul Circular, Januarv-.Tune, 1877, p. 339. ^Erysipelas and Childbed Fevir, Cincinnati, 1874. 606 THE PUERPERAL STATE. of Q^ cases of puerperal disease seen in consultation, no less than 37 .were distinctly traced to the scarlatinal poison. Of these, 20 had the characteristic rash of the disease, but the remaining 17, although the history clearly proved exposure to the contagium of scarlet fever, showed none of its usual symptoms, and were not to be distinguished from ordi- nary typical cases of the so-called puerperal fever. On the theory tliat it is impossible for the specific contagious diseases to be modified by the puerperal state, we have to admit that one physician met with 17 cases of puerperal septicsemia in which, by a mere coincidence, the contagium of scarlet fever had been traced, and that the disease nevertheless origi- nated from some other source — an hyjsothesis so improbable that its mere mention carries its own refutation. With regard to the other zymotic diseases the evidence is not so strong, probably from the comparative rarity of the diseases. Hicks mentions one case in which the diphtheritic poison was traced, although none of the usual phenomena of the disease were present. I lately saw a case in which a lady a few days after delivery had a very serious attack of septicaemia without any diphtheritic symptoms, her husband being at the same time attacked with diphtheria of a most marked type. Here it would be difficult not to admit the dependence of the two dis- eases on the same poison. !It is, however, certain that all the zymotic diseases may attack a newly-delivered woman and run their characteristic course without any peculiar intensity. Probably most practitioners have seen cases of this kind ; and this is precisely one of the points of difficulty which we cannot at present explain, but on which future research may be expected to throw some light. It seems to me not improbable that the explana- tion of the fact that zymotic poison may in one. puerperal patient run its ordinary course, and in another produce symptoms of intense septi- ceemia, may be found in the channel of absorption. It is, at any rate, comprehensible that if the contagium be absorbed through the skin or the ordinary channel it may produce its characteristic symptoms and run its usual course, while if brought into contact with lesions of con- tinuity in the generative tract it may act more in the way of septic poi- son, or with such intensity that its specific symptoms are not developed. It may reasonably be objected that if puerperal and surgical septice- mia be identical, the zymotic poisons ought to be similarly modified when they affect patients after surgical operations. The subject of spe- cific contagium as a cause of surgical pytemia has been so little studied that I do not think any one would be justified in asserting that such an occurrence is not possible. Fritsch of Halle and other German physi- cians have recently shown how elaborate antiseptic precautions in lying-in hospitals may prevent the origin of the disease from such sources. Sir James Paget in his Clinical Lectures seems to believe in the possibility of such modification. He says : " I think it not improb- able that in some cases results occurring with obscure symptoms within two or three days after operations have been due to scarlet-fever poison, hindered in some way from its usual progress." Sir Spencer Wells informs me that he has seen cases of surgical pyaemia which he had reason to believe originated in the scarlatinal poison ; and his well- PUERPERAL SEPTICEMIA. 607 known success as an ovariotomist is no doubt in a great measure to be attributed to his extreme care in seeing that no one likely to come in contact with his patients has been exposed to any such source of infec- tion. Sewer Gas and Defective Sanitary Arrangements. — Exposure to sewer ^-as may, I feel sure, produce the disease. In two cases of the kind i had the opportunity of closely watching an untrapped drain opened directly into the bedroom — in one instance into" a bath, in the other into a water-closet. Both cases were indistinguishable from the ordinary form of the disease, and in both improvement commenced as soon as the patient was removed into another room. In a case I saw some years ago in dotting Hill, the patient, who had been confined within a week, had all the symptoms of a most intense attack of septicaemia, but none of a diphtheritic character, while her husband lay in an adjoining room suffering from a diphtheritic sore throat. Here the waste-pipe of the bath was found to communicate directly with the sewer. In spite of her intense illness I had the patient removed to another house, and from that moment she began to improve. In two other cases in which the same source of disease was detected the removal of the patient from the infected atmosphere was immediately followed by a marked amelioration in the symptoms. I know of three similar cases which ended fatally in which I have every reason to believe that the cause of the disease was poisoning by sewer gas. Fraukenhauser has related a curious case of the poisoning of four puerperal women by sewer gas. In fact, the whole question of defec- tive sanitary conditions on the puerperal state deserves much more serious study than it has ever yet received, and I have long been satis- fied that they have often much to do with certain grave forms of illness in the lying-in state the origin of which cannot otherwise be traced.^ ^ Since the above was written I have published a special paper on this subject ("Defective Sanitation as a Cause of Puerperal Disease," ia?ice/, February 5, 1887). I append from it two cases, as I think the diagrams illustrating this source of danger may prove of interest. The annexed diagram (Fig. 197) represents a bedroom in a large house in the most fashionable part of the West End which had been recently taken and done up in the most costly way. I attended the lady of the house in her second confinement, and she lay in her bed at a. Shortly she developed well-marked septic symptoms, and I nat- urally investigated the sanitary state of the house to see if it threw any light on their origin. I could find nothing amiss. There was no bath or fixed washstand near the room, and the closets were at a distance, with the soil-pipe running down the outside wall, as it should do. It was not until some days afterward that I discovered tlie extraordinary arrangement depicted in the diagram, which no one could possibly have suspected, and the knowledge of which the patient had given special directions should be withheld from me. At b is represented a very handsome and innocent-looking piece of furniture which seemed to be a fixed wardrobe, to which purpose its ends were in fact devoted. The centre door, however, formed by a large mirror, opened on a concealed water-closet (c), which luxury no one could have looked for in such a situa- tion. I subsequently discovered that this was a brilliant idea of her husband's, who actually had had a special soil-pipe carried through the centre of the house which communicated directly with the main drain, with no ventilation, and who had thus contrived, at an enormous cost, to have a stream of sewer gas laid on close to his bed- side. And be it remarked that builders and plumbers had carried out this ingeniously dangerous arrangement without giving him the slightest hint that it was either un- usual or perilous. Of course as soon as T made this discovery I had the patient removed to another room, when her symptoms soon abated. 608 THE PUERPERAL STATE. Septicaemia from Contagion Conveyed from other Puerperal Patients. — Tho last source from which septic matter may 1)0 ccmveved I could easily go on multiplying examples of this kind, but I shall content mvself with one more ease, wliiili was tlioroughly worked out with very instructive results. It was that of a lady who was confined in the country of lier first child, in a large ;iud expensive house, newly built, and supposed to be supplied with all the most perl'ect BEID ROOM sanitary arrangements. There was nothing particular about the labor, and for the first ten days the convalescence left nothing to be desired. On the eleventh day she got up and lay on the sofa (Fig. 198, d) opposite the fire (f), which, as it was in January, was burning day and night. The day after, although she had a headache and felt poorly, she again got up and lay on the sofa. The subsequent day, although feeling very ill, she again insisted on getting up, and lay on the sofa at e in her husband's dressing- room. On the following day she was very ill indeed, with a temperature of 104° and a pulse of 130, and I was summoned to see her. It is needless to say more of her ill- ness, which rapidly increased, except that, feeling satisfied it was caused by defective sanitation, I axlvised her removal to a house in the neighborhood, in spite of the very grave symptoms that existed, with the most satisfactory result, for within twenty-four hours her temperature had fallen and she rapidly became convalescent. Of course at this time nothing was known of what actually existed, but I was led to form this con- clusion from the fact that a number of the servants and residents were sufiering from sore throats, and from being told that almost every one who came to stay felt ill and out of sorts. Subsequently the sanitary state of the house was thoroughly investigated by one of the most distinguished sanitary engineers in London, from whose reports the accompanying diagram (Fig. 198) is copied. It is useless to enter into a descri|)tion of all the abominations which were found to exist, which, in a liouse of the kind, in the building of which no expense was spared, were almost past belief. For the pur- pose of my story it will suffice to say that the smoke-test showed tluit there was a very abundant escape of sewer gas into both the bedroom and dressing-room, which, from the fact that there were large fires burning constantly in both rooms, pa.'ksed in a con- tinuous current in the direction of the arrows. In addition, the plumbing-work in the closet in the dressing-room had been so imperfectly done that its contents found their way out under the floor. Now, mark how thoroughly and curiously these facts prove the cause of the disease. The patient lay in the bed at c, which, from the accident of PUKRPERA L SEPTTCylJMrA. 600 is from a patient sulfci-inj;- iVoni piierporal sf'[)tieremia — a mode of origin which has of late attracted special attention. That this is the explana- tion of the occasional endemic prevalence of the disease in lying-in hospitals can scarcely be doubted. The theory of a special puerj^eral miasm pervading the hospital is not required to account for the facts, for there are a hundred ways impossible to detect or avoid — on the hands of nurses or attendants, in sponges, bed-pans, sheets, or even suspended in the atmosphere — in which septic material derived from one patient may be carried to another. The poison may be conveyed in the same manner from one private patient to another. Of this there are many lamentable instances recorded. Thus it was mentioned by a gentleman at the recent discus- sion at the Obstetrical Society that 5 out of 14 women he attended died, no other practitioner in the neighborhood having a case. This its being winter and the current of sewer gas being drawn therefore to the chimneys, was quite out of its reach, and for the first ten days after her confinement, while she remained in bed, she was perfectly well. On the eleventh day, when she got up, she was placed directly in the current of sewer gas at d, and instantly got poisoned. On the twelfth and thirteenth days she was again exposed to the absorption of further and Fig. ]9S. more intense poisoning, while immediately on her removal to fresh and uncontam- inated air all her thrratening symptoms disappeared. Remark also that there was nothing jieculiar in the symptomatology, nothing difl^erent from an ordinarv and rap- idly progressing case of puerperal septica^nia. It seems to me that this instructive history is about as complete a demonstration of the origin of puerperal disease from defective sanitation as any one could possibly desire, and I can see no fiawin tlie chain of evidence. ,39 610 THE PUERPERAL STATE. origin of the disease was clearly pointed ont by Gordon' toward the end of last centnry, w'ho stated that he himself " was the means of car- rying the infection to a great number of women," and he also traced the spread of the disease in the same way in the practice of certain raidwives. In some remarkable instances the unhappy ])roperty of carrying contagion has clung to individuals in a way which is most mysterious, and which has led to the supposition that the whole system becomes saturated with the poison. One of the strangest cases of this kind was that of Dr. Rutter of Philadelphia, which caused much dis- cussion. He had 45 cases of puerperal septicaemia in his own practice in one year, while none of his neighbors' patients were attacked. Of him it is related: "Dr. Rutter, to rid himself of the mysteri(jus influence which seemed to attend upon his practice, left the city for ten days, and before waiting on the next parturient case had his hair shaved off and put on a wig, took a hot bath, and changed every arti- cle of his apparel, taking nothing with him that he had worn or carried to his knowledge on any former occasion ; and mark the result ! The ladv, notwithstanding that she had an easy parturition, was seized the next day w'ith childbed fever, and died on the eleventh day after the birth of the child. Two years later he made another attempt at self- purification, and the next case attended fell a victim to the same dis- ease." Xo wonder that Meigs, in commenting on such a history, refused to believe that the doctor carried the poison, and rather thought "that he was merely unhappy in meeting with such accidents through God's providence." It appears, however, that Dr. Rutter was the subject of a form of oz?ena; and it is quite obvious that under such circumstances his hands coukf never have been free from septic matter.- This obser- vation is of peculiar interest as showing that the sources of infection may exist in conditions difficult to suspect and impossible to obviate, and it affords a satisfactory explanation of a case which was for years consid- ered puzzling in the extreme. It is quite possible that other similar cases, of which many are on record, although none so remarkable, may possiblv have depended on some similar cause personal to the medical attendant. The sources of septic poison being thus multifarious, a few words may be said as to the mode in which it may be conveyed to the patient. Mode in "which the Poison may be Conveyed to the Patient. — As on the view of puerperal septicseraia which seems most to agree with recorded facts, the poison, from whatever source it may be derived, must come into actual contact with lesions of continuity in the genera- tive tract, it is obvious~fh"?iT: one method of conveyance may be on the hands of the accoucheur. That this is a possibility, and that the dis- ^ See Lectures on Puerperal Fever, by Robert J. Lee, ]\I. D. *This is stated on tbe authority of an obstetrical contemporary of Dr. Rutter. i.See Amer. .Town, of Med. Science, 1875, vol. Ixix. p. 474 (Minor). I The author quotes from the editor. Dr. Rutter had an ozrena which in time much disfigured him from its effect upon tlie contour of his nose. He was unfortunately inoculated in his index finser from a patient, and neglected the ])ustule. He liad iir> cases of puerperal septicaemia in four years and nine months, with IS deaths. The question of Dr. Meigs, who was a non-contagionist in regard to puerperal peritonitis, was remarkably appo.site - "Did he distil a subtle essence which he carried with him ? " — Harris, note to 3d American edition. PUERPERAL SEPTICEMIA. 01 1 ease has often been uiiliappily conveyed in tin's way, no one can doubt. Still, it would be unfair in the extreme to conclude that this is the only way in which infection may arise. In town practice especially there are many other ways in which septic matter may reach the patient. The nurse may be tlie means of communication, and if she have been in contact with septic matter she is even more likely than the medical attendant to convey it when washing the genitals during the first few days after delivery, the time that absorption is most apt to occur. Barnes relates a whole series of cases occurring in a suburb of London in the practice of different practitioners, every one of which was attended by the same nurse. Again, septic matter may be carried in sponges, linen, and other articles. What is more likely, for example, than that a careless nurse might use an imperfectly washed sponge on which discharge has been allowed to remain and decompose ? Xor do I see any reason to question the possibility of infection from septic matter suspended in the atmosphere ; and in lying-in hospitals, where many women are congregated" Together, there can be little doubt that this is a common origin of the disease. It is certain, whatever view we may take of the character of the septic material, that it must be in a state of very minute subdivision, and there is no theoretical difficulty in the assumption of its being conveyed by the atmosphere. Conduct of the Practitioner in Relation to the Disease. — This question naturally involves a reference to the duty of those who are unfortunately brought into contact with septic matter in any form, either in a patient suffering from puerperal septicaemia, zymotic disease, or offensive discharges. The practitioner cannot always avoid such con- tact, and it is practically impossible to relinquish obstetric work every time that he is in attendance on a case from which contagion may be carried. jS^or do I believe, especially in these days when the use of antiseptics is so well imderstood, that it is essential. It was otherwise when antiseptics were not employed, but I can scarcely conceive any case in which the risk of infection cannot be prevented by proper care. The danger I believe to be chiefly in not recognizing the possible risk, and in neglecting the use of proper precautions. It is impossible, therefore, to urge too strongly the necessity of extreme and even exag- gerated care in this direction. The practitioner should accustom him- self, as much as possible, to use the left hand only in touching patients suffering from infectious diseases, as that which is not used, under ordi- nary circumstances, in obstetric manipulations. He should be most careful in the frequent employment of antiseptics in washing his hands, such as Condy'sfluid, carbolicacid, or the 1-iu-lOOO solution of perchloride of mercury. Clothing should be changed on leaving an infectious case. Much more care than is usually practised should be taken by nurses, espe- cially in securing perfect cleanliness in everything brought into contact with the patient. When, however, a practitioner is in actual and con- stant attendance on a case of puerperal septicaemia, when he is visiting his patient many times a day, especially if he be himself washing out the uterus with antiseptic lotions, it is certain that he cannot deliver other patients with safety, and he should secure the assistance of a brother-practitioner, although there seems no reason why he should not G12 THE PUERPERAL STATE. visit women already coufined in whom he has not to make vaginal examinations. Prophylaxis of Septicaemia. — If tlie views here inculcated as to the nature of, and mode of infection in, puerperal septicemia be cor- rect, it is obvious that much may be done in the way of p rophyla xis. A perfectly aseptic management of puerperal women is practically impossible. In most lying-in institutions very rigid rules are now laid down to prevent the possibilit}' of infectiye matter being conveyed to the patient either on the hands of the attendants or on instrupjents, napkins, and the like, and with the most satisfactory results. As the risk is much greater when lying-in women are collected together, such precautions, which this is not the place to discuss, are absolutely indi- cated. They are not, however, easily applicable in ordinary private practice, but there are certain simple precautious which every one might adopt without trouble which will materially lessen the risk of septic poisoning. Amongst these may be indicated the use of antiseptic lotions, with which the practitioner and nurse should always wash their hands before attending any case or touching the genital organs ; the use of carbolized vaseline, 1 in 8, for lubricating the fingers, catheter, for- ceps, etc. ; syringing out the vagina night and morning with diluted Coudy's fluid; rigid attention to cleanliness in bedding, napkins, etc. Precautions such as these, although they may appear to some frivolous and useless, indicate a recognition of danger and an endeavor to re- move it, and if they were generally inculcated on nurses (see note, p. 560) and others, might go far to prevent the occurrence of septic mischief. Nature of the Septic Poison.— ^As to the precise character of the septic jpoison — although of late much has been said about it, and there is good /reason to believe that further research may throw light on this obscure (subject — too little is known to justifH^ any positive statement.) The researches of Heiberg, Von Eecklinghausen, Steurer, and others have shown that in puerperal septicaemia, as in surgical fever, eiysipelas, and other infectious diseases, micrococci in large numbers may be traced passing between the muscular and connective-tissue fibres, through the lymphatics, and thus into the general circulation, and that they may be found in various organs and pathological products. More recently, Frjinkel isolated from a number of cases a chain-forming micrococcus, which he at first regarded as specific, and named it the Streptococcus puerperalis. Subsequently he satisfied himself of its identity witli a similar micro-organism in pus. Winkel also cultivated a sti'eptococcus from a case of puerperal peritonitis. It produced an erysipelatous rash in the ear of a rabbit, and was similar in its characters, both morpho- logically and in artificial cultivations, to the streptococcus found in erysipelas. Gushing found streptococci in endometritis diphtheritica and in secondary puerperal inflammation, and Baumgarten, Bumm, Pfannestiel, and others have recorded similar observations. Pfannestiel investigated four cases of puerperal septicaemia with diphtheritic end.o- metritis and purulent peritonitis, and he concluded that a specific micro- organism could not be differentiated in puerperal fever. In his opinion the streptococci from pus, from erysipelas, and diphtheritic affections of PUERPERAL SEPTICAEMIA. 613 the pharynx had all the power of setting up puerperal septictcniia. These observations are of niueh importance, as tending to confirm by scientific observation the intimate relation between these various forms of disease which has long been believed to exist. It may be taken as certaiiD that streptococci bear an intimate and important relation to the disease,] but wheffiei" they themselves form the septic matter or carry it, or/ whether they are mere accidental concomitants of the jiysemic processes,' it is impossible, in the present state of our knowledge, to decide. ■ Channels of Diffusion. — Passing on to the channels of diffusion through which the septic matter may act, we have to consider its effects on the structures with which it is brought into contact and the mode in which it may infect the system at large; and this will include a consideration of the pathological phenomena. Local changes consequent on the absorption of the poison are pretty constant, and of these we may form an intelligible idea by think- ing of them as similar in character and causation to those which we have the opportunity of studying when septic matter is applied to a wound open to observation, as, for example, in cases of blood-poison- ing following a dissection wound. Distinct traces of local action are not of invariable occurrence, and in some of the worst class of cases, when the amount of septic matter is great and its absorption rapid, death may occur after an illness of short duration but great intensity, and before appreciable local changes, either at the site of absorption or in the system at large, have had time to develop themselves. The ^^ fact that puerperal fever may prove fatal without leaving any tangible I post-mortem signs has often iDcen pointed out, such cases most fre- / quently occurring during the endemic prevalence of the disease in ' lying-in hospitals. There can be little doubt, however, that in such cases of intense septicsemia marked pathological changes exist in the form of alterations of the blood and degenerations of tissue, but not •of a character which can be detected by an ordinary post-mortem examination. In the great majority of cases indications of the disease exist at the site of absorption. These are described by pathologists as identical in their character with the inflammatory oedema which occurs in connection with phlegmonous erysipelas. (If lacerations exist in the cervix or vagina, they take on unhealthy action, their edges swell, and their surface becomes covered with a yellowish coat similar in appear- ance to diphtheritic membrane.! The mucous membrane of the uterus is also generally found to be affected, and in a degree varying with the intensity of the local septic process. There is evidence of s evere endometritis, and very frequently the whole lining of the uterus is proJoundly altered, softened, covered with patches of diphtheritic deposit, and it may be in a state of general necrosis. /In the severer cases these changes affect the muscular tissue of the uterus, which is found to be swollen, soft, imperfectly contracted, and even partially necrosed — a condition which is likened by Heiberg to hospital gan- grene. The connective tissue surrounding the generative tract is also swollen and oedematous, and the inflammation may in this way reach the peritoneum, although peritonitis, so often observed in puerperal septicemia, does not necessarily depend on the direct transmission of 614 THE PUERPERAL STATE. inflammation from the pelvic connective tissue, but it is more often a secondary phenomenon. The channels through ■which general systemic infection may supervene are the lymphatics and the venous sinuses, the former being by far the most im]3ort"ant. Recent researches have shown tlie great number and complexity of the lymphatics in connection with the pelvic viscera, and marked traces of the absorption of septic matter are almost always to be found, except in those very intense cases already alluded to in which mo appreciable post-mortem signs are discoverable. The septic matter is probably absorbed from the lymph -spaces abounding in the connective tissue and carried along the lymphatic canals to the near- est glands. (The result is inflammation of their coats and thrombosis of their contents, which may be seen on section as a creamy purulent sub- stanceA (The absorption of septic material may, as Virchow^ has shown, be delayed by the local changes produced in the lymphatics and in the glands with which tney communicate, Avhich are therefore conservative in their action ; and the further progress of the case may in this way be stopped and local inflammation alone result, such cases being believed bv Heiberg to be examples of abortive pygemia. On the other hand, the free septic material may be too abundant and intense to be so arrested ; it may pass on through the lymph-canals and glands until it reaches the blood-current through the thoracic duct, and so 2)roduce a general blood- infection. This mode of absorption of septic matter, and the tendency of the glands to arrest its further progress, serve to explain the pro- gressive character of many cases in which fresh exacerbations seem to occur from time to time, since fresh quantities of poison, generated at its source of origin, may be absorbed as the case progresses. The uterine veins are sujDposed by D'Espine to be the channel of absorp- tion in the intense form of disease which proves fatal very shortly after delivery, too soon for the more gradual process of lymphatic absorption to have become established. It is evident that the veins are not likely to act in this Avay, since they must, under ordinary circumstances, be completely occluded by thrombi, otherwise hemorrhage would occur. If, how^ever, uterine contraction be incomplete, the occlusion of the ven- ous sinuses may be imperfect, and absorption of septic material through them may then take place. Some writers have laid great stress on imperfect uterine contraction in predisposing to septicemia, and its influence may thus be well explained. The veins may bear an import- ant part in the production of septiceemia, independent of the direct absorption of septic matter through them, by means of the detachment of minute portions of their occluding thrombi in the form of emboli. If phlegmonous inflammation occur in the immediate vicinity of the veins, the thrombi they contain may become infected. AYhen once blood-infection has occurred by any of these channels, general septi- caemia, the so-called puerperal fever, is developed. Four Principal Types of Pathological Change. — The variety of pathological phenomena found on post-mortem examination has had much to do with the prevalent confusion as to the nature of the dis- ease. This has resulted in the description of many distinct forms of puerperal fever, the most remarked pathological alteration having been PUERPERAL SEPTICEMIA. 615 taken to be the essential element of the disease. As a matter of fact, there is no doubt that various types of pathological change are met with. Heiberg describes four chief classes which are by no means distinctly separated from one another, are often found simultaneously in the same subject, and are certainly not to be distinguished by the symptoms during life. (Of these thefirgtjg^the dass of cases in which no appreciable morbid phenomena are~%und after death. ) This formidable and fatal form of the disease has long been well known, and is that described by some of our authors as adynamic or malignant puerperal fever. It is the variety which was so prevalent in our lying-in hospitals, and which Ramsbotham^ talks of as being second only to cholera in the severity and suddenness of its onset and in the rapidity with which it carried off its victims. It is quite erroneous to suppose that the existence of pathological changes in this form of disease has never been recognized. Even with the coarse methods of examination formerly used, the occurrence of a fluid and altered state of tlie blood and ecchymoses in connection with vari- ous organs — especially the lungs, spleen, and kidneys — were noticed and specially described by Copland in his Dictionary of Medicine. More recently it has been clearly proved by the microscope that there exist, in addition, the commencement of inflammation in most of the tissues, shown by cloudy swellings and granular infiltration and disintegration of the cell-elements, proving that the blood, heavily charged with septic matter, had set up morbicl action wherever it circulated, the patient succumbing before this had time to develop. In the second type, and that perhaps most commonly met with, the morbid changes are more frequently found in the serous membranes, in the pleura, in the pericardium, but above all in tEe^eriitoneum, the alterations in which have long attracted notice, and have been taken by many writers as proving peritonitis to be the main element of the disease. Evidences of more or less peritonitis are very general. In the more severe cases there is little or no exudation of plastic lymph, such as is found in peritonitis unassociated with septicaemia. There is a greater or less quantity of brownish serum only, the coils of intestine, distended with flatus and highly congested, being surrounded by it. More often there are patchy deposits of fibrinous exudation over many of the viscera, the fundus uteri, the under surface of the liver, and the distended intestines. There is then also a considerable quantity of sero-purulent fluid in the abdominal cavity. The pleural cavities may also exhibit similar traces of inflammatory action, containing imperfectly organized lymph and sero-purulent fluid. Schroeder states that pleurisy is more often the direct result of transmission of inflam- mation through the substance of the diaphragm or lung than a secondary consequence of the septicaemia. In like manner, evidences of pericarditis may exist, the surface of the pericardium being highly injected and its cavity containing serous fluid. Inflammation of the synovial mem- branes of the larger joints, occasionally ending in suppuration, is not uncommon, and may probably be best included under this class of cases. In the third type the mucous membranes appear to bear the brunt 616 THE PUERPERAL STATE. of the disease. The pathulogical changes are most marked iu the mucous memljrane liuing the intestiues, which is highly congested and evecTurcerated in patches, with numerous small spots of blood extra va- sated in the submucous tissue. Similar small apoplectic eifusions have been observed iu the substance of the kidneys and under the mucous membrane of the bladder.' Pneumonia is of common occurrence. In most cases it is probably secondary to the impaction of minute emboli iu the smaller branches of the pulmonary artery, but it may doubtless arise from independent inflammation of the lung-tissue, and will then be included in a class of cases now under consideration. Fig. 199. Name. A. S , age 30; confined Feb. 27, 1879; died March 10. TIME m:e m'e m|e M|E M!E M E M E ME M E - E -^ E ^ E 1 1 1 1 107 lOb lOf joi z 202 I - NORM.TEM. OF BODY g8° ' I _ 1 , H- i — — — i — — — — — ' — — — — 1 ^- 1 1 1 1 — j 1 _j 1 1 1 1 I j — 1 1 1 1 [ i 1 1 ' — ^_ — 1— ~l~ — — — — — 1— H— — i~ ~i — — — - 1 — — — ]— A — — — , \- ^= \_ — V A^= — — — — — Y -/il- 1 -^ - 1 \ ■ ^ i 1 ' • _ , ./^ 1 ~~ .^ 1 ■ -^ — __^ K f\ _!_ l-l- \ l\ / N i — — r '— V. ■r-y i — ]— — ■ E % =i= — 1 ■ 1 1 - — - -H Y j i 1 — : — \^ r \ 1 --I - 1 — — -I— — 1- — 1— ^^ — — - t-i — 1 1 — ;— \ — 1— — — -: = / \ — I— — j— 1 — 1 "in E e: 1 / 1 — -J- y — — 1— — ^ — -i- ■ ■ : ! _ = _ E'E 1 i i 1 1 1 — I 1 ^ — — i— —!— d- ^— -,- = = — - =1=- ' ^- — i— -i— — — — |— — — — !- — I- -;— - — t- 1 EE = = EE ^^ ~ — — — — — — — — — 1 1 DAY OF DIS. 1ST. 2nd. 3RD. 4TH. 5TH. 6TH. 7TH. 8TH- 9TH. 10TH ITH. PULSE "H^ \126 126\ ^ "J^ ^>\ ;v ;^ \ \ \, DATE 27 28 Marl 2 3 4 5 6 7 8 9 10 The fourtli c la ss of pathological phenomena are those which are pro- duced chiefl^n^n' the imp act i pn of minute infected emboji in small ves- sels in various parts of the body. These are the cases which most closely resemble surgical pyaemia both in their symptoms and post-mortem signs, and which by many writers are described under the name of " puerperal pysemia." The dependence of puerperal fever on phlebitis of the uterine veins was a favorite theory, and in a large proportion of cases the coats of the veins show signs of inflammation, their canals being occupied with thrombi in a more or less advanced state of disin- tegration. The mode in which these thrombi may become infected has been shown by Babnoff, who has proved that leucocytes may penetrate P IJ ERF ERA L SEPTICEMIA . 617 the coats of the vein, aucl, eiiterhig its contained coagulum, may set up disintegration and suppuration. This observation brings these pysemic forms of disease into close relation with septiceemia, such as we have been studying, and justifies the conclusion of Verneuil that purulent infection is not a distinct disease, but only a termination of septicaemia, with which it ought to be studied. We have, moreover, to differentiate these results of embolism from those considered in a subsequent chap- ter, the characteristic of these cases being the infected nature of tiie minute emboli. Localized inflammations and abscesses, from the impaction of minute capillary emboli, are found in many parts of Fig. 200. Mrs. D , age 25; confined May 1, 1879. Puerperal septiceemia ; recovery. An untrapped pipe, communicating with sewer, was found in bath close to this patient's bed. TIME M E M E M E M ^ M E M E ME M|E M E m|e M E 7 E M E M E 1^ E 1 1 i o TO? job° IOJ° 104° i 103° I < Q -^ lOI UI c 2 100 •s. '^ 09° NORM.TEM OF BODY 95= . — 1 1 -L o; -J 1 ■i- - — — — — — 1 i — — — — -J — — L < — - — — L— 5-L — _Q. — ^ — L — >lO~ — — » — ~'i5- v' — — — -Q. i^ — ■i^ — - -J in' — — -^ -y^ — ^ .3 <" — — — - fTl n ' 7 H 1 Q. IT - — .q:. ^ A -s- # V — K \ 1- A ^ ii ' \ ' \ iij J ' fT I ■ \ v. 1 '\ 1 1 V \ K 1 1 K \ \ 1 1 \ i ' ' f 1 1 1 1 \ , \i \ / \ j 1 f W \: 7 \ j fl 1 I « \ 1 1 ' 1 1 /l 1 1 1 \ 1 ( 1 / 1 I \ W 1 I ' i I / 1 1 1 w ' \ \r 1 I y \/' - r \/ /i 1 1/ • / ! y 1 1 1 1 1 f\ _ ^ I / V ■ / / ) DAY OF DIS. 1ST. 2ND. 3RD. 4TH. 5TH. 6TH. 7th. 8th. 9th. 10TH 11TH 12TH. 13T« 14TH PULSE 102 88 100 108 DATE 2 3 4 5 6 7 8 9 10 11 12 13 14 15 the body ; most frequently in the lungs, then in the kidneys, spleen, and liver, and also in the muscles and connective tissues. Pathologists are by no means agreed as to the invariable dependence of these on embol- ism, nor is it possible to prove their origin from this source by post- mortem examination. Some attribute all such cases to embolism; others think that they may be the results of primary septicemic inflam- mation. It has been proved by AYeber that minute infected emboli may pass through the lung-capillaries ; and this disposes of one argu- ment against the embolic theory based on the supposed impossibility of their passage. It is probable that both causes may operate, and that 618 THE PUERPERAL STATE. Fig. 201. Mrs. P , age 21 ; labor natural ; confined May 22, 1S80. A piece of decomposed membrane the size of hand washed out of her uterus at first intra-uterine injec- tion ; rapid recovery. localized iiiflaniniatious occurring a short time after delivery are directly produced by the infected blood, while those occurring after the lapse of some time, as in the second or third week, depend upon embolism. Description of the Disease. — From what has been said as to the mode of infection in puerperal septicaemia, and as to the very various pathological changes which accompany it, it will not be a matter of surprise to find tiiat the symptoms are also very various in different cases. This can readily be explained by the amount and virulence of the poison absorbed, the channels of infection, and the organs which are chiefly implicated ; but it renders it very difficult to describe the dis- ease satisfactorily. The symptoms generally show themselves within two or three days after delivery. As infection most often occurs during labor, or in cases which are autogenetic within a short time afterward, and before the lesions of continuity in the generative tract have commenced to cicatrize, it can be understood why septicaemia rarely commences later than the fourth or fifth day. In the great majority of cases the disease begins insidiously. There are^ generally, some chilliness and rigor, but by no means always, and even when present they frequently escape observation or are referred to some transient cause. The first symptom which excites attention is a rise iii the pulse, M'hich may vary from 100 to Mti or more according to the severity of the attack, and the thermometer will also show that the tempera tiu'e is raised to 102°, or in bad cases to X0'4° or 106°r Still, it must be borne in mind that both the pulse and tem- perature may be increased in the puer- peral state from transient causes, and do not of themselves justify the diagnosis of septicsemia. In the more intense class of cases, in which the whole system seems overwhelmed with the severity of the attack, the disease progresses with great rapidity, and often without any appreciable indication of local complication. The pulse is very rapid, small, and feeble, varying from 120 to 140, and there is generally a temperature of 103° to 104°. In the worst form of cases the temperature is steadily high, witliout marked remissions. (See Figs. 204, 199, and 205.) There may be little or no_ pain or tliere may be slight tenderness on pressure over the abdomen or liTerus, and as the disease j)rogresses the intestines get largek^disteided TIME rM- E M E U E M E M F M E M E lof 104 103 1 103 I < ° Ji JOI < 100 Q. E «ORM.TEM. Ofi BODY ^ ^ ^ ^ ^ \90 \90 ^ ^ DATE 26 21 28 29 30 31 Aug1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 tender. As the abdominal pain and tenderness spread, the suiFerings of the patient greatly increase, the intestines become enormously distended with flatus, and the breathing is entirely thoracic, in consequence of the upward displacement of the diaphragm and the fact that the abdominal muscles are instinctively kept as much in repose as possible. The patient lies on her back, with her knees drawn up, and sometimes can- not bear the slightest pressure of the bed-clothes. There is generally much vomiting, and often severe diarrhoea. The temperature generally ranges from 102° to 104°, or even 106°, and is subject to occasional exacerbations and remissions, possibly depending on fresh absorption of P UERPERA L SEPTICEMIA . 621 septic matter. (See Figs. 200, 203, and 202.) The case generally lasts for a week or more, the syrajjtoms going on from bad to worse and the patient dying exhausted. D'Espine points out that rigors, with exacer- bations of the general symptoms, not unfrequently occur about the sixth or seventh day, which he attributes to fresh systemic infection from fetid pus in the peritoneal cavity. It must not be supposed that all these symptoms are necessarily present when the peritonitic complica- tion exists. _ Painis especially often entirely absent, and I have seen cases^ in which'post-mortem "exam^iiiation proved the existence of peri- touitis^ in a very marked degree, in which pain was entirely absent.' Sometimes the pain is only slight, and amounts to little more than ten- derness over the uterus. Fig. 204. Mrs. M. K , age 21 ; infection believed to be due to scarlatina. Confined .\ng. 5, 1878 ; recovery: TIME M E M E M B M E i E M E M E M E M E m|e M E M E r— ) — M|E M E M E m|e mIe mIe ME mIe 1 1 1 107 job 105 104 "p " 102 -z. 1 ^ 2 loi m i ^°° H 99 KORM.TEM OF BODY 1 1 1 1 1 1 [ : 1 \ ■ 1 1 - -^ -+- = — o— 1 w zn — — J ^rz ^ ' z ^ ^ — TTT z _ t 1 _J 'Z^'-(^ ~ 1 o^ — 1 L^- — — ~ _ o 'z 'Z ii< ^z. q:-' — 1 <" JSj\_< 1 -Q-j — — 1 — — = i- — _ = ~ .5 -O i ~ H .c ■'if-' — '-S- — \t -Q^UJ ^ — — ~i .g — ^ 1 LJL — ^UJ^ 1 , ^\ ' 1 1 — \^ — ' — — ' ' ' n <>- — r^" -Dl-2 1 orr~ — 1 — \ - \~ -CE- ^j^; 9 1 1 1 pr^ -y— c\ ■01 , L _ 1 , _ - ^ 1 _jZI 1 .O- , ~ — — — ' ^^ -r" /j — 1 — CC ; -u.- l\ 1 1 ■ / f 1 A 1 / 1 ^ I _) / \ 4^ < 'I ^ 1 V, %^ 1 / \ 1 1 V) 1 1 \\ j \ / i \ _| 1 \ ^ \ I 1 /[ 1 1 \ /' 1 •n 1 \ / 1 \ 1 V 1 1 1 1 1 1 i 1 1 1 1 I 1 1 1 \^ ^ 1 • 1 1 1 1 1 1 1 1 1 ' DAY OF DIS. 1ST. 2nd. 3RD. 4th. 6TH. 6th. /TH. 8TH. 9TH. 10TH. 11th 12th. ISth! 14th. 15TH 16TM 17TH 1STH. I9TH 20TH. PULSE 130 120 150 -.0 DATE Aug6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Symptoms of other local complications are characterized by their own special symptoms : thus, pneumonia by dyspnoea, cough, dulness, etc. ; pericarditis by the characteristic rub ; pleurisy by dulness on percussion ; kidney affection by albuminuria and the presence of casts ; liver compli- cation by jaimdice ; and so on. Pysemic Forms of the Disease. — The cours e of the di.sease is not always so intense and rapid, being in some cases oTa nlore chronTc'c'lia- racter and lasting many weeks. The symptoms in the early stage are oiten indistin^uTsEable from those already described, and it is generally only after the second week that indications of purulent infection develop themselves. Then we often have recurrent and very severe rigors, with marked elevations and remissions oOemj^erature. At the same time, 622 THE PUERPERAL STATE. there is generally an exacerbation ctf the general symptoms, a })eciiliar yellowish discoloration of the skin, and occasionally Avell-develo])ed jaundice. Transient patches of erythema are not uncommonly observed on various parts of the skin, and such eruptions have often been mistaken for those of scarlet fever or other zymotic disease. Localized inflammations and suppuration may rapidly follow. Amongst the most common are inflammation, or even suppuration, of the joints — the knees, shoulders, or hips — which is preceded by difficulty of movement, swelling, and very acute pain. Large collec- tions of pus Jn various parts of the muscles and connective tissue are not rare. "SujDpurative inflammation may also be found in connection with many organs, as in the eye, in the pleura, pericardium, or -lungs ; each of Avhich will of course give rise to characteristic symjDtoms, more or less modified by the type of the disease and the intensity of the inflammation. Puerperal Malarial Fever. — There is a peculiar form of febrile disturbance which sometimes occurs in the puerperal state, and which is apt to be confounded with septicaemia, to which attention has recently been specially directed by Fordyce Barker^ under the name of ''puer- peral malarial fever." = It is specially apt to be met with in Momen who have been exposecLto malaria] poison during their former lives, the recurrence of tlie fever being probably determined by the puer- peral state. Of this I have seen several very well-marked examples in ladies who have formerly contracted fever and ague in India.,/ One of my patients, who has long been in India and suffered from inter- mittent fever for years, is invariably attacked with it after delivery, and herself warnecl me of the fact the first time I attended her. The diagnosis is not always easy. Barker insists on the fact that puerperal malarial fever generally commences after the fifth day from delivery, while septicaemia almost always does so before that time. In the malarial fever, moreover, the intermissions are much more marked, while there are frequently recurring chills or rigors; which is not the case in septicasmia. Treatment. — In considering the all-important subject of treatment the views of the practitioner are naturally biassed by the theory he has adopted of the nature of the disease. If that here inculcated be correct, the indications we have to bear in mind are — 1st, to discover, if possible, the source of the poison, in the hope of arresting further septic absorp- tion ; 2dly, to keep the patient alive until the effects of the poison are worn off; and 3dly, to treat any local complication that may arise. The first is likely to be of great importance in cases of self-infection, as fresh quantities of septic matter may be from time to time absorbed. AVe, fortunately, are in possession of a powerful means of preventing further absorption by the application of antiseptics to the interior of the uterus and to the canal of the vagina. This is especially valuable when the existence of decomposing coagula or other sources of septic matter is sus^^ected in the uterine cavity or when offensive discharges are present. Disinfection is readily accomplished by washing out the uterine cavity at least twice daily by means of a Higginsou syringe 1 "Puerpei-al Malarial Fever," Amer. Journ. of Obstet., 1880, vol. xiii. p. 271. PUERPERAL SEPTICMMIA. 62; with a long vaginal pipe attached.^ The results are sometimes very remarkable, the threatening symptoms rapidly disappearing, and the Fig. 205. Mrs. B , age 29; confined March 29; died April 7, 1879. TIME M E M E M E M E M E M E M E 1 1 MIE M E M E 'iob° las' J04 I I 102° < i 100 99° NORM.TEM OF BODY ■■ E = E i ~ ~ E ~ ~ — E E — — — ~ — z d — E — ^ ZZ ~ — — — - — — — — — — — — / — — — 1 R 4- - pi rj»- ■««- _ - -r-\ / — \- P ^ — 4- LJ_ 1 l V ■ \- — — Y~ 1 1- — '~\ ^ — F A 1 — > — — \ V, - — ^ ~ ~ ~ _ — — — — — — — —^ - - — ' — — — P ' 1 1 — \f 1 DAY OF DIS , 1ST. 2n0. 3rd. 4TH. 5TH. 6th. 7TH. STH. 9th. PULSE \ ,>^ \100 \126 \136 \ \ \ t^ DATE IVlr29 30 3t Apr.l z 3 4 5 6 7 temperature and pulse falling so soon after the use of the antiseptic injections as to leave no doubt of the beneficial effects of the treatment. I cannot better illustrate the advantages of this treatment than by the temperature chart (Fig. 207), which is from a case which came under my observation in the outdoor practice of King's College Hospital. It was that of a healthy woman, thirty-six years of age, who had an easy and natural labor. jSTotliing remarkable was observed until tlie third day after delivery, when the temperature was found to be slightly increased. On the morning of the eighth day the temperature had ^ My colleague, Dr. Hayes, has invented a silver tube for the purpose of administer- ing such intra-uterine injections (Fig. 206), which answers its purpose admirably. The Fig. 206. Hayes' Tube for Intra-uterine Injections. numerous apertures at its extremity allow of a number of minute streams of fluid being thrown out in the form of a spray over the interior of the uterus, the complete bathing of its surface and washing out of its cavity being thus ensured. It is, moreover, introduced more easily than the ordinary vaginal pipe, and can be attached to a Higginson syringe. 624 THE PUERPERAL STATE. risen to 105.8°. She was delirious, with a rapid thready pulse, clammy perspiration, tympanitic abdomen, and her general condition indicated the most urgent danger. On vaginal examination a piece of com- pressed and putrid placenta was found in the os. This was removed by my colleague, Dr. Hayes, and the uterus thoroughly washed out with Condy's fluid and water. The same evening the temperature had sunk to 99° and the general symptoms w^ere much improved. The next day there was a slight return of offensive discharge and an aggra- vation of the symptoms. After again washing out the uterus the tem- perature fell, and from that date the patient convalesced without a single bad symptom. (See also Fig. 201.) This is a very well-marked example of the value of local antiseptic treatment, and I have seen many cases of the same kindT" "It sliould therefore never be omitted in all cases in which self-infection is possible ; and, indeed, even when there is no reason to suspect the presence of a local focus of infection the use of antiseptic lotions is advisable as a matter of j)recaution, since it can do no Fig. 207. harm and is generally comforting to the patient. Various antiseptics may be used, such as a weak solution of carbolic acid, 1 in 50, tincture of iodine dropped into warm water until it has a pale sherry color, Condy's fluid largely diluted, or a solution of perchloride of mercury of the strength of lju_^Q00. Of these, the perchloride-of-mercury solution is the most eifective germicide, and Koch's experiments have conclusively proved that it is the only recognized antiseptic which can be relied upon for destroying the spores of micro-organisms after a single application. [Solution of the biniodide of mercury, 1 part to 4000, has been fully tested as a ger- micide in this country, Russia, France, and Italy, and has been pro- nounced a less poisonous and more pow-erful antiseptic than corrosive sublimate by several careful observers : it is also less irritating. By the addition of iodide of potassium it is made readily soluble. (See paper by Dr. Eugene P. Bernarcly of Philadelphia in Trans. County Med. Soc. Fhila., for Jan. 23, 1889.)— Ed.] As, how^ever, there is a possibility that a too free and incautious use of the corrosive sublimate might prove poisonous, it would be well that such intra-uterine injec- tions should not be stronger than 1 in 2000, and that they should be practised by the medical man himself, the quantity for such irrigation not exceeding two quarts.^ One or other of these may be advantage- ously used alternately — one in the morning, the other in the evening. Occasionally I have employed a l-in-50 solution of carbolic acid, with about 5 grs. to the ounce of iodoform suspended in it. This has the advantage of not only being a powerful antiseptic, but of acting more continuously, in consequence of the powdered iodoform remaining 1 Herff, Gyniik., li IJeber Ursachen und Verhiitung der Sublimat-Vergiftung, etc., 35, Bd. XXV. S. 487. Arch. f. PUERPERAL SEPTICEMIA. 625 partially attached to the uterine walls ; or, as some have advised, an iodoform bougie ^ may be placed in the uterine cavity or powdered iodoform insufflated through the cervix. The nozzle of the syringe should be guided well through the cervix, and the cavity of the uterus thoroughly washed out until the fluid that issues from the vagina is no longer discolored. As the os is always patulous, there is no risk of producing the troublesome symptoms of uterine colic which occasion- ally follow the use of intra-uterine injections in the unimpregnated state. It is quite useless to entrust the injection to the nurse, and it should be performed at least twice daily by the practitioner himself in all cases in which the discharges are oflFeusive. It is not advisable, however, that such injections should be used indiscriminately, since they are not entirely free from risk, nor should they be continued for more than a few days. It has been pointed out ^ that sometimes the intra-uterine injection itself produces rigors and other nervous troubles. I am certain that this observation is correct, and I have myself more than once seen a severe rigor rapidly follow its administration. The vulva should in all cases be carefully inspected, with the view of ascer- taining if the source of infection be not some local slough or necrotic ulcer about the perineum or orifice of the vagina, in which case its surface should be freely covered with iodoform. I have seen more than one instance in which this simple procedure has sufficed to cut short symptoms of a very threatening character. In a disease characterized by so marked a tendency to prostration the importance of sustaining the vital powers by an abundance of easily assimilated nourishment cannot be overrated. Strong beef-tea or other forms of animal soup, milk alone or mixed either w1th'~Iime~'or soda- water, and the yolk of eggs beat up with milk and brandy, should be given at short intervals and in as large quantities as the patient can be induced to take ; and the value of thoroughly efficient nursing will be especially apparent in the management of this important part of the treatment. As there is frequently a tendency to nausea, the patient may resist the administration of food, and the resources of the practitioner will be taxed in administering it in such form and variety as will prove least distasteful. Generally speaking, not more than one or two hours should be allowed to elapse without some nutriment being given. The amount of stimulant required will vary with the intensity of the symp- toms and the indications of debility. Generally, stimulants are well borne, prove decidedly beneficial, and require to be given pretty freely. In cases of moderate severity a tablespoonful of good old brandy or whiskey every four hours may suffice; but when the pulse is very rapid and thready, when there is much low delirium, tympanites, or sweat- ing (indicating profound exhaustion), it may be advisable to give them in much larger quantities and at shorter intervals. The careful prac- titioner will closely watch the effects produced, and regulate the amount by the state of the patient rather than by any fixed rule; but in severe 1 These may be made of gum arable and glycerin, about 2^ inches in length, each containing 90 grains of iodoform. 2 Mangin, " Quelques accidents provoqufe par les injections intra-ut«rines," Nowv. Arch. d'Obstet. et de Gyn., 1888, p. 38. 40 626 THE PUERPERAL STATE. cases eight or twelve ounces of braudy, or even more, in the twenty- four hours may be given with decided benefit. Venesection, both general and local, was long considered a sheet- anchor in this disease. Modern view^s are, however, entirely opposed to its use; and in a disease characterized by so profound an alteration of the blood and so much prostration it is too dangerous a remedy to employ, although it is possible that it might alleviate temporarily the severity of some of the symptoms, especially in cases in which peritoni- tis is well marked and much local pain and tenderness are present. The rational indications in medicinal treatment are to lessen the force of the circulation as much as is possible wdthout favoring exhaustion and to diminish the temperature. For the former purpose Barker strongly advocates the use of the tincture of veratrum viride, in doses of five drops every hour, until the pulse falls to below 100, wdien its eifects are subsequently kept up by two or three drops every second hour. Of this drug I have no per- sonal experience, but I have extensively used minute doses of tincture of aconite for the same purpose, and when carefully given I believe it to be a'most valuable remedy. The way I have administered it is to give a single drop of the tincture, at first every half hour, increasing the interval of administration according to the effect produced. Gener- ally, after giving four or five doses at intervals of half an hour, the pulse begins to fall, and afterw^ard a few doses at intervals of one or two hours will suffice to prevent the heart's action rising to its former rapid- ity. The advantage of thus modifying cardiac action wdth the view of preventing excessive waste of tissue cannot be questioned. It is evi- dent that so powerful a remedy must not be used without the most careful supervision, for if continued too long or given at too frequent intervals it may unduly depress the circulation and do more harm than good. It is necessary, therefore, that the practitioner should constantly watch the effect of the drug, and stop it if the pulse become very weak or if it intermit. It is most likely to be useful at an early stage of the disease before much exhaustion is present, and then only when the pulse is of a certain force and volume. Barker says of the veratrum viride, what is also true of aconite, that "it should not be given in those cases in which rapid prostration is manifested by a feeble, thread- like, irregular pulse, profuse sweats, and cold extremities." The reduction of temperature must form an important part of our treatment, and for this purpose many agents are at our disposal. Quinine in large doses, of from 10 to 30 grains, has been much used for tliis^purpose, especially in Germany. After its exhibition the tem- perature frequently falls one or two degrees. It may be given morning and evening. Unpleasant head-symptoms, deafness and ringing in the ears, often render its continuance for a length of time impossible. These may, however, be much lessened by the addition of 10 to 15 minims of hydrobromic acid to each dose. Antipyrine in doses of 20 grains every three or four hours sometimes proves very efficacious, but as it is ajjt to depress it should be combined with some stimulant, such as 30 minims of sal-volatile. Salicylic acid, in doses of from 10 to 20 grains, or the salicylate of PUERPERAL SEPTICEMIA. 627 socla in the same doses, is a valuable antipyretic which I have found on the whole more manageable than quinine. Under its use the tempera- ture often falls considerably in a short space of time. It is, however, apt to depress the circulation, and thus requires to be carefully watched while it is being administered, and should the pulse become very small and feeble it should be discontinued. In some cases, especially when the fever has assumed a remittent type, I administer with marked benefit a drug which is of high repute in India in the worst class of malarious remittent fevers, and the almost marvellous effects of which in such cases I had myself witnessed in India many years ago. This is the so-called Warburg's tincture, the value of which has been testified to by many high authorities, among whom I may mention Dr. Maclean of Netley, Dr. Broadbent, and Sir Alexander Armstrong, the director-general of the medical department of the navy, who informs me that it is now supplied to all Her Majesty's ships in the tropics, because it is found to be of the utmost value in cases in which quinine has little or no effect. Recently its composition has been made public by Dr. Maclean. The basis is quinine, in com- bination with various aromatics and bitters, some of which probably intensify its action. Be this as it may, the testimony in favor of the anti2:)yretic action of the remedy is very strong. I have found its exhi- bition followed by a profuse diaphoresis (this being its almost invaria- ble effect), and sometimes a rapid amelioration of the symptoms. In other cases in which I have tried it, like everything else, it has proved of no avail. Of its use in ten malarial cases above alluded to Dr. Fordyce Barker says : "For nearly two years past, in those cases Avhere the stomach will tolerate it, I have found Warburg's tincture much more effective and speedy in producing the results desired than the largest doses of quinine."^ Col^ may be advantageously tried in suitable cases. The simplest mo^eof using it is by Thornton's ice-cap, by which a current of cold water is kept continuously running round the head. This has been found of great value in pyrexia after ovariotomy, and I have also found it useful as a means of reducing temperature in puerperal cases. It is a comforting application, and gives great relief to the throbbing headache, which often causes much suffering. Under its use the tem- perature often falls two or more degrees, and it is easily continued day and night. In very serious cases, when the temperature reaches 105° and upward, the external application of cold to the rest of the body may be tried. I have elsewhere relatecP a case of puerperal septicaemia with hyper- pyrexia, the temperature continuously ranging over 105°, in which I kept the patient for eleven days nearly constantly covered with cloths soaked in iced water, by which means only was the temperature kept within moderate bounds and life preserved. But this method of treat- ment is excessively troublesome, and is in no way curative. It is only of use in moderating the temperature when it has reached a point at 1 Op. eit., p. 278. ^ " A Lecture on a Case of Puerperal Septicaemia, with Hyperpyrexia, treated by the Continuous Application of Cold," Brit. 3Ied.Jouni., 1877, vol. ii. p. 687. 628 THE PUERPERAL STATE. Avhich it could not coutinue loug without destroying the patient. I should therefore never think of employing it unless the temperature was over 105°, and then only as a temporary expedient, requiring inces- sant watching, and to be desisted from as soon as the temperature has reached a niore moderate height. It is clearly impossible to place a puerperal patient in a bath, as is practised in hyperpyrexia associated with acute rheumatism or typhoid fever. The same effect may, how- ever, be obtained by placing her on macintosh sheeting, or, still better, on a water-bed, into which cold water is run from time to time, and covering the body M'ith towels soaked in iced water, which are frequently renewed by the attendant nurses. During the application the temper- ature should be constantly taken, and as soon as it has fallen to 101° the cold applications should be discontinued. Amongst other remedies which have been used is turpentine, which was highly thought of by the Dublin school. In cases with much tym- panitic distension and a small weak pulse it is sometimes of unquestion- able value, and it probably acts as a strong nervine stimulant. Given in doses of 15 to 20 minims rubbed up with mucilage, it can generally be taken in spite of its nauseous taste. Purgatives, diaphoretics, or even emetics, have often been employed as eliminants of the poison. The former are strongly recommended by Schroeder and other German authorities, and in England they were formerly amongst the most favorite remedies, and there is a general con- currence of opinion amongst our older writers as to their value. In the first volume of the Obstetrical Journal there is a paper by Mr. Mor- ton in which this practice is strongly advocated, and some interesting cases are recorded in which it apparently acted well. He administers calomel in doses of 3 or 4 grains with compound extract of colocynth, so as to keep up a free action of the bowels. \ It seems quite reasonable, when there is constipation, to promote a gentle action of the bowels by some mild aperient ; but, bearing in mind that severe and exhausting diarrhoea is a common accompaniment of the disease, I should myself hesitate to run the risk of inducing it artificially, especially as there is no proof w'hatever that septic matter can really be eliminated in this way. At the commencement of the disease, however, I have often given one or two aperient doses of calomel with decided benefit. It is possible that further research will give us some means of coun- teracting the septic state of the blood, and the sulphites and carbolates have been given for this purpose, but as yet with no reliable results. The tincture of the perchloride of iron naturally suggests itself, from its well-known effects in surgical pyfemia. In the less intense forms of the disease, especially when local suppurations exist, it is certainly use- ful, and may be given in doses of 10 to 20 minims every three or four hours. In very acute cases other remedies are more reliable, and the iron has the disadvantage of not unfrequently causing nausea or vom- iting. When restlessness, irritation, and want of sleep are prominent symp- toms sedatives may be required. Under such circumstances oi)iates may be given at night, and Battley's solution, nepenthe, or the hypodermic injection of morphia is the form which answers best. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 629 Pain and tenderness and local complications must Ije treated on general principles. The distress from them is most experienced when peritonitis is well marked. Then warm and moist applications in the form of poultices or fomentations are very useful. Relief is also sometimes obtained from turpentine stupes, and when the tym- panites is distressing turpentine enemata are very serviceable. I have found the free application over the abdomen of the flexible collodium of the Pharmacopoeia decidedly useful in alleviating the suffering from peritonitis. Such are the remedies most used in this disease. It is needless to say that it is quite impossible to lay down fixed rules for the management of any individual case ; and it is obvious that if puerperal septiceemia be not a special and distinct disease, its judicious treatment must depend on the general knowledge of the attendant and on a careful study of the symptoms each separate case presents. CHAPTER YI. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. Puerperal Thrombosis and its Results. — Under the head of Thrombosis we may class several important diseases connected with the puerperal state which have received far less attention than they deserve. It is only of late years that some — we may probably safely say the majority — of those terribly sudden deaths which from time to time occur after delivery have been traced to their true cause — viz. obstruc- tion of the right side of the heart and pulmonary arteries from a blood- clot, either carried from a distance or, as I shall hope to show, formed in situ. Although the result and, to a great extent, the symptoms are identical in both, still a careful consideration of the history of these two classes of cases tends to show that in their causation they are distinct, and that they ought not to be confounded. (In the former we have pri- marily a clotting of blood in some part of the peripheral venous sys- tem, and the separation of a portion of such a thrombus due to changes undergone during retrograde metamorphosis tending to its eventual absorption) In the latter we have a local deposition of fibrin, the result of blood-changes consecpient on pregnancy and the puerperal state. The formation of such a coagulum in vessels the complete obstruction of which is incompatible with life explains the fatal results. When, however, a coagulum chances to be formed in more distant parts of the circulation, the vital functions are not immediately interfered with, and we have other phenomena occurring, due to tlie obstruction. The disease known as phlegmasia^ dolens I shall presently attempt to 630 THE PUERPERAL STATE. show is oue result of blood-clot forming in peripheral vessels. But from the evident and tangible symptoms it produces it has long been considered an essential and special disease, and the general blood-dyscra- sia which produces it, as well as other allied states, has not been studied separately. I shall hope to show that all tliese various conditions, dis- similar as they at first sight appear, are very closely connected, and that they are in fact due to a common cause; and thus, I think, we shall arrive at a clearer and more correct idea of their true nature than if we looked upon them as distinct and separate affections, as has been com- monly done. I am aware that in phlegmasia dolens, the pathology of which has received perhaps more study than that of almost any other puerperal aflPection, something beyond simple obstruction of the venous system of the affected limb is probably required to account for the pecu- liar tense and shining swelling which is so characteristic. Whether this be an obstruction of the lymphatics, as Dr. Tilbury Fox and others have maintained with much show of reason, or whether it is some as yet undiscovered state, further investigation is required to show. But it is beyond any doubt that the important and essential part of the dis- ease is the presence of a thrombus in the vessels ; and I think it will not be difficult to prove that in its causation and history it is precisely similar to the more serious cases in which the pulmonary arteries are involved. It will be well to commence the study of the subject by a considera- tion of the conditions which in the puerperal state render the blood so peculiarly liable to coagulation, and we may then proceed to discuss the symptoms and results of the formation of coagula in various parts of the circulatory system. Conditions which Favor Thrombosis. — The researches of Vir- chow, Benjamin Hall, Humphry, Richardson, and others have rendered us tolerably familiar with the conditions which favor the coagulation of the blood in the vessels. These are, chiefly — 1. A stagnant or arrested circulation ; as, for example, when the blood coagulates in the veins which draw blood from the gluteal region in old and bed-ridden people, or, as in some forms of pulmonary thrombosis, in which the clots in the arteries are probably the result of obstruction in the cir- culation through the lung-capillaries, as in certain cases of emphysema, pneumonia, or pulmonary apoplexy. 2. A m echani cal obstruction around which coagula form, as in certain morbid states of the vessels ; or, a better example still, secondary coagula which form around a travelled embolus impacted in the pulmonary arteries. 3. And most important of all, in which the coagulation is the result of some mox- bid state of the blood itself. Examples of this last condition are fre- quently met with in the course of various diseases, such as rheumatism or fever, in which the quantity of fibrin is increased and the blood itself is loaded with morbid material. Thrombosis from this cause is by no means of infrequent occurrence after severe surgical operations, especially such as have been attended with much hemorrhage or when the patient is in a weak and ansemic condition. This has been specially dwelt upon as a not infrequent source of death after operation by Fayrer and other surgeons.^ ^ Edin. Med. Journ., March, 1861 ; Indian Annals of Med., July, 1867. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 631 Coagulation in the Puerperal State. — But little consideration is required to show why thrombosis plays so important a part in the puer- peral state, for there most of the causes favoring its occurrence are pres- ent. Probably there is no other condition in which they exist in so marked a degree or are so frequently combined. The blood contains an excess of fibrin, which largely increases in the latter months of utero-gestationTuutil, as has been pointed out by Andral and Gavarret, it not unfrequently contains a third more than the average amount present in the non-pregnant state. As soon as delivery is com[)leted other causes of blood-dyscrasia come into operation. Involution of the largely hypertrophied uterus commences, and the blood is charged with a quantity of effete material, which must be present in greater or less amount until that process is completed, j It is an old observation that phlegmasia dolens is of very common occurrence in patients who have lost much blood during labor. Thus Dr. Leishman says : " In no class of cases has it been so frequently observed as in women whose strength has been reduced to a low ebb by hemorrhage either during or after labor ; and this no doubt accounts for the observation made by Merrimau, that it is relatively a common occurrence after placenta prsevia." ' An examination of the cases in which death results from pulmonary thrombosis shows the same facts, as in a large proportion of them severe post-partum hemorrhage has occurred. The exhaus- tion following the excessive losses so common after labor must of itself strongly predispose to thrombosis ; and, indeed, loss of blood has been distinctly pointed out by Richardson to be one of its most common ante- cedents. " There is," he observes, " a condition which has been long known to favor coagulation and fibrinous deposition. I mean loss of blood and syncope or exhaustion during impoverished states of the body." Since, then, so many of the predisposing causes of thrombosis are present in the puerperal state, it is hardly a matter of astonishment that it should be of frequent occurrence or that it should lead to con- ditions of serious gravity. And yet the attention of the profession has been for the most part limited to a study of one only of the results of this tendency to blood-clotting after delivery, no doubt because of its comparative frequency and evident symptoms. True, the balance of professional opinion has lately held that phlegmasia dolens is chiefly the result of some morbid condition of the blood, producing plugging of the veins ; but the wider view which I am attempting to maintain, which would bring this disease into close relation with the more rarely observed but infinitely important obstructions of the pulmonary arteries, has scarcely, if at all, been insisted on. Doubtless, further investigation will show that it is not in these parts of the venous system alone that puerperal thrombosis occurs ; but the symptoms and effects of venous obstruction elsewhere, important though they may be, are unknown. Distinction between Thrombosis and Embolism. — I propose, then, to describe the symptoms and pathology of blood-clot in the right side of the heart and pulmonary artery. It may be useful here to repeat that this is essentially distinct from embolism of the same ^ Leishman, System of Obstdrics, p. 720, 2d ed., 1S7G. 632 /^ ^ fHE PUERPERAL STATE. parts. The lattei^is obstruction due to the impaction of a sepa- rated portion of a tnrombus formed elsewhere, and for its production it is essential that thrombosis should have preceded it. Embolism is, in fact, an accident of thrombosis, not a primary affection. The con- dition we are now discussing I hold to be primary, precisely similar in its causation to the venous obstruction which in other situations gives rise to phlegmasia dolens. At the threshold of this inquiry we have to meet the objection, started by several w'ho have written on this subject,^ that spontaneous coagula- tion of the blood in the right side of the heart and pulmonary arteries is a mechanical and physiological impossibility. This was the view of VirchoM^, who with his followers maintained that whenever death from pulmonary obstruction occurred an embolus was of necessity the start- ing-point of the malady and the nucleus round which secondary deposi- tion of fibrin took place. Virchow holds that the primary factor in thrombosis is a stagnant state of the blood, and that the impulse imparted to the blood by the right ventricle is of itself sufficient to prevent coagulation. It is to be observed that these objections are purely theoretical. Without denying that there is considerable force in the arguments adduced, I think that the clinical history of these cases strongly favors the view of spontaneous coagulation ; and I would apply to the theoretical objections advanced the argument used by one of their strongest upholders with regard to another disputed point : " Je prefere laisser la parole aux faits, car devant eux la theorie s'incline." ^ The anatomical arrangement of the pulmonary arteries shows how spontaneous coagulation may be favored in them ; for, as Dr. Hum- phry has pointed out,^ " the artery breaks up at once into a number of branches which radiate from it at different angles to the several parts of the lungs. Consequently, a large extent of surface is presented to the blood, and there are numerous angular projections into the currents; both which conditions are calculated to induce the spontaneous coagula- tion of the fibrin." We know also that thrombosis generally occurs in patients of feeble constitution, often debilitated by hemorrhage, in whom the action of the heart is much weakened. These facts of themselves go far to meet the objections of those who deny the possibility of spon- taneous coagulation at the roots of the pulmonary arteries. Results of Post-mortem Examinations. — The records of post- mortem examinations show also that in many of the cases the right side of the heart, as well as the larger branches of the pulmonary arteries, contained firm, leathery, decolorized, and laminated coagula, which could not have been recently formed. The advocates of the purely embolic theory maintain that these are secondary coagula formed round an embolus. But surely the mechanical causes which are sufficient to prevent spontaneous deposition of fibrin would also suffice to prevent its gathering round an embolus; unless, indeed, the obstruction w^as sufficient to arrest the circulation altogether, when death would occur before there was any time for a secondary deposit. ^ See especially Bertin, Des Embolies, p. 46 et seq. ^ Bertin, Des Embolies, p. 149. * Humphry, On the Coagulation of the Blood in the Venous System during Life. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 633 Before we can admit the possibility of embolism we must have at least one factor — that is, thrombosis — in a peripheral vessel from which an embolus can come. In many of the recorded cases nothing of the kind was found, and although, as is argued, this may have been over- looked, yet such an oversight can hardly always have been made. The strongest argument, however, in favor of the spontaneous origin of pulmonary thrombosis is one which I originally pointed out in a series of papers "On Thrombosis and Embolism of the Pulmonary Artery as a Cause of Death in the Puerperal State." ^ I there showed, from a careful analysis of 25 cases of sudden death after delivery in which accurate post-mortem examinations had been made, that cases of spontaneous thrombosis and embolism may be divided from each other by a clear line of demarcation, depending on the period after delivery at which the fatal. result occurs. In 7 out of these cases there was dis- tinct evidence of embolism, and in them death occurred at a remote period after delivery ; in none before the nineteenth day. This con- trasts remarkably with the cases in which the post-mortem examination afforded no evidence of embolism. These amount to 15 out of 25, and in all of them, with one exception, death occurred before the fourteenth day, often on the second or third. The reason of this seems to be that in the former time is required to admit of degenerative changes taking place in the deposited fibrin leading to separation of an embolus; while in the latter the thrombosis corresponds in time, and to a great extent, no doubt, also in cause, to the original peripheral thrombosis from which, in the former, the embolus was derived. Many cases I have since col- lected illustrated the same rule in a very curious and instructive way. Another clinical fact I have observed points to the same conclusion. In one or two cases distinct signs of pulmonary obstruction have shown themselves without proving immediately fatal, and shortly afterward peripheral thrombosis, as evidenced by phlegmasia dolens of one extremity, has commenced. Here the peripheral thrombosis obviously followed the central, both beiug produced by identical causes, and the order of events necessary to uphold the purely embolic theory was reversed. I hold, then, that those who deny the possibility of spontaneous coagulation in the heart and pulmonary arteries do so on insufficient grounds, and that we may consider it to be an occurrence, rare no doubt, but still sufficiently often met with, and certainly of sufficient importance, to merit very careful study. History. — Dr. Charles D. Meigs of Philadelphia was one of the firet to direct attention to spontaneous coagulation of the blood in the right side of the heart and pulmonary arteries as a cause of sudden death in the puerperal state. The occurrence itself, however, has been carefully studied by Paget, whose paper was ]3ublished in 1855, four years before Meigs wrote on the subject.^ It is true that none of Paget's cases happened after delivery, but he none the less clearly apprehended the nature of the obstruction. In 1855, Hecker ^ attributed the majority ' Lancet, 1867. "^ Medico-Chir. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352 ; Philadelphia MeiUcal Examiner, 1849. '^Deutsche Klinik, 1855. 634 THE PUERPERAL STATE. of these cases to embolism proper, and since that date most authors have taken the same view, believing that spontaneous coagulation only occurs in exceptional cases, such as those in ^vhich, on account of some obstruc- tion in the lung or of the debility of the last few hours before death, coag- ula form in the smaller ramifications of the pulmonary arteries and gradually creep backward toward the heart. Symptoms of Pulmonary Obstruction. — The symptoms can hardly be mistaken, and there seems to be no essential difference between the symptomatology of spontaneous and embolic obstructions, so that the same description will suffice for both. In a large proportion of cases the attack comes on with an appalling suddenness which forms one of its most striking characteristics. Nothing in the condition of the patient need have given rise to the least suspicion of impending mischief, when aU at once an intense and horrible dyspno ea comes on : she gasps and struggles for breath, tears off the coverings from her chest in a vain endeavor to get more air, and often dies in a few minutes, long before medical aid can be had, with all the symptoms of asphyxia. The mus- cles of the face and thorax are violently agitated in the attempt to oxy- genate the blood, and an appearance closely resembling an epileptic con- vulsion may be presented. The face may be either pale or deeply cyanosed. Thus in one case I have elsewhere recorded, which was an undoubted example of true embolism, Mr. Pedler, the resident accouch- eur at King's College Hospital, who was present during the attack, writes of the patient : ^ " She was suffering from extreme dyspnoea, the countenance was excjessively pale, her lips white, the face generally expressing deep anxiety." In another, which was probably an example of spontaneous thrombosis^ occurring on the twelfth day after delivery, it is stated : " The face had assumed a livid purple hue, which was so remarkable as to attract the attention both of the nurse and of her mother, who was with her." The extreme embarrassment of the cir- culation is shown by the tumultuous and irregular action of the heart in its endeavor to send the venous blood through the obstructed pul- monary arteries. Soon it gets exhausted, as shown by its feeble and fluttering beat. The pulse is thread-like and nearly imperceptible, the respirations short and hurried, but air may be heard entering the lungs freely. The intelligence during the struggle is unimpaired, and the dreadful consciousness of impending death adds not a little to the patient's sufferings and to the terror of the scene. Such is an imperfect account of the symptoms gathered from the record of what has been observed in fatal cases. It will be readily understood Mhy, in the presence of so sudden and awful an attack, symptoms have not been recorded with the accuracy of ordinary clinical observation. Is Recovery Possible ? — A question of great practical interest which has been entirely overlooked by Avriters on the subject is. Have we any ground for supposing that there is a possibility of recovery after symptoms of pulmonary obstruction have developed themselves ? That such a result must be of extreme rarity is beyond question, but I have little doubt that in some few cases, entirely inexplicable on any other hypothesis, life is prolonged until the coagulura is absorbed and the pul- ^ Brit. Med. Journ., 1869, vol. i. p. 282. ^ Obst. Trans., 1871, vol. xii. p. 194. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. G35 monaiy circulation restored. lu order to admit of this it is of course essential that the obstruction be not sufficient to ])revent the passage of a certain quantity of blood to the lungs to carry on the vital functions. The history of many cases tends to show that the obstructing clot was present for a considerable time before death, and that it was only when some sudden exertion was made, such as rising from bed or the like, calling for an increased supply of blood which could not pass through the occluded arteries, that fatal symptoms manifested themselves. This was long ago pointed out by Paget,' who says: "The case proves that in certain circumstances a great part of the pulmonary circulation may be arrested in the course of a week (or a few days more or less) without immediate danger to life or any indication of what had happened." And after referring to some illustrative cases, " Yet in all these cases the characters of the clots by which the pulmonary arteries were obstructed showed plainly that they had been a week or more in the process of formation." If we admit the possibility of the continuance of life for a certain time, we must, I think, also admit the possibility, in a few rare cases, of eventual complete recovery. What is required is time for the absorption of the clot. In the peripheral venous system coagula are constantly removed by absorption. So strong, indeed, is the tendency to this that Humphry observes with regard to it, " It appears that the blood is almost sure to revert to its natural channel iu process of time."^ If, then, the obstruction be only partial, if suffi- cient blood pass to keep the patient alive, and a sudden supply of oxy- genated blood is not demanded by any exertion which the embarrassed] circulation is unable to meet, it is not inconceivable that the patienj may live until the obstruction is removed. Illustrative Cases. — Such I believe to be the only explanation of certain cases, some of which, on any other hypothesis, it is impossible to understand. The symptoms are precisely those of pulmonary obstruc- tion, and the description I have given above may be applied to them in every particular ; and after repeated paroxysms, each of which seems to threaten immediate dissolution, an eventual recovery takes place. What, then, I am entitled to ask, can the condition be if not that which I sug- gest "? As the question I am considering has never, so far as I am aware, been treated of by any other writer, I may be permitted to state very briefly the facts of one or two of the cases on which I found my argument, some of which I have already published in detail else- where : K. H , delicate young lady. Labor easy. First child. Profuse post-partum hemorrhage. Did well until the seventh day, during the whole of which she felt weak. Same day an alarming attack of dyspnoea came on. For several days she remained in a very critical condition, the slightest exertion bringing on the attacks. A slight blowing murmur heard for a few days at the base of the heart, and then dis- appeared. For two months patient remained in the same state. As long as she was in the recumbent position she felt pretty comfortable, but any attempt at sitting up in bed or any unusual exertion immediately brought on the embarrassed respiration. During all this time it was found necessary to administer stiiiiulants profusely to ward ofl" the attacks. Eventually the patient recovered completely. Q. F , set. 44, mother of twelve children. Confined on July 6. On the eleventh day she went to bed feeling well. There was no swelling or discomfort of any kind ' Op. ciL, p. 358. ^ Med.-Chir. Trans., vol. xxvii. p. 14. 636 THE PUERPERAL STATE. about the lower extremities at this time. About half-past three a.m. she was sitting up in bed when she was suddenly attacked with an indescribable sense of oppression in the chest, and fell back in a semi-unconscious state, gasping for breath. She remained in a very critical condition, with the same symj^toms of embarrassed respiration, for three days, when they gradually passed away. Two days after the attack of phlegmasia dolens came on, the leg swelled, and remained so for several months. This case is an example of the fact I have ah*eadj referred to, of phlegmasia dolens coraiug on after the symj)toms of pulmonary obstruction had manifested themselves, the inference being that both depended on similar causes operating on two distinct parts of the circu- latory system. C. H , set. 24. Confined of her first child on August 20, 1 867. Thirty hours after delivery she complained of great weakness and dyspnoea. This was alleviated by the treatment employed, but on the ninth day, after making a sudden exertion, the dyspnoea returned with increased violence, and continued unabated until I saw the patient on September 4, fourteen days after her confinement. The following are the notes of her condition, made at the time of the visit : " I found her sitting on the sofa propped up with pillows, as she said she could not breathe in the recumbent position. The least excitement or talking brought on the most aggravated dyspnoea, which was so bad as to threaten almost instant death. Her sufferings during these paroxysms were terrible to witness. She panted and struggled for breath and her chest heaved with short, gasping respirations. She could not even bear any one to stand in front of her, wav- ing them away with her hand and calling for more air. These attacks were very fre- quent, and were brought on by the most trivial causes. She talked in a low suppressed voice, as if she could not spare breath for articulation. On auscultation air was found to enter the lungs freely in every direction, both in front and behind. Immediately over the site of the pulmonary arteries there M-as a distinct harsh, rasping murmur, confined to a very limited space and not propagated either upward or downward. The heart-sounds were feeble and tumultuous." These symptoms led me to diagnose pul- monary obstruction, and I of course gave a most unfavorable prognosis, but to my great surprise the patient slowly recovered. I saw her again six weeks later, when her heart- sounds were regular and distinct and the murmur had completely disappeared. E. E , £et. 42, was confined for the first time on November 5, 1873, in the sixth month of utero-gestation. She had severe post-jDartum hemorrhage, depending on partially adherent placenta, which was removed artificially. She did perfectly well until the fourteenth day after delivery, when she was suddenly attacked with intense dyspncea, aggravated in paroxysms. Pulse pretty full, 130, but distinctly intermittent. Air entered lungs freely. The heart's action was fluttering and irregular, and at the juncture of the fourth and fifth ribs with the sternum there was a loud blowing systolic murmur. This was certainly non-existent before, as tlie heart had been carefully aus- cultated before administering chloroform during labor. For two days the patient remained in the same state, her death being almost momentarily expected. On the 21st — that is, two days after the appearance of the chest-symptoms — phlegmasia dolens of a severe kind developed itself in the right thigh and leg. She continued in the same state for many days, lying more or less tranquilly, but having paroxysms of the most intense apncea, varying from two to six or eight in the twenty-four hours. Xo one who saw her in one of these could have expected her to live through it. Shortly after the first appearance of the paroxysms it was observed that the cellular tissue of the neck and part of the face became swollen and oedematous, giving an appearance not unlike that of phlegmasia dolens. The attacks were always relieved by stimulants. These she incessantly called for, declaring that she felt they kept her alive. During all this time the mind was clear and collected. The pulse varied from 110 to 130; respirations about 60; temperature 101° to 102.5°. By slow degrees tlie patient seemed to be rallying. The paroxysms diminished in number, and after December 1st she never had another and the breathing became free and easy. The pulse fell to 80, and the cardiac murmur entirely disa23peared. The patient remained, however, verj' weak and feeble, and the debility seemed to increase. Toward the second week in December she became delirious, and died, apparently exhausted, without any fresh chest-symp- toms, on the 19th of that month. No post-mortem examination was allowed. I have narrated tliis case, although it terminated fatally, because I hold it to be one of the class I am considering. The death was cer- PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 637 tainly not due to the obstruction, all symptoms of which had dis- appeared, but apparently to exhaustion from the severity of the former illness. It illustrates, too, the simultaneous appearance of symptoms of pulmonary obstruction and peripheral thrombosis. The swelling of the neck was a curious symptom which has not been recorded in any other cases, and may possibly be a further proof of the analogy between this condition and phlegmasia dolens. Such Cases can only Depend on Pulmonary Obstruction. — Xow, it may of course be argued that these cases do not prove my thesis, inas- much as I only assume the presence of a coagulum. But I may fairly ask, in return, what other condition could possibly explain the symp- toms? They are precisely those which are noticed in death from undoubted pulmonary obstruction. No one seeing one of them, or even reading an account of the symptoms while ignorant of the result, could hesitate a single instant in the diagnosis. Surely, then, the infer- ence is fair that they depended on the same cause. In the very nature of things my hypothesis cannot be verified by post-mortem examina- tion ; but there is at least one case on record in which, after similar symptoms, a clot was actually found. The case is related by Dr. Richardson.^ It was that of a man who for weeks had symptoms precisely similar to those observed in the cases I have narrated. In one of his agonizing struggles for breath he died, and after death it was found " that a fibrinous band, having its hold in the ventricle, extended into the pulmonary artery." This observation proves to a certainty that life may continue for weeks after deposition of a coagu- lum ; and, moreover, this condition w^as precisely what we should antici- pate, since of course the obstructing coagulum must necessarily be small, otherwise the vital functions would be immediately arrested. Cardiac Murmurs in Pulmonary Obstruction. — There is a symp- tom noted in two of the above cases, and to a less extent in a third, which has not been mentioned in any account of fatal cases occurring after delivery — viz. a murmur over the site of the pulmonary arteries. It is a sign we should naturally expect, and very possibly it would be met with in fatal cases if attention were particularly directed, to the ■ point. In both these instances it was exceedingly well marked, and in both it entirely disappeared when the symptoms abated. The probability of such a murmur being audible in cases of thrombosis of the pulmonary artery has been recognized by one of our highest authorities in cardiac disease, who actually observed it in a non-puer- peral case. In the last edition of his work on diseases of the heart Dr. Walshe ^ says : " The only physical condition connected with the vessel itself would probably be systolic basic murmur following the course of the pulmonary main trunk and of its immediate divisions to the left and right of the sternum. This sign I most certainly heard in an old gentleman Mdiose life was brought to a sudden close in the course of an acute affection by coagulation in the pulmonary artery, and to a moderate extent in the right ventricle. Similar cases have probably been overlooked or misinterpreted. Many 1 Clinical Essays, p. 224 et seq. 2 Walshe, On Diseases of the Heart, 4th ed., 1873. 638 Till-: PUERPERAL STATE. setiii to liave heoii attril>uted to shock, in the ahsencc ol" a better expla- nation — a condition to Mliidi tliey bear no kind of" resemblance. Causes of Death. — 'i'lie precise mode of death in pulmonary obstruction, whether dependent ou thrombosis or embolism, has given rise to considerable diliercnce of opinion, Vircliow attributes it to syncope,^ depending on stoppage of the cardiac contraction. Panum,^ on the other hand, contests this view, maintaining that the heart con- tinues to beat even after all signs of life have ceased. Certainly, tumultuous and irregular j)ulsati()ns of the heart are prominent symp- toms in most of the recorded cases, and are not reconcilable with the idea of syncope. Panum's own theory is that death is the result of cerebral ansemia. Paget seems to think that the mode of death is altogether peculiar, in some respects resembling synco])e, in others aufemia. Bertin, who has discussed the subject at great length, attributes the fatal result purely to asphyxia. The condition, indeed, is in all respects similar to that state, the oxygenation of the blood being prevented, not because air cannot get to the blood, but because blood cannot get to the air. The symptoms also seemed best explained by this theory : the intense dyspnoea, the terrible struggle for air, the preservation of intelligence, the tumultuous action of the heart, are certainly not characteristic either of syncope or anaemia. Post-mortem Appearances of Clots. — The anatomical character of the clots seems to vary considerably. Ball, by whom they have been most carefully described, believes that they generally commence in the smaller ramifications of the arteries, extending backward toward the heart and filling the vessels more or less completely. Toward its cardiac extremity the coagulum terminates in a roimded head, in which respect it resembles those spontaneously formed in the peripheral veins. It is non-adherent to the coats of the vessels, and the blood circulates, when it can do so at all, between it and the vascular walls. Such clots are white, dense, and of a homogeneous structure, consisting of layers of decolorized fibrin, firm at the periphery, where the fibrin has been most recently deposited, and softened in the centre, where amylaceous or fatty degeneration has commenced. Ball maintains that if the coag- ulum have commenced in the larger branches of the arteries, it must have first begun in tlie ventricle and extended into them. According to Humphry, the same changes take })lacc in pulmonary as in peri})h- eral thrombi, and they may become adherent to the walls of the vessels or converted into threads or bands. AMien the obstruction is due to embolism, provided the case is a well-marked one and the embolus of some size, the appearances presented are different. We have no longer a laminated and decjolorized coagulum with a rounded head, similar to a peripheral thrombus. The obstruction in this case generally takes place at the point of bifurcation of the artery, and we there meet with a grayish-white mass, contrasting remarkably with the more recently deposited fibrin before and behind it. It may be that the form of the embolus shows that it has recently been separated from a clot elsewher.e, and in many cases it has been possible to fit the travelled ])ortion to the extremity of the clot from which it has been broken. Vs^c may also, 1 Gesamm. Abhandi, 1862, p. 316. '^ Vircfmv's Arckiv, 1863. PUERPERAL VENOrrS THROMBOSIS AND EM HOLISM. 030 perliaps, find that tli(! ombolus has undergone an amount of lelmorade metanioi-phosis con-esponding with that of the peripheral thromljus from which we suppose it to have come, but differing from that of the more recently dejiosited fibrin around it. It must be admitted, how- ever, that the anatomical peculiarities of the coagula will by no means always enable us to trace them to their true origin. In many cases emboli may escai)e detection from their smallness or from the quantity of fibrin surrounding them. Treatment. — But few words need be said as to the treatment of pul- monary obstruction. In a large majority of cases the fatal result so rapidly follows the appearance of the symptoms that no time is given us even to make an attempt to alleviate the patient's sufferings. Should\ we meet with a case not inmiediately fatal, it seems that there are but! two indications of treatment affording the slightest rational ground of I hope : 1. To keep the patient alive by the administration of sti mula nts — brandy, ether, ammonia, and the like — to be repeated at intervals cor- responding to the intensity of the paroxysms and the results produced. In the cases I have above narrated iu which recovery ensued this took the place of all other medication. Possibly leeches or dry cupping to the chest might prove of some service iu relieving the circulation. 2. To enjoin the most absolute j^d_comple^tej;ejj The object of this is evident. The only chance for the patient seems to be that the vital functions should be carried on until the coagulura has been absorbed, or at least until it has been so much lessened in size as to admit of blood passing it to the lungs. The slightest movements may give rise to a fatal paroxysm of dyspnoea from the increased supply of oxygenated blood required. It must not be forgotten that in a large proportion of cases death immediately followed some exertion in itself trivial, such as rising out of bed. Too much attention, then, cannot be given to this point. The patient should be absolutely still ; she should be fed with abundance of fluid food, such as milk, strong soups, aud the like ; aud she should on no account be permitted to raise herself iu bed or attempt the slightest muscular exertion. If we are fortunate enough to meet with a case apparently tending to recovery, these pre- cautions must be carried on long after the severity of the symptoms has lessened, for a moment's imprudence may suffice to bring them back iu all their original intensity. Bertin,^ indeed, recommends a system of treatment very different from this. Iu the vain hope that the violent effort induced may cause the displacement of the impacted embolus (to which alone he attributes pulmonary obstruction), he recommends the administration of emetics. Few, I fancy, will be found bold enough to attempt so hazardous a plan of treatment. Various drugs have been suggested iu these cases. Richardson-' recommended ammonia, a deficiency of wdiich he at that time believed to be the chief cause of coagulation. He has since advised that liquor ammonia? should be given in large doses, 20 minims every hour, in the hope of causing solution of the deposited fibrin ; and he has stated that ^ Op. cil., p. 393. ^ Hmrt Disease durint/ Pregminci/, p. 209. 640 THE PUERPERAL STATE. he has seen fjood results from the practice. Others advise the adminis- tration of alkalies, in the hope that thcv may favor absorption. 'J'hc best that can be said for them is that they are not likely to do much harm. Puerperal Pleuro-pneumonia. — This is, perha])s, the best place to mention an important but little understood cla-ss of cases which I believe to be less uncommon than is generally supposed. I refer to severe pleuro-pneumonia occurring in connection with the puerperal state, but not distinctly associated ^vith septicjcmia. Two carefully observed cases of this kind are recorded by ]MacDonald occurring in his practice ; I myself have met with three very marked examples within the past three years, one of which proved fatal, the other two giving rise to most serious illness, from which the patient recovered with difKculty. So far as my own observation goes, there are marked peculiarities in such cases which clearly differentiate them from the ordinary course of pneumonia. The onset is sudden and unconnected with exposure to cold or other cause of lung disease; there is no definite crisis, but a continuous pyrexia of moderate intensity, lasting a variable time ; and the physical signs differ from those of ordinary pneumonia. In MacDonald's cases, as well as in my own, they were peculiar in this respect, that there was very slight crepitation, marked rusty sputum, and a wooden dulness, much more intense than in ordinary pneumonia, extending over a large lung space, with a very slight entrance of air into the lung-tissue, It is also remarkable that a very large proportion of the cases were associated with phlegmasia dolens. Thus it existed in one of jSIacDonald's two cases, and in two out of my own three. Like phlegmasia dolens, moreover, the disease generally commenced some weeks after delivery; my OAvn cases, for example, occurred respectively fifteen, twenty-eight, and thirty-five days after labor. It is difficult to believe that there is not some connection between these two conditions ; and there is much in their peculiar history to lead to the belief that such forms of lung disease depend, in fact, on the thrombotic or embolic obstruction of the minute branches of the pul- monary arteries, caused by conditions similar to those which have pro- duced the phlebitic obstructions in the lower extremities. In the absence of careful post-mortem examination this hypothesis is clearly not susceptible of proof. MacDonald, while admitting that "a limited thrombosis of the pulmonary arteries would no doubt explain the facts of the cases," is rather inclined to " seek the chief explanation of their occurrence in the alterations Mhich the pregnant and puerperal condi- tions impress upon the blood and the blood vascular system." I confess that to my mind the former hypothesis is not only the most definite, but the one which most readily explains all the peculiarities of these cases. I cannot, however, do more tlian suggest it, in the hope that further observations, and especially carefully conducted autopsies, may throw some light on this obscure and little-studied subject. Treatment. — As regards treatment, it is obvious that it must be con- ducted on general principles, carefully avoiding over-severe measures, and supporting the patient through a trial to the system that must necessarily be severe. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 641 CHAPTER VII. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM, Arterial Thrombosis and Embolism. — The same condition of the blood M'liieh so strongly predisposes to coagulation in the vessels through which venous blood circulates tends to similar results in the arterial sys- tem. These, however, arc by no means so common, and do not, as a rule, lead to such important consequences. The subject has been but little studied, and almost all our knowledge of it is derived from a very interesting essay by Sir James Simpson.^ As I have devoted so much space to the consideration of venous thrombosis and embolism, I shall but briefly consider the effects of arterial obstruction. Causes. — In a considerable number of recorded cases the obstruction has resulted from the detachment of .vegetations deposited on the car- diac valves, the result of endocarditis, either produced by antecedent rheumatism or as a complication of the puerperal state. Sometimes the ol)struction seems to depend on some general blood-dyscrasia, similar to that producing venous thrombosis, or on some local change in the artery- itself. Thus, Simpson records a case apparently produced by local arteritis which caused acute gangrene of both lower extremities, ending fatally in the third week after delivery. In other cases it has been attributed to coagulation following spontaneous laceration and corruga- tion of the internal coat of the artery. Symptoms. — The symptoms of puerperal arterial obstruction must of course vary with the particular arteries affected. Those with the obstruction of which we are most familiar are the cerebral, the brachial, and the femoral. The effects produced must also be modified by the size of the embolus and the more or less complete obstruction it pro- duces. Thus, for example, if the middle cerebral artery be blocked up entirely, the functions of those portions of the brain suiDplied by it will be more or less completely arrested, and hemiplegia of the oppo- site side of the body, followed by softening of the brain-texture, will probably result. If the nervous symptoms be developed gradually or increase in intensity after their first appearance, it may be that an obstruction, at first incomplete, has increased by the deposition of fibrin around it. So the occasional sudden supervention of blindness with destruction of the eyeball — cases of which are recorded by Simpson — not improbably depends on the occlusion of the ophthalmic artery, the function of the organ de[)cnding on its supply through the single artery. The effects of obstruction of the visceral arteries in tlu' puerperal state are entirely unknown, but it is far from unlikely that further investiga- tion may prove them to be of great importance. In the extremities arterial obstruction produces effects which are well marked. They ^ Selected Obst. Works, vol. i. p. 523. 41 642 THE PUERPERAL STATE. are classified bv Simpson under tlie I'ollowin^ lirocecd u])ward towai-d the pelvis. The pain abates somewhat after swelling of the hmb (which generally begins within twenty-four hours), but it is always a distressing 1 ObsUt. Trans., 1869, vol. x. p. 28. 646 Till-: i'ri:i:ri:i:AL state. symptom, :uul coiitiiUK-'s as lung- iis the :icut<' st;i<:c ol' the (li.seii.^c la.sts. The resit lessness, want of" sleep, and snt1('i-in slight, none of these constitutional sym])toms are observed. Condition of the Affected Limb. — The chariicteristie swelling rap- idly follows the commencement of the symptoms. It generally begins in the groin, whence_Jt_extejnd§.do>vnward. It may be limited tonfTie th[gli, or the whole limb, even to the feet, may be imjilicated. More rarelv it commences in the calf of the leg, extending u])ward to the thigh and downward to the feet. The affected parts have a peculiar appearance which is pathognomonic of the disease. They are hard, tense, and brawny, of a shiny white color, and not yielding on pressure except toward the beginning and end of the illness. The appearances presented are quite different from those of ordinary axlema. When the whole thigh is affected the limb is enormously increased in size. Frequently the venous trunks, especially the femoral and pojillteal veins, are felt obstructed with coagula and rolling under the finger. They are painful when handled, and in their course more or less red- ness is occasionally observed. Either leg may be attacked, but the l^fi more frequen tly than the right. There is a marked tendency for the disease to spread, and we often find in a case which is progressing apparently well a rise of temperature and an accession of febrile symj)- toms followed !)y the swelling of the other limb. Progress of the Disease. — After the acute stage has lasted from a week to a fortnight the constitutional disturbance becomes less marked, the pulse and temperature fall, the pain abates, and the sleeplessness and restlessness are less. iThe swelling and tension of the limb now begin to diminish and absorption commences.^ This is invariably a s low process. It is always many weeks before the effusion has disappeared, and it may be many months. The limb retains f"or a length of time the peculiar icooden feeling, as Dr. Churchill terms it. Any im]iru- dence, such as jPtoo early attempt at walking, may bring on a relajise and fresh swelling of the limb. This gradual recovery is by far the most common termination of the disease. In some rare cases suppura- tion may take place, either in the sul)eutaneous cellular tissue, the lym- phatic glands, or even in the joints, and death may result^from exhaus- tion. The possibility of pulmonary obstruction and sudden death from separation of an embolus has already been ]iointed out, and the fact tiiat this lamentable occurrence has generally followed some undue exertion should be borne in mind as a guide in the management of our patient. Period of Commencement. — The disease usually begins within a PERIPHFAiAL VENOUS TlIliOMIiOSIS. 647 short time aftor (U'ljvery, rarely before tlie seeoiid week. In 22 cases tabulated by Dr. Ivobert Lee, 7 were attacrked between the fourth and twelfth days, and 14 after the second week. Sonic cases have Vjceii described as coniiucncing even months after delivery. It is question- al)le if these can be classed as puerperal, for it must not be forgotten that phlegmasia dolens is by no means necessarily a puer])eral disease. There are many utlu^r conditions which may give rise to it, all of them, liowever, such as [)roduce a septic and hypei-inosed state of the blood, such as malignant disease, dysentery, ])lithisis, and the like. My own experience would lead me to think that cases of this kind are much more common than is generally believed. [I have seen two attacks, several years apart and in different legs, in a male subject. — Ed.] History and Pathology. — The disease has long attracted the atten- tion of the profession. Passing over more or less obscure notices by Hi|)pocrates, I)e Castro, and others, we find the first clear account in the writings of Mauriceau, who not only gave a very accurate descrip- tion of its symptoms, but made a guess at its pathology which was cer- tainly more happy than the speculations of his successors : it is, he says, caused ''by a reflux on the parts of certain humors which ought to have been evacuated by the lochia." Puzos ascribed it to the arrest of the secretion of milk and its extravasation in the affected limb. This theory, adopted by Levret and many subsequent writers, took a strong hold on both professional and public opinion, and to it we owe many of the names by which the disease is known to this day, such as oedema lacteum, milk leg, etc. In 1784, Mr. White of ^Manchester attributed it to some morbid condition of the lymphatic glands and vessels of the affected parts; and this or some analogous theory, such as that of rup- ture of the lymphatics crossing the pelvic brim, as maintained by Tyre of Gloucester, or general inflammation of the absorbents, as held by Dr. Ferrier, was generally adopted. It was not until the year 182-3 that attention was drawn to the condi- tion of the veins. To liouillaud belongs the undoubted merit of first pointing out that /the veins of the affected liml) were blocked up by coagula,'^although the fact had been previously observed by Dr. Davis of University College. Dr. Davis made dissections of the veins in a fatal case, and found, as Bouillaud had done, that they were filled with coagula, which he assumed to be the results of inflammation of their coats; hence the name of" crural phlebitis" which has been extensively ado])ted, instead of j^hlegmasia dolens. Dr. Robert Lee did much to favor this view, and, finding that thrombi were present in the iliac and uterine, as well as in the femoral veins, he concluded that the phlebitis eonuiicnced in the uterine branches of the hypogastric veins and extended downward to the femorals. Me ])oint(!d out that jihleg- masia dolens was not limited to the j)uerperal state, l)ut that when it did occur in(le})endently of it other causes of uterine phlebitis were jM'esent, such as cancer of the os and cervix uteri. The inflammatory theory was ])retty generally received, and even now is considered by many to be a sufficient explanation of the disease. Indeed, the fact that more or less thrombosis was always present could not be denied; and on the supposition that thrombosis coukl only be caused by phle- C4S THE PUERPERAL STATE. bitis, as was long suppo.sccl t<» he tlio ca.se, the iiiHainniatorv theory was the natural one. Before long, however, pathologists pointed out that thrombosis was by no moans necessarily, or even generally, the result of inHannnation of the vessels in which the clot was contained, but that the intlanimation was more generally the result of the coagulum. The late Dr. Mackenzie took a j)rominent part in opposing the phle- bitic theory. He proved by numerous experiments on the lower ani- mals that inflammation is not .sufficient of itself to produce the exten- sive thrombi which are found to exi.st, and that inflammation originat- ing in one part of a vein is not apt to spread along its canal, as the phlebitic theory a.ssumes. His conclusion is that the origin of the dis- ease is rather to be .nought in .'^ome .septic or altered condition of the blood, producing coagulation in the veins. Dr. Tyler Smith ' jwinted out an occasional analogy between the causes of pldegmasia dolens and puerperal fever, evidently recognizing the dependence of the former on l3lood-dyscrasia. " I believe," he says, " that contagion and infection play a very important part in the })roduction of the disease. I look on a woman attacked Avith ]>hlegmasia dolens as having made a fortunate escape from the greater dangers of diffuse phlebitis or puerperal fever." In illustration of this he narrates the following instructive hi.story : "A short time ago a friend of mine had been in close attendance on a patient dying of erysipelatous sore throat M'ith sloughing, and was him.self affected with sore throat. Under these circumstances lie attended, within the space of twenty-four hours, three ladies in their confinements, all of whom were attacked with phlegmasia dolens." The latest important contribution to the pathology of the di.sease is contained in two papers by Dr. Tilbuiy Fox, published in the second volume of the Obstetrical Transactions. He maintained that something beyond the mere presence of coagula in the veins is required to produce the phenomena of the disease, although he admitted that to be an important, and even an essential, part of the pathological changes pres- ent. The thrombi he believed to be produced either by extrin.sic or intrinsic causes, the former comprising all cases of pres.sure by tumor or the like ; the latter, and the most important, being divisible into the heads of — 1. True inflammatory changes in the ve.s.sels, as seen in the epidemic form of the disea:??*;"- — ' 2. Si m])le _thrombus, produced by rapid absorption of morbid fluid. 3. Vims action and thrombus conjoined, the phlegmasia dolens itself )eing the result of simple throml)us, and not produced by disea.sed [inflamed) coats of vessels ; the general .symptoms the result of the reneral blood-state. He further pointed out that the peculiar swelling of the limbs can- not be explained by the mere presence of a-dema, from which it is €.ssentially dift'erent; the white appearance of the skin, the .severe neur- algic pain, and the ])ersistent nund:)ne.ss indicating that the whole of the cutaneous textures, the cutis vera, and even the epithelial layer, are infiltrated with fibrinous deposit. He conclndcHl, therefore, that the swelling is the result of (edema ^j^ks something else, that something ' Tyler .Smith, Manual of Obstetrics, p. 538. I'F.rJI'IIERAL VENOUS TiiimMnosis. 640 being obstruction of the lympliatifs, by wliidi the absorption of offiisi'resence of throndn so extensive as those that are found. The view which traces the disease solely to inflamma- tion or obstruction of lymi)hatics is purely theoretical, has no i)asis of facts to support it, and finds now-a-days no supjiorters. The experi- ments of Mackenzie and Lee, as well as the vastly increased knowledge of the causes of thrombosis which the researches of modern pathologists have given us, seem to point strongly to the view already stated, that the disease can only be explained by a g enei'al blood-dyscras ia depend- ing on the puerperal state. It by no means follows that we are to con- sider Dr. Fox's speculations as incorrect. It is far from improbable that the lymphatic vessels are implicated in the production of tlie jiecu- liar swelling, only we are not as yet in a position to prove it. There is no inherent improbability in the supposition that some morbid state of the l)lood Avhich j^roduces thrombosis in the veins may also give i-ise to such an amount of irritation in the lymphatics as may interfere with their functions, and ev^en obstruct them altogether. The essential and all-importaut point in the pathology of the disease, however, seems undoubtedly to be thrombosis in the veins ; and the ju'obability of there being some as yet undetermined pathological changes in addition to this by no means militates against the view I have taken of the intimate connection of the disease with other results of thrombosis in diflcrcnt vessels. Chang-es occurring in the Thrombi. — The changes which take place in the tlirombi all tend to their ultimate absorption. These have been described by various authors as leading to organization or suppu- ration. It is probable, however, that the appearances which have led to such a supposition are fallacious, and that they are really due to retro- grade metamorphosis of the fibrin, generally of an amylaceous or a tatty character. Detachment of Emboli. — The peculiarities of a clot that must f:ivor detachment of an emlx^lus are that it ))resents such a shai>e as admits of a portion floating freely in the blood-current, by the force of which it is detached and carried to its ultimate destination. When the accident has occurred it is often possible to recognize the j)eripheral thrombus from which the embolus has separated by the fact of its terminal extremity presenting a fleshy fractured end, instead of the rounded head natural to it. Such detachment is unlikely to occur, even when favored by the shape of the clot, unless sufficient time have ela])sed af\er its formation to admit of its softening and becoming brittle. The curious fac-t I have before mentioned, of true inier|)eral embolism (x-enrring in the large majority of cases oidy after the nineteenth ilay fnun tielivery, 650 TIIK PUERPERAL STATE. finds a ready explanation in this theory, wliich it remarkably cor- roborates. [Although crural phlebitis is a rare secpiel of the Ciesarean section, it lias followed it and the Porro operation, both in this city and New York, in two cases of each, three of which were seen by the writer. It is most likely to occur in antemic subjects or where there has been a secondary destruction of tissue from injurious j)ressure in a long labor. In my experience it is most likely to show itself about the middle of the third week. The disease may occur in delicate men and in unmar- ried Avomen. — Ed.] Treatment. — On the supposition tha.t phlegmasia dolens was the result of inflammation of the veins of the affected limb an antiphlo- gistic course (^f treatment was naturally adopted. Accordingly, most writers on the subject recommended depletion, generally by the applica- tion of leeches along the course of the affected vessels. A\'^e are told that if the pain continue the leeches should be applied a second or even a third time. If we admit the septic origin of the disease, we mnst, I think, see the impropriety of such a practice. The fact that it occurs in a large majority of cases in patients of a weakly and debilitated con- stitution, often in women who have suffered from hemorrhage, is a further reason for not adopting this routine custom. If local deple- tion be employed, it should be strictly limited to cases in which there is much tenderness and redness across the course of the veins, and then only in patients of plethoric habits and strong constitution. Cases of this kind will form a very small minority of those coming under our observation. What has been said of the pathology of the affection tends to the conclusion that active treatment of any kind in the hope of curing the disease is likely to be useless. (Our chief reliance must be onetime and perfect rest in order to admit of the thrombi and the secondary effusion being^sorbed, while we relieve the pain and other prominent symptoms and support the strength and improve the constitution of the patient. n?he constant application of heat and moisture to the affected limb will do much to lessen the tension and pain. J Wrapping the entire limb in linseed-meal poultices, frequently changed, is one of the best means of meeting this indication. If, as is sometimes the case, the Aveight of the poultices be too great to be readily borne, we may substi- tute Avarm flannel stupes covered with oiled silk. Lpgil anodyne appli- cations afford nuich relief, and may be advantageously used along with the poultices and stupes, either by sprinkling their surface freely with laudanum or chloroform and belladonna liniment or by soaking the flannels in poppy-head fomentations. It is needless to say that the most absolute rest in l)cd should be enjoined even in slight cases, and that the limb should be effectually guarded from undue pressure by a cradle or some similar contrivance. Locajcounter-irritation has been strongly recommended, and frequent blisters liave been considered by some to be almost specific. I shoidd myself hesitate to use blisters, as they would certainly not be soothing applications, and one hardly sees how they can be of much service in hastening the absorption of the effusion. PERIPHERAL VENOUS THROMBOSIS. i\')\ During the acute stage of the disease the con.stitiitioiial treatment must he rcguhited hy the CMjudition of tlie patient. Light hut nutri- tious diet nuist he achuinistered in ahun(huH'o, such as milk", hccf-tca, and soups. Should tlicre he nuich dchility, stinudants in niodci-ation may prE5:. ABDOMEN, adiijose, enlargement of, 161 [color-line in pregnant women, 528] enlargement of, as a sign of pregnancy, 151 state of, after delivery, 556 Abdominal pregnancy. See Extra-uterine Pregnancy. Abortion, 246 causes of, 248 difficidty in procuring artificial, 252 liability to recurrence of, 248 [opium treatment in threatened, 254] production of, in vomiting of pregnancy, 203 retention of secundines in, 253, 257 symptoms of, 252 treatment of, 253 value of opium in prevention of, 253 [Viburnum prunifolium in threatened, 254] Abscess of mammas. See Mammary Ab- scess. pelvic. See Pelvic Cellulitis. After-coming head, application of forceps to, 313 After-pains, 557 treatment of, 559 Age, influence of, in labor, 345 Albuminuria in pregnancy, 146, 208 relation of, to eclampsia, 581 to puerperal insanitv, 591 Allantois, 108 Amnii, li(|Uor, 110 Anniio-chorionic fluid, 112 Anniion, formation of, 110 pathology of, 239 structure of, 110 Amputations (intra-uterine), 244 Ana?mia in pregnancy, 207 [pernicious, in parturient women, 207] Anaesthesia in labor, 299 in forceps operations, 485 value of, in difticult cases of turning, 476 Anasarca in pregnancy, 210 Anteversion of the gravid uterus, 219 Antiseptic midwifery, 611 Apople.xy during or after labor, 643 Arbor vita', 59 Area germinativa, 106 Area peliucida, 106 Areola, 8t) changes of, during pregnane}', 150 Arm, presentation of (see Shoulder Presen- tation) ; dorsal displacement of, 336 Arterial transfusion, 547 Artificial human milk, 575 resijiration in cases of apparent still- birth, 563 Ascites as a cause of dystocia, 380 Aspliyxia (idiopathic), 643 of newborn children, 562 Atropine, hypodermic injection of, in ri- gidity of cervix, 359 Auscultatory signs of pregnancy, 156 BAGS (Barnes'). See Dilators. Ballottement, 155 Bandl's ring, 139, 440 Basilyst, the, 515 Bilobed uterus, gestation in, 193 Binder, uses of, 298 Bladder, distension of, as a cause of pro- tracted labor, 345 exfoliation of lining membrane of, 215 state of, after delivery, 558 Blastodermic membrane, 100 division and layers of, 10& Blastosphere, 99 Blood, alteration in, after delivery, 552 changes of, during pregnancy, 143 Blood-diseases transmitted to foetus, 241 Blunt-hook in breech presentation, 314 Bowels, action of, after delivery, 561 Breech presentations. See Pelvic Presen- tations. "Broad ligaments of uterus, 69 Bronchitis as a cause of protracted labor, 346 Brow presentations, 323 C CESAREAN section, 335, 364, 404, 519 causes of mortality al"ter, 524 causes requiring the operation, 521 description of, 528 history of, 518 post-mortem operation, 523 results to child in, 521 statistics of, 521 substitutes for, 533 sutures in, 530 [( "a'sarean ojieration, before labor, 526] [causes of deatii from. 525] [dangers of, overestimated, 406] I in America, 521] [in cancer of the cervix, 361] 601 G(j2 INDEX. [Caesarean operation in impaetion of (Ve- tus, 335] [records of tumor lases, 364] [nnder relative indications, •')22] Calculus of bladder obstructing labor, 366 Ca|)ut succedaneuni, 283 Carcinoma in pregnancy, 225 obstructing labor, 300 Cardiac murmurs in pulmonary obstruc- tion, 637 Caries of teeth in pregnancy, 205 Carnnculfe myrtiformes, 53 Catheter, introduction of, 51 Caul, 268 Cellulitis, pelvic. See Pelvic Cellulitis. Cephalotribe, 507 Cephaloti'ipsy. See Craniotomy. Cervix uteri, 59 alterations of, after childbirth, 59 cavity of, 59 dilatation of, in labor, 263 hypertrophic elongation of, 360 impaction of, before foetal head, 290 incision of, for rigidity, 361 lacerations of, 445 modification of, by pregnancy, 139 mucous membrane of, 63 obstetrical, 440 organic causes of rigidity of, 360 rigidity of, as a cause of protracted la- bor, 358 treatment of rigiditv, 359 villi of, 63 Charlotte, princess of Wales, death of, 354 Child, the newborn. See Infant. risks to, in forceps operations, 492 Childbirth, mortalitv of, 551 Chloral, in labor, 299 in rigidity of cervix, 359 Chloroform in labor, 301 in difficult cases of turning, 469 in rigidity of cervix, 359 Chorea in pregnancv, 214 Chorion, 112 " primitive. 113 vesicular degeneration of, 232 Circulation of foetus, 132 Cleavage of yelk, 99 Clitoris, 51 Cocaine in labor, 547 Coccyx, 35 ligaments of, 37 moljility of, 36 ossification of, 36 Cold in the treatment of puerperal hyper- pyrexia, 627 Colostnmi, 564 Complex presentations, 335 Concealed internal Jiemorrhage, 420 Conception, signs of, 147 Constipation in pregnancy, 204 Constriction of uterus, tetanoid. 362 Continued fever in pregnancy, 223 Convulsions (puerperal). See Eclampsia. Corps reticul^, 110 Corpus luteum, 84 false, 84 Cranioclast, 506 Craniotomy, 504 cases requiring, 509 comparative merits of, and cephalotrip- sy, 512 description of cephalotripsy, 513 extraction of head by craniotomy-for- ceps, 515 method of perforating, 511 perforation of after-coming head, 512 l^erforators, 506 religious objections to, 504 Craniotomy-forceps, 506 Crotchets, 506 Cyclical theory of menstruation, 92 Cystocele, olistructing labor, 366 [Cysts, dermoid, prolapsed, obstructing pelvis, 366] DEATH, apparent, of newborn child. See In/ant. from air in the veins, 644 functional causes of, 643 organic causes of, 643 sudden, during labor and the puerperal state, 643 Decapitation of foetus, 517 Decidua, 101 at end of pregnancv and after deliverv, 105 cavitv between decidua vera and reflexa, 104 divisions of, 101 fatty degeneration of, as the cause of labor, 260 formation of decidua reflexa, 103 structure of, 102 [Deformities, spinal and pelvic, associated, 387]- Delivery, state of patient after, 552 contraction of uterus after, 554 [Macdurs, 519] management of patient after, 558 nervous shock after, 552 prediction of date of, 165 signs of recent, 168 state of pulse after, 552 [very rapid, case of, 357] weight of uterus after, 555 Diabetes, 146 Diameters of foetal skull, 125 of pelvis, 41 Diarrhoea in pregnancy, 203 Diet of lying-in women, 559 Differential diagnosis of pregnancy, 161 Dilators (caoutchouc) in the induction of premature labor, 460 in rigidity of cervix, 360 Diphtheria in the i)uerperal state, 606 Diseases of pregnancv, 199 albuminuria, 208 ana?mia and clilorosis, 207 carcinoma, 225 INDEX. G6;3 Diseases of pregnancy, cardiac diseases, 224 chorea, 2H constipation, 204 diarrhQ?a, 203 disorders of the nervous system, 212 respiratory organs, 205 teetli, 205 urinary system, 215 disphicements of gravid uterus, 218 epilepsy, 225 eruptive fevers, 222 fibroid tumors, 227 hemorrhoids, 204 icterus, 225 leucorrlioea, 216 ovarian timior, 226 palpitation, 206 paralysis, 213 pneumonia, 223 pruritus, 216 ptyalism, 205 syncope, 206 syphilis, 224 varicose veins, 217 vomiting (excessive), 199 Dropsies aflecting the foetus, 243 Ductus arteriosus, 133 venosus, 133 Dystocia from foetus, 370 ECLAMPSIA, 578 cause of death in, 581 condition of patient between tlie attacks, 580 confusion from defective nomenclature, 578 exciting causes of, 583 obstetric management in, 586 pathology of, 581 premonitory symptoms of, 579 relation of, to labor, 580 results to mother and child in, 581 symjjtoms of, 579 transfusion in, 549 Traiibe and Rosenstein's theory of, 582 treJitment of, 583 unemic theory of, 581 venesection in, 584 views of MacDonald, 583 Ecraseur, use of, as a substitute for crani- otomy, 508 Embolism. See Thrombosis. Embryotomy, 516 Emotion, mental, as a cause of proti'acted labor, 346 Epi blast, 106 Epilepsy in pregnancy, 225 Epileptic convulsions, 578 Ergot of rye, 348 as a means of inducing labor, 459 mode of administration, 348 objections to use of, 348 value of, after delivery, 298 Ergotine, hypodermic injection of in post- partum liemorrhage, 428 Eruptive fevers in pregnancy, 222 Erysipelas as a cause of puerperal septica;- mia, 605 Etlier in labor, 301 [safer to inhale than cldoroform, 302, 303] Evisceration, 518 Exhaustion, importance of distinguisliing between temporary and permanent, in labor, 348 [Exostosis, pelvic, an obstruction to deliv- ery, 395] Expression, uterine (see Pressure) ; of tlie placenta, 296 Extra-uterine pregnancy, 176 abdominal variety of, 185 causes of, 177 changes of the foetus in, 186 classification of, 176 diagnosis of abdominal variety, 188 of tubal variety, 181 gastrotomy in, 185, 190 pseudo-labor in, 187 symptoms of rupture in, 181 treatment after rupture, 185 of abdominal variety, 189 tubal variety, 179 treatment of tubal variety, 183 vaginal section in, 183 Eye, diseases of, in pregnancy, 225 FACE presentation, 315 causes of, 315 diagnosis of, 316 difiiculties connected with, 322 erroneous views formerly entertained of, 315 mechanism of delivery in, 317 mento-posterior positions in, 320 prognosis in, 321 treatment of, 322 Fallopian tubes, 71 False corpus luteum, 84 False pains, character and treatment of, 287 Faradization in apparent stillbirth, 563 in destroying the vitality of the foetus in abnormal pregnancies, 183 in hemorrhage after delivery, 432 in labor, 350 [Fatigue, recurrent uterine, 346] Fibroid tumor in pregnancy, 227 obstructing labor, 363 Fillet, 503 in breech presentations, 314 nature of the instrument, 503 objections to its use, 503 Flattened pelvis, 305 Foetal head, anatomy of, 123 induction of premature labor for large size of, 457 heart, sounds of, in jiregnancy, 156 Foetus, anatomy and physiology of, 121 appearance of a putrid, 246 of, at various stages of development, 121 at term, 122 664 INDEX. Foetus, circulation of, 132 changes in circulation of, as cause of la- bor, 254 in position of, during pregnancy, 126 death of, 245 detection of position in utero by palpa- tion, 127 early viability of, 247 excessive development of, as a cause of 1 difficult labor, 381 explanation of its position in utero, 128 functions of, 130 nutrition of, 130 pathology of, 241 position of, in idero, 126 respiration of, 131 signs and diagnosis of death of, 246 [Foetuses, very small, habitually produced by some mothei's, 128] Fontanelles, 124 Foot, diagnosis of, 306 Foot presentations. See Pelvic Presenta- tions. Foramen ovale, 132 Forceps, 478 action of, 482 advantage of pelvic curve in, 479 application of, to after-coming head in breech presentations, 312 within the cervix, 361 [breech, 314] cases in which a straight instrument should be used, 480 dangers of, 353, 491 to child, 492 descrijjtion of, 478 the operation, 485 difl'erence between high and low opera- tions, 484 disadvantages of a weak instrument, 481 [frequent use of, 355, 356] in modern practice, 352, 478 high operations, 490 [in America, 492-501] long, 480 [Meigs' craniotom.y, 516] preliminary considerations before using, 485 short, 478 use of anaesthetics in forceps delivery, 485 use of, in deformed pelvis, 401 in difficult occipito-posterior positions, 326 in protracted labor, 352 Forceps-saw, 508 Fossa navicularis, 53 Funis. See Umbilical Cord. [corkscrew-formed, 238] Funnel-shaped pelvis, 385 GALACTAGOGUES, 569 Galactorrhcea, 570 Galvanism as a .means of inducing labor, 459 Gangrene of limbs from arterial obstruc- tion, 642 Gastrotomy, after rupture of uterus, 444 in extra-uterine pregnancy, 185, 190 Gastro-elytrotomy. See Laparo-elytrotomy. Generative organs in the female, 49 division according to function, 49 Germinal vesicle, disappearance of, after impregnation, 99 Gestation. See Pregnancy. Glycosuria in pregnancy, 146 in lactation, 554 Graafian follicle, 75 structure of, 77 HEMATOCELE, obstructing labor, 367 Hand-feeding of infants, 574 artificial human milk in, 575 ass's milk in, 575 causes of mortality in, 574 cow's milk in, and its preparation, 575 goat's milk in, 575 method of, 577 Head presentations, 272 descri|)tion of cranial positions in, 272 division of, 273 explanation of, 274 frequency of first position, 274 mechanism of first position, 274 second position, 280 third position, 280 fourth 2^osition, 283 relative frequency of various positions, 273 Heart, diseases of, in pregnancy, 224 hypertrophy of, in pregnancy, 144 Hemorrhage, accidental, 418 causes and pathology of, 419 concealed internal, 420 diagnosis, prognosis, and treatment of concealed internal, 420 prognosis of, 420 symptoms and diagnosis of, 419 treatment of, 421 after delivery, 421 causes of, 422 constitutional predisposition to, 426 curative treatment of, 428 from laceration of maternal structures, 434 nature's mode of preventing, 270, 422 preventive treatment of, 427 secondary causes of, 424 treatment of, 434 symptoms of, 426 transfusion of blood in, 434 vinegar as a styptic in, 434 (secondary), 434 distinction between, and profuse lochial discharge, 435 local causes of, 436 treatment of, 437 unavoidable. See Placenta Prcevia. Hemorrhoids, in pregnancy, 204 Hernia, in labor, 367 Hour-glass contraction of uterus, 424 INDEX. 665 Hour-glasfe contraction, ante-partum, 362 Hydatids of uterus, 231 Hydraianios, 239 [240] Hydrocephalus of foetus as a cause of dif- ficult labor, 378 Hydrorrhoea gravidarum, 230 Hymen, 52 Hypoblast, 106 Hysteria during labor, 578 TCTEEUS, 225 JL [Impaction of bowels from eating clay an obstacle to delivery, 367] Induction of premature labor. See Pre- mature Labor. Inertia of the uterus, frequent child-bear- ing as a cause of, 345 Infant, apparent death of, 562 appearance of, in cases of apparent death, 562 clothing of, 564 evils of over-suckling, 565 management of, 566 when food disagrees, 577 treatment of apjjarent death of, 562 various kinds of food of, 577 washing and dressing of, 564 Infantile mortality, diminution of, as a reason for more frequent use of for- ceps, 352 Inflammatory diseases aflfecting the foetus, 242 [Injections, uterine, of hot water, 431] Insanity (puerperal), 594 classification of, 587 of lactation, 593 of pregnancy, 588 predisposing causes of, 589 puerperal (proper), 590 causes of, 591 form of, prognosis of, 589 post-mortem signs of, 598 question of removal to an asylum, 597 symptoms of, 593 transient mania during delivery, 590 treatment of, 595 during convalescence, 597 Insomnia in pregnancy, 212 Intermittent fever affecting the foetus, 241 Intestines, disorders of, as influencing labor, 345 Inversion of uterus. See Uterus. Involution of uterus, 554 Irregular uterine contractions after labor, 424 as a cause of lingering labor, 347 Irritable bladder in pregnancy, 215 Ischium, planes of the, 46 TAUNDICE in pregnancy, 225 KIESTEIN, 146 _ Knee presentation, 306 Knots on the umbilical cord, 238 Kyphotic deformity of pelvis, 393 LABIA majora, 49 Labia minora, 50 Labor, 259 age, influence of, on, 345 anpesthesia in, 299 arrest of, 168 causes of, 259 [of missed, 196-199] of precipitate, 356 of protracted, 343 character and source of pain in, 265 of false pains, 267 cocaine in, 347 dilatation of cervix in, 263 duration of, 271 effect of uterine contractions in, 261 evil effects of protracted, 342 induction of See Premature Labor. influence of stage of, in protracted, 343 management of, in deformed pelvis, 400 of natural, 284 of third stage of, 294 mechanism of, in head presentation, 272 obstructed by faulty condition of the soft parts, 358 period of day at which labor commences, 271 phenomena of, 259 position of patient during, 288, 290 . precipitate, 352 preparatory treatment, 284 prolonged and precipitate, 842 rupture of membranes in, 263 stages of, 263 symptoms of protracted, 344 treatment of protracted, 347 Lactation, defective secretion of milk in, 569 diet of nursing women during, 567 diseases of the eye during, 571 evil results of prolonged, 565 excessive flow of milk in, 570 importance of, to mother, 565 of wet-nursing to child, 565 insanity of, 593 management of, 567 means of arresting secretion of milk in, 568 period of weaning in, 568 Lamina? dorsales, 106 Laparo-elytrotomy, 534 [inadmissible in many Csesarean cases, 535] [performed on either side, 537] [statistics of, 535] Lead-poisoning, affecting tlie foetus, 241 as a cause of abortion, 251 Leucorrlioea, in pregnancy, 216 Lever. See Ft'c//'s. Liojuor amnii, 110 deficiency of, 241 source of, 112 spurious, 112 uses of, 112 Lithopjedion, 188 Liver, acute yellow atrophy of, 225 666 IXBEX. Liver, changes of, in pregnancy, 145 lyochia, 556 occasional fetor of, 557 vai'iation in amount and duration of, 557 Lying-in hospitals, mortality in, 589 Lypothemia, 150, 206 iyiALAEL\L puerperal fever, 622 ifl Malpresentations, iieculiar form of bag of membranes in, 305 Mammary abscess, 571 l antiseptic treatment of, 572 signs and symptoms of, 571 ! treatment of, 572 changes during pregnancy, 150 their diagnostic value, 151 i glands, 79 their sympathetic relations with the j uterus, 81 I Mania, puerperal. See Insanity, Puerperal. Mastitis, 571 Measles, aflecting the foetus, 241 in pregnancy, 223 Meconium, 135 Membranes, artificial rupture of, 289 puncture of, as a means of inducing labor, 458 Menstruation, 81 cessation of, 93 changes in Graafian follicle after, 82 during pregnancy, 148 [from unimpregnated side of a double uterus, 146] period of, duration, and recurrence, 87 purpose of, 92 quantity of blood lost in, 88 sources of blood in, 89 theory of, 90 vicarious, 93 Mesoblast, 106 Milk, artificial human, 575 ass's, 575 cow's, and its preparation, 575 defective secretion of, 569 [diet for nursing mothers, 569] excessive secretion of, 570 goat's, 575 means of arresting the secretion of, 568 secretion of, after delivery, 565 transfusion of, 544 Milk fever, 553 Miscarriage. See Abortion. Missed labor, 194 Moles, 250 Monstro.sity (double), 374 classification of, 374 mechanism of delivery in, 375 Mons Veneris, 49 ^lontgomery's cujjs, 103 Morning sickness, 149 Mortality of childbirth, 551 [of infants delivered by induction of pren:ature labor, 463] ]Mucous membrane of uterus. vSee Uterus. Miiiler's operation, 532 Myxoma fibrosum, 234 VfERVOUS shock after delivery, 552 IN Nervous system, changes in, during pregnancy, 145 disorders of, in pregnancy, 212 excitability of, in puerperal Avomen, 583 Neuralgia in pregnancv. 213 Nipple, 80 Nipples, depressed, 569 fissures and excoriations of, 570 Nursing. See Lactation. Nutrition of fretus, 130 Nymphse. See Labia Minora. OBLIQLELY-contracted pelvis, 392 Obstetric bag, 285 Obstetrical cervix, 440 Occipito-posterior positions, difficult cases of, 324 causes of face-to-pubes deliverv in, 325 forceps in, 326 treatment of, 325 vectis or fillet in, 325 Omphalo-mesenteric artery and vein, 108 Opiates, use of, after delivery, 558 Os innominatum, 33 Osteomalacia, as a cause of deformity, 38S [not an American disease, 392] Osteophytes, formation of, during preg- nancy, 145 Os uteri, constriction of internal, as a cause of dystocia, 362 dilatation of, as a means of inducing labor, 460 occlusion of, in labor, 360 Ovarian pregnancy. See Extra-uterine Pregnancy. tumor in pregnancy, 226 Ovariotomy in pregnancy, 226 Ovary, 73 functions of, 81 structure of, 74 vascular arrangements of, 78 Ovule, 78 changes in, after impregnation, 98 when retained in utero after its death, 250 formation of, 75 Ovum, blighted, retained in utero, 250 Oxytocic remedies, 348 PAINS, after-, 557 false, 286 irregular and spasmodic, as a cause of protracted labor, 347 labor-, 265 Palpitation in jiregnancy, 206 Pampiniform plexus, 66 Paralysis in pregnancy, 213 from embolism of the cerebral arteries, 642 • from embolism of the main arteries of the limb, 642 Parovarium, 69 Parturient canal, axis of, 44 Pathology of decidua and ovum, 229 INDEX. 667 Pelvic cellulitis and peritonitis, 652 connection with septicaemia, 653 etiology of, 653 importance of distinguishing the two forms of disease, 653 opening of abscess in, 658 prognosis of, 657 relative frequency of the two forms of disease, 655 results of physical examination, 655 seat of inflammation in cellulitis, 654 in peritonitis, 654 suppuration, in, 656 symptomatology, 655 terminations of, 656 treatment of, 657 two distinct forms of disease, 652 Pelvic presentations, 303 application of forceps to the after- coming head in, 313 causes of, 304 danger to children in, 304 diagnosis of, 305 frequency of, 304 management of impacted breech in, 313 mechanism of, 306 prognosis in, 304 treatment of, 310 Pelvis, alterations in articulations of, dur- ing pregnancy, 39 anatomy of, 33 articulations of, 36 axes of, 44 Cfesarean section in deformities of, 404 causes of deformity of, 382 comparative estimate of turning and forceps in deformity of, 404 [coxalgic deformity of, 392] craniotomy in deformity of, 404 diagnosis of deformity, 398 deformities of, 382 development of, 46 difference according to race, 47 differences in the two sexes, 40 division into true and false, 34 equally contracted, 384 enlarged, 384 flattened, 385 forceps in deformity of, 401 funnel-shaped, 385 induction of premature labor in deform- ity of, 404 infantile, 46 kyphotic, 393 ligaments of, 37 masculine, 385 mechanism of delivery in deformed,396 movements in the articulations of, 38 obliquely contracted, 392 planes of, 43 Kobert's, 393 scoliotic, 387 [small, masked by external develop- ment of adipose tissue, 384] soft parts connected with, 48 Pelvis, tumors of, 394 turning in deformity of, 402 undeveloped, 384 Pelvimeters, various forms of, 398 Perchloride of iron, injections of, in post- partum hemorrhage, 433 Perforation of after-coming head, 512 Perforators, 505 Perineum, distension of, in labor, 269, 291 incision of, 292 laceration of, 293 relaxation of, 291 rigidity of, as a cause of protracted la- bor, 363 Peritonitis, pelvic. See Pelvic Cellulitis. puerperal. See Septiccemia. Phlegmasia dolens. See Thrombosis, pe- ripheral venous. Placenta, adhesion of, after delivery, 425 degeneration of, 119 detachment of, in labor, 269 diseases of, 235 expression of, 296 [expulsion of, 295] fo?tal portion of, 115 form of, in man and animals, 114 formation of, from chorion, 113 functions of, 119 maternal portion of, 116 minute structure of, 115 pathology of, 234 sinus, system of, 117 sounds produced during separation of, 160 treatment of adherent, 430 of, in extra-uterine foetation, 191 Placenta membranacea, 234 Placenta pnevia, 407 causes of, 407 causes of hemorrhage in, 410 natural termination of labor in, 411 pathological changes of placenta in, 411 pi'ognosis. in, 412 sources of hemorrhage in, 409 summary of rules of treatment in, 417 symptoms of, 408 treatment of, 413 turning in, 416 Placentfe succenturife, 235 Placentation, metadiscoidal, 114 discoid al, 114 Placentitis, 236 Plugging of vagina, 256 Plural births, 170, 370 arrangement of placentge and mem- branes in, 172 causes of, 171 diagnosis of, 173 relative frequency of, in diflerent countries, 170 sex of children in, 171 treatment of 370 Pneumonia in pregnancy, 223 puerperal embolic, 639 "Polar globule," 99 668 INDEX. [Polypus, an obstacle to labor, 3G9] Porro's operation, 531 [followed by crural phlebitis, 650] [in Great Britain, 532] [statistics, 532] Position of cranium in head presentation. See Head Presentation. Post-partum hemorrhage. See Hemor- rhage. Pregnancy, 136 abnormal, 170 affections of respiratory organs, 205 alteration of color of vaginal mucous membrane, as a sign of, 155 ballot tement, as a sign of, 155 changes in the blood during, 143 changes in the liver, lymphatics, and spleen during, 144 changes in the urine during, 145 cocaine in, 201. Vide Labor. complicated with ovarian tumor, 226 ■with fibroid tumor, 227 [cough of, 206] deposits of pigmentarv matter during, 152 _ diabetes in, 212 difierential diagnosis of, 161 diseases of eye during, 225 dress of patient in, 285 duration of, 164 [dyspnoea of, 206] [eneuresis of, 216] enlargement of abdomen as a sign of, 152 extra-uterine (see Extra-uterine Preg- nancy), [183, 184] [exsective operation where the foetus IS living and viable, 191, 192] fojtal movements in, 153. [toxic injection of cvst, dangerous, 184] formation of osteophytes during, 145 hypertrophy of the heart during, 144 in cases of double uterus, 67 in the absence of menstruation, 148 intermittent uterine contractions, as a sign of, 153 liver, changes of, in, 145 prolapse of the uterus in, 218 protraction, 166 pruritus in, 216 ptyalism in, 205 quickening, 153 sickness of, 149 signs and diagnosis of, 147 sounds produced by the foetal move- ments in, 160 spurious, 163 sympathetic disturbances of, 149 tetanus in, 215 uterine fluctuation in, 155 vaginal signs of, 154 pulsation in, 155 Premature labor, 247 historv of the operation of induction of, 456 Premature labor, induction of, 456 in deformed pelvis, 404 injection of carbonic acid gas as a means of inducing, 462 insertion of flexible bougie as a means of inducing, 462 objects of the operation of induction of, 456. oxytocics as a means of inducing, 459 period for the induction of, in de- formed pelvis, 406 precautions as regards the child in the induction of, 463 puncture of the membranes as a means of inducing, 458 separation of the membranes as a means of inducing, 461 vaginal and uterine douches as a means of inducing, 461 Pressure as a means of inducing uterine contractions, 350 mode of applying, 351 Prolapse of umbilical cord. See Umbil- ical Cord. Pronucleus, female, 99 male, 99 [Protector for Iving-in bed, Kellv's rub- ber, 286] ■ Pseudo-labor, 187 Ptyalism in pregnancy, 205 Puerperal convulsion. See Eclampsia. fever. See Septiccemia. mania. See Insanity. jjneumonia, 640 state, 551 after-treatment in, 561 diet and regimen in, 558 diminution of uterus in, 554 importance of prolonged rest in, 561 pulse in, 552 secretions and excretions in, 553 temperature in, 553 [Pullulation, arrested, 245] Pulmonary arteries, anatomical arrange- ment of, as favoring thrombosis, 632 Q UICKENING, 153 Quinine as an oxytocic, 349 RACE, as influencing the size of the fcetal skull, 126 Recto-vaginal fistula, 446 Respiration of fcetus, 131 Retroversion of the gravid uterus, 219 Rickets as a cause of pelvic deformitv, 383 Ringof Bandl, J39, 440 Rosenmiiller, organ of. See Parovarium. Round ligaments of the uterus, 71 Rules for monthly nurses, 560 Rupture of uterus. See Uterus. SACRUM, anatomy of, 35 mechanical relations of, 35 Salivation in pregnancy, 205 Scarlet fever afiecting the fcetus, 241 INDEX. 669 Scarlet fever, in pregnancy, 223 in the puerperal state, 605 Scoliotic deformity of pelvis, 387 Scybala; in the rectum obstructing labor, 367 Septicaemia (puerperal), 598 bacteria in, 612 channels of difiusion in, 613 thn)ugh which septic matter may be absorbed, 602 cold in treatment of, 627 conduct of practitioner in regard to, 611 contagion from other puerperal patients as a cause of, 609 description ol', 618 division in auto-genetic and hetero-gen- etic forms, 603 epidemics of, 600 history of, 599 importance of antiseptic precautions in, 611 influence of cadaveric poison as a cause of, 604 of zymotic disease in causing, 605 its connection with pelvic cellulitis and peritonitis, 653 local changes in, 613 malarial, 622 mode in which the poison may be con- veyed to patients in, 610 mortality in lying-in hospitals, 599 nature of septic poison, 612 pathological phenomena in, 614 prevention of, 612 pypemic forms of, 621 sewer gas as a source of infection, 607 sources of auto-infection in, 603 of hetero-infection, 604 symptoms of the intense forms, 618 theorv of an essential zvmotic fever, 601 of identitv with surgical septicaemia, 601 of local origin, 600 treatment of, 622 venesection in, 626 Warburg's tincture in the treatment of, 627 Sex, discovery of, of fcetus during preg- nancy, 157 of foetus as influencing the size of the skull, 126 Shoulder presentations, 328 diagnosis of, 331 division of, 328 mechanism of, 332 prognosis and frequency of, 330 spontaneous version in, 333 evolution in, 333 treatment of, 335 Siamese twins, how born, 375 Sickness of pregnancy, 149 Smallpox affecting the foetus, 241 in yjregnancy, 222 Smith's, Tyler, theory of labor, 261 Spondyl-olisthesis, 388 [389] Spondylolizeraa, 390 Spontaneous evolution, 333 version, 333 Spurious liquor amnii, 112 pregnancy, 163 diagnosis of, 164 symptoms of, 1 63 [Statistics of old Caesarean operations of little practical value now, 520] Stillbirtli, apparent, 562 treatment of, 562 Subzonal membrane, 107 Sugar, in urine of pregnancy, 146 Superfecundation and superfoetation, 173 [Sutures in CVsarean operations, 530] of fcetal liead, 124 Symphysiotomy, 533 [in Naples, 533] Syncope during or after labor, 643 in pregnancy, 206 [relieved by elevating the body and lowering the head, 432] Syphilis affecting the foetus, 242 as a cause of abortion, 251 in pregnancy 224 TEMPERATURE after delivery, 553 Tetanus in pregnancy, 215 Thrombosis (peripheral venous), 645 changes in thrombi in, 649 condition of the affected limb, 646 detachment of emboli in, 649 history and pathology of, 647 progref^s of the disease, 647 symptoms of, 645 treatment of, 650 (puerperal), 629 arterial thrombosis and embolism, 641 cardiac murmur in pulmonary, 637 cases illustrating recovery from pulmo- nary, 635 causes of death in pulmonary, 638 clinical facts in favor of pulmonary, 633 conditions which favor thrombosis in the puerperal state, 631 distinction between thrombosis and em- bolism, 631 phlegmasia dolens a consequence of, 629 post-mortem appearance of clots in pul- monary, 638 pulmonary, as a cause of plearo-pneu- monia, 640 question of primary thrombosis in the pulmonary arteries, 632 of recovery from pulmonary, 634 symptoms of arterial, 641 of pulmonary obstruction in, 634 treatment of arterial, 642 of pulmonary, 639 of uterine vessels, 422 Thi'ombus. See Hrematocele. Toothache in pregnancy, 205 Transfusion of blood, 539 addition of chemical reagents to prevent coagulation of fibrin, 542 670 INDEX. Transfusion of blood, cases suitable for tlie operation, 544 dangers of the operation, 544 defibrination of blood in, 548 diflficulties of the operation, 541 effects of successful transfusion, 550 histoi'y of tlie operation, 589 immediate transfusion, 541 metiiod of injecting defibrinated blood, 549 of performing immediate transfusion, 546 of preparing defibrinated blood, 548 nature and object of the operation, 540 Scliiifer's directions for immediate, 546 secondary effects of, 549 statistical results of, 544 [with defibrinated blood, 550] Tropics, infiuence of residence in, on labor, 345 Trunk, presentation of. See Shoulder Pres- entations. Tumors, diagnosis of uterine and ovarian, 162 foetal, 243 obstructing labor, 3S0 (maternal) obstructing delivery, 363 Tunica albuginea, 75 Turning, 464 after perforation, 512 antesthesia in, 469 [Braxton Hicks' bimanual method in placenta prtevia, 418] by combined method, 470 by external manipulation only, 466 cases suitable for the operation, 466 for operating by combined method, 465 cephalic, 464 choice of hand to be used, 469 history of the operation, 464 in abdomino-anterior positions, 475 in deformed pelvis, 415 in placenta prsevia, 415, 475 method of cephalic, 467 of performing by external manipu- lation, 466 of podalic, 472 object and nature of the operation, 465 period when the operation should be performed, 469 podalic, 469, 472 position of patient in, 468 statistics and dangers of, 465 value of antesthetics in diflBcult cases of, 476 Twins. See Plural Birihs. [Carolina, how born, 377] conjoined, 374 locked, 371 TTMBILTCAL cord, 119 U knots of, 120, 238 lisjature of, 294 pathology of, 238 prolapse of, 337 diagnosis of prolapse of, 339 Umbilical cord, prolajise of, causes of, 339 frequency of, 337 postural treatment of, 340 prognosis of, 338 reposition of, 341 treatment by laceration, 293 Umbilical souffle, 159 vesicle, 108 Urachus, 109 Uriiemia, in connection with eclampsia, 581 in connection with puerperal insanity, 591 Urethra, 52 Urine, changes in, during pregnancy, 145 retention of, after delivery, 558 [to be examined at once in eclamptic cases, 587] [Uterine contractions during gestation, in- termittent, and sometimes painful. 154] fluctuation, as a sign of pregnancy, 155 [rupture, rational treatment of, 448, 449] souffle, 159 Utero-sacral ligaments, 71 Uterus, 56 analogy of interior of, after delivery, and stump of an amputated limb, 105 anomalies of, 67 ' ante-partum hour-glass contraction, 362 arrangement of muscular fibres of, 61 axis of, during pregnancy, 138 changes in cervix during pregnancy, 139 in form and dimensions of, during pregnancy, 136 in mucous membranes of, after deliv- ery, 554 in mucous membranes of, after im- pregnation, 100 in tissues of, during pregnancy, 141 in the vessels of, after delivery, 555 congestive hypertrophy of, 162 contractions of, in labor, 262 dimensions of, 58 diminution in size of, after delivery, 554 distension of, as a cause of labor, 260 by retained menses, 161 fatty transformation of, after deliverv, ^555 gastrotomy in, 444 hour-glass contraction, 424 intermittent contractions of, during preg- nancy, 153 internal surface of, 59 inversion of, 449 [inverted, spontaneous reposition of the, 454, 455] involution of, 554 differential diagnosis of, 451 production of, 451 results of phvsical examination in, 450 symptoms of, 450 treatment of, 453 ligaments of. 69 INDEX. 671 Uterus, lymphatics of, 66 malposition of, as a cause of protracted labor, 346 mode of action in labor, 264 mucous membrane of, 62 muscular fibres of, 61 nerves of, 66 [partitioned, 68] regional division of, 59 relations of, 57 retroversion of gravid, 220 rupture of, 438 alterations of tissues in, 439 causes of, 439 comparative result of various methods of treatment in, 444 prognosis of, 443 seat of laceration in, 438 symptoms of, 441 treatment oi", 443 size of, at various periods of pregnancy, 137 _ state of, in protracted labor, 344 structures composing, 60 utricular glands of, 62 vessels of, 64 weight of, after delivery, 555 YAGINA, 53 'f . ;, _ V bands and cicatrices of, obstructing , delivery^.. 360 contraction of, after delivery, 556 lacerations of, 445 orifice of, 52 ■ structure of, 54 A'^aricose veins in pregnancy, 217 ^ Vectis, 502 action of, 502 cases in which it is applicable, 502 Veins, entrance of air into, as a cause of sudden death after delivery, 644 Venesection for rigidity of cervix, 361 A'^ersion. Se6 Ttirnimj. [bimanual, in breech cases, 305] [by the vertex, 327] Vesico-uterine ligaments, 71 Vesico- vaginal fistula, 446 Vestibule, 51 Vicarious menstruation, 93 Vinegar as a styptic in post-partum hem- orrhage, 433 Vomiting in pregnancy, 199 Vulva, 49 condition of, after delivery, 556 oedema of, obstructing labor, 367 vascular supply of, 53 Vulvo-vaginal glands, 53 WAEBUEG'S tincture, 627 Weaning. See Laclalion. Wet-nurse, selection of, 566 [diet of, 567] Wolffian bodies, 69, 121 [Womanhood, precocious physical, 86] [Womb, circular contraction of the middle of the (Blundell), 362] Wounds of the foetus, 2^ ^, , ZONA pellucida, 78 Zymotic disease, afiecting the fcetus, ■ 241 ■ as a cause of septicremia, 606 t \ THE END 2->e^ (l^^xZ^iv^ -■ »^/*v**' L^^^-z**- 1/^,^ V*'^^^ wX^tt^^-^-^— ^^'^/^ // V -'Crv-^ ^■V ^ LEA BROTHERS S GO.'S CM f- CLASSIFIED CATALOGUE a> tMEDlCflL AND SURGICAL « Piiblication0. 1_ In asking tlie attention of the profession to the works advertised in the following pages, the publishers would state that no pains are spared to secure a continuance of the confi- dence earned for the publications of the house by their careful selection and accuracy and finish of execution. 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Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, has been appended to the present edition as it was to the previous one. This work gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work will furnish all the assistance that can be rendered by type and illustration in anatomical study. The most popular work on anatomy ever written. It is sufficient to say of it that this edition, thanks to its American editor, surpasses all other edi- tions. — Jour, of the Amer. Med. Ass'n, Dec. 31, 1887. A work which for more than twenty years has had the lead of all other text-books on anatomy throughout the civilized world comes to hand in such beauty of execution and accuracy of text and illustration as more than to make good the large promise of the prospectus. It would be in- deed difficult to name a feature wherein the pres- ent American edition of Gray could be mended or bettered, and it needs no prophet to see that the royal work is destined for many years to come to hold the first place among anatomical text- books. The work is published with black and colored plates. It is a marvel of book-making. — American Practitioner and News, Jan. 21, 1888. Gray's Anatomy is the most magnificent work upon anatomy which has ever been published in the English or any other language.— Ci'/icinnafi Medical News, Nov. 1887. As the book now goes to the purchaser he is re- ceiving the best work on anatomy that is published in any language. — Virginia Med. Monthly, Dec. 1887. Gray's standard Anatorny has been and will be for years the text-book for students. The book needs only to be examined to be perfectly under- stood. — Medical Fress of Western New York, Jan. 1888. Also for sale separate — MOLJyFN, LJJTMBMf F, M, C, S., Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomv in the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. This little book is all that can be desired within its scope, and its contents will be found simply in- valuable to the young surgeon or physician, since they bring before him such data as he requires at every examination of a patient. It is written in language so clear and concise that one ought almost to learn it by heart. It teaches diagnosis by external examination, ocular and palpable, of the body, with such anatomical and physiological facts as directly bear on the subject. It is eminently the student's and young practitioner's book.— /'Aj/- sician and Surgeon, Nov. 1881. ,_...• The study of these Landmarks by both physi- cians and surgeons is much to be encouraged. It inevitably leads to a progressive education of both the eye and the touch, by which the recognition of disease or the localization of injuries is vastly as- sisted. One thoroughly familiar with the facts here taught is capable of a degree of accuracy and a confidence of certainty which is otherwise unat- tainable. We cordially recommend the Landmarks to the attention of ever.v physician who has not yet provided himself with a copy of this useful, practical giride to the correct placing of all the anatomical parts and orgims,— Canada Medical and Surgical Journal, Dec. 1881. 6 Lea Brothers & Co.'s Publications — Anatomy. ALLBN, HARBISON, M, !>., Profesfior of Physiology in the University of Pennsylvania, A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. With an Intro- ductory Section on Histology. By E. O. Shakespf.ake, M. D., Ophthalmologist to the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 illustrations on 109 full page lithographic plates, many of which are in colors, and 241 engravings in the text. In six Sections, each in a portfolio. Section I. Histology. Section II. Bones and Joints. Section HI. Muscles and Fascia. Section IV. Artekies, Veins and Lymphatics. Section V. Nebvous System. Section VI. Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, AND General and Clinical Indexes. Price per Section, $3.50 ; also bound in one volume, cloth, $23.00 ; very handsome half Russia, raised bands and open back, $25.00. For sale by subscription only. Apply to the Pvhlishers. It is to oe considered a study of applied anatomy In its widest sense — a systematic presentation of such anatomical facts as can be applied to the practice of medicine as well as of surgeiy. Our author is concise, accurate and practical in his statements, and succeeds admirably in infusing an interest into the study of what is generally con- sidered a dry subject. The department of Histol- ogy is treated in a masterly manner, and the ground is travelled over by one thoroughly famil- iar with it. The illustrations are made with great care, and are simply superb. There is as much of practical application of anatomical points to the every-day wants of the medical clinician as to those of tne operating surgeon. In fact, few general practitioners will read the work without a feeling of surprised gratification that so many points, concerning which they may never have thought before are so well presented for their con- sideration. It is a work which is destmed to be the best of its kind in any language. — Medical Record, Nov. 25, 1882. CLAMKB, W. B,, F,B, C.S. & LOCKWOOI>, C. B,, F,B, C.S, Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 4. Messrs. Clarke and Lockwood have written a book that can hardly be rivalled as a practical aid to the dissector. Their purpose, whicn is " how to de- scribe the best way to display the anatomical structure," has been fully attained. They excel in a lucidity of demonstration and graphic terseness of expression, which only a long training and intimate association with students could have given. With such a guide as this, accompanied by so attractive a commentary as Treves' Surgical Applied Anatomy (same series), no student could fail to be deeply and absorbingly interested in the study of anatomy. — New Orleans Medical a»cj >Siw- gieal Journal, April, 1884. TBEVES, FBEI>BBICK, F, B, C, S., Senior Demonstrator of Anatomy and Assistant Surgeon at the London SospitaL Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. He has produced a work which will command a larger circle of readers than the class for which it was written. This union of a thorough, practical acquaintance with these fundamental branches, quickened by daily use as a teacher and practi- tioner, has enabled our author to prepare a work which it would be a most difficult task to excel. — The American Practitioner, Feb. 1884. This number of the " Manuals for Students " is most excellent, giving just such practical knowl- edge as will be requiredforapplication in relieving the injuries to which the living body is liable. The book is intended mainly for students, but it will also be ofgreat use to practitioners. The illus- trations are well executed and fully elucidate the text. — Southern Practitioner, Feb. 1884. BFLLA3IT, FDWABD, F. B. C, S., Senior Assistant-Surgeon to the Charing-Oross Hospital, London, The Student's Guide to Surgical Anatomy : Being a Description of the most Important Surgical Regions of the Human Body, and intended as an Introduction to operative vSurgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. WILSON, FBASMUS, F. B. S, A System of Human Anatomy, General and Special. Edited by VV, H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College ol Ohio. In one large atid handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00 ; leather, $5.00. " CLMIjAND, JOHN, M, D., F, B. S., Professor of Anatomy and Physiology in Queen's College, Qaiway, A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Cloth, $1.25. hartshorne's handbook of anatomy and physiology. Second edition, revised. In one royal 12mo. volume of 310 pages, with 220 woodcuts. Cloth, 81.75. HORNER'S SPECIAL ANATOMY AND HISTOL- OGY. Eighth edition, extensively revised and modified. In two octavo volumes of 1007 pages, with 320 woodcuts. Cloth, 86.00. Xea Brothers & Co.'s Publications — Physics, I^hySioi.,Atiat. t I>RAPJEM, JOMJSr a, M, JD., LL, D., Professor of Chemistry in the University of the City of New York. Medical Physics. A Text-book for Students and Practitioners of Medicine. In one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. FROM THE PREFACE. The fact that a knowledge of Physics is indispensable to a thorough understanding of Medicine has not been as fully realized in this country as in Europe, where the admiraljle works of Desplats and Gariel, of Kobertson and of numerous German writers constitute a branch of educational literature to which we can show no parallel. A full appreciation of this the author trusts will be sufficient justification for placing in book form the sub- stance of his lectures on this department of science, delivered during many years at the University of the City of New York. Broadly speaking, this work aims to impart a knowledge of the relations existing between Physics and Medicine in their latest state of development, and to embody in the pursuit of this object whatever experience the author has gained during a long period of teaching this special branch of applied science. This elegant and useful work bears ample testi- mony to the learning and good judgment of the author. He has fitted his work admirably to the exigencies of the situation by presenting the reader with brief, clear and simple statements of such propositions as he is by necessity required to master. The subject matter is well arranged, liberally illustrated and carefully indexed. That it will take rank at once among the text-books is • certain, and it is to be hoped that it will find a place upon the shelf of the practical physician, where, as a book of reference, it will be found useful and agreeable. — Louisville Medical News, ■■ September 26, 1885. Certainly we have no text-book as full as the ex- cellent one he has prepared. It begins with a statement of the properties of matter and energy. After these the special departments of physics are explained, acoustics, optics, heat, electricity and magnetism, closing with a section on electro- biology. The applications of all these to physiology and medicine are kept constantly in view. The text is amply illustrated and the many difficult points of the subject are brought forward with re- markable clearness and ability. — Medical and Surg- ical Reporter, July 18, 1885. That this work will greatly faalUtate the study of medical physics is apparent upon even a mere cursory examination. It is marked by that scien- tific accuracy which always characterizes Dt. Draper's writings. Its peculiar value lies in the fact that it is written from the standpoint of the medical man. Hence much is omitted that ap- pears in a mere treatise on physical science, while much is inserted of peculiar value to the physi- cian. — Medical Record, August 22, 1885. BOBBBTSOW, J, McGMEGOM, M. A., M, B,, Muirhead Demonstrator of Physiology, University of Olasgow. Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustre "tions. Limp cloth, $2.00. See Students' Series of Manuals, page 4. The title of this work sufficiently explains the nature of its contents. It is designed as a man- ual for the student of medicine, an auxiliary to his text-book in physiology, and it would be particu- Jarly useful as a guide to his laboratory experi- ments. It will be found of great value to the practitioner. It is a carefully prepared book of reference, concise and accurate, and aa such we heartily recommend it. — Journal of the American Medical Association, Dec. 6, 1884. DALTON, JOHW C, M, !>., Professor Emeritus of Physiology in the College of Physicians ond Swgeons, New York. Doctrines of the Circulation of the Blood. A History of Physiological •Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 12mo. volume of 293 pages. Cloth, $2. Dr. Dal ton's work is the fruit of the deep research ■ of a cultured mind, and to the busy practitioner it -cannot fail to be a source of instruction. It will inspire him with a feeling of gratitude and admir- ation for those plodding workers of olden times, ■ who laid the foundation of the magnificent temple of medical science aa it now stands. — New Orleans Medical and Surgical Journal, Aug. 1885. In the progress of physiological study no fact "Was of greater moment, none more completely revolutionized the theories of teachers, than the discovery of the circulation of the blood. This explains the extraordinary interest it has to all medical historians. The volume before us is one of three or four which have been written within a few years by American physicians. It is in several respects the most complete. The volume, though small in size, is one of the most creditable con- tributions from an American pen to medical history that has appeared.— Med. £ Surg. Rep., Dec. 6, 1884. BMLL, F, JEFFMEY, M. A., Professor of Comparative Anatomy at King's College, London. Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 'with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 4. The manual is preeminently a student's book— I it the best work in existence in the English ■ clear and simple in language and arrangement, language to place in the hands of the medictil It is well and abundantly illustrated, and is read- student.— ^ristoi Medico- ClUrurgical Journal, ilar. ,»ble and interesting. On the whole we consider | 1886. ELLIS, GEORGE VINEB, Emeritus Professor of Anatomy in University College, London. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. From the eighth and revised London edition. In one very :handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. MOBEMTS, JOH]^ B,, A, M., M. L>., Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. for Oraduates in Medicine. The Compend of Anatomy. For use in the dissecting-room and in preparing for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 8 Lea Brothers & Co.'s Publications — Physiology, Cliemistry. CHAPMAN, SBNBT C, M. D,, Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia. A Treatise on Human Physiology. In one handsome octavo volume of 925 pages, with 605 fine engravings. Cloth, $5.50 ; leather, |6.50. farther, and the latter will find entertainment and instruction in an admirable book of reference. — North Carolina Medical Journal, Nov. 1887. It represents very fully the existing state of physiology. The present work has a special value to the student and practitioner as devoted more to the practical application of well-known truths which the advance of science has given to the profession in this department, which may be con- sidered the foundation of rational medicine.— .Bm/- falo Medical and Surgical Journal, Dec. 1887. Matters which have a practical bearing on the practice of medicine are lucidly expressed; tech- nical matters are given in minute detail ; elabo- rate directions are stated for the guidance of stu- dents in the laboratory. In every respect the work fulfils its promise, whether as a complete treatise for the student or for the physician ; for the former it is so complete that he need look no The work certainly commends itself to both student and practitioner. What is most demanded by the progressive physician of to-day is an adap- tation of physiology to practical therapeutics, and this work is a decided improvement in this respect over other works in the market. It will certainly take place among the most valuable text-books. — Medical Age, Nov. 25, 1887. It is the production of an author delighted with his work, and able to inspire students with an en- thusiasm akin to his own. — American Practitioner and News, Nov. 12, 1887. DAZTON, JOHN a, M. JO,, Professor of Physiology in the College of Physicians and Surgeons, New York, etc. « A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo volmne of 722 pages, with 252 beautiful engravings on wood. Cloth, $5.00; leather, |6.00. Frona the first appearance of the book it has been a favorite, owing as well to the author's renown as an oral teacher as to the charm of simplicity with which, as a writer, he always succeeds in investing even intricate subjects. It must be gratifying to him to observe the fre- quency with which his work, written for students and practitioners, is quoted by other writers on physiology. This fact attests its value, and, in great measure, its originality. It now needs no such seal of approbation, however, for the thou- sands who have studied it in its various editions have never been in any doubt as to its sterling worth.— iV. T. Medical Journal, Oct. 1882. Professor Dalton's well-known and deservedly- appreciated work has long passed the stage at which it could be reviewed in the ordinary sense. The work is eminently one for the medical prac- titioner, since it treats most fully of those branches of physiology which have a direct bearing on the diagnosis and treatment of disease. The work is one which we can highly recommend to all our readers. — Dublin Journal of Medical Science, Feb.'SS. FOSTJEM, MICHAEL, M, D., F, M, S,, Prelector in Physiology and Fellow of Trinity College, Cambridge, England. Text-Book of Physiology. New (fourth) American from the fifth and revised English edition, with notes and additions by E. T. Eeicheet, M. D., Professor of Physi- ology in University of Pennsylvania. Preparing. A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED. It is delightful to meet a book which deserves only unqualified praise. Such a book is now before us. It is in all respects an ideal text'book. With a complete, accurate and detailed knowledge of his subject, the author has succeeded in giving a thoroughly consecutive and philosophic account of the science. A student's attention is kept throughout fixed on the great and salient ques- tions, and his energies are not frittered away and degenerated on petty and trivial details. Review- ing this volume as a whole we are justified in say- ing that it is the only thoroughly good text-book of physiology in the English language, and that it is probably the best text-book in any language. —Edinburgh Medical Journal, December 1888. FOWFB, HENMY, M. B,, F, M, C. S., Examiner in Physiology, Royal College of Surgeons of England. Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 4. SIMON, W., Fh, D,, M. D., Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry m the Maryland College of Pharmacy. Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates illustrating 56 of the most important chemical tests. Just ready. Cloth, $3.25. FROM THE PREFACE. It has been the aim of the Author to present a work on general chemistry which may be used to advantage as a text-book by beginners, and which, at the same time, covers the special needs of the medical and pharmaceutical student. While the general character of the second edition is the same as that of the first, many changes and numerous additions have been made with the view of render- ing the work more complete and useful. For the special benefit of pharmaceutical and medical stu- dents all chemicals mentioned in the United States Pharmacopoeia are included, and when of sufficient interest, are fully considered. Having frequently noticed the difficulty experienced by beginners in becoming familiar with the variously shaded colors of chemicals and their reactions, the Author decided to illustrate the work with a number of plates, presenting the colors of those most important Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated by Ira Eemsen, M. T>., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. LEHM ANN'S MANUAL OP CHEMICAL PHYS- I CARPENTER'S PRIZE ESSAY ON THE USB AND lOLOGrY. In one octavo volume of 327 pages, 1 Abtoe of Alcoholic Liqttoes in Health and Dis- CARPENTORt HUMAN PHySoLOGY. Edited ^^«=- With explanations of scientific words. Small by Henby Powee. In one octavo volume. 1 12mo. 178 pages. Cloth, 60 cents. Lea Brothers & Co.'s Publications — Chemistry. FBANKLAND, E., J>. C. L,, F.B.S,, &JAI*I>, F, M., F, I, C, Professor of Chemistry in the Normal School of Science, London. Assist. Prof, of Chemistry in the Normal School of Science, London. Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. This work should supersede other works of its class in the medical colleges. It is certainly better adapted than any work upon chemistry,with which we are acquainted, to impart that clear and full knowledge of the science which students of med- icine should have. Physicians who feel that their chemical knowledge is behind the times, would do well to devote some of their leisure time to the study of this work. The descriptions and demon- strations are made so plain that there is no diffi- culty in understanding them.— Cincinnati Medical News, January, 1886. This excellent treatise will not fail to take Its place as one of the very best on the subject of which it treats. We have been much pleased with the comprehensive and lucid manner In which the difficulties of chemical notation and nomenclature have been cleared up by the writers. It shows on every page that the problem of rendering the obscuritfes of this science easy of comprehension has long and successfully engaged the attention of the Anthoia,— Medical and Surgical Beporter, October 31, 1885. FOWNES, GEOMGE, I*h. J>. A Manual of Elementary Chemistry; Theoretical and Practical. Em- bodying Watts' Physical Inorganic Chemistry. New American, from the twelfth English edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood and a colored plate. Cloth, $2.75 ; leather, $3.25. Fownes^ Chemistry has been a standard text- book upon chemistry for many years. Its merits are very fully known by chemists and physicians everywhere in this country and in England. As the science has advanced by the making of new discoveries, the work has been revised so as to keep it abreast of the times. It has steadily maintained its position as a text-book with medi- cal students. In this work are treated fully: Heat, Light and Electricity, including Magnetism. The influence exerted by these forces in chemical action upon health and disease, etc., is of the most important kind, and should be familiar to every medical practitioner. We can commend the work as one of the very best text-books upon chemistry extant. — Cincinnati Medical News, Oc- tober, 1885. Of all the works on chemistry intended for the use of medical students, Fownes' Chemistry is perhaps the most widely used. Its popularity is based upon its excellence. This last edition con- tains all of the material found in the previous, and ijt is also enriched by the addition of Watts' Physical and Inorganic Chemistry. All of the mat- ter is brought to the present standpoint of chemi- cal knowledge. We may safely predict for this work a continuance of the fame and favor it enjoys among medical students. — New Orleans Medical and Surgical Journal, March, 1886. ATTFIELD, JOSN, FJi, D., Professor of Practical Chemistry to the Pharmaceutical Society of Oreat Britain, etc Chemistry, General, Medical and Pharmaceutical; Including the Chem- istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. A new American, from the twelfth English edition, specially revised by the Author for America. In one handsome royal 12mo. volume of about 750 pages, with about 100 illustrations. In press. A notice of the previous edition is appended. It is a book on which too much praise cannot be bestowed. As a text-book for medical schools it is unsurpassable in the present state of chemical science, and having been prepared with a special view towards medicine and pharmacy, it is alike Indispensable to all persons engaged in those de- partments of science. It includes the whole chemistry of thelast Pharmacopoeia. — Pacific Medi- cal and Surgical Journal, Jan. 1884. A text-book which passes through ten editions in sixteen years must have good qualities. It seems desirable to point out that feature of the book which, in all probability, has made it so popular. There can be little doubt that it is its thoroughly practical character, the expression being used in its best sense. The author under- stands what the student ought to learn, and is able to put himself in the student's place and to appre- ciate his state of miud.— American Chemical Jour- nal, April, 1884. BLOXAM, CMABLES L,, Professor of Chemistry in King's College, London. Chemistry, Inorganic and Organic. New American from the fifth Lon- don edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00, Comment from us on this standard work is al- most superfluous. It diflfers widely in scope and aim from that of Attfield, and in its way is equally beyond criticism. It adopts the most direct meth- ods in stating the principles, hypotheses and facts of the science. Its language is so terse and lucid, and its arrangement of matter so logical in se- quence that the student never has occasion to complain that chemistry is a hard study. Much attention is paid to experimental illustrations ol chemical principles and phenomena, and the mode of conducting these experiments. The book maintains the position it has always held as one ol the best manuals of general chemistry hi the Eng- lish language. — Detroit Lancet, Feb. 1884. We know of no treatise on chemistry which contains so much practical information in the same number of pages. The book can be readily adapted not only to the needs of those who desire a tolerably complete course of chemistry, but also to the needs of those who desire only a general knowledge of the subject. We take pleasure in recommending this work both as a satisfactory text-book, and as a useful book of reference.— £og- ton Medical and Surgical Journal, Juoe 19, 18S4. GBEEWE, WILLIAM S,, M, JD., Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. A Manual of Medical Chemistry. For the use of Students. Based upon Bow. man's Medical Chemistry. In one 12mo. volume of 310 pages, with /4 lUus. Cloth, $1.75: It is a concise manual of three hundred pages, I the recognition of compounds due to pathological sivine an eSlent summary of the best methods conditions. The detection of poisons is treated If SziSXuidrandiolidsofthebody,both with sufficient fulness for the purpose of thesta- for ttierstSiWof their normal constituents and dent or practitioner.-Boston Jl. of Chem. June.'SO. 10 Lea Brothers & Co.'s Publications — Chemistry. BEMSBN, IRA, M. D., I^h. J>., Professor of Chemistry in the Johns Hopkins University, Baltimore. Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- some royal 12mo. volume of 316 pages. Cloth, |2.00 This work of Dr. Remsen is the yery textbook needed, and -the medical student who has it at his fingers' ends, so to speak, can, if he chooses. make himself familiar with any branch of chem- istry which he may desire to pursue. It would be difficult indeed to find a more lucid, full, and at the same time compact explication of the philos- ophy of chemistry, than the book before us, and we recommend it to the careful and impartial examination of college faculties as the text-book of; chemical instruction. — St. Louis Medical arid Sur- gical Journal, January, 1888. It is a healthful sign when we see a demand for a third edition of such a book as this. This edi- tion is larger than the last by about seventy-five- pages, and much of it has been rewritten, thus- bringing it fully abreast of the latest investiga- tions. — N. T. Medical Journal, Dec. 31, 1887. C SABLES, T, CBANSTOVN, M. 2>., F, C. S,, M, S., Formerly Asit. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast^ The Elements of Physiological and Pathological Chemistry. A Handbook for Medical Students and Practitioners. Containing a general account of Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the methods for pre- paring or separating their chief constituents, as also for their examination in detail, and an outline syllabus of a practical course of instruction for students. In one handsome octavo volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50, Dr. Charles is fully impressed with the import- ance and practical reach of his subject, and he has treated it in a competent and instructive man- ner. We cannot recommend a better book than the present. la fact, it fills a gap in medical text- books, and that is a thing which can rarely be said nowadays. Dr. Charles has devoted much space to the elucidation of urinary mysteries. He does this with much detail, and yet in a practical and intelligible manner. In fact, the author has filled his book with many practical hints. — Medical Rec- ord, December 20, 1884. HOFFMAJnS^, F,f A,M», Fh,I>,, & FOWFM F,JB,, Fh,D., Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. A Manual of Chemical Analysis, as applied to the Examination of Medicinal Chemicals and their Preparations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Pliysicians, Druggists and Manufacturing Chemists, and Pharmaceutical and Medical Students. Third edition, entirely rewritten and much enlarged. In one verT handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. We congratulate the author on the appearance of the third edition of this work, jiublished for the first time in this country also. It is admirable and the information it undertakes to supply is both extensive and trustworthy. The selection of pro- cesses for determining the purity of the substan- ces of which it treats is excellent and the descrip- tion of them singularly explicit. Moreover, It is exceptionally free from typographical errors. We have no hesitation in recommending it to those who are engaged either in the manufacture or the testing of medicinal chemicals. — London Pfiarma- ceutical Jou/mal and Transactions^ 1883. CLOWES, FJRAJSTK, D, Sc, London, Senior Science- Master at the High School, Newcastle-under-Lyme, etc. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. Third American from the fourth and revised English edition. In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth, $2.50. This work has long been a favorite with labora- tory instructors on account of its systematic plan, carrying the studentst«p by step from the simplest Questions of chemical analysis, to the more recon- dite problems. Features quite as commendable are the regularity and system demanded of the student in the performance of each analysis. These characteristics are preserved in the present edition, which we can heartily recommend as a sat- isfactory guide for the student of inorganic chem- ical analysis. — Nero York Medical Journal, Oct. 9, 1886. RALFE, CJaCARLES S., M. D., F, R. C. F,, Assistant Physician at the London Hospital. Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 See Students^ Sei^ of Manuals, page 4. cine. Dr. Ralfe is thoroughly acquainted with the latest contributions to his science, and it is quite refreshing to find the subject dealt with so clearly and simply, yet in such evident hai'mony with the modern scientific methods and spirit.— il/edicrB Record, February 2, 1884. illustrations. Limp cloth, red edges, $1.50. This is one of the most instructive little works that we have met with in a long time. The author is a physician and physiologist, as well as a chem- ist, consequently the book is unqualifiedly prac- tical, telling the physician just what he ougnt to know, of the applications of chemistry in medi- CLASSEN, ALEXANDER, Professor in the Royal Polytechnic School, Aix-la-Chapelle. Elementary Quantitative Analysis. Translated, with notes and additions, by Edgae F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, $2.00. It is probably the best manual of an elementary and then advancing to the analysis of ininerals and nature extant, insomuch as its methods are the such products as are met with in applied chemis- best. It teaches by examples, commencing with try. It is an indispensable book for students irb single determinations, followed by separations, chemistry. — Boston Journal of Chemistry, Oct. 1878i. Lea Brothers & Co.'s Publications— Pharm., Mat. Med., Therap. 11 BRVWTOK, T. LAVJDEIt, M,I>,, I),Sc., F.B.S., F,B C I> LectuTer on Materia Medica arui Therapeutics at St. Bartholomew^, Hospital, London ttr *' T 1^ •.? 5?°^ °^ Pharmacology, Therapeutics and Materia Medica- Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drags' New (3d) edition. Octavo, 1305 pages, 230 illustrations. Cloth, §5.50 ; leather S6 50 No words of praise are needed for this work, for -—*" v-— -> j-J-^^V !■--.» vo.OU it has already spoken for itself in former editions. It was by unanimous consent placed among the foremost books on the subject ever published in any language, and the better it is known and studied the more highly it is appreciated. The present edition contains much new matter, the insertion of which has been necessitated by the advances rnade in various directions in the art of therapeu- tics, and it now stands unrivalled in its thoroughly scientific presentation of the modes of drug action. -No one who wishes to be fully up to the times in this science can afford to neglect the study of Dr. Brunton's work. The indexes are excellent, and add not a little to the practical value of the book. — Medical Record, May 25, 1S89. Nothing so original and so complete on the action of drugs on the body generally and on its various parts, has appeared during the life of the present generation. This is strong language, but it is the truth. The great merit of this work is that tho author has been able so well to coordinate facta into an intelligible and rational .system of pharma- cology, and henceforth no treatise on therapeutics will be considered complete which does not in some measure adopt this method. The busy physician will approach this book to learn some- thing that will better fit him for his work, and on every page he will find something that will reward him for the time spent in its perusal. We com- mend this book as one which every physician should own and study. It is a work which if once owned will be likely to be read and consulted till the covers fall off from much ns&.—Boston Medical and Surgical Journal, Dec. 20, 1888. MAISCM, JOMNM,, JPhar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists and Physicians. New f3d) edition, thoroughly revised. In one handsome royal 12mo. volume^ of 523 pages, with 257 illustrations. Cloth, $3. author are a guarantee that his manual is well adapted for its purpose, viz. : a text- and reference- book for students, pharmacists and physicians, con- taining the most recent and reliable information in regard to drags.— Cincinnati Med. News,NQy, 1887. Prof. Maisch is one of the most distinguished pharmacists of this country. He and Prof. Stille are the authors of The National Dispensatory, which is not excelled by any work of its kind ever published. The learning and experience of the BAMTMOJLOW, ROBEMTS, A, M,, M, !>., XX. X)., Professor of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Philadelphia New Remedies of Indigenous Source: Their Physiological Actions and Therapeutical Uses. In one octavo volume of about 300 pages. Preparing. I*AMMISS, En WARD, Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. A Treatise on Pharmacy : designed as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, There is nothing to equal Parrish's Pharmacy in this or any other language. — London Pharma- ceutical Journal. No thorough-going pharmacist will fail to possess himself of so useful a guide to practice, and no physician who properly estimates the value of an accurate knowledge of the remedial agents em- ployed by him in daily practice, so far as their miscibility, compatibility and most effective meth- ods of combination are concerned, can afford to leave this work out of the list of their works of reference. The country practitioner, who must always be in a measure his own pharmacist, will find it indispensable. — Louisville Medical News, March 29, 1884. All that relates to practical pharmacy — apparatus, processes and dispensing — has been arranged and described with clearness in its various aspects, so as to afford aid and advice alike to the stuaentand to the practical pharmacist. The work is judi- ciously illustrated with good woodcuts — American Journal of Pharmacy, January, 1884. MEMMAJnsr, Dr, X., Professor of Physiology in the University of Zurich. Experimental Pharmacology. A Handbook of Methods for Determining the Physiological Actions of Drugs. Translated, with the Author's permission, and with extensive additions, by Egbert Meade Smith, M. D., Demonstrator of Physiology in the University of Pennsylvania. 12mo., 199 pages, with 32 illustrations. Cloth, $1.60. BBUCE, J, MITCHELL, M. X)., F. B, C, B., Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, L., Professor of Theory and Practice of Med. and of Clinical Med. m the Univ. of Penna. '• Therapeutics and M.ateria Medica. A Systematic Treatise on the Action and Uses of Medicinal Agents, iacluding their Description and History. Fourth edition, revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. ■Cloth, $10.00 ; leather, $12.00._ GBIFFITH, BOBEBT EGLESFIELB, M. B, A Universal Formulary, containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The wnole adapted to Physicians and Pharmaceut- ists. Third edition, thoroughly revised, with numerous additions, by John M JVIaisch, Phar. D., Professor of Materia Medica and Botany in the Philadelphia CoUege of Pharmacy. In one citavo volume of 775 pages, with 38 illustrations. Cloth, $4.o0 ; leather, $5.50. 12 Lea Brothers & Co.'s Publications — Mat. Med., Therap. STILLE, A,, M,JJ,,LL,n,, & MAISCS, J, M.,Phar,I>,, Professor Sm&ritus of the Theory and Prac- Prof, of Mat. Med. and Botany in Phila, tice of Medicine and of Clinical Medicine College of Pharmacy, Sec'y to the Ameri- in the University of Pennsylvania. can Pharmaceutical Association. The National Dispensatory. CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPCEIAS OF THE UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS REFERENCES TO THE FRENCH CODEX. Fourtli edition revised, and covering the new British Pharmacopoeia. In one mag- nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price in cloth, $7.25 ; leather, raised bands, $8.00. *^*2%is work will he furnished with Patent Ready Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding. In this new edition of The National Dispensatory, all important changes in the recent British Pharmacopoeia have been incorporated throughout the volume, while in the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical novelties which have been established in professional favor since the publication of the third edition two years ago. Since its first publication. The National Dispensatory has been the most accurate work of its kind, and in this edition, as always before, it may be said to be the representative of the most recent state of American, English, German and French Pharmacology, Therapeutics and Materia Medica. It is with much pleasure that the fourth edition of this magnificeBt work is received. The authors and publishers have reason to feel proud of this, the most comprehensive, elaborate and accurate work of the kind ever printed in this country. It is no wonder that it has become the standard au- thority for both the medical and pharmaceutical profession, and that four editions have been re- quired to supply the constant and increasing demand since its first appearance in 1879. The entire field has been gone over and the various articles revised in accordance with the latest developments regarding the attributes and thera- peutical action of drugs. The remedies of recent discovery have received due attention. — Kansas City Medical Index, Nov. 1887. We think it a matter for congratulation that the profession of medicine and that of pharmacy have shown such appreciation of this great work as to call for four editions within the comparatively briel period of eight years. The matters with which it deals are of so practical a nature that neither the physician nor the pharmacist can do without the latest text-books on them, especially those that are so accurate and comprehensive as this one. The book is in every way creditable both to the authors and to the publishers. — New York Medical Journal, May 21, 1887. FAMQUSABSOW, MOBBBT, M. J>., F, B, C, JP., LL. J>., Lecturer on Materia Medica at St. Mary's Hospital Medical School, London. A Guide to Therapeutics and Materia Medica. New (fourth) American, from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia, iiy Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo. volume of 581 pages. Cloth, $2.60. Just ready. It may correctly be regarded as the most modem work of its kind. It is concise, yet complete. Containing an account of all remedies that have a place in the British and United States Pharma- copoeias, as well as considering all non-official but important new drugs, it becom es in fact r miniature dispensatory. — Pacific Medical Journal, June, 1889. Farquharson's Guide is becoming more widely known, and doubtless will be more acceptable with each revision, as it has in this. It is just the book the young doctor will consult with profit in very many of nis daily emergencies, and to all such, yes, and to many of the grave and reverend seniors we commend it most heartily. — North Carolina Medical Journal, July, 1889. We have in the preceding issues of this journal had occasion to call attention to the previous edi- tions of this excellent work, which m its present form retains all the special features of its former editions.— -SowiAern Practitioner, July, 1889. BDBS, BOBEBT T., M, J),, Jackson Professor of Clinical Medicine in Harvard University, Medical Department. A Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. Octavo, 544 pages. Cloth, $3.50 ; leather, $4.50. cine. Such they can find in the present author. All the newest drugs of promise are treated of. The clinical index at the end will be found ver^ useful. We heartily commend the book and con The treatise will be found to be concise and practical, bringing the subject down to the latest developments of therapeutics and pharmacology. The student and practitioner will find the book a valuable one for reference and study, the former being facilitated by a full and excellent index.— St. Louis Medical and Surgical Journal, Jan. 1888. The present work seem s destined to take a prom- inent place as a text-book on the subjects of which treats. It possesses all the essentials which we expect in a book of its kind, such as conciseness, clearness, a judicious classification, and a reason- able degree of dogmatism. The style deserves the highest commendation for its dignity and purity of diction. The student and young practi- tioner need a safe guide in this branch of medi- gratulate the author on having produced so good a one.— iV. Y. Medical Journal, Feb. 18, 1888. Dr. Edes' book represents better than any older book the practical therapeutics of the present day. The book is a thoroughly practical one. The classification of remedies has reference to their therapeutic action, and such a classification will always meet the approval of the student. The rela- tive importance of different remedies is indicated by the space devoted to each, and by the use of larger type in the titles of the more important articlea.— Pharmaceutical Era, Jan. 1888. Lea Brothers & Co.'s Publications— Patliol., Histol. 13 JPATNE, JOSEFS F,, M. D., F. B, C. P., Member of the Pathological Society, Senior Assistant Physician and Lecturer on Patholoaical Anat- omy, St. Thomas' Hospital, London. _ A Manual of General Pathology. Designed as an Introduction to the Prac- tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50 Knowing, as a teacher an!f examiner, the exact needs of medical students, the author has in the work before us prepared for their especial use what we do not hesitate to say is the best introduc- tion to general pathology that we have yet ex- amined. A departure which our author has taken is the greater attention paid to the causa- tion of disease, and more especially to the etiologi- cal factors in those diseases now with reasonable certainty ascribed to pathogenetic microbes. In this department he has been very full and explicit, not only in a descriptive manner, but in the tech- nique of investigation. The Appendix, giving methods of reseaich, ia alone worth the price of the book, several times over, to every student of pathology. — St. Louis Med. and Surg, /owr., Jan,'89. SFWJ!^, NICHOLAS, M.D., Fh,D., Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago. Surgical Bacteriology. In one handsome octavo of 259 pages, with 13 plates, of which 9 are colored. Cloth, $1.75. Just ready. The author in this excellent monograph has very concisely yet fully and comprehensively gone over the iield, and placed before the medical public a most valuable treatise on the subject. "We know of no one better qualified for the task he has assumed, and doubt if anyone could have dis- charged the duty so well. Those who would not be behind the wonderful developments of the day will make a mistake in not supplying themselves with this work. The facts in regard to this im- portant subject are made so plain and considered in such a satisfactory manner that we can but regard it as one of the most important contributions to the medical literature of the year. — Southern Practitioner, June 1, 1889. COATS, JOSEFM, M, J)., F. F. F. S., Pathologist to the Glasgow Western Infirmary. A Treatise on Pathology. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. The work before us treats the subject of Path- ologjr more extensively than it is usually treated In similar works. Medical students as well as physicians, who desire a work for study or refer- ence, that treats the subjects in the various de- partments in a very thorough manner, but without prolixity, will certainly give this one the prefer- ence to any with which we are acquainted. It sets forth the most recent discoveries, exhibits, in an interesting manner, the changes from a normal condition effected in structures by disease, and points out the characteristics of various morbid agencies, so that they can be easily recognized. But, not limited to morbid anatomy,it explains fully how the functions of organs are disturbed by abnormal conditions.— Oincinnaft Medical News, Oct. 1883. GJRFBW, T. MENMY, M, JD,, Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. Pathology and Morbid Anatomy. New (sixth) American from the seventh revised English edition. In one octavo vol. of 539 pp., with 167 engravings. Cloth, $2.75. Just ready. WOODHFAD, G. SIMS, M, D., F. M. C. F. E., Demonstrator of Pathology in the University of Edinburgh. Practical Pathology. A Manual for Students and Practitioners. In one beau- tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. It forms a real guide for the student and practi- themselves with this manual. The numerous tioner who is thoroughly In earnest in his en- drawings are not fancied pictures, or merely deavor to see for himself and do for himself. To schematic diagrams, but they represent faithfully the laboratory student it will be a helpful com- the actual images seen under the microscope. panion, and all those who may wish to familiarize The author merits all praise for having produced themselves with modern methods of examining a valuable work. — Memcal Record, May 31, 1884. morbid tissues are strongly urged to provide SCHAFEB, EnWABn A,, F. M. S., Assistant Professor of Physiology in University College, London. The Essentials of Histology. In one octavo volume of 246 pages, with 281 illustrations. Cloth, $2.25. This admirable work was greatly needed. It has been written with the object of supplying the student with directions for the microscopical examination of the tissues, which are given in a clear and understandable way. Although espe- cially adapted for laboratory work, at the same time it is Intended to serve as an elementary text-book of histology, comprising all the essen- tial facts of the science. The author has recom- mended only those methods upon which long ex- perience has proved that full dependence can be placed. — The Physician and Surgeon, July, 1887. KLEIN, E., M. !>., F, B. S., Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hasp., London. Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, with 194 illus. Limp cloth, $1.75. Just ready. See Students' Series of Manuxils, page 4. Considered with regard to its contents, it can only be looked on as a large and comprehensive volume. New and original illustrations have been added, with the help of which the structure of each tissue becomes clear to the reader. A copious index affords a ready reference to the histology of every tissue and organ, and presents, at the same time, a complete glossary of the scientific terms. — Provincial Medical Journal, May 1, 1889. FEFFEB, A, J,, M. B., M, S,, F, B. C. S., Surgeon and Lecturer at St. Mary's Hospital, London. Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. Its form is practical, its language is clear, and in it nothing that is unnecessary. The list of the information set forth is well-arranged, well- subjects covers the whole range of surgery.— iVew indexed and well- illustrated. The student will find York Medical Journal, May 31, 1884. 14 Lea Brothers & Co.'s Publications — Practice of Med. FLINT, AUSTIN, M. D., LI. D. Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. 7, A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. New (sixt^) edition, thoroughly re- vised and rewritten by the Author, assisted by "WrLLiAii H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore, and Austin Flixt, Jr., M. D., LL. D., Professor of Physiology, Bellevue Hospital Medical College, IST. Y. In one very handsome octavo volume of 1160 pages, with illustratious. Cloth, $5.50 ; leather, ?6.50. A new edition of a work of such established rep- ' general approval by medical students and practi- ntationas Flint's Medicine needs but few words to tioners as the work of Professor Flint. In all the commend it to notice. It may in truth be said to : medical colleges of the United States it is the fa- embody the fruit of his labors in clinical medicine, , vorite work upon Practice; and, as we have stated ripened by the experience ofa long life devoted to i before in alluding to it, there is no other medical its pursuit. America may well be proud of having work that can be so generally found in the libra- produced a man whose indefatigable industry and | ries of physicians. In every state and territory gifts of genius have done so much to advance med- i of this vast country the book that will be most likely ' icine; and all English-reading students must be to be found in the office of a medical man, whether frateful for the work which he nas left behind bim. ! in city, town, village, or at some cross-roads, is t has few equals, either in point of literary excel- I Flint's Practice. We make this statement to a lence, or of scientific learning, and no one can i considerable extent from personal observation, and study its pages without being struck by the lu- I it Is the testimony also of others. An examina- cidity and accuracy which characterize them. It | tion shows that very considerable changes have is qualities such as these which render it so valu- been made in the sixth edition. The work may un- able for its purpose, and give it a foremost place doubtedly be regarded as fairly representing the among the text-books of this generation. — The present state of the science of medicine, and as London Lancet, March 12, 1887. i reflecting the views of those who exemplify in No text-book on the principles and practice of i their practice the present stage of progress of med- medicine has ever met in this country with such ; ical a-rt.— Cincinnati Medical News, Oct. 1886. SARTSSOBNE, HBNRY, M. D., LL. D., Lately Professor of Hygiene in the University of Pennsylvania. Essentials of the Principles and Practice of Medicine. A Handbook for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; haK bound, $3.00. Within the compass of 600 pages it treats of the history of medicine, general pathology, general symptomatology, and physical diagnosis (including laryngoscope, ophthalmoscope, etc.), general ther- apeutics, nosology, and special pathology and prac- tice. There is a wonderful amount of information contained in this work, and '.i is one of the best of its kind that we have seen. — Glasgow Medical Journal, Nov. 1882. An indispensable book. No work ever exhibited & better average of actual practical treatment than this one; and probably not one writer in our day had a better opportunity than Dr. Hartshorne for condensing all the views of eminent practitioners into a 12mo. The numerous illustrations will be very useful to students especially. These essen- tials, as the name suggests, are not intended to supersede the text-books of Flint and Bartholow, but they are the most valuable in affording the means to see at a glance the whole literature of any disease, and the most valuable treatment. — Chicago Medical Journal and Examiner, April, 1882. BHISTOWJE, JOSN STUM, M. D., F. R. C. F., Physician and Joint Lecturer on Medicine at St. Thomas'' Hospital, London. A Treatise on the Practice of Medicine. Second American edition, revised by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. Cloth, $5.00 ; leather, $61)0. The book is a model of conciseness, and com- bines, as successfully as one could conceive it to be possible, an encyclopaedic character with the smallest dimensions. It differs from other admi- rable text-books in the completeness with which it covers the whole field of medicine. — Michigan Medical Neics, May 10, 1880. His accuracy in the portraiture of disease, his care in stating subtle points of diagnosis, and the faithfully given pathology of abnormal processes have seldom been surpassed. He embraces many diseases not usually considered to belong to theory and practice, as skin diseases, syphilis and insan- ity, but they will not be objected to by readers, as he has studied them conscientiously, and drawn from the life. — Medical and Surgical Reporter, De- cember 20, 1879. The reader will find every conceivable subject connected with the practice of medicine ably pre- sented, in a style at once clear, int-eresting and concise. The additions made by Dr. Hutchinson are appropriate and practical, and greatly add to its usefulness to American readers. — Buffalo Med- ical and Surgical Journal, March, 1880. WATSON, SIM TJSOMAS, M. D., Late Physician in Ordinary to the Queen. Lectures on the Principles and Practice of Physic. A new American from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. LECTURES ON THE STUDY OF FEVER. By A. Hudson, M. D., M. R. I. A. In one octavo volume of 308 pages. Cloth, «2.50. A TREATISE ON FEVER. By Robert D. Lyons, K. C. C. InoneSvo. vol. of354pp. Cloth, $2.26. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological and Therapeutical Relations. In two large and hand- some octavo volumes of 1468 pp. Oloth, $7.00. Lea Brothers & Co.'s Publications — System of Med. 16 For Sale by Subscription Only. A System of Practical Medicine. B Y AMERICAN A UTHOBS. Edited by WILLIAM PEPPER, M. D., LL. D., PROVOST AND PROFESSOR OP THE THEORY AND PRACTICE OF MEDICINE AND OF OIiINICAIi MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the Hospital of the University of Pennsylvania. The complete work, in five volumes, containing 6573 pages, vnth 198 illustrations, is now ready. Price per volume, cloth, $5; leather, $6 ; half Russia, raised hands and open hack, $7. In this great work American medicine is for the first time reflected by its worthiest teachers, and presented in the full development of the practical utility which is its pre- eminent characteristic. The most able men — from the East and the West, from the North and the South, from all the prominent centres of education, and from all the hospitals which afford special opportunities for study and practice — have united in generous rivalry to bring together this vast aggregate of specialized experience. The distinguished editor has so apportioned the work that to each author has been assigned the subject which he is peculiarly fitted to discuss, and in which his views will be accepted as the latest expression of scientific and practical knowledge. The practitioner will therefore find these volumes a complete, authoritative and unfailing work of reference, to which he may at all times turn with full certainty of finding what he needs in its most recent aspect, whether he seeks information on the general principles of medi- cine, or minute guidance in the treatment of special disease. So wide is the scope of the work that, with the exception of midwifery and matters strictly surgical, it embraces the whole domain of medicine, including the departments for which the physician is accustomed to rely on special treatises, such as diseases of women and children, of the genito-urinary organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology and otology. Moreover, authors have inserted the formulas which they have fou ad most efficient in the treatment of the various affections. It may thus be truly regai ded as a Complete Library of Practical, Medicine, and the general practitioner possessing it may feel secure that he will require little else in the daily round of professional duties. In spite of every effort to condense the vast amount of practical information fur- nished, it has been impossible to present it in less than 5 large octavo volumes, containing about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary octavos. Illustrations are introduced wherever requisite to elucidate the text. A detailed prospectus will he sent to any address on application to the publishers. These two volumes bring this admirable work to a close, and fully sustain the high standard reached by the earlier volumes; we have only therefore to echo the eulogium pronounced upon them. We would warmly congratulate the editor and his collaborators at the conclusion of their laborious task on the admirable manner in which, from first to last, they have performed their several duties. They have succeeded in producing a work which will long remain a standard work of reference, to which practitioners will look for fuidance, and authors will resort for facts, 'rom a literary point of view, the work is without any serious blomlsh, and in respect of production, it has the beautiful finish that Americans always give their works. — Edinburgh MedicdL Journal, Jan. 1887. * * The greatest distinctively American work on the practice of medicine, and, indeed, the super- lative adjectiv« would not be inappropriate were even all other productions placed in comparison. An examination of the fire volumes is sufficient to convince one of the magnitude of the ent«r- prise, and of the success which has attended its fulfilment.— TAe Medical Age, July 26, 1886. This huge volume forms a fitting close to the great system of medicine which in so short a time has won so high a place in medical literature, and has done such credit to the profession in this country. Among the twenty-three contributors are the names of the leading neurologists in America, and most of the work in the volume is of the highest ordex.— Boston Medical aitd Surgical Journal, July 21, 1887. We consider it one of the grandest works on Practical Medicine in the English language. It is a work of which the profession of this country can feel proud. Written exclusively by American physicians who are acquainted with all the varie- ties of climate in the United States, the character of the soil, the manners and customs of the peo- ple, etc., it is peculiarly adapted to the wante of American practitioners of medicine, and it seems to us that every one of them would desire to have it. It has been truly called a "Complete Library of Practical Medicine," and the general practitioner will require little else in his, round of professional duties. — Cincinnati Medical JVeics, March, 1886. Each of the volumes is provided with a most copious index, and the work altogether promises to be one which will add much to the medical literature of the present century, and reflect great credit upon the scholarship and practical acumen of its authors. — TTie London Lancet, Oct. 3, 1885. The feeling of proud satisfaction with which the American profession sees this, its representative system-of practical medicine issued to the medi- cal world, IS fully justified by the character of the work. The entire caste of the system is in keep- ing with the best thoughts of the leaders and fol- lowers of our home school of medicine, and the combination of the scientific study of disease and the practical application of exact and experimen- tal knowledge to the treatment of human mal- adies, makes every one of us share in the pride that has welcomed Dr. Pepper's labors. Sheared of the prolixity that wearies the readers of the German school, the articles glean these same fields for all that is valuable. It is the outcome of American brains, and is marked throughout by much of the sturdy independence of thought and originality that is a national characteristic. Yet nowhere is there lack of study of the most advanced views of the d&y.— North Carolina Medi- cal Journal, Sept. 1886. 16 Lea Brothers & Co.'s Publications — Clinical Med., etc. FOTSJERGILLf J, M,, M, J)., Edin,, M, B, C. I*,, Lond,, Physician to the City of London Hospital for Diseases of the Chest. The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75 ; leather, $4.75. To have a description of the normal physiologi- cal processes of an organ and of the methods of treatment of its morbid conditions brought together in a single chapter, and the relations between the two clearly stated, cannot fail to prove a great convenience to many thoughtful but busy physicians. The practical value of the volume is greatly increased by the introduction of many prescriptions. That the profession appreciates that the author has undertaken an important work and has accomplished it is shown by the demand for this third edition.— JV. T. Med. Jour., June 11,'87. This is a wonderful book. If there be such a thing as "medicine made easy," this is the work to accomplish this result. — Va. Med. Month., June,'87. It is an excellent, practical work on therapeutics, well arranged and clearly expressed, useful to the student and young practitioner, perhaps even to the old. — Dublin Journal of Medical Science, March, 1888. We do not know a more readable, practical and useful work on the treatment of disease than the one we have now before na.— Pacific Medical and Surgical Journal, October, 1887. VAVGHAN, nCTOJR C, P/i. D., M. JD., Prof. ofPhys. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. and ]!fOrY, FItJE DBBICK G,, M. D. Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. Ptomaines and Leueomaines, or Putrefactive and Physiological Alkaloids. In one handsome 12mo. volume of 311 pages. Just ready. Cloth, $1.75. This book is what has been wanted for some years by the medical profession. The subject of ptomaines and leueomaines, so far as their disease- producing relations are concerned, has been under special study scarcely more than a decade, but within that period facts have been discovered upon which theories of permanent standing have been built, until now the practitioner is far be- hind the times if he does not appreciate the importance of ptomaines. This is the first attempt made to collect into book form the results of observers and experimenters on micro-organisms, and to trace the relationship of cause and effect of the putrefacative alkaloids. We congratulate the autnors upon the successful presentation of the current views ou the subject in such manner as to make them easily comprehensible, while to the practitioner, after he has carefully read the book, it will serve, also, as a frequent reference work, because of the technical information it gives. Va. Medical Monthly, Sept 1888. BBTWOLDS, J, BTISSBLL, M, X>., Professor of the Principles and Practice of Medicine in University College, London. A System of Medicine. With notes and additions by Henr"? Haetshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Eussia, raised bands, $6.50. Per set, cloth, $15; leather, $18. Sold only by subscription. 8TILLB9 ALFUBJDf M, 2)., ii. !>., Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in ttie Univ. of Penna. Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. FUnOATSOJV, JAMBS, M. D., Editor, Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc Clinical Manual for the Study of Medical Cases. With Chapters by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephenson on Diseases of the Female Organs; Dr. Eobertson on Insanity; Dr. GemmeU on Physical Diagnosis; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- taking, Family History and Symptoms of Disorder in the Various Systems. New edition. In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. This manual is one of the most complete and perfect of its kind. It goes thoroughly into the ?uestion of diagnosis from every possible point, t must lead to a thoroughness of observation, an examination in detail of every scientific appliance, and a study of means to the end which cannot fail in laying an excellent foundation for the student for future success as an able diagnostician. —Medical Record, August 13, 1887. FENWICK, SAMUEL, M. J)., Assistant Physician to the London Hospital. The Student's Guide to Medical Diagnosis. From the third revised and enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 87 illustrations on wood. Cloth, $2.25. HABEBSSOJ^, S. O., M, D., Senior Physician to and late Lect. on Principles and Practice of Med. at Ony^s Hospital, London. On the Diseases of the Abdomen ; Comprising those of the Stomach, and other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illu strations. Cloth, $3.50. TANNEB, THOMAS SAWKBS, M, 1>. A Manual of Clinical Medicine and Physical Diagnosis. Third American from the second London edition. Eevised and enlarged by TrLBUBY Fox, M. D. In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 17 BABTSOLOW, BOBEBTS, A, M,, M, X>., ii. J)., Brof. of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. Medical Electricity. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 308 pages, with 110 illustrations. Cloth, $2.50. _ The fact that this work has reached its third edi- tion in six years, and that it has been kept fully abreast with the increasing use and knowledge of electricity,demonstrates its claim to be considered a practical treatise of tried value to the profession. The matter added to the present edition embraces the most recent advances in electrical treatment. The illustrations are abundant and clear, and the work constitutes a full, clear and concise manual well adapted to the needs of both student and practitioner.— TTie Medical News. IMay 14, 1887. This "practical treatise on tne applications of electricity to medicine and surgery" has grown to be so important a work that every practitioner should read it, especially when it is recalled what possibilities lie in the path of the further study of the therapeutics of electricity. Dr. Bartholow has here presented the profession with a concise work that, beginning with elementary descriptions and I)rinciples, gradually grows, page by page, into a niaguificently practical treatise, descrioing opera- tions in detail, and giving records of successes that prove electricity to be marvellous as a curative agent in many forms of disease. The doctor can- not now do better than to possess himself of Dr. Bartholow's treatise, just as it is. — Virginia Medi- cal Monthly, June, 1887. BICSABDSOW, B, W., M.D,, LL. JD., F,B.S,, Fellow of the Royal College of Physicians, London. Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5 ; very handsome half Russia, raised bands, $5.50. Dr. Richardson has succeeded in producing a work which is elevated in conception, comprehen- sive in scope, scientific in cliaracter, systematic in arrangement, and which is written in a clear, con- cise and pleasant manner. He evinces the happy faculty of extracting the pith of what is known on the subject, and of presenting it in a most simple, intelligent and practical form. There is perhaps no similar work written for the general public thatcontains suchacomplet^eliable and instruc- tive collection of data upon me diseases common to the race, their origins, causes, and the measures for their prevention. The descriptions of diseases are clear, chaste and scholarly ; the discussion of the question of disease is comprehensive, masterly and fully abreast with the latest and best knowl- edge on the subject, and the preventive measures advised are accurate, explicit and reliable.— 77ie American Journal of the Medical Sciences, April, 1884. This is a book that will surely find a place on the table of every progressive physician. To the medi- cal profession, whose duty is quite as much to prevent as to cure disease the book will be a boon. — Boston Medical and Surgical Journal, Marcli 6, '84. The treatise contains a vast amount of solid, val- uable hygienic information.— il/edicaJ and Surgical Reporter, Feb. 23, 1884. TSE YEAB-BOOK OF TBEATMENT FOB 1889. A Comprehensive and Critical Review for Practitioners of Medi- cine. In one 12mo. volume of 349 pages, bound in limp cloth, $1.25. Jv^t ready. ^*:^ For special commutations with periodicals see page 2. TME YEAB-BOOK OF TBEATMENT FOB 1887, Similar to above. 12mo., 341 pages. Limp cloth, $1.25. this is one of the most valuable books for its price which is published in this or any coun- try. It contains a summary of the changes in medical practice, the new remedies introduced, and the experience with them and with others which have been longer in use, during the year 1887, made up from the reading and observation of a number of very capable men. The classifica- tion is according to diseases, so that one who con- sults these pages can obtain in a few minutes an excellent idea of the present status of therapeu- tics in regard to any given ailment. The book also has a good index, by means of which the reader may ascertain the diflferent diseases for which any particular drug has been used during the year past. — Medical and Surgical Reporter, April 14, 1888. TME YEAB-BOOK OF TBEATMENT FOB 1886. Similar to that of 1887 above. 12mo., 320 pages. Limp cloth, $1.25. 8CSBEIBEB, DB. JOSEPH. A Manual of Treatment by Massage and Methodical Muscle Ex- ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome octavo volume of 274 pages, with 117 fine engravings. Just ready. Cloth, $2.75. This is a work abounding in common sense, a book that sweeps away a great deal of nonsense by which a simple matter has been made obscure, a volume that ought to be read by every one inter- ested in modern thera])eutics. The work gives admirable directions for the employment of mas- sage, and capital descriptions of methodical exer- cise, after which there is a detailed account of the results of treatment of different diseases by these methods. A full bibliography adds to the value of the volume, which canT)e recommended as one of the best on the subjects with which it deals. — Edinburgh Medical Journal, April, 1888. STURGES' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome 12mo. volume of 127 pages. Cloth, 81.25. DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES. By N. S. Davis. M. D. Edited by Fbank H. Davis, M. D. Second edition. 12mo. 287 pages. Cloth, 81.75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. Cloth, $2.50. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one octavo volume of 238 paces. Cloth, 82.00. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With additions by D. F. Conbie, M. D. 1 vol. 8vo., pp. 603. Cloth, 82.50. CHAMBERS' MANITAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- some octavo volume of 302 pp. Cloth, 82.75. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 18 Lea Brothers & Co.'s Publications — Throat, Liiings, Heart. FLINT, AUSTIN, M. D., Xi. 2>., Profeisor of the iVinctpies and Practice of Medicine in Bellevue Hospital Medical College, N. Y. A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fourth edition. In one handsome royal 12mo. volume of 278 pages, Avith 14 illustrations. Cloth, $1.75. The original work done by Dr. Flint in the devel- opment of the art of physical diagnosis will always make this manual an authority on this subject. Among all the works issued on this topic during the last few years, none exceeds this one in sim- plicity and completeness. The fact that it has passed through four editions attests its popularity. There is a tendency among physical diagnosti- cians to make altogether too many varieties of morbid chest sounds, and especially of rales. The conciseness of Dr. Flint's Manual is one of its chief advantages — Medical Record, June 10, 1888. B7 THE SAME AUTHOR. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, $4. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 pages. Cloth, $1.38. BBOWKE, LJENNOX, F. B. C, S., E,, Senior Physician to the Central London Throat and Ear Hospital. A Practical Guide to Diseases of the Throat and Nose, including Associated Affections of the Ear. With 120 illustrations in color, and 200 en- gravings on wood designed and executed by the Author. New (second) and enlarged edition. In one imperial octavo volume of 628 pages. Cloth, $6. Mr. Browne's book can be recommended to students and still more to practitioners as a clear, sound and practical guide to the diagnosis and treatment of diseases of the throat. His experi- ence is not only large, but ripe, and he gives his readers the full benefit of it. A particularly praise- worthy feature is that from beginning to end Mr. Browne, whilst giving due prominence to local measures, never fails to insist on the necessity of supplementing these by proper constitutional treatment. — London Medical Recorder, May, 1888. SEILEB, CABL, M, 2)., Lecturer on Laryngoscopy in the University of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. Just ready. Few medical writers surpass this author in ability to make his meaning perfectly clear In a few words, and in discrimination in selection, both of topics and methods. The book deserves a large sale, especially among general practitioners — Chi- cago Medical Journal and Examiner, April, 1889. GBOSS, S. D., M,D., LL.I>., D.CL. Oxon., LL.I>. Cantab, A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. COHEN, J. SOUS, M, 2)., Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third edition, thoroughly revised and rewritten, with a large number of new illustrations. In one very handsome octavo volume. Preparing. BBOADBENT, W. M., M. D., F. B. C. F,, Physician to and Lecturer on Medicine at St. Mary's Hospital. The Pulse. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. FULLER ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Di- agnosis, Symptoms and Treatment. From the second and revised English edition. In one octavo volume of 475 pages. Cloth, $3.50. WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edi- tion. In 1 vol. 8vo.. 416 pp. Cloth, 83.00. BLADE ON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Second and revised edition. In one 12mo. vol., pp. 158. Cloth, §1.25. SMITH ON CONSUMPTION ; its Early and Reme- diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 pages. Cloth, $3.00. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. V/ith an analysis of one thousand cases to exemplify ita duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19 MOSS, JAMES, M.n., F.B.C.P., LL.D., Senior Assistant Physician to the Manchester Royal Infirmary. A Handbook on Diseases of the Nervous System. In one volume of 725 pages, with 184 illustrations. Clotli, $4.50 ; leather, $5.50. This admirable work is intended for students of medicine and for suchi medical men as have no time for length)' treatises. In tlie present instance the duty of arranging the vast store of material at the disposal of the author, and of abridging the de- scription of the different aspects of nervous dis- eases, has been performed vcith singular skill, and the result is a concise and philosophical guide to octavo the department of medicine of which it treats. Dr. Ross holds such a high scientific position that any writings which bear his name are naturallv expected to liave the impress of a powerful intel- lect. In every part this handbook merits the highest praise, and will no doubt be found of the greatest valueto the student as well as to the prac- titioner. — Edinburgh MedicalJournal, Jan. 1887. MITCSBLL, S, WJEin, M, D., Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. Lectures on Diseases of the Nervous System; Especially in Women. Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. No work in ouc language develops or displays more features of that many-sided affection, hys- teria, or gives clearer directions for its differen- tiation, or sounder suggestions relative to its general management and treatment. The book IS particularly valuable in that it represents in the main the author's own clinical studies, which have been so extensive and fruitful as to give iiis teachings the stamp of authority all over the realm of medicine. The work, although written by a specialist, has no exclusive character, and the general practitioner above all others will find its perusal profitable, since it deals with diseases which he frequently encounters and must essay to treat. — A7nerican Practitioner, August, 1885. SAMIZTOW, ALL AW McLANJE, M. J),, Attending Physician at the Hospital for Epileptics and Paralytics, BlaekweU's Island, N. T. Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. characterized this book as the best of its kind in When the first edition of this good book appeared we gave it our emphatic endorsement, and the present edition enhances our appreciation of the book and its author as a safe guide to students of clinical neurology. One of the best and most critical of English neurologicaljournals, Brain, has any language, which is a handsome endorsement from an exalted source. The improvements in the new edition, and the additions to it, will justify its purchase even by those who possess the old. — Alienist and Neurologist, April, 1882. TVKB, I>ANTEL BLACK, M. D., Joint Author of The Manual of Psychological Medicine, etc. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. New edition. Thoroughly re^yised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, 1 It is impossible to peruse these interesting chap- ters without being convinced of the author's per- fect sincerity, impartiality, and thorough mental grasp. Dr. Tuke has exhibited the requisite amount of scientific address on all occasions, and the more intricate the phenomena the more firmly has he adhered to a physiological and rational method of interpretation. Guided by an enlight- ened deduction, the author has reclaimed for science a most interesting domain in psychology, previously abandoned to charlatans and empirics. This book, well conceived and well written, must commend itself to every thoughtful understand- ing. — New York Medical Journal, September 6, 1884. CLOUSTOW, TSOMAS S., M. D,, F, M. C. P., i. M. C, S., Lecturer on Mental Diseases in the University of Edinburgh. Clinical Lectures on Mental Diseases. With an Appendix, containing an Abstract of the Statutes of the United States and of the Several States and Territories re- lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume oi 541 pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. The practitioner as well as the student will ac- cept the plain, practical teaching of the author as a forward step in the literature of insanity. It is refreshing to find a physician of Dr. Clouston's experience and high reputation fifing the bed- side notes upon which his experience has been founded and his mature judgment established. Such clinical observations cannot but be useful to the general practitioner in guiding him to a diag- nosis and indicating the treatment, especially in many obscure and cfoubtful cases of mental dis- ease. To the American reader Dr. Folsom's Ap- pendix adds greatly to the value of the work, and will miiie it a desirable addition to every library. — American Psychological Jownal, July, 1884. 108 pages. •. Folsom's Abstract may also be obtained separately in one octavo volume of Cloth, $1.50. SAVAGE, GEORGE S,, M, D., Lecturer on Mental Diseases at Cfuy's Hospital, London. Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 4. BLAYFAIM, W. S,, M, D., F, M. C. JP. The Systematic Treatment of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, $1.00. Blandford on Insanity and its Treatment: Lectures on the Treatment, Medical and Legal, of Insane Patients. In one very handsome octavo volume. Jones' Clinical Observations on Functional Nervous Disorders. Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25. 20 Lea Brothers & Co.'s Publications — Surgery. ASHJBCURST, JOSN, Jr., M, D,, Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. The Principles and Practice of Surgery. New (fourth) edition, enlarged and revised. In one large and handsome octavo volume of 1114 pages, with 597 illustra- tions. Cloth, $6 ; leather, $7. As with Erichsen so with Ashhurst, its position in professional favor is established, and one has now but to notice the changes, if any, in theory and practice, that are apparent in the present as compared with the preceding edition, published three years ago. The work has been brought well up to date, and is larger and better illustrated than before, and its author may rest assured that it will certainly have a "continuance of the favor with which it has heretofore been received." — The American Journal of the Medical Sciences, Jan. 1886. Every advance in surgery worth notice, chroni- cled in recent literature, has been suitably recog- nized and noted in its proper place. Suffice It fo say, we regard Ashhurst's Surgery, as now pre- sented in the fourth edition, as the best single volume on surgery published in the English lan- guage, valuable alike to the student and the prac- titioner, to the one as a text-book, to the other as a manual of practical surgery. With pleasure we give this volume our endorsement in full. — New Orleans Medical and Surgical Journal, Jan., 1886. GJROSS, S, n,, M, n,, LL, D,, D. a L. Oxon,, LL, n. Cantab., Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings; Strongly bound in leather, raised bands, $15, Dr. Gross' System of Surgery has long been the standard work on that subject for students and practitioners. — London Lancet, May 10, 1884. The work as a whole needs no commendation Many years ago it earned for itself the enviable reputation of the leading American work on sur- gery, and it is still capable of maintaining that standard. A consideraole amount of new material has been introduced, and altogether the distin- guished author has reason to be satisfied that he has placed the work fully abreast of the state of our knowledge.— ilfed. Becord, Nov. 18, 1882. His System of Surgery, which, since its first edi- tion in 1859, nas been a standard work in this country as well as in America, in "the whole domain of surgery," tells how earaest and labori- ous and wise a surgeon he was. how thoroughly he appreciated the work done by men in other countries, and how much he contributed to pro- mote the science and practice of surgery in his own. There has been no man to whom America is so much indebted in this respect as the Nestor of snTgery.— British Medical Journal, May 10, 1884. DJRUITT, BOBBItT, 31. B. C. S., etc. Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- ley Boyd, M. B., B. S., F. E. C. S. In one 8vo. volume of 965 pages, with 373 illustra- tions. Cloth, $4 ; leather, $5. It is essentially a new book, rewritten from be- ginning to end. The editor has brought his work up to the lat«st date, and nearly every subject on wnich the student and practitioner would desire to consult a surgical volume, has found its place here. The volume closes with about twenty pages of formulee covering a broad range of practical therapeutics. Th( student will find that the new Druitt is to this generation what the old one was to the former, and no higher praise need be accorded to any volume. — North Carolina Medical Journal, October, 1887. Druitt's Surgery has been an exceedingly popu- lar work in the profession. It is stated that 50,000 copies have been sold in England, while in the United States, ever since its first issue, it has been used as a text-book to a very large extent. Dur- ing the late war in this country it was so highly appreciated that a copy W£ks issued by the Govern- ment to each surgeon. The present edition, while it has the same features peculiar to the work at first, embodies all recent discoveries in surgery, and is fully up to the times. Cincinnati 3Ieaieal News, September, 1887. BALL, CBLABLBS B., M. Ch., Bub., F. B. C. S. E., Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. Diseases of the Rectum and Anus. In one 12mo. volume of 417 pages, with 54 engravings and 4 colored plates. Cloth, $2.25. Just ready. See Series of Clinical Manuals, page 4. It is a pleasure to read an exhaustive and well- arranged book, such as the one before us. It covers all the ground, and yet is written in a terse and concise style that makes it exceedingly good reading. The work is far in advance of the ordi- nary text-book on this specialty. It is very com- plete, and the matter is all of practical importance and well arranged. The writer has done for rectal surgery what Treves in the companion volume has done for intestinal obstruction, and both works are alike creditable. — N. Y. Medical Journal, Jan. 28, 1888. A capital book in a capital series of clinical manuals. Thoroughly practical, it is both compre- hensive and condensed and the possessor of it will find but little use for any more extended work on the subject. Mr. Ball is a most sound surgeon.— The Medical News, Feb. 4, 1888. GIBNJEY, V. JP., M. D., Surgeon to the Orthopaedic Hospital, New York, etc. Orthopaedic Surgery. For the use of Practitioners and Students. In one hand- some octavo volume, profusely illustrated. Preparing. BOBJEBTS, J. B., M. D., and MOBTOJ^, T. S. K., M. X>., Professor of Anatomy and Surgery in the Adjunct Professor of Operative Surgery in the Philadelphia\Polyclimc. Philadelphia Polyclinic. The Principles and Practice of Modern Surgery. For the use of Students and Practitioners of ^ledicine and Surgery. In one very handsome octavo volume of about 500 pages, with many illustrations. Preparing. Lea Brothers & Co.'s Publications — Surgery. 21 EHICHSEN, JOHN JE., F, B, S., F, JR. C. S,, Professor of Surgery in University College, London, etc. The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- eases and Operations. From the eighth and enlarged English edition. In two large and beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. Cloth, $9; leather, raised bands, |11 We have always regarded "The Science and Art of Surgery" as one of the best surgical text- books in the English language, and this eighth edition only confirms our previous opinion. We take great pleasure in cordially commending it to our readers. — The Medical Neios, April 11, 1885. For many years this classic work has been made by preference of teachers the principal text-book on surgery for medical studenis, while through translations into the leading continental languages it may be said to guide the surgical teachings of the civilized world. No excellence of the former edition has been dropped and no discovery, device or improvement which has marked the progress of surgery during the last decade has been omitted. The illustrations are many and executed in the highest style of art. — Louisville Medical News, Feb. 14, 1885. We cannot speak too highly of this excellent work. It represents the most ad vanced and settled views in regard to the science of surgery, and will ever be found a faithful guide and counsellor in practice. — Canada Lancet, May, 1885. It appears simultaneously in England, America, Spain and Italy, and is too well known as a safe guide and familiar friend to need further com- ment.— iVew York Medical Journal, March 28, 1885. BBTAJSTT, THOMAS, F, B. C. S,, Surgeon and Lecturer on Surgery at Gfuy^s Hospital, London. • The Practice of Surgery. Fourth American from the fourth and revised Eng- lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 727 illustrations. Cloth, $6.50 ; leather, $7.50. The fourth edition of this work is fully abreast of the times. The author handles his subjects with that degree of judgment and skill which is attained by years of patient toil and varied ex- perience. The present edition is a thorough re- vision of those which preceded it, with much new matter added. His diction is so graceful and logical, and hia explanations are so lucid, as to place the work among the highest order of text- books for the medical student. Almost every topic in surgery is presented in such a form as to enable the busy practitioner to review any subject in every-day practice in a short time. No time is lost with useless theories or superfluous verbiage. In short, the work is eminently clear, logical and practical. — Chicago Medical Journal and Examiner, April, 1886. This book is essentially what it purports to be, viz.: a manual for the practice of surgery. It is peculiarly wel! fitted for the student or busy general practitioner.— TAe Medical News, August 15, 1885. TBEVES, FBEDBBICK, F, M. C. S., Eunterian Professor at the Royal College of Surgeons of England. A Manual of Surgery. _ In Treatises by Various Authors. In three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See Students' Series of Manuals, page 4. the salient points and the beginnings of new sub- jects are always printed in extra-heavy type, so that a person may find whatever information he may be in need of at a moment's glance. — Oin- cinnati Lancet-Clinic, August 21, 1886. We have here the opinions of thirty-three authors, in an encyclopsedic form for easy and ready reference. The three volumes embrace every variety of surgical aflfections likely to be met with, the paragraphs are short and pithy, and MABSS, MOWABD, F, JR, O. S,, Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Mamuals, page 4. BUTLIN, SFJVBT T., F. B. C. S., Assistant Surgeon to St. Bartholomew's Hospital, London. Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 4. The language of the text is clear and concise. The author has aimed to state facts rather than to express opinions, and has compressed within the compass of this small volume tne pathology, etiol- ogy, etc., of diseases of the tongue that are incon- veniently scattered through general works on sur- gery and the practice of medicine. The physician and surgeon will appreciate its value as an aid and gm&e.—Physician and Surgeon, Sept. 1886. TBEVES, FBEDEBICK, F. B, C. S., Surgeon to and Lecturer on Surgery at the Loixdon Hospital. Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 illustrations. Limp cloth, blue edges, $2.00. A standard work on a subject that has not been so comprehensively treated by any contemporary English writer. Its completeness renders a full review difficult, since every chapter deserves mi- nute attention, and it is impossible to do thorough See Series of Clinical Manuals, page 4. justice to the author in a few paragraphs. Intes- tinal Obstruction is a work that will prove of equal value to the practitioner, the student, the pathologist, the physician and the operating sur- geon.— £ri«usA Medical Journal, Jan. 31, 1885. GOUZJD, A, BEABCE, M. S., M, B,, F. B, C. S., Assistant Surgeon to Middlesex Hospital. Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 pages. Cloth, $2.00. See Students' Series of Manuals, page 4. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D. In one 8vo. vol. of 784 pp. with 316 illus. Cloth, 83.75. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh edition. In one 8vo. vol. of 638 pages, with 340 illustrations. Cloth, 33.75. MILLER'S PRACTICE OP SURGERY. Fourth and revised American edition. In one large 8vo. vol. of 682 pp., with 364 Illustrations. Cloth, $3.75» 22 Lea Brothers & Co.'s Pttblioations — Surgery, Frac., Dlsloc. SMITH, STEPHEN, M, D., ProfcsHor of Clhiical /SiirQtn/ in the Universih/ of the dtf/ of New York. The Principles and Practice of Operative SurgexTr. New (second) and thoronglily revised edition. In one very liandsorae octavo volume of 892 pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00, This excellent and very valuable hook is one of the most satisfactory works on modern operative surgery yet published. Its author and publisher have spared no pains to make it as far as possible an ideal, and their efforts have given it a position prominent among the recent works in this depart- ment of surgery. The book is a compendium for the modern surgeon. The present, the only revised edition since 1879, presents many changes from the original manual. The volume is much en- larged, and the text has been thoroughly revised, 60 as to give the most improved methods in asep- tic surgery, and the latest instruments known foi operative work. Itcan be truly said thatas ahand- book for the student, acompanion forthe surgeon, and even as a hook of reference for the physician not especially engaged in the practice or surgery, this volume will long hold a most conspicuous place, and seldom will its readers, no matter how unusual the sul>ject, consult its pages in vain. Its compact form, excellent print, numerous illustra- tions, and especially its decidedly practical char- acter, all combine to commend it. — Boston Medical and Surgical Journal, May 10, 1888. HOLMES, TI3IOTHY, M, A., Surgeon and Lecturer on Surgery at St. George's JTospital, London. A Treatise on Surgery ; Its Principles and Practice. New American from the fifth English edition, edited by T. Pickering Pick, F. K. C. S., Surgeon and Lecturer on Surgery at St. George's Hospital, London. In one octavo volume of 997 pages, with. 428 illustrations. Cloth, $6 ; leather, $7. Jtcst ready. To the younger members of the profession and toothers not acquainted with the book and its merits, we take pleasure in recommending it as a surgery complete, thorough, well-written, fully illustrated, modern, a work sufficiently volumi- nous for the surgeon specialist, adequately concise for the general practitioner, teaching those things that are necessary to be known for tne successful prosecution of the physician's career, imparting nothing that in our present knowledge is consid- ered unsafe, unscientific or inexpedient. — Pacific Medical Journal, July, 1889. HOLMES, TIMOTHY, M. A,, Surgeon and Lecturer on Surgerv at St. George's Hospital, London. A System of Surgery; Theoretical and Practical. IN TREATISES BY VARIOUS AUTHORS. American edition, thoroughly revised and re-edited by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. Li three large imperial octavo volumes containing 3137 double-columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per set, cloth, $18.00; leather, $21.00. Sold only by syhscription. STIMSON, LEWIS A., B, A., M, D., Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical Faculty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgie of Paris. A Manual of Operative Surgery. New (second) edition. In one very hand- some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. There is always room for a good book, so that while many works on operative surgery must be considered superfluous, that of Dr. Stimson has held its own. The author knows the difficult art of condensation. Thus the manual serves as a work of reference, and at the same time as a handy guide. It teaches what it professes, the steps of operations. In this edition Dr. Stimson has sought to indicate the changes that have been effected in operative methods and procedures by the antiseptic system, and has added an account of many new operations and variations in the steps of older operations. We do not desire to extol this manual above many excellent standard British publications of the same class, still we be- lieve that it contains much that is worthy of imi- tation. — British Medical Journal, Jan. 22, 1887. By the same Author. A Treatise on Fractures and Dislocations. In two handsome octavo vol- umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- tions, 540 pages, with 163 illustrations. Complete work jxist ready, cloth, $5.50 ; leather, $7.50. Either volume separately, cloth, $3.00; leather, $4.00. The appearance of the second volume marks the completion of the author's original plan of prepar- ing a work which should present in the fullest manner all that is known on the cognate subjects of Fractures and Dislocations. The volume on Fracturesassumedatoncetfheposition of authority on the subject, and its companion on Dislocations will no doubt be similarly received. The closing volume of Dr. Stimson's work exhibits the surgery | of Dislocations as it is taught and practised by the most eminent surgeons of the present time. Con- taining the results of such extended researches It must for a long time be regarded as an authority on all subjects pertaining to dislocations. Every practitioner of surgery will feel it incumbent on nim to have it for constant reference. — Cincinnati Medical News, May, 1888. HAMILTON, FRANK H., M. D., LL. 2)., Surgeon to Bellevue Hospital, New York. A Practical Treatise on Fractures and Dislocations. Seventh edition thoroughly revised and much improved. In one very handsome octavo volume of 998 pages, with 379 illustrations. Cloth, $5.50: leather, $6.50. This book is without a rival in any language. It is essentially a practical treatise, and it gathers within its covers almost everything valuable that has been written about fractures and dislocations. The principles and methods of treatment are very fully given. The book is so well known that it does not require any lengthened review. We can only say that it is still unapproached as a treatise. — The Dublin Journal of Medical Science, Feb. 1886. I'ICK, T, PICKERING, F. B, C, S., Surgeon to and Lecturer on Surgery at St. George's Hospital, London. Fractures and Dislocations. In one 12mo. volume of 530 pages, with 9S illustrations. Limp cloth, $2.00. See Series of Qinical Manimls, page 4. Lea Brothers & Co.'s Publications — Otol., Ophtlial. 23 BVRNBTT, C HAULMS II., A. 31., 31. 2>., ProfcjiS'fr of Otology in the Philaiielphin Polyclinic; Prcsiilcnt of the American OtoUigical Society. The Ear, Its Anatomy, Physiology and Diseases. A Pmctical Treatise for the i!se of Mnlical Htiiilents and Practitioners. Second editifin. In one liandsf)nie octavo volume of oSU pages, with 107 ilhistrations. Cloth, $4.00; leather, $5.00. We note with pleasure the appearance of R second ] rnrripd out, and much new matter added. Dr. edition of tliin vaUiahle work. When it first came | Hiirnett's work must he re);ardcd as a very vahia- OUt it was accepted hy the profession as one of 1 hie contribution to aural surgery, not only oi> the standard works on modern aural surgery the Knglish lanKuaxc; and in his secoml edition I>r. Burnett ha.s fully maintained his reputation, for the hook is replete with valuable information and sui., Lecturer ou Medicine i»i the Manchester iSchnol of Mettieine, etc. A Practical Treatise on Urinary and Renal Diseases, including Uri- nary Deposits. Fourth American from tlie fourth London etlition. In one hand- some octavo volume of 609 p:iges, with 81 illustrations. Cloth, $3.50. It may be said to be the best book In print on the subject of which it treats. — The American Journal of the Medical Sciences, Jan. 1886. The peculiar value and finish of the book are In a measure derived from its resolute maintenance of a clinical and practical character. It is an un- rivalled exposition of everything which relates directly or indirectly to the diagnosis, prognosis and treatment of urinary diseases, and possesses a completeness not found elsewhere in our lan- guage In its account of the different affectionB. — The Manchester Medical Chronicle, July, ISS.'J. The value of this treatise as a guide oook to the physician in daily practice can hardly be over- estimated. That It 18 fully up to the level of our present knowledge is a fact reflecting grfat credit upon Dr. Roberts, who has a wide reputation as a busy practitioner. — The Medical Record, July 31, 1886. JPURDT, CHARLES TF., M, Z>., CMcar/o. Bright's Disease and Allied Affections of the Kidneys. In one octavo volume of 288 pages, with illustrations. Cloth, $2. The object of this work is to "furnish a system- atic, practical and concise description of the Sathoiogy and treatment of the chief organic iseases of the kidney associated with albuminu- ria, whicli shall represent the most recent ad- vances in our knowledge on these subjects ;" and this definition of the object is a fair description of the book. The work is a useful one, giving in a short space the theories, facts and treatments, and going more fully into their later developments. On treatment the writer is particularly strong, steering clear of generalities, and seldom omit- ting, what text-booKs usually do, the unimportant items which are ah important to the general prac- titioner.— TAe Manchester Medical Chronicle, Oct 188G. MORRIS, SENRY, M, B., F, R, C, S., Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. Surgical Diseases of the Kidney. woodcuts, and 6 colored plates. Limp cloth, ^ In this manual we have a distinct addition to I surgical literature, which gives information not elsewhere to be met with in a single work. Such a book was distinctly required, and Mr. Morris has very diligently and ably performed the task | In one 12mo. volume of 554 pages, with 40 )2.25. See Series of Clinical Manuals, page 4. he took in hand. It is a full and trustworthy book of reference, both for students and prac- titioners in search of guidance. The illustrations in the text and the chromo-lithographs are beau- tifully executed.— r/jel/ondo/t Lancet, Feb. 26, 1886. See Series LUCAS, CLEMEWT, M, B., B, S,, F. R. C. S., Senior Assistant Surgeon to Ouy^s Hospital, London. Diseases of the Urethra. In one 12mo. volume. Preparing, of Clinical Manuals, page 4. ^^ TH03IFS0N, SIR LLENRY, Surgeon and Professor of Clinical Surgery to University CoUege Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one Svo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Fistulas. From the third English edition. In one octavo volume of 359 pages, with 47 cuts and 3 plates. Cloth, $3.50. TSE AMERICAN SYSTEM OF DENTISTRY, In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- taining 3160 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6 ; leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by svhscription only. As an encyclopaedia of Dentistry it has no su- perior. It should form a part of every dentist's library, as the information it contains is of the greatest value to all engaged in the practice of dentistry. — American Jour. Dent. Set., Sept. 1886. A grand system, big enough and good enough and handsome enough for a monument (which doubtless it is), to mark an epoch in the history of dentistry. Dentists will be satisfied with it and proud of it — they must. It is sure to be precisely what the student needs to put him and keep him In the ri^ht track, while tne profession at large will receive incalculable benefit from ii.—Odonta- graphic Journal, Jan. 1887. COLEMAN, A,, L, R, C, F,, F, R. C. S., Exam. L. D. S., Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hasp, and the Dent. Hasp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. It should be in the possession of every practi- tioner in this country. The part devoted to first and second dentition and irregularities in the per- manent teeth is fully worth the price. In fact, price should not be considered in purchasing such a work. If the money put into some of our sci- called standard text-books could be converted into such publications as this, much good would result. —Southern Dental Journal, May, 1882. The author brings to his task a large experience acquired under the most favorable circumstances. There have been added to the volume a hundred pages by the American editor, embodying the views of the leading home teachers in dental sur- gery. The work, therefore, may be regarded as strictly abretist of the times, and as a very high authority on the subjects of which it treats. — American Practitioner, July, 1882. BASHAM ON RENAL DISEASES: A Clinical Guide to their Diagnosis and Treatment. In one 12mo. vol. of 304 pages, with 21 illostratlODS. Cloth, 82.00. Lea Brothers & Co.'s Publications — Venereal, Impotence. 25 GJROSS, SAMUEL W., A, M,, M, D., LL. D., Professor of the Principlcn of Surgery and of Clinical Surgery in the Jeffernon Mclicnl College of Philn. A Practical Treatise on Inapotence, Sterility, and Allied Disorders of the Male Sexual Organs. New (third) edition, tlioruuglily revised. In one very handsome octavo volume of 163 pages, with 16 illustrations. Cloth, $1.50. It must be gratifying to both author and pub- lishers that large first and .second editions of this little work were so soon exhausted, while the fact that it liiis befn translated into Russian may indi- cate that it filled a void even in foreign literature. His is a careful and physiologioal study of the Bexual act, so far as concerns the male, and all his conclusions are scientifically reached. The book has a place by itself in our literature, and furnishes a large fund of information concerning important matters that are too often passed over in silence. — The Medical Press, June, 1887. Thi.H now classical work on tlio subject of Impo- tence and sterility in the male needs no eztenaed review, for it is already well known to the f/ro- fession. Dr. Gross has by his tireless labor done more towards clearing up the diagnosis and treat- mentof these obscure cases than any other Ameri- can i)hy8ician. The fact that this book has rapidly run through two large edit ions, and that the author is now forced to issue a third, is good and sufficient evidence of its excellence. — Atlanta Medical and Surgical Journal, April, 1888. TAYLOJR, a, W,, A, M,, M. J>., Surgeon to Cfiarity Hospital, New York, Prof, of Venereal and Skin Diseases in the University of Vermont, Pres. of the Am. Dermatological Ass'n. The Pathologjr and Treatment of Venereal Diseases. Including the results of recent investigations upon the subject. Being the sixth edition of Bumstead and Taylor. Entirely rewritten by Dr. Taylor. Large and handsome 8vfi. volume, about 900 pages, with about 150 engravings, as well as numerous chromo-lithographs. Preparinr/. A few notices of the previous edition are appended. It is a splendid record of honest labor, wide research, just comparison, careful scrutiny and original experience, which will always be held as a high credit to American medical literature. This is not only the best work in the English language upon the subjects of which it treats, but also one wnich has no equal in other tongues for its clear, comprehensive and practical handling of its themes. — Am. Jour, of the Med. Sciences, Jan, 1884. It is certainly the best single treatise on vene- re' in our own, and probably the best in any lan- guage. — Boston Med. and Sicrg. Journal, April 3, 1884. The character of this standard work is 80 well known that it would be superfluous here to pass In review its general or special points of excellence. The verdict of the profession has been passed; it has been accepted as the most thorough and com- plete exposition of the pathology and treatment of venereal diseases in the language. Admirable as a model of clear description, an exponent of sound pathological doctrine, and a guide for rational and successful treatment, it is an ornament to the medi- cal literature of this country. The additions made to the present edition are eminently judicious from the standpoint of practical utility. — Joumalof Cutaneous and Venereal LHsecises, Jan. 1884. COMNIL, F., Professor to the Faculty of Medicine of Paris, and Physician to the Loureine Hospital. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially revised by the Author, and translated with notes and additions by J. Henky C. Simes, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery in the University of Pennsylvania, In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. perusal without the feeling that his grasp of the wide and important subject on which it treats is stronger and surer one. — The London Practi- The anatomy, the histology, the pathology and the clinical features of syphilis are represented in this work in their best, most practical and most inatructive form, and no one will rise from its tioner, Jan. 1882. MTITCSIWSON, JOWATSAN, F, B. S,, F, JR. C, S,, Consulting Surgeon to the London Hospital. Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. $2,25. See Series of Clinical Manuals, page 4. Cloth, Those who have seen most of the disease and those who have felt the real difficulties of diagno- sis and treatment will most highly appreciate the facts and suggestions which abound in these pages. It is a worthy and valuable record, not only of Mr. Hutchinson's very large experience and power of observation, hut of his patience and assiduity in taking notes of his cases and keep- ing them in a form available for such excellent use as he has put them to in this volume. — London Medical Record, Nov. 12, 1887, GROSS, S, JD,, M. D., LL. D., D. C, L., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised by Samuel W. Gkoss, M. D. In one octavo volimie of 574 pages, with 170 illustrations. Cloth, $4.50, CUZLFJRIFH, a., & BUMSTFAD, F. J., 3I.D., ll.b., Surgeon to the H6pital du Midi. Late Professor of Venereal Diseases in the College of Physician* and Surgeons, JV'eu) York. An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- stead, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Strongly bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 eta. HILL ON SYPHILIS AND LOCAL CONTAGIOUS I FORMS OF LOCAL DISEASE AFFECTING DISORDERS. In one 8vo vol. of 479 p. Cloth, 83.26. I PRINCIPALLY THE ORGANS OF GENERA- LEE'a LECTURES ON SYPHILIS AND SOME 1 TION. In one Svo. vol. of 246 pages. Cloth, 82.26. 26 Lea BaoTHEEs & Co.'s Publications — Venereal, Skiii. TATLOB, ROBERT W., A.M., M.D., Surgeon In Chnrit'i Uospilnl, New York, and lo the Department of Venereal and Skin Ditetuet of the'.\tio V'jrk Jl'/^rnlal. A Clinical Atlas of "Venereal and Skin Diseases: Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 68 beautifully-colored plates with 184 figures, and 42-5 pages of text with 85 engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, half Russia, $27; half Turkey Morocco, $28. For sale by subscriplion only. Specimen plates sent on receipt of 10 cents. A full prospectus sent to any address on application. This magnificent CUnicnl Atlas, we donothesi- j recognized su^ a standard »ulhority on its subjects, tate to say, will be regarded as one of the most The strong fnith of its publishers in the merit valuable and handsome contributions to the medi- and wide appreciation which they must feel cal literature of the age. As its name implies, the | assured awaits the Clinical Atlas at the hands of a Clinical Atlas is intended as a working guide for j discriminating medical public is evidenced by any practitioner who chooses to deal with the wide- j the very moderate figure at which it is supplied, a spread class of chronic diseases included in its '' figure so much below that customarily charged title. For the adequate accomplishment of its | for works of this class that only the widest tlis- fiurpose such a work must comprise pictures, life- I semination can possibly bring them a fair return ike in form and color, of a size as large as is com- i for their evidently lavish outlay. — Southern Prac- patible with convenience, together with a descrip- litioner,S&pt., 1888. tire, clinical and didactic text. The entire litera- Viewing this collection as awhole it may be said ture of the subjects has baen searched for its best ] that it is difficult to overestimate its clinical value illustrations, and selections made with proper permission of living authors. These have been complemented by numerous reproductions from a collection of original paintings from life, gathered by the author during many years of practice. The text tias been designed to furnish the practitioner with clear and explicit directions for the proper management of his csises, and at the same time to stimulate the interest of those who may wish to devote their life-work to these subjects. A full statement of the clinical history, varying features, etiology, diagnosis, and prognosis has therefore been followed by definite and complete thera- peutical information. In their respective spheres the author and publishers have left nothing undone to make the Clinical Atlas a work which will be to the practitioner and diagnostician. A careful study of even the smallest of these portraits of disease will repay the student. Their practical value in teaching is exactly proportioned to their faithfulness to fact. In the important matters of etiology and treatment, the author is as lucid and practical as might be anticipated from one of his experience and previous contributions to derma- tological literature. Dr. Taylor's Atlas is to be warmly commended to the expert, the general practitioner, and the student, as an invaluable aid in acquiring a knowledge of the subjects illus- trated, combining in a high degree the advantages of a sound text-book, with the special assistance of colored illustrations. — The ATnerican Journal of the Medical Sciences, April, 1889. MYDJE, J. mSVINS, A. M., M. D., Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50 ; leather, $5.50. Just ready. We can heartily commend it, not only as an admirable texi^book for teacher and student, but in its clear and comprehensive rules for diagnosis, its sound and independent doctrines in pathology, and its minute and judicious directions for the treatment of di.^ease, as a most satisfactory and complete practical guide for the physician.— .4 7«ert- can Journal of the Medical Sciences, July, 1888. A useful glossary descriptive of terms is given. The descriptive portions of this work are plain and easily understood, and above all are very accurate. The therapeutical part is abundantly supplied with excellent recommendations. The picture part is well done. Tlie value of the work to practitioners is great because of the excellence of the descriptions, the suggestiveness of the advice, and the correctness of the details and the principles of therapeutics impressed upon the Te&der.— Viy ginia Med. Monthly, May, 1888. The second edition of his treatise is like his clinical instruction, admirably arranged, attractive in diction, and, strikingly practical throughout. The chapter on general symptomatology is a model in its way ; no clearer description of the various Erimary and consecutive lesions of the .skin is to e met with anywhere. Those on general diagno- sis and therapeutics are also worthy of careful study. Dr. Hyde has shown himself a compre- hensive re(»der of the latest literature, and has in- corporated into his book all the best of that which the past years have brought forth. The prescrip- tions and formulae are given in both common and metric systems. Text and illustrations are good, and colored plates of rare cases lend additional attractions. Altogether it is a work exactly fitted to the needs of a general practitioner, and no one will make a mistake in purchasing it. — Medical Press of Western JS'ew York, June, 1888. FOX, T., M. D., F.B. C. JP., and FOX, T. C, B.A., M.B. C.S., Physician to the Departvient for Skin Diseases, Physician for Diseases of the Skin to the University College Hospital, London. Westminster Hospital, London. An Epitome of Skin Diseases. With Formulae. For Students and Prac- titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume of 238 pages. Cloth, $1 .25. The third edition of this convenient handbook I manual to He upon the table for instant reference, calls for notice owing to the revision and expansion 1 Its alphabetical arrangement is suited to this use, which it has undergone. The arrangement of skin disea-ses in alphaVietical order, which is the method of classification adopted in this work, becomes a positive advantage to the student. The book is one which we can strongly recommend, not only for all one htus to know is the name of the disease, and here are its description and the appropriate treatment at hand and ready for instant applica- tion. The present edition has been very carefully revised and a number of new diseases are de- to students but also to practitioners who require a I scribed, while most of the recent additions to compendious summary of the present state of dermal therapeutics find mention, and the formu- dermatologv.— £ri7(.sA 'Medical Journal, July 2, 1883. ' lary at the end of the book has been considerably We cordially recommend Fox's Epitome to those | augmented.— T/ie J/edicaJ News, December, 1883. whose time is limited and who wish a handy | WILSON, EBAS3IUS, F.B.S. The Student's Book of Cutaneous Medicine andDiseases of the Skitu Tn one handsome small octavo volume of 535 pages. Cloth, $3.50. HILLTER'S HANDBOOK OF .SKIX DISEASES; for Students and Practitioners. Second Ameri- can edition, with plates. In one 12mo. volume of 353 pages. Cloth, S2.2o. Lea Brothers & Co.'s Publications — Dis. of Women. 27 The American Systems of Gynecology and Obstetrics. Systems of Gynecology and Obstetrics, in Treatises by American Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics and Gynecology in the Medical Department of the University of Buffalo; and Obstet- rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- taining 3612 pages, 1092 engravings and 8 plates. Complete work juat ready. Per vol- ume: Cloth, lo.OO; leather, $6.00; half Russia, $7.00. For sale by subscription only. Address the Publishers. Full descriptive circular free on application. LIST OF WILLIAM H. BAKER, M. D., ROBERT BATTEY, M. D., SAMUEL C. BUSEY, M. D., JAMES C. CAMERON, M. D., HENRY C. COE, A. M., M. D., EDWARD P. DAVIS, M. D., G. E. De SCHWEINITZ, M. D., E. C. DUDLEY, A. B., M. D., B. McE. EMMET, M. D., GEORGE J. ENGELMANN, M. D., HENRY J. GARRIGUES, A. M., M. D. WILLIAM GOODELL, A. M., M. D., EGBERT H. GRANDIN, A. M., M. D. SAMUEL W. GROSS, M. D., ROBERT P. HARRIS, M. D., GEORGE T. HARRISON, M. D., BARTON C. HIRST, M. D. STEPHEN Y. HOWELL, BI. D., A. REEVES JACKSON, A. M., M. D., W. W. JAGGARD, M. D., EDWARD W. JENKS, M. D., LL. D., HOWARD A. KELLY, M. D., CONTRIBUTORS. CHARLES CARROLL LEE, M. D., WILLIAM T. LUSK, M. D., LL. D., J. HENDRIE LLOYD, M. D , MATTHEW D. MANN, A. M., M. D., H. NEWELL MARTIN, F. R. S., M. D., D.Sc, M.A., RICHARD B. MAURY, M. D., C. D. PALMER, M. D., ROSWELL PARK, M, D., THEOPHILUS PARVIN, M. D., LL. D., , R. A. F. PENROSE, M. D., LL. D., THADDEUS A. REAMY, A. M., M. D., J. C. REEVE, M. D., A. D. ROCKWELL, A. M., M. D., ALEXANDER J. C. SKENE, M. D., J. LEWIS SMITH, M. D., STEPHEN SMITH, M. D., R. STANSBURY SUTTON, A. M., M. D., LL. D., T. GAILLARD THOMAS, M. D., LL. D., ELY VAN DE WARKER, M. D., W. GILL WYLIE, M. D. This is a very valuable contribution to the liter- ature of obstetrics. The editors, contributors and f)ublishers are entitled to most hearty congratu- ations for the complete kind of work that has appeared. — The Obstetric Gazette, August, 1888. This, the companion work to the System of Gynecology by American Authors, equals it in the excellence of the subject-matter and the perfec- tion of the publishers' art. As a treatise for the use of the practitioner the work will be found to represent admirably the obstetric science of the day as exemplified in American practice.— TTje Medical Neios, August 25, 1888. There can be but little doubt that this work will find the same favor with the profession that has been accorded to the " System pf Medicine by American Authors," and the "System of Gynecol- ogy byAmerican Authors." One is at a loss to know what to say of this volume, for fear that just and merited praise maybe mistaken for flattery. The subjects of some of the papers are discussed in various works on obstetrics, though not to the full extent that is found in this volume. The papers of Drs. Engelmann, Martin, Hirst, Jaggard and Reeve are incomparably beyond anything that can be found in obstetrical works. Certainly the Edi- tor may be congratulated for having made such a wise selection of his contributors. — Journal of the American Medical Association, Stpt. 8, 1888. In our notice of the "System of Practical Medi- cine by American Authors," we made the follow- ing statement: — "It is a work of which the pro- fession in this country can feel proud. Written exclusively by American physicians who are ac- quainted with all the varieties of climate in the United States, the character of the soil, the man- ners and customs of the people, etc., it is pecul- iarly adapted to the wants of American practition- ers of medicine, and it seems to us that every one of them would desire to have it." Every word thus expressed in regard to the "American Sys- tem of Practical Medicine" is applicable to the "System of Gynecology by .American .Authors," which we desire now to bring to the attention of our readers. It, like the other, has been written exclusively by American physicians who are acquainted with all the characteristics of American people, who are well informed in regard to the peculiarities of American women, their manners, customs, modes of living, etc. As every practis- ing physician is called upon to treat diseases of females, and as they constitute a class to which the familly physician must give attention, and cannot pass over to a specialist, we do not know of a work in any department of medicine that we should so strongly recommend medical men gen- erally purchasing. — Cincinnati Med. News, July,1887» TMOMAS, T, GAILLAMD, M, D., Professor of Diseases of Women in the College of Physic ians and Surgeons, N. 7. A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00 ; leather, $6.00. That the previous editions of the treatise of Dr. rician and gyncecologist as a safe guide to practice. Thomas were thought worthy of translation into No small number of additions have been made to German, French, Italian and Spanish, is enough the present edition to make it correspond to re- to give it the stamp of genuine merit. At home it cent improvements in treatment. — Pacific Medical das made its way into the library of every obstet- and Surgical Journal, Jstn. 1881. UDIS, AUTJETUIt W„ M, D., Lond,, F.B. C. JP., M.B. C.S., Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. The Diseases of Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students and Practitionei-s. In one handsome octavo volume of 576 pages, with 14b illustrations. Cloth, $8.00 ; leather, $4.00. It is a pleasure to read a boon so thoroughly 1 are among the more common methods of treat- good as this one. The special qualities which are ment, ana yet very little is said about them in conspicuous are thoroughness in covering the many of the text-books. The book is one to be whole ground, clearness of description and con- warmly recommended especially to students and ciseness ot statement. Another marked feature of the book is the attention paid to the details of many minor surgical operations and procedures, as, for instance, the use of tents, application of leeches, and use of hot water injections. These general practitioners, who need a concise but com- plete regime of the whole subject. Specialists, too, will find many useful hints in its pages. — Boston Med. and Surg. Joum., March 2, 1882. 28 Lea Brothers & Oo.'s Publications — Dis. of Women, Midwfy. BMMET, THOMAS ADBIS, M, D,, LL, J>., Surgeon to the Woman's Hospital, Neio York, etc. The Principles and Practice of Gynaecology ; For the use of Students and Practitioners of Medicine. Kew (tiiird) edition, thoroughly revised. In one large and very handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; very handsome half Bussia, raised bands, $6.50. snce of the third edition of this well-known work. The time has passed when Emmet's Oyncccology was to be regarded as a book for a single country or for a single generation. It has always been his aim to popularize gynaecology, to bring it within easy reach of the general practitioner. The orig- inality of the ideas compels our admiration and respect. We may well take an honest pride in Dr. Emmet's work and feel that his book can hold its own against the criticism of two conti- nents. It represents all that is most earnest and most thoughtful in American gyniecology. — Amer- ican Journal of Obstetrics, May, 1885. We are in doubt whether to congratulate the author more than the profession upon the appear- Embodying, as it does, the life-long experience of one who has conspicuously distinguished hiipself as a hold and successful operator, and wh<» has devoted so much attention to the specialty, we feel sure the profession will not fail to appreciate the privilege thus offered them of perusing the views and practice of the author. His earnestness of purpose and conscientiousness are manifest. He gives not only his individual experience but endeavors to represent the actual state of gynee- cological science and art. — British Medical Jour- nal, May 16, 1885. TAIT, LA WSOJSr, F. B, C, S.^ Fellow of the Royal Medico- Cliirurgical Society^ London, Honorary Member of the Boston Oyne- cological Society, Surgeon to the Birmingham ana>Midland Hospital for Women. Diseases of Women and Abdominal Surgery. In one very handsome octavo volume of 600 pages, fully illustrated. In press. DAVEJS^POItT, F, H., M, !>., Assistant in Gyncecology in the Medical Department of Harvard University, Boston. Diseases of Women, a Manual of Non-Surgical Gynsecology. De- signed especially for the Use of Students and General Practitioners. In one handsome 12mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. Just ready. FROM THE PREFACE. This book has two main objects: in the first place to give the student clearly but with considerable detail the elementary principles of the methods of examination and the simple forms of treatment of the most common diseases of the pelvic organs ; and in the second place to help the busy general practitioner to understand and treat the gynaecolog- ical cases which he meets with in the course of his everyday practice. The treatment has been mainly confined to such measures as have been practically found of the greatest benefit in the author's hands. J)VNCA:N^, J, MATTHEWS, M,D,, LL, D., F, H. S, F., etc. Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. rule, adequately handled in the text-books ; others of them, while bearing upon topics that are usually treated of at length in such works, yet bear such a They are in every way worthy of their author ; indeed, we look upon them as among the most valuable of his contributions. They are all upon matters of great interest to the general practitioner. Some of them deal with subjects that are not, as a stamp of Individuality that they deserve to be widely read. — N. Y. Medical Journal, March, 1880. MAT, CHABLFS H,, M, H., Late House Surgeon to Mount Sinai Ho spit al, New York. A Manual of the Diseases of Women. Being a concise and systematic expo- sition of the theory and practice of gynaecology. In one 12mo, volume of 342 pages; Cloth, $1.75. HOHGF, JaUGHL., 31, 2)., Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. On Diseases Peculiar to Women; Including Displacements of the Uterus. Second edition, revised and enlarged. In one beautifully printed octavo volume of 619 pages, with original illustrations. Cloth, $4.50. By the Same Author. The Principles and Practice of Obstetrics. Illustrated with large litho- graphic plates containing 159 figures from original photographs, and with nimierous wood- cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in cloth, $14.00. Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. MAMSBOTHAM, FBANCIS FT., 31. H, The Principles and Practice of Obstetric Medicine and Surgery: In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With additions by "VV. V. Keating, M. D., Professor of Obstetrics, etc., in the Jefferson Medical College of Philadelphia. In one large and handsome imperial octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. WFST, CHABLFS, 31. J). Lectures on the Diseases of Women. Third American from the third Lon- don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. Lea Brothers & Co.'s Publications — Midwifery. 29 PABVUS^, THEOPHILVS, M, D., LL. D., Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. The Science and Art of Obstetrics. In one handsome 8vo, volume of 697 pages, with 214 engravings and a colored plate. Cloth, $4.25 ; leather, $5.25. It is a ripe harvest that Dr. Parvin offers to his readers. There Is no book that can be more fafel v recommended to the student or that can be turned to in moments of doubt with greater assurance of aid, as it is a liberal digest of sBife counsel that has been patiently gathered. — The American Journal of the Medical Sciences, July, 1887. Tliere is not in the language a treatise on the subject which so completely and intelligently gleans the whole field of obstetric literature, giv- ing the reader the winnowed wheat in concise and well-jointed phrase, in language of exceptional purity and strength. The arrangement of the matter of this work is unique and exceedingly favorable for an agreeable unfolding of the science and art of obstetrics. This new book is the easy superior of any single work among its predeces- sors for the student or practitioner seeking the best thought of the day in this department of medicine. — The American Practitioner and News, April 2, 1887. BAMNES, BOBJEBT, M, J)., mid FAJSTCOVBT, M. !>., Phys. to the General Lying-in Eosp., Lond. Obstetric Phys. to St. Thomas^ Hosp., Lond. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For the Student and the Practitioner. The Section on Embryology contributed by Prof. Milnes Marshall. In one handsome octavo volume of 872 pages, with 231 illus- trations. Cloth, $5 ; leather, $6. The immediate purpose of the work is to furnish a handbook of obstetric medicine and surgery for the use of the student and practitioner. It is not an exaggeration to say of the bonk that it is the best treatise in the English language yet published, and this will not be a surprise to those who are acquainted with the work of the elder Barnes. Every practitioner who desires to have the best obstetrical opinions of the time in a readily accessible and condensed form, ought to own a copy of the book. — Journal of the American Medical Association, June 12, 1886. The Authors have made a text-book which is in every way quite worthy to take a place beside the best treatises of the period. — New York Medical Journal, July 2, 1887. rZAYFAIB, W, S,, M, D,, F, B, C, J>., professor of Obstetric Medicine in King^s College, London, etc, A Treatise on the Science and Practice of Midwifery. New (fifth) American, from the seventh English edition. Edited, with additions, by Egbert P. Has- Eis, M. P. In one handsome octavo volume of about 700 pages, with 3 plates and about 200 engravings. In press. A notice of the previous edition is appended. Students and practitioners alike have already found out the advantage of possessing a work em- bodying all the recent advances in the science and practice of midwifery. It has deservedly he- come a standard treatise upon the subject. The Author has endeavored to dwell especially on the practical part of the subject, so as to make the work a useful guide in this most anxious and re- sponsible branch of the profession. At the same time, the purely theoreti^cal portion has not been neglected. Dr. Playfair's treatise may fairly be said to represent the modern school of teaching. It is a well-arranged and carefully digested epitome of the science and practice of midwifery which has greatly contributed to the advancement of the study.— British Medical Journal, Jan. 3, 1885. KING, A, F, A., M, D,, Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- sity, Washington, D. C, and in the University of Vermont, etc. A Manual of Obstetrics. IS^ew (fourth) edition. In one very handsome 12mo. volume of about 400 pages, with 140 illustrations. In press. A notice of the previous edition is appended. This little manual, certainly the best of its kind, fully deserves the popularity which has made a third edition necessary. Clear, practical, concise, its teachings are so fully abreast with recent ad- vances in obstetric science that but few points can be criticised. — American Journal of Obstetrics, March, 1887. BABKFB, FOBDTCF, A. M., M, J)., LL, B. Fdin,, Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, NeiB York, honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. Obstetrical and Clinical Essays. In one handsome 12mo. volume of about 300 pages. Preparing. BABBT, JOBJS' S., M. B., Obstetrician to the Philadelphia Hospitcd, Vice-President of the Obstet. Society of Philadelphia. Extra - Uterine Pregnancy : Its Clinical History, Diagnosis, Prognoeds and Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. WrS^CKFL, F. A Complete Treatise on the Pathology and Treatment of Childbed, For Students and Practitioners. Translated, with the consent of the Author, from the second German edition, by J. R. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00, ASHWELL'S PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Third American from the third and revised London edition. In one 8vo. vol., pp. 520. Cloth, $3.50. TANNER ON PREGNANCY. Octavo, 490 pages, colored plates, 16 cuts. Cloth, §4,25. CFTTRCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WO- MEN. In one 8vo. vol. of 464 pages. Cloth, 82.50. MEIGS ON THE NATURE, SIGNS AND TREAT- MENT OF CHILDBED FEVER. In one 8vo, volume of 346 pages. Cloth, 82.00. -V 30 Lea Brothers & Co.'s Publications — Midwiy., Dis. Childn. LEISHWA W, WILLIA3I, M, D., Regius Professor of Midwifery in the University of Qlasgow, etc, A System of Midwifery, Including the Diseases of Pregnancy and the P^ierperal State. Third American edition, revised by the Author, with additions by John S. Parry, M. D., Obstetrician to the Philadeljdiia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, $5.50. The author Is broad in his teachings, and dis- cusses briefly the comparative anatomy of the pel- vis and the mobility of the pelvic articulations. The second chapter is devoted especially to the study of the pelvis, while in the third the female organs of generation are introduced. The structure and development of the ovum are admirably described. Then follow chapters upon the various subjects embraced in the study of mid- wifery. The descriptions throughout the work are plain and pleasing. It is sufficient to state that in this, the last edition of this well-known work, every recent advancement in this field has been brought forward. — Physician and Stirgeoyi, Jan. 1880. To the American student the work before us must prove admirably adapted. Complete in all its parts, essentially modern in its teachings, and with demonstrations noted for clearness and precision, it will gain in favor and be recognized a,s a work of standard merit. The work cannot fail to be popular and is cordially recommended. — N. O. Med. and Surg. Journ., March, 1880. It has been well and carefully written. The views of the author are broad and liberal, and in- dicate a well-balanced judgment and matured mind. We observe no spirit of dogmatism, but the earnest teaching of the thoughtful observer and lover of true science. Take the volume as a whole, and it has few equals. — Maryland Medical Journal, Feb. 1880. ZAJ^DIS, HENHY G,, A, M,, M, JD,, Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. The Management of Labor, and of the Lying-in Period. In handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. one The author has designed to place in the hand; of the young practitioner a book in which he can find necessary information in an ijistant. As far as we can see", nothing is omitted. The advice is sound, and the proceedures are safe and practical. Centralblatt fiir Gynakologie, December 4, 1886. This is a book we can heartily recommend. the author goes much more practically into the details of the management of labor than most text-books, and is so readable throughout as to tempt any one who should happen to commence the book to read it through. The author pre- supposes a theoretical knowledge of obstetrics, and has consistently excluded from this little work everything that is not of practical use in the lying-in room. We think that if it is as widely read as it deserves, it will do much to improve obstetric practice in general. — New (Orleans Medi- cal and Surgical Journal, Mar, 1886. SMITM, J, LBWISf M. D,, Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. A Treatise on the Diseases of Infancy and Childhood. New (sixth) edition, thoroughly revised and rewritten. In one handsome octavo volume of 867 pages, with 40 illustrations. Cloth, $4.50 ; leather, $5.50. For years it has stood high in the confidence of the profession, and with the additions and alter ations now made it may be said to be the best book in the language on the subject of which it treats. An examination of the text fully sus- tains the claims made in the preface, that "in preparing the sixth edition the author has revised the text to such an extent that a considerable part of the book may be considered new." If the young practitioner proposes to place in his library but one book on the diseases of children, we would unhesitatingly say, let that book be the one which is the subject of this notice. — The American Journal of the Medical Sciences, April, 1886. No better work on children's diseases could be placed in the hands of the student, containing, as It does, a very complete account of the symptoms and pathology of the diseases of early life, and possessing the further advantage, in which it stands alone amongst other works on its subject, of recommending treatment in accordance with the most recent therapeutical views. — British and Foreign. Mcdico-Chirurgxcal Review. Those familiar with former editions of the work will readily recognize the painstaking with which this revision has been made. Many of the articles have been entirely rewritten. The whole work is enriched with a research and reasoning which plainly show that the author has spared neither time nor labor in bringing it to its present ap- proach towards perfection. The extended table of contents and the well-prepared index will enable the busy practitioner to reach readily and quickly for reference the various subjects treated of in the body of the work, and even those who are familiar with former editions will find the improvements in the present richly worth the cost of the work. — Atlanta Medical and Surgical Journal, Dec. 1S86. Dr. Smith's work hasjustly become the standard all over the world as the book on children's dis- eases. The whole book is admirable, both for the practitioner and the student. Dr. Smith writes from a large experience and a close observation of cases at the bedside. He is extremely prac- tical, and these facts make the work what it is — the best of all works on the diseases of children. — Virginia Medical Monthly, June, 1886. OWEN, EDMUND, 31. B,, F, JS. C. S,, Surgeon to the Children's Hospital, Great Ormond St., Loiulon. Surgical Diseases of Children. In one 12mo. volume of 525 pages, with 4 chromo-lithographic plates and 85 woodcuts. Cloth, $2. See Series of Clinical Manvxds, page 4. One is immediately struck on reading this book with its agreeable style and the evidence it every- where presents of the practical familiarity of its author with his subject. The book rnay be honestly recommended to both students and practitioners. It is full of sound information, pleasantly given. — Annals of Surgery, May, 1886. WEST, CHABLES, 31. D., Physician to the Hospital for Sick Children, London, etc.. On Some Disorders of the Nervous System in Childhood. 12mo. volume of 127 pages. Cloth, $1.00. In one small CONDIE'S PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, re- vised and augmented. In one octavo volume of 779 pages. Cloth, $5.25 ; leather, 86.25. Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 31 TIDY, CHABLES METMOTT, M. B., F. C. S., Professor of Chemistry arul of Forensic Medicine aiui Public Health at the London Hospital, etc Legal Medicine. Voltime II. legitimacy and Paternity, Pregnancy, Abor- tion, Eape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00. Volume I. Containing 664 imperial octavo pages, with two beautiful colored plates. Cloth, $6.00; leather, $7.00. The satisfaction expressed with the first portion of this work is in no wise lessened by a perusal of the second volume. We find it characterized by the same fulness of detail and clearness of ex- pression which we had occasion so highly to com- mend in our former notice, and which render it so valuable to the medical jurist. The copious tables of cases appended to each division of the subject must have cost the author a prodigious amount of labor and research, but they constitute one of the most valuable features of the book, especially for reference in medico-legal trials. — Afiierican Journal of the Medical Sciences, April, 1884. TAYLOR, AZEBED S., M. D., Lecturer on Medical Jurisprtidence and Chemistry in Ouy^s Hospital, London. A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by .John J. Eeese, M. D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00. The American editions of this standard manual have for a long time laid claim to the attention of the profession in this country; and the eighth comes before us as embodying the latest thoughts and emendations of Dr. Taylor upon the subject to which he devoted his life with an assiduity and success which made him jacile princeps among English writers on medical jurisprudence. Both the author and the book have made a mark too deep to be affected by criticism, whether it be censure or praise. In this case, however, we should only have to seek for laudatory terms. — American Journal of the Medical Sciences, Jan. 1881. This celebrated work has been the standard au- thority in its department for thirty-seven years, both in England and America, in both the profes- sions which it concerns, and it is improbable that it will be superseded in many years. The work is simply indispensable to every physician, and nearly so to every liberally-educated lawyer, and we heartily commend the present edition to both pro- fessions. — Albany Law Journal, March 26, 1881. By the Same Author. The Principles and Practice of Medical Jurisprudence. Third edition. In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; leather, $12. For years Dr. Taylor was the highest authority in England upon the subject to which he gave especial attention. His experience was vast, his judgment excellent, and his skill beyond cavil. It is therefore well that the work of one who, as Dr. Stevenson says, had an " enormous grasp of all matters connected with the subject," should be brought up to the present day and continued in its authoritative position. To accomplish this re- sult Dr. Stevenson has subjected it to most careful editing, bringing it well up to the times. — Ameri- can Journal of the Medical Sciences, Jan. 1884. By the Same Author. Poisons in Relation to Medical Jurisprudence and Medicine. Third American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, $5.50 ; leather, $6.50. PEPPEM, AUGUSTUS J,, M. S,, M, B., F. B. C. S,, Examiner in Forensic Medicine at the University of London. Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See StudemUf Series of Manuals, page 4. LEA, SENBY a Superstition and Force : Essays on The Wager of Law, The Wager of Battle, The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volume of 552 pages. Cloth, $2.50. This valuable work Is in reality a history of civ- ilization as interpreted by the progress of jurispru- dence. . . In "Superstition and Force" we have a philosophic survey of the long period intervening between primitive barbarity and civilized enlight- enment. There is not a chapter in the work inat should not be most carefully studied ; and however well versed the reader may be in the science of jurisprudence, he will find much in Mr. Lea's vol- ume of which he was previously ignorant. The book is a valuable addition to the literature of so- cial science. — Westminster Review, Jan. 1880. By the Same Author. Studies in Church History. The Rise of the Temporal Power— Ben- efit of Clergy — Excommunication. octavo volume of 605 pages. Cloth, $2.50. The author is pre-eminently a scholar. He takes up every topic allied with the leading theme, and traces it out to the minutest detail with a wealth of knowledge and impartiality of treatment that compel admiration. The amount of information compressed into the book is extraordinary. In no other single volume is the development of the New edition. In one very handsome royal ♦ primitive church traced with so much clearness, and with so definite a perception of complex or conflicting sources. The fifty pages on the growth of the papacy, for instance, are admirable for con- ciseness and freedom from prejudice. — Boston Traveller, May 3, 1883. Allen's Anatomy .... 6 Americau Journal of the Medical Sciences . 3 American Systems of Gynecology and Obstetrics 27 American System of Practical Medicine . . 15 An American .System of Dentistry . . 24 Aslihurst's Surgery ..... 20 Ashwell on Diseases of Women . . .29 Attfleld'8 Chemistry . . . -' . -9 Ball on the Kectum and Anus . . .4,20 Barker's Obstetrical and Clinical Essays, . 29 Barlow's Practice of Medicine ... 17 Barnes' System of Obstetric Medicine . . 29 Bartholow on Klectricity .... 17 Bartholow's New Kemedies and their UBes . 11 Basbam on Renal Diseases .... 24 Bell's Comparative Physiology and Anatomy . 4, 7 Bellamy's Surgical Anatomy ... 6 Billings' Universal Medical Dictionary . . 4 Blandford on Insanity .... 19 Bloxam's Chemistry ..... 9 Bristowe's Practice of Medicine . . .14 Broadbent on the Pulse . . . .4,18 Browne on the Ophthalmoscope . . . 23 Browne on the Throat, Nose and Ear . . 18 Bruce's Materia Medica and Therapeutics . 11 Brunton's Materia Medica and Therapeutics . 11 Bryant's Practice of Surgery ... .21 Bumstead and Taylor on Venereal. See Taylor. 25 Burnett on the Ear ..... 23 Butlin on the Tongue . . . . .4,21 Carpenter on the use and Abuse of Alcohol Carpenter's Human Physiology Carter & Frost's Ophthalmic Surgery Chambers on Diet and Regimen Chapman's Human Physiology Charles' Physiological and Pathological Chem Churchill on Puerperal Fever Clarke and Lockwood's Dissectors' Manual Classen's Quantitative Analysis Cleland's Dissector .... Clouston on Insanity .... Clowes' Practical Chemistry Coats' Pathology .... Cohen on the Throat . . ^ • Coleman's Dental Surgery Condie on Diseases of Children Cornil on Syphilis .... Dalton on the Circulation Dalton's HumanPhysiology Davenport on Diseases ofWomen . Davis' Clinical Lectures Draper's Medical Physics . . . Druitfs Modern Surgery . . . Duncan on Diseases of Women . . Dungllson's Medical Dictionary Edes' Materia Medica and Therapeutics Edis on Diseases of Women . Ellis', Demonstrations of Anatomy Emndet's Gynaecology Erichsen's System of Surgery Farquharson's Therapeutics and Mat. Med. Fen wick's Medical Diagnosis rinlayson's Clinical Diagnosis . . Flint on Auscultation and Percussion Flint on Phthisis .... Flint on Respiratory Organs Flint on the Heart . • «>' • Flint's Essays ..... Flint's Practice of Medicine Folsom's Laws of U. S. on Custody of Insane Foster's Physiology .... Fothergill's Handbook of Treatment Fownes' Elementary Chemistry . . Fox on Diseases of the Skin . Frankland and Japp's Inorganic Chemistry Fuller on the Lungs and Air Passages . Gibney's Orthopedic Surgery Gould's Surgical Diagnosis . Gray's Anatomy ..... Greene's Medical Chemistry . Green's Pathology and Morbid Anatomy Grlfiath's Universal Formulary Gross on Foreign Bodies In Air-Passages Gross on Inapof ence and Sterility . Gross on Urinary Organs Gross' System or Surgery Habershon on the Abdomen Hamilton on Fractures and Dislocations Hamilton on Nervous Diseases Hartshorne's Anatomy and Physiology . Hartahorne's Conspectus of the Med. Sciences Hartshorne's Essentials of Medicine Hermann's Experimental Pharmacology Hill on Syphilis HUller's Handbook of Skin Diseases Hoblyn'a Medical Dictionary Hodge on Women .... Hodge's Obstetrics .... Hoflrmann and Power's Chemical Analysis Holden's Landmarks .... Holland's Medical Notes and Beflectlona Holmes' Principles and Practice of Surgery Holmes' System of Surgery . . Horner's Anatomy and Histology • Hudson on Fever Hutchinson on Syphilis Hyde on the Diseases of the Skin . Jones (C. Handfleld) on Nervous Disorders Juler's Ophi lialmic Science and Practice Kinji's Miiiiiial 01 Obstetrics . Klein's Histology . . . . . Landls on Labor . . . . La Koche on Pneumonia, Malaria, etc. . La Koclie on Yellow Fever . Laurence and Moon's Ophthalmic Surgery Lawson on the Kye, Orbit and Kyelld Lea'u Studies in Church History Lea's Hupersliliou and Force . Lee on Wj'philis 4,23 17 8 10 29 4,6 10 6 19 10 13 18 24 30 25 7 8 28 17 7 20 28 4 12 27 28 21 12 16 16 18 18 18 18 18 14 19 8 16 9 26 9 18 20 4,21 5 9 13 11 18 25 25 20 le 22 19 6 3 14 11 25 26 4 28 28 10 5 17 22 22 6 4 4,25 26 Lehmann s Chemical Physiology . Lelshman's Midwifery Lucas on Diseases of the Urethra . Ludlow's Manual of Examinations Lyons on Fev er . Maisch's Organic Materia Medica . Marsh on the Joints May on Diseases of Women . Medical News Medical News Visiting List . Medical News Physicians' Ledger . Meigs on Childbed Fever Miller's Practice of Surgery . . . Miller's Principlesof Surgery Mitchell's Nervous Diseases of Women . Morris on Diseases of the Kidney . NeiU and Smith's Compendium of Med. Scl. Nettleship on Diseases of the Eye . Norris and Oliver on the Eye Owen on Diseases of Children Parrish's Practical Pharmacy Parry on Extra-Uterine Pregnancy Parvin's Midwifery .... Pavy on Digestion and its Disorders Payne's General Pathology . Pepper's System of Medicine Pepper's Forensic Medicine . Pepper's Surgical Pathology Pick on Fractures and Dislocations Pirrie's System of Surgery . Play fair on Nerve Prostration and Hysteria Playfair's Midwifery .... Folitzer on the Ear and its Diseases Power's Human Physiology . . . Purdy on Eright's Disease and AUied A flections Ralfe's Clinical Chemistry Kamsbotham on Parturition Renisen's Theoretical Chemistry . Reynolds' System of Medicine Richardson's Preventive Medicine Roberts on Urinary Diseases Roberts' Compend of Anatomy Roberta' Principles and Practice of Surgery Robertson's Physiological Physics Ross on Nervous Diseases Savage on Insanity, including Hysteria . Schafer's Essentials of Histology, Schreiber on Massage . Seller on the Throat. Nose and Naso-Pharynx Senn's Surgical Bacteriology Series of Clinical Manuals Simon's Manual of Chemistry Slade on Diphtheria .... Smith (Edward) on Consumption . Smith (J. Lewis) on Children Smith's Operative Surgery . Stllle on Cholera .... Stilie <. \ \